Updated Guide to Basic Infection Prevention Practices (Regulatory Standards CE)

OSHA’s Bloodborne Pathogens Standard (BPS)¹ provides guidance to employers to protect their workers who have possible occupational exposure to infectious materials. Because dental laboratories receive potentially infectious items such as impressions and dentures, and in many cases provide onsite services to dental practices, these employers must identify the risk to their workers, develop good infection control practices, train their workers on the correct protection methods, and monitor and enforce worker compliance with the employer’s protocols.

OSHA publishes the Bloodborne Pathogen Standard at 29 CFR 1910.1030; however, the agency that is relied upon most often for recommendations on how to apply good infection control practices is the Centers for Disease Control and Prevention (CDC). It is the most recognized authority on diseases and prevention of their transmission. The latest Guidelines for Dentistry were published by the CDC on December 19, 2003.² In March 2016, the CDC issued a Summary of Infection Prevention Practices in Dental Settings³ (Summary). This Summary is not intended to be a substitute for the 2003 CDC guidelines but is based primarily upon elements of Standard Precautions and represents a summary of basic infection prevention expectations for safe care in dental settings as recommended in the 2003 CDC Guidelines. Dental health care personnel (DHCP) referred to in these publications include: dentists, dental hygienists, dental assistants, dental laboratory technicians, students and trainees, contractual personnel, and more.

The Summary indicates that DHCP referred to in this document include all paid and unpaid personnel in the dental health care setting who might be occupationally exposed to infectious materials, including body substances and contaminated needles, equipment, environmental surfaces, water, or air. The list includes noth in-office and commercial dental laboratory technicians. The relevance to dental laboratories is important because they are providing more and more services that require the presence of dental technicians in the dental office.

This article will focus on the issues to be addressed by employers in the development of an effective infection prevention program based on the CDC guidelines. The recent CDC Summary is broken down into the areas of fundamental elements needed to prevent transmission of infectious agents in dental settings. The six fundamental elements are:

1. Administrative Measures
2. Infection Prevention Education and Training
3. Dental Health Care Personnel Safety
4. Program Evaluation
5. Standard Precautions
6. Dental Unit Water Quality

The Summary also includes Appendix A, which is an Infection Prevention Checklist for Dental Settings: Basic Expectations for Safe Care. This should be used to develop a checklist specific to the facility and program that is being evaluated. Appendix B provides relevant recommendations for dental infection prevention and control published by the CDC since the 2003 Guidelines. It includes:

• Infection prevention program administrative measures
• Infection prevention education and training
• Respiratory hygiene and cough etiquette
• Updated safe injection practices
• Administrative measures for instrument processing.

The following are the six elements referred to in the Summary for the development of an effective infection prevention program.

Administrative Measures

1. Develop and maintain infection prevention and occupational health programs: OSHA’s Bloodborne Pathogens Standard (BPS) requires employers to develop an Exposure Control Plan (Plan). This Plan describes the risk areas in the laboratory, and how employees will be protected through controls such as administrative and engineering, as well as through the use of personal protective equipment. It also indicates the person in the facility who is responsible for providing protective equipment, training workers, and monitoring the infection prevention controls. Annually this Plan must be assessed to ensure that the controls are being followed by workers in risk areas and those individuals who are responsible for administering the components of the Plan. This annual assessment should be documented.

2. Provide supplies necessary for adherence to Standard Precautions: These supplies include hand-hygiene products, safer devices to reduce percutaneous injuries, and personal protective equipment. In a dental laboratory the use of hand-hygiene products for infection prevention would be applicable in the receiving area, model room, denture repair areas, and shade verification area. Further information on this prevention method will be discussed under Standard Precautions.

3. Assign one individual with training in infection prevention: In most workplaces the Safety Coordinator or Safety Officer is responsible for administration of the health and safety program. In a dental laboratory, this individual’s knowledge of chemical hygiene, infection control, environmental hazards, and emergency planning can all be included in the scope of the position. The Summary recommends that at least one individual with training in infection prevention be responsible for developing the written infection prevention policies and procedures based on evidence-based guidelines, regulations, or standards. The employer is responsible for providing the training that is necessary for this individual to be knowledgeable in all phases of infection prevention that are applicable to the employer’s workplace.

4. Develop and maintain written infection prevention policies and procedures: These policies and procedures must be appropriate for the services provided by the facility and based on evidence-based guidelines, regulations, or standards. Development of an infection prevention program begins with an assessment of the hazards. In a dental laboratory, the assessment starts with the incoming work from dental clients. The BPS requires the employer to protect its workers; therefore, presuming that the dental client’s staff disinfected the items prior to shipment is not sufficient worker protection. All items that can withstand disinfection must be disinfected upon receipt and handled by workers downstream of the Receiving Area. Disinfection doesn’t stop at that point. If the assessment determines that workers can be exposed in other areas of the laboratory, then infection prevention controls must be developed and implemented.

5. Employer must have a system in place for early detection and management of potentially infectious persons at initial points of patient encounter: In a dental practice there would be more extensive controls for these purposes. In the dental laboratory, there would be patient encounters when dental technicians perform services at the dental practice and when patient shade verifications involve the actual patient at the dental laboratory.

Infection Prevention Education and Training

Infection prevention training must be specific to the job or task being performed. Workers must be trained upon hire, when new tasks or procedures are introduced, and at a minimum annually. This training includes temporary workers, contract workers, and volunteers. A dental laboratory also must train dental technicians who will be performing services in the dental client’s facility and ensure that the dental technician understands the infection prevention policies for the specific dental practice.

Dental Health Care Personnel Safety

The infection prevention program should address occupational health needs that include vaccination of DHCP, management of exposure or infections that require post-exposure prophylaxis or work restrictions, and compliance with OSHA’s BPS.

There may be more extensive vaccination requirements in dental practices, but in dental laboratories employers must offer the Hepatitis B vaccine to workers in risk areas. As stated above in Item 1 of Administrative Measures, the Exposure Control Plan requires assessment of risk areas. Workers in those risk areas must be offered the Hepatitis B vaccine within 10 days of hire or job assignment should their job change from the initial hire. The employer’s responsibility is to educate the worker on the risks and then offer the Hepatitis B vaccine. If the worker declines the vaccine for any reason, then the employer must have the worker sign a Refusal form. Should the worker change his or her mind after the initial offering, then the employer would provide the vaccine and keep a record of the immunizations.

In a dental laboratory, an employer may offer other vaccines to workers; however, currently just the Hepatitis B vaccine is required by OSHA.

Post-Exposure Evaluation and Follow-up is required by OSHA in the BPS. Whenever a worker is exposed to body fluids by a cut or splash/splatter into the body, then the employer must follow the Post-Exposure requirements. This procedure requires the employer to offer the affected employee blood testing. The worker can decline this offer; however, the employer must document this offer on OSHA’s Post-Exposure Evaluation and Follow-up form. It is then the duty of the employer to contact the dental client to inform them of the exposure incident, and ask the dental client to request for the patient to consent to testing. The consent or denial of the dental client and/or patient will also be documented on the Post Exposure form. Results of the testing will be kept confidential by the employer and released to the employee. Follow-up consultation for the employee will be provided by the employer as needed.

Program Evaluation

After infection prevention programs are developed and documented into standard operating procedures, routine evaluations should be performed. These evaluations will review that the practices established for work protection are being applied consistently. The Summary provides a checklist in Appendix A. An employer could use that Appendix A to develop a thorough evaluation procedure by adapting the content to the specific workplace.

Part of the evaluation process is to review occupational exposure to blood and any work-related illnesses that have occurred and been reported to the employer. The evaluation process will only be complete, however, when the employer takes the appropriate action to re-train workers and implement additional measures needed to protect workers.

Standard Precautions

The Summary reaffirms Standard Precautions as the foundation for preventing transmission of infectious agents. OSHA refers to Universal Precautions; however, the CDC refers to Standard Precautions as the minimum infection prevention practices.

Universal Precautions are defined by OSHA as “an approach to infection control. According to the concept of Universal Precautions, all human blood and certain human body fluids are treated as if known to be infectious for HIV, HBV, and other bloodborne pathogens.”

The CDC refers to Standard Precautions as representing “the minimum infection prevention measures that apply to all patient care, regardless of suspected or confirmed infection status of the patient, in any setting where health care is delivered. These evidence-based practices are designed to both protect health care personnel and prevent the spread of infections among patients. Standard Precautions replaces earlier guidance relating to Universal Precautions and Body Substance Isolation. Standard Precautions include: 1) hand hygiene; 2) use of personal protective equipment (eg, gloves, gowns, facemasks), depending on the anticipated exposure; 3) respiratory hygiene and cough etiquette; 4) safe injection practices; and 5) safe handling of potentially contaminated equipment or surfaces in the patient environment.”⁴

The following is a review of the seven Standard Precautions referred to in the Summary by the CDC:

1. Hand hygiene: The CDC considers this the most important measure to prevent the spread of infections. Use water and plain soap or antimicrobial soap that is specific to your workplace activities. The CDC indicates that alcohol-based hand rubs are effective; however, soap and water should be used when hands are visibly soiled (eg, dirt, blood, body fluids). The Summary refers to the CDC’s Guideline for Hand Hygiene in Health-Care Settings5 for more detailed information.

2. Use of personal protective equipment (PPE): This PPE must be appropriate for the activities for which it is required. PPE can include gloves, facemasks, protective eyewear, face shields, and protective clothing.

Gloves must be worn when there is possible contact with blood or body fluids, mucous membranes, non-intact skin, or other potentially infectious materials (OPIM).

Protective clothing is used to protect the skin and clothes where there may be contact with blood or body fluids.

Face and eye protection must be used when there is a possibility of splashes or sprays of blood or other body fluids.

Cross contamination can occur when removing PPE; therefore, workers must be trained on the proper removal procedures. Also, PPE must not be worn outside the risk area to prevent further cross contamination into other areas of the laboratory. The Summary refers to the CDC’s 2007 Guidelines for Isolation Precautions6 for more information on application and removal of PPE.

3. Respiratory Hygiene/Cough Etiquette: These preventive measures are designed to limit the transmission of respiratory pathogens spread by droplet or airborne routes. The primary concern would be where there is contact with a patient; however, it could apply to co-workers who have signs of illness. These signs include cough, congestion, runny nose, or increased production of respiratory secretions.

In 2007 good coughing etiquette was added to Standard Precautions. It’s not uncommon to see the sign that was available from the CDC posted in dental offices and other health care settings. The Summary refers to the 2007 Guideline mentioned above for additional information on respiratory hygiene and coughing etiquette.

4. Sharps Safety: The Summary states that sharps injuries continue to occur and pose a risk of bloodborne pathogen transmission to DHCP and patients. The primary methods used to reduce these exposures are engineering and work-practice controls. When utility knives are used in the dental laboratory to trim back an overextended border on an impression, the worker must wear gloves and be trained on good work practices to prevent cuts. It’s not uncommon for blood and saliva to be exposed during this procedure. A sharps container should be available for disposal of the blades used in the utility knife. An engineering control that can be used to minimize this risk is to use surgical scissors rather than the utility knife.

5. Safe Injection Practices: Parenteral medications are administered in the dental practice. They can be intravenous or intramuscular injections. The methods used to perform these injections must prevent the DHCP from an unintended needle stick because transmission of an infectious disease between the patient and the DHCP can occur. Dental technicians may also be participating in a situation at the dental practice where the patient is undergoing conscious sedation. The Summary states that even though safe injection practices were covered in the 2003 CDC dental guidelines, there still are reports of transmission of infectious diseases by inappropriate handling of injectable medications. That is why safe injection practices are now a formal element of Standard Precautions.

Dental Unit Water Quality

This part of the Summary discusses how dental unit waterlines can promote bacterial growth and the development of biofilm in the plastic tubing that carries water to the high-speed handpieces, air/water syringe, and ultrasonic scaler. The CDC recommendations are to:

1. Use water that meets EPA regulatory standards for drinking water.
2. Consult with the dental unit manufacturer for the appropriate methods to use on the equipment to maintain the quality of the dental water.
3. Follow the manufacturer’s guidelines or the waterline treatment product for monitoring the water quality.
4. Use sterile saline or sterile water when performing surgical procedures.

Conclusion

DHCP have a right to be protected in the workplace. The employer has the duty and responsibility to assess the hazards and then take action to develop and implement health and safety programs that will protect its workers. The responsibility doesn’t end with the development of the programs. The employer must train workers on the infection prevention methods and then monitor and enforce compliance. Periodic evaluations of infection prevention practices will assist in identifying the gaps so further training can be provided to workers. Employers should use tools provided by OSHA and the CDC to gain knowledge on not only regulatory requirements but also best practices to make a part of the health and safety program.

References

1. OSHA’s Bloodborne Pathogen Standard. OSHA Website. https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=standards&p_id=10051. Accessed August 19, 2016.

2. Guidelines for Infection Control in Dental Health-Care Settings --- 2003. Centers for Disease Control and Prevention Website. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5217a1.htm. Accessed August 19, 2016.

3. Summary of Infection Prevention Practices in Dental Settings: Basic Expectations for Safe Care. Centers for Disease Control and Prevention Website. http://www.cdc.gov/oralhealth/infectioncontrol/pdf/safe-care.pdf. Accessed August 19, 2016.

4. Basic Infection Control and Prevention Plan for Outpatient Oncology Settings. Centers for Disease Control and Prevention Website. http://www.cdc.gov/HAI/settings/outpatient/basic-infection-control-prevention-plan-2011/fundamental-of-infection-prevention.html. Accessed August 19, 2016.

5. Guideline for Hand Hygiene in Health-Care Settings. Morbidity and Mortality Weekly Report. http://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf. Accessed August 19, 2016.

6. 2007 Guidelines for Isolation Precautions. Centers for Disease Control and Prevention Website. http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf. Accessed August 19, 2016.

About the Author

Mary A. Borg-Bartlett
President
SafeLink Consulting, Inc.