Breaking the Infection ChainB

8/3/2019 Breaking the Infection ChainB

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Learning to think Learning to think insideinside the box.the box.Patho en

a ogen

ReservoirReservoir

ModePortal

Nonimmunity

Peter O. SildvePeter O. SildveDirector/ Dentronix UltronicsDivision of Coltene Whaledent, Inc.

The World has changed.The World has changed. Common AbbreviationsCommon AbbreviationsBBP Standard Bloodborne Pathogens Standard

CDC Centers for Disease Control

CFR Code of Federal Regulations

DHCP Dental Health Care Personnel (CDC)

DHCW Dental Health Care Workers (OSHA)

ECP Exposure Control Plan

ISO International Standards Organization

OPIM Other Potentially Infectious Material

OSDB Ohio State Dental Board

PPE Personal Protective Equipment

OSHAOSHA Your BoxYour BoxOrin Scrivello, DDS

Insurance CompaniesInsurance Companies

OSDBOSDBCDCCDC


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The Occupational Health & Safety The Occupational Health & Safety Administration (OSHA)Administration (OSHA)

Established by the US Congress in 1970, to insure safe and healthful working con t ons or wor ng men an women y setting and enforcing standards and by providing training, outreach, education, and

assistance.OSHA is part of the US Department of Labor.

Bloodborne Pathogens StandardBloodborne Pathogens StandardCFR29.1910.1030CFR29.1910.1030

Established in 1991Protects all workers that are occupationally expose to oo or OPIM.Cornerstone of OSHAs Infection Control guidelines.

Other OSHA Standards That Affect Other OSHA Standards That Affect the Dental Officethe Dental Office

Hazard Communication Standard (29CFR.1910.1200)

Ionizin Radiation Standard (2 CFR.1 10.10 6)

Exit Routes Standards (CFR29.1910.3539)

Electrical Standards (CFR29.1910.301399)

Posting your OSHA Poster

The Centers for Disease Control (CDC)The Centers for Disease Control (CDC) Agency of the US Public Health ServiceResponsible for guidelines and

recommendations regarding

infectious agents.Focused on DHCP and Patient Exposure.Is not a regulatory body.Has a broad reach through OSHA and State Dental Boards.

The Centers for Disease Control (CDC)The Centers for Disease Control (CDC)Primary document is Infection Control in Infection Control in the Dental Health Care Setting (2003)the Dental Health Care Setting (2003)[ www.cdc.gov/mmwr/preview/mmwrhtml/rr5217a1.htm]

61 of 180 specific CDC guidelines are mandated by state or federal law.

Balance of recommendations can be argued to provide a strong basis for Standard of Care.

The Centers for Disease Control (CDC)The Centers for Disease Control (CDC)

Is it safe?

Dr. Christian Szell

Actual CDC document mandated by Federal Law is Recommendations for Preventing Transmission of Recommendations for Preventing Transmission of HIV and HBV to Patients during ExposureHIV and HBV to Patients during Exposure prone prone Invasive Procedures.Invasive Procedures.[www.cdc.gov/mmwr/preview/mmwrhtml/00014845.htm]


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It all started withIt all started withKimberly Bergalis19681991

December 1987 Molar . . .

March 1989 symptoms of AIDS.

1990 Diagnosed with

AIDS. 1991 Deceased.

The The BoxBox takes shape.takes shape.5 other patients were allegedly infected by Dr. David Acer in Florida.The Kimberly Bergalis Bill The Kimberly Bergalis Bill was introduced in the US House of Representatives in 1991 to require HIV testing of all HCW in the US. It didnt pass.

ect on 33 o t e reasury, osta erv ce, an ect on 33 o t e reasury, osta erv

ce, an General Appropriations Act of 1991General Appropriations Act of 1991was passed to make legally binding certain CDC recommendations to be enforced by states.

OSHA Bloodborne Pathogens Standards OSHA Bloodborne Pathogens Standards 1991Task Force on the Transmission of Bloodborne Task Force on the Transmission of Bloodborne Pathogens by Healthcare Professionals Pathogens by Healthcare Professionals was established by the Ohio General Assembly 1992.

The The BoxBox takes shape.takes shape.The CaliforniaThe California ModelModel CA State Board of Dental Examiners has taken the CDC

guidelines and systematically stripped them of any flexibility making them easier to enforce.

agg ng gu e ne or s er za on ex en e o s n ec on procedures. Recently repealed.

Guidelines administered by individuals with little knowledge of dentistry.

Due to

states

financial

crisis,

compliance

enforcement

is

seen as a revenue building tool.

What happens in CA usually happens later in other parts of the country.

The The BoxBox takes shape.takes shape.

Insurance CompaniesInsurance Companies The last wall of the box. Active in s ecific re ions. .

Use CDC guidelines as primary tool. Administered by individuals usually lacking in dental

knowledge. Target specific areas of non compliance of interest to

insurance liability and risk such as sterilization procedures.

Different boxes.Different boxes.

ChallengesChallenges Tremendous variety of products. All require measurable consistency. Must incorporate customer feedback. Meet global regulatory and compliance requirements. Effective communication of expectations in a large facility. We need to make money to stay in business.


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Our BoxOur Box

ISO ISO International Standards OrganizationInternational Standards OrganizationMinimum operating system for anyone with global operations.

1. Documented Procedures2 On oin Trainin. 3. Corrective and Preventive Action4. Management Review

Say what you do and do what you say. Say what you do and do what you say.

Benefits of a Process Control System. Benefits of a Process Control System.

Defining an optimum protocol. Creating a baseline from which to measure

success or failure.

and employee input that centers on continual improvement.

Compliance can be a burden or a tool for Compliance can be a burden or a tool for making your business unit better.making your business unit better.

Bringing outside experiences Bringing outside experiences inside the box.inside the box.

Curleys Curleys Tattoo.Tattoo.

Single or multiple needles inject

indelible ink into the

dermal layer.

Another kind of drilling and filling. Not much splash and splatter.


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Commonly OccurringCommonly Occurring Infectious Infectious Diseases in DentistryDiseases in Dentistry

BloodborneBloodborneHepatitis BHepatitis C

DropletDropletMumpsRubella (German Measles)

HIV

ContactContactChickenpoxHepatitis A Herpes Simplex

Influenza

Airborne AirborneChickenpoxMeasles

Tuberculosis

A susceptible host must be present

for an infection to occur.

Get Immunized. US Public Health Service recommends the following immunizations:HBV InfluenzaMeasles

Mumps

RubellaTetanus (booster every 10 years)

ChickenpoxReport occupational injuries and exposures immediately.Follow the advice of your medical adviser evaluating your occupational exposure.

Treat every patient as infectious.

Wear gloves, protective clothing, and face & eye protection.Handle sharps with care.Use safety devices as appropriate.Use mechanical devices to clean instruments whenever possible.

Any item that you contaminate can become a source

of potential infection

Set up the operatory before starting treatment. Use unit dose supplies.Cover surfaces that may become contaminated.Minimize splash and spatter.Properly dispose of all waste .

Clean.Disinfect.Sterilize.

Know the different decontamination processes.Read germicide labels.Monitor processes to make sure they are efficacious.Follow manufacturers use guidelines for sterilization and disinfection.

If Saliva were RedOSAP Video1990 something.8 minutes


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Everyone loves jewelry. Use of PPEs have changed over the years, but aerosols are still aerosols. The chart connects the front office with the operatory in this practice.

Breaking the Chain can be about changing behavior and breaking bad habits.

OSHA can be administered at the federal OSHA can be administered at the federal level or the state level.level or the state level.

OSHA requires that you maintain a copy and comply with the Bloodborne Pathogens Standard.

Current y t ere are 25 states w t t e r own OSHA p an. Ohio is not one of them.

In 2009 2010, the 5 most cited violations of OSHA standards in dental offices were:

1910.1030, Bloodborne Pathogens Standard 1910.1200, Hazard Communication 1910.132o,Personal protective equipment, general requirements 1910.120,Hazardous waste operations and emergency response 1910.37,Maintenance, safeguards, and operational features for exit routes


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Step 1 in staying compliant is keeping Step 1 in staying compliant is keeping your OSHA Binder up to date. your OSHA Binder up to date.

1. The Bloodborne Pathogens Standard (CFR29.1910.1030)

2. The Hazard Communication Standard (CFR29.1910.1200)

3. Written procedures on how you comply with these standards including an Exposure Control Plan

4. Vaccination records5. Annual OSHA training documentation

In addition, OSAP recommends that the practice should have a comprehensive personnel health service program (employee health handbook) that addresses: Immunization programsExposure prevention and post exposure managementMedical conditions, workrelated illnesses, and work restrictionsLatex hypersensitivity and other workrelated allergic reactionsMaintenance of records, data management, and confidentiality

Other OSAP recommendations include:Other OSAP recommendations include: A referral arrangement with a qualified medical professional so that jobrelated injuries or illness can be evaluated and treated appropriately and quickly. An education and training schedule tailored to each employees duties and responsibilities. A written immunization program that outlines all recommended vaccinations for staff by job title plus a

referral to get those vaccinations. A confidential, uptodate medical record for all workers. These records should only include immunizations and any tests related to occupational exposure.

OSHA Compliance HierarchyOSHA Compliance HierarchyExposure Control Plan

Universal Precautions

Engineering Controls

Work Practice Controls

Personal Protective Equipment (PPEs)

Exposure Control Plan (ECP)Exposure Control Plan (ECP)

This is a written plan to eliminate or minimize occupational exposures to blood and OPIM.

It must include a list of all job classifications that have potential occupational exposure and the tasks and procedures which result in that exposure. This evaluation should then target methods and technologies to minimize exposures .

Exposure Control Plan (ECP) A key element of the ECP is an annual review that reflects any changes in tasks, procedures and positions that effect occupational exposures, as well as documented evidence of evaluation and review of new technologies and commercially available products that are safer and minimize or eliminate exposures .


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Universal Precautions / Standard PrecautionsTreat all blood and OPIM as if it was infected with HIV/ HBV and other bloodborne pathogens.

There is virtually no difference other than Universal was focused primarily on blood while

Standard addresses blood and all other potentially infectious bodily fluids (OPIM).

Engineering ControlsThese are devices that isolate or remove the bloodborne atho ens hazard from the workplace. These include sharps disposal containers,

self sheathing needles, and safer medical devices such as needle less systems.

Work Practice Controls

based practices and procedures that reduce the potential for

exposure by changing the way that a task is performed.

PPEsPersonal Protective Equipment is an important part of protecting yourself during

pat ent treatment. oves, masks, goggles and shields, gowns, shoe covers all are essential to breaking the chain of crosscontamination and crossinfection.

And theres more..The availability of HBV vaccinations within 10

da s of

initial

assi nment

to

a

ob with

occupational exposure and

The availability of post exposure evaluation and followup to any occupationally exposed staff member.

An exposure incident is a specific eye, mouth, mucous membrane, nonintact skin or parenteral contact with blood or OPIM.

And theres more..Needlestick Safety and Prevention Plan (2000)

1. U dates Ex osure Control Plan. Take into account innovations in procedures and technological developments that reduce the risk of exposureDocument consideration and use of appropriate commercially available and effective safer devices.


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2. Employee inputEmployers must solicit input from non managerial employees responsible for direct patient care regarding the identification, evaluation, and selection of effective engineering controls.3. Documentation of employee input


4. RecordkeepingSharps Injury Log

29 CFR 1904.1

If your company had ten (10) or fewer employees at all times during the last calendar year, you do not need to keep OSHA injury and illness records unless OSHA or the BLS informs you in writing that you must keep records under 1904.41 or 1904.42. However, as required by 1904.39, all employers covered by the OSH Act must report to OSHA any workplace incident that results in a fatality or the hospitalization of three or more employees.

Basic ComplianceBasic ComplianceTo Start:

OSHA Binder your ECP your HAZCOM data your vaccinations your training documentation

The OSAP GuideThe OSAP Guide

Connects what you do with the guidelines.

The OSAP GuideThe OSAP GuideInfection Control/ CDC Guidelines: From Policy to Practice . Appendix A summary of the

re uirements listed

in

the

CDC

uidelines

for

Infection Control in the Dental Health care setting. There are 180 specific recommendations. 61 are mandated by federal or state laws. This appendix identifies which is which. Furthermore, each recommendation is categorized:


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Get started!If you dont have one, create an Exposure Control Plan. Many Standards allow flexibility. Just figure out what you want to do based on your professional assessment of risk and the guidelines.

Get up to date on vaccinations, medical histories, training, and annual review documentation.

[email protected]

Documents

Breaking the Infection ChainB