________________________________________________________ Infection Control for Dental Professionals
Categorizing Patient-Care Items Patient-care items (e.g., dental instruments, devices, and equipment) are categorized using the Spaulding classification system as critical, semicritical, or noncritical, depending on the potential risk for infection associated with their intended use. Critical items are those items that enter sterile spaces, such as soft tissue or bone, or items that come into contact with the bloodstream. These items pose the greatest risk of transmitting infection and require sterilization. Examples of critical dental instruments include surgical instruments, periodontal scalers, scalpel blades, and surgical dental burs [9; 10]. Critical instru- ments, items, and devices should be discarded or pre-cleaned, packaged or wrapped, and sterilized after each use. Methods of sterilization include steam under pressure (autoclaving), chemical vapor, and dry heat. If a critical item is heat-sensitive, it should, at minimum, be processed with high-level disinfec- tion and packaged or wrapped after disinfection. These instru- ments, items, and devices shall remain sealed and stored in a manner so as to prevent contamination, and shall be labeled with the date of sterilization and the specific sterilizer used if more than one sterilizer is utilized in the facility [9; 10]. Semicritical items touch intact mucous membranes or non- intact skin and have a lower risk of transmission. Examples of semicritical dental instruments include mouth mirrors, amalgam condensers, reusable dental impression trays, and dental handpieces. Because the majority of semicritical items in dentistry are heat-tolerant, they should be sterilized using heat. If a semicritical item is heat-sensitive, it should, at a minimum, be processed with high-level disinfection, which kills all microbial life except spores [9; 10; 21]. Semi-critical instruments, items, and devices should be pre-cleaned, pack- aged or wrapped, and sterilized after each use. Methods of sterilization include autoclaving, chemical vapor, and dry heat. If a semi-critical item is heat sensitive, it should, at minimum, be processed with high-level disinfection and packaged or wrapped upon completion of the disinfection process. These packages or containers shall remain sealed, shall be stored in a manner so as to prevent contamination, and shall be labeled with the date of sterilization and the specific sterilizer used if more than one sterilizer is utilized in the facility [9; 10]. Noncritical items pose the least risk of transmission of infec- tion and include devices, equipment, and surfaces that come in contact with soil, debris, saliva, blood, OPIM, and intact skin, but not mucous membranes [9; 10]. Noncritical items include radiograph heads/cones, blood pressure cuffs, face- bows, and pulse oximeters. In the majority of cases, cleaning and disinfection with an EPA-registered hospital low-level disinfectant labeled effective against HBV and HIV is adequate. When the item is visibly contaminated with blood or OPIM, an EPA-registered hospital intermediate-level disinfectant with a tuberculocidal claim (i.e., intermediate-level disinfectant) should be used [9; 10].
Surface disinfection is an important part of environmental cleaning. Most bacteria and mycobacteria (e.g., TB) survive for several months on dry surfaces [20]. Respiratory viruses, such as coxsackie or influenza, can persist on surfaces for a few days. Hepatitis viruses and HIV can persist for more than one week, and herpes viruses have been shown to persist from only a few hours up to seven days [20]. All surfaces in patient care areas should be cleaned then disinfected according to the manufacturer’s instructions and allowed to dry completely. Sterilization is a process that destroys or eliminates all forms of microbial life and is carried out in healthcare facilities by physi- cal or chemical methods. Sterile and nonsterile are absolute concepts. If a sterile item is touched by anything nonsterile, the formerly sterile item is contaminated. The sterilization area should be separate from any patient care or staff break areas. The sterilization section of the processing area should include the sterilizers and related supplies, with adequate space for loading, unloading, and cool down [10]. The area can also include incubators for analyzing spore tests and enclosed storage for sterile items and single-use items. Manu- facturer and local building code specifications will determine placement and room ventilation requirements. According to the CDC guideline, heat-tolerant dental instru- ments usually are sterilized by steam under pressure (auto- claving), dry heat, or unsaturated chemical vapor [10]. All sterilization should be performed by using medical sterilization equipment cleared by the FDA. The sterilization times, tem- peratures, and other operating parameters recommended by the manufacturer of the equipment used, as well as instructions for correct use of containers, wraps, and chemical or biological indicators, should always be followed [10]. Sterilization most often fails due to overloading. Devices being sterilized should first be cleaned, as debris interferes with the sterilization process. If an ultrasonic unit is utilized, it should be covered while actively in use. Instruments should be fully dry prior to packaging and storage. Storage practices for wrapped sterilized instruments can be either date- or event-related. Packages containing sterile sup- plies should be inspected before use to verify barrier integrity and dryness. Although some facilities continue to date every sterilized package and use shelf-life practices, other facilities have switched to event-related practices [10]. This approach recognizes that the product should remain sterile indefinitely, unless an event causes it to become contaminated (e.g., torn or wet packaging). Even for event-related packaging, the date of sterilization should be placed on the package, and if multiple sterilizers are used in the facility, the sterilizer used should be indicated on the outside of the packaging material to facilitate the retrieval of processed items in the event of a sterilization failure [10]. If packaging is compromised, the instruments should be re-cleaned, sterilized again, and packaged in new wrap.
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