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IMS-511/0910

Description: This seminar introduces infection control principals and best practices pertaining to sterilization and disinfection of patient care items as well as dental unit waterlines, in accordance with the CDC guidelines.

Objectives:You will learn strategies to assist you in maximizing safety and efficiency of instrument processing. In addition, you will learn how to optimize the quality of water that you deliver to your patients.

What are the CDC Guidelines? n Consolidated recommendations for preventing and controlling infectious diseases n Strategies designed to protect patients and health care workers n Guidelines only, not government regulations

To access guidelines visit: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5217a1.htm

Standard precautions to prevent disease transmission include: n Hand Washing n Use of Personal Protective Equipment (PPE) n Cleaning and decontamination with PPE n Cleaning and disinfection of environmental surfaces n Injury prevention

MODUlE 1: 5 Steps of Instrument Processing

Transportation “Minimizing handling of loose contaminated instruments during transport to the instrument processing area. Use work practice controls (e.g., carry instruments in a covered container) to minimize exposure potential.” - MMWR2003:52 (No.RR-17), VI, C1

Transportation Considerations: Sterilization Cassettes n Organize instruments and accessories per procedureBenefits include: n Increased chair-side efficiency n Improved office flow n Faster instrument processing n Faster set-up/tear down (no sorting instruments, prepping tray) n Improves safety n Less injury potential due to reduced handling of contaminated instruments n Reduces Costs n Less potential to lose or damage instruments due to being secured tightly in cassettes n Makes staff training easy

Receiving, Cleaning and Decontamination“Designate a central processing area. Divide the instrument processing area, physically or, at a minimum, spatially, into distinct areas for:

1) Receiving, Cleaning and Decontamination 2) Preparation and Packaging 3) Sterilization 4) StorageDo not store instruments in an area where contaminated instruments are held or cleaned.”-MMWR 2003; 52 (No.RR-17), VI, B1

Required Practices in Instrument Processing Area n Wear appropriate PPE (utility gloves, mask, glasses, gown) n Use automated cleaning equipment n Follow processing guidelines of equipment manufacturers

“Use automated cleaning equipment (e.g., ultrasonic cleaner or washer-disinfector) to remove debris to improve cleaning effectiveness and decrease worker exposure to blood.” - MMWR 2003; 52 (No.RR-17), VI, C2

Proper Use of Ultrasonic n Use only correct solution; change daily or more often n Never overload; follow weight limits n Submerge all instruments n Keep lid on during use n Conduct monthly foil test to determine cleaning effectiveness

Enzymatic Ultrasonic Cleaning Solution n Include proteolytic enzymes which break up bioburden and debris more rapidly

than non-enzymatic solutions n Shown to reduce the need, if any, for hand scrubbing n Dual enzyme cleaners include multiple enzymes for better cleaning n Protease – protein enzyme that breaks down blood n Amylase – which breaks down plaque and starches

Dental Instrument Washers* n More effective, efficient, streamlined infection control process than manual cleaning n Less exposure to blood and body fluids, exposure to sharps

n Must be used according to manufacturer’s instructions – no mixing of metals *Dental Instrument Washers are not the same as Dishwashers. Dishwashers are not FDA approved for cleaning dental instruments.

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Sterilization Cycle Components n Heat-up period - Must reach sterilizing temperature n Exposure interval - Time required for sterilization of load n Cool-down period: n Allow sufficient cooling for handling n Remove excess moisture n Important for handpiece sterilization and function Considerations for Sterilizers - MMWR 2003; 52 (No.RR-17), Sterilization n Use only FDA cleared medical devices n Allow to dry in the sterilizer before handling to avoid contamination n Arrange to permit free circulation of the sterilizing agent n Follow manufacturer’s instructions n Do NOT overload n Observe weight limits Sterilization Monitoring “The ability of equipment to attain physical parameters required to achieve sterilization should be monitored by mechanical, chemical, and biological indicators.” -MMWR 2003; 52 (No.RR-17), Sterilization 1. Mechanical Indicators (each load) n Observe the gauges or displays on the sterilizer to assess time, temperature and pressure 2. Chemical Indicators (each load) n Change in color upon reaching physical parameter 3. Biological Indicators/Spore Tests (at least weekly). When sterilizing an implantable device, it

needs to be completed with each load. n Assesses the sterilization process directly n Uses the most heat-resistant microorganisms n Refer to state and local guidelines n If there is a failure, remove sterilizer from service. Ensure sterilization process was followed in order to rule out “operator” error. Correct any procedural errors, re-test the sterilizer using biological, mechanical, and chemical indicators. n If repeat spore tests are negative, return sterilizer to service Biological Monitoring n Why Spore Testing? n More resistant than the common microbes found on patient-care equipment n Inactivated BI n Indicates other potential pathogens have been destroyed

Storage- MMWR 2003; 52 (No.RR-17), Storage n Use “event” or “date” related shelf life practices n Examine wrapped items carefully prior to use n If the packaging of sterile items is damaged: n Re-clean, re-wrap, re-sterilize n Store sterile items in closed or covered cabinets (also dry area)

Patient Perception n Keep instruments wrapped until patient treatment n The pay off: Patients note sterile packages (perception and reality)

Manual Instrument Cleaning (Hand Scrubbing) “Use work-practice controls that minimize contact with sharp instruments if manual cleaning is necessary.” -MMWR 2003; 52 (No.RR-17), VI, C3 n To be done when automated methods are not possible n Requires use of long-handled brush n Requires user to wear utility gloves and other PPE n Is effective at removing debris n Is not as efficient as automated cleaners n Can be dangerous, increasing potential for sharps exposures

Optional Step: Pre-CleaningGoal: Maintain moisture and prevent debris drying onto instruments n Holding solutions n Enzymatic spray pre-cleaners also help dissolve blood, tissue and other debris n Never use gluteraldyhydes (CDC) – They are toxic, could cause tissue injuries and respiratory

problems; not all instruments are compatible Rinsing and Drying n Rinse instruments thoroughly before drying n Completely dry instruments before placing in pouches / wraps n Reduces occurrence of corrosion and discoloration

Preparation and Packaging“Instruments are to be inspected for cleanliness; then wrapped or placed in containers designed to maintain sterility during storage.” - CDC MMWR 2003; 52 (No. RR-17), VI D2 Internal chemical indicator n Place into every packageExternal chemical indicator n Use when internal indicator cannot be seen from outsideHinged instruments n Process open and unlocked Choose an Effective Post-Cleaning Packaging Material* n Allows penetration of the sterilizing agent n Maintains sterility after sterilization n Provides an adequate barrier to microorganisms n Puncture and tear-resistant n Low linting, free of toxic elements and dyes n Cost effective *Practical Infection Control in Dentistry, Third Edition, John A. Molinari, Jennifer A Harte, page 226, Table 16-3

Sterilization and Monitoring n Heat sterilization of critical and semi-critical items n Critical: Anything that touches soft tissue or bone n Semi-Critical: Anything that touches soft tissue or non-intact skin Types of Heat-Based Sterilization n Steam under pressure (Autoclaving) n Dry heat n Unsaturated chemical vapor

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MODUlE 1: 5 Steps of Instrument Processing

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Biofilm n A coating or covering on the surface of a living or nonliving substrate composed

of microorganisms such as bacteria, protozoa, and algae (Plaque is an example). n Highly complex microbial structural entity n Exists in all environments, including water and solidsColonization Sequence n Organisms attach to surface of walls n They grow, thicken and reproduce n New bacteria attach and grow

DUWl and Biofilm n Microorganisms grow into thick biofilm colonies and stick to internal waterline surfaces n Biofilm colonies quickly grow, contaminating treatment water for patients n As the rushing water comes into contact with the established biofilm, pieces break off

Rapid growth of microorganisms is caused by: n Small diameters of waterlines n Slow water flow n Low volume of water used n Water warms to room temperature n Low usage

Recommendations n CDC - Dental treatment output water should meet regulatory standards

for drinking water (<500CFU/ml of heterotrophic water bacteria) - MMWR 2003; 52 (No.RR-17), Dental Unit Waterlines

n ADA recommends < 200 CFU/ml – ADA Statement on Dental Unit Waterlines, 1995

Sources of bacteria n Incoming municipal water n Is sanitized, but can have up to 500 cfu/ml n Biofilm will develop if not properly cleaned and maintained

n Patient’s mouth n As water is retracted into the air/water syringe, the anti-retraction valve could be

coated with biofilm causing delay in closing of valve n This delay may cause fluid from the patient’s mouth to be “retracted” back into the

line, then re-introduced into next patient’s mouth

- MMWR 2003; 52 (No.RR-17), Dental Unit Waterlines n Municipal water supply is primary source of microorganisms n Does not pose high disease risk for HEALTHY persons n Research shows microbial counts can be < 200,000 within 5 days

of new DUW installation. n Using water of uncertain quality is inconsistent with infection control principles. n Untreated dental units cannot reliably produce water that meets drinking

water standards. n Unacceptable to use highly colonized water for any kind of dental treatment

Treating Dental Unit WaterlinesComplete dental unit waterline systems include use of an antimicrobial cleaner and a maintenance product n Over time, bacteria can overwhelm the waterline environment n Cleaning with registered antimicrobial is necessary to remove microbial deposits n Using a proper maintenance product is also necessary to keep tubing surfaces clean

between antimicrobial treatments n Prevents waterborne organisms from attaching, colonizing, proliferating in tubing

Treating Dental Unit WaterOne option: Vista Tab Antimicrobial Cleaner (EPA registered) n Cleans lines of microbial contaminants (periodic) n Non-corrosive solution 7x more effective than bleach n Environmentally friendly – no heavy metals n Easy to Use – Requires only 5 minutes a month n Non-corrosive; no harmful byproducts

VistaClean – Daily Maintenance Product n Dissolves waterline contaminants n Maintains lines daily n Derived from organic, citrus botanicals – safe for use on patients n Environmentally friendly n Easy to use n No effect on bond strength

Monitoring Options - MMWR 2003; 52 (No.RR-17), Dental Unit Waterlines n Water testing using a professional laboratory n In-office testing with self-contained kits n Follow recommendations provided by the manufacturer for use

of the dental unit or waterline treatment product

MODUlE 2: Dental Unit Waterlines

Dental Unit Water Quality

Biofilm

Biofilm Formation

Biofilm Lifecycle—Courtesy of Dr. Ettinger