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Following an extensive consultation process that commenced in 1995, the Chinese

Medicine Registration Act 2000 (CMR Act) established a comprehensive system to

regulate the practice of Chinese medicine, including acupuncture, and the dispensing of

Chinese herbs. Victoria is the first state in Australia to register Chinese medicine

practitioners and consequently there is national and international interest in its progress.

The CMR Act was replaced by theHealth Professions Registration Act 2005 (HPR Act),which came into effect 1 July 2007. The HPR Act is a single piece of legislation

governing 12 health professions in Victoria.

Chinese Medicine Registration Board of Victoria

727 Heidelberg Rd

(PO Box 5088)

Alphington

Victoria 3078

AUSTRALIA

Ph 03 9499 3800

Fax 03 9499 8688Email [email protected]

Web http://www.cmrb.vic.gov.au

This work may be reproduced in whole or in part for study or training purposes on

condition that the source is acknowledged. This document is not available for commercial

use or sale.

Reproduction for purposes other than those indicated above requires written permission

from the Chinese Medicine Registration Board of Victoria, PO Box 5088, Alphington,

3078.

Chinese Medicine Registration Board of Victoria 2009

Published by the Chinese Medicine Registration Board of Victoria, and the Department of

Human Services, Victoria, Australia.


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F o r e w o r d

When the Chinese Medicine Registration Act 2000 (CMR Act) was passed by the

Victorian State Parliament in May 2000, Victoria became the first state in Australia tolegislate to regulate the profession of Chinese medicine. This was a milestone in the

practice of Chinese medicine in Australia and a critical step to protect the increasing

number of consumers who use Chinese medicine services for their primary healthcare.

The CMR Act established a framework for regulating practitioners of acupuncture,

Chinese herbal medicine and Chinese herbal dispensing.

The Chinese Medicine Registration Board of Victoria (CMR Board) comprises six

practitioners, a lawyer and three non-practitioners. It is empowered to:

establish standards of training for entry to the profession

approve training courses that meet the CMR Boards standards

publish codes for the guidance of registered practitioners

receive and investigate complaints of unprofessional conduct and apply sanctions,

including deregistration, if necessary.

The CMR Board has been registering and regulating practitioners since 1 January 2002

and has recently entered its third 3-year term. Given that the CMR Board is the first of its

kind in Australia, it has faced the enormous task of implementing the CMR Act, setting

up the systems required to register practitioners and deal with complaints, as well as

publishing policies and procedures to guide registered practitioners and ensure safe

practice.

Since the CMR Acts proclamation on 1 January 2002, practitioners who offer

acupuncture services to the public have either had to be registered in the acupuncture

division of the Register of Chinese Medicine Practitioners, or, for other registered health

practitioners, have an endorsement from their own registration board.

One effect of the introduction of the CMR Act was to move from the previous system of

registration of acupuncture premises under theHealth Act 1958, to a new system of

registration of practitioners under the CMR Act.

This means that in Victoria, it is no longer necessary for acupuncturists, who have been

granted registration under the CMR Act, to also have their premises registered with localgovernment, under theHealth Act 1958, for the provision of acupuncture services. Under

the previous system, acupuncturists referred to the Standards of Practice for Acupuncture,

Health (Infectious Diseases) Regulations 1990, issued by the Department of Human

Services under the Health (Infectious Diseases) Regulations 1990, for information on

infection control.

TheHealth Professions Registration Act 2005 (HPR Act) new legislation governing

the operations of the CMR Board came into effect on 1 July 2007, replacing the CMR

Act. This is a single piece of legislation governing 12 health professions in Victoria that

replaced 11 existing acts of the Parliament of Victoria.

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A draft version of the Guidelines on Infection Prevention and Control for Acupuncturists

and a summary of that draft were published in 2004, and an extensive consultation

process followed. The draft version was published on the CMR Boards website and

copies were issued to all registered practitioners and relevant stakeholders. Public

consultation meetings were held in both English and Chinese. Responses to the draft

guidelines were received from practitioners, education institutions and governmentbodies, and the comments made in these responses and at the public consultation

meetings were duly considered by the CMR Board before finalising these guidelines.

With the publication of this document, Guidelines on Infection Prevention and Control

for Acupuncturists, acupuncturists in Victoria are now required to comply with these

standards. Responsibility for ensuring compliance rests with the CMR Board.

These guidelines have been jointly issued with the support of:

Prof Vivian Lin

President


Victorian Advisory Committee on Infection Control

Department of Human Services, Victoria

Guidelines on Infection Prevention and Control for Acupuncturistsiv


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A c k n o w l ed g m en ts

This document outlines infection control guidelines for the practice of acupuncture in

Victoria. The guidelines have been developed primarily from other documents (which arelisted in the reading list at the end of these guidelines) and in consultation with the

Communicable Diseases Prevention and Control Unit of the Department of Human

Services.

The assistance of the following organisations is acknowledged:


Department of Human Services Practitioner Regulation Unit

Department of Human Services Communicable Diseases Prevention and Control Unit

Victorian health practitioner regulation boards.

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C o n t e n t s

Foreword .......................................................................................................................... iii

Acknowledgments..............................................................................................................v

Introduction ................................................................................................................... xiii

Glossary............................................................................................................................xv

Acronyms and abbreviations.........................................................................................xix

Chapter 1 Principles of infection control..............................................................11

1.1 Introduction ............................................................................................11

1.2 How infections occur..............................................................................11

1.2.1 Causes of contamination and cross-contamination....................12

1.3 Regulatory requirements for acupuncturists...........................................12

1.3.1 Health (Infectious Diseases) Regulation 2001...........................12

1.3.2 Health Professions Registration Act 2005.................................131.3.3 Occupational Health and Safety Act 1985 .................................13

1.4 Requirements for acupuncture training providers ..................................14

1.5 Workplace safety, infection control and risk assessment.......................15

1.5.1 Written infection control policies and procedures .....................15

1.5.2 Standard and additional precautions ..........................................15

1.5.3 Risk-assessment approach .........................................................16

1.5.4 Clinics and risk assessment........................................................16

1.5.5 Patients and risk assessment ......................................................16

1.5.6 Instruments and risk assessment ................................................171.5.7 Procedures and risk assessment .................................................19

1.5.8 Hazard analysis critical control point (HACCP) riskmanagement ...............................................................................19

1.6 Staff training and incident management.................................................19

1.6.1 Employees and student assistants ............................................110

1.6.2 First-aid certification................................................................110

1.6.3 Managing bleeding...................................................................110

1.6.4 Managing occupational exposure.............................................111

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Chapter 2 Clinics ....................................................................................................21

2.1 Risk assessment of clinics ......................................................................21

2.2 General requirements for clinics ............................................................21

2.3 Treatment room requirements ................................................................22

2.4 Reprocessing area ...................................................................................22

2.5 Flooring ..................................................................................................23

2.6 Ventilation ..............................................................................................23

2.7 Hand basins ............................................................................................24

2.8 Hand-cleaning agents and dispensers.....................................................24

2.9 Linen.......................................................................................................25

2.10 Cleaning of clinics ..................................................................................25

2.10.1 Standard precautions apply when cleaning................................25

2.10.2 Daily and weekly cleaning routine.............................................25

2.10.3 Procedures for cleaning work surfaces ......................................26

2.10.4 Cleaning surfaces contaminated with blood and bodyfluids ..........................................................................................27

2.10.5 Maintaining cleaning equipment................................................27

2.10.6 Cleaning standards for change and shower rooms and

toilets..........................................................................................272.10.7 Cleaning agents..........................................................................27

2.11 Waste disposal ........................................................................................28

2.11.1 Clinical and related waste disposal ............................................28

2.11.2 Sharps disposal...........................................................................29

2.11.3 General waste disposal...............................................................29

2.12 Animals in the clinic.............................................................................210

Chapter 3 Staff hygiene and protection................................................................31

3.1 Hand washing and drying.......................................................................31

3.1.1 Broken skin and noninfectious skin conditions .........................31

3.1.2 When hands must be washed .....................................................31

3.1.3 How to wash hands ....................................................................32

3.1.4 Hand drying ...............................................................................33

3.1.5 Hand cleaning and disinfecting agents.......................................33

3.1.6 Alcohol-based hand rubs............................................................33

3.1.7 Jewellery and artificial nails ......................................................34

3.2 Gloves.....................................................................................................34

3.3 Personal protective clothing and equipment...........................................34

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3.4 Hepatitis B vaccinations for health care workers ...................................35

3.5 Smoking and eating ................................................................................35

Chapter 4 Instruments ...........................................................................................41

4.1 Instrument precleaning and cleaning......................................................41

4.1.1 Need for precleaning and cleaning.............................................41

4.1.2 Workflow patterns for cleaning procedures...............................42

4.1.3 Use of personal protective clothing and equipment...................42

4.1.4 Detergents ..................................................................................42

4.1.5 Precleaning procedure................................................................42

4.1.6 Cleaning procedure ....................................................................43

4.1.7 Cleaning instruments that would be damaged if immersedin water.......................................................................................44

4.1.8 Using ultrasonic cleaners ...........................................................44

4.2 Instrument disinfection...........................................................................46

4.2.1 Thermal disinfection ..................................................................46

4.2.2 Chemical disinfection ................................................................48

4.2.3 Cleaning and disinfecting thermometers....................................49

4.3 Instrument sterilisation.........................................................................410

4.3.1 Instrument sterilisation.............................................................410

4.3.2 Sterilisers..................................................................................411

4.3.3 Contract sterilisation services ..................................................411

4.4 Differing levels of instrument reprocessing .........................................412

4.4.1 Hazard analysis critical control point risk management ..........413

4.5 Suitable instrument materials for reprocessing ....................................413

4.5.1 Nonsharps instruments.............................................................413

4.5.2 Gua sha devices and cups........................................................413

4.5.3 Reusable dermal hammers .......................................................414

4.5.4 Instruments unsuitable for immersion in water........................414

4.6 Flow diagrams for precleaning and cleaning instruments....................414

Chapter 5 Clinical procedures...............................................................................51

5.1 Following a risk-management approach ................................................51

5.2 Choosing instruments and needles .........................................................51

5.3 Dispensing ointments, creams, oils and liniments..................................51

5.4 Preparing the work area ..........................................................................52

5.5 Following clinical procedures ................................................................52

5.5.1 Practitioner preparation..............................................................53

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5.5.2 Skin preparation.........................................................................53

5.5.3 Aseptic needle penetration procedures ......................................54

5.5.4 Using needle insertion tubes and gloves to guide insertionand manipulation........................................................................55

5.5.5 Using cups..................................................................................55

5.5.6 Using gua sha devices ...............................................................56

5.6 Cleaning work areas after each patient...................................................56

5.6.1 Disposal of clinical and related waste........................................56

5.6.2 Disposal of general waste ..........................................................57

5.6.3 Reusable nonsharps instruments ................................................57

5.6.4 Used linen ..................................................................................57

5.6.5 Cleaning work surfaces..............................................................57

5.7 Managing bleeding and injuries in the clinic .........................................58

5.8 Off-site acupuncture ...............................................................................58


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Appendix 1 Checklist of requirements for acupuncture clinics................................ I

Appendix 2 Hazard analysis critical control point (HACCP) tables foracupuncture clinics ............................................................................................ III

Appendix 3 Managing bleeding ................................................................................ IX

Appendix 4 Managing occupational exposure to blood.......................................... XI

Appendix 5 Checklist of requirements for clinic and treatment rooms............. XIII

Appendix 6 Suggested clinic cleaning program......................................................XV

Appendix 7 Clean-up procedures following blood and body fluid spills ..........XVII

Appendix 8 Cleaning up after a treatment session .............................................. XIX

Appendix 9 Cleaning standards for change or shower rooms and toilets.......... XXI

Appendix 10 Using and storing detergents, disinfectants and otherchemicals XXIII

Appendix 11 Hand care............................................................................... XXV

Appendix 12 Using single-use gloves in acupuncture treatment.......... XXVII

Appendix 13 Safe needle insertion and removal procedures..................XXIX

References ..................................................................................................................XXXI

Legislation..................................................................................................... XXXII

Reading list ................................................................................................... XXXII

Australian Standards ............................................................................................ XXXIII

Relevant Australian Standards..................................................................... XXXIII

Additional Australian Standards ..................................................................XXXIV

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Tables

Table 1.1 Risk categories and instrument reprocessing requirementsa.........................18

Table 2.1 Risk assessment within acupuncture clinics .................................................21

Table 3.1 Hand washing procedures for low, medium and high-risk procedures ........32Table 4.1 Precleaning procedure for instruments .........................................................43

Table 4.2 Cleaning procedure for instruments..............................................................43

Table 4.3 Time:temperature ratios for thermal disinfection .........................................48

Table 4.4 Reprocessing requirements for low, medium and high-risk instruments ...412

Table 5.1 Dispensing of ointments, creams and liniments ...........................................52

Table 5.2 Notes on aseptic skin penetration procedures..............................................55

Table A.1 Hazards associated with clinic design and workflow .....................................IV

Table A.2 Hazards associated with cleaning of clinics ...................................................IV

Table A.3 Hazards associated with the reprocessing and cleaning of instruments ..........V

Table A.4 Hazards associated with storage and handling of stock...................................V

Table A.5 Hazards associated with waste control ...........................................................VI

Table A.6 Hazards associated with acupuncture and other skin penetrationprocedures..................................................................................................... VII

Table A.7 Hazards associated with risk of infection from cooling towers.................... VII

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I n t r o d u c t i o n

In these guidelines, acupuncture is narrowly defined as the therapeutic practice of inserting

and manipulating fine needles into specific points of the body.

Purpose of these guidelines

The skin provides a protective barrier for the body. Penetration of the skin with

acupuncture needles increases the risk of contracting an infectious disease. These

guidelines are designed to guide acupuncturists in infection control and the safe practice

of acupuncture, thereby ensuring maximum safety for practitioners and for the public.

Acupuncturists must follow proper procedures for infection control, including

maintaining their clinic in a clean and hygienic state. One of the provisions of theHealthProfessions Registration Act 2005 (the HPR Act) is for registration of, and investigations

into, the professional conduct and fitness to practise of registered practitioners of Chinese

medicine (HPR Act, pp. 131132). These guidelines are consistent with the

Communicable Diseases Network Australia (CDNA) guidelines, as well as Australian

and New Zealand standards.

Where the CMR Board investigates and hears complaints of unprofessional conduct, the

board will take into account compliance with these guidelines when determining whether

a practitioner has engaged in unprofessional conduct. A ruling of unprofessional conduct

may lead to the suspension of a practitioners registration.

Terminology used in these guidelines

These guidelines are based on evidence from current best-practice standards and include

expert advice from infection-control specialists. The wording used to give directions

reflects the varying levels of potential risk (adapted from RACGP 2006 p. v):

mustis used when the direction given is considered a requirement, stemming from

situations of high risk of harm if the direction is not followed

shouldis used where the suggestion given is considered best practice; practitioners

must make decisions based on individual and practical circumstances.

may is used where alternative strategies can be considered.

Poor infection-control practices may result in the transmission of infectious diseases.

Practitioners have a legal and ethical responsibility to provide a safe service to their

patients. Poor infection control can result in litigation against a practitioner, as well as a

finding of unprofessional conduct under the HPR Act.

Identifying and managing the potential hazards in health care clinics reduces the

likelihood of spread of infectious diseases. A risk-management approach to infection

control will enable practitioners to take all reasonable precautions and meet their duty of

care. It also assists in legal protection.

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Structure of these guidelines

These infection control guidelines contain the following chapters and topics:

Chapter 1 provides an overview of infection-control principles, including how

infections occur, the regulatory requirements for acupuncture clinics, and

occupational health and safety requirements.

Chapters 24 cover infection-control procedures at all levels, from cleaning and

maintaining acupuncture clinics, to staff hygiene and instrument preparation and

cleaning.

Chapter 5 describes how to apply these infection-control guidelines to clinical

procedures.

The appendixes contain guidelines and checklists for specific aspects of infection

control (eg clean-up procedures for spills, cleaning standards, hand care). They are

intended to be a useful and practical resource for acupuncturists and staff of

acupuncture clinics.

Throughout the guidelines, important information and specific issues for practitioners to

note are set out in key point boxes. Key terms and abbreviations are defined in the

glossary and abbreviations list, respectively. Words that appear in the glossary are in bold

font at first mention in the guidelines.

References and a list of further reading are also provided at the end of the guidelines.

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G l o s s a r y

Acupuncture In these guidelines, acupuncture is narrowly defined as the therapeutic practice of inserting

and manipulating fine needles into specific points of the body.Acupuncture needle Special needles used to penetrate the body surface for a therapeutic purpose

Additional precautions Precautions required when standard precautions might not be sufficient to preventtransmission of infection. These are used for patients known or suspected to be infected orcolonized by highly transmissible pathogens that can be transmitted by airborne, droplet orcontact transmission, or for those patients suspected of being infectious for CJD. Additionalprecautions are designed to prevent transmission of infection by these agents and should beused in addition to standard precautions when transmission of infection might not becontained by using standard precautions alone (CDNA 2004, G-1).

Aerosol A gaseous suspension of fine solid or liquid particles.

Antiseptic A substance, not represented for internal use, recommended by its manufacturer for dermalapplication to kill microorganisms, or to prevent the growth of microorganisms to a level thatmay cause clinical infection (TGA 1998, p. 2).

Aseptic technique Those practices that reduce the risk of post-procedure infections in clients by decreasing thelikelihood that microorganisms will enter tissues during an invasive procedure (DHS 2004,p. 81).

Biofilm A fine film of matter containing microorganisms on the surface of an instrument.

Canaliculated instrument An instrument that contains a channel or groove (eg a needle).

Cleaning The physical removal of foreign matter using water, detergent and mechanical action, toreduce the number of microorganisms from a surface

Clinical waste Discarded sharps, human blood and tissues, and materials, equipment or solutionscontaining blood or body fluid (CDNA 2004, G-2).

Contamination The introduction of microorganisms or foreign matter (or both) to sterile or nonsterilematerials or living tissue (RACGP 2006, p. 159).

Cross-contamination The indirect spread of microorganisms from one person to another through impropersterilisation procedures, unclean instruments, or inadequately treated reusable products(Mondofacto 2009).

Cross-infection Any infection contracted by a patient in a healthcare facility or infections transmitted betweenindividuals who are infected with different pathogenic microorganisms (Mondofacto 2009).

Cups (or cupping devices,suction cups)

Cup-like therapeutic devices used in Chinese medicine for lifting the skin via vacuum actionin a procedure known as cupping. The vacuum may be produced by insertion of a flame orremoving air via a pump.

Dermal hammer A hammer-like device, the head of which contains several short needles. It is used inacupuncture practice to stimulate the skin surface and to promote superficial bleeding. Alsocalled plum-blossom needle, seven-star needle or cutaneous needle.

Disinfectant A substance for external use (usually a chemical liquid) that destroys all microorganismsexcept bacterial spores (DHS 2004, p. 83).

Disinfection The inactivation of all microorganisms except bacterial spores by chemical or thermal (heatand water or boiling) means (DHS 2004, p. 83).

General waste Waste that is not categorised as clinical or related waste; general waste produced by healthcare facilities is of no more risk to public health than household waste (CDNA 2004, G-3).

Gua sha A noninvasive procedure where the skin is scraped using a tool with a smooth edge.

Gua sha devices Therapeutic devices used in Chinese medicine for the scraping of the skin in a procedureknown as gua sha or skin scraping.

Insertion tube A metal or plastic tube through which an acupuncture needle is inserted to facilitate insertion.Packaged sterilised needles for single-use are often packaged together with an insertiontube.

Intradermal needle A small acupuncture needle or small stud-like needle designed to be inserted in an

acupuncture point and retained for a period of time. The needle penetration is shallow and itis usually kept in place by adhesive tape.

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Lancet A small sharp blade intended for making shallow incisions in the skin to induce bleeding.

May Where the word may is used, alternative strategies can be considered (RACGP 2006,p. 161).

Monitoring A programmed series of challenges and checks, repeated periodically, and carried outaccording to a documented protocol which demonstrates that the process being studied isboth reliable and repeatable (for example, steriliser cycles) (DHS 2004, p. 85).

Moxa Dried plant matter intended for burning in order to produce heat on the skin surface. Themain plant used isArtemesia vulgaris (leaves), although it may be combined with othersubstances. The moxa is usually supplied as the loose, dried plant matter or as packed rolls;however, other preparations are available.

Moxibustion The procedure of applying heat to the skin surface using moxa. The moxa may be applieddirectly to the skin surface (direct moxibustion) or burnt a short distance from the skin surface(indirect moxibustion). The term, moxibustion, also refers to the therapeutic application ofheat to acupuncture points and zones of the skin using other heat sources.

Must Where the word must is used, the direction given is considered a requirement, stemmingfrom situations of high risk of harm if the direction is not followed (RACGP 2006, p. 161).

Nonsharps Any equipment or instrument used in treatment not intended to penetrate the skin (see alsoSharps).

Occupational exposure When an operator is exposed to something harmful while fulfilling the duties of their job(DHS 2004, p. 85).

Pathogen Any microorganism that can cause infection in a susceptible host.

Pharmaceutical waste Waste including disinfectants and antiseptic solutions used for skin cleansing anddisinfecting before procedures and pharmaceuticals that have reached their use-by date.

The Environmental Protection Authority requires all pharmaceutical waste to be incinerated.Proprietors/operators [are to] obtain suitable containers from an approved waste disposalcontractor who will arrange incineration. Disposal via the sewer or general waste IS NOT anapproved method of disposal (DHS 2004, p. 86; see also Related waste).

Precleaning Precleaning or initial cleaning is the process of removing visible contaminants frominstruments, equipment and sharps immediately after use and as close as possible to thepoint of use (CDNA 2004, p. 16-7).

Pressure stud A small metal ball that is placed over an acupuncture point, usually on the ear, and held inplace with adhesive tape, for the purpose of providing prolonged stimulation to theacupuncture point. Unlike intradermal needles, pressure studs do not penetrate the skin.

Related waste A category of health industry waste that includes cytotoxic waste; pharmaceutical waste; andchemical waste (CDNA 2004, G-6).

Reprocessing Any process to prepare a device for reuse (which can include precleaning, cleaning anddisinfecting or sterilising)

Sharps A sharp instrument that is designed to penetrate skin or mucous membrane for example aneedle, lancet or scalpel (DHS 2004, p. 87).

Sharps injury Percutaneous injury with any sharps designed for use in health care that may potentiallytransmit infectious agents, and particularly bloodborne viruses. Sharps may or may not havebeen used on a patient (CDNA 2004, G-5; see also needlestick injury and sharps).

Sharps waste Waste that is classified as sharps (see above) and requires appropriate storage, transportand disposal.

Should Where the word should is used the suggestion given is considered best practice (RACGP2006, p. 162). Practitioners must make decisions based on individual and practicalcircumstances.

Single-use item An item designed, labelled and intended to be used once only, and that must be disposed ofimmediately after use (using appropriate waste disposal procedures).

Skin disinfectant A substance applied to the intact skin to prevent the transmission of skin bacteria from a skinpenetration site to underlying tissue, or from one person to another. Skin disinfectantsinclude antimicrobial and antiseptic soaps, and hygienic and surgical handwashes and handrubs (CDNA 2004, G-7).

Sonication Using ultrasonic sound waves to disrupt or agitate particles, a chemical solution or biological

medium (eg to break it down).Spore A minute, typically single-celled, reproductive unit characteristic of lower plants, fungi,

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protozoans, and bacteria capable of giving rise to a new individual without sexual fusion(DHS 2004, p. 87).

Standard precautions Work practices required for the basic level of infection control. Standard precautions arerecommended for the treatment and care of all patients, and apply to all body fluids,secretions and excretions (excluding sweat), regardless of whether they contain visible blood(and including dried body substances such as dried blood or saliva), non intact skin and

mucous membranes. Standard precautions include good hygiene practices, particularlywashing and drying hands before and after patient contact, use of protective barriers(including gloves, gowns, plastic aprons, mask eye-shields or goggles), appropriate handlingand disposal of sharps and other contaminated or infectious (clinical)waste, and the use ofaseptic technique. (See also Additional precautions) (CDNA 2004, G-7).

Sterile The state of being free from viable microorganisms, including bacterial spores (DHS 2004,p. 88).

Sterilisation The validated process used to achieve complete destruction of all microorganisms, includingspores (DHS 2004, p. 88).

Thermal disinfection Use of moist heat through boiling at temperatures that destroy pathogenic vegetativeorganisms.

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A c r o n y m s an d ab b r ev i at i o n s

AACMA Australian Acupuncture and Chinese Medicine Association

ARTG Australian Register of Therapeutic Goods

CDNA Communicable Diseases Network Australia

AS Australian Standard

AS/NZS Australian and New Zealand Standard

CCP critical control point

CJD Creutzfeldt-Jakob Disease

CMR Act Chinese Medicine Registration Act 2000 (Victoria)

CMR Board Chinese Medicine Registration Board of Victoria

DHS Department of Human Services (Victoria)

EPA Environment Protection AuthorityHACCP hazard analysis critical control point

Health Act Health Act 1958 (Victoria)

Health Regulations Health (Infectious Diseases) Regulations 2001 (Victoria)

HIV human immunodeficiency virus

HPR Act Health Professions Registration Act 2005 (Victoria)

MSDS material safety data sheet

OHS Act Occupational Health and Safety Act 1985 (Victoria)

RACGP Royal Australian College of General Practitioners

SPU sterilising processing unit

TGA Therapeutic Goods Administration

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Ch a p t er 1 Pr i n c i p l es o f i n f ec t i o nc o n t r o l

This chapter is about the principles of infection control. Appendix 1 contains a practical

checklist for the requirements in an acupuncture clinic.

1.1 Introduction

Infection control, including prevention, is the process of minimising the risks of spreading

infection while performing procedures on patients. Professionally competent

acupuncturists practise acupuncture using safe and hygienic procedures in clean clinics.

Unsafe or unhygienic procedures can adversely affect the health of the patient as well as

the practitioner. If procedures involving skin penetration are not performed safely and

hygienically, they can be a means of transmission of staphylococcal and streptococcalinfections and infectious diseases, including hepatitis B, hepatitis C and human

immunodeficiency virus (HIV).

It is essential for practitioners of acupuncture to be fully aware of the potential dangers of

these procedures and to understand the precautions required to minimise the risk of

infection.

The purpose of these guidelines is to assist acupuncturists to minimise the risk of

infection and spread of infectious diseases. These guidelines explain how infection can be

associated with the procedures used, as well as the precautions to be taken to protect

patients, the practitioner and the community.

1.2 How infections occur

Serious infection can occur during acupuncture procedures. Contamination is the spread

or introduction of microorganisms or foreign matter (or both) to sterile or nonsterile

materials or living tissue (RACGP 2006, p. 159).

Cross-contamination is the indirect spread of microorganisms from one person to

another through impropersterilisation procedures, unclean instruments, or inadequately

treated reusable products (Mondofacto, 2009).

Organisms that cause infections can be spread throughout acupuncture clinics by

contamination and cross-contamination. Both patients and practitioners may be at risk.

Instruments that penetrate the skin, such as acupuncture needles, lancets anddermal

hammers, are contaminated by blood or body fluids. Blood or body fluids do not have to

be visible on an instrument or needle for infection to be transmitted. Infection can occur

when the instruments used are contaminated, and are not cleaned and sterilised before use

on another person, or are not disposed of appropriately. The person at risk of infection

may be the next patient being treated with the contaminated instrument, or the practitioner

if accidental penetration of his or her skin occurs. Such an injury is called a sharps

injury, which includes the common term needle-stick injury (CDNA 2004, G-5).

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Procedures that do not involve skin penetration may also spread infections caused by

bacteria, viruses or fungi. Such infections may be caused by contact of blood, body fluids

or contaminated instruments with open cuts, sores or broken skin. Examples of these

include staphylococcal infections (such as impetigo), viral infections (such as warts and

herpes) and fungal infections (such as tinea pedis, a skin infection). Therefore, all

instruments must be reprocessed appropriately before use on another patient. Theappropriate level ofreprocessing of instruments is discussed further in Section 1.5.6 and

Chapters 4 and 5.

Maintaining a clean working environment is an essential component in preventing

contamination and cross-contamination.

Key points

Blood or body fluids do not have to be visible on an instrument or needle for infection

to be transmitted.

Infectious diseases, including HIV and hepatitis B and C, can be spread throughacupuncture if poor infection control procedures are used.

All instruments that penetrate the skin of a person must be sterile at the time of use.

1.2.1 Causes of contamination and cross-contamination

Contamination and cross-contamination can occur in an acupuncture practice if (DHS

2004, pp. 12):

strict practitioner hygiene is not observed (see Chapter 3)

practitioners share the same equipment or materials clean instruments are placed on unclean surfaces or come into contact with used or

unclean instruments or equipment

sterile instruments are placed on nonsterile surfaces or come into contact with

nonsterile instruments or equipment

contaminated needles, spatulas, dressings and disposable gloves are not disposed of

immediately and appropriately after use

structural facilities, furnishings and fittings of the clinic are not cleaned adequately

between patients or maintained in a good state of repair

towels and other articles used on clients are not changed or cleaned thoroughlybetween patients.

1.3 Regulatory requirements for acupuncturis ts

1.3.1 Health (Infectious Diseases) Regulation 2001

In the context of aiming for best-practice standards, familiarity and compliance with the

Health (Infectious Diseases) Regulations 2001 is appropriate.

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TheHealth Act 1958and the Health (Infectious Diseases) Regulations 2001 can be found

under Victorian Law Today at the Victorian Legislation and Parliamentary Documents

website (http://www.dms.dpc.vic.gov.au).

1.3.2 Health Professions Registration Act 2005

Acupuncturists who do not follow safe and hygienic practices risk infecting themselves

and others. They may also be guilty of unprofessional conduct under theHealth

Professions Registration Act 2005 (HPR Act). The definition of unprofessional conduct

includes but is not limited to the following:

Conduct of a health practitioner occurring in connection with the practice of thepractitioners health profession that is of a lesser standard than a member of thepublic or the health practitioners peers are entitled to expect of a reasonably

competent health practitioner of that kind

Professional performance which is of a lesser standard than that which the registered

health practitioners peers might reasonably expect of a registered health practitioner

The failure to act as a health practitioner when required under an Act or regulationsto do so

The contravention of, or failure to comply with a condition imposed on theregistration of the health practitioner by or under this Act (HPR Act pp. 910).

For a complete definition of unprofessional conduct, refer to Section 3 of the HPR Act

(pp. 910).

The Chinese Medicine Registration Board (CMR Board) has statutory powers to

investigate complaints about the professional conduct of Chinese medicine practitioners,and to conduct informal and formal hearings into conduct. The CMR Board also has the

power to enforce penalties on practitioners, including imposing conditions, limitations or

restrictions on the registration of a practitioner; imposing a fine on the practitioner;

requiring the practitioner to undertake further education; and suspension or cancellation

of the registration of a practitioner. Part 3 of the HPR Act sets out provisions for

investigating registered practitioners.

The HPR Act can be viewed on the CMR Boards website

(http://www.cmrb.vic.gov.au/registration/hpract.html).

1.3.3 Occupational Health and Safety Act 1985

The Occupational Health and Safety Act 1985 (OHS Act) is Victorian legislation that

specifies occupational health and safety requirements in the workplace. Under the OHS

Act, employers have a responsibility to their employees, patients and other people

entering their clinics, to provide and maintain as far as practicable a safe work

environment that is without risks to health (OHS Act 1985, pp. 78). This includes proper

maintenance of facilities and equipment, and a clean and suitably designed workplace to

minimise potential hazards (DHS 2004, p. 8).

Guidelines on Infection Prevention and Control for Acupuncturists 13
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The responsibilities towards patients, and people other than employees, are set out under

Section 22 of Part 3 of the OHS Act, which says:

every employer and every self-employed person shall ensure so far as is practicablethat persons (other than the employees of the employer or self-employed person) arenot exposed to risks to their health or safety arising from the conduct or the

undertaking of the employer or self-employed person (OHS Act 1985, p. 8).

Occupiers of a workplace have a duty under the OHS Act to:

take such measures as are practicable to ensure that the workplace and the means ofaccess to and egress from the workplace are safe and without risks to health (OHS

Act 1985, p. 8).

Employers also have a responsibility under the OHS Act to provide:

such information, instruction, training and supervision to employees as necessary to

enable the employees to perform their work in a manner that is safe and without risksto health (OHS Act 1985, p. 8).

Adequate staff training, which includes infection control and hygiene, must be provided(DHS 2004, p. 8).

Employees also have responsibilities under the OHS Act to:

take reasonable care of his or her own health and safety and for the health and safetyof anyone else within the workplace who may be affected by his or her acts or

omissions in the workplace; and co-operate with his or her employer with respect toany action taken by the employer to comply with any requirement imposed by orunder this Act (OHS Act 1985, p. 9).

For more information, refer to the OHS Act, which can be found under Victorian Law

Today at http://www.dmz.dpc.vic.gov.au.

Key point

Employers, occupiers of a workplace and employees have responsibilities under the

Occupational Health and Safety Act 1985.

1.4 Requirements for acupuncture training providers

All schools, colleges, universities and other institutions providing training courses in

acupuncture, including teachers and students of acupuncture, are required to comply with

the relevant provisions of the following Acts and regulations in relation to any clinics in

which acupuncture is carried out, the equipment used and the practise of acupuncture:

Health (Infectious Diseases) Regulations 2001

Health Act 1958

Occupational Health and Safety Act 1985

Health Professions Registration Act 2005.

Clinical supervisors, or teachers supervising practical learning components of

acupuncture education, must be registered with the CMR Board in the division of

acupuncture, or be endorsed by another health practitioner registration board to use thetitle acupuncturist. Within Victorian acupuncture training institutions, students must

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only practise acupuncture under the supervision of an acupuncture teacher who is

registered with the CMR Board or endorsed with another Victorian health practitioner

board.

1.5 Workplace safety, infection control and risk assessmentInfection control is the process of minimising the risks of spreading infection while

providing acupuncture treatment. This risk minimisation is implemented to protect both

the patient and the practitioner.

Any invasive procedures, including acupuncture, carry a particularly high risk of

infection (CDNA 2004, p. 16-5). By its nature, the practice of acupuncture also poses a

particular risk to the practitioner ofoccupational exposure through sharps injuries and

the consequent potential for infection with bloodborne viruses.

1.5.1 Written infection control policies and procedures

Registered acupuncturists must have written policies and procedures for infection control,

(including a written program of instructions for reprocessing instruments and procedures

for cleaning clinics) that are consistent with the infection control principles outlined in

these guidelines and relevant legislation (CDNA 2004, p. 1-2).

1.5.2 Standard and additional precautions

The key to infection control is observation ofstandard precautions and, when

necessary, additional precautions. The CDNA defines standard precautions as follows:

Standard precautions are work practices required for the basic level of infectioncontrol. Standard precautions are recommended for the treatment and care of allpatients, and apply to all body fluids, secretions and excretions (excluding sweat),

regardless of whether they contain visible blood (and including dried bodysubstances such as dried blood or saliva), non-intact skin and mucous membranes.Standard precautions include good hygiene practices, particularly washing and dryinghands before and after patient contact, use of protective barriers (including gloves,gowns, plastic aprons, mask eye-shields or goggles), and appropriate handling anddisposal of sharps and other contaminated or infectious waste and the use of aseptic

techniques (CDNA 2004, G-7).

Standard precautions assume that all blood and body substances are potentially infectious

(CDNA 2004, p. 2-2). Standard precautions are designed to protect patients and healthcare workers and must be used as a first line of infection control (CDNA 2004, p. 2-2).

Standard precautions include good hygiene practices, particularly regular hand washing

and drying before and after patient contact; use of personal protective clothing and

equipment; safe handling and disposal of sharps and contaminated orclinical and related

waste; routine cleaning of the work environment; immunisation of health care workers;

and the use ofaseptic techniques (CDNA 2004, p. 2-3; RACGP 2006, p. 11). These

procedures are presented in detail in Chapters 25 of these guidelines.



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Additional precautionsmust be applied in addition to standard precautions when standard

precautions may be insufficient to prevent transmission of infection (RACGP 2006, p. 20;

CDNA 2004, p. 2-4). Additional precautions are defined as follows:

Precautions required when standard precautions might not be sufficient to prevent

transmission of infection. These are used for patients known or suspected to be

infected or colonised by highly transmissible pathogens that can be transmitted byairborne, droplet or contact transmission, or for those patients suspected of beinginfectious for CJD. Additional precautions are designed to prevent transmission ofinfection by these agents and should be used in addition to standard precautions whentransmission of infection might not be contained by using standard precautions alone

(CDNA 2004, G-1).

1.5.3 Risk-assessment approach

A risk-assessment approach to infection control is one in which the practice of

acupuncture is analysed, according to the risk of spreading infection, to determine how

these risks can be minimised. Practical procedures should then be developed to addressthese risks. These guidelines use a risk-assessment approach to demonstrate the

application of infection control procedures. This risk-assessment approach has been used

inInfection Control Guidelines for the Prevention of Transmission of Infectious Diseases

in the Health Care Setting (CDNA 2004) andInfection Control Standards for Office

Based Practices (RACGP 2006), and is based on Spauldings (1968) classification

system, which categorises instruments according to the risk that they pose to patients (see

Section 1.5.6 of these guidelines).

This risk-assessment process can be applied in the following four key areas, which are

explained below:

clinics patients

instruments

procedures.

Procedures for minimising the risk of spreading infection relate to the level of risk

involved.

1.5.4 Clinics and risk assessment

The physical areas within an acupuncture clinic can be classified according to risk. For

example, the areas in which skin penetration anddisinfection or sterilisation of

acupuncture needles is carried out are considered high-risk areas, whereas the waiting

room is considered low risk.

1.5.5 Patients and risk assessment

Patients may not always disclose information or may be unaware that they have a

communicable disease. Therefore, they must be assumed to be high risk.



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1.5.6 Instruments and risk assessment

Spauldings classification system categorises instruments as non-critical (low risk), semi-

critical (medium risk) and critical(high risk) depending on their use. The classification

also outlines recommended reprocessing methods for instruments according to their

intended use (CDNA 2004, Section 16.2.2; RACGP 2006, p. 51). For example, a high-risk instrument (eg an acupuncture needle) is one that is capable of entering tissues that

would be sterile under normal circumstances (RACGP 2006, p. 51).

The risk associated with an instrument can change depending on the instruments use. For

example, the use ofcups orgua shadevices on intact skin would be considered low risk

as long as the skin remained intact. If the skin was to break, then the instrument is

considered high risk.

The level of reprocessing required to reprocess instruments used in acupuncture depends

on the risk category of the instrument. For example, instruments used in acupuncture that

are considered low risk only require cleaning, whereas instruments considered medium-

risk require cleaning and disinfection and those that are considered high-risk requirecleaning and sterilisation.

Table 1.1, below, contains more information about risk categories and reprocessing

equipment, and Box 1.1 lists the steps of reprocessing. The table has been modified from

Infection Control Standards for Office Based Practices (RACGP 2006, p. 51) and

Infection Control Guidelines for the Prevention of Transmission of Infectious Diseases in

the Health Care Setting (CDNA 2004, Table 16.1, p. 16-5).



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Table 1.1 Risk categories and instrument reprocessing requirementsa

Category Example procedures Appli cation Examples ofinstruments

Process required

High-risk(critical)

Acupuncture, use ofcups on non-intactskin, use of a lancet,three-edged needleor dermal hammerand other similarpractices

Any procedure thatresults in instrumentscontacting non-intactskin, blood or bodyfluids

Instruments andequipment that enter,or are capable ofentering, tissue thatwould be sterileunder normalcircumstances,including thevascular system(CDNA 2004, p. 16-5)

Acupunctureneedles, dermalhammers andlancets

Cups used on non-intact skin

Anything thataccidentally breaksthe skin (eg cups orgua sha devices)

Dispose of single-use items as clinicalwaste

OR

Reprocess throughto sterilisation andstore

Medium-risk(semi-critical)

Physical examinationthat involves contact

with non-sterilemucosa

Wound or lesiondressing

Instruments andequipment that come

into contact withintact non-sterilemucosa (CDNA2004, p. 16-5)

Otoscopes,thermometers,

forceps

Dispose of single-use items as clinical

wasteOR

Reprocess throughto disinfection andstore

Low-risk(non-critical)

Massage,auscultation withstethoscope, cuppingorgua sha on intactskin

Instruments andequipment thatcontact intact skin(CDNA 2004, p. 16-6)

Cutaneouselectrostimulators(acupulsers, pointstimulators), pointdetector probes,thermometers, laserdevices,stethoscopes, bloodpressure cuffs, skinrolling devices,cupping andgua shadevices used onintact skin (ie withoutneedling or use ofdermal hammers andlancets)b

Dispose of single-use items as clinicalwaste

OR

Reprocess throughto dying and store

Source: table modified from RACGP (2006). Infection Control Standards for Office Based Practices and CDNA (2004).Infection Control Guidelines for the Prevention of Transmission of Infectious Diseases in the Health Care Setting .a Based on Spauldings Classification (CDNA 2004, pp. 33, 106; RACGP 2006, p. 51).b If any instruments contact non-intact skin, or blood or body fluids, they are then considered high risk and must be disposed ofor reprocessed accordingly.

Box 1.1 Reprocessing

Reprocessing is the process used to prepare an instrument or device for reuse. It includes

precleaning and cleaning and may include either disinfecting or sterilising the instrument.

Reprocessing encompasses the following steps:

preclean

disassemble as necessary

clean and rinse

dry



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assemble, inspect and test for functionality

disassemble for disinfection or sterilisation

disinfect or package if sterilising

sterilise

store in clean, closed containers.

The last step in the reprocessing of items will depend on the item and its risk category

(intentional or accidental)

For items that cannot be immersed in water refer to Section 4.1.7 for details on reprocessing.

1.5.7 Procedures and risk assessment

Procedures can be classified as low, medium and high-risk. Procedures that involve skin

penetration, such as acupuncture, are high-risk procedures. Refer to Table 1.1, above, for

more details. Chapter 3 addresses hand-washing requirements for different types ofprocedures carried out by acupuncturists.

1.5.8 Hazard analysis crit ical contro l point (HACCP) risk management

Hazard analysis critical control point (HACCP) risk management identifies potential

hazards and controls to minimise these hazards. HACCP provides a systematic approach

to the identification, evaluation and control of safety hazards based on the following

seven principles:

Principle 1: Conduct a hazard analysis

Principle 2: Determine the critical control points (CCPs)

Principle 3: Establish critical limits

Principle 4: Establish monitoring procedures

Principle 5: Establish corrective actions

Principle 6: Establish verification procedures

Principle 7: Establish record-keeping and documentation procedures.

HACCP risk management also sets out corrective action to be taken should a control not

be achieved at any time, the recording of problems or incidents, and the verification that

controls are in place. Appendix 2 explains how to apply HACCP risk management to thedesign of clinics, including organising workflow in cleaning areas; cleaning clinics;

reprocessing, sterilising and storing instruments; and waste disposal.

1.6 Staff training and incident management

Registered acupuncturists must provide adequate education, including training in good

hygiene practices and infection control, for employees and any students who may visit

clinics on practice visits (CDNA 2004, p. 5-2).



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Key points

Staff must be adequately trained in infection control.

Infection control policies and procedures must be easily accessible by staff.

1.6.1 Employees and student assistants

Employers must ensure that staff and student assistants are instructed in the risks and

responsibilities of working in an acupuncture practice. Staff and students who assist with

clinical procedures must receive adequate instruction in cleaning, disinfecting, sterilising

and other infection-control procedures. The acupuncture clinics infection control policies

and procedures must be easily accessible to all staff and students.

Employees and student assistants have a responsibility to comply with the prescribed

safety standards and procedures set by the acupuncture clinic, including the reporting of

actual or potential exposure to blood and body substances. All staff and students should

be aware of their own infectious status and seek appropriate medical care if they have aninfection (CDNA 2004, Section 5.2). Work options should be considered for staff or

students with infections. For example, they could be rostered to a different work area, or

given instructions on how to provide safe care (CDNA 2004, Section 5.2).

Key point

Employees and students have a responsibility to comply with the prescribed safety

standards and infection-control procedures set by the acupuncture clinic, which must be

consistent with legislation, and these guidelines.

1.6.2 First-aid certification

Under Section 118 of the HPR Act, the CMR Board has the power to regulate standards

of practice and issue guidelines in relation to those standards. The Boards Guidelines on

First Aidsets out guidelines for the availability of first aid. The guidelines, which apply

to all registered practitioners, state that:

At all times during practice by a registered practitioner:

the registered practitioner must hold a current First Aid Certificate Level 2 (orequivalent),

or

A person must be present at the clinic who has been appointed by the registeredpractitioner AND who holds a current first aid certificate Level 2 (or the equivalent)

AND who can swiftly and effectively administer first aid if required. (Guidelines onFirst Aid, p.1)

Each acupuncture clinic must have a first aid kit.

1.6.3 Managing bleeding

Standard precautions apply when dealing with bleeding (CDNA 2004, p. 18-4). All bloodand body fluids are considered potentially infectious, because patients may be unaware or



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may not disclose that they are infected with blood-borne viruses, including human

immunodeficiency virus (HIV) and hepatitis B and C.

Appendix 3 provides guidelines on how to manage bleeding in an acupuncture clinic.

1.6.4 Managing occupational exposure

Occupational exposure is where the acupuncturist or a clinic staff member is exposed to

something harmful while fulfilling the duties of their job (DHS 2004, p. 85). It includes

exposure of the acupuncturist or clinic staff member to blood and body fluids (by

penetrating injury with contaminated sharps or exposure to non-intact skin and mucous

membranes).

Appendix 4 explains how to manage occupational exposure to blood and body fluids,

including needle-stick injuries. A record of all injuries must be maintained.



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C h ap t e r 2 C l i n i c s

This chapter addresses infection control requirements for clinics in which acupuncture is

carried out. These include requirements for clinic layout, flooring, hand basins, linen, andcleaning and maintenance of the clinic. Cleaning and disinfection or sterilisation of

instruments and equipment used in an acupuncture practice is addressed in Chapter 4.

Appendix 5 provides a checklist for clinic and treatment room requirements.

2.1 Risk assessment of clin ics

Acupuncture clinics must adopt infection-control procedures that are appropriate for the

nature of the risk associated with each particular therapeutic and diagnostic procedure. In

general, there is a gradation of risk of infection in different parts of the clinic. Table 2.1

suggests a method for categorising the risk in different parts of an acupuncture clinic.

Table 2.1 Risk assessment within acupuncture clini cs

Risk category Examples

Low-risk(non-critical)

Waiting rooms and reception areas

Medium-risk(semi-critical)

Rooms used for consultation and examination

High-risk(critical)

Rooms used for skin penetration and reprocessing instruments

Hazard analysis critical control point (HACCP) risk management identifies potential

hazards and controls to minimise these hazards (see Section 1.5.8). Appendix 2 explains

how to apply HACCP risk management to the design of clinics, including workflow in

the reprocessing area and the cleaning of clinics.

2.2 General requirements for clin ics

The clinic design must have one area for treating patients, and a separate area for

reprocessing instruments and cleaning equipment.

The Australian/New Zealand standard for reprocessing reusable medical and surgicalinstruments (AS/NZS 4815:2006), says all furniture, fittings, floors and walls should be

made from smooth, impervious, washable materials for easy cleaning and maintenance.

The food preparation area must be separate from the reprocessing area.

Each acupuncture clinic must have (DHS 2004, p. 8):

adequate lighting

adequate ventilation

liquid soap in a non-refillable dispenser

paper towelling or clean, single-use cloth towelling for drying hands (see Section 2.9)

21


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a clean, dry cabinet or cupboard for storing instruments, equipment and linen

a separate area with a smooth, impervious surface for reprocessing used instruments

a sink for reprocessing instruments and cleaning equipment (other than the hand basin

for hand washing during treatment)

general-purpose utility gloves for cleaning purposes; plastic and vinyl gloves are notappropriate because they are permeable, can tear easily, do not breathe, and are not

protective

a first-aid kit.

2.3 Treatment room requirements

Each treatment room must have the following (DHS 2004, p. 6):

waste bins for general waste, with lids and plastic liners

a separate bin, marked clinical waste, for all contaminated waste (seeSection 2.11.1)

a rigid sharps disposal container, for disposal of single-use, disposable acupuncture

needles and other sharps (see Section 2.11.2)

a suitable receptacle for soiled linen (eg linen used on treatment tables), which is able

to be cleaned (see Section 2.9)

disposable paper towels or clean, single-use cloth towels

a surface for placing clean instruments before use; this should be smooth, impervious

and easily cleaned

a tray or other container that is used specontaminated nonsharps waste; this must be emptied into the clinical waste bin

immediately after treatment

liquid soap and antimicrobial hand washing

cifically for temporarily receiving

solution in a non-refillable dispenser for

ing hands

See Section 2.7 for details about hand basins.

2.4 Reprocessing areaThe reprocessing area must be designed to ensure that reusable instruments and

inimise

ated

In areas where used instruments and other clinical devices are reprocessed, a smooth,

Acupuncture clinics should have a separate sink that is used only for reprocessing

ust

hand cleaning

paper towelling or clean, single-use cloth towelling for dry

equipment moves in a one-way direction from dirty to clean to sterile to m

risk of cross-contamination of reusable instruments. Cross-contamination can cause

infection to acupuncturists or patients. Reprocessing areas must contain clearly separ

clean and dirty sections (DHS 2004, p. 4).

impervious work surface is required for ease of cleaning and maintenance.

instruments. This sink must be separate from the treatment room hand basin, and mhave hot and cold running water. The sink located in the reprocessing area of the clinic



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should have two basins (ie a double sink) so that instruments can be cleaned and then

rinsed without possible contamination. Instruments must not be cleaned in the hand basin.

Where mechanical or other instrument reprocessing equipment is used, such as ultrasonic

2.5 Flooring

Flooring must be maintained in a clean, hygienic and safe condition to minismise

ilding

rous,

Treatment rooms should not be carpeted. Carpets are not easy to clean, and they may also

astic or

Carpets in waiting and reception areas must be short-piled and easy to clean.

2.6 Ventilation

Adequate ventilation is necessary in an acupuncture practice, particularly in the treatment

Air-conditioners and cooling towers1 must comply with, and be maintained according to,

In rented clinics, practitioners must identify who is responsible for maintaining air-d out.

Key point

cleaners, such equipment should be selected to meet the users need for efficient use and

ease of maintenance. Note: AS 2773.2:1999 specifies requirements for benchtopultrasonic cleaners for health care facilities.

occupational health and safety risks. Flooring material must meet fire safety and bu

code requirements (eg it must be nonflammable), and be smooth, impervious, easily

cleaned and in good repair. All fixtures and fittings should allow easy cleaning and

discourage the accumulation of dust. Flooring in reprocessing areas should be nonpo

smooth and easily cleaned (CDNA 2004, Sections 11.2 and 18.1).

trap dust or needles that are dropped accidentally. Where the treatment rooms are

carpeted and where the procedure may result in spillage of blood or body fluids, pl

rubber overlays must be used to prevent spills soaking into carpet (APC 2005, p. 26).

However, adequate precautions must be taken to prevent rubber or plastic overlays

becoming a tripping hazard for patients, practitioners and staff.

rooms where moxa may be used. Ventilation should maintain the inflow of fresh air and

maintain temperature, humidity and purity of air within prescribed limits (CDNA 2004,

p. 11-4).

the relevant Australian standards, and federal and state or territory guidelines on cooling

towers and hot and cold water services. Air-conditioning systems must be monitored

regularly and serviced by accredited technicians (CDNA 2004, p. 11-4).

conditioning systems and cooling towers, and be satisfied that maintenance is carrie

Ventilation should maintain the temperature, humidity, filtration of air inflow and air

changes.

1

Cooling towers can be a source of Legionnaires disease. Therefore, all Victorian cooling towers must complywith the Victorian Cooling Towers Regulations

(http://www.health.vic.gov.au/environment/legionella/index.htm).

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2.7 Hand basins

Clinical hand basins should be located in treatment rooms where acupuncture is

performed, to improve hand washing practices and decrease the risk ofcross-infection.

Clinical hand basins should be visible and accessible without having to negotiate

obstacles or walk very far either with clean hands before a procedure or withcontaminated hands after a procedure. For more information, see the Australian/New

Zealand standard,Hospital Acquired Infections Engineering Down the Risk(AS/HB

260:2003).

Hand basins must be of the arms-free or non-touch type (ie foot or knee-operated or with

sensor taps). Elbow-operated surgeons taps are not acceptable. Hand basins must provide

both hot and cold running water from a single outlet (DHS 2004, p. 4).

Hand basins must not be used to clean instruments used in an acupuncture clinic. A

separate sink for reprocessing instruments should be located in the reprocessing area of

the clinic (CDNA 2004, p. 11-8).

Key point

Hand basins must be the arms-free (non-touch) type.

2.8 Hand-cleaning agents and dispensers

A pH-neutral, liquid soap with no added substances that could cause irritation or dryness

should be used for hygienic hand washing for low and medium risk procedures (CDNA

2004, p. 12-2). An antimicrobial skin cleanser must be used for high-risk procedures, see

Section 3.1.5 for further information.

Bar or cake soaps must not be used at all, because they harbour contaminants including

bacteria (RACGP 2006, p. 9).

Nonrefillable dispensers for liquid soap and antimicrobial hand-washing solution should

be used in acupuncture clinics because:

they do not permit a topping-up process

they are not messy

they do not waste solution

refillable soap containers are a potential source of contamination.

If refillable dispensers are used, the dispenser and pump nozzle must be washed and dried

thoroughly before being refilled. Liquid soap dispensers must never be topped up,

because contamination of the liquid soap may occur bacteria can multiply in many

soap andantiseptic solutions (CDNA 2004, p. 12-2).

See Section 3.1 for more details on hand washing and drying.



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2.9 Linen

An adequate supply of disposable paper towelling or clean, single-use cloth towels, must

be available for drying hands in the treatment room and also in bathrooms and toilets

within the clinic (CDNA 2004, p. 11-6).

Roller towels are unsuitable for use in treatment rooms, because people often use them

incorrectly, leading to contamination of hands. Air dryers are also unsuitable for use

because they create turbulence that spreads contaminants.

Soiled linen should be placed in a covered, washable laundry receptacle that conforms to

AS/NZS 4146:2000. This should be done immediately after use and at the point of

generation (CDNA 2004, p. 19-1). Soiled linen, towels and protective clothing should be

laundered using hot water (80C) and detergent according to AS/NZS 4146:2000.

Commercial laundry services may be used providing they comply with

AS/NZS 4146:2000.

Clean linen should be transported and stored in a clean, dry place, separate from soiledlinen, to prevent cross-contamination (CDNA 2004, p. 19-2).

2.10 Cleaning of clinics

Regular cleaning of acupuncture clinics is a key part of infection control, because dust,

soil and microorganisms on surfaces can transmit infection (CDNA 2004, p. 18-1;

RACGP 2006, p. 37). The acupuncture clinic should have written cleaning procedures

included in the infection control policies and procedures (see Section 1.5.1; CDNA 2004,

p. 18-1).

2.10.1 Standard precautions apply when cleaning

Standard precautions must be used when cleaning (RACGP 2006, p. 37). Staff should

wear general-purpose utility gloves when cleaning, and personal protective clothing

including face protection (protective eyewear and face mask or shield) as appropriate to

the task (CDNA 2004, Section 18.1; RACGP 2006, p. 37).

Key point

Regular cleaning of an acupuncture clinic is a key part of infection control.

2.10.2 Daily and weekly cleaning routine

Acupuncture clinics should have a documented cleaning schedule for use by clinic staff

and cleaners (RACGP 2006, p. 39). If outside contractors are employed, such a schedule

should be included in the cleaning contract.

Cleaning staff must be instructed on how to safely handle and dispose of any sharp that

inadvertently has not been discarded into a sharps container. All clinic staff and cleaners

must:



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ask the acupuncturist for instruction if they are unsure of how to safely handle any

sharp

report any such sharps to the clinic manager or practitioner with the aim of preventing

recurrence (RACGP 2006, p. 37).

Work surfaces must be cleaned and dried (CDNA 2004, Section 18.1; ACCMA 1997,p. 12):

before and after each treatment session (to deal with dust settling)

when visibly soiled

before and after contact with contaminated instruments or other material

before and after instruments are cleaned on the work surface

at the end of each day.

The level of activity in the practice will influence the frequency of cleaning required

(RACGP 2006; p. 39). Appendix 6 provides a suggested cleaning program foracupuncture clinics, in summary:

hand basins, sinks, benchtops in treatment rooms and reprocessing area, clean daily or

more often if required

floors in treatment rooms and reprocessing area, clean daily

floors in other clinic areas, clean weekly

walls and blinds or curtains, keep clean (CDNA 2004, Section 18.1).

Key point

The clinic should have a documented cleaning schedule for use by staff and cleaners.

2.10.3 Procedures for cleaning work surfaces

Routine cleaning with detergent and water and a mechanical action is sufficient for most

ean, single-use, lint-free cloth or paper towel.

Alcohol wipes are unsuitable for wiping treatment tables and face-holes, because alcohol

surfaces (see Section 2.10.7 for information on cleaning agents). Wiping surfaces with a

damp cloth, and mopping smooth floors with a damp mop, are the preferred methods of

cleaning (CDNA 2004, p. 18-2; RACGP 2006, p. 40). Dry dusting and sweeping with

brooms disperse dust and bacteria into the air and are inappropriate in patient areas

(CDNA 2004, p. 18-2).

To clean work surfaces, including surfaces of treatment tables and workbenches and the

face-holes of treatment tables:

wash with warm water and neutral detergent, then

rinse, then

dry with a cl

will fix grease and other soils, making the surfaces difficult to maintain and increasing

the microbial load.



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Other work surfaces should be washed with warm water and detergent, then dried with a

clean cloth (CDNA 2004 p. 18-2; RACGP 2006, p. 40). Surfaces should not be left wet,

because this encourages microorganisms to grow.

2.10.4 Cleaning surfaces contaminated with blood and body fluids

Any surfaces contaminated with blood, body fluids or substances are potentially

infectious and require prompt cleaning. Treatment tables contaminated with blood or

body fluids during the course of a treatment must be cleaned according to the procedures

set out in Appendixes 6 and 7. This must occur after the soiled covers have been removed

and before they are replaced with fresh covers or linen (DHS 2004, p. 47, Table 6).

2.10.5 Maintaining cleaning equipment

Cleaning buckets and mops should be washed in warm water and detergent, rinsed in hot

water and allowed to dry (CDNA 2004, p. 18-2). Cleaning cloths and mop heads shouldbe stored clean and dry between uses. Detachable mop heads should be laundered

between uses. Buckets should be emptied after use and stored dry.

Sponges should not be used, because they do not dry out easily are easily contaminated.

All cleaning equipment and utensils should be changed regularly. If they are used for

cleaning blood or body substance spills or contaminated areas, they must be disposed of

with clinical waste (CDNA 2004, p. 18-2; RACGP 2006, p. 39).

2.10.6 Cleaning standards for change and shower rooms and toi lets

Change and shower rooms and toilets must be cleaned to minimum standards. This

includes surfaces, fittings (eg basins) and regular disposal of waste. Appendix 9 lists these

minimum cleaning standards.

2.10.7 Cleaning agents

A neutral detergent and warm water, followed by rinsing and drying, is sufficient for

routine cleaning of surfaces in acupuncture clinics (eg treatment tables).

Use a neutral to slightly alkaline detergent to clean instruments. The Australian/New

Zealand Standards for reprocessing medical and surgical equipment (AS/NZS 4815:2006)

suggests avoiding common household detergents, because they contain foaming agents

and leave residues that are difficult to remove.

Detergents may be purchased from a medical supplies company and should come with a

material safety data sheet (MSDS). Practitioners should refer to AS/NZS 4815:2006 for

detailed information on the characteristics of cleaning agents for manual and mechanical

cleaning and information on correct labelling of cleaning agents.

The manufacturers recommended dilution must be followed when making up a detergent

solution for cleaning (CDNA 2004, p. 18-2). To be effective, detergents anddisinfectants

must be used and stored according to the manufacturers instructions. Appendix 10provides guidelines on using and storing detergents and disinfectants.



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Mixed cleaning agents that have been contaminated (eg a mixture in a mop bucket) must

be discarded at the end of the day. Commercially prepared spray bottles can be used until

the use by date, providing the nozzle does not become contaminated. Mixtures prepared

by the practice and that are contained in a reusable spray bottle may be safe to use for a

number of days or weeks, providing the nozzle is not contaminated (RACGP 2006, p. 39).

2.11 Waste disposal

Health industry wastes are all wastes generated by medical, dental, nursing,

pharmaceutical and other similar practices. This includes clinical waste, related waste and

general waste (CDNA 2004, p. 15-2). However, various terms are used to describe waste

produced in health care establishments. These guidelines use the following terminology,

which is consistent with the CDNAs infection control guidelines for preventing

transmission of infectious diseases in the health care setting:

Clinical waste from a health care facility has the potential to cause injury, offence or

infection and includes discarded sharps, human tissue or free-flowing blood, as wellas materials, equipment or solutions containing human tissue or free-flowing blood or

body fluids (CDNA 2004, p. 15-2). In an acupuncture facility, clinical waste includes

acupuncture needles, lancets, dermal hammers, or anything capable of penetrating

the skin; and materials or equipment containing blood or body fluids, such as

contaminated cotton swabs.

Related waste includes cytotoxic, chemical andpharmaceutical waste (CDNA

2004, p. 15-2)

General waste is anything not considered clinical or related waste and includes

kitchen and office wastes and packaging, as well as nonhazardous pharmaceutical

waste, and may be disposed of to landfill without further treatment (or recycled or

composted if applicable) (RACGP 2006, p. 48). General waste is no greater public

health risk than domestic or household waste (CDNA 2004 p. 15-2).

Standard precautions, as described in Section 1.5.2, must be followed when handling

clinical and related wastes (RACGP 2006, pp. 11, 47; CDNA 2004, Section 2.2). Sharps

require particular care in handling and disposal because of the potential for occupational

exposure to sharps injury (including needle-stick injury) and transmission of infection.

2.11.1 Clinical and related waste disposal

Clinical and related wastes must be properly stored, lab

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