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Bloodborne Pathogens and Infection Control

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					Bloodborne Pathogens
 and Infection Control
         Dental Branch
    2007 Annual Clinic Update
   Presented by Environmental
        Health and Safety
                    Objectives
   Bloodborne Pathogens
   Statistics
   Injury Process
   Infection Control
   Personal Protective Equipment
   Water lines and Water Quality
   General Safety (x-ray, laser, physical, drills)
   Pandemic Preparedness
           Regulatory Agencies
   Occupational Safety and Health
    Administration (OSHA)
   Center for Disease Control and Prevention
    (CDC)
   American Dental Association (ADA)
   Texas Department of State Health
    Services (DHSH)
   Texas Commission on Environmental
    Quality (TCEQ)
        Bloodborne Pathogens
           OSHA 1910.1030
Definition:
   Any pathogenic microorganism that is
   present in human blood or other
   potentially infectious materials (OPIM)
   and can infect and cause disease in
   persons who are exposed to blood
   containing the pathogen.
      Bloodborne Pathogens
Examples of bloodborne pathogens:
     HIV
     HBV
     HCV
     T. pallidum
     Herpes Virus
     M. tuberculosis (typically an aerosol hazard)
     Human T-lymphotropic Virus Type I (HTLV-I)
           Bloodborne Pathogens

Examples of body fluids that can potentially
  carry the HIV and HBV viruses:
     Blood
     Semen and vaginal secretions
     Saliva involved in dental procedures
     Synovial fluids
     Cerebrospinal fluid
     human tissue and cell cultures
     All body fluids containing blood
                  Transmission
   Mucous membrane contact - example splash to
    the eyes, nose and/or mouth.
   Percutaneous inoculation - misuse of sharps
    (broken glass, needles, etc.)
   Exposure to broken/damaged skin - the risk
    increases, if contact involves a large area of the
    skin or if contact is prolonged. Risk also
    increases with increased HIV titer levels in the
    source patient’s blood.
             Exposure Incidents
   Confidential medical evaluation and follow-up

       Confidential medical evaluation and follow up
        – UT Student or Employee Health

       Testing of source patient for STDs HIV and
        Hepatitis infectivity
               Medical Surveillance
   Baseline Labs
       HIV antibody (with consent)
       RPR (Syphilis)
       HBsAB (Hepatitis B surface antibody)
       anti-HCV; if source patient is know to be Hepatitis
        C+, also obtain a liver function test and HCV RNA
       CBC with differential and platelets, chemistry profile,
        urine pregnancy test if source is know HIV+ and if
        exposed personnel chooses to utilize PEP
   Hepatitis B Vaccination
       Three shot series
   Tuberculosis skin test
         Hepatitis B Vaccination
   All health care workers must have
    vaccination

   Available at no cost to employees

   Employees can decline vaccination, but
    must sign a declination statement
                     Rights
   In the event of a possible exposure to
    bloodborne pathogens, the person is
    entitled to:
     Confidential medical evaluation and follow-up
     Documentation of routes of exposure

     Identification, documentation, testing and
      results of the source individual
     Counseling

     Evaluation of reported illness
            Training Requirements
   All health care workers with potential for
    exposure to blood and body fluids must
    receive training
       At time of initial assignment
       Annually
             Record Keeping
   Medical records related to exposure
    incidents must be retained for duration of
    employment plus 30 years.

   Training records must be maintained for
    three years
    TB Presentation / Isolation

 Cough
 Chest Pain

 Coughing up blood

 Weakness

 Fever and/or Night
  Sweats
 Weight loss
    Dec 2006
Harris County had
122 Tb cases for
 the year & 661
   under case
  management
 (14% increase
   over 2005)
          Assessing Patient Risk for
               Tuberculosis
   Routinely ask all patients:

       whether they have a history of TB disease

       whether they have symptoms suggestive of
        TB
Patients With History or Symptoms
       of Undiagnosed TB
   Should be referred promptly for medical
    evaluation of possible infection
   Should not remain in the dental facility any
    longer than required to arrange a referral
   Should wear surgical mask while in the dental
    facility
   Should have urgent dental care provided in
    areas that can provide TB isolation
       Patients With History of or
       Symptoms of Undiagnosed TB
   Should have elective dental treatment
    deferred until a physician confirms that
    the patient does not have infectious TB

   If diagnosed as having active TB, elective
    dental treatment should be deferred until
    no longer infectious
           Exposure Incident
REMEMBER!

   If you have received a puncture or
    laceration injury from a contaminated
    needle or instrument…

    REMOVE THE ANESTHETIC SYRINGE OR
    INSTRUMENT FROM TRAY – DO NOT
    REUSE INSTRUMENT!
          Exposure Incident
REMEMBER!

   STOP THE PROCEDURE

   DO NOT DISMISS THE PATIENT

   REPORT THE INCIDENT TO THE NEAREST
    DISPENSARY
DO NOT DISMISS THE PATIENT
            “Please wait
           here for a few
             minutes”
     Dental Branch Injuries 2005-2007
TOTAL INJURIES      2005   2006   2007
TOTAL                49     46      47

Red Handled Knife   26%    15%     25%
Needlestick         19%    9%      12%
Instrument          19%    26%     21%
Bur                 10%    15%     21%
Splash to Eye        0%     4%      0%
Falls               10%    13%     17%
Suture Needle        2%     2%      6%
Disc (Laceration)    2%     0%      0%
Miscellaneous       12%    15%      6%
   BBP Exposure Incidents = 49%
                 of all injuries for ‘07


Red Handled Knife                          5
Needlestick                                5
Instrument                                 9

Bur                                        0
Splash to Eye                              1

Suture                                     3
Other Injuries                             0
    PREVENTION OF INJURIES
   Remove burs from handpiece immediately after
    completion of dental procedure

   Recap anesthetic needles

   Restrict use of fingers in tissue retraction or
    palpation during suturing or administration of
    anesthesia

   Avoid uncontrolled movements of dental
    instruments. THINK BEFORE MOVING AN
    INSTRUMENT!
    Why Is Infection Control Important
               in Dentistry?

 Both patients and dental health care
  personnel (DHCP) can be exposed to
  pathogens
 Contact with blood, oral and respiratory
  secretions, and contaminated equipment
  occurs
 Proper procedures can prevent
  transmission of infections among patients
  and DHCP
          Standard Precautions
   Standard Precautions – A standard of care
    designed to protect health care providers
    and patients from pathogens that can
    spread by blood and other body fluids

   ALL BLOOD AND BODY FLUIDS ARE
    CONSIDERED TO BE INFECTIOUS!
   Cross-Infection




Infection Control in the Former Wet Finger Environment.
             Robert R Runnells, DDS 1987
Modes of Transmission in Dentistry

     Direct contact with blood or body fluids
     Indirect contact with a contaminated
      instrument or surface
     Contact of mucosa of the eyes, nose, or
      mouth with droplets or spatter
     Inhalation of airborne microorganisms
    Exposure To Blood and Body Fluids

   Laceration

   Needle stick

   Puncture with dental bur

   Splash of blood or saliva to mucus
    membranes of mouth, nose or eyes
           Exposure Control Plan
   Written plan to eliminate exposure to
    blood and body fluids
      Exposure determination
      Plan must be accessible

      Compliance

   Dental School Clinic Manual- section 2
    www.db.uth.tmc.edu/clinic-
    pat/Documents/Clinic_Manual.pdf
   UTHSC-H Biological Safety Manual
    www.uth.tmc.edu/safety
    Who Conducts I.C. Monitoring
   Clinical Affairs Committee Members -
    Undergraduate Clinical Bays (dental and
    dental hygiene)
   Clinical Staff - Undergraduate Clinics such
    as Assessment, Urgent Care, Oral Surgery,
    OMP and Radiology
   Faculty and clinical staff - Graduate
    Program Clinics
           Factors Monitored
   Disinfection before and after treatment
   Application and removal of barriers
   Contaminated items in clean areas
   Personal protective attire
   Biohazard bag in place when applicable
   Presence of food or drink
   Extraneous items in operatory
   Location of patient record
            Monitoring Results

       Total    Total    Total      Total   Total      Total
       Surveyed Infract. Surveyed   Infract Surveyed   Infract
       2005     2006     2006       2006    2007       2007

U.G.   195      77      231         81     247         123

D.H.   35       7       16          1      16          0

Grads 95        23      117         25     119         90
     Personal Protective Equipment
   Consider that all patients are infectious
   Wear personal protective equipment
     Gowns

     Gloves

     Masks

     Protective Eyewear
             Clinic Gown
   The official protective gown for
    use in all Dental Branch clinics is
    the Clinic Gown
      white for faculty

      blue for students
           Laboratory Gown
Working in a clinical
dental laboratory
  laboratory (yellow)
  gown should be
  used.
                 Gloves
Vinyl, nitrile, or latex examination gloves
must be worn when treating nonsurgical
patients
              Gloves

Sterile disposable
gloves must be
worn during all
surgical procedures
                  Utility Gloves
•Each student must have a
pair of heavy-duty utility
gloves for break down after
patient treatment

  •Must be washed with
  antimicrobial soap,
  rinsed and dried

  •Stored in plastic bag in
  locker
             Masks
Masks must be worn to protect:
 -Face
 -Oral and nasal mucosa
                Masks

 Masks must be changed if they
  become damp
 The mask must be changed for each
  new patient, except for short exams!
 If a face shield is worn it must be
  worn at the same time as a surgical
  mask
       Using Masks in Other
            Situations.
A laser plume
face mask must be
worn during a
laser or
electrosurgery
procedure
Protective Eyewear

 Must be worn to protect from aerosol
  and spatter
 Regular eyewear must have side
  shields
 Side shields must be securely
  attached to the eyewear frame
  abutting the lenses and free of vents
  or openings
              Sharps

Used needles,
blades, burs and
anesthetic
cartridges are to
be discarded in
sharps
containers
        Recapping Needles

Recap anesthetic
needles by using
the needle recapper
        One Handed Scoop

Use the one handed
scoop technique to
recap if a recapper
is not available
                   Sharps
USE OF SHARP INSTRUMENTS
    To prevent accidental exposure injuries
     related to trimming wax with a red
     handled lab knife at chair-side,
     DISINFECT when possible and…

     BE EXTREMELY CAREFUL WHEN USING THE
     RED HANDLED LAB KNIFE!

    Policy 2.39
                Sharps
 Handle carefully
 Do not recap with
  two hands
 Discard in sharps
  container
 Do not bend or
  break needles
 Report all injuries
              Good Work Practices
   Eating and drinking
    prohibited in all
    clinical areas

   Hand Hygiene

   Jewelry

   Hair
                      Hair

   Hair should be short and well-managed
   Long hair should be pulled back or
    completely covered with a surgical cap to
    minimize the possibility of contamination
   Beards, mustaches, or other facial hair
    must be neatly trimmed to fit under the
    mask
                      Fingernails

   Fingernails must be short in order to
    prevent collections of microbes and
    tears in gloves
   Colored nail polish is prohibited
       may obscure soil under the nails
   False fingernails also prohibited
    Proper hand washing is
 VITAL to infection prevention
Wash your hands, even if gloves have been worn:
 Before patient contact
 After contact with anything contaminated
 Between contact with different patients
 During patient care…
    before and after invasive procedure
    before and after contact with wound
    between procedures on different body parts of the
     same patient
    Between glove changes
    Immediately, if skin is contaminated or an injury
     occurs
                 Proper Hand Washing
      (Should be done between patients and procedures)
   Wet your hands with warm water (Not hot water)
   Put soap on your hands
       It is better to use a liquid soap because germs can live on wet bars
        of soap
   Rub your hands together for 10 to 15 seconds
       Wash longer if you can still see dirt on your hands. Make sure that
        you wash in between your fingers, the backs of your hands, your
        thumbs, and under your fingernails
   Rinse your hands thoroughly with warm water
   Pat your hands dry. If there is a blow dryer for your hands,
    push the button with your elbow
   Use the towel to turn off the water

What song is about 15 seconds long….

Source: Hand Hygiene Resource Center http://www.handhygiene.org/
Where do we miss?
        Proper Hand Washing (cont.)
   Alcohol sanitizers
       62% Ethyl Alcohol
       Accepted as effective under certain
        conditions
       Should not be used when there is visible dirt
        or grime
                 Housekeeping
   Housekeeping
       Worksite must be maintained in a clean and
        sanitary condition
       Equipment and work surfaces must be
        cleaned and decontaminated after contact
        with blood and other infectious materials
       Protective coverings used to cover equipment
        and work surfaces
Contact Surfaces
Cleaning Clinical Contact Surfaces

   Risk of transmitting infections
    greater than for housekeeping
    surfaces
   Clean and disinfect surfaces
   Apply barriers
           Surface Covers
Handles, handpieces
or similar surfaces
that may be
contaminated by
blood or saliva must
be wrapped with clear
plastic wrap
       Infection Control for Clinical
          Computer Equipment:
   Avoid contamination when possible
   Ideally, procedures should be followed to
    avoid contamination of electronic
    equipment
   If it is necessary to enter data during the
    time the patient is in the operatory,
    barrier protection and disinfection of high
    touch areas becomes necessary
   Follow established guidelines
Computer Keyboard & Screen -
          Barrier
                  -Use Sani Cloth Plus Wipes

                  -Disinfect daily or if
                  contaminated or visibility
                  soiled

                  -Apply two lengths of the
                  perforated plastic wrap to the
                  keyboard

                  -Cover the entire keyboard
                  and tuck in on the sides

                  -Touch screen with cotton
                  tipped applicator only (no Sani
                  Cloth Plus wipes on the
                  screen)
       Regulated Medical Waste
   Contaminated waste
    disposal

   Sharps disposal

   In compliance with
    OSHA and TDH
      Disposal of Contaminated
             Bio Waste
   Blood or saliva
    saturated items must
    be placed in small
    plastic biohazard bags
    at chairside
   Small biohazard bags
    must be disposed of
    at the dispensary
What is Biological Waste and What is
                trash?
              Used needles
              Bloody gloves

           Paper gowns (unsoiled)
            Unsoiled exam gloves
           Blood Spill Clean up
   All blood spills should be cleaned up
    using 10% bleach or another approved
    EPA disinfectant
   The disinfectant should be allowed to
    soak for at least 15 minutes
   Apply the approved disinfectant to the
    perimeter of the spill, slowly wipe
    inwards
   Materials used to clean up the spill
    (towels, etc) should also be disposed in
    biohazard bag
       Dental Unit Waterlines
            and Biofilm
 Microbial biofilms form
  in small bore tubing of
  dental units
 Biofilms serve as a
  microbial reservoir
 Primary source of
  microorganisms is
  municipal water supply
    Dental Unit Water Quality

 Using water of uncertain quality is
  inconsistent with infection control
  principles
 Colony counts in water from untreated
  systems can exceed 1,000,000
  CFU/mL (CFU=colony forming unit)
 Untreated dental units cannot reliably
  produce water that meets drinking
  water standards
        Dental Water Quality

For routine dental
treatment, meet regulatory
standards for drinking
water.
<500 CFU/mL of heterotrophic
water bacteria
Dental Unit Water Quality ICX
                  Available on gray
                   cabinets at the
                   back of the bays

                  Instructions
                   posted in each
                   cubicle
Dental Unit Water Quality – ICX

   Rinse empty water bottle with tap water
   Prior to rinsing make sure the water from
    tap has run for at least 30 seconds or until
    clear
   Add one tablet of ICX to empty water
    bottle – avoid touching the tablet
   Fill bottle with tap water
   Wait 60 seconds for tablet to fully dissolve
             General Safety
   Odor Complaints (ext. 5832)
   Hazardous Waste (ext. 5837)
   Animals
   Emergency Response
   Preparedness
                    Fire Alarms
   Drills & Alarms
       Stabilize patient, send one person to
        emergency exit to listen to announcement
        and that person should to tell you if there is a
        need to evacuate

       If you see smoke or fire, stabilize patient and
        evacuate immediately using the nearest
        stairwell exit
    High Rise Alarm Design
  (a high rise is 75 ft or taller)
                                 9
-Stabilize patient, send one
person to emergency exit to      8

listen to announcement and       7
that person should to tell you   6
if there is a need to evacuate   5

                                 4
-If you see smoke or fire,
                                 3
stabilize patient and evacuate
                                 2
immediately using the nearest
                                 1
stairwell exit
       X-Ray and Laser Safety
   X-Ray and Lasers users need to have
    specialized training
   Programs available for those that are
    pregnant
Pandemic Preparedness
            University has a Task
             Force appointed by Dr.
             Willerson

            Includes input from
             Harris County and City of
             Houston Health
             Departments, TMC and
             Memorial Hermann
             Hospital
    Pandemic Preparedness: How to
           protect yourself
   Wash hands frequently
   Get vaccinated for seasonal flu
   Practice and teach cough etiquette
   Avoid close contact with sick people
   When sick keep distance from others
   Stay home if sick
Questions??

				
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