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??