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C.1 INFECTION CONTROL




Purpose:
To establish policies and procedures to protect dental personnel from work related exposures to infectious diseases and to protect dental patients from exposures to infectious diseases resulting from dental treatment.
Authority:


  1. Centers for Disease Control and Prevention. Guidelines for Infection Control in Dental Health-Care settings-2003. MMWR 2003;52 (No. RR-17)

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5217a1.htm



  1. (Handpiece manufacturer name) recommendation for maintenance and sterilization of high speed and low speed handpieces

  2. Atest manufacturer’s instructions

  3. (Facility Name) infection control policies relating to ambulatory patient care

  4. (Facility Name) safety policies relating to infection control

  5. (Facility Name) personnel policies relating to infection control

  6. HIPAA act of 1998


Procedure:


  1. Policies are numbered as IC/D (Infection Control/ Dental).

  2. All policies in the Dental Infection Control Policy Guide are consistent with manufacturer’s recommendations, CDC, IHS(if applicable), and (Facility Name) recommendations and regulations.

  3. Authority for all policies can be located in one of the above listed sources

  4. Whenever possible, policies will defer to (Facility name) wide policies. Specific questions should be directed to the (Facility Name) Safety Officer, the (Facility Name) Infection Control Officer, Medical Records Chief (HIPPA regulations), or other appropriate authorities at (Facility Name).

  5. When updating policies and procedures, current authoritative sources should be referenced and if possible, copied and placed in this guide as a reference.

  6. Guide should be updated annually or as soon as new recommendations become available

  7. Copies of the Dental Infection Control Policy Guide will be maintained at (Facility(ies) Name(s))

  8. Periodic quality assurance studies will be conducted to ensure compliance with this guide. Lack of compliance or changes in procedures will be discussed at dental staff meetings. The Chief- Dental Services will approve changes to the guide prior to implementation

  9. Recommendations may be classified by the following categories:

Category IA. Strongly recommended for implementation and strongly supported by well-designed experimental, clinical, or epidemiologic studies.

Category IB. Strongly recommended for implementation and supported by experimental, clinical, or epidemiologic studies and a strong theoretical rationale.

Category IC. Required for implementation as mandated by federal or state regulation or standard. When IC is used, a second rating can be included to provide the basis of existing scientific data, theoretical rationale, and applicability. Because of state differences, the reader should not assume that the absence of a IC implies the absence of state regulations.

Category II. Suggested for implementation and supported by suggestive clinical or epidemiologic studies or a theoretical rationale.

Personnel Health Elements of of an Infection Control Program
A. General Recommendations

1. Develop a written health program for DHCP that includes policies, procedures, and guidelines for education and training; immunizations; exposure prevention and postexposure management; medical conditions, work-related illness, and associated work restrictions; contact dermatitis and latex hypersensitivity; and maintenance of records, data management, and confidentiality (IB).
2. Establish referral arrangements with qualified health-care professionals to ensure prompt and appropriate provision of preventive services, occupationally related medical services, and postexposure management with medical follow-up (IB, IC).


B. Education and Training

1. Provide DHCP 1) on initial employment, 2) when new tasks or procedures affect the employee's occupational exposure, and 3) at a minimum, annually, with education and training regarding occupational exposure to potentially infectious agents and infection-control procedures/protocols appropriate for and specific to their assigned duties (IB, IC).
2. Provide educational information appropriate in content and vocabulary to the educational level, literacy, and language of DHCP (IB, IC).


C. Immunization Programs

1. Develop a written comprehensive policy regarding immunizing DHCP, including a list of all required and recommended immunizations (IB).
2. Refer DHCP to a prearranged qualified health-care professional or to their own health-care professional to receive all appropriate immunizations based on the latest recommendations as well as their medical history and risk for occupational exposure (IB).

D. Exposure Prevention and Postexposure Management

1. Develop a comprehensive postexposure management and medical follow-up program (IB, IC).

a. Include policies and procedures for prompt reporting, evaluation, counseling, treatment, and medical follow-up of occupational exposures.
b. Establish mechanisms for referral to a qualified health-care professional for medical evaluation and follow-up.
c. Conduct a baseline TST, preferably by using a two-step test, for all DHCP who might have contact with persons with suspected or confirmed infectious TB, regardless of the risk classification of the setting (IB).

E. Medical Conditions, Work-Related Illness, and Work Restrictions

1. Develop and have readily available to all DHCP comprehensive written policies regarding work restriction and exclusion that include a statement of authority defining who can implement such policies (IB).
2. Develop policies for work restriction and exclusion that encourage DHCP to seek appropriate preventive and curative care and report their illnesses, medical conditions, or treatments that can render them more susceptible to opportunistic infection or exposures; do not penalize DHCP with loss of wages, benefits, or job status (IB).
3. Develop policies and procedures for evaluation, diagnosis, and management of DHCP with suspected or known occupational contact dermatitis (IB).

4. Seek definitive diagnosis by a qualified health-care professional for any DHCP with suspected latex allergy to carefully determine its specific etiology and appropriate treatment as well as work restrictions and accommodations (IB).

F. Records Maintenance, Data Management, and Confidentiality

1. Establish and maintain confidential medical records (e.g., immunization records and documentation of tests received as a result of occupational exposure) for all DHCP (IB, IC).


2. Ensure that the practice complies with all applicable federal, state, and local laws regarding medical recordkeeping and confidentiality (IC).
Preventing Transmission of Bloodborne Pathogens


A. HBV Vaccination

1. Offer the HBV vaccination series to all DHCP with potential occupational exposure to blood or other potentially infectious material (IA, IC).


2. Always follow U.S. Public Health Service/CDC recommendations for hepatitis B vaccination, serologic testing, follow-up, and booster dosing (IA, IC).
3. Test DHCP for anti-HBs 1--2 months after completion of the 3-dose vaccination series (IA, IC).
4. DHCP should complete a second 3-dose vaccine series or be evaluated to determine if they are HBsAg-positive if no antibody response occurs to the primary vaccine series (IA, IC).
5. Retest for anti-HBs at the completion of the second vaccine series. If no response to the second 3-dose series occurs, nonresponders should be tested for HBsAg (IC).
6. Counsel nonresponders to vaccination who are HBsAg-negative regarding their susceptibility to HBV infection and precautions to take (IA, IC).
7. Provide employees appropriate education regarding the risks of HBV transmission and the availability of the vaccine. Employees who decline the vaccination should sign a declination form to be kept on file with the employer (IC).

B. Preventing Exposures to Blood and OPIM

1. General recommendations

a. Use standard precautions (OSHA's bloodborne pathogen standard retains the term universal precautions) for all patient encounters (IA, IC).
b. Consider sharp items (e.g., needles, scalers, burs, lab knives, and wires) that are contaminated with patient blood and saliva as potentially infective and establish engineering controls and work practices to prevent injuries (IB, IC).
c. Implement a written, comprehensive program designed to minimize and manage DHCP exposures to blood and body fluids (IB, IC).

2. Engineering and work-practice controls

a. Identify, evaluate, and select devices with engineered safety features at least annually and as they become available on the market (e.g., safer anesthetic syringes, blunt suture needle, retractable scalpel, or needleless IV systems) (IC).
b. Place used disposable syringes and needles, scalpel blades, and other sharp items in appropriate puncture-resistant containers located as close as feasible to the area in which the items are used (IA, IC).
c. Do not recap used needles by using both hands or any other technique that involves directing the point of a needle toward any part of the body. Do not bend, break, or remove needles before disposal (IA, IC).
d. Use either a one-handed scoop technique or a mechanical device designed for holding the needle cap when recapping needles (e.g., between multiple injections and before removing from a nondisposable aspirating syringe) (IA, IC).

3. Postexposure management and prophylaxis

a. Follow CDC recommendations after percutaneous, mucous membrane, or nonintact skin exposure to blood or other potentially infectious material (IA, IC).
Hand Hygiene
A. General Considerations

1. Perform hand hygiene with either a nonantimicrobial or antimicrobial soap and water when hands are visibly dirty or contaminated with blood or other potentially infectious material. If hands are not visibly soiled, an alcohol-based hand rub can also be used. Follow the manufacturer's instructions (1A)


2. Indications for hand hygiene include
    a. when hands are visibly soiled
    b. after barehanded touching of inanimate objects likely to be contaminated by blood, saliva, or respiratory secretions
    (IA, IC);
    c. before and after treating each patient (IB);
     d. before donning gloves (IB); and
     e. immediately after removing gloves (IB, IC)
3. For oral surgical procedures, perform surgical hand antisepsis before donning sterile surgeon's gloves. Follow the manufacturer's instructions by using either an antimicrobial soap and water, or soap and water followed by drying hands and application of an alcohol-based surgical hand-scrub product with persistent activity (IB)

4. Store liquid hand-care products in either disposable closed containers or closed containers that can be washed and dried before refilling. Do not add soap or lotion to (i.e., top off) a partially empty dispenser.



B. Special Considerations for Hand Hygiene and Glove Use

1. Use hand lotions to prevent skin dryness associated with handwashing (IA).


2. Consider the compatibility of lotion and antiseptic products and the effect of petroleum or other oil emollients on the integrity of gloves during product selection and glove use (IB)
3. Keep fingernails short with smooth, filed edges to allow thorough cleaning and prevent glove tears (II)
4. Do not wear artificial fingernails or extenders when having direct contact with patients at high risk (e.g., those in intensive care units or operating rooms) (IA)
5. Use of artificial fingernails is usually not recommended (II)
6. Do not wear hand or nail jewelry if it makes donning gloves more difficult or compromises the fit and integrity of the glove (II)
Personal Protective Equipment (PPE)
A. Masks, Protective Eyewear, and Face Shields

1. Wear a surgical mask and eye protection with solid side shields or a face shield to protect mucous membranes of the eyes, nose, and mouth during procedures likely to generate splashing or spattering of blood or other body fluids (IB, IC).


2. Change masks between patients or during patient treatment if the mask becomes wet (IB).
3. Clean with soap and water, or if visibly soiled, clean and disinfect reusable facial protective equipment (e.g., clinician and patient protective eyewear or face shields) between patients (II).

B. Protective Clothing

1. Wear protective clothing (e.g., reusable or disposable gown, laboratory coat, or uniform) that covers personal clothing and skin (e.g., forearms) likely to be soiled with blood, saliva, or OPIM (IB, IC).


2. Change protective clothing if visibly soiled; change immediately or as soon as feasible if penetrated by blood or other potentially infectious fluids (IB, IC).
3. Remove barrier protection, including gloves, mask, eyewear, and gown before departing work area (e.g., dental patient care, instrument processing, or laboratory areas) (IC).

C. Gloves

1. Wear medical gloves when a potential exists for contacting blood, saliva, OPIM, or mucous membranes (IB, IC).


2. Wear a new pair of medical gloves for each patient, remove them promptly after use, and wash hands immediately to avoid transfer of microorganisms to other patients or environments (IB).
3. Remove gloves that are torn, cut, or punctured as soon as feasible and wash hands before regloving (IB, IC).
4. Do not wash surgeon's or patient examination gloves before use or wash, disinfect, or sterilize gloves for reuse (IB, IC).
5. Ensure that appropriate gloves in the correct size are readily accessible (IC).
6. Use appropriate gloves (e.g., puncture- and chemical-resistant utility gloves) when cleaning instruments and performing housekeeping tasks involving contact with blood or OPIM (IB, IC).
7. Consult with glove manufacturers regarding the chemical compatibility of glove material and dental materials used (II).

D. Sterile Surgeon's Gloves and Double Gloving During Oral Surgical Procedures

1. Wear sterile surgeon's gloves when performing oral surgical procedures (IB).


2. No recommendation is offered regarding the effectiveness of wearing two pairs of gloves to prevent disease transmission during oral surgical procedures. The majority of studies among HCP and DHCP have demonstrated a lower frequency of inner glove perforation and visible blood on the surgeon's hands when double gloves are worn; however, the effectiveness of wearing two pairs of gloves in preventing disease transmission has not been demonstrated (Unresolved issue).
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