OSHA and Infection Control Compliance: Checklists and Resources

Transcription

1 OSHA and Infection Control Compliance: Checklists and Resources A single incident can put the health and welfare of your employees, students and/or patients at risk; therefore, safety MUST be a priority in every healthcare environment. While infection prevention may seem an overwhelming task, there are resources available to help you walk this important path. This session will provide a review of applicable regulations and the CDC recommendations for dental settings, as well as tools that can assist with overall compliance. Karen Gregory, RN 2016 CADAT Annual Conference Manhattan Beach Marriott Saturday, April 23, 2016

2 Disclaimer OSHA and Infection Control Compliance: Checklists and Resources Karen Gregory, RN Total Medical Compliance Sponsored by: OSAP Karen Gregory is an employee of Total Medical Compliance, serves on the OSAP Board of Directors, a Hu Friedy Key Opinion Leader, and a presenter for SciCan. No commercial support has been provided for this activity. Any reference to a commercial product is for example purposes only and does not reflect endorsement. Learning Outcomes Why Is IC Important in Dentistry? The Three P s Explain the basic safety concepts outlined in the Bloodborne Pathogen Rule. Describe what changes are required by alignment of the Hazard Communication Standard with the Globally Harmonized System of Classification (GHS). Recall four critical (4) steps in instrument processing. Identify resources to assist with creating a safe environment. Potential exposure to pathogens for both patients and healthcare workers Potential exposure to blood, oral and respiratory secretions and contaminated surfaces/equipment Proper procedures can prevent transmission of infection to patients and workers Worker Awareness Worker awareness, Instrument processing, Surface decontamination Care CAN Be Delivered Safely Safety Culture Standards policies and procedures Orientation Training OSHA and infection control Competency Demonstration High Risk Areas Surface disinfection Instrument processing Worker exposure/health issues 1

3 Infectious Hazards Chemical Hazards Hep B, C, HIV o HIV More than 1 million people are living with HIV. o Hepatitis B Over 1 million people living with chronic HBV infection. o Hepatitis C Over 3 million people living with chronic HCV infection. Herpes Staph, MRSA Chicken pox, measles, mumps Influenza, colds, enterovirus D 68 TB Disinfectants Surface High level Sterilants Dental procedure materials Bleach Chloform Amalgam Physical Hazards Electrical Fire Cuts Falls Burns Flying objects Exposure to ionizing radiation Processing and exposure to saliva Worker Safety Prevention is the Key Bloodborne Pathogen Standard 1991 Potential Routes of Transmission of BBP Enacted to protect employees from exposure to HIV, hepatitis B, and hepatitis C Specifically defines what employers must do to protect employees through job functions Must have written plan in place to outline safeguards A copy of the Bloodborne Pathogen Rule must be available during training If asked, you must provide a written copy of the Exposure Control Plan to employees Patient DHCP Patient DHCP Patient Patient 2

4 Reasons for Standard Precautions HIV May have flu like symptoms or none at all People with HIV infection are often affected by viral hepatitis Risk of infection if exposed by needlestick is.3% Hepatitis B May have fever, joint pain, nausea, vomiting, weakness times more infectious than HIV Best protection? Vaccination Hepatitis C May have fever, joint pain, nausea, vomiting, weakness Estimated that 3.2 million people living in the US with chronic HCV infection, most not knowing they are ill 75 85% of people will move to chronic infection Hepatitis B Vaccination Hepatitis B vaccination made available to employees who are occupationally exposed: Free of charge at a reasonable time and place After training and within 10 working days of initial assignment Anti HBs testing should be performed 1 2 months last dose of the vaccine series Proof of series or declination on file Exception: Employee has been vaccinated Antibody testing reveals immunity Five Measures to Protect Against Exposure Exposure Determination Standard Precautions Everyone has the potential to spread infection Use of PPE Masks, face shields, goggles, gloves, gowns Engineering Controls Pieces of equipment to reduce the likelihood of exposure Work Practice Controls Employee behaviors to protect against exposure to blood or body fluid Surface/instrument decontamination Reduce the likelihood of patient to patient transfer of disease List of job classifications in which all or some employees have occupational exposure. List of all tasks and/or procedures in which occupational exposure occur. Exposure determination made without regard to the use of PPE. PPE Personal Protective Equipment Masks Use based on task being performed Employer must ensure proper utilization of PPE Must be accessible, properly cleaned, laundered, repaired, and disposed of at no cost to employees Removed when leaving area or upon contamination Required when contamination of mucous membranes with body fluids may occur through splashes or aerosolization Change between patients and if becomes moist during a procedure May use in combination with a face shield or eye protection Are people appropriately utilizing PPE? 3

5 Eye Protection Gowns Safety glasses Prescription glasses, but must be equipped with solid side shields Face shield Must be used in combination with mask to protect the nose and mouth Clean after use Clean and disinfect if visibly soiled Reusable or disposable gowns, lab coats when clothing or uniform is likely to be soiled with blood or OPIM Change gowns at least daily or as soon as it becomes moist or visibly soiled Remove barrier protection before leaving patient care areas Employer must launder contaminated protective clothing Gloves Heavy Duty Utility Gloves Expected contact with blood, salvia, or mucous membranes Utilized for all pre clinical, clinical, post clinical, and lab procedures When touching contaminated surfaces Remove after patient care and if torn New pair for EACH patient. Cannot be washed for reuse Handling contaminated sharp items: during post procedure clean up in sterilization area when handling/using hazardous chemicals Puncture and chemical resistant, sizable May wash or surface disinfect Some gloves can be sterilized Discard when cracked, peeling, torn, punctured or when ability to protect is compromised Needlestick Safety and Prevention Act Engineering Controls Safety devices to be evaluated by the employees utilizing the devices If using safety devices always activate the safety mechanism Feedback or work practice controls Blade Remover Safety Aspirating Syringe Cassettes Safety Scalpel Recapping Device Sharps Container 4

6 Work Practice Controls Identify These Work Practices Controls Alter the way a task is performed Based on employee behavior instead of equipment One handed recapping of needles Only pass needles which are recapped Placing contaminated sharps immediately or as soon as possible in a sharps container Do not reach by hand into container of contaminated sharps No eating, drinking, applying lipstick or contact lenses in areas where there is likelihood of exposure to blood or body fluids Safe transport of sharps Eliminate reaching into a container of sharps Employee Training BBP Medical Record No cost to the employee and during work hours At the time of initial assignment to tasks where exposure may occur and annually thereafter Annual training within one year of previous training Within 90 days after the effective date of any change in a standard An opportunity for interactive questions and answers Employees at risk of exposure includes name, social security number HBV vaccination status Copy of results of examinations, medical testing, follow up procedures. Employer s copy of healthcare professional s written opinion Copy of information provided to healthcare provider after exposure All incident reports Retained for duration of employment plus 30 years. If records requested provide a copy: To the employee or anyone with the employee s written consent Director of NIOSH or HHS and/or Assistant Secretary of Labor Hazard Communication and GHS Hazard Communication and GHS This is the Year for GHS Globally Harmonized System of Classification and Labeling (GHS) Collection of best practices by the United Nations Communicating severity of hazards of chemicals consistently Classification Type of risk associated with use/exposure Labeling Include pictograms, signal words, hazard statement Safety Data Sheets Specified 16 section format Final compliance date June 1,

7 GHS Manufacturer s Labels Symbols Pictograms: Convey health and physical hazard information Signal Words: "Danger" or "Warning. Only one signal word on a label Hazard Statements: Describes the nature of the hazard Precautionary Statements: Measures to minimize or prevent adverse effects First aid measures ToxiFlam (Contains: XYZ) Danger! Signal Word Toxic If Swallowed, Flammable Liquid and Vapor Do not eat, drink or use tobacco when using this product. Wash hands thoroughly after handling. Keep container tightly closed. Away from heat/sparks/open flame. No smoking. Wear protective gloves and eye/face protection. Ground container and receiving equipment. Use explosion-proof electrical equipment. Take precautionary measures against static discharge. Use only non-sparking tools. Store in cool/well-ventilated place. IF SWALLOWED: Immediately call a POISON CONTROL CENTER or doctor/physician. Rinse mouth. In case of fire, use water fog, dry chemical, CO 2, or "alcohol" foam. See Material Safety Data Sheet for further details regarding safe use of this product. MyCompany, MyStreet, MyTown NJ 00000, Tel: Safety Data Sheet Review Compliance Date June 1, 2016 Section 2 Hazard Identification Section 4 First aid measures Section 6 Spill clean up Section 8 Personal protection Review the current status of MSDS and SDS sheets Reach out to vendors/manufacturers to obtain SDS, but not required Review the current inventory, consider elimination of any products no longer used Educate supply personnel to retain any SDS received Manufacturers are only required to provide the SDS with the first shipment or first shipment if changes to the document Review new SDS for any change in hazards associated with the use and educate staff An Exposure Has Occurred Items to Consider Who will mange the post exposure process Employee Health Occupational Medicine Emergency Departments/Urgent Care Difficulty in locating a care partner Worker s Compensation provider Local dental societies Establish the relationship in advance Payment of services Wait times to be evaluated Rapid HIV testing for source patient Availability of post exposure medication Current with most recent guidance on bloodborne exposures 6

8 What Are the Next Steps? Incident Evaluation Clean and flush Wash with soap and water for sharps injury to the skin Where is the closest eyewash for a splash to the face? Report Who is the person to respond to these reports? Employees will be offered medical evaluation which may include baseline testing, and counseling Source patient tested for Hepatitis B and C, and HIV Type and amount of body substance involved Type of exposure percutaneous, mucous membrane, intact/non intact skin, bites resulting in blood exposure Infection status of the source Susceptibility of the exposed person Source Patient Exposed Worker Obtain patient consent based on state law Obtain testing if disease status is unknown HIV Antibody Rapid HIV test must be used if available If rapid HIV is not available, expedite the HIV test Hepatitis B Surface Antigen (HBsAG) Source patient testing is not indicated if exposed worker has documented serologic evidence of hepatitis B immunity Anti Hepatitis C virus (Anti HCV) Obtain consent or declination for medical evaluation and counseling If employee declines HIV testing, offer the option to draw and hold blood for 90 days If source patient test results are negative for infection, no further testing of employee will be indicated Testing Environmental Infection Control Medical evaluation and counseling Conduct baseline testing of employee for all exposures: HIV Antibody Hepatitis B Surface Antigen (HBsAG) Testing of employee not indicated, if documented titer indicates immunity to hepatitis B. Anti Hepatitis C Virus (Anti HCV) Or test only if source patient testing indicates disease or an unknown exposure event Dependent on source patient test results additional testing for worker may occur for up to a 6 (six) month window. Must maintain a clean and sanitary workplace Clinical Contact Surfaces High potential for direct contamination from spray or spatter or by touch Housekeeping surfaces Limited risk of disease transmission Clean on a routine basis 7

9 Written Cleaning Schedule Cleaning and decontamination. Location within the facility. Type of surface to be cleaned. Type of soil present. Tasks or procedures being performed. May use barriers. Surfaces must be appropriately disinfected after completion of procedures with splash or splatter blood or OPIM. Housekeeping Surfaces CDC Cleaning Housekeeping Surfaces Include housekeeping surfaces on cleaning schedule. Cal/EPA registered detergent disinfectant prepared fresh each day. Mops and cloths cleaned after use, allow to dry or use disposables. Consider break area and other non patient care areas. Clinical Contact Surfaces CDC Clean or Use Barriers Tips on Barrier Use Risk of transmitting infections greater than for housekeeping surfaces Surface barriers can be used and changed between patients OR Clean then disinfect using an Cal/EPA registered low (HIV/HBV claim) or when visibly soiled an intermediate level (tuberculocidal claim) hospital disinfectant Clean surfaces Beginning of day End of day Barrier compromised Fluid proof If using plastic wrap must meet FDA weight for food wrap Best to utilize commercial barriers Consider: Saliva ejector holder Light switches Light handles Air water syringe handle CDC 8

10 Disinfection Levels Surface Disinfection Review High inactivates vegetative bacteria, mycobacteria, fungi, and viruses but not necessarily high numbers of bacterial spores Intermediate destroys vegetative bacteria, most fungi, and most viruses; inactivates Mycobacterium tuberculosis Low destroys most vegetative bacteria, some fungi, and some viruses. Does not inactivate Mycobacterium tuberculosis Surface disinfectant contact time? Follow manufacturer s instructions for use Don t forget handpiece cradles, light switches, door handles Use PPE Based on exposure potential Utilize Two Step Method Cal/EPA registered Hospital Disinfectant Engineering Controls Safety Devices Sharps Safety Devices or equipment controls that eliminate, isolate or remove the bloodborne pathogens hazard from the workplace. Safety devices are required by the Needlestick Safety and Prevention Act. Comprehensive program of devices to reduce the likelihood of a sharps exposure. If needed, only pass needles which have been recapped Use needle re capper or one handed scoop method to recap used needles Dispose of non reusable sharps immediately in the area of use Remove burs immediately once no longer needed Sharps Safety Hand Hygiene Avoid cleaning instruments chairside by hand or by wiping on the patient s bib Utilize cotton rolls taped together for cleaning Purchase commercial product to avoid hand cleaning of instrument Grasps instruments by handle as opposed to sharp end Use great care when handling double ended instruments Only pass instruments one at a time Transport contaminated reusable sharps appropriately Hands most common means to spread pathogens Increased use of gloves increased the need for handhygiene Possibility of cross contamination during removal or through breaks in glove material. 9

11 Exudative Lesions or Dermatitis Disinfection and Sterilization If lesions on hands/wrists the DHCP must refrain from: Handling patient care equipment Handling devices used for invasive procedures All direct care activities likely to have contact with lesion How to Proceed Questions to Ask State law Must post California Dental Board IC regulations Manufacturer s validated instructions for use CDC Spaulding System Policies and procedures Is there an appointed individual to oversee all infection control standards? Can you locate the manufacturer s validated instructions for use on all equipment, including instruments utilized? Are written policies in place for instrument cleaning, disinfection, sterilization? Have workers been trained? Is there written proof of workers competency and training? Disinfection and Sterilization EH Spaulding Critical Instruments How an object is processed depends on the object s intended use. CRITICAL objects which enter normally sterile tissue or the vascular system or through which blood flows should be sterile. SEMI CRITICAL objects that touch mucous membranes or skin that is not intact require a disinfection process (high level disinfection HLD) that kills most microorganisms except for high numbers of bacterial spores. NONCRITICAL objects that touch only intact skin require low level disinfection. Penetrate mucous membranes or contact bone, the bloodstream, or other normally sterile tissues (of the mouth) Heat sterilize between uses or use sterile single use, disposable devices Examples include surgical instruments, scalpel blades, periodontal scalers, and surgical dental burs 10

12 Semi critical Instruments Noncritical Instruments and Devices Contact mucous membranes but do not penetrate soft tissue Heat sterilize or high level disinfect Examples: Dental mouth mirrors, amalgam condensers, and dental handpieces Contact intact skin Clean and disinfect using a low to intermediate level disinfectant Examples: X ray heads, facebows, pulse oximeter, blood pressure cuff Guidelines for Infection Control in Dental Health Care Settings 2003 Dental Handpieces and Other Devices Attached to Air and Waterlines Use only FDA cleared medical devices for sterilization and follow the manufacturer's instructions for correct use. Clean and heat sterilize critical dental instruments before each use. Clean and heat sterilize semi critical items before each use. Use of heat stable semi critical alternatives is encouraged. Reprocess heat sensitive critical and semi critical instruments by using FDA cleared sterilant/high level disinfectants or an FDAcleared low temperature sterilization method (e.g., ethylene oxide). Clean and heat sterilize handpieces and other intraoral instruments that can be removed from the air and waterlines of dental units between patients. Follow the manufacturer's instructions for cleaning, lubrication, and sterilization of handpieces and other intraoral instruments. Do not surface disinfect, use liquid chemical sterilants, or ethylene oxide on handpieces and other intraoral instruments that can be removed from the air and waterlines of dental units. Dental Board Specifics Steps in the Process All high speed dental hand pieces, low speed hand pieces, rotary components and dental unit attachments such as reusable air/water syringe tips and ultrasonic scaler tips, shall be packaged, labeled and heatsterilized in a manner consistent with the same sterilization practices as a semi critical item. Cleaning Packaging Sterilization or disinfection Monitoring Physical Chemical Biological Storage 11

13 Divide and Conquer Establish the flow in the instrument processing area Receiving, cleaning, and decontamination Preparation and packaging Sterilization Storage Must utilize PPE Limit hand washing of instruments Ultrasonic cleaner Equipment must be cleared by the FDA Rinse and DRY instruments prior to packaging Cleaning First Step Courtesy of Andrea Cook Preparation and Packaging CDC Guidance Sterilization Use an internal chemical indicator in each package. If the internal indicator cannot be seen from outside the package, also use an external indicator. Use a container system or wrapping compatible with the type of sterilization process used and that has received FDA clearance. Elimination /destruction of all forms of microbial life Heat Based Steam under pressure (autoclaving) Gravity displacement Pre vacuum Dry heat Unsaturated chemical vapor Chemical Steam Sterilization Steam Sterilizers Advantages Non toxic Cycle easy to control and monitor Inexpensive Rapidly microbicidal Least affected by organic/inorganic soils Rapid cycle time Penetrates medical packing, device lumens Disadvantages Potential for burns Inappropriate for heat or moisture sensitive instruments Dulling Rusting Loading Allow for circulation Dry non porous containers must be positioned so that water will run out Non perforated trays on edge All peel packs on edge All instruments open Maintain dedicated loads 12

14 Packaging Package Labeling Peel packs limit number of instruments/weight Rigid containers Self seal roll stock Sterile wraps woven and non woven Compatible with sterilization method Must be FDA cleared Date Sterilizer number if more than one unit Load number Record on plastic side of peel pouches or on sterilization tape Ink that does not run 3/31/2016 Dry Heat Sterilization Storage of Sterile Items Transfers heat energy from air inside the oven to the instruments Good for items that are likely to dull or rust in the autoclave, Good for powders, cellulose and ink Packaging must be able to withstand high temperatures Utilize internal and external indicators Ensure proper spore testing is performed Well ventilated to protect against dust and moisture. Consistent temperature and humidity. Packaging should include load number, sterilization date, and expiration date if indicated. Packages should not be stored resting on top of each other. Storage of Sterile Items Chemical Disinfectants/Sterilant Event related shelf life recognizes that the product remains sterile until an event causes it to become contaminated (e.g. moisture). Time related Remains sterile for an assigned period of time based on packaging type. Packages should be evaluated before use for loss of integrity. Repack and reprocess if compromised. Use of heat stable semi critical alternatives is encouraged. Reprocess heat sensitive critical and semi critical instruments by using FDA cleared sterilant/highlevel disinfectants or an FDAcleared low temperature sterilization method (e.g., ethylene oxide). 13

15 Chemical Disinfectants/Sterilant Sterilization Monitoring Prepare solution according to manufacturer s instructions and record expiration date Clean Rinse and dry Soak for appointed time Remove and rinse Test strip solution each day of use according to manufacturer s instructions Physical cycle time, temperature, pressure Chemical heat or chemical sensitive inks that change color when germicidal related parameters reached Biological Bacillus spores that directly measure sterilization Types of Indicators AAMI Class 1 process indicator Class 2 Bowie Dick (dynamic air removal only) Class 3 Single variable Class 4 Multi variable Class 5 Integrating indicator Class 6 Emulating indicator load specific Chemical Indicators Biological Monitors External indicator Provides visual of sterilization process Internal Chemical Indicator Visual sterilant penetrated the pack or tray Pack control monitor packages in multiple locations Detect local problem Perform weekly and with implants Types: Steam Geobacillus stearothermophilus Dry heat B. atrophaeus (formerly B. subtillis) ETO B. atrophaeus APIC Disinfection/Sterilization2005. WA Rutala 14

16 Positive Spore Test Positive Spore Test Following a single positive biological indicator: Remove the sterilizer from service and review sterilization procedures (e.g., work practices and use of mechanical and chemical indicators) to determine whether operator error could be responsible. Retest the sterilizer by using biological, mechanical, and chemical indicators. Repeat spore test is negative, put the sterilizer back in service Positive If REPEAT test positive: Do not use the sterilizer until it has been inspected or repaired or the exact reason for the positive test has been determined. Recall, to the extent possible, and reprocess all items processed since the last negative spore test. Before placing the sterilizer back in service, re challenge the sterilizer with biological indicator tests in three consecutive empty chamber sterilization cycles after the cause of the sterilizer failure has been determined and corrected. Maintain sterilization records (physical, chemical and biological) A NEVER Event Dental Laboratory Ensure instruments are safe for use: Packaging is intact sealed appropriately. External indicator has changed color. Internal indicator has changed color. Instruments show no visible evidence of contamination. Communication protocols and responsibilities. Clean or dirty lab area on site? Materials, impressions, and intra oral appliances must be cleaned and disinfected before being handled, adjusted or sent to out to dental lab. Select and follow manufacturers directions for proper chemical based on type of dental material in use. Dental Laboratory Dental Unit Water Lines Splash shields and equipment guards used on dental laboratory lathes Fresh pumice and a sterilized or new rag wheel used for each patient Devices used to polish, trim, or adjust contaminated intraoral devices must be disinfected or sterilized, properly packaged or wrapped and labeled If packaging is compromised, re clean the instruments, re package, and re sterilize Store sterilized items to prevent contamination For routine dental care, the ADA and the CDC recommend using water that meets EPA standards for drinking water (i.e., <500 CFU/mL of heterotrophic water bacteria) Consult with the dental unit manufacturer for appropriate methods and equipment to maintain dental water quality Follow recommendations for monitoring water quality provided by the unit manufacturer or waterline treatment product 15

17 Why the Concern? Possible Solutions Small diameter of dental waterline tubing, design and flow rate, enable bacteria and other microorganisms to form a biofilm. Coats lining of tubing and may slough off resulting in contamination of the water. 82 year old otherwise healthy woman who developed Legionnaire's disease after a dental visit. Treatment of dental unit waterlines At the beginning of each workday Purge dental unit lines and devices with air or flushed with water for at least two (2) minutes prior to attaching handpieces, scalers, air water syringe tips, or other devices. Flush dental unit lines and devices between each patient for a minimum of twenty (20) seconds Single Use (Disposable) Devices Single Use Items Intended for use on one patient during a single procedure Solutions/medications typically do not have preservatives Usually not heat tolerant Cannot be reliably cleaned Examples: Syringe needles, prophylaxis cups, and plastic orthodontic brackets FDA Law prevents reuse of labeled single use patient products or devices Dispose Appropriately Practicing in the Real World Regulated Waste means waste that is any of the following: (1) Liquid or semi liquid blood or OPIM; (2) Contaminated items that: (A) Contain liquid or semi liquid blood, or are caked with dried blood or OPIM; and (B) Are capable of releasing these materials when handled or compressed. (3) Contaminated sharps. (4) Pathological and microbiological wastes containing blood or OPIM. (5) Regulated Waste includes medical waste regulated by Health and Safety Code Sections through Continuing education New kid on the block We didn t learn that in school! 16

18 Dental Laboratory Radiology Clean impression with a camel hair brush. Disinfect for proper period of time must stay wet for label contact time. Surface disinfectants are not tested/approved for reuse (soaks). Rinse thoroughly. Do not transfer to laboratory in container containing disinfectant. What s missing? Follow manufacturer s recommendations on barrier protection and cleaning and disinfection of digital sensors. XCP (extension cone paralleling) film holder positioning system heat sterilize or HLD based on manufacturer s instructions. 3/31/2016 Multiuse Dispensers Do Devices used to deliver to site in the mouth impression materials adhesives dental composites endodontic (root canal) materials Avoid contact of the reusable parts (e.g., the body of the multiple use dental dispenser) with the patient s mouth Apply disposable barrier sleeves/wraps over multiple use dental dispensers before use with each patient Use new, uncontaminated gloves when handling multipleuse dental dispensers Dental assistants dispense material for the dentist alproducts/ucm htm Do Not Thank You! Contact Information Reuse the multiple use dental dispenser if contaminated Reprocess a contaminated multiple use dental dispenser by using chemical wipes or disinfectants Immerse multiple use dental dispensers in a high level chemical disinfectant. May damage the dispenser and material in the device Sterilize multiple use dental dispensers. May damage the material in the device Karen Gregory, RN Director of Compliance and Education Karen@TotalMedicalCompliance.com