Jo Russell Oracle Practice Business … are we facing? There is a real and present danger of...

Jo Russell

Oracle – Practice Business Solutions Ltd

www.oracle-pbs.co.uk

© Jo Russell Oracle – Practice Business Solutions Ltd

Aims

Delegates will comprehend the standard requirements for good decontamination practice


Objectives

Look at pre-sterilisation cleaning & use of PPE

Discuss the Code of Practice’s relevant contents

Look at the implications of the HSE law for re sheathing needles

Apply the HTM 0701 for waste regs

Create a hand hygiene programme

Create an induction programme for new employees including trainees

© Jo Russell Oracle – Practice Business Solutions

Outcomes

Delegates will at the end of this course appreciate the role of Decontamination Lead and Infection Prevention Control Lead in the dental setting according to the relevant regulations

Jo Russell 31 years in dentistry

7 years in the Royal Naval Dental Branch, then DDS

Area Manager with IDH (My Dentist) – 16 practices in London and the South

Teaching qualification

NEBOSH Health and safety qualification

Since 2007 teaching management & CPD nationally

CQC bank inspector

Expert Witness at the GDC

Compliance consultant in practices

What is said in the room, stays in the room!

Confidentiality

What are we facing?

There is a real and present danger of infection from dentistry

Patients trust us to provide infection control

The GDC says pts expect a “clean and safe environment” for pts and we must treat them in a “hygienic and safe environment”

Health and Social Care Act 2008 (2014) - Dental practices have a responsibility to adopt safe systems of working with respect to cross-infection control and decontamination (BDA).


Practice Registration


What it means:

Includes the provision of safe, clean environment and appropriate decontamination

Emphasis on quality management and self-audit

Compliance with

HTM 01-05 (or equivalent guidance)

The Health and Social Care Act 2008: Code of Practice for the prevention and control of infections and related guidance

What would you do? You go for a job interview at a practice and it goes well. After the interview, the manager (a registered dental nurse) takes you to one side and explains, “we do things a bit differently here, we’re NHS so we reuse gloves, files and sqiveland matrix bands and we don’t sterilise aspirator tips, 3 in 1 tips or impression trays.”

You get offered the job

Discuss what, if any, course of action you might take

Immunisation Hepatitis B – surgery work can begin after 1st dose after

initial training and risk assessment

Routine boosters are no longer given

Non responders

Keep a log of Hep B

TB in high risk areas/groups

HIV infected workers

Essential Quality Requirements Instruments free of visible contamination

Validated decontamination

Instruments sterile at end of cycle

Maintained in a clinically acceptable condition to point

of use

Detailed gap analysis to best practice…


Instrument cleaning is carried out with a washer disinfector

Instruments are dealt with a first in first out basis

Separate decontamination facilities Less frequently used instruments are subject to careful controls on the storage times

Reprocessed surgical instruments are stored appropriately to ensure restraint of microbiological re-colonisation

Instruments are reprocessed if not used within the designated storage period

Safe and orderly storage of instruments Easy-clean waterproof keyboards

Instruments are stored in an appropriate clean room

What is Validation?

“Validation is a documented procedure for obtaining, recording and interpreting test results to show that a process is working consistently and that its products – such as decontaminated instruments – meets required standards.”

Demonstrates that decontamination equipment is working correctly & consistently

What do we validate and how?

Sterilisers, ultrasonic baths, washer disinfectors

Logs kept for 2 years

Sterilisers

It is the Registered Manager’s legal & insurance related duty to carry out periodic tests and maintenance tasks

Keep a logbook of:

Maintenance

Validation – (manually record - date, completion of cycle, time, temp pressure, signature of operator)

Faults

Modifications

Routine tests

Best Practice Refers to the full level of compliance that may

be achieved immediately or via documented improvement from essential quality requirements


Best Practice Cleaning with validated washer-disinfector

Separate room(s) for decontamination

Suitable, safe storage for instruments


“A fundamental and motivating factor to cross infection control is

self-preservation” * Website: Copdend.


What is Infection?


What is Infection?


Antibiotics & Resistance

Penicillin was first discovered in 1928

No new class of natural antibiotics have been found since 1987

Dame Sally Davies, CMO, “poses a catastrophic threat”

New natural class ‘Teixobactin’ discovered in the soil Jan 15

Effective against TB and MRSA in mice

At least 30 years of resistance estimated from this class

Marketable in 4 years, in 1 year clinical trials will start

At a cost of several hundred million US dollars

Anti Microbial Prescribing Is only indicated:

As an adjunct to the management of acute or

chronic, spreading infection

Treating ANUG

Where definitive treatment has to be delayed due to referral to specialist service. E.g. inability establish drainage in a pt who needs sedation or GA or pt who has comorbidities

There is no indication for the prescribing of antimicrobials for acute pulpitis, where surgical intervention and analgesics are more appropriate.

PPE

Personal Protective Equipment must be worn

Includes mask, goggles/visor, gloves, apron, shoes and uniform

Treat as single use where appropriate, have enough uniforms, enclosed shoes

Claim tax relief from HMRC

All should be CE marked

Latex alternatives such as Vinyl and Nitrile available

Single use – do not use alcohol on them

Jewellery should not be worn

Removed from the cuffs to ensure end up inside out

Single use only, disposed in clinical waste

Thick household gloves for manual cleaning.

Face masks - break the straps at the back or lift over the ears, avoid touching the outer surface of the mask

Never allow mask to hang around neck

Single use only, disposed in clinical waste.

Used during all clinical and decon procedures

Facemasks are single use

Wear these over spectacles

Clean when visibly dirty & at end of session

Take care not to touch outer surfaces


Used during all decontamination procedures

Plastic disposable apron break the neck straps and gathering the apron together touching the inside only


Disinfection – a Definition • ‘a process used to reduce the number of micro-

organisms, but does not usually kill or remove them all, rather it reduces them to a level which is not harmful to health.’

• Is to minimise the risk of cross-infection between patients and between patients and staff


What do we use as disinfectants?

Sprays with biocides

Impregnated wipes

Alcohol spray or wipes – can these be used?


Decontamination - Definition

‘The destruction or removal of microbial contamination

to render an item safer to handle’.*

This is the process by which reusable items are rendered safe for further use and for staff to handle.

Known as ‘reprocessing’.


Sterile and Sterilised


Storage times

Covered storage

Transportation to decon room

Items stored in decon room

http://images.google.com/imgres?imgurl=http://dentalsterilizer.cn/upload/200904/m_2009041614374331.jpg&imgrefurl=http://dentalsterilizer.cn/?p=3&a=view&r=8&usg=__Gqt0H7dkxenNtPRP3-TKzP2IZP8=&h=345&w=460&sz=17&hl=en&start=12&tbnid=XNHVHfsU4ueRPM:&tbnh=96&tbnw=128&prev=/images?q=dental+steriliser&gbv=2&hl=en

How do we clean day to day items?

Waterlines

Hand pieces

Aspirator tubes

Burs

Matrix bands

Amalgam carriers

Endodontic Reamers and Files


Single Use Items Gloves

Masks

Aprons and bibs

Aspirator tips

3 in 1 tips

Steel burs

Reamers and files with the logo

Matrix bands

Pre-sterilisation cleaning

Manual

Ultrasonics

Washer/disinfector

Enzymatic


Cleaning Instruments - Manual

Wear appropriate PPE

Maintain dirty to clean workflow

Dismantle complex instruments

Fill sink with water and detergent at appropriate concentration and temperature

Fully immerse instruments

Agitate/scrub with long handled plastic bristle brushes..


Rinse in second sink (bowl) filled with suitable potable fresh distilled or RO water

Drain (dry if they are to be wrapped)

Inspect under illuminated magnifier

Clean and dry brushes

Dispose of all solutions

Complete the appropriate documentation


Week commencing:

PPE worn Solution correct concentration & temp

Rinsed Inspected Solution changed

Brushes rinsed and dried

Signature

Monday AM PM AM PM AM PM AM PM AM PM AM PM AM PM

Tuesday

Wednesday

Thursday

Friday

Example Checklist

Manual Cleaning

Not as effective

Can’t reproduce results

Danger of sharps & foreign body injuries


Coldsores

© Jo Russell Oracle – Practice Business Solutions ltd


Ultrasonic bath


Use of Ultrasonic Bath

Degassed prior to first use

Interlocking lid

Fluid changed at least twice a day

Ensure all fluid is rinsed off use

Inspect instruments

Scrub any rejects

How often do you test the ultrasonic bath?


Washer Disinfectors


WD Cycle

Cold rinse

Hot wash with detergent

Rinse

Hot (80-90oC) rinse

Drying


Validation – WD & Ultrasonics

Weekly residual protein test

Quarterly soil test

Quarterly cleaning efficacy test


HSE Sharps Guidance From 2013 systems to be in place to reduce risk to staff

from inoculation injuries

Control the risks Team training

PUWER risk assessment provides the guidelines.

What do you do if you receive a sharps injury?

If you suffer an injury from a sharp which may be contaminated: Encourage the wound to gently bleed, ideally holding it under

running water Wash the wound using running water and plenty of soap Don't scrub the wound whilst you are washing it Don't suck the wound Dry the wound and cover it with a waterproof plaster or

dressing Seek urgent medical advice (for example from your

Occupational Health Service) as effective prophylaxis (medicines to help fight infection) are available

Report the injury to your employer.

Health and Safety (Sharp Instruments in Healthcare) Regulations 2013

Risk of transmission of blood-borne viruses from patient to healthcare worker

Infection Patient to healthcare worker

Hepatitis B (HBV) 6 - 30%

Hepatitis C (HCV) 1-3%

HIV 0.3%

Work Equipment Provision and Use of Work Equipment Regulations

Risk Assessment For Needles Serial Number: Date assessment carried out Review date for assessment List significant hazard here (What would the outcome be?)

Likelihood X Level of Harm (risk score)

List the groups of people who are at risk from the significant hazards you have identified

List existing controls or note where the information may be found. List risks which are not adequately controlled and the action needed

New level of risk

Contact – when resheathing a used needle – risk of inoculation injury possibly causing infection or contraction of a pathogen

25 (5x5)

Dentists, nurses, hygienists, therapists Any young workers

Eliminate – replace the separate components with a whole disposable system where possible Safe Systems – re-sheathing device to be used to prevent injury IITS – the team is trained in the safe use of sharps Young workers supervised

10 (5x2)

Risk assessment is significant hazard posing significant harm. So is calculated as likelihood x level of harm posed. Scored 1 (not likely) to 5 (very likely) x 1 (minimal harm) to 5 (significant/serious injury)

Signed: Name:

Risk Assessment For Sharps Serial Number: Date assessment carried out Review date for assessment List significant hazard here Level

of risk List the groups of people who are at risk from the significant hazards you have identified

List existing controls or if new control measures are necessary. Include remedial action needed

New level of risk

Risk of inoculation injury from infected sharps such as used needles, scalpels, instruments leading to deep lacerations or contracting biological agents

4x4=16

Staff Young workers Pregnant mothers Waste contractors

All staff are trained in infection control – updated annually Scrubbing instruments is avoided & ultrasonic bath used Sharps container is used Inoculation injury policy is enforced If required, medical advice is sought All staff immunised against Hep B HTM 0105 is followed

1x4=4

Risk assessment is significant risk posing significant harm. So is calculated as likelihood x level of harm posed. Scored 1 (not likely) to 5 (very likely) x 1 (minimal harm) to 5 (significant/serious injury)

Signed: Name:

COSHH Assessment Number

COSHH Assessment Form

About the substance Name of substance

Pathogenic micro organism delivered by accidental inoculation injury

Hazardous ingredient

Biological agents

What is it used for

Who uses it/exposed to it

All clinical member of the team

How often is it used

Daily

How should it be disposed of

Nature of the Risk Chemical Flammable Poisonous Biological Carcinogen

Health Effects What will happen if exposed Inoculation Possible contraction of BBV namely

hepatitis or HIV

Skin

Inhalation

Ingestion

First aid measures Inoculation Follow current inoculation injury protocols

Skin

Inhalation

Ingestion

Control measures Eyewear Gloves Facemask

Other Vaccination against Hepatitis B

Ventilation General Local

Health monitoring

Staff Training Staff training in safe resheathing and disarming of used needles on a regular basis. Robust induction and

evidenced initial and ongoing training as per Code of Practice of prevention and control of infections and

related guidance.

Emergency Action

Code of Practice &

Waste Regulations

Health and Social Care Act 2008: Code of

Practice on the prevention and control

of infections and related guidance

(updated 7/2015)

‘The wider aspects of infection prevention’

Criterion 1 Infection Prevention Programme which documents:

Prevention & cleanliness measures needed

Policies, procedures needed, how they will be kept up to date & monitored

Initial and ongoing training

IPC Lead Annual Statement

The IPC lead annual statement, the will need to ensure their annual statement provides a short review of:

Known infection transmission event and actions arising from this

Audits undertaken & subsequent actions taken

Risk assessments undertaken for prevention and control of infection

Training received by staff

Review and update of policies, procedures and guidance.

Audit Summary Sheet Date:

Audit topic: __________________________________________________________ Audit aim: ___________________________________________________________ Comments on findings, was the aim met?: _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Strengths: _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Weaknesses: ____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Proposed action: _____________________________________________________________________ _____________________________________________________________________ By whom: _________________________________________________________ By when: _________________________________________________________ Re-audit date: _________________________________________________________

Audit Summary Sheet

Audit topic Infection Control Audit date 1st March 2017

Aim of the Audit To achieve 90% of the standards set

Comments on findings

As a whole, the audit showed the practice performed reasonably well. We achieved 88% of the standards set. There has been a big push on correct handwashing and we are looking to improve again in that area. We don’t have a washer disinfector so can never be 100% in all areas so we are looking to improve only in the areas we can. Protaper files are used and are reused only for the same patient so, again, scored less on that one.

Strengths On the whole the nurses know the correct procedure for effective infection control.

Weaknesses The ticksheet evidence is not always signed daily The decon lead has missed countersigning on occasion The domestic cleaners are new and still getting the hang of the evidence sheets

Proposed action 1. Reinforce the evidence sheets in all areas 2. Encourage the dentists to allow more

clean up time 3. Impressions should be labelled as having

been disinfected 4. More monitoring of hand hygiene

By whom and when

Decon lead to address the above issues in the next team meeting on 15.4.17

Re-audit date Focused re audit on the above 15.7.17 General re audit on 1.3.18

Criterion 2

Designated lead for cleaning and decontamination of the environment and equipment

A cleaning schedule should be in place for clinical areas, including specifying which areas are to be cleaned between patients

Care of DUWL

Risk assessment and written control scheme for Legionella. Logbooks, including testing, service, maintenance and repair records should be maintained in the practice for at least two years.

Criterion 3 Providers should ensure that antimicrobial prescribing is

covered in induction procedures for dentists and training is given

Criterion 4 Not really applicable in primary dental care

Criterion 5 Standard universal precautions used following mh

Criterion 6 The registered provider must ensure that everyone

understands and complies with the need to prevent and control infections.

Criterion 7 & 8 Do not apply

Criterion 9 9a - All staff should be trained in hand hygiene and use of

PPE during clinical work and decon. Policies should be in place for safe handling and disposal of waste and sharps

9f – immunisation and maintenance of records of Hep B. Staff trained in sharps handling and blood and body fluid spills

9p – HTM 0701, correct waste segregation and disposal

Criterion 10 Policies for protection of staff should include:

Risk assessment of need for immunisation, in particular hepatitis B immunisation

Health screening for communicable disease, including tuberculosis and where appropriate, BBV screening for those undertaking exposure prone procedures

Use of PPE, including safe use and disposal

inoculation injury management

Staff will require ongoing training in infection prevention and cleanliness.

A record should be kept of all staff training.

Waste Management

Hazardous

Sharps – yellow lidded

Yellow/Orange bag

Amalgam waste

Developer and fixer

Non hazardous

Lead foils

Domestic waste

Sanitary bins.

Teeth?

Study Models?

Study Models

“This material is prohibited from disposal at normal landfill as it may produce hydrogen sulphide gas when it breaks down. Must be segregated and either sent for recycling as gypsum waste. Your local authority should have a suitable facility – probably your local amenity site.”

Daniel McAlonan

Health & Safety Adviser

BDA

Documentation needed Contracts

Labelled with practice details and classification codes

Consignment notes Tracks movement and safe disposal of hazardous waste

Kept in a register for 3 years

Waste transfer notes Legal responsibility for describing the waste is that of the

practice

Season ticket

Kept for 2 years


Hand washing


Patients

Our patients are walking germs, they and their potential for carrying and spreading nasties should not be underestimated….


http://www.google.com/imgres?imgurl=http://specialedandme.files.wordpress.com/2009/01/man-sneezing.jpg&imgrefurl=http://specialedandme.wordpress.com/2009/01/14/mystery-to-medicine-unit-opener/&usg=__fBDiUP2De7ZzykBEiydweaKNXmU=&h=425&w=425&sz=25&hl=en&start=3&tbnid=Tfko5COJbEAr1M:&tbnh=126&tbnw=126&prev=/images?q=germs&as_st=y&hl=en

http://www.google.com/imgres?imgurl=http://gaudiumdegaea.files.wordpress.com/2009/02/cold-germs.jpg&imgrefurl=http://gaudiumdegaea.wordpress.com/2009/02/&usg=__8CRtY44Ne5bVM3FQnv1I7eZU8dI=&h=553&w=534&sz=82&hl=en&start=2&tbnid=3Tvv4tviuK9QlM:&tbnh=133&tbnw=128&prev=/images?q=germs&as_st=y&hl=en

• Then….

• 1980’s meant no gloves, no masks, Health & Safety?

• Coughs, colds, cold sores, D & V bugs, chicken pox

• HIV came to light and scared people

• Now….

• HIV, Hep A, B, C

• vCJD, TB

• MRSA

• Campylobacter bacteria

• E-Coli

• Clostridium Difficile

• Prevalent D&V bugs such as Norovirus

• Herpes – to name but a few


Resident and Transient Micro-Organisms

Resident:

Part of an individual’s normal flora (commensals)

Primary function to protect the skin from harmful micro-organisms

Live deep within the epidermis and not easily removed

Not usually responsible for causing infection


Transient:

Found on the surface of the skin

Able to transfer, by direct contact, harmful micro-organisms such as:

Staphylococcus Aureus –MRSA, boils, toxic shock syndrome, impetigo, food poisoning

C Difficile & E Coli

Damaged skin, moisture, nail varnish, false nails or wearing of rings increases colonisation

Removed by good hand hygiene


Hand Hygiene

If it is ineffective or non-existent = major factor in

spreading infection

A hand washing poster should be by every hand wash

basin

Nails short, no acrylic

Use water based hand cream at the end of each session


http://www.google.co.uk/imgres?imgurl=http://seseo.files.wordpress.com/2009/01/acrylic-nails.jpg&imgrefurl=http://seseo.wordpress.com/2009/01/&h=450&w=600&sz=62&tbnid=KvMBu7Ni7wR2LM:&tbnh=101&tbnw=135&prev=/images?q=acrylic+nails&usg=__YmmRaA05g_f0i-py1KjE7vhZu00=&ei=viFaSpOACp-OjAevuNUb&sa=X&oi=image_result&resnum=1&ct=image

http://www.google.com/imgres?imgurl=http://wusa9.com/news/columnist/blogs/uploaded_images/neutrogena-hand-cream-781989.jpg&imgrefurl=http://www.wusa9.com/news/columnist/blogs/2007/12/great-channel-9-hand-lotion-survey.html&usg=__zA44Xy5arJiTceU8v4NIUvb9LoQ=&h=300&w=300&sz=17&hl=en&start=1&tbnid=fJ8-1LSmjgd56M:&tbnh=116&tbnw=116&prev=/images?q=hand+cream&as_st=y&hl=en

Surface tension created on

water, strong enough to hold

this insect

Water is held together

with this surface

tension and creates a

barrier

Add detergent to break the

surface tension and make water

wetter. No splash and dash

Hand Washing • Wet hands first!

• Liquid soap and running water

• Sing happy birthday twice

• Thoroughly rinse and dry paper towels

• Use blunt orange stick to clean nails

• When do we revert to soap and water?

• Beginning and end of each session

• If hands become visibly soiled

• If hands become sticky with hand rub build up

• After carrying out decontamination


Create a Hand Hygiene Update Include the following:

The reason/rationale behind hand hygiene

What you are aiming to achieve

The method they should use

The products they should use

Include how often it should hand hygiene be reviewed

Inductions/training Think about what areas will be included:

Reasons for controlling infection Hand hygiene

Surgery routines

Disinfection of surfaces

Decontamination of equipment

Use of equipment

Validation of equipment

Safe disposal of sharps

Segregation and disposal of waste

Correct use and disposal of PPE

Domestic cleaners induction and checklists

Keep records of staff training and Hep B

Domestic cleaning schedule What can be included:

Daily

Weekly

Monthly

6 monthly

Devise a checklist

Mops

Toilets

Waiting room and corridors

Kitchen

Surgeries

To delegate or not? What can we delegate?

Validation

Alpron (or the like) dip slide

Water temperatures

IPS Audit

Foil ablation test

What are our direct tasks? Daily surgery evidence sign off

Domestic cleaning sign off

Random checks

Policy update

Inductions

Regular training schedule

Servicing the equipment

To Summarise Look after yourself and the result will be that we take

care of the patient

GDC Standards 1.9 state ‘know about the laws and regulations that affect your work and follow them’

Undertake your 5 hours of verifiable CPD over your 5 year cycle and ensure it is continuous

Watch each other and ensure standards don’t slip

Support each other to achieve the highest standards.

http://www.oracle-pbs.co.uk/




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