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



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Appendix E Dental Clinic Inspection Form Form # 910.5.3 B

Clinic/Location ________________________Date__________

Observer _________________


Category

Critical


X = not met

Observations Evaluated


Comments

Proper use of work

practice/

engineering controls





Proper hand washing







Proper use of PPE







Availability of appropriate PPE







Proper handling of sharps (no bending, breaking, recapping of needles, disposal in sharps container)

Dental Clinic-use of recapping cuff or single hand scoop technique









Appropriate use of approved safety devices




Proper handling/

disposal


of biohazardous waste




Sharps containers stable, accessible and not overfilled







Contaminated waste placed in red biohazardous bags and covered/uncontaminated waste placed in regular trash

.




Single use (disposable) items not reprocessed








Appropriate placement of biohazardous labels




Adequate staff knowledge/

education






Can locate Exposure Control Plan







Knowledge of blood spill cleanup procedure







Can state procedure to follow in the event of a blood or other potentially infectious material exposure

--immediate first aid, persons to notify, have source pt. remain available









Can state signs and symptoms of TB







Knowledge of N-95 mask and PAPRA







Knowledge of negative pressure rooms

Monthly gauge log maintained

(Dental clinics NA)








Annual BBP/TB training of all staff







Other




Sterilization





Cleaning routine for sterilizer







Chemical indicators used in every pack







Biological monitors used weekly or

with each run if used less than weekly









Documentation of monitoring maintained







Staff skills validated for processing of instruments




Disinfection





Approved surface disinfectant available
















Test strip bottle dated when opened,

documentation of QA check (NA)









Cavacide container labeled with date of activation

Soaking containers covered and labeled





Category

General




Observations Evaluated

X= not met



Comments

Clear separation of clean and dirty activities




Separate sinks for hand washing and specimen discarding/cleaning instruments.






Reprocessing area separate from packaging area or a divider in place







No eating, drinking, applying cosmetics in areas where specimens are handled




Hand washing facilities




Hand washing sink labeled in Central Sterilization







Functional soap available







No topping off of soap dispensers







Paper towels in dispenser, not stored behind faucet







Waterless hand cleaner available in absence of soap and water



Medications




No preparation within 3ft. of sink







No expired medications







Multi dose vials dated when opened







Single dose vials discarded




Storage




No pt care items under sinks







No pt care items within 3 ft of sink






No pt care items/boxes on floor (8” off floor, 12” from ceiling)







No shipping cartons







Sterile items stored so package is not compromised. Cabinets closed.




Refrigerators




Appropriate contents (medications, specimens, nourishments)







Temperature monitored and recorded.

Refrigerator temp 1º to 5ºC, 34º to 41º F



Freezer temp -10ºto -20ºC, -4ºto 14ºF







Clean, no spills or standing water







Open items dated




Noncritical patient care equipment




Maintain regular cleaning schedule

.





No visible soiling




Linen/laundry




Clean linen covered or in closed closet/cabinet







6” off floor, 18” from sprinkler







Impervious bags for soiled linen







Soiled linen covered and bags not overfilled




Housekeeping




Door closed to housekeeping closet







Containers labeled, dated







Mop heads changed hung to dry







Horizontal surfaces clean, dust free





Toys (if applicable)





No stuffed toys







Routine cleaning schedule







Approved disinfectant (no phenolics)




Facility




Carpet/ceiling tiles dry/free of stains/soil







Signage displayed regarding coughing, masks, small pox vaccinations







Bathrooms clean







Employee lounge clean





Other:

Waterline Testing-hand piece, suction, waterline


Dental unit maintenance, handpiece, air/water and suction treatment, shocking
Suction trap maintenance-cleaning/replacing
Water bottle maintenance log
Soap/water spray bottles date/labels




Observations Evaluated

X= not met




Comments


Rev May 2014
Appendix F Clinic Employee Infection Control Training Requirements:
Initial Orientation and Annual Review

Infection Control Training Checklist

  • Autoclave Competency

  • Biological Waste Management/Packaging (Stericycle protocol)

  • Bloodborne Pathogen Exposure Control Protocol and Post Exposure Protocol

  • Chemical Hygiene Plan & MSDS

  • Dental Asepsis and PPE Selection

  • Laboratory Drain Log Sinks Documentation and Location

  • Engineering Controls and Work Practices

  • Hand Hygiene

  • Hand Washing Sink

  • Handling Contaminated Waste

  • Handling Sharps

  • Laboratory Safety Procedures

  • Radiation Safety and Infection Control

  • Routine Environmental Cleaning

  • Refrigerator Temperature Monitoring

  • Standard Operating Procedures

  • TB Surveillance

  • Waterline Testing

ECU School of Dental Medicine Infection Control Orientation and Annual Training Checklist
Name____________________ Title_________________ Date ____________
__ Initial Orientation __ Annual Training
Supervisor _________________ Title _________________ Date ____________

I have read the Infection Control Manual, understand and will comply with all items within this manual, including the following topics. I agree to follow the Standard Operating Procedures as they apply to my job responsibilities. I am able to locate all relevant Clinic Manuals (hard copy and online versions).
__Autoclave Use and Monitoring

__Biological Waste Management/Packaging (Stericycle protocol)

__Bloodborne Pathogen Exposure Control

__Bloodborne Pathogen Post Exposure Protocol (location and procedure)

__Central Sterilization, Instrument Processing including Dental Handpieces

__Chemical Hygiene Plan & MSDS (location of manual and MSDS)

__Dental Asepsis

__Drain Log, Documentation and Location

__Engineering Controls and Work Practices

__General Cleaning, Disinfecting Dental Surfaces

__Hand Hygiene

__Hand Washing Sink

__Handling Contaminated Waste

__Handling Sharps

__Laboratory Safety Procedures

__Radiation Safety and Infection Control

__Routine Environmental Surface Cleaning

__Refrigerator Temperature Monitoring and Cleaning

__Standard Operating Procedures

__TB Surveillance

__Waterline Testing
Other: _______________________________
Autoclave Competency Checklist
Name: ___________________________ Date: _____________________
Title: ____________________________ Clinic: ___________________
Competency Criteria: Must meet all elements Circle Grade: Pass Fail


Met

Not Met

Criteria







Verifies knowledge and performance of routine maintenance per manufacturer’s recommendations







Assures items are appropriately cleaned and dried prior to packaging for sterilization







Places a chemical indicator inside each package to verify steam penetration







Places all instruments in the open position and/or dissembles to their smallest parts; protects sharp points with gauze







Labels package with date of sterilization; load number; initials of person preparing package







Follows manufacturer’s directions for the loading and operation of autoclave ensuring that packs are loaded in manner that allows for free steam and air circulation







Knows biological monitoring is done on a weekly basis or with each load if run less than weekly

Knows how to process outside vendor testing









Knows how to interpret the chemical and biological indicator results, and appropriate follow up







Describes the recall procedure for a positive results

Removes items from that load number

Repackages items from that load number

Runs a test load without instruments

Notifies supervisor of positive test result

Requests Manufacturer Service

Labels Autoclave as “not in service”








Assures all results are recorded in autoclave log and stored in an organized manner







Checks processed packages for tears, puncture, moisture or broken seal

I certify that this individual has met all competencies for sterilization.



Supervisor: ________________________ Date: __________________

Appendix G Clinic Logs

I. Autoclave Sterilization Testing Log


II. Chemical Drain Log for Designated Laboratory Sinks
III. Refrigerator Temperature and Cleaning Log
IV. Waterline Testing Schedule and Testing Log

ECU School of Dental Medicine Autoclave Sterilization Log

Clinic Location _____________

Month _______ Year _____ Number (if more than one per location) _____



Date

Load Number

Contents

Result

Pass Fail

Supervisor Notified

yes/no


Facilities Notified
yes/no

Action taken

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Annual Maintenance Date of Service _________



Instructions: http://www.ecu.edu/cs-admin/oehs/ih/upload/instructions_for_Drain_Log.doc


























Department :

Building:




Room #:
















Date

Chemical Name

Amount (volume)

pH

Responsible Party

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
ECU School of Dental Medicine Laboratory (dedicated sink) Drain Log
ECU School of Dental Medicine Refrigerator/Freezer Monitoring and Cleaning Log
SoDM Clinic Location __________________ Month____________ Year____


Type of Refrigerator

Temperature Requirements

Nutrition

1˚-5˚C ( 34˚-41˚F)

Medication

2˚-8˚C (36˚-46˚F)

Freezers

ˉ20˚-ˉ10˚C (ˉ4-14˚F)

Pathology specimens

2˚-8˚C (36˚-46˚F)



Day

Temp

Temperature Adjusted and Result

Initials

Date Cleaned

(monthly)

Initials

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ECU School of Dental Medicine Waterline Testing Log
Clinic _________________________ Month ________ Year _______


Day

Dental Unit Tested

Initials

Result must be

500 CFU to pass



PASS or FAIL

Action Taken

Repeat Test Result
PASS or FAIL

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Appendix H Autoclave Use and Monitoring
Purpose: Successful sterilization of any item depends not only on proper cleaning but also on proper preparation, packaging, and positioning in the load. These elements are as critical as choosing the correct exposure time and temperature. It is important that each item be prepared in a manner that will facilitate air removal, steam penetration, and steam contact with all surfaces of the device that are intended to be sterilized. In addition, efficient steam removal is necessary for proper drying and the prevention of wet packages at the end of the sterilization cycle
A. Acceptable wrapping materials

  • Single use peel packages

  • Specifically designed metal or plastic container

  • Medical grade steam sterilization wrap following the AAMI double wrap method

  • Only sterilization indicator tape should be used to secure packages.

B. Quality Control

External chemical indicators



  • Denote that the package has been exposed to physical conditions (i.e. steam and temperature) present in the steam sterilizer.

  • It should be placed on the outside of packaging material. This may be used as a form of closure for the package, such as indicator tape. Peel packs are pre-printed with the chemical indicator.

  • External indicator does not guarantee sterility.

Internal Chemical Indicators

  • An internal indicator must be used in each package to be sterilized.

  • The internal indicator should be placed in that area of the package considered least accessible to steam penetration; this may or may not be the center of the pack.

  • Internal indicator shows that steam and heat penetrated the package interior, but does not guarantee sterility.

Biological indicators

  • Only Biological spore indicators, consisting of spores of Bacillus stearothermophilus that comply with the American National Standard for saturated steam sterilization processes in health care facilities should be used.

  • Frequency of use:

    • during initial installation testing

    • after any major repairs of the sterilizer

    • at least weekly or with each load if run less than weekly The Biological Indicator shows that the steam and elevated temperature is sufficient to kill spores and verifies the effectiveness of sterilization process.

C. Labeling

  • The package must be labeled with a description of contents, if not visible (example: suture set).

  • Date of run/cycle

  • Identification of sterilizer if more than one sterilizer is used

  • Cycle/run number if used more than once per day

  • Initials of packer

  • Use a felt tip indelible ink marker to record on the tape or plastic side of a peel pack. Do not write on wrapper material or paper side of peel packs. This will prevent the ink from running, fading, or bleeding through the package and contaminating the contents.

D. Documentation

The following information should be recorded and maintained



  • date and time of the cycle

  • general description of the contents of the load

  • exposure time and temperature

  • name and initial of the operator

  • results of biological indicators, whenever used

  • chemical-indicator results maintenance record

E. Package Configurations and Regulations

  • Instruments should be carefully inspected for cleanliness and flaws or damage and then dried before packaging.

  • Instrument sets should be sterilized with all instruments held open and unlocked. Items that can be easily disassembled into component parts should be disassembled prior to sterilization.

  • Surgical supplies, such as syringes, needles and similar items, must be packaged individually. Syringes should be packaged so that the barrel lies next to the plunger. Stylets should be removed from syringes or trocars.

  • Tip protectors should be steam-permeable, fit loosely, and be used according to manufacture’s instructions.

  • Follow manufacture’s recommendations for size, weight, and density of textile packs. Folding textiles in alternating directions will enhance steam penetration, air removal and drying. Packs should not touch chamber walls.

  • Nested basins should differ in diameter and be processed with absorbent towels or other absorbent material between nested basins of similar size.

  • Devices with stylets or plugs should be disassembled prior to steam sterilization. Devices with lumens (e.g., catheters, needles, and tubing) should be flushed with distilled, demineralized, or deionized water (as recommended by the manufacturer for use with the sterilizer) immediately before sterilization. If sterilization is delayed more that 24 hours, the devices should be unwrapped, the lumens flushed, and the devices repackaged. Devices with lumens should be placed on the shelf in the chamber so that the lumen is horizontal to the shelf.


Appendix I Forms


  1. ECU School of Dental Medicine Event Report-complete and send confidentially to the Office of Clinical Affairs




  1. ECU Prospective Health Non-Patient Incident Report-complete and send confidentially to the Office of Prospective Health

II. ECU Supervisor’s Report –complete and sends confidentially to the Office of Clinical Affairs


III. North Carolina Industrial Commission Form 19-complete and send confidentially to the Office of Prospective Health
Form 910.4.3

ECU School of Dental Medicine Event Report Rev. Nov 2013
Directions: Administer First Aid (when indicated). Notify Supervisor.

Is this is a possible Blood borne Pathogen Exposure (BBP)?

Vidant employees follow Vidant’s protocol.

  • Do NOT discharge source patient

  • Injured Person Calls ECU Office of Prospective Health for

Mandatory Risk Assessment

252-744-2070 (M-Fri 8-4:30 PM) Office closes at 4:30 PM

Do NOT place this form in the patient’s record

Submit this form to Office of Clinical Affairs within 24-hours of event. Attach a 2nd page if needed Phone: 252 737-7008 or Fax 252 737-7198
Reported by _________________________________ Title ______________________ Phone __________________
Date of Event ____/____/____ Time _____ Location (be specific) ________________________________
Dental Provider Name (Do not enter name if provider is the injured party) ___________________________________
Dental Provider Status (Check one) Faculty Resident Student

Supervising Clinical Faculty Name ___________________ Phone __________________
Staff Supervisor ___________________________________ Phone __________________
Witness(es) _______________________________________ Phone __________________
Injured Patient* Name ______________________ axiUm number ________ Date of Birth ___/___/___

*If injured party is NOT a patient, only check injured party’s status Faculty Resident Student Staff Visitor
Family member notified: yes no Family Member Name & Phone # ____________________________________
Nature of Injury & how it happened be specific:

(E.g., 1-inch laceration right index finger while placing a contaminated 23-gauge needle in sharps container)

_________________________________________________________________________________


Document the Interventions Provided Below (Leave Blank if N/A)

Prospective Health Risk Assessment for possible BBP Exposure Yes No N/A

First Aid (specify) ___________________________________ ☐ BLS ☐ EMS arrival time: ________

Temp ______ Pulse _____ Respiration _____ BP ____ /____ Pulse Oximetry _______ %

Blood Glucose _________ Repeat Glucose ___________

Oxygen __ liters/minute Nasal Cannula Face Mask

Person Repositioned, Trendelenburg
Medications Administered (list medication(s)/route/dose/time) __________________________________________________________________________________________________

__________________________________________________________________________________________________

Status

Treated on site, no further intervention required

Transported to medical facility via ☐EMSFamily

Refused medical assessment (excludes possible BBP exposure) or refuses medical transport or treatment,

Completed Refusal of Assessment &Treatment Form
Disposition

Employee, Resident, or Student: Returned to work ☐Sent for BBP Evaluation



Patient: Continued Appointment Stopped Appointment, discharged Sent for BBP Evaluation

ECU School of Dental Medicine Event Report


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