In PracticeINFECTION CONTROL

August 2019Vol. 18, No. 4

TEAM HUDDLE: Understanding the Responsibility of Infection Prevention and Control: The Importance of Written DocumentsDental infection prevention and control is a system of policies and procedures de-signed to ensure the use of best practices to enhance safety and reduce the risk of transmitting potentially dangerous microbes from the treatment environment and support areas. An effective infection control program hinges on the understanding of the WHAT, the WHY, and the HOW of the preventive policies and procedures as well as techniques that enhance compliance.

CONTENTS TEAM HUDDLE: Written Documents . . . . . . . . . . . . . . . . . . 1 Learning Objectives

SCENARIO: The Incident . . . . . . . . . 2

Potential Consequences and Prevention . . . . . . . . . . . . . . . . . . . . 3

Strategies: Checklist of Essential Written Documents . . . . . . . . . . . 4

What’s Wrong With This Picture? . . .5 Educational Spotlight Thanks to Our Sponsors

Silent Video Challenge . . . . . . . . . . . 6 Team Huddle Discussion Guide Links to Resources Glossary

Continuing Education . . . . . . . . . . 7 Key Takeaways

From the Editor’s Desk . . . . . . . . . . 8 Dental Infection Control Credentialing

IN THIS ISSUEThis issue of Infection Control in Practice emphasizes the need for written documents to show that procedures are in place to limit the spread of contamination and pro-mote compliance to help the Infec-tion Control Coordinator (ICC) com-municate the importance of the safestdentalvisitTM

LEARNING OBJECTIVES

After reading this publication, the reader should be able to:• describe the importance of an Exposure Control Plan and Standard Operating Procedures .• give examples of infection control and safety documents and records that need to be present in dental facilities .

OSAP .org PAGE 1

PAGE 2 OSAP .org Vol . 18, No . 4 INFECTION CONTROL IN PRACTICE Team Huddle™

EDITORIAL STAFF Denise Sabol RDH MEdManaging Editor

Alison HirdLayout Editor

Michelle LeeExecutive Director

Therese Long MBA CAEOSAP Executive Director Emeritus

EDITORIAL REVIEW BOARD Enrique Acosta-Gio DDS PhD National University of Mexico

Sarah Cabral RDHRegistered Dental Hygienist in Private Practice

Jennifer Cleveland DDS MPHCenters for Disease Control and Prevention (RET)

Eve Cuny MSUniversity of the Pacific

Jackie Dorst RDH BSSafe Practices

J. Hudson Garrett Jr. PhD MSN MPH FNP-BS CSRN PLNC VA-BCPentax Medical

Karen Gregory RNTotal Medical Compliance

Michael Joseph DDS MSD Periodontics

Leann Keefer RDH MSMCrosstex International

Noel Brandon Kelsch RDHAPRegistered Dental Hygienist in Alternative Practice

Jonathan Lawoyin DDS MScNigeria College of Medicine

Theresa Mayfield DMD University of Louisville (RET)

Nita Mazurat MSc DDSUniversity of Manitoba (RET)

Patricia Podolak DDS MPHSpringhurst Associates, LLC

Lakshman Samaranayake BDS DDSUniversity of Sharjah

Sheila Strock DMD MPHDelta Dental Illinois

Infection Control In Practice Team HuddleTM is a resource prepared for clinicians by the Organization for Safety, Asepsis and Prevention (OSAP) with the assis-tance and expertise of its members. OSAP is a nonprofit, independent organi-zation providing information and education on infection control and prevention and patient and provider safety to dental care settings worldwide. ICIP Team HuddleTM is published six times per year and is a trademark belonging to OSAP. OSAP assumes no liability for actions taken based on information herein.

The contents of the issue are copyrighted ©2019 by OSAP. All rights reserved under international and Pan-American copyright conventions. Printed in the USA. Reproduction in whole or part is forbidden without prior written permis-sion. Back issues are available for a small fee. Send requests for permissions, purchases of back issues and address changes to OSAP, 3525 Piedmont Road NE, Bldg. 5, Suite 300, Atlanta, GA 30305 or office@osap.org.

Dr. P was fortunate to find and hire a very experienced replacement (Tristen) from the recently closed practice, and she was to identify and train a new sec-ond assistant. Tristen asked Dr. P if she could see the office’s Exposure Control Plan (ECP) and Standard Operating Pro-cedures (SOPs) to help train the new assistant.

Dr. P said that he left a lot of the “be-hind the scenes” infection control pro-cedures up to Mona, and he didn’t think she ever wrote them down.

Tristen said she could figure out many procedures used by seeing the prod-ucts and equipment on hand, but there were several questions she had that Dr. P couldn’t answer. For example:

• How long do you ultrasonically clean each batch of instruments?

• What is done if some of the instruments are not well cleaned?

• How are the handpieces cleaned before sterilization?

• How often do you change the ultrasonic cleaning solution?

• What instruments are processed through the dry heat sterilizer rather than the autoclave?

• What type of water is used in the autoclave reservoir?

• Who is called for sterilizer and cleaner repair and maintenance service?

• How often do you monitor the dental unit waterlines?

• How do you disinfect the vacuum lines and how often do you change the traps?

• Which office surfaces are cleaned by the housekeeping staff?

• Who has been identified to serve as the evaluating healthcare provider in the event of an exposure incident?

• Who calls the evaluating healthcare provider after an exposure incident?

• How do you rotate sterile instrument packages?

• How do you identify the availability of safer injection syringes/needles and other safer medical devices for evaluation?

Dr. Poe was about to accept several new patients from a dentist classmate who was retiring. So, Dr. P wanted to activate his previously unused second operatory and hire a new dental assistant. Just as he was ready to make the changes, Dr. P’s only dental assistant (Mona) informed him that she had to immediately move out of state to take care of her ailing parents.

SCENARIO: The IncidentEDITOR-IN-CHIEFChris H. Miller PhDDr. Miller is Professor Emeritus of Microbiology, Executive Associate Dean Emeritus, and Associate Dean Emeritus for Academic Affairs and for Graduate Education at Indiana University School of Dentistry. He is past Chair and a founding member of OSAP. email: cmiller005@indy.rr.com

INFECTION CONTROL IN PRACTICE Team Huddle™ Vol . 18, No . 4 OSAP .org PAGE 3

Potential Consequences and Prevention(See further details, pg 4, “Strategies”)

Dr. P needs to have a better understand-ing of his office procedures, and he needs to enhance compliance with infection con-trol regulations and recommendations.

Dr. P said that he left a lot of the “behind the scenes” infection control procedures up to Mona, and he didn’t think she ever wrote them down.

WHAT: The Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens Standard requires employers with employees who have exposure to bloodborne pathogens to have a written ECP.1 The Centers for Disease Control and Prevention (CDC) recommends having writ-ten SOPs2 for infection prevention in dental facilities.3

WHY: ECPs and SOPs are important in maintaining a safe and compliant health-care facility because they serve as the foun-dation of the infection control program.

1. Not having an ECP violates the OSHA Bloodborne Pathogens Standard.1 If an OSHA inspection ever occurs from a pos-sible infection control violation, an early de-mand from the inspector will be “may I see your ECP.” The ECP identifies how infection control is to be managed in the practice, and the inspector wants to determine if the ECP is being followed.

2. CDC recommends to “develop and maintain written infection prevention pol-icies and procedures appropriate for the services provided by the facility and based on evidence-based guidelines, regulations or standards.”3

3. A successful infection control program depends upon developing SOPs.4

4. Clearly written policies, procedures and guidelines can help ensure consistency, efficiency and effective coordination of activities.5

5. Written procedures facilitate initial and periodic infection control training of employees.5

6. Written SOPs are used in evaluating the infection prevention program.6

7. Without written SOPs it’s highly likely that prompt management and medical follow-up of an exposure incident may not occur. Since exposure incidents are usually not common occurrences, unwritten proce-dures can be forgotten which could lead to confusion and delay in evaluation and care.

HOW: Exposure Control PlanThe OSHA-required ECP is to contain at least the following sections:• Exposure determination (a list of all job classifications in which all employees in those classifications have occupational exposure; a list of all job classifications in which some employees have occupational exposure; a list of all tasks and procedures in which occupational exposure occurs and that are performed by employees in job classifications listed)• Implementation of various methods of exposure control, including: – Universal precautions/standard precautions – Engineering and work practice controls – Personal protective equipment (PPE) – Housekeeping and surface decontamination – Waste management – Consideration and evaluation of safer medical devices – Laundry management• Hepatitis B vaccination procedures• Post-exposure evaluation and follow-up procedures• Communication of biohazards to employees • Recordkeeping procedures• Procedures for evaluating circumstances surrounding exposure incidents.1,7

OSHA has a model ECP and a Hazard Com-munication program available, but they must be modified to fit your office.8

Since the OSHA Bloodborne Pathogens Standard does not mention instrument ster-ilization, these SOPs and policies will have to be added to OSHA’s ECP.

HOW:Standard Operating ProceduresOne approach to organizing SOPs is as follows:9

1. Behind the Scenes (Regulations, recommendations, administration, recordkeeping, education and training, health programs for employees, medical conditions and work restrictions, immunizations and testing, post-exposure management, waterline management, etc.)

2. General Preparations (Reception area, clinical area, etc.)

3. Before Seating the Patient (PPE, operatory set-up, etc.)

4. After Seating the Patient (Patient mouth rinsing, hand hygiene, etc.)

5. During Patient Treatment (Sharps safety, aseptic retrieval, use of lasers, etc.)

6. After Patient Treatment (Operatory clean-up, instrument processing, waste management, etc.)

7. Radiographic Asepsis (Unit/patient preparation, darkroom, daylight loader, etc.)

8. Laboratory Asepsis (PPE, disinfection, interacting with off-site laboratory, etc.)

PAGE 4 OSAP .org Vol . 18, No . 4 INFECTION CONTROL IN PRACTICE Team Huddle™

HOW WOULD YOU SCORE?Use this checklist to see if you have these U.S. infection prevention and safety documents/records on hand.

Regulatory and Guidance Documents and App

❑ OSHA Bloodborne Pathogens Standard❑

❑

OSHA Hazard Communication StandardOSHA Emergency Standards:osha.gov/SLTC/etools/evacuation/evaluate.html

[ ] Design and Construction requirements for exit routes

[ ] Emergency action plans*

[ ] Fire prevention plans*

[ ] Maintenance, safeguards and operational features for exit routes

[ ] Portable fire extinguishers

[ ] Fire detection systems

[ ] Fire extinguishing systems

[ ] Fire alarm systems.

❑ State, local or other regulatory documents that may apply (e.g., sterilization monitoring, waste disposal)

❑ CDC Guidelines for Infection Control in Dental Health-care Settings – 2003

❑ CDC Summary of Infection Prevention Practices in Dental Settings: Basic Expectations for Safe Care

❑ CDC DentalCheck app (cdc.gov/features/dental-check-app/index.html)

Policy Documents❑ OSHA written Exposure Control Plan

❑ OSHA written Hazard Communication program

❑ CDC written health program for employees

❑ CDC tuberculosis infection control plan

❑ Policies not covered by OSHA (e.g., state regulations on instrument sterilization, sterilization monitoring, waste managementand waterline management and testing)

❑ OSHA poster “Job Safety and Health”- publication number 3165 (see osha.gov/Publications/poster.html)

Records❑ OSHA Bloodborne Pathogens Standard and Hazard Communication training records

❑ OSHA required written schedule for cleaning and disinfecting areas in the facility

❑ OSHA confidential employee medical records

[ ] Includes written opinions from evaluating healthcare provider on employee vaccination status andpost-exposure evaluation and follow-up when needed

❑ Hepatitis B vaccination declination (refusal) forms (if needed)

❑ Exposure incident reports

❑ Results from sterilization monitoring (mechanical, chemical and biological)

❑ Records on the routine maintenance of sterilization equipment

❑ Radiographic equipment certification

❑ Manifests from regulated medical waste haulers

❑ Verification of on-site treatment of regulated medical waste (if needed)

❑ Safety data sheets for hazardous chemicals used

❑ Chemical list

❑ Annual sharps safety screening/evaluation forms

❑ Dental unit waterlines testing records

STRATEGIES Checklist of Essential Written Documents in Dental Settings

* If 10 or fewer employees, plans may be oral rather than written. This only applies to the emergency action plan and fire preventionplan not to SOPs or ECPs.

Note: Documents on employee health, OSHA training, chemical safety, sterilization and waste management will be discussed in the next issue of Infection Control In Practice.

INFECTION CONTROL IN PRACTICE Team Huddle™ Vol . 18, No . 4 OSAP .org PAGE 5

Help Us Take Safety ViralWe’re ramping up for Dental Infection Control Awareness Month (DICAM) taking place this September and challenge you to join our movement to “Take Safety Viral”. OSAP’s DICAM campaign is to reach a broad digital audience to educate more dental teams, clinicians, and infection control coordi-nators on the Safest Dental Visit™. Every week will have a different dental infection control theme with tips, scripts, and more. This cam-paign is important to help advance patient safety and increase your patients’ confidence in your infection control practices. Ready to get involved?

Join our DICAM priority email list for advance notice of campaign tools and themes! Register now at osap.org/DICAM We’re excited to support your efforts to make every visit the Safest Dental Visit™. Let’s “Take Safety Viral”! #DICAM19

Thanks to our sponsorsOSAP thanks the following companies that help to un-derwrite each issue of this special series of Infection Control in Practice: Team HuddleTM in 2019.

Super SponsorsAir Techniques www.airtechniques.com

Benco Dentalwww.benco.com

Coltenewww.coltene.com Crosstexwww.crosstex.com

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Henry Schein www.henryscheindental.com

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the safestdentalvisitTM

OSAP appreciates the commitment of our sponsors in supporting

Educational Spotlight

What’s Wrong With This Picture?Can you identify the breach(es) in this photo of a dental procedure?

Answer: Answer: The clinician is not wearing protective eyewear. The patient has not been given protective eyewear. The clinician is not wearing long-sleeved protective clothing or overgown, leaving forearms and neck exposed during a procedure that will cause splatter. It is hoped that the light han-dle and handpiece hose /connector will be cleaned and disinfected during operatory clean-up since they are not barrier protected.

Note: Documents on employee health, OSHA training, chemical safety, sterilization and waste management will be discussed in the next issue of Infection Control In Practice.

Be The First To Know

PAGE 6 OSAP .org Vol . 18, No . 4 INFECTION CONTROL IN PRACTICE Team Huddle™

Links to Resources1. OSHA. Bloodborne Pathogens. Accessed June 2019 at:

osha.gov/laws-regs/regulations/standardnumber/1910/1910.1030.

2. Eklund KJ, Bednarsh H, and Haaland CO. A Practical Program for Exposure Control-Your Daily Procedures. In OSHA and CDCGuidelines: OSAP Interact Training System. OSAP, Atlanta, 2017, p 4-1 to 4-3.

3. CDC. Summary of Infection Prevention Practices in Dental Settings: Basic Expectations for Safe Care. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention andHealth Promotion, Division of Oral Health; May 2016, p 6. Accessed June 2019 at: cdc.gov/oralhealth/infectioncontrol/guidelines/index.htm.

4. CDC. Guidelines for Infection Control In Dental Health-care Settings – 2003. Morb Mortal Wkly Rpts 2003; 52(No RR-17):37.Accessed June 2019 at: cdc.gov/mmwr/preview/mmwrhtml/rr5217a1.htm.

5. CDC. Guidelines for Infection Control In Dental Health-care Settings – 2003. Morb Mortal Wkly Rpts 2003; 52(No RR-17):6.Accessed June 2019 at: cdc.gov/mmwr/preview/mmwrhtml/rr5217a1.htm.

6. CDC. Summary of Infection Prevention Practices in Dental Settings: Basic Expectations for Safe Care. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention andHealth Promotion, Division of Oral Health; May 2016, p 8. Accessed June 2019 at: cdc.gov/oralhealth/infectioncontrol/guidelines/index.htm.

7. Miller, CH. Infection Control Rationale and Regulations. In Infection Control and Management of Hazardous Materials for the Den-tal Team. Elsevier, St. Louis, 6th ed, 2018, Chapter 8, Box 8.2, p 67.

8. OSHA. Model Plans and Programs for the OSHA Bloodborne Pathogens and Hazard Communications Standards.Accessed June 2019 at: osha.gov/Publications/osha3186.html.

9. Miller, CH. Asepsis Protocols, SOPs and Checklists. In Infection Control and Management of Hazardous Materials for the DentalTeam. Elsevier, St. Louis, 6th ed, 2018, Chapter 20, pp 187-195.

TEAM HUDDLE DISCUSSION GUIDE1. How would you answer Tristen’s questions asked of Dr. P?2. When was your ECP reviewed?3. Do you have SOPs for all procedures and are they current?

Can you identify the actions in this short video that breach infection control? osap.org//2019-08video

Challenge your knowledge and compare to the lesson below.

The Scenario: Personal Protective Equipment

Take the Micro-Learning Silent Video Challenge!

The Lesson: The order in which the clinician is donning PPE is cause for cross-contamination. In this example, gloves were donned before facemask andface shield, thus contaminating gloves before starting dental treatment. Gloves should be the last item of PPE to be donned. The patient has not been given protective eyewear. The assistant should be wearing an overgown during a procedure that will cause splatter. It is hoped that the handpiece hose/connector and HVE hose will be cleaned and disinfected during operatory clean-up since they are not barrier protected.

GlossaryStandard Operating Procedures (SOPs): a set of step-by-step instructions compiled by an organizationto help workers carry out complex routine operations

INFECTION CONTROL IN PRACTICE Team Huddle™ Vol . 18, No . 4 OSAP .org PAGE 7

QUESTIONS FOR ONLINE QUIZ1. Which governmental agency requires each dental facility to post the “Job Safety and Health” poster?

a. CDC b. OSHAc. FDAd. EPA

2. Which governmental agency requires each dental facility to have a written Exposure Control Plan?

a. CDC b. EPA c. FDAd. OSHA

3. Keeping records on the routine maintenance of sterilization equipment comes from what governmental agency?

a. CDC b. OSHAc. FDAd. EPA

4. SOPs for infection prevention aid in training of employees, ensuring consistency, efficiency and effective

*ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the CE provider or to ADA CERP ADA.org/goto/cerp. Please email the OSAP central office at office@osap.org or call 410-571-0003 if you wish to be in contact with the course author/creator(s) with any questions or for clarification of course concepts. All participants assume individual responsibility for providing evidence of contact hours of continuing education to the appropriate authorities and for the maintenance of their individual records. Publication date: August 2019. Expiry date: August 2022.

GET YOUR CE CREDIT ONLINE OSAP is recognized by the American Dental Association as a CERP provider.*

Follow the instructions below to complete the quiz to receive 1 hour of CE credit FREE to OSAP members! Step 1: Go to bit.ly/OSAPICIPAUGUST2019 and obtain access to the CE exam through the OSAP Store. OSAP members, 1 CE credit FREE! Non-members, 1 CE credit $20.

Step 2: OSAP will send you a registration confirmation email and a separate email with the link to the online CE exam. Click on that link to access the exam.

Step 3: Complete the online exam. You have 2 attempts to pass with 7 out of 10 correct answers. When finished, you can print out or download your CE record of completion for your records. Your record of completion will also be emailed to you.

KEY TAKEAWAYS 1. An ECP and SOPs are the foundation of the infection control program.2. Adherence to these documents are key to providing patient and workers safety, training of

employees, and evaluating the office safety program.3. All dental facilities are to have several infection prevention and safety documents on hand.

coordination of activities, and in:a. billing patients.b. filling cancelled appointments.c. evaluating the program.d. categorizing hazardous chemicals.

5. Plans for Emergency Action and Fire Prevention may be stated orally rather than being written in facilities with how many employees?

a. 1-10b. 11-25c. 26-50d. Over 50

6. The exposure determination is part of what document?

a. Fire Prevention Planb. Radiographic Equipment Certificationc. Emergency Action Pland. Exposure Control Plan

7. What type of SOP should be organized under the “Behind the Scenes” heading?

a. Immunizations and testingb. Patient mouth-rinsingc. Sharps safetyd. Aseptic retrieval

8. An Exposure Control Plan has several sections including hepatitis B vaccination procedures, post- exposure evaluation and follow-up procedures, communication of biohazards to employees, and:

a. collection of safety data sheets.b. listing of hazardous chemicals used.c. instrument sterilization procedures.d. recordkeeping procedures.

9. Which governmental agency has a model ECP and Hazard Communication program available?

a. CDC b. OSHAc. FDAd. EPA

10. Which governmental agency recommends that dental health care facilities have a written tuberculosis infection control plan?

a. CDC b. OSHAc. FDAd. EPA

PAGE 8 OSAP .org Vol . 18, No . 4 INFECTION CONTROL IN PRACTICE Team Huddle™

SUPPORT EDUCATION INNOVATION.

The Safest Dental Visit™

OSAP Exclusively committed to the safety of every

dental patient.

Moving Forward! Updates on the New Dental Infection Control Education and Certification ProgramsOSAP, the Dental Assisting National Board (DANB) and the Dental Auxiliary Learning Education (DALE) Foundation are collaborating on a dental infection control education program and two professional certifications.

The initiative establishes three main elements:

• OSAP-DALE Foundation Dental Infection Prevention and Control Certificate Program™

— A standardized dental infection control educational program

• Certified in Dental Infection Prevention and Control™ (CDIPC™)

— A clinically-focused professional certification

• Dental Industry Specialist in Infection Prevention and Control™ (DISIPC™)

— An industry (dental trade)-focused professional certification

These collaborative initiatives advance the organizations’ missions of enhancing patient and practitioner safety.

Discover how an educational certificate program and/or a professional certification can help you elevate your professional value in dentistry and lead the next generation of dental infection preventionists.

Find out more at: dentalinfectioncontrol.org

Q U I C K B I T E S

F R O M T H E Editor’s DeskOSHA’s Dentistry section presents information on; – beryllium, – bloodborne pathogens, – ergonomics, – mercury, – silica dust, – waste anesthetic gases, – record keeping, – hazard communication, – and others.

Check it out at: osha.gov/SLTC/dentistry/recognition.html