Standard Precautions & Managing High risk cases Tuminah Binti Jantan (SRN)
Outline 1. Infection risk 2. Infection control in dental practice 3. Standard precautions 4. The element of SP (sharps injury) 5. Transmission based precautions. (TB)
Infection risk Dental patient & DHCP can be exposed to pathogenic organism that colonize or infect the oral cavity & the respiratory tract Consequently, they are at risk of infection with bloodborne viruses The risk of infection for health workers depends on the prevalence of disease in the patient population The nature and frequency of exposures. Transmission via: direct contact with blood oral fluid and other patient materials or indirect contact with contaminated objects used for patients Airborne /droplets
Infected Dental practitioner Dental practitioners who are infected with, or who are carriers of bloodborne viruses should seek the advice of infectious disease specialists familiar with the requirements of dental practice and an advisory panel regarding their fitness to practice. They may need to modify their clinical practice,
Infection Control in Dental Practice The purpose of infection control in dental practice is to prevent the transmission of disease-producing agents such as bacteria, viruses and fungi from one patient to another patient, from dental practitioner and dental staff to patients, and from patients to dental practitioner or other dental staff. In addition, it is necessary that endogenous spread of infection also be prevented by limiting the spread of infectious agents.
CDC recommendations Develop and maintain infection prevention and occupational health programs. Provide supplies necessary for adherence to Standard Precautions (e.g., hand hygiene products, safer devices to reduce percutaneous injuries, personal protective equipment). Assign at least one individual trained in infection prevention responsibility for coordinating the program.
CDC recommendations - cont Develop and maintain written infection prevention policies and procedures appropriate for the services provided by the facility and based on evidence-based guidelines, regulations, or standards. Facility has system for early detection and management of potentially infectious persons at initial points of patient encounter
Standard precautions o SP are guidelines recommended by Centre of Disease control and prevention (CDC) o Standard precautions (1996) synthesizes the major features of Universal Precautions (1985) & Blood Substance Isolation (1987) o Reviewed 2004: Guidelines for Isolation Precaution: Preventing Transmission of Infectious agents in Healthcare Settings- Healthcare Infection Control Practices Advisory Committee (HICPAC). Published 2007
Standard precautions SPs are the minimum infection prevention practices that apply to all patient care regardless of suspected or confirmed infection status of the patients. Complying to these practices provide protection DHCP from infection and prevent DHCP from spreading infections among patient. These standard precautions minimise the risk of transmission of infection from person to person, and are required for the treatment of all dental patients regardless of whether a particular patient is infected with or is a carrier of an infectious disease.
Standard precautions They apply to all situations whenever dental practitioners or their clinical support staff: touch the mucous membranes or nonintact skin of a dental patient. cleaning the dental surgery environment
Standard precautions When handling items contaminated with saliva (e.g. radiographs, dentures, orthodontic appliances, wax rims and other prosthetic work that have been in a patient s mouth), handling blood (including dried blood), saliva and other body fluids (excluding sweat) whether containing visible blood or not. when cleaning and processing instruments
The element of SPs 1. Hand hygiene 2. Use of PPE 3. Respiratory hygiene 4. Sharp safety & Safe injection practice 5. Sterile instrument & devices 6. Cleaned & disinfected environmental surfaces 7. Healthcare waste management
Hand hygiene in healthcare setting Alcohol-based hand rub is the preferred method for cleaning hands. when hands are not visibly soiled. It is better than washing hands antibacterial soap
Hand hygiene in healthcare setting Handwashing with soap and running water must be done when hands are visibly soiled. If running water is not available, use moistened towelettes to remove the visible soil, followed by alcohol-based hand rub. 14
Effective hand hygiene Correct indication Appropriate and adequate agent Using recommended technique
Hand hygiene indication
Appropriate & adequate agents Alcohol base hand rub
Recommended technique From (from WHO) + other GL
Local reference KKM
Technique matters otherwise..
Use of PPE Provide sufficient and appropriate PPE and ensure it is accessible to DHCP. DHCP should be able to assess the potential risk that could arise from patient care activities Educate all DHCP on proper selection and use of PPE.
Gloves Wear gloves whenever there is potential for contact with blood, body fluids, mucous membranes, non-intact skin or contaminated equipment. Do not wear the same pair of gloves for the care of more than one patient. Do not wash gloves. Gloves cannot be reused. Perform hand hygiene immediately after removing gloves.
Protective clothing Wear protective clothing that covers skin and personal clothing during procedures or activities where contact with blood & saliva to prevent soiling.
Respiratory protection Wear mask N95 respirator when managing known or suspected cases PTB.
Goggles & face shield During procedure likely to generate aerosol, splashes, or spray of blood, oral secretion To protect mucous membrane of the eyes, nose and mouth
Donning Hand Hygiene Sequence Gown first Mask or respirator Goggles or face shield Gloves
Removing Sequence: Gloves Face shield or goggles Gown Mask or respirator Remove before leaving pt care unit Hand hygiene
Respiratory hygiene/cough etiquette Respiratory viruses are easily disseminated in a closed setting and can cause outbreaks that contribute to the morbidity of patients and health care staff.
Respiratory hygiene/cough etiquette Personnel and patients with a respiratory illness commonly transmit viruses through droplets generated during sneezing, talking, and coughing and can settle on surfaces. Transmission occurs by direct contact and indirect contact with mucous membranes, sometimes by aerosol dissemination
Respiratory hygiene/cough etiquette Implement measures to contain respiratory secretions in patients and accompanying individuals who have signs and symptoms of a respiratory infection, beginning at point of entry to the facility and continuing throughout the visit. Educate DHCP on the importance of infection prevention measures to contain respiratory secretions to prevent the spread of respiratory pathogens when examining and caring for patients with signs and symptoms of a respiratory infection.
Respiratory hygiene/cough etiquette Post visual alerts (in appropriate languages) at the entrance to outpatient facilities instructing patients and escorts to notify HCW of symptoms of a respiratory infection when they first register for care.
Respiratory hygiene/cough etiquette Offer masks to persons who are coughing (surgical) Encourage coughing persons to sit at least 3 feet away from others in common waiting areas. Provide tissue/receptacles for disposal Provide resources and instruction for performing hand hygiene
Respiratory hygiene/cough etiquette Health care personnel should wear a surgical for close contact when examining a patient with symptoms Maintain precautions unless it is determined that the cause of symptoms is not an infectious agent.
Sharps safety: Prevention strategies Sharps injury: risk of blood exposure both to the patients and dental staff. Ensure that health care workers are properly trained in the safe use and disposal of needles (CME, seminars, user training, etc) Promote safety awareness in the work environment. (campaign, reminders) Establish procedures for and encourage the reporting and timely follow up of all needle stick and sharps-related injuries.
Sharps safety: Prevention strategies Analyze needle stick and other sharpsrelated injuries in your work place, note trend and identify problem areas. Evaluate the effectiveness of prevention effort and provide feedback on performance
Sharps Safety Practices Be prepared Be aware Dispose with care
Be Prepared Before Beginning a Procedure Organize equipment at the point of use Make sure work space has adequate lighting Keep sharps pointed away from the user Locate a sharps disposal container, or have one nearby Assess the patient s ability to cooperate Get help if necessary Ask the patient to avoid sudden movement
Be Aware During a Procedure Maintain visual contact with sharps during use Be aware of staff nearby Control the location of sharps to avoid injury to yourself and others Do not handpass exposed sharps from one person to another Use predetermined neutral zone for placing/retrieving sharps
Be aware -Cont Alert others when sharps are being passed Activate safety feature of devices with engineered sharps injury prevention features as soon as procedure is completed Observe audible or visual cues that confirm the feature is locked in place
Clean Up and Dispose with Care During Cleanup Be accountable for sharps you use Check procedure trays, waste materials, and bedding for exposed sharps before handling Look for sharps/equipment left behind inadvertently Transport reusable sharps in a closed container Secure the container to prevent spillage
Clean Up and Dispose With Care While Disposing of Sharps Inspect container Keep hands behind sharps Never put hands or fingers into sharps container If you are disposing sharps with attached tubing Be aware that tubing attached to sharps can recoil and lead to injury. Maintain control of both tubing and the device during disposal
Clean Up and Dispose With Care After Disposing of Sharps Visually inspect sharps container for overfilling Replace containers before they become overfilled Keep filled containers for disposal in a secure area If You Find Improperly Disposed Sharps in Work Environment use mechanical device to pick up sharps
Sharps containers
Safe injection practice Prepare injections using aseptic technique2 in a clean area. Disinfect the rubber septum on a medication vial with alcohol before piercing. Do not use single-dose (single-use) medication vials, ampules, and bags or bottles of intravenous solution for more than one patient. Do not combine the leftover contents of singleuse vials for later use.
Safe injection practice Do not use needles or syringes* for more than one patient (this includes manufactured prefilled syringes and other devices such as insulin pens). Medication containers (single and multidose vials, ampules, and bags) are entered with a new needle and new syringe, even when obtaining additional doses for the same patient. Use single-dose vials for parenteral medications when possible.
Safe injection practice The following apply if multidose vials are used Dedicate multidose vials to a single patient whenever possible. If multidose vials will be used for more than one patient, they should be restricted to a centralized medication area and should not enter the immediate patient treatment area (e.g., dental operatory) to prevent inadvertent contamination.
Safe injection practice If a multidose vial enters the immediate patient treatment area, it should be dedicated for single-patient use and discarded immediately after use. Date multidose vials when first opened and discard within 28 days, unless the manufacturer specifies a shorter or longer date for that opened vial. Do not use fluid infusion or administration sets (e.g., IV bags, tubings, connections) for more than one patient.
Sharps injury Needle Stick, cuts, bite & scratches : Allow blood to flow freely and wash under running water. Wipe with antiseptic & apply dressing as necessary
SPLASH EXPOSURE Skin - wash area thoroughly with soap and water. Eyes rinse gently and thoroughly with water or normal saline. Mouth spit out and rinse the mouth several time with water
Risk from sharps injury Hepatitis B Virus (HBV): from single NSI 6-30% (NIOSH, CDC 1999) Hepatitis C Virus (HCV):1.8% 78-85% develop chronic infection, 60-70% liver disease (10-20% develop cirrhosis, 1-5% develop liver cancer) (CDC 1998) HIV: Percutaneous 0.3% Mucous membrane 0.1% Non-intact skin <0.1%
Post exposure management Report immediately to supervisor: Supervisor examine DHCP Identify index case if possible. Refer to local policies for referral and subsequent counselling & management Investigate, record, report incident & use data for improvement initiatives to reduce future occurrence.
Disinfection & sterilization of patient care equipment Clean and reprocess (disinfect or sterilize) reusable dental equipment appropriately before use on another patient. Clean and reprocess reusable dental equipment according to manufacturer instructions. If the manufacturer does not provide such instructions, the device may not be suitable for multi-patient use. Have manufacturer instructions for reprocessing reusable dental instruments / equipment readily available, ideally in or near the reprocessing area
Disinfection & sterilization of patient care equipment Assign responsibilities for reprocessing of dental equipment to DHCP with appropriate training. Wear appropriate PPE when handling and reprocessing contaminated patient equipment. Use mechanical, chemical, and biological monitors according to manufacturer instructions to ensure the effectiveness of the sterilization process. Maintain sterilization records in accordance with state and local regulations.
Environmental infection prevention & control Establish policies and procedures for routine cleaning and disinfection of environmental surfaces in dental health care settings. Use surface barriers to protect clinical contact surfaces, particularly those that are difficult to clean (e.g., switches on dental chairs, computer equipment) and change surface barriers between patients.
Environmental infection prevention & control Clean and disinfect clinical contact surfaces that are not barrier-protected with an approved hospital disinfectant after each patient. Use an intermediate-level disinfectant if visibly contaminated with blood. Follow manufacturer instructions for use of cleaners and disinfectants (e.g., amount, dilution, contact time, safe use, disposal). Follow local policy & procedures for healthcare waste, spillage & linen management
Transmission Base Precautions There are a number of situations where patients have a specific highly infectious condition that necessitates the use of transmission-based precautions in addition to standard precautions, to address the increased risk of transmission. Transmission-based precautions are applied to patients suspected or confirmed to be infected with agents transmitted by the contact, droplet or airborne routes.
Transmission Base Precautions The agents of most concern to dental practice are TB and respiratory viruses. The range of measures used in transmissionbased precautions depends on the route(s) of transmission of the infectious agent involved. The application of transmission-based precautions is particularly important in containing multi-resistant organisms (MROs) in hospital environments
Transmission base precautions Air borne Droplets Contact Protective environment Combination
Airborne precautions Airborne transmission: Dissemination of airborne droplets or dust particles (<5um) containing pathogen that can remain suspended in the air and can be disperse by air current within a room or over long distance. Examples PTB, measles, varicella Standard precautions + Respiratory protection (N95) & negative pressure room
Handling patients with respiritory illness Risk depends on the concentration of airborne infectious particle in the environment. The generation of oerosol is recognized risk for transmission for droplet spread. Educate dental team on SS TB and its transmission Assess each patient for indication of PTB
Handling patients with respiratory illness Active PTB patient should be mask and should observe strict respiratory hygiene & cough etiquette in the waiting area Surgical mask do not offer protection against potential TB transmission, DHCP should put on N95. Defer elective non-urgent dental treatment until patient is confirmed non-infectious. For urgent cases patient should be attended last. (dedicated facility)
Droplet precautions For patients known or suspected of having illness spread by large particle droplets Droplets (> 5 um) containing pathogen generated from the source person during coughing, sneezing, talking or the performance of procedures. Examples: Meningococcal infection, Mumps, Rubella, diphtheria, influenza, adenovirus Standard precautions + respiratory protection, goggles & face shield
Contact precautions For patients with or suspected to have serious illness easily spread by direct client contact or contact with fomites Direct contact direct surface to surface Indirect contact contact with contaminated equipment or object. Example: MRSA/MRO, Enteric infections, skin infections/lesions, wounds Standard precautions **glove & hand hygiene
Conclusion Compliance to SP & TBP not cheap Risk assessment/ mode of transmission Select the appropriate PPE Monitor and evaluate Compliance = reduce risk / protection/ reduce transmission / reduce contamination..
Resources: Centres for Disease Control and Prevention http://www.cdc.gov/ World Health Organization http://www.who.int/en/ Guidelines for Isolation Precaution: Preventing Transmission of Infectious agents in Healthcare Settings- Healthcare Infection Control Practices Advisory Committee (HICPAC). Published 2007
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