Infection Prevention and Control Standards and Practice Guidelines

General Policies and Procedures

  • There are written IPAC policies and procedures that are based on the most current best practices
  • Policies and procedures are developed and reviewed on an ongoing basis and are based on current scientific literature and best practices.
  • Staff members have access to the IPAC policies and procedures and are familiar with their use.

Role of Infection Prevention and Control Charge Person

  • A job description for this position should clearly describe the duties, responsibilities, as well as the training and education requirements of the infection prevention and control charge person.
  • IPAC charge person should be granted the authority to manage any compliancy issues as per the IPAC standards and practice guidelines.
  • IPAC charge person should be given designated time (at minimum 1 hour) each week to carry out duties and responsibilities related to IPAC standards and best practices.
  • Staff should be educated and understand the importance of this position as part of employment.
  • Regular meetings should be scheduled at minimum one each month at a designated time for the charge person to inform/educate staff about infection prevention and control issues.
  • The charge person should meet with the owner(s) of the dental clinic regularly to discuss infection prevention and control issues.

Legislation Relating to Infection Prevention and Control Practices

  • Responsible dentist(s), dental hygienists, owner(s), operator(s) or manager(s) understand their duties and responsibilities under Ontario’s Occupational Health and Safety Act (OHSA) to ensure workers know about hazards and dangers by providing information, instruction, supervision on how to work safely (e.g., appropriate handling of chemicals) and training and access to appropriate PPE based on risk assessment of exposure.
  • Staff need to be aware of the Occupational Health and Safety Act (OHSA).
  • Staff need to be familiar with the Workplace Hazardous Materials Information System (WHMIS).
  • All hazardous products (e.g., cleaning and disinfecting agents) are labelled according to WHMIS requirements.
  • There must be an Employee Exposure Protocol readily available.
  • An eyewash fountain/station is provided when there is the potential for injury to the eye due to contact with a biological or chemical substance and used/managed, as per MIFU.
  • The clinic should have a written and up-to-date Healthy Workplace Policy.
  • IPAC and Occupational Health and Safety policies and procedures are followed by all staff, including dental assistants, dental hygienists and dentists.
  • Needles are safety-engineered medical sharps (SEMS) whenever possible.
  • There are written policies and procedures to prevent and manage injuries from sharp objects. Resource: Ontario Regulation 474/07 Needle Safety.
  • Waste management, waste from any clinical office setting is divided into two categories: biomedical and general. Management of contaminated infectious waste shall follow provincial regulations and local bylaws and address issues such as collection, storage, transport, handling and disposal of contaminated waste, including sharps and biomedical waste.
  • The clinic should have a written waste management program included in the office manual that is compliant with current legislation and national standards.

Personal Protective Equipment (PPE)

  • All PPE should be put on immediately before the activity and removed immediately after the activity for which it is indicated. Perform hand hygiene after removal of PPE due to possible contamination.
  • Wearing gloves is not a substitute for hand hygiene.
  • Appropriate use of gloves: wear gloves for contact with mucous membranes, non-intact skin.
  • Appropriate use of gowns: wear a gown or plastic apron when providing care that may contaminate skin or clothing with blood, body fluids, secretions or excretions. Wear gown properly, i.e., appropriately tied at neck and waist.
  • Appropriate use of masks: secure mask on the nose and mouth, change mask if it becomes wet, do not touch the mask while being worn, do not allow mask to hang around the neck, do not fold mask or store in a pocket, and do not re-use mask.
  • Appropriate use of eye protection: ensure that eye protection is comfortable, fits securely and does not interfere with vision. Remove eye protection by grasping the side arms and pulling eye protection forward, without touching the front of the eyewear.
  • Staff must practice proper technique when removing PPE to prevent self-contamination.

Booking and Reception

  • All patients should be screened during the booking process for symptoms of communicable disease or acute respiratory infection.
  • Respiratory Etiquette: all waiting rooms should have self-screening signage, face masks (with instructions on proper use and disposal), tissues, waste containers, and ABHR for hand hygiene for patients and family members.

Control of the Environment

  • Maintaining a clean and safe health care environment is an essential component of infection prevention and control.
  • Environmental cleaning and disinfection should be performed on a routine and consistent basis.
  • The three office settings: public, clinical and surgical components each require specific level of environmental cleaning and disinfection.
  • Surfaces and finishes in the clinical setting require specific infection prevention and control considerations for cleaning and choice of disinfectant solutions.
  • Responsibility for cleaning between patients, end of day cleaning and scheduled cleaning must be clearly defined and understood.
  • Manufacturer’s Instructions for Use (MIFU) and recommendations for cleaning must be followed.
  • All water lines must be flushed and cleaned between patients according to MIFU.
  • All suction lines must be purged by aspirating water or an appropriate cleaning solution with air to produce turbulent flow in the lines.
  • Suction lines are flushed out with an enzymatic cleaner or appropriate cleaning solution at least once per week or as per MIFU.
  • All staff who clean the instruments and equipment must be trained.
  • Waste from any clinical office setting is classified as either biomedical or general. Waste management must follow national and/or provincial regulations and local bylaws.
  • Sharps are devices that are capable of causing a cut or puncture wound should be managed according to current legislation and national standards.
  • Precautions must be taken to prevent sharps-related injuries to staff and sharps containers must be easily accessible in every “point of use” area.

Reprocessing Equipment

  • The clinic or office must have written policies and procedures for all aspects of reprocessing that are based on current recognized standards / recommendations and these must be reviewed regularly and/or as new information becomes available.
  • The office manual must include a policy on the recall of improperly reprocessed equipment.
  • Staff assigned to reprocess dental/medical equipment/devices/instrumentation must receive device-specific reprocessing instructions from the device manufacturer’s representative and have access to written instruction materials.
  • Single use items MUST not be re-used. Staff must clearly understand all symbols used to define items that are designed for single use only.
  • All single-use items are disposed of following use.
  • Staff must have access to all personal protective equipment necessary to safely complete reprocessing of dental instruments and equipment.
  • Physical space layout of reprocessing area should be designed according to infection prevention and control standards and practice guidelines.
  • Non-critical items (e.g., radiograph head / cone, blood pressure cuff, face bow, pulse oximeter) are cleaned and low-level disinfected between uses.
  • Semi critical items (e.g., mouth mirrors, amalgam condensers, reusable impression trays and handpieces) that come into contact with mucous membranes and critical equipment/devices (e.g., all surgical instruments, periodontal scalers, and ultrasonic scaler tips) are cleaned and sterilized, as per the MIFU.
  • All critical and semi-critical instruments used in dentistry, including handpieces, are available in heat-tolerant and/or single-use (disposable) forms. All heat-tolerant reusable critical and semi-critical instruments are heat-sterilized between uses.

Sterilization

  • All critical instruments/items are either disposable or sterilized using an approved sterilization process.
  • Items must be packaged according to manufacturer recommendations for both the package and the instruments.
  • Each package is labeled with date processed, sterilizer used, cycle or load number and the health care provider’s initials in a manner that does not puncture or dampen the package.
  • Chemical indicators (CI) are placed appropriately in and/or on each package.
  • Items are placed in the sterilizer according to sterilizer manufacturer’s instructions for use (MIFU).
  • Sterilizer mechanical display, printout or USB is checked, verified and signed for each cycle by the person sterilizing the instruments.
  • Sterilizer is tested with biological indicator (BI) each day the sterilizer is used.
  • Items in the processed load should not be released until the results of the BI test are available.
  • Records must be kept to document that all sterilization parameters have been met.
  • Sterilized items are not used until the clinical indicators are checked.
  • Instrument packs are allowed to dry inside the sterilizer chamber before removing and handling.
  • If a failed chemical indicator is found, the contents of the package must be re-packaged and reprocessed before use.
  • All Sterile packages must be inspected for integrity.

Storage

  • Sterile items are stored in their sterile packaging until time of use.
  • Packaged, sterilized instruments are store securely in a manner that keeps them clean, dry and prevents contamination.
  • Equipment/devices which have been reprocessed and sterilized can be differentiated from those which have not been reprocessed and sterilized.
  • Sterile items should be stored in a manner that does not compromise the integrity of the packaging.
  • The clinic should have a written policy and procedure about how long a package remains sterile. This is known as the “shelf life” (or expiry date). The Length of shelf life depends on the type of outer package used. Follow manufacturer’s recommendations. Shelf life is typically defined either by time or by an event related event. For example, after a specific period of time such as 6 months or 1 year from the date of sterilization or an event such as moisture penetrating package, the item in the package is not sterile and should be remove from storage.
  • If for any reason the integrity of the package is compromised, item in package is no longer considered to be sterile.

Dental Unit Waterlines and Water Quality

  • Staff have received training regarding water quality, biofilm formation, water treatment methods and appropriate maintenance protocols for water delivery system.
  • Waterlines are monitored for damage and/or visible contamination and replaced as needed or as directed by the manufacturer.
  • Waterline heaters are not used.
  • All waterlines are purged at the beginning of each workday by flushing them thoroughly with water for at least two minutes. Before purging is carried out, handpieces, air/water syringe tips and ultrasonic tips are removed from the waterlines.
  • Handpieces using water coolant are run for a minimum of 20 seconds after patient/client care in order to purge all potentially contaminated air and water. The handpiece is then removed. Cleaning and disinfection of clinical contact surfaces occurs before another sterilized handpiece is attached for use with the next patient/client.
  • Sterile water or sterile saline is used when irrigating open surgical sites and whenever bone is cut during invasive surgical procedures. Appropriate devices, such as bulb syringes or single-use disposable products, are used to deliver sterile irrigation solutions.
  • For offices using closed or other water delivery systems: The MIFU related to dental units and equipment are followed for daily and weekly maintenance.

Medications

  • There are facilities for hand hygiene in the medication room/area; these include either a dedicated hand hygiene sink and/or alcohol based hand rub (ABHR).
  • Medications are stored and prepared in a clean area on a clean surface that is separate from other areas.
  • Single-dose injectable medications are prepared at the time of use, used once on a single patient/client and discarded immediately.
  • Rubber stoppers (diaphragm/septum) of vials are scrubbed with 70% alcohol and stopper is allowed to dry prior to entry into vial.
  • Product monograph is followed and referred to for further clarification regarding correct storage (e.g., refrigeration, keep away from light), handling, preparation, expiry date, and directions for administration.
  • Multidose vials are replaced with single dose vials wherever possible.
  • All needles are single use only.
  • All syringes are single use only.
  • Multidose vials are never entered with a used needle or a used syringe.
  • Once medication is drawn up, the needle is immediately withdrawn from the vial; a needle is never left in a vial to be attached to a new syringe.
  • Multidose vials are discarded immediately if sterility is compromised or questioned.

Specimen Handling

  • There is a policy or procedure for handling of all blood and body fluids. This includes blood specimens obtained through veni puncture (e.g, platelet rich plasma for bone grafts) and biopsy specimens.
  • There is a designated storage area for specimens (e.g., biopsy) separate from clean supplies.
  • Biopsy specimens are placed in a sturdy, leak-proof container that has a secure lid and is clearly labelled with the universal biohazard symbol.
  • Care is taken when collecting specimens to avoid contaminating the outside of the container. If the outside of the container is suspected to be or has been contaminated, it is cleaned and disinfected or placed in an impervious bag prior to transportation.

Blood Collection and Testing Devices

  • Single-use blood collection tube holders are preferred. If blood tube holders are reused, they are designed for multi-patient/client use and are cleaned and disinfected after each use, as per the MIFU. Discard if visibly soiled.
  • Tourniquets are non-latex and are preferably single use. If reusable, low-level disinfection is required between patients/clients.
  • Glucometers (blood glucose monitoring devices) are not shared between patients/clients unless the device is designed for multi-patient/client use and cleaned and low-level disinfected after use with each patient/client, as per MIFU.
  • Lancing devices are auto-disabling or for single patient/client use.
  • Lancet holders (e.g., pen-like holder) are single patient/client use only.

Dental Radiology

  • After a radiograph is exposed, the film packet is dried with disposable gauze or a paper towel to remove blood or excess saliva and then placed in a container, such as a disposable cup, for transport to the developing area.
  • The film packet is cleaned of gross debris and saliva and disinfected with an appropriate low-level disinfectant before opening to develop the film. Alternatively, a contaminated film packet may be opened using gloves. The film is dropped onto a clean surface without touching it and the empty packet is discarded, being careful to avoid contamination. Gloves are then removed and hand hygiene performed before developing the film. If a barrier pouch is used over the film, the film packet is carefully removed from the pouch to avoid contamination and then placed in a container for transport to the developing area.
  • Digital radiography sensors and intra-oral cameras are cleaned and heat-sterilized between patients/clients as they come into contact with mucous membranes. Alternatively, they are protected with barriers to reduce gross contamination.Following barrier removal, sensors are cleaned of gross debris and saliva, and disinfected with a low-level disinfectant or as per manufacturer’s instructions.

Dental Laboratory

  • Impressions, prostheses or appliances are cleaned and disinfected as soon as possible after removal from the patient’s/client’s mouth, before drying of blood or other organic debris.
  • All items returned from an outside laboratory to a dental office are cleaned and disinfected prior to placing in a patient’s/client’s mouth.
  • Heat-tolerant items used in the mouth, such as impression trays or face bow forks, are sterilized after each patient/client use. Other items that do not normally come in contact with the patient/client, but frequently become contaminated, such as articulators and case pans, are cleaned and disinfected according to the manufacturer’s instructions.
  • Items used in the typical in-office dental laboratory, such as: burs, polishing points, rag wheels, laboratory knives and dental lathes, that frequently become contaminated during adjustments to prostheses and appliances, are reprocessed or discarded after use, as per the manufacturer’s recommendations.