By Karen Gregory, RN, Director of Compliance and Education for Total Medical Compliance.
Today I sit looking out my office window thinking about the snow we had this past winter. It seems winter was long and very unusual this year. Even the coast of our fair state (NC) received some of the white flakes. I must admit I long for the day I can throw open the windows and just air out my little space, otherwise known at our house as “spring cleaning”.
But, what does spring cleaning have to do with compliance? At each of the Infection Control/SPICE seminars I present I have attendees go through an activity. I will challenge each of you now, as I do for those attending the seminar: the next time you enter your office, walk in the front door as a patient or potential new employee or even an OSHA inspector would enter. Now, ask your selves the following questions:
□ Is the waiting area clean and organized?
□ Are there silk plants that have dust bunnies attached?
□ Is the carpet in good repair?
□ How old are the magazines?
□ Are the operatories filled with items not in use?
□ Are the counters free of clutter so surface disinfection can easily occur?
□ Are sharps containers overfilled?
□ Is the sterilization area clean and well organized?
I think you can see where I am going with this one, but actually there are some compliance basics that go along with appearance and overall well being of your physical location.
In the past year we have seen significant increases in office inspections and enforcement of regulations by OSHA. In fact, in 2010 some 83 dental practices were inspected by the North Carolina Departement of Labor, aka, North Carolina OSHA. This is in comparison to three practices inspected in 2009. Of these 83 practices, 55% were issued citations, some of which received fines. Interestingly fines ranged anywhere from $100 to well over $11,000. From all indications inspections will continue to occur and based on our experience, inspectors are becoming more and more focused on items specific to the healthcare environment.
The following are a few examples of citations which received fines:
No written Exposure Control Plan
Lack of documentation that hepatitis B vaccination was offered
Inadequate process for cleaning/laundering of reusable PPE
Lack of process for new employees to receive training
Appropriate use of engineering and work practice controls
No written Hazard Communication Plan
Evidence surfaces had not been appropriated cleaned and disinfected
Additionally there have been several instances of employees, volunteers, and patients contracting hepatitis B through the delivery of health care. In most of these scenarios, the sterilization process, surface disinfection and the appropriate use of single use devices have been at the center of investigations.
So, back to the spring cleaning scenario! Go through the physical process of looking at the practice as well as evaluating the processes around the delivery of care. When defining compliance, we will look at it from two different perspectives: employee safety and patient safety. Hopefully you won’t have too many cobwebs to clear away!
Employee safety standards are often referred to as OSHA standards. The following are some examples of safeguards which must be in place in your practice to ensure employees are provided a safe work environment.
□ Training is essential in order for employees to understand safety measures in place in their work environment. Annual training is not only a best practice; bloodborne pathogen training is required by law on an annual basis. In fact, we have worked with a client who has been cited for not having annual training within a 365 day window from the previous year.
□ Written plans on exposure control and hazardous communication must be available at all times to employees. Each employee should know where to locate the written plan as well as where to locate Material Safety Data Sheets for all chemicals they work with in their particular practice environment.
□ Appropriate documentation of hepatitis B vaccination or vaccination declination.
□ Personal protective equipment (PPE) is provided by the employer at no cost to the employee. Employers must also provide laundering of reusable PPE. Employees should not take their contaminated PPE home for cleaning.
□ Availability and use of engineering controls was mandated by the Needlestick Safety and Prevention Act of 2001. Examples of engineering controls include sharps containers, safety scalpels, safety needles for aspirating syringes, and safety needles if IV access is performed in the practice.
□ Written cleaning schedule outlining surfaces to be disinfected, frequency, and product to be used.
When walking through the practice check for the following items as well.
√ GFIC outlets in restrooms and outlets where there is the potential for splash or splatter of water.
√ Clearance of at least three feet around breaker box and all breakers with appropriate labeling.
√ Fire extinguisher visual checks on a monthly basis and annual maintenance by outside source to ensure proper functioning if needed.
√ Sharps containers in each operatory.
√ When transporting contaminated, reusable, sharps ensure employees are placing the sharps in a container that is leak proof on sides and bottom and closable. For those utilizing cassettes, the leak proof standard can be addressed by placing the cassette back into the paper or packaging utilized for sterilization of instruments.
Patient safety is provided in part by following established standards for infection control.
- The CDC issued guidelines specific to the dental environment in a 2003 publication, Guidelines for Infection Control in Dental Healthcare Settings. By following the established guidelines overall risk from acquiring infection through the delivery of dental care should be reduced.
- For medical there are a number of publications that provide guidance. CDC Guidelines for Disinfection and Sterilization 2008, Safe Injection Practices, Guidelines for Environmental Infection Control 2003, and others. (See CDC site for a full list.)
Additionally, in the state of North Carolina each practice is required by State Law .0206 to identify one person to attend a state approved training and oversee infection control compliance for the practice. Sometimes referred to as SPICE training, this program reviews basic concepts of infection control in the dental environment and provides practices with tools to successfully implement an effective infection control program. Most states have some laws related to mandatory Infection Control training similar to North Carolina.
Key items to review in your practice include:
√ Clearly identified process for cleaning of instruments focusing on reduction in actual handling of soiled instrumentation, i.e. use of ultrasonic cleaner instead of scrubbing by hand. The use of heavy duty utility gloves during this process should be an expectation for all employees.
√ Proper monitoring of the sterilization process which includes the use of internal and external indicators in every package and performance of spore testing every fifth day of use of the autoclave.
√ Attention to the sterilization cycle focusing on appropriate loading of the unit, and removal of instrument packages at the end of the dry cycle. Packages should be dry when removed from the sterilizer. If not, there may be an issue with appropriate use of the equipment, overloading of the chamber, or an issue with the drying element.
√ Reuse of single use devices or improper use of multi-dose vials. Single use devices must be discarded, not disinfected or sterilized after use. Following the manufacturer’s directions is imperative from a risk management perspective. While multi-dose vials of medications are not customarily utilized in a dental practice think about other items such as acid etch which is frequently utilized on multiple patients. Is a new tip applied in between each patient? Is the outside of the container properly disinfected?
√ Is hand washing a top priority for all personnel? Research has proven this is a challenge in all health care environments, yet it is the one thing which will consistently reduce the likelihood of spread of infection.
√ Can you identify one person who has attended Infection Control/SPICE training?
So, how did you do on your walk-through? I visit medical and dental offices frequently and usually find a correlation between practices that are clean, neat, and organized and a strong culture of employee and patient safety. It is apparent their compliance programs are effective. This year take the opportunity to spring clean. Throw open the windows letting the fresh air in and throw out the items you don’t need! Well, perhaps not literally, but you know what I mean!
See related articles on the TMC website on sterilization, PPE, OSHA inspections and more.
The schedule of Infection Control Seminars and Webinars are in the TMC webstore.
