Infection Control: Ending the Day

There are several important things that go on in a dental office behind the scenes in regard to office safety and asepsis procedures. While some of these tasks are performed throughout the day, many are taken care of at the end of the day as you get ready for the next day’s activities. Examples of these tasks are listed below and they are further discussed under Putting It All Together.

Of course it’s not possible or necessary to perform all of these tasks every night, so they need to be prioritized and properly scheduled. Things that must be ready for tomorrow may vary from day-to-day, but they take priority. They are mainly items or procedures directly involved with patient care. For example, the dental unit water and water lines must be managed. Contaminated chairside surfaces need to be cleaned and disinfected. Management of the contaminated instruments must begin to assure their timely reuse. Sufficient sterile instrument set-ups must be available. Unit dosed clinical supply packages must be ready. There must be adequate infection control supplies available (e.g., gloves, masks, surface barriers). The other tasks can be performed on a more relaxed timeframe but need to be scheduled to assure timely completion.

Communicating for Compliance

Communication is important in any business, and in a dental office the infection control coordinator plays a key role in disseminating information to the boss, the rest of the staff, and patients.

Employer

Inform the employer of:

• any problems with OSHA infection control and safety documents.
• sterilizer spore testing results.
• equipment maintenance problems.
• waste or laundry management problems.
• the need for re-certification of x-ray equipment.

Staff

Communicate with the other staff about ending the day procedures. Make sure everyone knows about:

• emergency evacuation routes.
• where the fire extinguishers and alarms are located.
• the presence of any new hazardous chemicals in the office and the corresponding Material Safety Data Sheets (MSDS).

Have them report to you any problems with:

• their equipment.
• availability of sufficient instrument set-ups for the next day.
• supply needs.
• completion of any ending the day tasks they have performed.

Patients

As mentioned in other issues, some patients may have questions about safety issues in the office. Here’s what can be said about general safety aspects of the office. We:

• have an emergency evacuation plan in place.
• check or certify our equipment to ensure proper functioning.
• maintain a good quality of water used in your treatment.

Putting It All Together

The types of tasks and their priority for completion (to plan ahead) may vary from office to office. Some of these tasks are described below.

Final decontamination

Contaminated operatory surfaces should be cleaned and disinfected at the end of the day. Appropriate surfaces can be covered with environmental barriers the next morning.

Confirm that sufficient instrument set-ups are available for the next day

Begin to process contaminated instruments as time permits at the end of the day. If instruments are left to dry overnight, presoak in the morning to facilitate final cleaning. If they are soaked overnight, make sure the solution used contains a rust inhibitor.

Dental unit water asepsis

A variety of systems are available to help maintain good quality dental unit water. Some require attention every evening and others are managed at different intervals. A general approach, if disconnected from city water, is to flush out the lines at the end of the day and leave them to “dry” overnight to slow down microbial multiplication.

Waste management

The key to safe waste management is to make sure that all sharps are handled carefully and that the waste is properly contained during handling. Regulated waste as defined by OSHA¹ consists of:

• Contaminated sharps (including the used glass anesthetic carpules). For disposal place in leakproof, puncture-resistant, color-coded, closable, non-glass containers.
• Non-sharp solid waste that would release blood or saliva in liquid or semi-liquid form if compressed (e.g., dripping wet cotton rolls). For disposal place in leakproof, color-coded bags.
• Non-sharp items that are caked with dried blood or saliva and are capable of releasing these materials during handling (e.g., a 2 x 2 caked with dried blood). For disposal place in leakproof, color-coded bags.
• Pathological materials (e.g., extracted teeth that are not disinfected and returned to the patient). For disposal place teeth in the sharps container unless they contain amalgam. These need to be chemically disinfected and picked up by a medical waste hauler or disposed of by other means depending upon local laws.
• Liquid blood or saliva. For disposal carefully pour (without splashing) down a drain (installed according to the local building codes) and rinse with water.

Check the sharps containers and replace if 3⁄4 or more full. If waste is transported by a medical waste hauler, make sure appropriate manifests have been received from the hauler. Make sure the sharps containers are closed when moving them so their contents will not spill if dropped. If local laws allow sterilization of the waste before disposal in regular trash, be sure the lids of the sharps containers are open during sterilization and then process through an autoclave for 60 minutes (either one long cycle or two 30-min cycles). Close the lid after processing. Also be sure that the plastic sharps containers used will not melt inside the sterilizer.

Removal of protective clothing and final hand hygiene

Protective clothing (the outer layer of clothes) should not be worn out of the clinical area.

Hand hygiene at the end of the day should be handwashing with soap and water. Handwashing is important at this time, particularly if alcohol hand rubs have been used throughout the day. Since there is no rinsing with the hand rubs, materials can build up on the skin, and this is removed by handwashing and rinsing.

Laundry management

If disposable gowns are used, they can be discarded in the regular trash. If washable protective clothing is used, it can be laundered in the office or sent out to a medical laundry service. If sent out, the contaminated laundry must be “red-bagged” unless the laundry service handles all laundry as contaminated.

Unit dosing

Unit dosing is preparing and setting out clinical supplies in the quantity needed before seating the patient. It’s an approach to supplies distribution that provides everything that is needed before the appointment begins. This helps to eliminate obtaining supplies after patient treatment has begun, thus reducing the chances of spreading contamination away from chairside. Those unit dosed supply items that are not used are considered contaminated and are discarded at the end of the appointment.

Perform any necessary infection control/safety equipment maintenance according to manufacturer’s directions

• Check the proper functioning of eye-wash stations.
• Make sure emergency showers (if present) work.
• Flush the autoclave drain and clean the chamber.
• Disinfect and rinse the ultrasonic cleaner chamber.
• Make sure routine sterilizer spore testing records are up to date.
• Check the dates of certification on fire extinguishers and x-ray equipment.
• Cleanse the vacuum lines and replace the disposable trap.

Management of infection control and safety documents and records

• Make sure the required OSHA Infection Control Plan is updated with any new infection control procedures or products used or any evaluations of safety devices that have been conducted. The contents of this plan are described in the OSHA Bloodborne Pathogens Standard.²
• Update the collection of MSDSs, hazardous chemicals list and Hazard Communication Plan⁵ when new chemicals are purchased.
• Make sure the required OSHA poster (Job Safety and Health: It’s the Law) is properly displayed where employees and applicants for employment can see it. Dental facilities are required to display a poster prepared by the Department of Labor informing employees of the protections of the 1970 Occupational Safety and Health Act. OSHA developed a new OSHA poster in 2007 that can be downloaded and printed in English⁶ or Spanish.⁷ Previous versions of the poster do not need to be replaced.
• If recent initial or annual OSHA bloodborne pathogens training has been provided to the staff, make sure training records have been updated with the date of the training, the names and job classification of all those who received the training, the general content of the training and the qualifications of the trainer. The training records are to be kept for 3 years.
• Make sure the emergency action plan as required by OSHA⁸ is up to date and that the emergency exit routes are appropriately identified and marked.

Q&A

Question: Have there been any major changes in OSHA’s bloodborne pathogens standard since it first came out in the early 1990s?

Answer: Yes, two. In 2001 the needlestick prevention act was added to the standard requiring evaluation of safety devices for possible use in the office.² The evaluations and the decision to accept or reject the device need to be explained in the Exposure Control Plan. Also, as of 2002, “offices and clinics of dentists” are no longer required to keep injury and illness records.³ But incidents causing a fatality or hospitalization of two or more employees are to be reported to OSHA.

Resources

1. OSHA. Bloodborne pathogens standard. Accessed September 2008 at: http://www.osha. gov/pls/oshaweb/owadisp.show_document?p_ table=STANDARDS&p_id=10051.

2. OSHA. Revisions to OSHA’s Bloodborne Pathogens Standard. Accessed September 2008 at: http://www.osha.gov/needlesticks/ needlefact.html.

3. OSHA. Injury and Illness Recordkeeping– Partially Exempt Industries. Accessed September 2008 at: http://www.osha.gov/record keeping/ppt1/RK1exempttable.html.

4. CDC. Guideline for Disinfection and Sterilization in Healthcare Facilities–2008. Accessed November, 2008 at: http://www.cdc.gov/ ncidod/dhqp/pdf/guidelines/Disinfection_ Nov_2008.pdf.

5. OSHA. Hazard communication. Accessed September 2008 at: http://www.osha.gov/pls/ oshaweb/owadisp.show_document?p_table= STANDARDS&p_id=10099.

6. OSHA. New OSHA workplace poster Job Safety and Health: It’s the Law (in English). Accessed September 2008 at: http://www.osha. gov/Publications/poster.html.

7. OSHA. New OSHA workplace poster Job Safety and Health: It’s the Law (in Spanish). Accessed September 2008 at: http://www.osha.gov/ Publications/poster2.html.

8. OSHA. Evacuation plans and procedures. Accessed September 2008 at: http://www.osha.gov/ SLTC/etools/evacuation/eap.html.