Download Forms For Documenting Training Dental Assistant Certificates

2/4/2015
OSHA Program For The Dental Office
Robert Cooley, DMD, MS
Email [email protected]
Forms For Documenting Training
Hazard Communication Training Record
BLOODBORNE PATHOGENS TRAINING RECORD
Name of Office
Date of Training Session
Name of Office:
Date of Training Session:
Person Conducting Training Session: Dr. Robert Cooley
Name of Persons Attending
Person Conducting Training Session Dr. Robert Cooley
Name of Persons Attending
Summary of Training Session
•Hazard Communication Plan – New Globally Harmonized Rules
•Signal Words
•Pictograms
•Labels - Primary and Secondary
•MSDS
EMPLOYEE INPUT FOR SAFETY NEEDLES & SYRINGES
Products Reviewed and Suggestions For Safer
Devices Or Synopsis of Article Reviewed
Dental Assistant Certificates
DATE:
Employee Names
HypoSafety Syringe
Safe Mate Safety Needle
Sandel Safety Scalpel
Futura Safety Scalpel
• State Board Certificates for dental assistants
must be posted in the office where employed.
• Certificates must be originals. Copying of the
certificates is forbidden by the State Board
Rules.
Employee’s Input For Safety Devices
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Internet Course
For Dental Assistant Registration
Texas Academy Of General Dentistry
www.tagd.org
OSHA New Reporting Requirements
For Work Related Deaths and Hospitalizations
• Death must be reported within 8 hours
• In-patient hospitalization, amputation, or loss
of an eye must be reported within 24 hours.
• Dallas Area Office
(972) 952-1330
• Call 1-800-321-OSHA (6742)
• Visit http//:www.osha.gov/report_online
Texas State Board Dental Examiners
RULE §108.6 Report of Patient Death or Injury Requiring Hospitalization
• Death of a dental patient which may have
occurred as a consequence of the receipt of
dental services – 72 Hours.
• Hospitalization of a dental patient, as a
possible consequence of receiving dental
services – 30 Days.
OSHA Training Involves 3 Areas
• Bloodborne Pathogens
• Hazard Communication
• Building, Equipment, Fire Safety
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Posters Required By Texas
Payday
Workers Compensation
Unemployment Insurance
Notice To Injured Employee - Ombudsman Program
Posters Required By Federal Government
OSHA
Equal Employment Opportunity
Federal Minimum Wage
Family & Medical Leave Act
Employee Polygraph Protection Act
Americans With Disabilities (may be included in the EEO section)
Uniformed Services Employment and Reemployment Rights Act (USERRA)
These posters are available in laminated form from:
• Compliance Pro
1-800-997-5545
• G. Neil Company
1-800-999-9111
Other Requirements From State of Texas
• Texas Bureau Of Radiation Control requires a Radiation Poster entitled:
Notice To Employees Poster
http://www.dshs.state.tx.us/radiation/pdffiles/Rules/232-1frm_10_08.pdf
• State Board Of Dental Examiners requires that the Consumer Information Sign
be posted where visible to patients. This can be ordered from the State
Board or you can make one on your computer.
http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_
dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=22&pt=5&ch=108&rl=3
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Other Requirements From State of Texas
• Texas Bureau Of Radiation Control requires a Radiation Poster entitled:
Notice To Employees Poster
http://www.dshs.state.tx.us/radiation/pdffiles/Rules/232-1frm_10_08.pdf
• State Board Of Dental Examiners requires that the Consumer Information Sign
be posted where visible to patients. This can be ordered from the State
Board or you can make one on your computer.
http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_
dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=22&pt=5&ch=108&rl=3
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Fire Safety Plan
The Practice Of Dentistry is Regulated by the Texas Dental Practice Act and the
Rules of the State Board of Dental Examiners (SBDE).
The mission of the SBDE is to assure that the people of the State of Texas receive
the highest quality dental care.
For Information, Concerns or Complaints, contact the:
State Board Of Dental Examiners
333 Guadalupe, Tower 3, Suite 800
Austin, Texas 78701
Phone 1-800-821-3205
512- 463-6400
When To Do Training On Bloodborne
Pathogens
Exposure Control Plan For The Office Of
1. At the time of initial assignment.
2. When there are changes in duties or job
assignments.
3. At least annually thereafter.
12.
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Exposure Determination Form
EXAMPLE OF ENTRIES
All employees in the following jobs have occupational exposure:
Job Classification
Dentist (if the practice is incorporated)
Dental Assistant
Dental Hygienist
Dental Technician
Some employees in the following jobs have occupational exposure:
Job
Task or Procedure
Secretary
Dental Assisting
Receptionist
Cleaning Operatories
Office Manager
Cleaning Instruments
EXPOSURE DETERMINATION FORM
All employees in the following jobs have occupational exposure:
Job Classification
Some employees in the following jobs have occupational exposure:
Job
Task or Procedure
14.
Procedures For Employees With Occasional Exposure
Tasks Involving Exposure to Blood, Saliva or Tissues
Task or Procedure
Protective Equipment Required
Assisting With Patient Procedures
Gloves, Mask, Glasses, Protective Gown
Cleaning Operatories
Gloves, Mask, Glasses, Protective Gown
Cleaning and Sterilizing Instruments
Gloves, Mask, Glasses, Protective Gown
16.
UNIVERSAL PRECAUTIONS
Because not all patients with infectious diseases can be identified by medical
history, physical examination, or laboratory tests, the blood and saliva of all dental
patients should be treated as if they were infective.
ENGINEERING CONTROLS
These are physical things that remove or isolate a hazard from the workplace.
Examples of engineering controls are sharps containers and high volume evacuators.
The following engineering controls will be used in this office:
Sharps Containers
EXAMINATION AND MAINTENANCE OF ENGINEERING CONTROLS
Engineering controls will be examined every
to
ensure that they are present and in good condition, including the following items:
• Sharps containers will be examined to determine if they are located in the proper
location and that they are being replaced at sufficiently frequent intervals to prevent
over filling. Sharps containers should be replaced when filled to the "Fill Line" below
the opening. Sharps containers must be closed when moved from one place to
another. When full, the sharps container should be placed in the regulated waste
container for disposal.
• High volume evacuator will be examined on the same schedule to determine that
it is in good working condition and the filters are clean.
15.
Procedures For Employees With Occasional Exposure
Tasks Involving Exposure to Blood, Saliva, or Tissues
Tasks or Procedures
Protective Equipment Required
17.
Consideration of Safety Needles: These devices will be considered or evaluated
each year by reviewing safety products and with discussions with employees. Some
publications indicate that they are unacceptable and can cause more incidents than
conventional needles.
Eve Cuny et al. Safety Needles......... CDA Journal 27:525, 1999.
Eve Cuny et al. Dental Safety Needles .....JADA 11:1443, October, 2000
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Safety Scalpels
Hypo Safety Syringe
Safe Mate Safety Needle
Futura Safety Scalpel
Sandel Safety Scalpel
Needlestick Log
For Offices or Clinics With 11 or More Employees
To Be Used Until January, 2002 - Then Use OSHA Log 300
EMPLOYEE INPUT FOR SAFETY NEEDLES & SYRINGES
Safety Devices Discussed
Date
Brand of Device
Work Area
Explanation Of How Incident Occurred
Date:
Employee Name
MedPro Safe-Mate
HypoSafety Syringe
Sandel Safety Scalpel
This Log Not Required In Dentistry At This Time
Futura Safety Scalpel
____________________________________________________________________
Employee’s Comments and Suggestions For Devices
21.
WORK PRACTICE CONTROLS
This is changing or altering a task or procedure to reduce the likelihood of
exposure to bloodborne pathogens. Examples of work practice controls are
prohibiting recapping of needles by a two-handed technique and prohibiting eating
and drinking in work areas.
HANDWASHING
• Hands should be washed immediately or as soon as feasible after removal of
gloves or other personal protective equipment.
• Hands and any other skin should be washed with soap and water immediately
following contact with blood or other potentially infectious materials.
• Flush mucous membranes with water immediately or as soon as feasible following
exposure to blood or saliva. An eyewash station is located in
.
SHARPS
RECAPPING OF NEEDLES
Recapping of needles is permitted for procedures when there is no feasible
alternative to recapping. In this office, frequently it is necessary to administer
incremental doses of an anesthetic to the same patient. There is no feasible
alternative to recapping of the needle. Recapping will be accomplished with
resheathing instruments, forceps, or a one- handed scoop technique.
EATING AND DRINKING
Eating, drinking, smoking, applying cosmetics or lip balm, and handling contact
lenses in the work areas where there is a reasonable likelihood of occupational
exposure is prohibited. This is not to restrict use of hand cream or lotion. No
food or drinks will be stored in refrigerators, freezers, shelves, cabinets or on
countertops or bench tops where blood or other potentially infectious materials are
present.
MINIMIZE SPLASHING AND SPRAYING
• Contaminated sharps are considered to be any object that can penetrate the skin.
Sharps include needles, scalpels, broken glass and exposed ends of dental wires.
• Immediately or as soon as feasible after use, contaminated sharps must be placed
in a sharps container.
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• All procedures involving blood or saliva must be performed in a way to minimize
splashing, spraying, spattering, and generation of droplets.
• The high volume evacuator should be used with all procedures involving blood
and saliva to minimize exposure.
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One Hand Scoop Technique
RECAPPING OF NEEDLES
Recapping of needles is permitted for procedures when there is no feasible
alternative to recapping. In this office, frequently it is necessary to administer
incremental doses of an anesthetic to the same patient. There is no feasible
alternative to recapping of the needle. Recapping will be accomplished with
resheathing instruments, forceps, or a one- handed scoop technique.
Needle Recapping Devices
EQUIPMENT TO BE REPAIRED
EATING AND DRINKING
Equipment that becomes contaminated with blood or other potentially infectious
materials should be examined prior to servicing or shipping and should be
decontaminated. If the equipment cannot be decontaminated, a label should be
attached to the equipment stating which portions remain contaminated.
Eating, drinking, smoking, applying cosmetics or lip balm, and handling contact
lenses in the work areas where there is a reasonable likelihood of occupational
exposure is prohibited. This is not to restrict use of hand cream or lotion. No
food or drinks will be stored in refrigerators, freezers, shelves, cabinets or on
countertops or bench tops where blood or other potentially infectious materials are
present.
PERSONAL PROTECTIVE EQUIPMENT
• When there is a potential for occupational exposure, the employee should use
appropriate personal protective equipment.
• PPE used will depend on the tasks and amount of anticipated exposure. Use PPE
that will prevent blood or saliva from contacting the employee's skin, street clothes,
eyes, mouth, or mucous membranes as well as underwear.
MINIMIZE SPLASHING AND SPRAYING
GLOVES
WHEN TO WEAR
Gloves should be worn when the employee has the potential for the hands to have
direct skin contact with blood, other potentially infectious materials.
WHEN TO REPLACE
Disposable (single-use) gloves, such as surgical or examination gloves, should be
replaced as soon as possible when visibly soiled, torn, punctured, or when they are
compromised. They should not be washed or disinfected for reuse.
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• All procedures involving blood or saliva must be performed in a way to minimize
splashing, spraying, spattering, and generation of droplets.
• The high volume evacuator should be used with all procedures involving blood
and saliva to minimize exposure.
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MASKS, EYE PROTECTION, AND FACE SHIELDS
Masks and eye protection OR chin-length face shields must be worn whenever
splashes, spray, spatter, droplets, or aerosols of blood or other potentially infectious
materials may be generated and there is a potential for eye, nose, or mouth
contamination. A chin-length face shield may be worn in place of a mask and eyewear.
GOWNS
• Appropriate protective clothing should be worn when the employee has a potential for
occupational exposure. The clothing selected should form an effective barrier.
• Gowns, lab coats, clinic jackets, or similar clothing should be worn if there is a
potential for soiling of clothes with blood or other potentially infectious materials.
• Garments that become penetrated by blood or saliva will be removed immediately or
as soon as feasible.
• These protective garments should not be worn outside the office or taken home.
They should be placed in the laundry bags which have been provided for
contaminated laundry.
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LAUNDRY
Contaminated laundry is that which has been soiled with blood or other potentially
infectious materials or may contain sharps. It will be handled as little as possible, bagged
where it is used, not be sorted or rinsed where it is used, placed and transported in bags
that are labeled with biohazard label or color-coded red.
Laundry will be cleaned by (circle one)
• Outside laundry service.
• Washer and dryer on site.
• Unincorporated dentist does cleaning.
• Designated employee does cleaning at Laundromat using PPE.
(Employee must be trained, use PPE, and carry laundry in labeled bag).
REGULATED WASTE
All containers of regulated waste (infectious or biomedical) will be labeled with an
orange or orange-red label with the Biohazard Symbol and the word Biohazard.
The 3 categories of regulated waste are:
•
•
•
Sharps
Items saturated with blood or saliva.
Tissues removed from the patient.
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Contaminated Laundry
Washing Machine As Laundry Container
Container should have Biohazard Label & label
with wording “Contaminated Laundry”.
LAUNDRY
Contaminated laundry is that which has been soiled with blood or other potentially
infectious materials or may contain sharps. It will be handled as little as possible, bagged
where it is used, not be sorted or rinsed where it is used, placed and transported in bags
that are labeled with biohazard label or color-coded red.
Laundry will be cleaned by (circle one)
• Outside laundry service.
• Washer and dryer on site.
• Unincorporated dentist does cleaning.
• Designated employee does cleaning at Laundromat using PPE.
(Employee must be trained, use PPE, and carry laundry in labeled bag).
REGULATED WASTE
All containers of regulated waste (infectious or biomedical) will be labeled with an
orange or orange-red label with the Biohazard Symbol and the word Biohazard.
The 3 categories of regulated waste are:
•
•
•
Sharps
Items saturated with blood or saliva.
Tissues removed from the patient.
Amarillo
A local TV station sent a reported out to dig through the dumpster of a dental
office looking for medical waste. The reporter found bloody gauze and called
the dentist requesting a statement and informing him that this would be part
of a TV report.
• Commission on Environmental Quality
 Writes Medical Waste Rules
 Gauze with blood is OK in regular waste
• What Cannot Go Into The Regular Trash?
 Sharps
 Tissues, such as teeth
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Isolyzer Sharps Container
Texas Regulations on Medical Waste
Effective Date April 30, 2012
TCEQ REGULATORY GUIDANCE
RG-001 Revised January 2012
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Requirements for Generators of
Medical Waste
• Generators of medical waste that ship their waste
off-site for treatment are required to properly
package and label it.
• The rules require generators to list the weight of
each medical-waste container on the generator
label. Prior to transportation off-site.
• TCEQ is allowing transporters to assist in the
labeling of medical waste containers including
weighing the containers for the generator before
the waste leaves the point of generation.
Generators That Treat Their Own
Medical Waste On-site
Less Than 50 lbs/month
• Required to notify the TCEQ of the
operation as specified in 30 TAC 330.11(f).
• Required to maintain records of each load
of medical waste treated.
• Maintain records such as the date and
method of treatment, the amount of
waste treated, the name of the person
performing the treatment.
Maintain The Following Records
(A) Date of treatment
(B) Amount of waste treated
(C) Method of treatment (encapsulation)
(D) Name (printed) and initials of the
person(s) performing treatment; and
(E) If applicable, name, address, telephone
number, and registration number of the
entity providing treatment.
Medical Waste Regulations
• Generators are required to obtain a signed
shipping receipt from a registered transporter.
• Maintain records of all shipments of untreated
medical waste sent off-site for three years.
• Make the records available for inspection by the
TCEQ.
• Generators must also obtain a receipt from the
medical-waste treatment facility certifying that
the waste has been properly treated and must
also maintain these records.
Encapsulation Of Sharps
Letter Of Notification To TCEQ
TCEQ
Christine Bergren, Section Manager
Municipal Solid Waste Permits
MC -124, Building F
P.O. Box 13087
Austin, Texas 78711-3087
Biohazard Symbol
Used on sharp containers, regulated waste,
contaminated laundry or where there is blood or body
fluids.
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CLEANING AND DISINFECTION SCHEDULE
HOUSEKEEPING
The safety and health manager, will assure that this office is maintained in a clean
and sanitary condition. The safety and health manager will determine and implement the
appropriate schedule for cleaning and method of disinfection.
Our disinfectants are chemical germicides that have:
• EPA Number
• Effective against TB
OR HIV and HBV.
(Will be on the label)
Work surfaces should be decontaminated with an appropriate disinfectant after
completion of procedures; when surfaces are overtly contaminated; immediately after
any spill of blood; and at the end of the work shift.
Protective coverings such as plastic wrap, aluminum foil, or imperviously backed
absorbent paper may be used to cover equipment and environmental surfaces.
Bins, Pails, Cans, and similar receptacles intended for reuse that have a potential
for becoming contaminated with blood or other potentially infectious materials should be
inspected and cleaned daily. Decontamination can be done with soap and water.
Broken glassware that may be contaminated must not be picked up directly with
the hands. It should be cleaned up using mechanical means, such as a dust pan and
tongs.
Reusable Sharps (such as explorers and scalers) must be placed in appropriate
containers immediately or as soon as feasible after contamination. Reusable sharps
that are contaminated with blood or other infectious materials will not be stored or
processed in a manner that requires reaching by hand into the container
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The Location of Personal Protective Equipment in Our Office is as Follows:
HBV VACCINATION AND POSTEXPOSURE EVALUATION AND FOLLOW-UP
All employees identified in the "Exposure Determination" as having possible
exposure to blood and other potentially infectious materials will be offered the
hepatitis B Vaccination free of charge. Any employee who declines to take the
vaccination must sign the declination form as required by the Bloodborne Pathogens
Standard. Additional information on the hepatitis B vaccine is provided under the "HBV
Vaccination" section of this manual.
Antibody Test: The hepatitis B antibody (anti-HB) test will be offered one to two
months after the last injection of the vaccine to determine if seroconversion has taken
place (development of antibodies in blood).
25. Bottom
Personal Protective Equipment
Location
Gloves, Non-sterile
Gloves, Sterile
Gloves, Utility
Masks
Protective Eyewear
Protective Gowns
Resuscitation Equipment
THE BASIS FOR SELECTION OF PERSONAL PROTECTIVE EQUIPMENT
Selection of personal protective equipment will depend on the degree of anticipated
exposure and the procedure to be performed. For example, an oral examination may
simply require gloves. However, the use of a rotary instrument (high or low speed),
ultrasonic scaler, or air prophy will require gloves, mask, protective eyewear, and
gowns.
26.
Pocket Masks
Ambu-Bag
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SEPARATE MEDICAL RECORDS FOR EACH EMPLOYEE
(CONFIDENTIAL)
TRAINING RECORDS
• Employee's Name and Social Security Number.
• Employee's Hepatitis B vaccination status including dates of
vaccination.
• Signed statement refusing Hepatitis B Vaccine.
If an exposure incident occurs, the following must be in the medical record.
• Exposure Incident Report.
• A copy of all results, examinations, medical testing, and follow-up
procedures.
Training records should include:
• Dates of the training sessions.
• Summary of the training sessions.
• Names of the person conducting the training.
• Names of all persons attending the training session.
NOTE: These records must be maintained for 3 years.
• A copy of the health care professional's written opinion.
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NOTE: All medical records must be maintained for the duration of employment
plus 30 years.
27. Top
EMPLOYEE MEDICAL RECORD FORM
HEPATITIS B VACCINATION
CONFIDENTIAL
Employee Medical Record Form
Employee name
Employee social security number
History of HBV vaccination
(Date vaccination received or Declination Statement)
Exposure Incidents – Needlestick or Splash of Blood Onto Mucous Membranes
(List Date and Describe What Happened)
Medical Follow-Up Procedures
(Was medical evaluation offered, was it accepted by employee, was employee informed
of blood test results, was hepatitis B vaccine offered and was it accepted)
Medical Records must be maintained for the duration of employment plus 30
years.
28.
WHO: Any employee who has exposure to bloodborne pathogens. Full time, part
time, temporary, and probationary employees.
WHEN: Within 10 working days of initial assignment.
COST: Must be made available at no cost to employees with occupational exposure.
May not use health insurance unless employer pays all costs of insurance.
REFUSAL: Employees may refuse to be vaccinated, but must sign "Informed Refusal
For Hepatitis B Vaccination" form. That form is included in this section.
BOOSTER: The US. Public Health Service guidelines do not currently recommend
"booster" doses. If a "booster" is recommended, it must be provided at no cost.
ANTIBODY TEST: Done to determine if seroconversion has taken place, that is, if
antibodies have developed and the person is now immune to hepatitis B. One to two
months after the last vaccination injection, the hepatitis B antibody test is offered.
RECORDS: Documentation of the Hepatitis B Vaccination should be placed in the
employee's medical record.
PROCEDURES: The procedures to follow for Hepatitis B Vaccination are illustrated on
the following page. This includes refusals and pre-vaccination evaluations.
29.
HEALTHCARE PROFESSIONALS WRITTEN
OPINION FOR HEPATITIS B VACCINATION
Please Return This Form To The Office Of:
Name Of The Employee
Is the hepatitis B vaccine indicated
Was the hepatitis B vaccine received
If so, dates the vaccine was received
Signature Of The Health Care Provider
Date:
30.
31.
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POSTEXPOSURE EVALUATION AND FOLLOW-UP
INFORMED REFUSAL FOR HEPATITIS B VACCINATION
CONFIDENTIAL
WHO
I understand that due to my occupational exposure to blood or
other potentially infectious materials I may be at risk of acquiring hepatitis B virus (HBV)
infection. I have been given the opportunity to be vaccinated with hepatitis B vaccine, at
no charge to myself. However, I decline hepatitis B vaccination at this time. I understand
that by declining this vaccine, I continue to be at risk of acquiring hepatitis B, a serious
disease. If in the future I continue to have occupational exposure to blood or other
potentially infectious materials and I want to be vaccinated with hepatitis B vaccine, I can
receive the vaccination series at no charge to me.
Any employee who has an exposure incident (needlestick or
blood splash on mucous membranes) must be provided a
confidential medical evaluation and follow-up
WHEN: Immediately after the exposure incident, the confidential medical evaluation
and follow-up shall be made available.
PROCEDURES: The procedures to follow are illustrated in the chart on the following
page.
DOCUMENTATION: Documents and information that are to be sent to the Health
Care Professional are listed on the chart on the following page. Documentation to be
returned from the Health Care Professional is also listed.
Signature
Name
Address
City
Date
Witness
State
Zip Code
FORMS:
One form is provided in this section to document the employee's
refusal for medical evaluation and follow-up (Employee Informed Refusal Of
Postexposure Medical Evaluation). Another form is provided to assist in getting the
required information to and from the Health Care Provider.
33.
32.
HEALTHCARE PROFESSIONALS WRITTEN OPINION FOR POSTEXPOSURE EVALUATION
Name Of The Employee
Date Of Exposure
Location of Exposure
Circumstances, description, and route of exposure
Was employee informed of evaluation results
and need for any further follow-up:
Is the hepatitis B vaccine indicated:
Was the hepatitis B vaccine received:
If so, dates the vaccine was received:
Signature Of The Health Care Provider
34.
Date
35.
REFUSAL OF POSTEXPOSURE MEDICAL EVALUATION
Name:
Date:
Job:
Describe Exposure Incidence:
Needlestick Package
On the above date, I had an Exposure Incident and was offered a medical evaluation.
I understand that the Bloodborne Pathogens Standard requires that I be offered a
medical evaluation to determine if I have been exposed to or contracted a bloodborne
disease. However, I have decided to not to go for the medical evaluation for personal
reasons.
Signature
____________________________
36.
37.
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Needlestick Instructions
1. First Aid:
 Wash the needlestick wound.
 For a splash, go to the eyewash station and wash the eyes
until all the material is removed.
2. Report the exposure to the Doctor or Office Manager.
3. Offer the employee a medical evaluation. The employee is
not required to go, but the medical evaluation must be
offered. Take the Needlestick Package. Three blood test
should be run on the employee: HBV, HCV, HIV.
4. Explain to the source patient what has happened and obtain
their permission for blood testing for HBV, HBC and HIV.
Patient can agree or not agree to go for testing.
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Needlestick Instructions
5.
6.
7.
During the medical evaluation, give the form “Health Care
Professionals Written Opinion” to the physician or other
health care staff. Ask them to fill out this form and return it
to your office as this form is required by OSHA.
Ensure that the employee is informed of all blood test
results from both the employee and the source patient.
Ensure that the injured employee receives counseling on
the risk of becoming infected.
After the initial medical evaluation, report any flu-like
illnesses to the health care professional for follow-up.
38. Bottom
HEALTHCARE PROFESSIONALS WRITTEN OPINION FOR POSTEXPOSURE EVALUATION
Name Of The Employee
Date Of Exposure
Location of Exposure
Circumstances, description, and route of exposure
Was employee informed of evaluation results
and need for any further follow-up:
Is the hepatitis B vaccine indicated:
Was the hepatitis B vaccine received:
If so, dates the vaccine was received:
Signature Of The Health Care Provider
Date
39.
Occupational Safety & Health Administration
Regulations (Standards - 29 CFR)
Bloodborne pathogens. - 1910.1030
• Part Number:1910
EXPOSURE INCIDENT EVALUATION
1. Type of exposure and location in Office.
• Part Title: Occupational Safety and Health Standards
• Subpart's• Subpart Title: Toxic and Hazardous Substances
2. Explain the type of device being used and procedure being performed .
• Standard Number:1910.1030
• Title: Bloodborne pathogens.
3. Evaluation of policies, engineering controls, work practices and personal
protective equipment used at the time of the exposure incident.
Only the Post Exposure Evaluation and FollowUp section of the Bloodborne Pathogens
Standard will be included in the Needlestick
Package
4. Comments on how this could be prevented:
42.
40.
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EXPOSURE CONTROL CHECKLIST
Date:
Initials:
PERFORM THE EXPOSURE DETERMINATION.
Identify and document all positions with potential for occupational
exposure.
Perform exposure determinations without regard to the use of personal
protective equipment.
ESTABLISH AN EXPOSURE CONTROL PLAN.
Use the Bloodborne Pathogens Rule to establish a written exposure
control plan.
Specify the schedule of implementation for each of the requirements of
the exposure control plan.
Review and update the exposure control plan yearly or as necessary to
reflect significant changes in tasks or procedures.
Make sure that this exposure control plan is readily available for review
by employees and OSHA inspectors.
HAZARD COMMUNICATION PLAN
MAINTAIN MEDICAL AND TRAINING RECORDS
Establish a medical record for each employee.
Establish training records for each employee.
45.
43.
Changes To Hazard Communication
• Globally Harmonized System developed by
United Nations.
• This GHS is a world wide plan.
• Employees must be trained on this plan by
December 1, 2013.
Hazard Classification
• The definition of hazard has been changed
to provide specific criteria for classification
of health and physical hazards. These
specific criteria will help to ensure that
evaluations of hazardous effects are
consistent across manufacturers.
• This will make labels and safety data sheets
more accurate.
Three Areas of Change In HazCom
•
•
•
•
Hazard Classification
Labels
SDS (use to be MSDS)
Manufacturers are still required to provide a
label with:
1. Name of product or chemical
2. Hazardous warning
3. Manufacturers name and address
Labels
• Chemical manufacturers and importers will
be required to provide a label that includes
a harmonized:
 Signal Word
 Pictogram
 Hazard statement for each hazard class and
category.
14
2/4/2015
Signal Word
• A single word used to indicate the relative
level of severity of hazard and alert the reader
to a potential hazard on the label:
 Danger - used for the more severe hazards.
 Warning - used for less severe hazards
Secondary Labels Used In Your Office
 Can use a copy of original label that came on
container or,
 Color coded labels – as long as the
information supplied on these labels are
consistent with the revised Haz Com Standard,
e.g., no conflicting hazard warnings or
pictograms.
OSHA Secondary Labels
0
0
3
N
Glutaraldehyde
 Skin Irritant
 Eye Irritant
Standard Format Of The
16 Section SDS
• Section 1. Identification
Section 2. Hazard(s) identification
Section 3. Composition/information on ingredients
Section 4. First-Aid measures
Section 5. Fire-fighting measures
Section 6. Accidental release measures
Section 7. Handling and storage
Section 8. Exposure controls/personal protection
Section 9. Physical and chemical properties
Section 10. Stability and reactivity
Section 11. Toxicological information
Section 12. Ecological information
Section 13. Disposal considerations
Section 14. Transport information
Section 15. Regulatory information
Section 16. Other information, including date of preparation.
 Respiratory Irritant
15
2/4/2015
When do we need the new Safety Data Sheets
June 1, 2015
Compliance with all modified provisions of the
final rule.
HAZARD COMMUNICATION PLAN
Replace Your Hazard Communication
Plan and Standard
• Remove the old Hazard Communication Plan
and Standard from your OSHA Manual.
• Take the new Globally Harmonized Hazard
Communication Plan and Standard from your
handouts and place them in your OSHA
Manual.
CONTAINER LABELING:
Primary Container Labels
GENERAL
In order to comply with 29 CFR 1910.1200, the following written Hazard
Communication Plan (HCP) is to be implemented for personnel of this office.
It will be used by ALL personnel. The Safety & Health Manager will be responsible
for ensuring the program is current and enforced.
A copy of this plan is to be made available to an employees upon hiring, and a copy
will be supplied to any employees upon request. The Safety & Health Manager will be
contacted when a copy of the program is needed.
The plan will be updated when new chemicals or hazards are introduced into the
working environment, and reviewed annually.
The Safety & Health Manager will be responsible for all containers of hazardous
chemicals or dental products entering the workplace and will assure that the
chemical containers are properly labeled with:
•
•
•
Product Name
Hazard warnings to include target organ
Name and address of the manufacturer,
importer, or responsible party.
No containers shall be used until they have been checked by the Safety Manager.
46. Bottom
46. Top
OSHA Secondary Containers
Secondary Container Labels
If the chemical or dental product is to be transferred to a separate container,
the Safety & Health Manager will ensure that the new container is properly
labeled; i.e., that all secondary containers are labeled with a reproduced copy
of the original manufacturer's label or with generic labels which have a block
for:
1. Product Name
2. Hazard Warning to include target organ
Containers To Check In Your Office:
 Spray Bottles
 Cold Sterilization Tubs
 Ultrasonic Cleaner
47. Top
16
2/4/2015
OSHA Secondary Labels
SAFETY DATA SHEETS (SDS):
The Safety and Health Manager will be responsible for the following duties;
• Obtaining and Maintaining the SDS system,
• Review incoming data sheets for new and significant health/safety
0
0
information and ENSURE that this new information is given to employees.
3
• Annually review the SDS system for accuracy and completeness.
N
The SDS system shall include:
Glutaraldehyde
 Skin Irritant
•
Current list of all SDS indexed by numerical number which is then placed
on that Safety Data Sheet (SDS).
•
The identity used on the SDS shall be the same as used on the container
label.
•
The chemical and common name of all ingredients determined to present a
hazard shall appear on all SDS.
 Eye Irritant
 Respiratory Irritant
EMPLOYEE TRAINING AND INFORMATION:
47. Bottom
The minimum orientation and training for a new employee is:
1. An overview of the requirements contained in the Hazard
Communication Standard, 29 CFR 1910.1200.
2. Chemicals present in their workplace operations and this office.
3. Location of Hazard Communication Plan and availability.
4. Physical and health effects of the hazardous chemicals listed on the
inventory list of this program.
5. Methods and observation techniques used to determine the
presence or release of hazardous chemicals in the work area.
6. How to lessen or prevent exposure to these hazardous chemicals
through usage of engineering controls, work practices and personal
protective equipment.
7. Steps taken by our office to lessen or prevent exposure to the
chemicals listed on the inventory list.
8. Emergency procedures to follow if exposed to any chemicals.
9. Location of SDS file and location of hazardous inventory list.
Before starting work, the Safety and Health Manager will give go over the Hazard
Communication Plan (HCP) with the new employee and each MSDS applicable to
their job. This instruction will be accomplished with hand-outs an verbal instruction.
The following videos or manuals were used for training:
Before any new chemical or dental product is used, all employees will be informed of
its use, will be instructed on safe use, and will be trained on hazards associated with
the new chemical. All employees will attend additional training, as appropriate, to
review the HCP and MSDS. Appropriate library reference material will also be
discussed during the training sessions.
49. Top
48. Bottom
SAMPLE LIST OF SOME SAFETY DATA SHEETS
INVENTORY LIST OF HAZARDOUS Dental Products:
A list of the hazardous dental products and chemicals used in this
workplace is located in the front of the SDS notebook. Further
information can be obtained from the MSDS attached with this program or
from the Safety and Health Manager.
49. Middle
SDS INDEX #
PRODUCT (TRADE NAME)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Vital Defense S
MARATHON
VISAR-SEAL
LIGHTEN BLEACH
DRY BOND
TENURE KIT
IONOMER LIQUID
ZIONOMER POWDER
PAINT-ON DAM
COE-CIDE XL
LYSOL SPRAY
DYCAL
TRAY PLASTIC LIQUID
RAY PLASTIC POWDER
TOOTH POWDER
Not In The Handout
17
2/4/2015
NON-ROUTINE TASKS:
No non-routine tasks are known to exist at the time of preparation of
this program.
Disposable Plaster Trap
However, if any non-routine task is performed, employees shall be advised
they must contact the Safety & Health Manager for special precautions to
follow and then the Safety & Health Manager shall inform any other
personnel who could be exposed.
In the event such tasks are required, the Safety & Health Manager will
provide the following information about such activity as it relates to the
specific chemicals expected to be encountered:
 Specific chemical names and hazards.
 Personal protective equipment required and safety measures to
be taken.
 Measures that have been taken to lessen the hazards, including
ventilation, respirators, presence of other employees.
49. Bottom
OTHER PERSONNEL EXPOSURE (CONTRACTORS):
It will be the responsibility of the Safety & Health Manager to provide other personnel
or outside contractors with the following information:
•
•
•
•
Hazardous chemicals to which they may be exposed.
Measures to lessen the possibility of exposure.
Location of SDS for all hazardous chemicals.
Procedures to follow if they are exposed.
The Safety & Health Manager will also be responsible for contacting each contractor
before work is started to gather and disseminate any information concerning chemical
hazards the contractor is bringing into the workplace.
50. Bottom
EXPOSURE TO HAZARDOUS MATERIALS
1. Determine hazard from material label.
2. First aid or emergency procedures indicated on SDS.
3. If serious, medical evaluation by physician.
4. Continuous medical re-evaluation if necessary.
CHEMICAL SPILL
1. Determine hazard from material label.
2. Wear appropriate protective clothing (Usually gloves, mask, eye
wear, and gown).
3. Contain and remove chemicals with a chemical spill kit.
4. Place contaminated materials in appropriate containers.
5. Label containers.
6. Notify waste collector as to what chemical is contained.
7. If spill is of a very hazardous nature, call manufacturer.
MERCURY SPILL
1. Open the Mercury Spill Kit.
2. Put on protective clothing (gloves, eyewear, masks).
3. Collect the spilled mercury in the dust pan using the scraper.
4. Place the collected mercury in the amalgam waste container.
5. Use mercury sponges to clean up residual mercury spill.
51.
EXAMPLES OF SECONDARY CONTAINERS REQUIRING LABELING
 X-RAY PROCESSOR TANKS
 DISINFECTING TUBS or COLD STERILE TUBS
 PLASTER & STONE BINS
 SPRAY BOTTLES
 ULTRASONIC CLEANER
 AMALGAM CAPSULES PLACED IN OPERATORIES
 ANY UNLABELED BOTTLES OR CONTAINERS
MAKING YOUR OWN CHEMICAL SPILL KIT
• USE A CONTAINER SUCH AS A PAIL THAT HAS A LABEL
"CHEMICAL SPILL KIT"
• CHEMICAL SPILL INSTRUCTIONS
• UTILITY GLOVES & PROTECTIVE EYE WEAR
• KITTY LITTER
• BAKING SODA
• DUST PAN & WHISK BROOM & SPONGES
52.
CHECKLIST FOR HAZARD COMMUNICATION Plan
Date:
Initials:
The key elements that each employer must implement are a written program,
employee training, and program availability.
1. Have you prepared a written list or inventory of all the hazardous
dental products or chemicals present in the workplace?
2. Are you prepared to update your hazardous chemical list?
3. Do you have up-to-date Material Safety Data Sheets (MSDS) for those
materials on your hazardous chemical lists?
4. Is the list of hazardous chemicals cross-referenced (have an MSDS index
number) so that identifiers on the list refer to the MSDS ?
5. Have you developed a system to ensure that all incoming hazardous
products or chemicals are received with proper labels and MSDS?
6. Do you have procedures in your workplace to ensure proper labeling for
secondary containers that hold hazardous products or chemicals?
53.
18
2/4/2015
Enamel Etchant Dropper Bottles
Calcium Hydroxide Paste
And Dentist Doing Endo
pH is 12.5
Calcium Hydroxide Injury With Loss of Vision
Infection Control
vs
Infection Prevention
Oklahoma Dentist Exposes 7000 Patients To HIV,
Hepatitis B, Hepatitis C
Major Infection Control Failure In
Tulsa, Oklahoma
March 2013
19
2/4/2015
Dr. Scott Harrington
Tulsa, OK
Dr. Scott Harrington
•
•
•
•
Practiced in Tulsa for 35 years
Had 2 offices in the area
Had never had a compliant to State Board
Sued for malpractice twice, both settled out of
court
• When the State Board issued its Compliant, it
called him "a menace to the public health”
Violations
•
•
•
•
•
•
•
Practice was unsafe and unsanitary
Lack of sterilization checks
Committing gross negligence
No display of licenses and certifications
Failure to keep records of drugs
Allowing dental assistants to practice dentistry
Unsanitary dental materials in an unclean
environment
• Open vials of medications
• Expired medications, one expired in 1993
Dr. Harrington Compliant
Dr. Harrington Compliant
20
2/4/2015
Dr. Harrington Compliant
Check out Mailman Vs Cat
Comments From Susan Rodgers On Her
Office Visit
Oklahoma Board Of Dentistry
•
•
•
•
Has 6 employees – state law limit
3 investigators
To Monitor 2200 dentists
Oklahoma law prevents surprise
inspections
• Legislature has said it will not increase
funding for the State Board.
Comments From The Readers Of This
Article
• Unless I missed something, this whole incident will be
blamed on the dental assistants. There is no mention of the
dentist loosing his license, being fined, or jail time. Please
give me a break. Unless some, any or all of this happens,
this dentist will continue to practice in the same way. And,
I believe, the dentist already had settled two malpractice
suits. Let's put the responsibility on the person with the
power to practice independently. Please, I practice dental
hygiene for over 30 years and had to be very, very careful
for whom I worked.
• I had a very sick feeling because I knew what was coming. When the
initial investigators went there, they were physically sick by what they
found. I was literally sick the whole weekend from what I heard.
•
I couldn’t imagine that there was a dentist stupid enough to allow his
dental assistants to do anesthesia. . Let’s be clear about this … dental
assistants can’t insert a needle into a patient in Oklahoma.
• I think we’ll be doing more of a lockdown on dental assistants who are
in the operatory area. You may see dental assistants coming to get
permits before they can be in the operatory.
Comments From Readers
• I have been a registered dental hygienist for over 30 years. I have worked in
dentistry prior to dental school since I was 15, started in co-op. I have
worked for dentists in all aspects of care. I was very shocked to hear this
story .99.9 percent of dental offices go above and beyond to protect our
patients. It only takes one story like this to set off fear in patients. You must
have trust and a good relationship with your caregivers. Be observant and
ask questions about sterilization procedures. We who have the best
standards of care and always welcome any question. The entire office staff
should be prosecuted to the fullest extent of the law. These patient's placed
their full trust in these UNPROFESSIONALS . I will now have to spend weeks
easing the minds of my patient's because of this office.I will pray for the
patient's of this office.Please know as a whole dentistry holds the highest
standards of care for our patients safety and also OSHA safety for our staff.
All autoclaves in a proper practice are spore tested. I am proud of the
sterilization protocol we use, we would NEVER compromise that. This case
is VERY unusual and is not the standard of care.
21
2/4/2015
• I personally feel all staff in that practice needs to be held accountable. There
are no excuses for anyone letting this go for so long, common sense tells you
an instrument contaminated with bodily fluids is DIRTY and can't be used
until cleaned and sterilized!!! Come on!! Don't tell me they didn't know any
better, were not properly trained or ignored hygienic practices.
Free Blood Testing For Patients
• I managed 25 employees including: oral surgeon, periodontist, orthodontist,
general dentist and dental assistants. If I find a dirty instrument or something
not to my standards of clean, it does not get used on a patient!!! Plain and
simple. Reason #1 it's unethical , reason #2 a law suit will closed down the
business and therefore affect 25 families and thousand of our patients.
• In my office I get visits by the dental insurance companies we participate ever
single year, they check spore testing logs, emergency kit, nitrous oxide units,
CPR , credentials of all licensed practitioners and patient records. Maybe all
states need to enforce yearly reviews.
Oklahoma Department of Health
Interim Report
Surrender Of Dr. Harrington’s License
August, 2014
• 4202 Patents tested
• 89 + for HCV, 5 + for HBC, 5 + for HIV
• One event of patient to patient
transmission of HCV
• Genetic testing by CDC confirmed the HCV
transmission
• $710,000 cost to federal & state agencies
Surrender Of Dr. Harrington’s License At
State Board Meeting
Malpractice Lawsuits
• Did not admit to doing anything wrong
• No Penalties and No Fines
• State Board of Dentistry said that the case is
closed.
• Local District Attorney said that there would be
on criminal charges.
22
2/4/2015
Colorado Oral Surgeon May Have
Infected 8000 Patients
Accusations Against Dr. Stein
• Accused of reusing needles and syringes on
patients receiving IV sedation for 12 years
• Needles and syringes were saved and reused on
other patient IV lines.
• Denver Police Dept has an active on-going
investigation for prescription fraud
• Saved unused portions of Vicodin to be used on
other patients
Accusations Against Dr. Stein
• Wrote prescriptions for Vicodin, had patient bring
Vicodin to next appointment, then diverted the
Vicodin to his own use.
• Admitted to long battle with drug dependency and
voluntarily surrendered his license.
• Will be eligible for new license in 2 years
Aftermath of Harrington Incidence
• State Dental Board
• Legislature
Oral Maxillofacial Surgery Assistant
Oklahoma passed
a new law in the 2013 legislative session creating an oral
maxillofacial surgery assistant in Oklahoma. The Oklahoma
Board of Dentistry has not yet defined requirements and
scope of practice for the oral maxillofacial surgery assistant.
• Malpractice Lawsuits
• Will It Happen Again
23
2/4/2015
These Two Cases Are Not The First
Time This Has Happened
• New York ( 2 offices in New York City )
• Nebraska Oncology Clinic –Cluster of 10
Hep C infections. Resulted in 99 patients
infected with Hep C
• Oklahoma Pain Clinic – Cluster of 6 Hep C
infections, CRNA infected 69 HCV and 31
HBV patients.
POSSIBLE EXPOSURE TO HEPATITIS &
HIV: Endoscopy clinic shut down
City serves suspension order, locks center's doors
Mar. 01, 2008 Las Vegas Review-Journal
According to investigators, clinic staff
regularly reused syringes and vials of
medication on multiple patients, a practice
that risked spreading communicable
diseases. Six people who were treated at
the clinic -- five on the same day -- have
been diagnosed with hepatitis C. Up to
40,000 may have been exposed to
Hepatitis and HIV.
Transmission Of HBV, HCV or HIV
From Patient to Patient
Multi-Dose Drug Vials
• Multi-Dose Vials of Drugs
Aseptic Technique For Parenteral
Medications
IV Line With Injection Port
1.
Do not administer
medications from syringe to to
multiple patients. (IA)
2.
Use single dose vials when
possible. (II)
3.
Do not combine leftover
contents of single dose vials
for later use. (IA)
24
2/4/2015
Aseptic Technique For Parenteral Medications
When Multi-dose Vials Are Used
1. Clean the diaphragm with 70% alcohol. (IA)
2. Use a sterile needle to access the multiple-dose vial
and avoid touching the diaphragm. Both needle and
syringe should be sterile. (IA)
3. Keep multi-dose vials away from operatories to
prevent contamination from spray or spatter. (II)
4. Discard vial if sterility is compromised. (IA)
5. Use IV bags and tubing for only one patient. (IB)
How Long Can Virus Survive On A Surface ?
• HIV
• HBV
• HCV
HBV
How Long Can Virus Survive On A Surface ?
• HBV can survive outside the body for
months depending on the conditions
Single Use Disposable Devices
Suction Tips, Saliva Ejectors, Impression Trays Propy Angles and
Cups
• Use single use disposable devices for one
patient only and dispose of them. (IC)
HIV
How Long Can Virus Survive On A Surface ?
• HIV - several weeks under certain conditions
• Which body fluid it is in, volume of the body
fluid, concentration of the virus within it,
temperature, acidity, and exposure to sunlight
• HIV may survive for up to four weeks in syringes
after HIV-infected blood has been drawn up into
the syringe and then flushed out
HCV
How Long Can HCV Survive On A Surface ?
• HCV - Dried spots of blood contaminated with
hepatitis C virus (HCV) can remain infectious for up
to six weeks at normal room temperatures
• Commercially available disinfectants were highly
effective against the HCV-contaminated blood spots.
One minute of exposure to bleach (diluted to a ratio
of 1:10) was 100% effective, whereas Cavicide at a
similar concentration was 94% effective and ethanol
(70%) eliminated HCV in 87% of blood spots
25
2/4/2015
Who is the primary infection control coordinator in
your practice?
Dental Town Poll
Infection Control Practices
60 Offices Responded
Does your staff use a separate internal
processing indicator in each of your sterilization
pouches when processing your instruments?
18% Hygienist
32% Dental assistant
2% Practice manager
20% Dentist
28% There is no designated coordinator
Preparation & Packaging
Use internal chemical indicator in each package. If
cannot be seen from outside, use external indicator.
• 34% Yes
• 66% No
Internal/External Chemical Indicators
Do you perform spore testing on a
regular basis?
• 90% Yes
• 10% No
26
2/4/2015
Monitor Effectiveness of Sterilization Process
• Spore test the sterilizer once a week. Use a
matching control. Spore Test is the only way
to determine if sterilization process is
successful.
• Place a chemical indicator (color change
device) on the inside of each package.
• Monitor each load with mechanical indicators:
Timer
Pressure Gauge
Temperature Gauge
How Long Should You Keep Spore Test Results
• ADA Recommendations - Check your state
regulations.
• CDC Recommendations - retained long enough to
comply with state regulations.
• State Board of Dentistry - Check with OSHA.
• OSHA Requirements - Nothing found on the OSHA
website.
How do you sterilize the majority of your
hand instruments?
Department of State Health Services
Title 25 Texas Administrative Code
Chapter 133
Hospital Licensing Rules
Effective June 21, 2007
• (i) Performance records for all sterilizers
shall be maintained for each cycle.
• These records shall be retained and
available for review for a minimum of five
years.
Preparation & Packaging
•
•
•
•
62%
27%
12%
0%
Disposable Bags/Pouches
Wrapped Cassettes
Unwrapped
Other
Internal & External Chemical Indicators
 Use wrapping compatible with type of sterilization and has
FDA Clearance.
 Before sterilization, inspect instruments for cleanliness and
then wrap or place in containers designed to maintain
sterility.
27
2/4/2015
On average, how much do you think infection
control procedures cost per patient visit? (e.g.,
On average, how much time does your staff spend
turning over a room per patient visit? (including
instrument recycling and environmental asepsis)
gloves, masks, gowns, disinfectants and instrument sterilization)
•
•
•
•
•
28%
40%
20%
8%
3%
$0 - $5
$6 - $10
$11 - $15
$16 - $20
More than $20
 61%
8-10 minutes
• 25%
10-12 minutes
• 10%
• 3%
12-15 minutes
15 minutes or more
How would you rate the compliance with
infection control procedures in your
practice?
How often do you wash your hands?
•
•
•
•
0%
5%
68%
27%
Hygiene exams only
Dental procedures only
Every time I enter a room
As needed during the day
•
•
•
•
•
55%
4%
5%
13%
24%
Time limitations
Material availability
Cost
Inadequate training
Lack of enforcement
Excellent
Very good
Good
Poor
Very Poor
How often do patients ask you about the
infection control procedures used in your
practice?
In your opinion, which of the following is the
prime factor that limits compliance with infection
control procedures in your practice?
•
•
•
•
•
23%
57%
18%
0%
2%
•
•
•
•
0% Once a week
2% More than once a week
8% Several times a month
90% Rarely to never
28
2/4/2015
How do you explain infection control
procedures to your patients?
Do you disinfect your dental unit
waterlines?
• 931 responded to this poll
•
•
•
•
53%
8%
12%
27%
Verbally
Written information sheet
Signs displayed in office
I do not explain it to patients
• 48% Currently disinfect water lines
• 52% Do not
What is reason you do NOT disinfect
the dental unit waterlines ?
•
•
•
•
6%
14%
38%
9%
Cost
Requires too much time
It is not important
Lack of enforcement
29
2/4/2015
Denta Pure
Iodine Impregnated Tube
ICX by Adec
•
•
•
•
•
•
•
Effervescing Tablet
Non corrosive to unit
Silver Nitrate
Sodium percarbonate
Effective for 2 weeks
Continuous use product
No purging water lines at
night
Denta Pure
In-line Iodine Cartridges
Last 40 Working Days
Approximately $70
Sterisil PureTube
Silver Impregnated Tube & Bottle
Lasts One Year
Approximately $340
Water must be soft
and pH below 8 or
use Distilled Water
Sterilix
•
•
•
•
•
•
Ammonium chloride
Corrosive to eyes/skin
Once A Week Use
Overnight Soak
Flush lines next day
Pink Color
Should Scrubs Be Worn In Public
Places
On The Street
Restaurants
30
2/4/2015
Should Scrubs Be Worn In Public Places
Doctors sound off -- loudly -- about wearing scrubs on the street
Dr. David C. Martin may be onto something.
In three Antidote posts last week, he made the case that health care workers should not wear
surgical scrubs out in public and that, if they are seen doing so, they should be confronted.
Scrubs Have Not Been Shown To Be
Involved In Disease Transmission
• Seems to be a hospital related issue
• Dr. Harry Greenspun, chief medical officer at
Dell Services healthcare group.
"Given the choice between focusing on hand
hygiene, an issue that has very clear data
documenting transmission of infectious agents,
and scrubs outside the hospital, a practice that
has not been shown to be involved in disease
transmission, most organizations would focus
on the hands.
TEXAS STATE BOARD OF DENTAL EXAMINERS
Scrubs
• Perception Problem
• Public Relations Problem
CHAPTER 108
PROFESSIONAL CONDUCT
SUBCHAPTER B
SANITATION AND INFECTION CONTROL
Rule 108.20 Purpose
Rules and Regulations
CHAPTER 108
PROFESSIONAL CONDUCT
The purpose of rules contained in this subchapter is to establish proper
sterilization, disinfection, and other infection control procedures in the
practice of dentistry. Failure of a dental health care worker to practice and
maintain these procedures constitutes a significant danger to public health
and safety. Any violation of these rules regarding infection control
in this subchapter and other applicable statutes, rules, or regulations that may
be incorporated by reference herein or that may apply otherwise through
federal or state mandate or regulation shall be considered a failure to
safeguard the public interest and thus shall constitute, at a minimum,
negligence in the performance of dental services and failure to use proper
diligence in the conduct of a dental practice, pursuant to Section 263.002,
Dental Practice Act.
31
2/4/2015
Rule 108.21 Requirements
A person practicing dentistry in the State of Texas must maintain the entire dental
office in a clean and sanitary condition, and such premises shall be maintained
in full compliance with all health requirements of the city or county, or both, in which
such office or premises is located and in conformity with the health laws of the
State of Texas; further, a dentist shall provide restroom facilities for staff and
patients and use properly sterilized instruments and clean supplies.
SOURCE: The provisions of rule 108.21 adopted to be effective February 20,
2001.
Rule 108.23 Definitions
(1) Barrier techniques - the use of protective items against infection-transmission
during any intraoral or invasive procedure to include appropriate gloves for the
procedure performed. This definition shall include protective eye wear and
nasal/oral masks when "splash, spatter, or aerosol" of body fluids is possible or
expected.
(2) Disinfection - the partial elimination of active growth stage bacteria and the
inactivation of some viruses. The potential for infections remains after disinfection,
including infection with M. tuberculosis, hepatitis A virus (HAV) and hepatitis B virus
(HBV). The human immunodeficiency virus (HIV) may also remain active following
disinfection.
(3) Sterilization - a process by which all forms of life within a defined environment
are completely destroyed.
Rule 108.24 Required Sterilization and Disinfection
(a) Sterilization is required for all surgical and other instruments that may be
used intraorally or extraorally, where these instruments may be used invasively or
in contact with or penetration of soft tissue, bone or other hard tissue. Other
nonsurgical instruments, such as plastic instruments, that may come into contact
with tissue must be disinfected with an American Dental Association-registered
solution that is tuberculocidal.
(b) All instruments subject to sterilization must undergo at least one of the
following procedures:
(1)
(2)
(3)
(4)
Steam autoclave
Chemical Vapor
Dry-heat oven
Ethylene oxide
(5) Chemical sterilant (used in dilution amounts and time periods according to
manufacturer's recommendations or accepted OSHA standards). Sterilization
equipment and its adequacy shall be tested and verified in accord with American
Dental Association (ADA) recommendations
Chemical Sterilization
• Glutaraldehydes – 10 Hours
• Sporox – 6 Hours
• How do you keep the instruments sterile after they
come out of the chemicals??
1. Everything they touch must be sterile.
2. Sterile Gloves
3.. Sterile Tongs
4. Sterile Rinse Water
5. Sterile Towels
6. Sterile Trays
Ethylene Oxide Sterilizer
EtO Gas
(c) Following a dental procedure, all instruments and operatory equipment
that may have become contaminated with blood, saliva, or tissue debris must be,
at a minimum, disinfected and preferably sterilized by a CDC or ADAapproved method before utilization again for patient care.
EtO is toxic and a
potent carcinogen.
(d) Prior to sterilization, all instruments must be free of any visible debris
and must be either scrubbed thoroughly with a detergent and water solution or
debrided in an ultrasonic device containing cleaning solution.
Contact Time is 4-8 hrs.
Off Gas Time is 8-12 hrs
(e) Oral prosthetic appliances and devices from a dental laboratory must be
washed with a detergent and water solution, rinsed, disinfected, and rinsed
before the appliance or device is placed into patient's mouth.
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(f) Disposable (non-resterilizable) items, including but not limited to gloves,
needles, intravenous fluids, intravenous administration tubing, intravenous
catheters/needles, and like items, shall not be used in the treatment of more
than one patient.
(g) All items contaminated by body fluids during patient care must be treated as
biohazardous material. Before extracted teeth are returned to a patient or other
party, the teeth must be rendered non-biohazardous. All contaminated singleuse items must be disposed of through established OSHA guidelines for such
disposal. Teeth or tissue fragments to be used for microscopic, testing, or
educational purposes must be sterilized prior to use. Such tissues must be handled
and stored as biohazardous material until sterilization is performed.
(i) When it is necessary to return items (including but not limited to impressions,
bites, working casts, prosthetic appliances or devices) to a dental office from a
dental laboratory which item has been fabricated or repaired, those items that have
been potentially contaminated shall be rendered non-biohazardous. Before return
to the dentist by the dental laboratory or technician, the item must be
rendered non-biohazardous according to established OSHA guidelines.
(h) When it is necessary to send items (including but not limited to impressions,
bites, working casts, prosthetic appliances or devices) to a dental laboratory
for fabrication on repair, those items that are contaminated by body fluids must be
considered biohazardous. Before such items are delivered to the dental
laboratory or technician, they must be rendered non-biohazardous according
to established OSHA guidelines.
Rule 108.25 Dental Health Care Workers
(a) All dental health care workers shall comply with the universal precautions,
as recommended for dentistry by the Centers for Disease Control and required by
THSC, §85.202, et seq,1991, as amended, in the care, handling, and treatment of
patients in the dental office or other setting where dental procedures of any type
may be performed.
(b) All dental health care workers who have exudative lesions or weeping
dermatitis shall refrain from contact with equipment, devices, and appliances
that may be used for or during patient care, where such contact holds potential for
blood or body fluid contamination, and shall refrain from all patient care and
contact until condition(s) resolves unless barrier techniques would prevent
patient contact with the dental health care worker's blood or body fluid.
Updated CDC Recommendations for the
Management of Hepatitis B Virus–Infected HealthCare Providers and Students
• Defining exposure-prone procedures in dentistry and oral
surgery has been particularly difficult. Many intra-oral
procedures (e.g., injection or scaling) occur in a confined
cavity and might lead to injuries to the operator , so some
institutions have considered these procedures to be
exposure-prone. However, no transmission of HBV from a U.S.
dentist to a patient has been reported since 1987, and no
transmission has ever been reported from a dental or medical
student. Thus, Category I Procedures include only major oral
surgery, and do not include the procedures that medical and
dental students or most dentists would be performing or
assisting.
(c) A dental health care worker(s) who knows he/she is infected with HIV
or HBV and who knows he/she is HbeAg positive shall report his/her health
status to an expert review panel, pursuant to provisions of THSC, §85.204, et
seq,1991, as amended. (Texas Health & Safety Code).
(d) A dental health care worker who is infected with HIV or HBV and is
HbeAg positive shall notify a prospective patient of the dental health care
worker's seropositive status and obtain the patient's consent before the
patient undergoes an exposure-prone procedure performed by the notifying
dental health care worker.
(e) All dental health care workers should receive a tuberculin skin test at
least annually.
Category II. All other invasive and
noninvasive procedures
• These and similar procedures are not
included in Category I as they pose low or
no risk for percutaneous injury to a healthcare provider
• dental procedures other than major oral or
maxillofacial surgery;
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(c) A dental health care worker(s) who knows he/she is infected with HIV
or HBV and who knows he/she is HbeAg positive shall report his/her health
status to an expert review panel, pursuant to provisions of THSC, §85.204, et
seq,1991, as amended.
Guidelines for Infection Control In
Dental Health-Care Settings – 2003
December 19, 2003
(d) A dental health care worker who is infected with HIV or HBV and is
HbeAg positive shall notify a prospective patient of the dental health care
worker's seropositive status and obtain the patient's consent before the
patient undergoes an exposure-prone procedure performed by the notifying
dental health care worker.
(e) All dental health care workers should receive a tuberculin skin test at
least annually.
Purpose Of Infection Control Program
Break The Chain Of Infection From
Patient To Patient
Patient To Dental Staff
Dental Staff To Patient
Modes Of Disease Transmission In
Dental Offices
1. Direct contact with infectious lesion
2. Indirect transmission via contaminated
object
3. Bloodborne by splatter of blood, saliva or
nasal secretions onto broken skin or mucosa
4. Airborne by aerosolization of microbes
Infectious Diseases In The Dental Office
• Dental Assistant may come into contact with
a number of infectious diseases in the dental
office.
• These diseases fall into 4 categories
depending on their mode of transmission.
Modes Of Disease Transmission
Examples Of Each Mode
• Airborne - TB, Measles, Chickenpox
Precautions: Do not treat until disease is resolved.
• Bloodborne - Hepatitis & HIV
Precautions: (1) Standard Precautions (2) PPE
(3) Work Practice Controls
• Direct Contact - Herpes
Precautions: Do not treat until disease resolves.
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Herpes Of The Finger
Herpetic Whitlow
Herpes Of The Eye
Ocular Herpes
Hepatitis Viruses
Vaccinations Recommended by CDC
For Dental Staff
Spread By Fecal-Oral
Spread By Blood
Not Occupational Disease
Occupational Disease
 Hepatitis A
 Hepatitis E





Hepatitis B
Hepatitis C
Hepatitis D
Hepatitis F
Hepatitis G
•
•
•
•
•
•
Work Restrictions For Health Care Personnel
No Vaccination For Following Diseases
• HIV or AIDS
• Hepatitis C
• TB or Tuberculosis
Hepatitis B
Flu
Measles
Mumps
Rubella or German Measles
Varicella-Zoster or Chickenpox
Recommended By CDC
•
•
•
•
•
•
•
•
•
•
Conjunctivitis
Diarrhea
Hepatitis A
Herpes (on hands)
Measles
Mumps
Pertussis
Rubella
Staphylococcus aureus
TB
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HCW Works With Pertussis
Morbidity and Mortality Weekly Report
(MMWR)
Notes from the Field: Investigation of Contacts
of a Health Care Worker Who Worked While Ill
with Pertussis — Maryland, August–September
2014
Staphylococcus aureus
Rash, Impetigo, Boil or Skin Abscess
Sterilization & Disinfection
1. Use only FDA cleared devices for sterilization. (IB)
HCW Becomes Ill with Suspected Pertussis
• Consulted a colleague who started tests and
advised against patient contact
• Infected HCW continued to see patients and
met with other hospital personnel
• Exposed 31 patients and 15 HCW
• Patients placed on antibiotics and screened by
public health investigators
• Cause a major disruption in the hospital
Methicillin Resistant Staphylococcus aureus
MRSA – “Flesh Eating Bacteria”
Chemical Vapor Autoclave
or Chemiclave
What Is The Main Advantage
Fry Baby
Barnstead Autoclave
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VapoSteril Solution
Glass Bead Sterilizer
FDA Says Is Not Safe or Effective
Commercial Autoclaves
MidMark Ultraclave
Autoclave Sterilization
1.
2.
3.
4.
• Temperature: 121oC (250oF)
• Pressure: 15 psi
Unwrapped 1320C for 3 minutes
Pouches 1320C for 5 minutes
Handpieces 1320C for 6 minutes
Packs 1210C for 30 minutes
• Cycle Time: 30 minutes
Instrument Classification
Dr. Earle Spaulding
• Critical – will penetrate tissue and come in
contact with bone or blood vessels.
• Semi-Critical – will come in contact with
mucous membranes and non-intact skin.
• Non-Critical – will come in contact with intact
skin.
Preventing Cross-Contamination & Disease
Transmission In The Dental Office
•
•
•
•
Perform Proper Hand Washing
Use Disposable Items Wherever Possible
Unit Dose Concept
Utilize Barrier Techniques and PPE
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Proper Hand Washing
CDC Recommendations
Hand Sanitizers
Alcohol based hand rubs (hand sanitizers) if
the hands are NOT visibly soilded.
If the hands are visibly soiled, use regular soap
OR antimicrobial soap and water.
Recommended wash time is 15 seconds.
Surgery Procedures – wash hands with
antimicrobial soap and water for 2 to 6 min.
Hand Washing
Soap Containers: CDC Recommendations
(1) Use disposable containers OR
(2) Wash and dry containers before refilling.
(3) Do not “top off” containers.
When To Wash Hands
CDC Recommendations
When hands are visibly soiled with blood or
infectious matter.
2. After touching items contaminated by blood, saliva
or respiratory secretions.
3. Before and after treating patients.
4. Before and after glove use.
1.
• Hand washing is the MOST important step in
preventing cross contamination.
Fingernails
Fingernails are the dirtiest part of the hands

Keep fingernails short with smooth edges for (1)
thorough cleaning and (2) prevent glove tears.
 Use of artificial fingernails is usually not
recommended
 Do not wear hand or nail jewelry IF it makes
donning gloves difficult or compromises fit or
integrity of glove.
Use Of Disposable Items
• Use disposable items whenever possible to
prevent cross-contamination.
• Disposable items include:
Gloves
Saliva Ejector
High Volume Suction Tips
Prophy Angles & Propy Cups
Air-Water Syringe Tips
Impression Trays
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Disposable Items
Unit Dose Concept
Cannot be reliably cleaned
• State Board Rules state that disposable items
shall not be used in the treatment of more
than one patient.
• CDC recommends that disposable items not
be used in the treatment of more than one
patient.
Utilize Barrier Techniques and PPE To
Prevent Cross-Contamination
• Barrier techniques include plastic wrap, impervious
paper and aluminum foil.
• These can be placed over work surfaces and difficult to
clean items such as electrical switches.
• Work surfaces that can be barrier wrapped include
light switches, light handle, air water syringe, bracket
table, x-ray equipment and any surface that is touched
or comes in contact with contaminated items.
Changing Surgical Masks
CDC Recommendations
•
•
•
•
Dispensing the amount of material needed for a given procedure.
Done before the patient procedure.
Excess is discarded.
Examples: cotton balls, cotton rolls, 2x2s, waxes, compound,
Vaseline, cements.
• Unit dosing prevents cross contamination of cabinets and
drawers.
• To get supplies out of cabinet: (1) Remove gloves or (2) Use overgloves over latex gloves.
PPE Can Be Use To Prevent CrossContamination and Disease Transmission
• Gloves – Should Be Changed After Each Patient
• Masks – When To Change
1. Between Patients
2. When Wet
3. Splashed With Blood
• Eyewear – Face Shield or Glasses
1. Wash Between Patients
• Protective Gowns
1. Change if splattered with blood.
2. Long sleeves
3. Disposable or reusable cotton or cotton polyester
SARS Or Flu Epidemic
• Change between patients.
• Change when wet.
• Change when contaminated
with blood.
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N-95 Masks
N-95 Masks
• N – means normal air
with no oil in the air.
• 95 – means that it will
filter 95% of the
particles down to .3
microns.
Protective Eyewear
•
•
•
•
Safety Glasses
Goggles
Face Shields
Prescription glasses with side shields
Performing Disinfection Procedures
1. Select appropriate PPE.
2. Select, prepare and use chemical agents
following manufacturers instructions.
3. Prepare surfaces for disinfection.
4. After treating the patient, disinfect:
Utility Gloves – When To Use
CDC Recommendations
• Decontaminating the operatory
• Cleaning instruments
• Handling chemicals such as disinfectants
Selecting PPE For Disinfection Procedures
CDC Recommendations
 Wear the complete ensemble to include
gloves, mask, eyewear, and gown.
 Use puncture resistant utility gloves.
Treatment room
Darkroom
Instrument Processing Area
All associated equipment
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Select And Prepare Chemical
Disinfectants
Follow the manufacturer’s instructions for
correct use of disinfecting products.
 If using bleach, must be mixed daily.
Do not use Chemical Sterilants (such as
glutaraldehydes) on surfaces.
Chemicals That Can Be Used
Disinfectants For Surfaces
Chlorine, phenols and iodophors
Alcohol should not be used.
Glutaraldehydes should not be use.
EPA or Environmental Protection Agency is
the agency that registers disinfectants in the
USA. Your disinfectant should have an EPA
Number on the label.
Prepare Surfaces For Disinfection
Clinical Contact Surfaces
Light Switch, Light Handle, Bracket Table, Mobile Cabinet
CDC Recommendations
Use an EPA registered hospital disinfectant
* Low level activity (HBV and HIV claims)
* Intermediate level activity (TB claim)
Use Intermediate Level disinfectant if visibly
contaminated with blood.
Housekeeping Surfaces
Floors, Walls & Sinks
CDC Recommendations
Soap and Water
OR
EPA Registered Hospital Disinfectant
Clean blinds and window curtains in patient
care areas when visibly dusty or soiled.
Disinfecting Items Going To Lab
Short Contact Time Disinfectants
Surfaces must be clean before disinfecting.
Any debris may protect microorganisms from
the disinfectant.
Surfaces may be cleaned and disinfected
with a “Spray-Wipe- Spray” procedure. The
disinfectant is sprayed on the surface and
then wiped off as a cleaning procedure. Then
the disinfectant is again sprayed and left for
the contact time listed on the label.
1 Minute Contact Time
1 Minute Contact Time
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Short Contact Time Disinfectants
One Minute Contact Time
DisCide Ultra
CaviCide 1
One Minute Contact Time
Performing Sterilization Procedures
Properly Prepare Instruments For
Sterilization
1. Select appropriate PPE
Wear the complete ensemble of PPE
Wear utility gloves when cleaning instruments
2. Prepare dental instruments for sterilization
3. Apply appropriate method for sterilization of
dental instruments and equipment.
4. Label and store all instruments properly
5. Monitor effectiveness of sterilization process
Miele Instrument Washer
• Clean all blood or debris from instruments
State Board Rules require all visible debris removed before sterilizing
• Use Ultrasonic Cleaner OR Instrument Washer
• If Hand Scrubbing, use long handle brush
Long Handle Scrub Brush
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Ultrasonic Cleaner
Bubble Cleaning Action
Ultrasonic Cleaner Test
Ultrasonic Cleaner Test
Apply Appropriate Sterilization Method
CDC Recommendations
• Heat sterilize all Critical and Semi-critical
instruments.
 Autoclave
 Chemiclave
 Dry Heat Sterilizer
• Heat sensitive items (plastic instruments) can be
processed with high level disinfectant or chemical sterilant.
Label & Store Instruments Properly
• Wrap instruments or place in containers
designed to maintain sterility (cassettes or
trays)
• Place sterilization date on wraps or containers.
In event of sterilizer failure, packs can be resterilized.
• Store in covered or closed cabinets
• Do not store under a sink
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Sterilization of Unwrapped Instruments
Sterilization of Unwrapped Instruments
• Semi-critical instruments that will used
 Do not sterilize implants unwrapped.
 Do not store critical instruments unwrapped.
•
immediately can be sterilized unwrapped
provided that they are handled aseptically.
Critical instruments for immediate use can
be sterilized unwrapped if maintained sterile
(transported in a sterile covered container)
Dental Handpieces & Other Devices
Attached To Air & Waterlines
Turbines Sent In
For Repair
1. Clean & heat sterilize handpieces and other
waterline instruments between patients.
2. Do NOT surface disinfect, use chemical
sterilants or ethylene oxide on handpieces.
3. Any device attached to the waterlines should
be flushed for 20 to 30 seconds.
4. Do NOT tell patients to close their lips tightly
around the tip of the saliva ejector.
Identify Conditions For Potential CrossContamination
Computer Keyboard Contamination
• Bare hands touching contaminated instruments or
equipment.
• Removing bulk items (cotton rolls) with
contaminated gloves.
• Taking contaminated oral prosthesis into the dental
lab without disinfection.
• While working in the instrument processing area,
going from the dirty side to the clean side with
contaminated PPE.
• Touching paper records with contaminated gloves.
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Bacterial Contamination Of Keyboards: Impact
Of Disinfectants
Bill Rutala et al
• Several studies show bacterial contamination.
• Keyboards have more microorganisms than toilet
seats.
• This study found Staphylococci, Diptheroids,
Micrococcus, and Bacillus on keyboards.
• Keyboards were contaminated with 3 organisms.
• Keyboards were treated with 6 disinfectants: alcohol,
phenol, chlorine and quaternary ammonium. Also
sterile water.
Bacterial Contamination Of Keyboards: Impact
Of Disinfectants
Bill Rutala et al
• All disinfectants, as well as the sterile water control,
were effective at removing or inactivating more than
95% of the test bacteria.
• No functional or cosmetic damage to the computer
keyboards was observed after 300 disinfection
cycles.
Covering With Plastic Wrap
Disinfecting The Keyboard
Keyboard Skins
Washable Keyboards
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Practicon Dental
www.practicon.com
Indestructible Keyboard
OSAP
National Infection Control Organization
• Questions to ask your dentist about their
infection control procedures.
• What should a patient look for in a dental
office for assurance that the dentist and staff
are taking proper precautions to prevent cross
infection.
Utilize And Maintain A Quality Assurance
Program For Infection Control
• Develop a written Infection Control Manual.
• As part of this manual, develop a checklist of
the Infection Control Procedures discussed in
this lecture.
• At least once a year, review the checklist to
ensure these procedures are being done
correctly in your office.
5 Questions For Patient To Ask
1. Do you heat-sterilize all your instruments, including
handpieces ("dental drills"), between patients?
2. How do you know that the sterilizer is working properly?
3. Do you change your gloves for every patient?
4. Do you disinfect the surfaces in the operatory between
patients?
5. If you are unclear on or uncomfortable with the
precautions your dental practice takes to protect you
during treatment, talk to your dentist or dental team
member about your concerns and ask to see the office's
instrument processing area.
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