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3 Checking Out the Checklist: Improving Infection Prevention and Control Practices in Dental Care Settings Dr. Chris Swayze Giulia Galloro Anne Augustin January Public Health Ontario Grand Rounds

4 Disclosures Presenters: Dr. Chris Swayze Giulia Galloro Anne Augustin No conflicts to disclose Relationships with commercial interests: Grants/Research Support: none Speakers Bureau/Honoraria: none Consulting Fees: none Other: none 4

5 Objectives List gaps in practice that led to recent IPAC lapses in dental practice settings in Ontario and a subsequent examination of existing auditing tools. Describe limitations of the previously available tools for investigation of an IPAC lapse in dental practice settings in Ontario. Analyze how the new checklists can help improve IPAC practices in dental care settings in Ontario. Identify two actions that professionals can implement in dental care settings to reduce likelihood of an IPAC lapse. 5

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7 Common IPAC Practice Issues Inspect on a complaint driven basis. Most frequently noted IPAC practice issues were related to: Cleaning, disinfection and sterilization of equipment/instruments Improper medication administration practices 7

8 Cleaning, Disinfection and Sterilization Practice Issues? Poor pre-cleaning and cleaning practices of equipment/instruments rinsed rather than cleaned not disassembled prior to cleaning Reuse of single use devices Improper packaging too many per pack locked position no disassembly where MIFU indicates it is needed Lack of monitoring of sterilizer(s) no biological indicator (no testing or records of test results) 8

9 Reprocessing Cycle Complex Process Preclean Clean Inspect & Dry Package Sterilize Storage Patient use Quality Assurance 9

10 Improper Medication Administration Practices Pre-loading of syringes Improper labelling of multi-dose vials Needles left in multi-dose vials for quick access 10

11 RCDSO Guideline - Infection Prevention and Control in the Dental Office The College s guideline is consistent with the recommendations of the Provincial Infectious Diseases Advisory Committee (PIDAC), the Canadian Standards Association (CSA), Public Health Agency of Canada (PHAC) and with Public Health Ontario (PHO) documents. The College s guideline is currently being revised and a working group has been struck, including representation from the Ministry of Health, Public Health Ontario, general dentists, dental specialists, IPAC experts, public members and other stakeholders. 11

12 Tools and Limitations Centers for Disease Control Infection Prevention Checklist Dental Settings Infection Prevention and Control Canada Infection Prevention and Control Audit for Reprocessing in Dentistry Infection Prevention and Control Audit for General IPAC Practices in Dentistry Public Health Ontario Checklist for Infection Prevention and Control (IPAC) CORE Elements in Clinical Office Practice Checklist for Reprocessing of Medical Equipment/Devices in Clinical Office Practice 12

13 Working Group Dr. Michael Gardner, Royal College of Dental Surgeons of Ontario (RCDSO) Dr. Chris Swayze, RCDSO Giulia Galloro, College of Dental Hygienist of Ontario (CDHO) Robert Farinaccia, CDHO Janu Sritharan, Ministry of Health and Long-term Care (MOHLTC) Melissa Helferty, MOHLTC 13

14 Working Group representing Public Health Ontario Sandra Callery Barb Catt Dr. Sonica Singhal Laurie Rodnick Anne Augustin Dr. Maureen Cividino Donna Moore Virginia Tirilis 14

15 PHO Checklist Reprocessing and Core IPAC Goal - more applicable checklists Focused on the dental practice setting 15

16 Primary Resources Consulted Ontario Agency for Health Protection and Promotion (Public Health Ontario), Provincial Infectious Diseases Advisory Committee. Infection Prevention and Control for Clinical Office Practice. 1st Revision. Toronto, ON: Queen s Printer for Ontario; April Ontario Agency for Health Protection and Promotion (Public Health Ontario). Provincial Infectious Diseases Advisory Committee. Best practices for cleaning, disinfection and sterilization of medical equipment/devices. 3rd ed. Toronto, ON: Queen s Printer for Ontario; May Royal College of Dental Surgeons of Ontario. Guidelines Infection Prevention and Control in the Dental Office Canadian Standards Association. Z , Effective sterilization in health care settings by the steam process Centers for Disease Control. Guidelines for Infection Control in Dental Health-Care Settings

17 Primary Resources Consulted Centers for Disease Control. The Summary of Infection Prevention Practices in Dental Settings: Basic Expectations for Safe Care and accompanying checklist (Appendix A) IPAC Canada. Dental Checklist (Reprocessing and IPAC) Occupational Health and Safety Act [O. Reg. 67/93] Occupational Health and Safety Act [O. Reg. 851 s. 124] Canadian Centre for Occupational Health. Emergency Showers and Eyewash Stations. Available at: 17

18 Reprocessing Checklist Highlights Policies and Procedures Re-usable devices Purchase only devices which can be reprocessed based on current recognized standards Recall of improperly reprocessed devices Scheduled preventative maintenance of equipment, with written documentation Quality assurance monitoring and documentation of the reprocessing processes Single-use medial equipment/devices. All are based on current recognized standards, reviewed regularly and as new information becomes available. 18

19 Reprocessing Checklist Highlights Education and Training Reprocessing Organizational Risk Assessment - Determine what activities are being performed in your organization Trained to a level that is required for the volume and complexity of the equipment to be reprocessed New devices or equipment are purchased PHO online Reprocessing in The Community modules are designed for a typical office practice setting Certificate of completion Ontario Agency for Health Protection and Promotion (Public Health Ontario), Recommendations for education, training and certification for reprocessing in clinical office settings. Toronto, ON: Queen s Printer for Ontario;

20 Reprocessing Checklist Highlights Examples of equipment have been changed to reflect the dental practice Example Line 3.1 Single-use items including needles are not reprocessed (e.g., syringe needles, prophylaxis cups and brushes, and certain orthodontic brackets.) Some items, such as prophylaxis angles, high-volume suction tips and air/water syringe tips are commonly available in single-use forms or re-usable forms 20

21 Reprocessing Checklist Highlights Section 4 College of Physicians and Surgeons of Alberta. Reprocessing critical & semi-critical equipment : a physician tool kit. Edmonton, AB: College of Physicians and Surgeons of Alberta; 2008 [cited 2017 Oct 13]. Available from: A_Physician_Toolkit.pdf?pdf=Reprocessing-Toolkit 21

22 Reprocessing Checklist Highlights Physical Space Line 4.6 There is a puncture-resistant sharps container at point-of-use AND/OR sharps are transported to the reprocessing area in a covered container (e.g., plastic tray with hard plastic cover) or cassette. 22

23 Reprocessing Checklist Highlights Physical Space Line 4.7 Eyewash station There is a plumbed or self-contained eyewash station within a 10 second walk (16 to 17 metres [55 feet]) of the reprocessing area. Canadian Centre for Occupational Health and Safety American National Standards Institute (ANSI) Standard Z "Emergency Eyewash and Shower Equipment" is generally used as a guide. Ontario Occupational Health and Safety Act, R.R.O. 1990, Reg. 851, s

24 Reprocessing Checklist Highlights Section 6 - Cleaning of Semi-critical and Critical Dental/Medical Devices All items are reprocessed according to the manufacturers instructions for use (MIFUs) Gross soil (blood, saliva) is removed immediately Not achieved immediately keep moist Clean using an enzymatic or detergent cleaner Enzymatic or detergent cleaner is used according to MIFUs Ultrasonic washer or washer/disinfectors Ultrasonic washers and or washer/disinfectors, tested for efficacy at least weekly or according to MIFU-documented PM 24

25 Reprocessing Checklist Highlights Cleaning of Semi-critical and Critical Dental/Medical Devices Brushes used for cleaning are inspected & changed when dirty. Sterilize or disposed of at the end of the day Reusable cleaning items (e.g., brushes) are discarded if worn or damaged Dental/medical equipment/devices are dried with a lint-free prior to packaging 25

26 Reprocessing Checklist Highlights All references to High Level Disinfection (HLD) have been removed Rationale Semi-critical items are cleaned followed by sterilization. The majority of semi-critical items used in dentistry are available in heat-tolerant or disposable alternatives. Avoid the use of heat-sensitive semi-critical items that must be processed with liquid chemical germicides. RCDSO. Guidelines Infection Prevention and Control in the Dental Office. February

27 Reprocessing Checklist Highlights Sterilization Line 7.2 Items are packaged according to the manufacturer recommendations for both the packaging and the instruments. Sterilization Line 7.3 Packages labelled date, sterilizer used, load number, health care provider s initials Sterilization Line 7.4 Chemical indicators (CI) are placed appropriately in and/or on each package, if not part of the pouch/pack wrap. Internal CI at a minimum Class 4 External CI Class 1 27

28 More about chemical indicators External Indicators Class 1 Placed on outside of every package Tape gives visual that correct temperature achieved sometime during cycle Class 4, Class 5 or Class 6 Placed inside each package (if not integrated into the package) Colour change indicates that the steam reached the inside of package 28

29 Reprocessing Checklist Highlights Sterilization Line 7.8 Items in the processed load should not be released until the results of the BI test are available; if quarantine pending BI results is not possible, evaluation of a Class 5 or 6 chemical indicator and the specific cycle physical parameters may be used to justify the release of routine loads. There are contingency plans (i.e., recall policy and procedure) in the event of reprocessing failures. At a minimum, a Class 4 CI with verification of specific cycle physical parameters are checked, verified and documented. Inform and educate as necessary. 29

30 Reprocessing Checklist Highlights Sterilization Line 7.9 If dynamic air removal-type (i.e., pre-vacuum) sterilizer is used, an air-detection PCD (e.g., Bowie-Dick test pack) is used. For gravity and pressure-pulsed sterilizers follow the MIFUs. 30

31 Reprocessing Checklist Highlights Item 7.10 Sterilizer mechanical display, printout or USB is checked, verified and signed for each cycle by the person sterilizing medical devices. If your sterilizer does not have a printer - Plan to replace it. During each cycle, check and record the elapsed sterilization time and sterilization temperature during the sterilization exposure phase. Use a Class 5 chemical indicator strip (integrator) in each package that you sterilize. 31

32 Core Elements Checklist Highlights Additions! Section 4 Dental Unit Waterlines and Water Quality Section 5 Handpieces Section 6 Suction Section 8 Line 8.3 addresses the use of barriers Barriers are used on difficult to clean equipment Section 12 Dental Radiography 32

33 Core Elements Checklist Highlights More Additions! Section 13 Dental Laboratory Provide clarity on management of impressions, prostheses, and appliances Sections 15 and 16 Medication Room/Area and Injectable Medication Vials or Solutions Added notes to help provide a better understanding of how and when medications are used in the dental practice setting Removed! Removed sections vaccines and allergies 33

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35 Summary How can I improve my practice? Aim for best practice PHO Checklist Reprocessing in Dental Practice Settings PHO Checklist Core Elements in Dental Practice Settings Education and training PHO on-line Reprocessing course Canadian Standards Association (CSA) Medical Device Reprocessing Association of Ontario (MDRAO) Community Colleges Manufacturer when new equipment is purchased Quality Assurance program 35

36 Dental Checklists Living Documents Three public health units asked to review prior to release Post Release Asking for feedback from anyone who uses the checklists Plan for a more formal review after the checklists have been in place for one year 36

37 Questions 37