4/18/2013
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Infection Prevention and Recent Breaches
Presented by:
Mary Govoni, CDA, RDA, RDH, MBA
and Jessica Wilson
Sponsored by
Hu‐Friedy
What are the breach issues?
• Tulsa Oral Surgeon:• Improper disinfection/sterilization of instruments
• Surgical instruments placed in bleach
What are the breach issues?
• Tulsa Oral Surgeon:• Failure to follow standard precautions
• Using a set of instruments reserved for high‐risk patients
HIV
What are the breach issues?
• Tulsa Oral Surgeon:• Use of rusted/corroded instruments for patient care
What are the breach issues?
• Tulsa Oral Surgeon:• Use of contaminated needles in multi‐dose drug vials
What are the breach issues?
• Tulsa Oral Surgeon:• Failure to spore test the sterilizer
4/18/2013
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What are the breach issues?
• Tulsa Oral Surgeon:• Failure to spore test the sterilizer
What are the breach issues?
• Tulsa Oral Surgeon:• 7000 patients to test (6 years)
• One patient tested positive for HCV – precipitated the inspection
• One patient suing for unspecified infection
What are the breach issues?
• Rhode Island Dentists:• Lincoln and Cranston offices closed by the RI Dept. of Health
• Instruments not properly sterilized
• No monitoring of sterilizer
• Biohazardous waste not properly stored or disposed
• No utility gloves for processing instruments
What are the breach issues?
• Arkansas Dentist:• Was known to be a drug abuser
• Potentially contaminated medication vials used for sedation
• ~100 patients contacted for testing for HIV, hepatitis b and c and syphillis
What is the Fallout?
• Reluctant ‐ fearful patients
• Fearful dentists and team members• Inspections
• Citations/fines
• Decreased revenue
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CDC IC Guidelines
• Sterilization Guidelines• Classification of patient care items
• critical
• semi‐critical
• noncritical
• Heat sterilization of critical and semi‐critical items
OSHA Regulations
• Transporting of contaminated items
• OSHA BBP standard says – “in a covered, puncture‐resistant container”
• Prevents injury during transport
• Cassettes ideal to meet this requirement
CDC IC Guidelines
Sterilization Guidelines
• Cleaning instruments prior to packaging for sterilization
• Use of enzymatic detergents
• Ultrasonic cleaners and instrument washers – NO DISHWASHERS!
Maximizing Instrument Life
• Regular Visual Inspection
• Rust
• Pitting
• Discoloration
• Missing parts (Broken tips, hinges, etc.)
• Handles (cracked resin)
• Scratched mirrors
Maximizing Instrument Life
• Routine Maintenance
• Sharpening
• First sign of dullness
• Scaler (not removing calculus)
• Lubrication of hinged instruments
• Recommended weekly
• Rust removal
Maximizing Instrument Life
• Sharpening
• First sign of dullness
• Annual Sharpening protocol
• 10 – 15 daily sterilization cycles
• Scaler (not removing calculus)
• Is your scaler grabbing test stick?
• End of blade appears shiny
• Increased pressure to perform procedure
• Ortho Plier
• mail in 6‐9 mos
• Surgical (elevators, scissors)
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Maximizing Instrument Life
• Replace instruments as necessary
• Remove broken instruments from circulation
• What is the shelf life of instrument?
• Are instruments compatible with sterilization
protocols?
Maximizing Instrument Life
• Proper Handling
• Mixing of metals
• Carbon Steel & Stainless Steel
• Burs, Orthodontic instruments
• Exposure to chemicals
• Stain & Tarter Remover, Phenols, Bleach?
• Excess contact with other instruments
• Scratching? Nicking?
CDC IC Guidelines
• Sterilization Guidelines• Keep contaminated and clean/sterile items separated in the processing area
CDC IC Guidelines
• Sterilization Guidelines• Package/wrap instruments/cassettes prior to sterilization
• Dating packages – necessary or not?
• Use process integrators in each load/pack
Process Indicators and Integrators
• Not a substitute for biological indicators/spore tests
• A quality control measure, recommended by the CDC
• Validates that all instrument packs or cassettes in each load have been exposed to the necessary parameters for sterilization
Process Indicators and Integrators
• Available types of indicators – single or dual parameter
• autoclave tape – single
• printed on sterilization pouches – usually dual (inside and outside pouch)
• indicator strips placed in pouches or cassettes
• Steam sterilization integrators• multi‐parameter ( time‐temp‐steam penetration)
• Class 5 –equivalent to BI (again not a substitute for)
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CDC IC Guidelines
• Sterilization Guidelines• Monitor sterilizer “at least weekly” with a biological indicator
CDC IC Guidelines
Sterilization Guidelines
• Use high‐level immersion disinfectant/sterilant for heat sensitive items
• Cannot be monitored for effectiveness like spore‐testing a sterilizer
CDC IC Guidelines
• Follow standard precautions• Treat each patient as if they were potentially infectious
• No “extra measures” for infectious patients• Double gloving
• Not cleaning instruments in the ultrasonic
• Sterilizing instruments twice
CDC IC Guidelines
• Follow principles of aseptic technique• Remove gloves and wash hands before leaving the treatment room
• Remove gloves or use instrument pick‐ups to open drawers and retrieve items
• Change face mask after each patient• Or before if it becomes wet
CDC IC Guidelines
• Follow principles of aseptic technique• Washing hands before donning gloves and immediately after removal
• Use sterile gloves for surgical procedures
• Segregate and dispose of sharps and other contaminated items according to state/local regulations
CDC IC Guidelines
• Follow principles of aseptic technique• Dispose of or clean/sterilize lab items after each use:
• rag wheels, burs
• pumice
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CDC IC Guidelines
• Water quality from the dental units• <500 cfu/ml
• purging lines at the beginning of the day not sufficient to control biofilm
• water quality should be monitored periodically outside testing service
CDC IC Guidelines
• Filtration
• Point of use
• Point of entry
CDC IC Guidelines
• Use of FDA cleared waterline cleaners• Decreases level of contamination
• Continuous use products more efficient
• Shock treatment at 4‐6 week intervals• Removes build‐up not controlled by daily maintenance
Personal Protective Equipment
• Eye protection
• Respiratory protection –masks
• Protective apparel
Personal Protective Equipment
• Gloves• Procedure gloves
• Utility gloves
Infectious Disease Update
4/18/2013
7
• HBV vaccine
• Influenza (seasonal with H1N1)
• Tetanus (TDaP)
• MMR
• Shingles (Zostavax)
• HIV/AIDS • >1 million in US living with HIV/AIDS
• 21% unaware of their disease
• New drug approved for prevention
• Ongoing vaccine research
• Home test approved
Hepatitis C Update• Most common chronic bloodborne infection
• Risk factors• Received blood transfusion or solid organ transplant before 7/92
• Received clotting factor concentrates before 1987
• Long term dialysis
• Needlestick, tattoo, body piercing
• Injectable drug use
• Drug treatment for chronic hepatitis C• Antivirals (Ribivirin & Interferon)
• Protease inhibitors (Incivek & Victrelis)
Hepatitis C Update• CDC advisory on one‐time hepatitis C testing
• For “baby boomers” – born btw 1945‐1964
• 25% of U.S. population
• 73% of new cases of hep C come from this age group
• Exposure may have been >20 years ago
Norovirus
• Most common cause of gastroenteritis in the U.S.
• Very contagious• Spread from infected person or contaminated food/water
• Symptoms:• Diarrhea, vomiting, nausea, stomach pain, fever, headache, body aches
• Contagious when sick and 3 days after
• Outbreaks at highest levels since 1996• Cases in 23 states
• Including outbreak in July in Indiana
• No deaths, but 40% were hospitalized• Risk of pneumonia and encephalitis
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Tuberculosis• Standard precautions not sufficient to prevent transmission
• TB prevention program• Community risk assessment
• Screening patients for hx of TB or symptoms
• Defer elective tx for active TB patients
• Provide only emergency tx with N‐95 respirator
• TST for DHCP’s with symptoms
• “Whooping cough”
• Cases on the rise• Michigan and California
• Primarily in infants
• Health Care Professionals
• TDaP vaccine for all adults
• Deadly infection now an epidemic in U.S.• Severe diarrhea from toxins released by bacteria
• HAI – hospital acquired infection
• Elderly, and patients on antibiotics most vulnerable
• Use caution when prescribing antibiotics
MARY GOVONICDA, RDA, RDH, MBA
517‐214‐8223
www.marygovoni.com
@MaryGovoni
www.facebook.com/marygovoniandassociates
866‐628‐4149
JESSICA WILSON, B.A.
404‐484‐2036
773‐868‐3661
Jwilson@Hu‐Friedy.com
@Jessica1Wilson
Jessica Wilson