Ecu school of Dental Medicine Infection Control Manual Table of Contents Page



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Infection Control Manual

July 14, 2014
ECU School of Dental Medicine Infection Control Manual
Table of Contents Page
1.0 ECU School of Dental Medicine Infection Control Program Introduction

Purpose, Procedures, Compliance 4

2.0 ECU Office of Prospective Health Infection Control Policy 6

ECU School of Dental Medicine Immunization Requirements

Immunization Requirements 7

Health Record Management 8

Hepatitis B Requirements 8

Respiratory Fit Testing 8

Training Requirements: Employee and Students 8

Initial/Orientation 8

Annual Training Requirements 8

Training Record Management 9

3.0 Bloodborne Pathogen Exposure Control Plan 10

3.1 Responsibilities 10

3.2 Exposure Risk by Job Title 11

3.3 Standard/Universal Precautions 12

3.4 Hand Washing/Hand Hygiene (antibacterial soaps, and gels) 12

3.5 Personal Protective Equipment 13

3.6 Gloves and Glove Selection (vinyl, nitrile, surgical) 14

3.6.1 Latex Sensitivity and Contact Dermatitis 15

3.7 Bloodborne Pathogen Post Exposure Protocol (also see Appendix C) 15

(Rev 7-14)

3.8. Latex Sensitivity and Contact Dermatitis 15

4.0 Blood Spills 16

5.0 Clinic Inspection 17

6.0 Dental Asepsis 17

7.0 Engineering Controls 18

7.1 Work Practices 18

8.0 Standard Operating Procedures 20

9.0 Service Dogs in the Clinic 20

10.0 Appendices

Appendix A Definitions and Abbreviations 22

Important Resources: 24

American Dental Association

Centers for Disease Control

OSHA Regulatory Documents: US Department of Labor,

Occupational Safety and Health Administration

ECU Office of Prospective Health

ECU School of Dental Medicine Office of Clinical Affairs

Appendix B Dental Procedures and Required PPE 25

Appendix C Bloodborne Pathogen Post Exposure Quick Guide (Rev 3-14) 26

Appendix D Contact Dermatitis 31

Appendix E Clinic Inspection Form (Rev 5-14) 32

Appendix F Clinic Infection Control Training Requirements 35

Infection Control Training Log 36

Autoclave Competency 37

Appendix G Clinic Logs: Autoclave, Refrigerator, Drain Log, and Waterline Testing 38

Appendix H Autoclave Use and Monitoring Policy 43

Appendix I Forms 45

School of Dental Medicine Event Report (Rev 3-14) 46

ECU Non-Patient Incident Report 47

Supervisor’s Accident Investigation Report 48

North Carolina Industrial Commission Form-19 49
___________________________________________________________________________

Issued By: The Office of Clinical Affairs Effective Date:

Approved: Reviewed/Revised:

___________________________________________________________________________
Title: Infection Control Manual
Purpose:

To establish the East Carolina University School of Dental Medicine’s (“SoDM”) Infection Control Standard Operating Procedures to protect the health and safety of patients, employees, students and visitors.


Procedures:
1.1 Introduction

A. The goals of the Infection Control Program are to protect the health of all patients and employees and to comply with applicable federal, state, and local regulations governing infection control, job safety, and management of regulated medical waste. These guidelines are designed to comply with current federal regulations including those issued by the Occupational Safety and Health Administration (OSHA), the Food and Drug Administration (FDA), and the Environmental Protection Agency (EPA).


B. Guidelines and recommendations issued by non-regulatory agencies including the American Dental Association (ADA), the Centers for Disease Control and Prevention (CDC) and other institutions may be used as references in the development of dental service infection control and employee protection programs. The most current federal, state, and local ECU requirements take precedence over these guidelines when more stringent. This document provides guidance for ECU School of Dental Medicine (“SoDM”) dental clinics to develop and implement an infection control program. It also provides guidance that the dental clinic can adopt or modify to ensure that reasonable precautions are being taken to prevent, control, and contain infections in patients, staff, students and visitors. Background information and supporting references for specific recommendations are provided in the Centers for Disease Control and Prevention Guidelines for Infection Control in Dental Health-Care Settings—2003, available on the CDC website at www.cdc.gov/oralhealth/infectioncontrol. The American Dental Association is an additional resource.
C. Dental health care personnel (“DHCP”) refers to all personnel in the dental clinic setting who may be exposed to infectious materials, including body substances and contaminated supplies, equipment, environmental surfaces, water, or air. DHCP includes dentists, dental hygienists, dental assistants, dental laboratory technicians, students and trainees, contractual personnel, and other persons not directly involved in patient care but potentially exposed to infectious agents (e.g., administrative, clerical).
D. Responsibilities

The ECU SoDM Department of Clinical Affairs, Infection Control Sub Committee:



  • Advises ECU SoDM on current issues relevant to dental infection control and occupational health and safety.

  • Acts as a liaison with ECU Office of Prospective Health and local Health Departments.

  • Maintains lines of communication with federal regulatory and advisory agencies including OSHA, FDA, EPA, and the CDC as well as with other recognized authorities in the fields of dental infection control and occupational safety and health.

  • Develops and distributes ECU SoDM approved guidelines/standard operating procedures for the Dental Infection Control Program. The Infection Control Committee will review and update the program based on changes in federal regulations, recommendations from advisory agencies, and current ECU Infection Control policy.

  • Disseminates information via periodic infection control updates and by direct and written communication.

The ECU SoDM Clinic Business Manager (or Infection Control designee):



  • Completes the mandatory North Carolina online training for dental infection control

NC Infection Control Law 10A NCAC 41A.0206 at the following link:

  • http://www.mahec.net/AboutUs/re_dental.aspx

  • Assumes responsibility for oversight of the infection control and occupational health/safety programs within the clinic. He or she will appoint a Clinic Dental Infection Control Assistant who will provide clinical support as required. Appropriate education and training is required prior to assuming these duties. Responsibilities include, but are not limited to, the following:

  • Implements and directs an infection control program including measures to comply with current ECU SoDM policy, guidelines, and OSHA requirements for protection of Dental Healthcare Personnel (“DHCP”) from exposure to bloodborne pathogens.

  • Coordinates the dental infection control operating instructions within the clinic Bloodborne Pathogen Exposure

  • Represents the clinic in all matters concerning dental infection control to the SoDM Infection Control Committee, its Chairperson, and the Director of Community Service Learning Centers.

  • Ensures initial, annual, and periodic training for DHCP on dental infection control and occupational exposure control to prevent bloodborne pathogen exposure in accordance with OSHA regulations, CDC standards and ECU SoDM requirements.

  • Conducts ongoing surveillance in accordance with guidance from the ECU SoDM Dental Infection Control Committee and the Office of Prospective Health.

  • Oversees the management of regulated waste within the dental clinic in accordance with federal, state, and local regulations.

  • Maintains a copy of this manual and the Bloodborne Pathogen Exposure Control Plan and Clinic Inspection sheets. Updates manuals and informs DHCP as changes occur, e.g., when new chemicals are available in the clinic.

1.2 Compliance



The School of Dental Medicine complies with the ECU Office of Prospective Health’s Infection Control Policy as outlined below. The Community Service Learning Centers will contract with a local medical partner in the form of a Memorandum of Understanding to provide services consistent with the ECU Office of Prospective Health’s Infection Control policy. The SoDM Community Service Learning Centers will comply with the Infection Control Policy, but will modify certain practice elements to meet local clinic needs, e.g., by establishing a medical partner to provide local employee health or exposure management services, record management, orientation and training.
2.0 ECU Office of Prospective Health Infection Control Policy
I. Purpose: The Infection Control policy is established to help safeguard patients and personnel from the transmission of infection between patient and personnel during patient care. All ECU School of Dental Medicine personnel, students, and other healthcare workers are to comply with all ECU infection control polices
II. Personnel:
A. All new and current employees, students and residents will comply with employment screening as outlined in the Prospective Health Policy. Employee Health records will be maintained by the Office of Prospective Health.
B. Employees who have potential for blood or other potentially infectious material exposure will be offered hepatitis B vaccine at no charge to the employee. Dental faculty, residents, students and employees who have potential for exposure to Mycobacterium Tuberculosis (MTB) will be given TB surveillance by PPD skin testing with follow-up per Prospective Health protocol.
Other health care students with clinical rotations through ECU clinics, other non-employee healthcare workers, and any others who may have patient contact will have documentation of Infection Control training, required vaccines administered, and PPD skin testing results according to BSOM policy for students/visitors.
C. Any ECU staff (including physicians and dentists) or student who has an exposure to a communicable disease through a needle stick or other means will report that exposure to the appropriate supervisor or instructor and follow-up will be done per Bloodborne Pathogen Exposure Control Plan, Tuberculosis Exposure Control Plan or Prospective Health Policy depending on exposure. Residents and Faculty Dentists who have a potential exposure to a communicable disease in ECU clinics are to notify ECU Prospective Health for testing of the patient but will follow-up with Vidant Medical Center’s Occupational Health for monitoring/treatment. Non-ECU students will follow their institutional policy.
D. Clinical employees will receive education on infection control, standard precautions, OSHA TB and Bloodborne pathogen, and radiation safety standards upon employment and yearly thereafter. Clinical employees will complete an Employee Health Update annually.
E. The School of Dental Medicine Immunization Requirements, as part of credentialing and re-credentialing are noted below. As ECU Office of Prospective Health or Vidant Medical Center updates their respective policy, SoDM will respond accordingly. See Immunization Requirements: Faculty, Residents, Students and Staff ECU Office of Prospective Health and Vidant Medical Center Standard Operating Procedure in the Standard Operating Procedure Manual located in Central Sterilization.

ECU School of Dental Medicine Initial and Annual Immunization Requirements

Disease

ECU Office of Prospective Health as of 3/2011

Vidant Medical Center as of 10/2011

Initial Requirements







Measles

If born in 1957 or later, 2 doses of live attenuated measles vaccine after 1st birthday; or

If born in 1957 or later, 2 doses of live attenuated measles vaccine after 1st birthday; or




If born in 1956 or earlier, 1 dose of live attenuated measles vaccine after 1st birthday; or

If born in 1956 or earlier, 1 dose of live attenuated measles vaccine after 1st birthday; or




Positive measles antibody titer; or

Positive measles antibody titer; or




If measles antibody tests negative for immunity, vaccine is needed

If measles antibody tests negative for immunity, vaccine is needed

Mumps

If born in 1957 or later, mumps vaccine received on or after 1st birthday; or

If born before 1957, one dose of live mumps vaccine on or after 1st birthday, or;




Physician documentation of mumps disease; or

If born in 1957 or later, two doses of live mumps vaccine on or after 1st birthday; or




Positive mumps antibody titer; or

Positive mumps antibody titer




If mumps antibody titer tests negative for immunity, vaccine is needed




Rubella

Rubella vaccine received on or after 1st birthday; or

Rubella vaccine received on or after 1st birthday; or




Positive rubella antibody titer; or

Positive rubella antibody titer




If rubella antibody tests negative for immunity, vaccine is needed

Physician documentation of having the disease is not acceptable for rubella.

Varicella

2 doses of varicella vaccine; or

History of primary varicella (chicken pox); or




History of chicken pox; or

Positive varicella titer; or




Positive varicella (VZV) antibody titer; or

Varicella vaccination x 2 on appropriate schedule




If VZV tests negative for immunity, 2 doses of varicella vaccine is required

If above not met, varicella vaccination is required unless medically contraindicated. Active case of primary varicella: temporarily restrict from hospital until cleared by physician

Hepatitis B

3 doses of Hepatitis B vaccine; or

Vaccination- 3 on appropriate schedule; or




Serologic evidence of immunity; or

Positive Hepatitis B Surface Antibody titer (highly recommended); or




If documentation is not provided of 3 doses of Hepatitis vaccine and/or serologic evidence of immunity and the provider declines the vaccine, the provider must sign a waiver stating they have been informed of, acknowledge, understand, and appreciate any risks associated with not having this vaccine, including the risk of acquiring the disease.

Must sign Statement of Declination if vaccine is declined.
Active disease or carrier: see Medical Staff Bloodborne Pathogen Policy

Diphtheria, Tetanus, Pertussis

One dose of Tdap is strongly recommended

Tdap vaccination x 1 required (currently, no future booster of Tdap recommended)

Tuberculosis

Current negative PPD test within the past 12 months; or

Documentation is required at initial credentialing and annually thereafter




Negative Quantiferon test within the past 12 months

Initial credentialing requirements:

For those without history of positive TB testing or disease: a 2 step TB Skin Test (TST) or Interferon-Gama Release Assays (i.e. Quantiferon) test result is required at initial credentialing






If provider has documentation of positive PPD or Quantiferon test, a normal chest x-ray, i.e., no signs of active pulmonary tuberculosis infection within the last 2 years, along with a current negative symptom screen, verified by Office of Clinical Affairs will be required. If the provider has TB symptoms, a chest x-ray will be required.

For those with a history of positive TST or a positive Quantiferon test, documentation of a negative chest

X-ray less than 2 years and negative symptom survey.


For those that had a past positive TST or positive Quantiferon test at time of initial credentialing and met requirements above, a symptom survey is required annually. A chest x-ray is repeated only if symptomatic of TB.
For TST or Quantiferon converters: chest x-ray at time of conversion, and evaluation for chemoprophylaxis if no active disease. Signs and symptoms survey is required annually there after. A chest x-ray is repeated only if symptomatic of TB


Active Pulmonary TB

Restrict from hospital and clinic until cleared by physician

Restrict from hospital and clinic until cleared by physician










Annual Requirements

Annual TB test is required of all dental providers, questionnaire if unable to be tested. If TB symptoms develop, a chest x-ray will be required.

Annual TB test is required of all dental providers, questionnaire if unable to be tested. If TB symptoms develop, a chest x-ray will be required.







Negative TST or Quantiferon test

Influenza

Influenza vaccine, yearly (highly recommended)

Influenza vaccine, yearly (highly recommended)

Health Record Management

An accurate employee health record for each employee subject to medical surveillance under this document will be maintained by Prospective Health and/or contracted medical provider and will include:



  • The name and banner access number of the employee.

  • Employee Hepatitis B status including the dates of all Hepatitis B vaccinations and any medical records relative to the employee’s ability to receive vaccination.

  • All results of examinations, medical testing, follow-up, and written opinions as they relate to the employee’s ability to wear protective clothing and equipment or receive vaccination or to post-exposure evaluation following an occupational exposure incident is completed within 15 days.

  • A copy of the information provided to the provider and provider’s written opinions.

  • Employee Medical Records are retained for duration of employment plus 30 years

Hepatitis B Immunization Requirements



  • Employees in positions having occupational contact with blood or other potentially infectious materials will be offered the Hepatitis B vaccine within ten (10) working days of initial assignment.




  • If an employee for whom the Hepatitis B Vaccine is indicated declines HBV vaccine, a declination form will be signed and retained in the Employee Health Record. An employee may subsequently request vaccination, and it shall be provided at that time.




  • Currently booster doses are not recommended. Should booster doses become recommended in the future, such booster doses shall also be provided. After receiving the 3 doses of Hepatitis B Vaccine, a post vaccination titer shall be drawn to document immunity or the need for booster vaccinations.

Mandatory Respiratory Fit Testing

This testing will be conducted during the initial health assessment for new clinical staff, predoctoral students and residents. SoDM will comply with the Office of Prospective Health standards for periodic testing.
Training Requirements Employees and Students

Employees will participate in General Orientation which includes an overview of Infection Control principles, the Bloodborne Pathogen Exposure Control Plan and Protocol, Standard Precautions, Hand Hygiene, Chemical Hazard Communication, Laboratory Safety, Radiation Safety and other relevant OSHA topics related to patient safety and prevention of employee injury or exposure to bloodborne pathogens or other potentially infectious material.


Failure to comply with training and health screening deadlines will result in removal from the clinic until compliance is achieved.
Annual training for employees is available online through the Office of Prospective Health at http://www.ecu.edu/prospectivehealth/traininged.htm. The Community Service Learning Centers will provide access to specific dental asepsis and infection control training (online) that meets the annual training requirements.
The training program shall contain the following:

  • A copy of The OSHA Standard on Occupational Exposure to Bloodborne Pathogens (29CR part 1910.1030) and general explanation of its contents is available online.

  • A general explanation of the epidemiology and symptoms of bloodborne diseases.

  • The modes of transmission of bloodborne pathogens.

  • The Bloodborne Pathogen Exposure Control Plan and how the employee can obtain the written and online plan.

  • The Bloodborne Pathogen Post Exposure Algorithm.

  • The appropriate methods for recognizing tasks and other activities that may involve exposure to blood and other potentially infectious materials.

  • The use and limitations of practices that will prevent and reduce exposure including appropriate engineering controls, work practices, and personal protective equipment.

  • Information on the types, proper use, location, removal, handling, and decontamination or disposal of personal protective equipment.

  • The basis for selection of personal protective equipment.

  • Information on the hepatitis B vaccine, including information on its efficacy, safety, method of administration, the benefits of being vaccinated.

  • Information on the appropriate actions to take and persons to contact in an emergency involving blood or other potentially infectious materials.

  • The procedure to follow if an exposure incident occurs, including the method of reporting the incident and the medical follow-up that will be made available.

  • An opportunity for interactive questions and answers.

  • Review of standard operating procedures, safe equipment use/disinfection specific to designated equipment

Employee Training Records: Training records shall include the following information:



  • The dates of the training sessions.

  • The contents or title of the training sessions.

  • The name and qualifications of persons conducting the training

  • The name and job titles of all persons attending the training sessions.

  • The Office of Prospective Health shall maintain training records for a minimum of 5 years. Training records are also maintained on the ECU One Stop database for employees who register by that route.

  • Employee health records may be maintained by the Community Service Learning Center’s medical partner

  • The Office of Prospective Health will maintain initial training records per policy

  • A Copy of annual training records will be provided to the Office of Clinical Affairs.

3.0 Bloodborne Pathogen Exposure Control Plan

ECU SoDM is committed to providing a safe and healthful work environment for employees and students. This Bloodborne Pathogen Exposure Control Plan is used as a means to eliminate or minimize occupational exposure to human blood and other potentially infectious materials or fluids. It is designed to comply with the OSHA Standard 29 CFR 1910, 1030 Occupational Exposure to Bloodborne Pathogens. East Carolina University’s compliance program for the OSHA Bloodborne Pathogen Standard is administered by Prospective Health Infection Control Practices for clinical and biological research employees and students. The School of Dental Medicine complies with the Office of Prospective Health standards.
A copy of this plan and the Bloodborne Pathogen Post Exposure Algorithm will be accessible to each department through the Infection Control Manual located in Central Sterilization at the CSLCs, and in the Office of Clinical Affairs. The Algorithm is located in the Standard Operating Procedure Manual and the Forms Manual. An electronic version is available at the Office of Clinical Affairs intranet. The Office of Prospective Health Infection Control website is at the following link: www.ecu.edu/prospectivehealth
This plan will be reviewed and updated annually and whenever necessary to reflect new or modified tasks and procedures which affect occupational exposures, and to reflect new or revised employee positions with occupational exposure. The plan will also:


  • Reflect changes in technology that eliminate or reduce exposure to bloodborne pathogens

  • Document consideration and implementation of appropriate commercially available and effective safer medical devices designed to eliminate or minimize occupational exposure, in conjunction with the ECU Product Standardization Committee.

This plan applies to all SoDM clinics (CSLCs, Hospital Dentistry, and Ross Hall).
3.1 Responsibilities

Each clinical area shall evaluate its routine practices and reasonably anticipated tasks and procedures to determine where there is actual or potential exposure to blood or other potentially infectious materials. The employees who perform these tasks or procedures will receive the training and immunizations described below as described in the Exposure Control Plan,


Each clinic manager must ensure that:

  • This plan is accessible to all affected employees.

  • Education is provided within 10 scheduled working days for new employees and annually thereafter.

  • Staff compliance is monitored.

  • Personal protective equipment is available and maintained.

  • Equipment and environmental surface are cleaned and decontaminated.

The Division Chair or Section Chief of each department, faculty dentist, principal investigator of each lab, or other responsible administrators, managers, or supervisors will be responsible for implementing this plan by ensuring that healthcare workers/students in their department, lab or facility are educated, adhere to this policy and procedures to minimize, eliminate, and are protected from bloodborne pathogen exposure.


Departmental supervisors/managers/principal investigators will notify ECU Infection Control or Biological Safety when changes occur in personnel assignments, equipment, or responsibilities that increase employee exposure to bloodborne pathogens.
3.2 Exposure Risk by Job Title

The SoDM positions listed below have direct contact with patient secretions including saliva or mucous, which may contain blood from the mouth, including spatter and spray affecting Personal Protective Equipment (“PPE), dental instruments and work surfaces:



  • Director of Clinics (dental faculty-direct contact during patient treatment or oversight)

  • Dental Faculty (direct contact during patient treatment)

  • Dental Assistant (direct contact while assisting during patient treatment, handling sharps, relocating sharps containers, relocating biohazard waste bags to collection site)

  • Dental Assistant Supervisor (direct contact while assisting during patient treatment, handling sharps, relocating sharps containers, relocating biohazard waste bags to collection site)

  • Dental Hygienist (direct contact during patient treatment, handling sharps)

  • Dental Hygiene Supervisor (direct contact during patient treatment, handling sharps)

  • Housekeeper (housekeeping tasks in the patient-care areas where blood and other potentially infectious materials may be present)

  • Instrument Management Supply Technician (direct contact with contaminated dental instruments)

  • Instrument Management Supply Technician Supervisor (direct contact with contaminated dental instruments)

  • Predoctoral Dental Student (direct contact during patient treatment, handling sharps)

  • Laboratory Technician (direct contact with potentially contaminated items-impressions, removable prosthodontics-bridges, partial and complete dentures)

  • Laboratory Technician Supervisor (direct contact with potentially contaminated items-impressions, removable prosthodontics-bridges, partial and complete dentures)

  • Radiologic Technologist (direct contact during patient treatment)

  • Registered Nurse (direct contact during medication administration, starting/removing IVs, changing bloody gauze or assisting with sedation during dental treatment)

  • Research Faculty, Student, Assistant (handling patient blood, saliva, tissue samples)

  • Dental Resident (direct contact during patient treatment, handling sharps)

The following positions have potentially minimal contact with contaminated dental equipment during repairs, such as suction traps and dental units.



  • Director of Facilities

  • General Repair Technician

  • Dental Repair Technician

The administrative positions listed below work near the patient care area in which occupational exposure may occur via indirect patient contact (spills of blood and other potentially infectious materials, patient coughing, sneezing)



  • Administrative Support Associate

  • Administrative Support Specialist (Front Desk staff)

  • Cashier

  • Clinic Manager

  • Patient Care Coordinator (administrative duties)

  • Receptionist

  • Quality Assurance Coordinator/Director

NOTE: The individual’s need for coverage for bloodborne pathogen purposes is determined using the Initial Health History and the actual risk in the individual’s particular assignment, not on the job class.


Definitions of blood, body fluid or other potentially infectious materials in the dental clinic (see Appendix A for additional definitions)

  • Human blood

  • Body Fluid

  • Unfixed human tissue

3.3 Standard/Universal Precautions

Standard Precautions should be consistently used for work with human blood and other potentially infectious materials. To prevent contact with blood or other potentially infectious materials faculty, staff, students, residents and other healthcare workers shall observe Standard/Universal Precautions. All blood/body fluids should be considered potentially infectious materials. Standard/Universal Precautions include the routine use of appropriate barrier precautions to prevent skin and mucous membrane exposure with blood or other potentially infectious materials of any patient or specimen.

Compliance with Standard (Universal) Precautions and Work Practice Controls will be monitored through periodic clinic inspections and direct observation by designated employees.


Hands must be free of open, draining wounds, and gloved during patient assessment and dental treatment. Non-intact skin must be covered.
3.4 Hand Washing

Strict hand washing technique is to be used in all instances of contact with any patient’s blood or other potentially infectious fluids, by following the “Hand Washing Protocol”.

This protocol is designed to provide consistency in the technique and application of hand washing as an infection control measure to help safeguard patients and personnel from transmission of infection.
Hand washing is the MOST important means of preventing the spread of infection. Soap, running water, and friction are the three important components of hand washing. If hand washing facilities are not immediately available, (e.g., volunteer dental activities not on campus or at clinics) antiseptic hand cleaners in conjunction with clean cloth/paper towels or antiseptic hand wipes or antibacterial gels will be available. Hand washing is the preferred method, and is required when hands are visibly soiled.
Wash your hands:


  • Before and after work or clinic session

  • Between each patient contact

  • Before and after each procedure on a patient

  • Immediately after contact with blood or other potentially infectious materials, especially a needle stick

  • After removing any gloves and personal protective equipment

  • Before and after using the restroom

  • Before and after eating

  • Before and after entering a laboratory

  • Before putting on gloves

  • After removing gloves

Steps to Effective Hand Washing:



  • Wet hands

  • Apply soap

  • Scrub hands 20-30 seconds - pay close attention to the area between fingers, back of hands, underneath finger nails and wrists

  • Rinse hands well

  • Dry hands working up from hands to wrist (clean to dirty)

  • Turn off faucet (if needed) using a towel - the faucet handles are considered to be contaminated

  • Dispose of towel in appropriate receptacle

Alcohol Based Hand Rubs:

Unless hands are visibly soiled or contaminated with blood or body fluids, alcohol based hand rubs may be used to clean hands. Apply product to palm of hand according to manufacturer’s directions for amount.
Rub hands together, covering all surfaces of hands and fingers until hands are dry.

Alcohol based hand rubs are not effective against spore-forming bacteria such as C difficile. For



C difficile related infections, hands should be washed with soap and water to physically remove spores from the surface of contaminated hands.
3.5 Personal Protective Equipment (“PPE”)

  • PPE is provided to employees at no cost, and is located in each clinical and research area. The clinic manager or infection control coordinator is required to provide training in the use of the appropriate PPE for the tasks or procedures employees will perform.

See Appendix B for a listing of routine dental procedures and required PPE.

  • Each clinic manager is responsible for ensuring that appropriate PPE is available to every employee, and that it is used when needed. Required PPE shall be worn when the employee has potential for exposure to blood and other potentially infectious materials on their clothes or body.

  • Personal protective equipment is considered appropriate if it prevents blood or other potentially infectious materials to pass through to or reach the employee’s work clothes, street clothes, undergarments, skin, eyes, mouth or other mucous membranes under normal conditions of use and for the duration of time during which it is used.

  • Personal protective equipment such as gloves, gowns, laboratory coats, face shields or masks and eye protection, mouthpieces, resuscitation bags, pocket masks, and other related devices are kept available in appropriate sizes, and easily accessible to the employee.

  • Scrubs will be worn with PPE during dental exams and treatment appointments.

  • Face Masks or chin-length face shields and eye protection (safety glasses with side shields and loops), are worn when the employee is engaged in activities that have the potential for splashes, spray, spatters, droplets or aerosols of blood or other potentially infectious material or fluid to the eye or mouth. Masks must cover the nose and mouth and fit securely. Employees must not share goggles that have not been disinfected and will not wear masks dangling from neck. The patient will wear disinfected protective eyewear during the indicated dental treatment. Employees will be respiratory fit tested and retested as indicated in the Prospective Health Infection Control policy.

  • Fluid resistant protection will be worn if there is potential for splashing or spraying of blood or other potentially infectious material. Surgical caps shall be worn if there is potential for splash to the head. Fluid proof shoe covers shall be worn if there is potential for shoes to become contaminated or splashed.

  • If any garment is penetrated by potentially infectious material, the garment shall be removed immediately or as soon as feasible, and laundered separately.

  • Appropriate protective barriers will be used to prevent exposure to the plume generated by an electrosurgery or laser unit.

  • PPE shall be removed prior to leaving the clinic or research work area and placed in appropriately designated container for disposal or washing and decontamination.

  • PPE will not be worn outside of the clinic or research area.

  • Reusable personal protective equipment must be repaired or replaced when needed to maintain effectiveness, and will be cleaned, laundered or disposed of at no cost to the employee.

3.6 Gloves and Glove Selection

Gloves are worn when the worker has a potential for direct skin contact with blood, other potentially infectious materials, mucous membranes or non-intact skin of patients, or when handling items or surfaces contaminated with blood or other potentially infectious materials, and when performing vascular access procedures.
USED GLOVES ARE ASSUMED TO BE CONTAMINATED OR DIRTY, and must be removed before reaching for clean items and replaced with a fresh pair of gloves.


  • Nitrile gloves will be used during routine dental treatment. Double gloving may be used during surgical procedures when copious blood flow is anticipated. Sterile gloves should be used for procedures involving contact during surgical procedures such as oral, periodontal, or endodontic surgery.

  • Non-sterile examination gloves may be used for procedures involving contact with mucous membranes, and for other patient care or diagnostic procedures.

  • Single-use surgical or examination gloves are not to be washed or disinfected for reuse. They should be removed and replaced when visibly soiled, torn, punctured, or when their ability to function as a barrier is compromised. They should NOT be worn to handle items in the environment after the procedure has been completed.

  • Utility gloves (e.g. rubber or vinyl household gloves) for housekeeping chores involving potential blood contact or for instrument cleaning and decontamination procedures can be reused. Utility gloves may be disinfected and reused, but should be discarded if they are peeling, cracked, or discolored, or it they have puncture, tears, or other evidence of deterioration or other ability to function as a barrier is compromised.

  • Latex-free or hypoallergenic gloves, glove liners, powder-less gloves, or other similar alternatives, shall be readily accessible for those employees who are allergic to the gloves normally provided. Use of non-latex gloves for cleaning or other tasks not requiring tactile sensitivity is strongly encouraged. Latex-free gloves, vinyl gloves, and nitrile gloves are available in the in clinics and research laboratories.

3.6.1 Latex Sensitivity and Contact Dermatitis



Occupationally related contact dermatitis can develop from frequent and repeated use of hand hygiene products, exposure to chemicals, and glove use. Contact dermatitis is classified as either irritant or allergic. Irritant contact dermatitis is common, nonallergic, and develops as dry, itchy, irritated areas on the skin around the area of contact. By comparison, allergic contact dermatitis (type IV hypersensitivity) can result from exposure to accelerators and other chemicals used in the manufacture of rubber gloves (e.g., natural rubber latex, nitrile, and neoprene), as well as from other chemicals found in the dental practice setting (e.g., methacrylates). Allergic contact dermatitis often manifests as a rash beginning hours after contact and, similar to irritant dermatitis, is usually confined to the area of contact.
Latex allergy (type I hypersensitivity to latex proteins) can be a more serious systemic allergic reaction, usually beginning within minutes of exposure but sometimes occurring hours later and producing varied symptoms. More common reactions include runny nose, sneezing, itchy eyes, scratchy throat, hives, and itchy burning skin sensations. More severe symptoms include asthma marked by difficult breathing, coughing spells, and wheezing; cardiovascular and gastrointestinal ailments; and in rare cases, anaphylaxis and death.
ECU SoDM is committed to a latex-reduced environment, including the exclusion of latex gloves in the clinic and laboratories. Patient latex sensitivity will be assessed at the initial appointment. See Appendix D for further information.
3.7 Bloodborne Pathogen Post Exposure Protocol, also Appendix C

  • In the event of a bloodborne pathogen exposure, immediate attention is required.

  • Discontinue dental treatment, but DO NOT DISCHARGE THE SOURCE PATIENT (the source of the blood or other potentially infectious material) until advised.

  • Carefully remove contaminated PPE.

  • Immediately wash the affected area with an antimicrobial soap or rinse exposed eye(s) or mucous membranes for 15 minutes with cool water or rinse eyes at the Eye Wash Station.

  • Discuss the exposure with your supervisor, review source patient’s health history and contact the appropriate Medical Provider to determine risk of transmission from source patient.

  • Arrange for medical testing and subsequent follow up with the appropriate Medical Provider when indicated.

  • Arrange for source patient testing when an exposure is determined.

  • Document the event on SoDM forms available at the Office of Clinical Affairs intranet.

  • Employees are required to complete the following forms:

    • Employee Statement of Injury http://www.ecu.edu/cs-admin/oehs/ih/workerscomp.cfm

    • Form 19 http://www.ecu.edu/cs-admin/oehs/ih/workerscomp.cfm

  • Supervisors are required to complete the

    • Supervisor’s Report http://www.ecu.edu/cs-admin/oehs/ih/workerscomp.cfm

  • Notify the Office of Clinical Affairs 252 737-7008, maintaining confidentiality.

  • Employees and Predoctoral Students in Community Service Learning Centers-Contact the designated medical provider partner for risk evaluation of the injured employee/student and source patient, and indicated blood work.

  • Employees in Ross Hall, Greenville-contact Office of Prospective Health (252 744-2070) for further instructions.

  • After hours and when the Office of Prospective Health or identified medical partner for the CSLCs is closed, use the OraQuick Rapid HIV test. If the results are positive, the source patient and exposed party need to report to Vidant Medical Center’s emergency room for immediate testing. If the result is negative, the source patient and exposed party can report to the Office of Prospective Health or the designated medical partner the next business day for testing.

  • Community Service Learning Centers without access to a 24 hour pharmacy will maintain a minimum of a 3 day supply of the post exposure treatment medication in the office safe. This medication is to be distributed by the CSLC director with the approval of Dr. Paul Barry, Director of the Office of Prospective Health.

  • General Practice Residents in the Hospital Dentistry Clinic will follow Vidant Medical Center’s policy and procedures. Vidant Medical Center employees will report the incident to Vidant Occupational Health (252 847-4386 Mon-Friday 7am-7pm) and complete the Vidant Facility Incident Report. Vidant Occupational Health will investigate the source patient and the exposure.

  • Employees and students are required to comply with ECU’s policy and North Carolina’s requirement for work restrictions for infected healthcare workers.

  • ECU SoDM is committed to a latex-reduced environment, including the exclusion of latex gloves in the clinic and laboratories. Patient latex sensitivity will be assessed at the initial appointment. See Appendix D for further information.

4.0 Cleaning Blood Spills



Use protective gloves and other personal protective equipment (PPE), gown, mask, and protective eyewear appropriate for the cleaning up a blood spill. As a general guideline, spills larger than 100 ml (approximately 1⁄2 cup) are considered large. Those less than 20 ml (approximately 4 tablespoons) are considered small. For others, the pattern of the spill determines the cleaning approach.

  • To clean a small spill (<20 ml)

  1. Don gloves

  2. Use mechanical means such as forceps to pick up any contaminated sharps or broken glass and place in biohazard sharps containers.

  3. Carefully remove visible blood or other potentially infectious material with paper towels or other absorbent paper and dispose in biohazard waste container.

  4. Swab the area with a cloth or paper towel moderately wetted with a disinfectant (an EPA-registered sodium hypochlorite product such as Dispatch). Allow disinfectant to sit for 10 minutes. May use Cavi-wipes to clean small blood spills.

  5. Wipe with a clean paper towel or air dry.

  6. Dispose of gloves and all contaminated items in a biohazard waste container.

  7. Wash hands using soap and water for 20-30 seconds.

  • To clean large amounts of blood (>100ml) or more than can be absorbed by paper towels:

  1. Secure the area to prevent employees or visitors from exposure.

  2. Report spill to supervisor. Utilize Biohazard spill kit. Contact housekeeping if assistance is needed.

  3. Community Service Learning Centers will contact the local phone number for Stericycle (located in the business manager’s office) for extensive cleanup, e.g., exceeding 4x4 ft in area, trauma site, or crime scene (after police have investigated the crime).

  4. Don PPE (gloves, gown, mask and eye protection).

  5. Use mechanical means such as forceps to pick up any contaminated sharps or broken glass and place in biohazard sharps containers.

  6. Remove visible blood or other organic material.

  7. Sprinkle the fluid control solidifier (designated absorbent powder) on the spill. Allow the absorbent powder to sit for 10-15 minutes as needed to absorb all liquid.

  8. While using PPE, sweep contents and dispose in biohazard waste container.

  9. Discard all cleaning materials in a biohazard waste container.

  10. Apply disinfectant (an EPA-registered sodium hypochlorite product such as Dispatch) to the spill area, keeping the area wet for 10 minutes.

  11. Wipe clean or air dry.

  12. Remove personal protective equipment and place in the biohazard waste container.

  13. Wash hands using soap and water for 20-30 seconds.

  14. The supervisor will replace contents of the spill kit.

For advice about spills that cannot be contained by using the Biohazard Spill Kit or which exceeds the cleaning capability of Housekeeping, contact Infection Control (252-744-2070) or Biological Safety (252-744-3437). The Community Service Learning Center will also call Stericycle if needed.

5.0 Clinic Inspection

The Office of Prospective Health Infection Control Nurse will inspect dental clinics at least annually, using the inspection form in Appendix E, which may be periodically modified to better reflect the conditions prevailing in the dental clinic. Deficiencies discovered during clinic inspections will be reported to the clinic manager and infection control designee for immediate attention and at least quarterly to the Director of Clinics. The Office of Prospective Health will report aggregate inspection results to the ECU Infection Control Committee. Periodic inspections may be conducted by the clinic manager, the Quality Assurance Coordinator or designee.
6.0 Dental Asepsis

It is the responsibility of all clinic staff and dental providers to maintain a clean treatment area to prevent the transmission of disease to/from patients before, during and after dental treatment. The basic principle of “dirty to dirty and clean to clean” is relevant when setting up the operatory, treating the patient, cleaning the operatory between patients, terminal cleaning, and transporting items for sterilization. Strict hand hygiene will be followed. The Central Sterilization and Instrument Management Supply areas have clearly delineated areas for receiving, cleaning, packaging, sterilizing and storing dental instruments. Engineering controls, work practices and standard operating procedures address required activities that serve to protect the patient, staff and dental providers from transmission of disease.


7.0 Engineering Controls

  • Engineering controls will be used to eliminate or minimize worker exposure to chemicals and bloodborne pathogens. Changes in Engineering Controls or work practices will be made, as needed through review of exposure reports, inspections, employee input, and committee activities.

  • Hand washing facilities are located in areas that are readily accessible

  • Eyewash stations – in every clinic and research laboratory

  • Use of waterless hand cleaners to supplement hand washing of nonvisibly soiled hands will be available. Soap and antibacterial gel dispensers will not be “topped off”, instead inserts will be replaced as needed

  • Needles/Sharps: All employees should take precautions to prevent injuries caused by needles, scalpels, and other sharp dental instruments or devices and when handling used sharp instruments after before, during and after dental procedures

  • Contaminated needles and other contaminated sharps shall not be bent, recapped, removed, or otherwise manipulated by hand except when there is no alternative feasible or that such action is required by a specific dental procedure. If recapping or removing contaminated needles or sharps must be done, it is only to be done by use of a mechanical device (recapping cuff) or by using a one-handed scoop technique

  • Contaminated sharps and disposable syringes and needles, scalpel blades, and other sharp items should be placed in impermeable sharps containers as close as practical to the use area. Reusable sharps are placed into appropriate containers (cassettes and/or impermeable transport bins) for safe transport to the dirty entrance of Central Sterilization or Instrument Supply Management.

  • Containers for sharps are puncture resistant, labeled or color-coded, leak-proof on the sides and bottom and are not stored or processed in a manner that requires employees to reach by hand into the containers.

  • Containers for disposable sharps are located in each dental operatory, treatment rooms, clinical and research laboratories and any other area where sharps are used. Staff will check these containers routinely and when 2/3 to 3/4 full they are to be sealed and relocated for pick up by the Biohazardous Waste Collection Technician for incineration.

  • The ECU Standardization Committee, Safety Devices Subcommittee, chaired by the Office of Prospective Health’s Infection Control Nurse, evaluates new safety devices at least annually. Safer medical devices for vascular access, devices for intra muscular access, subcutaneous injections and other safety devices for specialty clinic situations are evaluated by the subcommittee and recommended for purchase through the Product Standardization Committee. The School of Dental Medicine will advise the Standardization Committee when new dental needles and other relevant safety devices become available for evaluation.

7.1 Work Practices



  • All procedures involving blood or other potentially infectious materials are performed in such a manner as to minimize splashing, spraying, aerosolization, or plume formation (e.g., use of electrosurgery) of the substances. Examples may include using dental dams and placing barrier film on dental units, lights, chairs and patient chair controls.

  • Personal Hygiene: Eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses are prohibited in clinic and research or work areas where blood or other potentially infectious materials are likely to be present. Food of any kind is not allowed in any clinical area.

  • Food and drink are not stored in refrigerators, freezers, or cabinets where blood or other potentially infectious materials or medications are stored or in other areas of possible contamination such as clinic or laboratory counter tops.

  • Medications/dental products that require refrigeration will be stored separately. The refrigerator will be clearly labeled accordingly. The temperature range will be established and maintained based on product manufacturer recommendations. Temperatures will be measured and recorded at least daily and recorded on a designated logs.

  • Refrigerators will be disinfected at least monthly and as needed for spills with an approved disinfectant, and the cleaning log updated.

  • Employees who have exudative lesions or weeping open wounds or sores on their hands, which preclude effective hand washing, may require removal from patient contact. Other lesions or skin breaks may be covered with a protective dressing if they do not preclude adequate hand washing. (Refer to the Work Restrictions for Personnel policy found at the following link: http://www.ecu.edu/cs-dhs/prospectivehealth/upload/01WORKRestriction-2-3.doc.) Additional information is available in Appendix D.

  • Employees infected with a bloodborne infectious illness are required to disclose this information to the Office of Prospective Health, which will determine risk and advise the employee what restrictions may be imposed on work practice. Prospective Health will follow the state of North Carolina’s procedures for reporting communicable diseases.

  • Vacutainer holders (for drawing blood) are disposed of after a single use, without removing the needle.

  • Broken glassware that may be contaminated will not be picked up directly by the hands. It shall be cleaned up using mechanical means, such as a brush and a dustpan, tongs, or forceps.

  • Labels and Warnings: Warning labels are affixed to containers of infectious waste, refrigerators and freezers containing blood or other potentially infectious material or other containers used to store or transport blood or other potentially infectious materials. The labels are fluorescent orange or orange-red, using the accepted biohazard label and affixed as closely as safely possible to the container by string, wire, adhesive, or other method that prevents their loss or unintentional removal. Red bags or red containers may be substituted for labels on containers of infectious waste.

  • Waste: Place non-contaminated trash in a plastic bag for pick-up by Housekeeping. Biohazardous (contaminated trash that is completely blood soaked, e.g., gauze) is placed into a covered receptacle lined with a red or orange bag with biohazard label to be placed in the biohazard area by clinical staff and pick up by Prospective Health or designated vendor. Designated staff may move the red bags to a central pick-up site. If outside contamination of the primary container occurs, the primary container shall be placed into a second container that prevents leakage during handling, processing, storage, transport, or shipping, and is labeled or color-coded appropriately. Waste materials known to be infectious should be rendered non-infectious by processes such as autoclaving or immersion in liquid disinfectant. ECU contracts with Stericycle for the collection and disposal of regulated waste.

  • Specimens: if the specimen could puncture the primary container, the primary container will be placed within a secondary puncture-resistant container in addition to the above characteristics.

  • Specimens of blood or other potentially infectious materials shall be placed in a closeable leak-proof container and labeled or color-coded prior to being stored or transported. If outside contamination of the primary container is likely, then a second leak-proof container that is labeled or color coded shall be placed over the outside of the first one and closed to prevent leakage during handling, storage, or transport. If a puncture in the container is likely, it shall be placed in a leak-proof, puncture-resistant secondary container.

  • All laboratory specimens will be placed in a container marked with the biohazard label. All specimens will be placed in a secondary container marked with the biohazard label. These containers will be located in each patient clinical area, clinical laboratory or research area for use.

  • All dental instruments will be cleaned to remove visible blood or tissue particles prior to sterilization following sterilization protocols and manufacturer recommendation. Autoclaves will be spore-tested at least weekly. Results will be recorded. If a result is unfavorable, the manufacturer’s recommendations will be followed to ensure adequate sterilization.

  • Electrosurgery and Laser Plume (smoke) inhalation exposure will be minimized by the use of high filtration face masks/shields along with placing the dental unit suction in close proximity to the source. At the end of the procedure the dental assistant will seal the suction tubing to provide negative pressure for at least 5 seconds before the electrosurgery unit is turned off. This will prevent flow of the plume out of the suction tubing.

  • The patient and employees will wear protective eyewear of the appropriate wavelength during laser treatment. A warning notice of “laser in use” will be posted just outside of the treatment area.

  • Equipment: equipment which may become contaminated with blood or other potentially infectious materials shall be cleaned and disinfected as necessary prior to servicing, shipping or being moved, stored or sent to surplus. If disinfection of such equipment or portions of such equipment is not feasible, a readily observable label shall be attached to the equipment stating which portions remain contaminated. This information is conveyed to all affected employees, the servicing representative, and/or the manufacturer, as appropriate, prior to handling, servicing, or shipping so the appropriate precautions will be taken. Examples may include centrifuges, chemistry/hematology machinery, refrigerators, laser machinery, etc.

  • Saliva Ejectors: backflow from low-volume saliva ejectors occurs when the pressure in the patient's mouth is less than that in the evacuator. When patients close their lips and form a seal around the tip of the ejector, a partial vacuum is created. Research suggests that in these situations previously suctioned fluids might be retracted into the patient's mouth. Furthermore, studies have shown that gravity pulls fluid back toward the patient's mouth whenever a length of the suction tubing holding the tip is positioned above the patient's mouth or when a saliva injector is used at the same time as other evacuation (high volume) equipment. Although no adverse health effects associated with the saliva ejector have been reported, dental health care personnel should be aware that backflow could occur when they use a saliva ejector. Do not advise patients to close their lips tightly around the tip of the saliva ejector to evacuate oral fluids. Suction lines should be disinfected daily.

8.0 Standard Operating Procedures

ECU SoDM has developed Standard Operating Procedures specifically for the CSLCs and Ross Hall. The manual is located in Central Sterilization and at the Office of Clinical Affairs intranet. SOP’s for imaging can be reviewed in the Radiation Safety Manual located in iBooks and the Imaging Area.

9.0 Service Dog in the Clinic

The American with Disabilities Act mandates that persons who require the use of a service dog (which is NOT a pet) shall have access to patient care and will be treated without discrimination. North Carolina General Statute follows:

a) Every person with a disability has the right to be accompanied by a service animal trained to assist the person with his or her specific disability in any of the places listed in G.S. 168?3, and has the right to keep the service animal on any premises the person leases, rents, or uses. The person qualifies for these rights upon the showing of a tag, issued by the Department of Health and Human Services, under G.S. 168?4.3, stamped "NORTH CAROLINA SERVICE ANIMAL PERMANENT REGISTRATION" and stamped with a registration number, or upon a showing that the animal is being trained or has been trained as a service animal. The service animal may accompany a person in any of the places listed in G.S. 1683

(b) An animal in training to become a service animal may be taken into any of the places listed in G.S. 168?3 for the purpose of training when the animal is accompanied by a person who is training the service animal and the animal wears a collar and leash, harness, or cape that identifies the animal as a service animal in training. The trainer shall be liable for any damage caused by the animal while using a public conveyance or on the premises of a public facility or other place listed in G.S. 1683 (1985, c. 514, s. 1; 1987, c. 401, s. 1; 1995, c. 276, s. 1; 1997443, s. 11A.118(a); 2004203, s. 62(a); 2005450, s. 1.)

The patient is responsible for the service dog at all times; the service dog may not disrupt the patient’s dental treatment. If deemed necessary, the patient appointment will be rescheduled when the patient is able to provide an adult to supervise the service dog during the dental appointment.



If at anytime the service dog is perceived as a threat at any location in the clinic, the patient’s appointment will be rescheduled without the service dog. For questions about service animals or other requirements of the ADA, call the U.S. Department of Justice's toll-free ADA Information Line at 800-514-0301 (voice) or 800-514-0383 (TDD).
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