Transcript CDC - Vermont Dental Hygienists` Association

OSHA Review 2015
Trisha A. Cloutier, CDA, RDH, BS, MA
[email protected]
Bristol Community College, Fall River MA
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OSHA Occupational Safety and Health Administration
www.osha.gov
• OSAP Organization for Safety and Asepsis Procedures
www.osap.org
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CDC Centers for Disease Control
www.cdc.gov
1793 Philadelphia > 4,000 died from yellow fever.
1832 NYC/New Orleans: over 7,000 killed in cholera epidemic.
1848 NYC > 5,000 deaths caused by cholera.
1853 New Orleans: yellow fever killed 7,790.
1867 New Orleans: 3,093 perished from yellow fever.
1878 Mississippi Valley > 13,000 died from yellow fever.
1916 Polio epidemic > 7,000 deaths/27,363 cases reported.
1918 U.S. worst single epidemic, Spanish Flu killed 50 million
1949 Polio epidemic: 2,720 deaths/42,173 cases reported.
1952 Polio killed: 3,300/57,628 cases reported.
1968 Hong Kong Flu, 1 million deaths worldwide
2009 H1N1 epidemic, 250,000 deaths worldwide
Noel Kelsch, RDHAP, RDH, October 2011
“Microbes on Parade”, Reynolds
Headliners
“An Old Bug Has Learned Lethal New Tricks”, Ricks,
Newsday, 2007
“Deadly Staph: Drug-resistant germ may kill more people
then AIDS”, Stein, Washington Post, 2007
2013, Tulsa, OK 7,000 patients
2013, RI 5 offices closed by Health Dept.
2012, UPitts School of Dentistry
2011, MA DMD license suspended for failing to perform weekly spore
tests
2011, VA Hospital, Columbus, OH, blood testing offered to 500
patients, DMD failed to change gloves, sterilize equipment, to date 3
patients tested positive for HBV, HCV
2010, VA Medical Center, Milwaukee, breach in sterilization forced
termination of all surgical procedures for 3 weeks
2010, John Cochran VA, St. Louis, breach in sterilization, 1,800
veterans notified of potential exposure to HBV, HCV, HIV
CDC defines Cross Contamination:
“As the act of spreading bacteria and viruses from one surface to
another. Blood-borne viruses can live on objects for up to a week.
Spread can occur when surfaces are not disinfected immediately or
if equipment is not cleaned and sterilized between patients.”
Pathogen
Source
Mode of transmission
Portal of entry/exit
Susceptible host
• Phase 1 (1849-1900) Elimination /control of diseases
• Phase 2 (1880-1930) Prevention born with immunization
• Phase 3 (1930-1975) More complex medical treatment
• Phase 4 (1975- present) Age of technology but limited
availability to all members of public
•Personnel Health Elements
•Immunization
•Work Restrictions
•Hand Hygiene
•Contact Dermatitis and Latex Allergy
•Hand Maintenance
1. Good nutrition
2. Sleep
3. Exercise
4. Meditation /prayer
5. Vaccinate
Vaccination
Motor-vehicle safety
Safer workplaces
Control of infectious diseases
Decline in deaths from coronary heart disease
and stroke
6. Safer and healthier foods
7. Healthier mothers and babies
8. Family planning
9. Fluoridation of drinking water
10.Recognition of tobacco use as a health hazard
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“Healthcare Personal Vaccination Recommendations”
www.immunize.org
HBV
Influenza
MMR
Varicella (chicken pox)
TDAP
MCV4
TRAVEL
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IV drug use
Receipts of blood transfusion or organ donation before 1992
Received tattoo or body piecing with unsterile instruments
HCPs with needlestick injuries
HIV infected
Undergoing hemodialysis
Children of infected mothers
Sex with infected person
Men who have sex with other men
Multiple sex partners
Blood contact with infected person
Sharing personal care items
Work or travel to areas with high rates
• Immunization for DHCP
3 doses, 1, 1 mos., 1, 6 mos.
• Employer required to offer
• May decline, Sign form
• Booster
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MMWR, 2012
• Who? ALL ADULTS
• Why? Flu viruses spread like wildfire, difficult to avoid
particularly in dental/medical offices
• When? Every year
-According to CDC, flu season typically ramps
up during December /January, peaks February
-About 2 weeks to develop immunity
• Increase in US and other countries
• Adult born after 1956 recmd one dose, unless had all 3 diseases
• Not advised for pregnant women
• Association between Autistic Spectrum Disorder (ASD) and
MMR vaccine?
• Systematic Review found 12 epidemiological studies which provided
NO evidence of association between ASD and MMR vaccine
Who? 13 years of age and older who never had chickenpox
• Healthcare professionals
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People who care for/around others with weakened immune systems
Teachers
Child care workers
Residents/staff in nursing homes/residential settings
College students
Inmates/staff of correctional institutions
Military personnel
Non-pregnant women of child-bearing age
Adolescents/adults living with children
International travelers
When? two doses, at least 28 days apart
Who? ALL ADULTS
• Tetanus bacterial infection-causes lockjaw, kills about 1 out of 5
• Pertussis (Whopping Cough) bacterial infection causes violent coughing,
vomiting, and even sleep apnea in adults
Kills infants, First case in years, coming to US, Shot not effective to this
strain attributed to over prescription of antibiotics
• Cold-like symptoms
• Persistent hacking cough for weeks
• Children/elderly-more serious or even fatal
When? Get Tdap vaccine ASAP if not received
Tetanus booster shot every 10 years
Bacterial infection of the covering of the brain and spinal
cord, can be life-threatening.
Who?
• College students in dorms at most risk
• Military recruit
• Adults with damaged/no spleen
• Traveling or residing in countries where common
Illness or infection that can be transmitted to patients and/or staff members
•Polices:
• Written: (based on CDC guidelines)
• http://www.cdc.gov//DiseasesConditions/
• Personal physician
• Training of Staff
CLEAN HANDS SAVE LIVES
Protect patients, protect yourself
• Candida
• Staphylococcus
• RSV
• Influenza
• Klebsiella
• Pseudomonas
• Enterococcus
www.cdc.gov/handhygiene
•Nonantimicrobial
•Antiseptic
•Alcohol-based
To remove all transient bacteria and as many residential
bacteria as possible.
Performed at beginning and end of day
Remove jewelry, clean nails, hands, forearms with antimicrobial agent
Wet hands and wrist under cool running water
Dispense antimicrobial agent to cover hands and wrist
Begin with finger tips, working down each finger, keeping hands above
elbow level to prevent contaminated water from running onto clean
fingers for 30 seconds
Rinse with cool water. Repeat for 2 minutes:
Wet hand, wrist with water
Dispense Antimicrobial agent
Clean fingers, hands, wrist
Rinse under cool water
Dry thoroughly by gently patting hand, wrist with paper towels
•Irritant Contact Dermatitis
•Allergic Contact Dermatitis
•Seek expert medical advice
• Moisturizing hands
• Lotions/Cremes
• Paraffin wax
• Petroleum based
• Water based
•Bloodborne Pathogens
•Standard Precautions
•Administrative Controls
•Engineering Controls
•Personal Protective Equipment (PPE)
•Work Practices Controls
•Exposure Prevention and Post exposure Management
•Disease spread through blood and other body excretions:
• Hepatitis B virus (HBV)
• Hepatitis C virus (HCV)
• Human immunodeficiency virus (HIV)
•Transmission
• Percutaneous injury
• Contact of mucous membrane with blood
• Contact of broken skin with blood
• Bites
• Eyes
Infectious Disease Update
• Tuberculosis
• Human Immunodeficiency Virus (HIV)
• Hepatitis C
Tuberculosis (TB)
Bacterial infection caused by Mycobacterium tuberculosis
2014 9,412 new cases in US, decrease of 2.2% from 2013
• Attacks lungs…
• Lives in people
• Mode of transmission - Airborne
• HCP require TB Skin test upon hire
www.cdc.gov/mmwr
March 2015
• Patients w/ HIV (weak immune system)
• IV drug users
• Residents/employees of shared habitation
settings
• Healthcare professionals
• Immigrants
• Medically underserved
Latent tuberculosis (Non infectious)
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No symptoms
Remain inactive, but alive, can become active but may not
Active tuberculosis (Infectious)
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Affects lungs
Coughing often only indication of infection
Cough lasting three or more weeks
Bloody sputum
Weight loss (greater than 10 lbs)
Fatigue/excessive tiredness, fever, night sweats, chills, loss of appetite,
pain when breathing or coughing
Diagnosis
• Physical exam/clinical
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symptoms
Chest radiograph
Diagnostic microbiological
tests/sputum culture
Patients w/ active TB should
be treated in hospital
Must have negative test to
treat
1980 – ID first case, “AIDS”
1983 – Discovery of AIDS
1981-2012: Total estimated U.S. cases: 1,218,400
Total estimated deaths: 658,507
• HIV - CDC: > than 1 million in US currently infected
• 1 in 8 not diagnosed, let alone reported
• Minority Americans represent 78% of new cases
• Women represent 20% of new cases
• Approx. 300 children born with virus in US per year
www.cdc.gov/hiv/statistics/surveillance
Only 57 documented (130 possible) occupational infections in the
healthcare professions in US
• 48 from needle sticks
• 8 from splashes to face
• 1 unknown
• Low risk
Why worry?
• No cure – fatal
• No vaccine
• Strains resistant
• Therapy expensive
OraSure Technologies presents
®
OraQuick
First FDA-approved oral swab in-home test for HIV
Molanari, 2011
• Most common chronic bloodborne infection in US
• Approx. 4.1 million in US infected
Of those infected – 1946-1964
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85% infected for life
60 -70% will develop chronic liver disease
10 – 20% will develop cirrhosis
1- 5% will develop liver cancer
• Needlestick injury, Splash onto non-intact skin or mucous
membrane
• Surface contamination, lives > 1 week
• Rxs available, clears the disease, not used prophylactically
• No Vaccine
CDC 1996 expanded definition of universal precautions to standard precautions
KEEP ACCURATE IMMUNIZATION RECORD ON FILE OF EMPLOYEES
•Blood
•Excretions and secretions including saliva, excluding sweat
regardless of whether they contain blood
•Non-intact skin
•Mucous membranes
History of polices, practices, and procedures designed to
reduce the risk of occupational exposure
• Written work restrictions policies
• HBV immunization polices
• Arrangements with qualified health-care professions for
coordinating an immunization program
PEP 24 hour HOTLINE 888-448-4911
• Polices and procedures about management and medical
follow-up for an occupational exposure
• Wash needlesticks and cuts with soap and water
• Flush splashes to the nose, mouth, or skin with water
• Irrigate eyes with clean water, saline, or sterile irrigants
• Do NOT apply caustic agents or inject antiseptics or
disinfectants into the wound
• Report the incident
• Immediately seek medical treatment.
Written Certification
Employer shall verify that each affected employee has received and
understood the required training through a written certification that
contains the name of each employee trained, the date(s) of training,
and the subject of the certification.
Hazard Communication-OSHA’s Hazard Communication Standard is
based on the concept that employees have both the need and the
“right to know “ the hazards and identities the chemicals they are
exposed to when working.
www.osha.gov/SLTC/dentistry/index.html
Controls to reduce/eliminate hazards to prevent exposure
•Examples include:
• Safety devices
• Retractable scalpels
• Self-sheathing needles
• Anesthetic syringes and needles with engineered safety
features
• Sharps disposal containers
• Cassettes
• PPE
• HVE
All DHCP in direct patient contact will wear the
appropriate PPE appropriate for the tasks performed
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Gloves
Face masks
Protective eyewear
Clothing
Face masks
CDC 2003 Guidelines for Infection Control in
Dental Health Care Settings
“Wear a surgical mask and eye protection with solid side shields
or a face shield to protect mucous membranes of the eyes, nose,
and mouth during procedures likely to generate splashing or
spattering of blood and other body fluids.”
Face masks-specific features
• Does not come into contact with nostrils or lips
• Has high bacterial filtration efficiency (BFE) rate (95%)
• Fits snugly around entire periphery
• Does not cause fogging of eyewear
• Made of a fabric that does not irritate skin or induce an allergic
reaction
• Comprised of material that does not collapse when worn or wet
• Easy to put on and remove
• Change for every patient (60 mins)
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Protective Clothing
Must be properly cleaned, laundered, repaired, disposed of at
no cost to employees
Must be removed when leaving the treatment area or upon
visible contamination
Cleaned by a professional service or cleaned in-house
Must not be taken home
Consider disposable gowns
Behavior basedChanging the way someone performs a task, to remove or lessen the
exposure, as opposed to the use of a physical device, such as an
engineering control.
Handling Emergencies
• Eye injury, quick action can prevent a permanent disability
• Emergency eyewashes should be placed in ALL hazardous
areas
• First-aid instructions should be posted close to potential
danger spots
• Employees must know where closest eyewash station is
and how to get there with restricted vision
Amalgam/Mercury protocol
Amalgam Separator Installation and Maintenance Requirements
www.mercvt.org/dental/amalgsepreq.htm
• Vermont - January 2007 Dental offices must install amalgam
separator
• List of approved amalgam separators
• Environmental Assistance Office at 800-974-9559
Safety Data Sheets (formerly known MSDSs)
June 1, 2015, Hazard Communication Standard will require new
SDSs to be in uniform format, include section numbers,
headings, associated info…etc.
www.osha.gov/Publications/HazComm_QuickCard_SafetyData.html
Employee training
www.osha.gov/Publications/OSHA3636.pdf
Control of Nitrous Oxide in Dental Operatories
• System maintenance
• Ventilation
• Work Practices
www.cdc.gov/niosh/docs/hazardcontrol/hc3.html
Exposure Determination
OSHA states - tasks in dental office be evaluated/classified by
categories of tasks
Category I:
that involve exposure to blood, body fluids, tissues
Category II:
that involve no exposure to blood, body fluids,
tissues, but may require performing unplanned Category I
tasks
Category III:
that involve no exposure to blood, body fluids, tissues
•Classification of Patient-Care Items
•Environmental Surfaces
•Instrument Processing
•Sterilization
•Sterilization Monitoring
•Critical
Penetrates soft tissue, contacts bone, enters bloodstream
Dental Hygiene instruments, dental burs, needles
•Semicritical
Contacts mucous membranes, nonintact skin, does not penetrate soft
tissue, contact bone, or enter bloodstream
Dental mirror, impression trays, *handpieces
•Noncritical
Contacts intact skin
Radiograph head, blood pressure cuff
• Many products available
• Consider surface barriers for difficult to clean areas
• Evaluate properties of surface cleaners and disinfectants
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before purchase
Surface cleaning can remove > 95% surface debris
Certain products useful both cleaners and disinfects
Surface wipes reduce aerosolized chemicals
Choices: no single available product is the only one to use
•Dental handpieces considered a semicritical item, should
always be heat-sterilized between uses
•Ultrasonic use
•Holding “baths”, transport, reduce drying
•No scrubbing!!!
•Protective eyewear must be worn for all clean-up procedures
“Process that destroys, eliminates, or inactivates all
forms of microbial life including bacterial
endospores”
Minimum Cycle Times for Steam Sterilization Cycles
Type of sterilizer
Gravity displacement
Dynamic-air-removal
Item
Exposure time at
Exposure time at
Drying time
121 C (250 F)
132 C (270 F)
Wrapped
instruments
30 min
15 min
15-30 min
Textile packs
30 min
25 min
15 min
Wrapped
instruments
4 min
20-30 min
Textile packs
4 min
5-20 min
(pre – vacuum)
Depaola, Fried, Access, Dec 2009
Autoclave Bags
Indicator Tape
Heat indicators
Biological Monitoring
• Improper timing
• Wrong temperature
• Incorrect sterilization method for item
• Unit malfunction
• Improper packaging
• Overloading
• Inappropriate operation
• Incorrect maintenance of sterilizer
• Inadequate cleaning of instruments
• Temperature exceeding temperature-pressure
relationship Ineffective or nonexistent monitoring
process
www.crosstex.com
• ConFirm Mail-in with results
www.hufriedy.com
Has Class 4 internal/external multi-variable indicators when ALL criteria are met:
• Time
• Temperature
• Steam
Remember:
• Store cool, dry place. Heat/moisture can compromise indicator,
adhesion, materials.
• Companies have instructions, videos to help you.
• Do not overload. Most units load vertically. If load horizontally, make
sure do not touch so maximum amount of exposure.
• Training must occur for every staff member.
• Do not remove until processed/dry.
• Shelf life is considered “event related”, check each bag for compromise
before use.
• Label date, cycle load, sterilizer-write on plastic side not paper
•Environmental Infection Control
•Medical Waste
•Dental Unit Waterlines
•Boil Water Advisory
US Environmental Protection Agency (EPA)
www.epa.gov/epahome/state.htm
Vermont Department of Environmental Conservation (VDEC)
www.anr.state.vt.us/dec/ead/index.htm
Risk of inspection, reporting , disgruntled worker/patient
• Check your Local Authority
• Needles, blood soaked gauze, infectious waste (teeth) must be
placed in closable, leakproof containers built to contain all contents
during handling, storing, transporting or shipping and be
appropriately labeled and color-coded.
•Flush air, water, suction lines for two minutes each at the
beginning of day and for 20 to 30 seconds between patients.
Flush the air/water syringe into the sink to remove debris
and stagnant water from lines.
•Flush lines using cleaning agents
Garland, Dimensions, Sept. 2012,
The Battle against Biofilms
Once an advisory has been issued follow local guidelines
http://emergency.cdc.gov/disasters/floods/cleanupwater.asp
http://www.cdc.gov/healthywater/emergency/flood/standing.html
http://emergency.cdc.gov/disasters/mold/reenter.asp
•Dental Radiology
•Parenteral Medications
•Oral Surgery
•Biopsy Specimen
•Extracted Teeth
•Dental Laboratory
• Use PPE and maintain asepsis when exposing,
processing radiographs
• Use heat tolerant or disposable intraoral devices
• Use FDA cleared barriers for digital radiography
sensors
Drugs that are given by injection or used in an IV
•Single Dose vials:
Preferred and use whenever possible
•Multi-Dose vials:
Clean access diaphragm with 70%
alcohol before inserting device into vial
Use sterile device to access multi-dose vial
Keep multi-dose away from immediate
patient treatment area to prevent
inadvertent contamination by spray or
splatter
•Perform surgical hand asepsis using antimicrobial product before
donning sterile surgeon's gloves
•Use sterile surgeon's gloves
•Use sterile saline/sterile water as coolant/irrigants when performing
surgical procedures
•During transport, place biopsy
specimens in sturdy, leak-proof
container with Biohazard
symbol
•If biopsy specimen container is
visibly contaminated, clean,
disinfect outside of a container or
place in an impervious bag labeled
with Biohazard symbol
•Extracted teeth are infectious, considered regulated medical
waste
•Do not incinerate extracted teeth containing amalgam
Mercury vapor
•Teeth transported to educational institutions/laboratories are to
be cleaned, disinfected, placed in leak proof container, labeled
with biohazard label
•Patient has right to their extracted teeth
OSHA regulations no longer apply once teeth are extracted
Teeth need to be cleaned, disinfected before given to patient
•Clean, disinfect, label with biohazard
symbol on ALL laboratory cases sent
offsite
•Use PPE when handling items received
in laboratory
•Clean, disinfect, rinse ALL items before
handled in laboratory
•Use approved disinfection procedures
for products as recommended by
manufacturer
•Clean/heat sterilize items used in
mouth (metal impression trays, etc)
•Review YOUR Infection Control Program
•Conduct a Work Practice Observation on Wearing PPE
•Conduct a Work Practice Observation on Using Alcohol
Hand Rub (gel)/ Handwashing
•Review Immunization Records
•Screen/Evaluate New Safety Devices
•Review Occupational Exposures
•HIPAA