Every year, lives are lost because of the spread of infections in hospitals. Health care workers can take steps to prevent the spread of infectious diseases. These steps are part of infection control.

Proper hand washing is the most effective way to prevent the spread of infections in hospitals. If you are a patient, don't be afraid to remind friends, family and health care providers to wash their hands before getting close to you.

Other steps health care workers can take include

• Covering coughs and sneezes
• Staying up-to-date with immunizations
• Using gloves, masks and protective clothing
• Making tissues and hand cleaners available
• Following hospital guidelines when dealing with blood or contaminated items

Although we can’t see them, germs are everywhere, and they need somewhere to grow – a place where they can live. These places, called reservoirs, are found on and in our bodies and in the environment.

Recognizing where germs live in health care is the first step in understanding how to stop their spread and protect patients.

Most germs are not harmful to us. But when we encounter germs that could be harmful or make us sick, our body’s natural defenses do a great job at keeping us healthy. In health care however, there’s a higher chance for germs to spread because that’s where people who are sick come for care. Patients are also more likely to have weakened immune systems or to need a procedure that might break through their body’s natural defenses, making them more vulnerable to infection. And sometimes you are the opportunity for germs to spread – throughout any given day you interact with a lot of coworkers and patients, touch a lot of things, and use shared devices and equipment.

Recognizing reservoirs – the places where germs live – throughout your workday is the first step in being able to see the risk for germs to spread – and knowing when to do something about it so that you can protect your patients and yourself.

Common activities that bypass or break down the body’s natural defenses:

• Surgery
• Inserting an IV
• Chemotherapy
• Antibiotic Use

Germs Live in and on the Body

Your body (and every body!) is home to many germs. Learn about the different reservoirs on and in the body, how germs can spread from them, and why it matters for infection control.

Germs Live in the Environment

There are places in the healthcare environment that are home to many germs. Learn about the different reservoirs in the environment, how germs can spread from them, and why it all matters for infection control.

The human body is full of reservoirs – places where germs can live.

Recognizing where germs live in and on the body (reservoirs) and how they can spread (pathways) can help you choose the right infection control actions to protect your patients, yourself, and your coworkers.

Common reservoirs in and on the human body include the skin, the gut the respiratory system, and blood.

Germs are everywhere, including on surfaces and things in the healthcare environment.

Recognizing where germs live in the healthcare environment (reservoirs) and how they can spread (pathways) can help you take the right infection control actions to protect your patients, yourself, and your coworkers.

Common reservoirs in the healthcare environment include water and wet surfaces, dry surfaces, dirt and dust, and devices.

Germs are a part of everyday life and are found in our air, soil, water, and in and on our bodies. Some germs are helpful, others are harmful. Many germs live in and on our bodies without causing harm and some even help us to stay healthy. Only a small portion of germs are known to cause infection.

How do Infections Occur?

An infection occurs when germs enter the body, increase in number, and cause a reaction of the body.

Three things are necessary for an infection to occur:

• Source: places where infectious agents (germs) live (e.g., sinks, surfaces, human skin)
• Susceptible Person with a way for germs to enter the body
• Transmission: a way germs are moved to the susceptible person

Source

A Source is an infectious agent or germ and refers to a virus, bacteria, or other microbe.

In healthcare settings, germs are found in many places. People are one source of germs including:

• Patients
• Healthcare workers
• Visitors and household members

People can be sick with symptoms of an infection or colonized with germs (not have symptoms of an infection but able to pass the germs to others).

Germs are also found in the healthcare environment. Examples of environmental sources of germs include:

• Dry surfaces in patient care areas (e.g., bed rails, medical equipment, countertops, and tables)
• Wet surfaces, moist environments, and biofilms (e.g., cooling towers, faucets and sinks, and equipment such as ventilators)
• Indwelling medical devices (e.g., catheters and IV lines)
• Dust or decaying debris (e.g., construction dust or wet materials from water leaks)

Susceptible Person

A susceptible person is someone who is not vaccinated or otherwise immune, or a person with a weakened immune system who has a way for the germs to enter the body. For an infection to occur, germs must enter a susceptible person’s body and invade tissues, multiply, and cause a reaction.

Devices like IV catheters and surgical incisions can provide an entryway, whereas a healthy immune system helps fight infection.

When patients are sick and receive medical treatment in healthcare facilities, the following factors can increase their susceptibility to infection.

• Patients in healthcare who have underlying medical conditions such as diabetes, cancer, and organ transplantation are at increased risk for infection because often these illnesses decrease the immune system’s ability to fight infection.
• Certain medications used to treat medical conditions, such as antibiotics, steroids, and certain cancer fighting medications increase the risk of some types of infections.
• Lifesaving medical treatments and procedures used in healthcare such as urinary catheters, tubes, and surgery increase the risk of infection by providing additional ways that germs can enter the body.

Recognizing the factors that increase patients’ susceptibility to infection allows providers to recognize risks and perform basic infection prevention measures to prevent infection from occurring.

Transmission

Transmission refers to the way germs are moved to the susceptible person.

Germs don’t move themselves. Germs depend on people, the environment, and/or medical equipment to move in healthcare settings.

There are a few general ways that germs travel in healthcare settings – through contact (i.e., touching), sprays and splashes, inhalation, and sharps injuries (i.e., when someone is accidentally stuck with a used needle or sharp instrument).

• Contact moves germs by touch (example: MRSA or VRE). For example, healthcare provider hands become contaminated by touching germs present on medical equipment or high touch surfaces and then carry the germs on their hands and spread to a susceptible person when proper hand hygiene is not performed before touching the susceptible person.
• Sprays and splashes occur when an infected person coughs or sneezes, creating droplets which carry germs short distances (within approximately 6 feet). These germs can land on a susceptible person’s eyes, nose, or mouth and can cause infection (example: pertussis or meningitis).
  • Close range inhalation occurs when a droplet containing germs is small enough to breathe in but not durable over distance.
• Inhalation occurs when germs are aerosolized in tiny particles that survive on air currents over great distances and time and reach a susceptible person. Airborne transmission can occur when infected patients cough, talk, or sneeze germs into the air (example: TB or measles), or when germs are aerosolized by medical equipment or by dust from a construction zone (example: Nontuberculous mycobacteria or aspergillus).
• Sharps injuries can lead to infections (example: HIV, HBV, HCV) when bloodborne pathogens enter a person through a skin puncture by a used needle or sharp instrument.

Standard Precautions are the minimum infection prevention practices 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 practices are designed to both protect DHCP and prevent DHCP from spreading infections among patients. Standard Precautions include —

1. Hand hygiene.
2. Use of personal protective equipment (e.g., gloves, masks, eyewear).
3. Respiratory hygiene/cough etiquette.
4. Sharps safety (engineering and work practice controls).
5. Safe injection practices (i.e., aseptic technique for parenteral medications).
6. Sterile instruments and devices.
7. Clean and disinfected environmental surfaces.

Each element of Standard Precautions is described in the following sections. Education and training are critical elements of Standard Precautions, because they help DHCP make appropriate decisions and comply with recommended practices.

When Standard Precautions alone cannot prevent transmission, they are supplemented with Transmission-Based Precautions. This second tier of infection prevention is used when patients have diseases that can spread through contact, droplet or airborne routes (e.g., skin contact, sneezing, coughing) and are always used in addition to Standard Precautions. Dental settings are not typically designed to carry out all of the Transmission-Based Precautions (e.g., Airborne Precautions for patients with suspected tuberculosis, measles, or chickenpox) that are recommended for hospital and other ambulatory care settings. Patients, however, do not usually seek routine dental outpatient care when acutely ill with diseases requiring Transmission-Based Precautions. Nonetheless, DHCP should develop and carry out systems for early detection and management of potentially infectious patients at initial points of entry to the dental setting. To the extent possible, this includes rescheduling non-urgent dental care until the patient is no longer infectious or referral to a dental setting with appropriate infection prevention precautions when urgent dental treatment is needed.

Hand Hygiene

Hand hygiene is the most important measure to prevent the spread of infections among patients and DHCP. Education and training programs should thoroughly address indications and techniques for hand hygiene practices before performing routine and oral surgical procedures.

For routine dental examinations and nonsurgical procedures, use water and plain soap (hand washing) or antimicrobial soap (hand antisepsis) specific for health care settings or use an alcohol-based hand rub. Although alcohol-based hand rubs are effective for hand hygiene in health care settings, soap and water should be used when hands are visibly soiled (e.g., dirt, blood, body fluids). For surgical procedures, perform a surgical hand scrub before putting on sterile surgeon’s gloves. For all types of hand hygiene products, follow the product manufacturer’s label for instructions.

Personal Protective Equipment

Personal protective equipment (PPE) refers to wearable equipment that is designed to protect DHCP from exposure to or contact with infectious agents. PPE that is appropriate for various types of patient interactions and effectively covers personal clothing and skin likely to be soiled with blood, saliva, or other potentially infectious materials (OPIM) should be available. These include gloves, face masks, protective eye wear, face shields, and protective clothing (e.g., reusable or disposable gown, jacket, laboratory coat). Examples of appropriate use of PPE for adherence to Standard Precautions include—

• Use of gloves in situations involving possible contact with blood or body fluids, mucous membranes, non-intact skin (e.g., exposed skin that is chapped, abraded, or with dermatitis) or OPIM.
• Use of protective clothing to protect skin and clothing during procedures or activities where contact with blood or body fluids is anticipated.
• Use of mouth, nose, and eye protection during procedures that are likely to generate splashes or sprays of blood or other body fluids.

DHCP should be trained to select and put on appropriate PPE and remove PPE so that the chance for skin or clothing contamination is reduced. Hand hygiene is always the final step after removing and disposing of PPE. Training should also stress preventing further spread of contamination while wearing PPE by:

• Keeping hands away from face.
• Limiting surfaces touched.
• Removing PPE when leaving work areas.
• Performing hand hygiene.

Respiratory Hygiene/Cough Etiquette

Respiratory hygiene/cough etiquette infection prevention measures are designed to limit the transmission of respiratory pathogens spread by droplet or airborne routes. The strategies target primarily patients and individuals accompanying patients to the dental setting who might have undiagnosed transmissible respiratory infections, but also apply to anyone (including DHCP) with signs of illness including cough, congestion, runny nose, or increased production of respiratory secretions.

DHCP should be educated on preventing the spread of respiratory pathogens when in contact with symptomatic persons. Respiratory hygiene/cough etiquette measures were added to Standard Precautions in 2007.

Sharps Safety

Most percutaneous injuries (e.g., needlestick, cut with a sharp object) among DHCP involve burs, needles, and other sharp instruments. Implementation of the OSHA Bloodborne Pathogens Standard has helped to protect DHCP from blood exposure and sharps injuries. However, sharps injuries continue to occur and pose the risk of bloodborne pathogen transmission to DHCP and patients. Most exposures in dentistry are preventable; therefore, each dental practice should have policies and procedures available addressing sharps safety. DHCP should be aware of the risk of injury whenever sharps are exposed. When using or working around sharp devices, DHCP should take precautions while using sharps, during cleanup, and during disposal.

Engineering and work-practice controls are the primary methods to reduce exposures to blood and OPIM from sharp instruments and needles. Whenever possible, engineering controls should be used as the primary method to reduce exposures to bloodborne pathogens. Engineering controls remove or isolate a hazard in the workplace and are frequently technology-based (e.g., self-sheathing anesthetic needles, safety scalpels, and needleless IV ports). Employers should involve those DHCP who are directly responsible for patient care (e.g., dentists, hygienists, dental assistants) in identifying, evaluating and selecting devices with engineered safety features at least annually and as they become available. Other examples of engineering controls include sharps containers and needle recapping devices.

When engineering controls are not available or appropriate, work-practice controls should be used. Work-practice controls are behavior-based and are intended to reduce the risk of blood exposure by changing the way DHCP perform tasks, such as using a one-handed scoop technique for recapping needles between uses and before disposal. Other work-practice controls include not bending or breaking needles before disposal, not passing a syringe with an unsheathed needle by hand, removing burs before disassembling the handpiece from the dental unit, and using instruments in place of fingers for tissue retraction or palpation during suturing and administration of anesthesia.

All used disposable syringes and needles, scalpel blades, and other sharp items should be placed in appropriate puncture-resistant containers located close to the area where they are used. Sharps containers should be disposed of according to state and local regulated medical waste rules.

Safe Injection Practices

Safe injection practices are intended to prevent transmission of infectious diseases between one patient and another, or between a patient and DHCP during preparation and administration of parenteral (e.g., intravenous or intramuscular injection) medications. Safe injection practices are a set of measures DHCP should follow to perform injections in the safest possible manner for the protection of patients. DHCP most frequently handle parenteral medications when administering local anesthesia, during which needles and cartridges containing local anesthetics are used for one patient only and the dental cartridge syringe is cleaned and heat sterilized between patients. Other safe practices described here primarily apply to use of parenteral medications combined with fluid infusion systems, such as for patients undergoing conscious sedation. Unsafe practices that have led to patient harm include 1) use of a single syringe — with or without the same needle — to administer medication to multiple patients, 2) reinsertion of a used syringe — with or without the same needle — into a medication vial or solution container (e.g., saline bag) to obtain additional medication for a single patient and then using that vial or solution container for subsequent patients, and 3) preparation of medications in close proximity to contaminated supplies or equipment.

Safe injection practices were covered in the Special Considerations section (Aseptic Technique for Parenteral Medications) of the 2003 CDC dental guidelines. However, because of reports of transmission of infectious diseases by inappropriate handling of injectable medications, CDC now considers safe injection practices to be a formal element of Standard Precautions.

Sterilization and Disinfection of Patient-Care Items and Devices

Instrument processing requires multiple steps using specialized equipment. Each dental practice should have policies and procedures in place for containing, transporting, and handling instruments and equipment that may be contaminated with blood or body fluids. Manufacturer’s instructions for reprocessing reusable dental instruments and equipment should be readily available—ideally in or near the reprocessing area. Most single-use devices are labeled by the manufacturer for only a single use and do not have reprocessing instructions. Use single-use devices for one patient only and dispose of appropriately.

Cleaning, disinfection and sterilization of dental equipment should be assigned to DHCP with training in the required reprocessing steps to ensure reprocessing results in a device that can be safely used for patient care. Training should also include the appropriate use of PPE necessary for safe handling of contaminated equipment.
Patient-care items (e.g., dental instruments, devices, and equipment) are categorized as critical, semicritical, or noncritical, depending on the potential risk for infection associated with their intended use.

• Critical items, such as surgical instruments and periodontal scalers, are those used to penetrate soft tissue or bone. They have the greatest risk of transmitting infection and should always be sterilized using heat.
• Semicritical items (e.g., mouth mirrors, amalgam condensers, reusable dental impression trays) are those that come in contact with mucous membranes or non-intact skin (e.g., exposed skin that is chapped, abraded, or has dermatitis). These items have a lower risk of transmission. Because the majority of semicritical items in dentistry are heat-tolerant, they should also be sterilized using heat. If a semicritical item is heat-sensitive, DHCP should replace it with a heat-tolerant or disposable alternative. If none are available, it should, at a minimum, be processed using high-level disinfection.

Note: Dental handpieces and associated attachments, including low-speed motors and reusable prophylaxis angles, should always be heat sterilized between patients and not high-level or surface disinfected. Although these devices are considered semicritical, studies have shown that their internal surfaces can become contaminated with patient materials during use. If these devices are not properly cleaned and heat sterilized, the next patient may be exposed to potentially infectious materials.

Digital radiography sensors are also considered semicritical and should be protected with a Food and Drug Administration (FDA)-cleared barrier to reduce contamination during use, followed by cleaning and heat-sterilization or high-level disinfection between patients. If the item cannot tolerate these procedures then, at a minimum, protect with an FDA-cleared barrier. In addition, clean and disinfect with an Environmental Protection Agency (EPA)-registered hospital disinfectant with intermediate-level (i.e., tuberculocidal claim) activity between patients. Because these items vary by manufacturer and their ability to be sterilized or high-level disinfected also vary, refer to manufacturer instructions for reprocessing.

• Noncritical patient-care items (e.g., radiograph head/cone, blood pressure cuff, facebow) are those that only contact intact skin. These items pose the least risk of transmission of infection. In the majority of cases, cleaning, or if visibly soiled, cleaning followed by disinfection with an EPA-registered hospital disinfectant is adequate. Protecting these surfaces with disposable barriers might be a preferred alternative.

Cleaning to remove debris and organic contamination from instruments should always occur before disinfection or sterilization. If blood, saliva, and other contamination are not removed, these materials can shield microorganisms and potentially compromise the disinfection or sterilization process. Automated cleaning equipment (e.g., ultrasonic cleaner, washer-disinfector) should be used to remove debris to improve cleaning effectiveness and decrease worker exposure to blood. After cleaning, dried instruments should be inspected, wrapped, packaged, or placed into container systems before heat sterilization. Packages should be labeled to show the sterilizer used, the cycle or load number, the date of sterilization, and, if applicable, the expiration date. This information can help in retrieving processed items in the event of an instrument processing/sterilization failure.

The ability of a sterilizer to reach conditions necessary to achieve sterilization should be monitored using a combination of biological, mechanical, and chemical indicators. Biological indicators, or spore tests, are the most accepted method for monitoring the sterilization process because they assess the sterilization process directly by killing known highly resistant microorganisms (e.g., Geobacillus or Bacillus species). A spore test should be used at least weekly to monitor sterilizers. However, because spore tests are only performed periodically (e.g., once a week, once a day) and the results are usually not obtained immediately, mechanical and chemical monitoring should also be performed.

Mechanical and chemical indicators do not guarantee sterilization; however, they help detect procedural errors and equipment malfunctions. Mechanical monitoring involves checking the sterilizer gauges, computer displays, or printouts; and documenting the sterilization pressure, temperature, and exposure time in your sterilization records. Since these parameters can be observed during the sterilization cycle, this might be the first indication of a problem.

Chemical monitoring uses sensitive chemicals that change color when exposed to high temperatures or combinations of time and temperature. Examples include chemical indicator tapes, strips or tabs, and special markings on packaging materials. Chemical monitoring results are obtained immediately following the sterilization cycle and therefore can provide more timely information about the sterilization cycle than a spore test. A chemical indicator should be used inside every package to verify that the sterilizing agent (e.g., steam) has penetrated the package and reached the instruments inside. If the internal chemical indicator is not visible from the outside of the package, an external indicator should also be used. External indicators can be inspected immediately when removing packages from the sterilizer. If the appropriate color change did not occur, do not use the instruments. Chemical indicators also help to differentiate between processed and unprocessed items, eliminating the possibility of using instruments that have not been sterilized.

Note: A single-parameter internal chemical indicator provides information regarding only one sterilization parameter (e.g., time or temperature). Multiparameter internal chemical indicators are designed to react to ≥ 2 parameters (e.g., time and temperature; or time, temperature, and the presence of steam) and can provide a more reliable indication that sterilization conditions have been met.

Sterilization monitoring (e.g., biological, mechanical, chemical monitoring) and equipment maintenance records are an important component of a dental infection prevention program. Maintaining accurate records ensures cycle parameters have been met and establishes accountability. In addition, if there is a problem with a sterilizer (e.g., unchanged chemical indicator, positive spore test), documentation helps to determine if an instrument recall is necessary.

Ideally, sterile instruments and supplies should be stored in covered or closed cabinets. Wrapped packages of sterilized instruments should be inspected before opening and use to ensure the packaging material has not been compromised (e.g., wet, torn, punctured) during storage. The contents of any compromised packs should be reprocessed (i.e., cleaned, packaged, and heat-sterilized again) before use on a patient.

Environmental Infection Prevention and Control

Policies and procedures for routine cleaning and disinfection of environmental surfaces should be included as part of the infection prevention plan. Cleaning removes large numbers of microorganisms from surfaces and should always precede disinfection. Disinfection is generally a less lethal process of microbial inactivation (compared with sterilization) that eliminates virtually all recognized pathogenic microorganisms but not necessarily all microbial forms (e.g., bacterial spores).

Emphasis for cleaning and disinfection should be placed on surfaces that are most likely to become contaminated with pathogens, including clinical contact surfaces (e.g., frequently touched surfaces such as light handles, bracket trays, switches on dental units, computer equipment) in the patient-care area. When these surfaces are touched, microorganisms can be transferred to other surfaces, instruments or to the nose, mouth, or eyes of DHCP or patients. Although hand hygiene is the key to minimizing the spread of microorganisms, clinical contact surfaces should be barrier protected or cleaned and disinfected between patients. EPA-registered hospital disinfectants or detergents/disinfectants with label claims for use in health care settings should be used for disinfection. Disinfectant products should not be used as cleaners unless the label indicates the product is suitable for such use. DHCP should follow manufacturer recommendations for use of products selected for cleaning and disinfection (e.g., amount, dilution, contact time, safe use, and disposal). Facility policies and procedures should also address prompt and appropriate cleaning and decontamination of spills of blood or other potentially infectious materials. Housekeeping surfaces, (e.g., floors, walls, sinks) carry less risk of disease transmission than clinical contact surfaces and can be cleaned with soap and water or cleaned and disinfected if visibly contaminated with blood.

Transmission-Based Precautions are the second tier of basic infection control and are to be used in addition to Standard Precautions for patients who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission.

Contact Precautions

Use Contact Precautions for patients with known or suspected infections that represent an increased risk for contact transmission.

• Ensure appropriate patient placement in a single patient space or room if available in acute care hospitals. In long-term and other residential settings, make room placement decisions balancing risks to other patients. In ambulatory settings, place patients requiring contact precautions in an exam room or cubicle as soon as possible.

• Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient’s environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens.
• Limit transport and movement of patients outside of the room to medically-necessary purposes. When transport or movement is necessary, cover or contain the infected or colonized areas of the patient’s body. Remove and dispose of contaminated PPE and perform hand hygiene prior to transporting patients on Contact Precautions. Don clean PPE to handle the patient at the transport location.
• Use disposable or dedicated patient-care equipment (e.g., blood pressure cuffs). If common use of equipment for multiple patients is unavoidable, clean and disinfect such equipment before use on another patient.
• Prioritize cleaning and disinfection of the rooms of patients on contact precautions ensuring rooms are frequently cleaned and disinfected (e.g., at least daily or prior to use by another patient if outpatient setting) focusing on frequently-touched surfaces and equipment in the immediate vicinity of the patient.

Droplet Precautions

Use Droplet Precautions for patients known or suspected to be infected with pathogens transmitted by respiratory droplets that are generated by a patient who is coughing, sneezing, or talking.

• Source control: put a mask on the patient.
• Ensure appropriate patient placement in a single room if possible. In acute care hospitals, if single rooms are not available, utilize the recommendations for alternative patient placement considerations in the Guideline for Isolation Precautions. In long-term care and other residential settings, make decisions regarding patient placement on a case-by-case basis considering infection risks to other patients in the room and available alternatives. In ambulatory settings, place patients who require Droplet Precautions in an exam room or cubicle as soon as possible and instruct patients to follow Respiratory Hygiene/Cough Etiquette recommendations.
• Use personal protective equipment (PPE) appropriately. Don mask upon entry into the patient room or patient space.
• Limit transport and movement of patients outside of the room to medically-necessary purposes. If transport or movement outside of the room is necessary, instruct patient to wear a mask and follow Respiratory Hygiene/Cough Etiquette.

Airborne Precautions

Use Airborne Precautions for patients known or suspected to be infected with pathogens transmitted by the airborne route (e.g., tuberculosis, measles, chickenpox, disseminated herpes zoster).

• Source control: put a mask on the patient.
• Ensure appropriate patient placement in an airborne infection isolation room (AIIR) constructed according to the Guideline for Isolation Precautions. In settings where Airborne Precautions cannot be implemented due to limited engineering resources, masking the patient and placing the patient in a private room with the door closed will reduce the likelihood of airborne transmission until the patient is either transferred to a facility with an AIIR or returned home.
• Restrict susceptible healthcare personnel from entering the room of patients known or suspected to have measles, chickenpox, disseminated zoster, or smallpox if other immune healthcare personnel are available.
• Use personal protective equipment (PPE) appropriately, including a fit-tested NIOSH-approved N95 or higher level respirator for healthcare personnel.
• Limit transport and movement of patients outside of the room to medically-necessary purposes. If transport or movement outside an AIIR is necessary, instruct patients to wear a surgical mask, if possible, and observe Respiratory Hygiene/Cough Etiquette. Healthcare personnel transporting patients who are on Airborne Precautions do not need to wear a mask or respirator during transport if the patient is wearing a mask and infectious skin lesions are covered.
• Immunize susceptible persons as soon as possible following unprotected contact with vaccine-preventable infections (e.g., measles, varicella or smallpox).

Overview

Mandated by the Needlestick and Prevention Act, changes to the Occupational Safety & Health Administration’s (OSHA) bloodborne pathogen standard were published January 18, 2001, to take effect April 18, 2001. The revisions clarify the need for employers to select safer needle devices as they become available and to involve employees in identifying and choosing the devices. Prior to the act, only a few dental devices incorporated safety features (e.g., anesthetic syringe needles with sliding sheathes), and most dental healthcare personnel are uncertain about how to select and evaluate the safer devices now available on the market. In collaboration with the American Dental Association and the Training for Development of Innovative Control Technologies Project (a collaboration based at San Francisco General Hospital of frontline healthcare workers, product designers, and industrial hygienists to prevent exposure to blood through better design and evaluation of medical devices and equipment), the Centers for Disease Control and Prevention (CDC) has developed two sample forms (with instructions for use) to assist dental personnel in screening and evaluating devices for clinical acceptability. These forms have been pilot tested with focus groups of different types of dental staff members, including end users and purchasers. To increase the safety of both dental personnel and their patients, we are making these forms available for general use. Although these forms are specific for anesthetic syringes, they can be modified for use with other types of dental devices.

Developing Programs to Prevent Sharps Injuries

Every dental office should develop and implement a program to prevent sharps injuries to dental personnel and patients. A staff person knowledgeable about or willing to be trained in injury prevention (i.e., a safety coordinator) should be assigned to

• Promote safety awareness,
• Facilitate prompt reporting and post-exposure management of injuries,
• Identify unsafe work practices and devices,
• Coordinate the selection and evaluation of safer dental devices,
• Organize staff education and training,
• Complete the necessary reporting forms and documentation, and
• Monitor safety performance.

Ideally, these activities should be described in a written plan and mechanisms for staff feedback should be available. This feedback will assist the safety coordinator in reviewing the effectiveness of the plan and making the modifications needed.

Identifying Safer Dental Devices

Information on specific brands and products of safer dental devices can be obtained from vendors, purchasing agents, scientific literature, lists published on the Internet or in trade journals, and other healthcare facilities. A variety of devices should be considered and the choice should not be limited to the product of any one vendor.

Developing Evaluation Criteria

Evaluation criteria are used to measure the design and performance of safer devices during the screening and clinical evaluation phases, and differ for each phase. Criteria for the screening phase will help determine whether the device is safe to use on patients, has safety features to protect dental personnel from sharps injury, is readily available for purchase, is easy and practical to use, and is compatible with other equipment. Criteria for the evaluation phase help determine impact on patient care, acceptability by users, and cost. The evaluation criteria for both phases should be unbiased and the evaluation forms should be easy to use and score.

Screening Devices

Screening assists dental personnel in making decisions about clinical and safety considerations before evaluating a dental device in the clinical setting. Screening usually consists of physically examining the safer device, then comparing it to the traditional device and established evaluation criteria. No device should be used on a patient before it has been screened to ensure that it meets clinical and patient safety needs.

Evaluating Devices

Device evaluation involves a trial (or pilot test) to determine the acceptability of a safer dental device in an actual clinical setting. This process includes identifying a safer dental device to test, selecting the area of the facility to be used as the test site and the staff who will be the end users of the device, selecting evaluation criteria, and determining how long the test will last. The testing should include plans for quickly bringing back the traditional device should the safer dental device being tested be determined unsafe. The device evaluation should provide the safety coordinator with enough information to make an informed decision on whether to continue using the safer device.

Q1. How do manufacturers ensure personal protective equipment (PPE) is safe and effective?

A1. To help ensure medical devices, including PPE are safe and effective, the FDA has established Quality Systems Regulations and Good Manufacturing Practices. Manufacturers are expected to use these regulations and practices to maintain consistent product quality and to guide performance testing to make sure that their products conform to recognized consensus standards. For PPE, these standards may include for fluid resistance, leak protection, filtering capacity, or resistance to tears and snags. When these regulations and practices are followed, they provide reasonable assurance that the device is safe and effective.

FDA has also issued device-specific guidance for some products so that manufacturers understand the Agency’s expectations.

Q2. Will personal protective equipment protect against a specific disease?

A2.PPE are designed to create a non-disease specific barrier to penetration of substances, solid, liquid, or airborne particles. In general, neither FDA nor the manufacturer can provide assurances that PPE will protect you against a specific disease. The data that FDA uses for the evaluation and clearance of PPE rarely includes performance evaluation or testing against specific viruses, such as Ebola or flu. If performance data has met FDA requirements and demonstrate protection against a specific disease, the product labeling will state the claim for protection against a specific virus or bacteria.

When there is an outbreak that affects the broad population, The Centers for Disease Control and Prevention (CDC), is responsible for making specific recommendations for infection control measures in different circumstances and settings. For example, the CDC has provided the following recommendations:

• What You Should Know about the Flu
• What You Should Know about Ebola

Q3. Should caregivers use PPE to help protect against infection when caring for a sick person at home?

A3.In some circumstances, a health care provider may recommend that caregivers use PPE when caring for a sick person at home. It is important to know that the use of PPE alone will not fully protect you from acquiring an infection or passing an infection to another person. Other infection control practices, such as hand-washing, using alcohol-based hand sanitizers, isolation of patients and using properly covering cough and sneezes, are also important steps to minimize your risk of infection.

Additionally, please be aware of proper removal and disposal procedures. Even if PPE successfully protects you while it is worn, improper removal and disposal of contaminated PPEs can expose the wearer and other people to infection.

Q4. Where can I buy PPE?

A4. Most types of PPE are available without a prescription. Pharmacies, medical supply stores, and Internet medical supply retailers sell PPE.

Q5. Can I reuse PPE?

A5. In general, most PPE is designed to be used only one time and by one person prior to disposal. There are a few exceptions, for example some types of elastomeric respirator masks and protective eyewear such as goggles may be reused if the user follows decontamination methods in the product labeling.

If PPE is exposed to infectious materials during use (e.g., body fluids from an infected person) the PPE is considered contaminated and the wearer should remove it promptly, using proper removal and disposal procedures. Please be aware that even if a PPE successfully protects you while it is being worn, improper removal and disposal of contaminated PPEs can expose the wearer and other people to infectious agents.

Q6. Can I wash disposable PPE?

A6. No. Disposable PPE is designed to be used only one time and by one person; it cannot be washed. Washing PPE changes its protective or barrier capabilities, and it may no longer be effective.

Q7. Can I share PPE with other users?

A7. In general, most PPE cleared by the FDA is intended to be used only one time and by one person. Sharing PPE is not advised. The protective capabilities of single use PPE cannot be assured when it is reused by the same person or used by more than one person. Sharing PPE that is intended for single use may expose another person to infectious materials. PPE should be removed promptly after use and disposed of properly.

Q8: Does every piece of PPE provide the same level of protection?

A8: PPE is designed to be used with other infection control practices such as hand-washing, using alcohol-based hand sanitizers and covering coughs and sneezes to minimize the spread of infection from one person to another.

Wearers of PPE can determine what protective level a PPE is rated for by the standards to which it has been tested.

Q9: If I experience a problem with my PPE, what should I do?

A9: If you suspect or experience a problem with your PPE, we encourage you to file a voluntary report through MedWatch, the FDA Safety Information and Adverse Event Reporting program and notify the manufacturer.

Health care personnel employed by facilities that are subject to FDA's user facility reporting requirements should follow the reporting procedures established by their facilities.

Patients need to be aware of a very serious threat to their health – the reuse of needles or syringes, and the misuse of medication vials. Healthcare providers (doctors, nurses, and anyone providing injections) should never reuse a needle or syringe either from one patient to another or to withdraw medicine from a vial. Both needle and syringe must be discarded once they have been used. It is not safe to change the needle and reuse the syringe – this practice can transmit disease.

A single-use vial is a bottle of liquid medication that is given to a patient through a needle and syringe. Single-use vials contains only one dose of medication and should only be used once for one patient, using a clean needle and clean syringe.

A multi-dose vial is a bottle of liquid medication that contains more than one dose of medication and is often used by diabetic patients or for vaccinations. A new, clean needle and clean syringe should always be used to access the medication in a multi-dose vial. Reuse of needles or syringes to access medication can result in contamination of the medicine with germs that can be spread to others when the medicine is used again.

Whenever possible, CDC recommends that single-use vials be used and that multi-dose vials of medication be assigned to a single patient to reduce the risk of disease transmission.

Healthcare providers should always adhere to Safe Injection Practices under Standard Precautions to prevent disease transmission from needles, syringes, or multi-dose vials.

Reusing a needle or syringe puts patients in danger of contracting Hepatitis C, Hepatitis B, and possibly HIV. When it is discovered that reuse of a needle or syringe has occurred, all patients who may have been affected should be notified and informed to get tested.

What is a Surgical Site Infection?

A surgical site infection (SSI) is an infection that occurs after surgery in the part of the body where the surgery took place. Surgical site infections can sometimes be superficial infections involving the skin only. Other surgical site infections are more serious and can involve tissues under the skin, organs, or implanted material.

Symptoms include:

• Redness and pain around the area where you had surgery
• Drainage of cloudy fluid from your surgical wound
• Fever

Can SSIs be treated?

Yes. Most SSIs can be treated with antibiotics. The type of antibiotic given depends on the bacteria (germs) causing the infection. Sometimes patients with SSIs also need another surgery to treat the infection.

What are some of the things that hospitals are doing to prevent SSIs?

To prevent SSIs, doctors, nurses, and other healthcare providers should follow CDC infection prevention guidelines including:

• Clean their hands and arms up to their elbows with an antiseptic agent just before the surgery.
• Clean their hands with soap and water or an alcohol-based hand rub before and after caring for each patient.
• If indicated, remove some of your hair immediately before your surgery using electric clippers if the hair is in the same area where the procedure will occur.
• Wear special hair covers, masks, gowns, and gloves during surgery to keep the surgery area clean.
• When indicated, give you antibiotics before your surgery starts. In most cases, you should get antibiotics within 60 minutes before the surgery starts and the antibiotics should be stopped within 24 hours after surgery.
• Clean the skin at the site of your surgery with a special soap that kills germs.

What can I do to help prevent SSIs?

Before surgery:

• Tell your doctor about other medical problems you may have. Health problems such as allergies, diabetes, and obesity could affect your surgery and your treatment.
• Quit smoking. Patients who smoke get more infections. Talk to your doctor about how you can quit before your surgery.
• Do not shave near where you will have surgery. Shaving with a razor can irritate your skin and make it easier to develop an infection.

At the time of surgery:

• Speak up if someone tries to shave you with a razor before surgery. Ask why you need to be shaved and talk with your surgeon if you have any concerns.

After surgery:

• If you do not see your providers clean their hands, please ask them to do so.
• Family and friends who visit you should not touch the surgical wound or dressings.
• Family and friends should clean their hands with soap and water or an alcohol-based hand rub before and after visiting you. If you do not see them clean their hands, ask them to clean their hands.
• Make sure you understand how to care for your wound before you leave the hospital.
• Always clean your hands before and after caring for your wound.
• Make sure you know who to contact if you have questions or problems after you get home.
• If you have any symptoms of an infection, such as redness and pain at the surgery site, drainage, or fever, call your doctor immediately.

As a patient in a healthcare setting, you are at risk of getting an infection while you are being treated for something else. Patients and their loved ones can play a role in asking and reminding healthcare providers to clean their hands. Your hands can spread germs too, so protect yourself by cleaning your hands often.

Clean Hands Count for Patients

Hand Hygiene: 5 Facts

FACT

On average, healthcare providers clean their hands less than half of the times they should.

• This can put you at risk for a serious infection. It’s okay to ask them questions like, “Before you start the exam, would you mind cleaning your hands again?” or “Would it be alright if you cleaned your hands before changing my bandages?”

FACT

Alcohol-based hand sanitizer kills most of the bad germs that make you sick.

• Your hands have good germs on them that your body needs to stay healthy. Your hands can also have bad germs on them that make you sick. Alcohol-based hand sanitizers kill the good and bad germs, but the good germs quickly come back on your hands.

FACT

Alcohol-based hand sanitizer does not kill C. difficile.

• Clostridium difficile or “C.diff” is a common healthcare-associated infection that causes severe diarrhea. If you have a C. difficile infection, make sure your healthcare providers wear gloves to examine you. You and your loved ones should wash your hands with soap and water to prevent the spread of C. difficile.

FACT

Alcohol-based hand sanitizer does not create antibiotic-resistant superbugs.

• Alcohol-based hand sanitizers kill germs quickly and in a different way than antibiotics. Using alcohol-based hand sanitizers to clean your hands does not cause antibiotic resistance.

FACT

Your hands can spread germs too.

• Make sure you and your visitors are cleaning your hands as well.

When should you clean your hands

• Before preparing or eating food
• Before touching your eyes, nose, or mouth
• Before and after changing wound dressings or bandages
• After using the restroom
• After blowing your nose, coughing, or sneezing
• After touching hospital surfaces such as bed rails, bedside tables, doorknobs, remote controls, or the phone

How should you clean your hands?

With an alcohol-based hand sanitizer:

• Put product on hands and rub hands together
• Cover all surfaces until hands feel dry
• This should take around 20 seconds

With soap and water:

1. Wet your hands with warm water. Use liquid soap if possible. Apply a nickel- or quarter-sized amount of soap to your hands.
2. Rub your hands together until the soap forms a lather and then rub all over the top of your hands, in between your fingers and the area around and under the fingernails.
3. Continue rubbing your hands for at least 15 seconds. Need a timer? Imagine singing the “Happy Birthday” song twice.
4. Rinse your hands well under running water.
5. Dry your hands using a paper towel if possible. Then use your paper towel to turn off the faucet and to open the door if needed.

When should your healthcare providers clean their hands?

• Every time they enter your room and when they remove gloves.
• Wearing gloves alone is not enough to prevent the spread of infection.

How should your healthcare providers clean their hands?

Using an alcohol-based hand sanitizer:

• Put product on hands and rub hands together
• Cover all surfaces until hands feel dry
• This should take around 20 seconds

Using soap and water:

1. Wet their hands with water.
2. Apply an amount of soap recommended by the manufacturer to their hands.
3. Rub their hands together for at least 15 seconds, covering all surfaces of the hands and fingers.
4. Rinse their hands with water and dry with a disposable towel.
5. Use the towel to turn off the faucet.

Speak up for clean hands

Protect yourself by asking questions:

1. Clean your own hands and ask those around you to do the same.
2. Don’t be afraid to use your voice: it’s ok to ask your healthcare provider questions, such as:
   • “I didn’t see you clean your hands when you came in, would you mind cleaning them again before you examine me?”
   • “I’m worried about germs spreading in the hospital. Will you please clean your hands once more before you start my treatment?”
3. Ask your loved ones to clean their hands too:
   • “I saw you clean your hands when you arrived some time ago, but would you mind cleaning them again?”

You go to the hospital to get well, right? Of course, but did you know that you can get infections in the hospital while you are being treated for something else?

Time in the hospital can put you at risk for a healthcare-associated infection (HAI), such as a blood, surgical site, or urinary tract infection.

Every day, patients get infections in healthcare facilities while they are being treated for something else. These infections can have devastating emotional, financial, and medical effects. Worst of all, they can be deadly.

Healthcare procedures can leave you vulnerable to germs that cause HAIs. These germs can be spread in healthcare settings from patient to patient on unclean hands of healthcare personnel or through the improper use or reuse of equipment.

These infections are not limited to hospitals. For example, in the past 10 years alone, there have been more than 30 outbreaks of hepatitis B and hepatitis C in non-hospital healthcare settings such as

• outpatient clinics,
• dialysis centers, and
• long-term care facilities.

Protect yourself and your family from harmful germs that can cause infections

• Keep your hands clean. Regular hand cleaning is one of the best ways to remove germs, avoid getting sick, and prevent spreading germs.
• Take antibiotics only when your provider thinks you need them. Ask if your antibiotic is necessary. If you take antibiotics when you don’t need them, you’re only exposing yourself to unnecessary risk of side effects and potentially serious infections in the future. If you do need antibiotics, take them exactly as they’re prescribed.
• Watch for signs of infection and its complications, like sepsis. Get care right away—don’t delay.
  • Tell your doctor if you think you have an infection, or if your infection is not getting better or is getting worse.
• Watch out for life-threatening diarrhea caused by C. difficile. If you have been taking an antibiotic, tell your doctor if you have 3 or more diarrhea episodes in 24 hours.
• Get vaccinated against flu and other infections to avoid complications.

Be a safe patient in the hospital

• Tell your doctors if you have been hospitalized in another facility, have recently received health care outside of the United States, or have recently had an infection.
• Ask your healthcare provider what they and the facility will do to protect you and your family from an antibiotic-resistant infection.
  • If you have a catheter, ask daily when it can be removed.
  • If you are having surgery, ask your doctor how they prevent infections. Also, ask how you can prepare for surgery to reduce your infection risk.
• Keep your hands clean. Make sure everyone cleans their hands before touching you. Remind healthcare personnel and your visitors to clean their hands.
• Let your doctors check you for resistant germs if needed. Hospitals need to screen patients if they’re exposed, and this helps protect you and those around you.
• Understand that if you have a resistant bacteria, healthcare providers may use gowns and gloves when caring for you.
• Allow people to clean your room while you’re in the hospital, even when it feels inconvenient for you.
  • Environmental services workers are the people who clean patient rooms in the hospital, and they are important members of the healthcare team.
  • Allowing them to clean and disinfect your room helps keep you safe by reducing your risk of developing an infection—don’t say, “come back later.”