Title Page
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Client / Site
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Document No.
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Location
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Conducted on
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Prepared by
1. All Current Resources are Available
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Staff have easy access to all listed documents
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NHMRC Infection Control Guideline 2010
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AS/NZS 4187:2014
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Therapeutic Guidelines Antimicrobial and Oral & Dental
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ADA Infection Control Guidelines 3rd Ed
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Organisational Polices and Procedures
2.Education
2.1 Health Care Workers Mandatory Requirements
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Orientation
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Infection Control - Annual
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Hand Hygiene - annual online Hand Hygiene Australia e learning.
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Aseptic Technique Education and Competency Assessments every 2-3 years.
2.2 Non Clinical Health Care Workers Requirements
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Orientation
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Generic Hand Hygiene - Annual online Hand Hygiene Australia e learning.
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Non Clinical Infection Control - Annual
3. Environment Design
3.1 Fittings and Fixtures
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Clinical surfaces i.e. bench tops, cupboards are smooth, impermeable and in good condition.
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Hand basins are fit for purpose and labeled as hand washing or utility.
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No evidence of damage or staining.
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Hands free either elbow or sensor operated taps.
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Clinical hand basins are cleaned at least daily.
3.2 Floor Surfaces
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Floors are easily cleaned.
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Floors surface is non slip.
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Floors are not stained or build up of dirt or grime especially he corners
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Vinyl flooring is welded in joins, coved with no gaps or missing welds or joins.
4. Hand Hygiene and Personal Protective Equipment
Hand Hygiene
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There are clearly labeled nominated hand washing sinks, one per Surgery
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Hand washing sinks are not used for cleaning equipment or tools.
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Neutral hand wash solution is available and dispensed from disposable, non refillable containers.
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Antimicrobial solution is available at specified clinical basins.
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Alcohol based hand rubs are available and easily accessible in all areas these are installed at a safe height.
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There is compatible moisturiser available for all staff.
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There is no evidence of soaps, alcohol rub or moisturiser that have NOT been provided by or endorsed by the organisation.
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Staff demonstrate sound hand hygiene practices.
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Staff have received hand hygiene education with annual updates. (online at HHA.org.au).
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There is signage at hand basins and other appropriate places illustrating correct hand hygiene practices.
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Alcohol based hand rub is used when hands are not visibly soiled otherwise washed with liquid soap & water.
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Alternative washing products are provided for staff with medically diagnosed allergies.
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Nails are short clean and neat.
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There are no evidence of nail polish, gel or artificial nails being worn.
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Staff are wearing single plain band ring only.
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Wrist jewelry is limited to a washable watch or fitness device. These MUST be regularly cleaned.
4.2 Gloves
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Gloves are available in a range of sizes.
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Latex free gloves are used.
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Alternative gloves are available for staff with diagnosed allergies.
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Storage of gloves protects them from environment contaminants they are stored in original containers in wall mounted holders.
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Gloves are worn for all procedures involving contact with mucous membrane, blood body fluids.
4.3 Gowns
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Short sleeved cloth gowns are ONLY to be worn by staff without a uniform. (long sleeved gowns are NOT to be worn).
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Semi permeable disposable gowns or plastic aprons are worn by all clinical staff for HIGH risk procedures. These are single use and disposed of between patients.
4.4 Protective Eyewear
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Protective eyewear is readily accessible for staff to use when there is a risk of exposure to blood or body fluids.
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Eyewear is well fitting and has adequate side protection. Note: Prescription glasses are not protective eyewear.
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Staff should have own dedicated eyewear if not they are to be washed and dried between individuals use.
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Protective eyewear worn by the patient is washed with neutral detergent wipes and dried between patient use.
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All eyewear is clean, in good condition.
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All protective eye wear is stored in a drawer or cupboard between use.
4.5 Masks
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Fluid resistant Category 3 masks are available and mask of choice.
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Masks are worn correctly, fitting firmly around face with no gaping sides.
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Respirators -P2 masks- are available for Transmission-based precautions.
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Masks with inbuilt visors are available as an option.
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Masks are dispensed from original packaging from wall mounted holders.
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Masks are dispensed close to point of use.
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Masked are disposed of in to general waste bins as soon as removed. They are NOT to be reused.
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Masks are not to be worn under chin, dangling from loop or tie at any time.
5. Single Use and Labelling of Dispensed Items
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There is a Procedure for single use items.
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There is no evidence of reusing any single use items.
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Single use vials of injectable agents are being used and not multiuse vials for multiple patients.
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Multiuse creams and solutions are dispensed into individual containers for each patient.
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The above containers are labeled with product and dilution if not used immediately.
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All items dispensed into syringes are correctly labeled if entire contents are not used immediately by the person who draw up the medication e.g. Endosure
6. Aseptic Technique
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All Clinical Staff have completed regular education for Aseptic Technique.
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All clinical staff have successfully undergone competency assessments compliance to Aseptic Technique every two years.
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Staff who use invasive devices have completed annual Education for Invasive Devices Aseptic Technique.
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Staff who use invasive devices have successfully undergone annual competency assessments for compliance to Invasive Devices Aseptic Technique.
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There is a schedule to undertake aseptic competency audits. (not individual competency assessments).
7. Antimicrobial Stewardship
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There is a Policy and Procedure for Antimicrobial Stewardship within the Organisation.
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Therapeutic Guidelines both Antimicrobial 2015 and, Oral & Dental 2012 are readily available either electronically or hardcopy for all prescribers.
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There is an audit schedule and process for reviewing antimicrobial prescribing or administering within the organisation.
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The audit results are reviewed and the results are tabled at staff meetings.
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Individual Prescribers are informed if their use of antimicrobials is not compliant with Therapeutic Guidelines.
8. Management and Storage of Sterile Stock and RMDs
8.1 Sterile items supplied by external Manufacturers
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Items that are supplied sterile from the manufacturer are to be stored in a dedicated cupboard or room.
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Stock is stored on washable shelving 250mm off the floor and 450mm from the ceiling.
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They are stored in undamaged original inner packets or fully decanted into lidded washable containers. Sterile items are not to be stored in open large cardboard boxes.
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Rotation of stock is to occur with new stock placed under or behind older stock.
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A documented cleaning and restocking process is required if plastic containers are used.
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The area is the be kept clean and uncluttered with a documented cleaning schedule.
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Items are clearly separated from Reprocessed Medical Devices (RMD) and non clinical items. (RMD are in house sterilised items).
8.2 Reusable Medical Devices
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RMDs are to be stored in a dedicated cupboard/room with a control environment, free from dust, moisture, traffic and contamination risk.
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Access to the area is restricted to trained staff restocking or collecting required RMD.
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There is to be a written restocking and cleaning process for the area.
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Sterile items are not held against the body or other non sterile items during transfer to clinical area.
9. Management of Instruments in Treatment Areas
9.1 Collection of RMD to be used in Surgery
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Sterile RMD are collected from the dedicated storage area.
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Only the items required for single session or day are collected.
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Hand Hygiene is to be applied before handling the sterile stock.
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Items are checked for integrity of packaging, batch/tracking label, indicator/tape color change and expiry date.
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Items are to be carried in a manner to prevent contamination of the packaging.
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Items are placed on a clean bench then placed in dedicated drawers or cupboards in an orderly manner.
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Sterile items are clearly separated from non sterile items in drawers or cupboards.
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Drawers are not overfilled as this causes damage, cracks and minute holes in the packaging.
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If any RMD's are not used on the day they are NOT returned to sterile store but kept in room to be part of following days requirements. They can be distributed to other surgeries if required.
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Expiry date of RMD once they are placed in surgeries in 28 days (unless 3 month expiry date occurs before the 28 days).
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Packs are checked for sterile integrity, intact packaging, date and indicator tape colour change before opening to use.
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Packs are not to be opened until the patient's identification has been confirmed. (Time out procedure).
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Packs are to be opened in a manner that facilitates aseptic removal of instrument, they not torn or ripped.
9.2 Batch Labels
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Tracking details are entered onto the patients Titanium/Dental record.
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Packs that are opened and not used have tracking details recorded as non conforming on the 'non conforming' list.
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If tracking details are missing, packaging damaged or item expired they are returned to Sterilisation for reprocessing.
9.3 Management used instruments
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Sharps are carefully handled and removed from the bracket table and placed into a sharps container once it is no longer required. The Clinician is to remove all sharps at end of treatment.
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All organic matter and consumables are removed from all instruments at point of use prior to sending for reprocessing.
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Dry or Wet gauze is used to remove product carefully holding the used or sharp end away from you and in a downward action towards the end.
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Care is taken packing up a cassette to ensure all instruments are secured fully within the cassette. No instruments are to be protruding.
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Loose instruments are place in a container an along with cassettes are transferred to the dirty holding area.
10. Management of Dental Chair Surrounds
10.1 Waterlines
a).Distilled Water and Weekly Bleaching
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Lines are flushed for 2 minutes at the beginning of each day.
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Lines are flushed for 30 seconds between each patient.
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Lines are purged with air at the end of each day and a dry bottle installed.
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Water bottles are filled with treated/distilled water at the commencement of each day and as required throughout the day.
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There is documented evidence that daily waterline management occurs.
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There is a written procedure for the weekly disinfection of waterlines and bottles.
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This process is documented.
b).ICX Tablets
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Bottles are filled with tap water and correct sized ICX tablet. Use 700 ml tablet for 700 ml bottle and 2000 ml tablet for 2000 ml bottle.
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Lines are flushed for 2 minutes at the beginning of each day.
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Lines are flushed for 30 seconds between each patient.
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Bottle remains in place until empty including overnight. When bottle is empty rinse and refill as above. ICX can remain active for 2 weeks.
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After final case for the week bottles are removed, emptied, washed and inverted to dry.
10.2 Anti retraction mechanism
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Weekly anti-retraction testing occurs according to manufacturers' instructions regardless of inbuilt device or not.
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There is clear documentation of weekly testing.
10.3 Evacuation Systems
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Evacuation lines are flushed with water between each patient.
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Appropriate disinfection is flushed through at the end of the day.
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There is a written procedure for flushing the evacuation system.
10.4 Suction tips
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Reusable suction tips are NOT used due to the difficulty in cleaning.
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Single use disposable triplex syringe, saliva ejector and HVE are discarded between each patient.
10.5 Surface Cleaning
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Surfaces are cleaned with disposable neutral detergent wipes or detergent and water on disposable cloths.
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Cleaning products are appropriately labeled either a commercial product or a legible label describing products, usage and material safety.
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Material Safety Data Sheets are easily accessible for all chemicals in use.
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Disposable cloths are used and disposed of appropriately after each use.
11. Management of Prosthodontics Material and Equipment
11.1 Clinical Area
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Reusable containers, bowls and spatulas are cleaned with detergent and water or disposable cloth after use.
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Impression and other devices are thoroughly washed and dried. This is documented prior to returning to the laboratory.
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There is a laboratory form/sticker/label documenting client information, procedures and verifying decontamination completed.
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All materials going to the dental laboratory are washed and all organic debris removed then placed in a sealed container.
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In coming cases are checked that decontamination procedure has occurred.
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On completion of laboratory work items are washed, rinsed dried and documented prior to returning to clinic.
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Minor adjustments are completed away from the patient area.
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Items are transported to the clinic in a container and rinsed before placing in patient's mouth. The containers are labeled with the patients details.
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Reusable metal trays are thermally disinfected or steam sterilised between use.
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Study models and articulated models are not handled with contaminated gloves.
11.2 Laboratory
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Hand hygiene is undertaken when entering or leaving the laboratory.
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All materials going to and from dental laboratories are cleaned and placed in sealed labeled container.
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All packing materials and waste is disposed of appropriately. All reusable containers are washed with detergent and water then dried.
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The receiving area is cleaned with detergent between cases.
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Persons working on prosthetic material or equipment wear personal protective equipment including disposable gloves, protective eyewear and a mask.
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Prosthetic equipment and materials that HAVE been inserted in the mouth requires that any instrumentations, attachments and materials which contact these prostheses are reprocessed between cases.
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Prosthetic equipment and materials which have NOT been inserted in the mouth requires that any instrumentation, attachments and materials which contact these prostheses are reprocessed daily.
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Work surfaces are cleaned before and after each session with detergent cloths.
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Strong exhaust air evacuation near work area is in use.
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A small amount of pumice is dispensed for individual use and discarded thereafter. Splash guards are cleaned between cases
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Separate polishing items when used on old or used appliances. Discarded when dental item has been used in mouth. Thermally disinfected, sterilised or discarded if dental item not inserted in mouth
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On completion of work, items washed in detergent and water then dried. Document procedure and transport device to clinical area in a container.
12. Staff Health
12.1 Immunisations
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There is a policy and procedure for staff immunisations requirements clearly outlining staff members responsibility regarding the vaccinations and evidence required prior to commencing work in the Health Care Facility.
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A process is established for staff who refuse the required vaccinations.
12.2 Staff Illness
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There is a procedure in place for staff who have an infectious illness such as Influenza like illness, diarrhoea and /or vomiting or other infectious illness not be at work.(medical clearance may be required) Note: D&V require 48 hours absence post last episode.
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Any open wounds on hands or arms are to be covered with waterproof dressing.
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There is a Policy and Procedure for relevant APHRA registered dental staff having knowledge of their Blood Borne Virus status and have ongoing annual testing.
13. Environmental Cleaning
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Ordinary household brooms are not used in clinical areas.
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Patient care areas are cleaned at least daily.
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Floor mops are laundered as per AS 4146 when used and soiled.
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Wet and soiled mops are not left in buckets with or without water.
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Buckets are emptied and washed with detergent and warm water after use then stored dry.
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Different cloths and mops are used for bathroom and toilets than used in clinical areas i.e. colour coded items.
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Non disposable cleaning equipment is laundered after use per AS 4146.
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Vacuum cleaners are fitted with particulate retaining filters.
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Walls are not visibly soiled or wiped if soiled.
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Sinks are cleaned with a suitable detergent at least daily.
14. Waste
14.1 1Waste
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There is signage at waste disposal areas indicating correct segregation of waste.
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Yellow bags or containers are available for Clinical waste close to the site where it is generated.
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Black/white bags are available for general waste.
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Sharps containers comply with AS/NZS 4031 or AS/NZS 4261 are fixed in place at between 1.1-1.2 metres above the ground or on a wall above a bench.
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Waste storage is separate from clinical and equipment storage.
14.2 Extracted Teeth
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Extracted teeth are disposed of in clinical waste. (May be placed in sharps container if deemed sharp) )
14.3 Amalgam Waste
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Mercury/amalgam waste is disposed of according to the chemical waste collection company - refer to own service contractors.
15. Food Services
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There is a dedicated staff food/drink refrigerator in an area away from clinical space.
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Staff eating and recreation areas are separate from work areas and patient treatment areas.
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There is no evidence of staff eating or drinking in clinical areas. (water bottle in nominated surgery cupboard excepted).
