YCH Oral Health IFC Site Audit

Information

Document No.
Site
Conducted on
Prepared by

CRITERIA 1: RESOURCES – GUIDELINES AND MANUALS

1.1 The following resources are available:

Health Service Infection Control Policies and Procedures (Hard Copy or Online)
PHCH Community Dental - Operational Guideline: Reprocessing & Sterilisation of Dental Instruments
ADA Guidelines for Infection Control (3rd Ed)
NRMRC - Australian Guidelines for the Prevention & Control of Infection In Healthcare
AS/NZS 4187: 2014 - Reprocessing of Reusable Medical Devices in Health Service Organisations
AS 2773/-1 Ultra sonic cleaners for health care facilities
ISO 14937 – sterilisation of health care products
ISO 15883/-1/-2/-6 washer disinfectors
ISO 17665/-1 STERLISATION OF HEALTH CARE PRODUCTS - MOIST HEAT
EN 285 STERILISATION – STEAM STERLISERS
Equipment Maintenance Records (Hard Copy or Online)
Equipment Manuals (Hard Copy or Online)

CRITERIA 2: SINGLE USE ITEMS & ADMINISTRATION OF INJECTIBLES

2.1 There are policy and procedures in place and no evidence of:

Reuse of single use items
Single use vials of injectable agents being used for multiple patients
Multiuse creams and solutions are dispensed into individual containers for each patient
Correct labeling of dispensed items occurs

CRITERIA 3: PERSONAL PROTECTIVE EQUIPMENT

3.1 GLOVES

Gloves are available in a range of sizes
Storage system protects gloves from contaminants e.g. aerosolation of water and secretions
Gloves are worn for all procedures involving contact with mucous membranes, blood or body substances fluid

3.2 GOWNS

Clinical staff wear an appropriate uniform with short sleeves or sleeves rolled up above the elbow
Single-use disposable gowns are available for use in procedures that are at high risk of generating contaminated aerosols
Clinical staff wear single-use disposable gowns when appropriate

3.3 PROTECTIVE EYEWEAR

Is available and readily accessible for staff to use when there is a risk of exposure to aerosols or splashing
Should have side protection
Where possible staff should have their own dedicated safety eyewear otherwise wash between use
Is available for patients to wear and washed between each patient use
Is clean and in good condition

3.4 FACE MASKS

Fluid resistant masks are available and worn correctly
Respirators (P2/N95) masks are available for specified cases (ie Duck Bill Masks)
Masks are dispensed from original container at point of use, disposed of after each client use and are NOT REUSED

CRITERIA 4: HAND HYGIENE

4.1 HAND HYGIENE

Neutral soap hand wash solutions are available at all hand washing basins
Hand washing solutions are dispensed in non-refillable, disposable containers
Antimicrobial hand washing solutions are available at specified clinical basins
Alcohol based hand rubs are available in all clinical areas at a safe height
There is a compatible moisturiser available for all staff
There is no evidence of a moisturiser dispenser in the sterilisation and reprocessing area
There is no evidence of soaps or moisturizers that are not provided or endorsed by the health service
Staff consistently demonstrate sound hand hygiene practices with posters available in clinical areas
Staff have had education on hand hygiene and undertake annual updates
Hand rubs are used when hands are not visibly soiled otherwise they are washed, with soap and water
Nominated clinical hand washing sinks are available and accessible

4.2 TOWELS

Waste bins are available and not overfilled in areas where paper towel is used
There is paper towel and working dispenser at all hand washing basins
Paper towel is single use only
Sterile, single-use hand towels are available for surgical procedures

4.3 JEWELLERY / NAIL POLISH

There is no evidence of staff wearing artificial or gel nails
There is no evidence of staff wearing nail polish
Nails are clean and neatly clipped
There is no evidence of staff wearing hand or wrist jewellery (single plain band excepted)

CRITERIA 5: MANAGEMENT OF INSTRUMENTS IN TREATMENT AREA

5.1 STERILE INSTRUMENT PACK

Are protected from potential for environmental contamination e.g. moisture, dust and soil
Are checked for sterility integrity - packaging intact, clean and dry
Are not opened in advance of procedure
Are opened in a manner that facilitates aseptic removal of instruments
Chemical indicators located inside instrument cassette, laminate pouch or textile packs are checked to confirm that chemical indicator has changed to the required colour prior to using the equipment

5.2 BATCH LABELS

All bagged instruments have a batch label to facilitate tracking. When opened and used on a patient this is removed and entered into the patient record on Titanium
When a batch label is missing, items are not used and returned to sterilizing area for reprocessing
Where an item is opened but not used the item is returned to sterilising area for reprocessing. Batch labels are placed on the non conforming record sheet

5.3 ASEPTIC TECHNIQUE

Standardised instrument sets used during any dental procedure are packaged within a cassette, autoplast tray or laminate pouches and have undergone steam Sterilisation prior to use
Aseptic 'non-touch' technique is used during retrieval of additional instruments
Zoning is used within treatment areas to prevent the contamination of multiuse items or environment
Staff complete annual refresher and competency assessments for Standard and Surgical Aseptic Technique
Staff routinely follow the principles of Standard and Surgical Aseptic Technique in the clinical setting

5.4 IMPERMEABLE BARRIER WRAPS

Changed and surfaces wiped between each case
Not retained on equipment overnight
Are single use and used routinely to cover equipment that is difficult to clean (grooves, holes)

CRITERIA 6: MANAGEMENT OF DENTAL CHAIR EQUIPMENT

6.1 WATERLINES

Are flushed for two minutes at the beginning of each day
Are flushed for 30 seconds between each patient
Lines are purged with air at end of each day
Water bottles are filled with water & ICX tablet at commencement of each day
There is documented evidence that daily management of waterlines occurs

6.2 ANTI-RETRACTION MECHANISMS

Weekly testing performed
Results are documented

6.3 EVACUATION SYSTEMS

Evacuation lines are flushed with water between each patient
Following all oral surgery procedures, the metal suction adapters are removed and reprocessed.
Staff can identify which type of evacuation system is used within their clinic (wet system)
Disinfectant solution is flushed through the system at completion of each clinic day
There is documented evidence that daily management of evacuation lines occurs
Single use / disposable triplex syringe tip, saliva ejector and high volume oral evacuation system are discarded between each patient
Reusable suction adapters are removed after each patient and returned to the sterilisation area for reprocessing

CRITERIA 7: MANAGEMENT OF SHARPS AND CLINICAL WASTE

7.1 POSITIONING OF SHARPS CONTAINERS

Positioned at a height of between 1.1-1.2 metres
Not positioned above waste bins
Opening visible
Not overfilled

7.2 SHARPS

Are disposed of at point of use by the user immediately after use
Where reusable syringes are used, needles are removed by the operator with artery forceps and disposed of in sharps container
Where disposable syringes are used, the entire assembly is disposed of in sharps container (ie. Irrigation Syringe)
Needles are not re-sheathed at any time
Fingers are not used for retraction when administering local anaesthetic

CRITERIA 8: MANAGEMENT OF PROSTHETIC MATERIAL AND EQUIPMENT WITHIN CLINICAL ENVIRONMENTS

8.1 The following applies

Study models and articulated models are regarded as client records and are not handled with contaminated gloves
Impressions or other prosthetic appliances (e.g. wax rims) are cleaned immediately after removal from the mouth by rinsing with running water and soaking in neutral detergent solution; ensuring all traces of blood and debris are removed.
Reusable rubber / plastic bowls and spatulas remain in the designated clean area of the surgery and are wiped with a neutral detergent wipe between cases to ensure appropriate removal of residues.
All materials going to dental laboratories are decontaminated and placed into a sealed container. The prosthetic equipment and material are managed so that contamination of other areas does not occur
Reusable containers are washed in warm detergent and water between cases
The method of cleaning/decontamination is documented on the laboratory form and in the clients electronic Titanium record
On completion of the laboratory work, the items are soaked in a neutral detergent solution, rinsed and dried. This procedure is documented prior to returning the material to the clinical site
Impressions or other prosthetic appliances being returned to the clinician or patient, is transported in a sealed container to prevent contamination of other areas
Impressions or other prosthetic appliances arriving at the clinical area are rinsed in running water, soaked in a neutral detergent solution, and rinsed, prior to placement in the mouth
Minor adjustments are made at the chair side, away from the patient. Major adjustments occur at the denture-adjustment area
Minor adjustments occur within the designated adjustment box or alternately where the dental assistant positions the high-speed evacuator near the procedure to minimise the dispersion of acrylic or other particles. On completion of the adjustment, the appliance is decontaminated, prior to polishing and returning to the patient
Denture adjustment burs are reprocessed after each use
The receiving area is cleaned with neutral detergent wipes between cases

CRITERIA 9: MANAGEMENT OF PROSTHETIC MATERIAL AND EQUIPMENT WITHIN THE LABORATORY

9.1 The following applies

All materials going to and from dental laboratories are decontaminated, and placed into a sealed container. The items are managed so that contamination of other areas does not occur
Standard precautions apply when handling denture materials. An area is set aside to receive incoming cases. The laboratory form is checked for details of the decontamination procedures performed
When work arrives without the required decontamination procedures having been completed, the work is returned unopened to the source for correct processing. If this is not possible then the decontamination is done in the laboratory before any work on the items is commenced
All packing materials and waste is disposed of. Reusable containers are washed in warm detergent and water between cases
The receiving area is cleaned with neutral detergent wipes between cases.
Persons working on prosthetic material and equipment, or pouring or removing moulds, wear protective clothing, disposable gloves, protective eyewear, and a mask
Work surfaces are cleaned before and after each session using neutral detergent wipes
A small amount of pumice is dispensed for individual use and discarded thereafter. Splash guards are cleaned between cases
Separate polishing items when used on old or new appliances:<br>1. Polishing buffs and rag wheels are discarded following use when dental items have already been inserted in the mouth<br>2. Polishing buffs and rag wheels used in the polishing process on dental items that have not been inserted in the mouth may be re-used and disposed of once deteriorated<br>
Strong exhaust air evacuation near the work area is in use
Hands are washed on entering and before leaving the work area
There is no evidence of eating and drinking in the work area
On completion of the work, the items are rinsed under running water and soaked in a neutral detergent solution before being dried. The procedure is documented prior to returning the material to the clinical site in a container to prevent contamination of other areas

CRITERIA 10: CLEANING AND DISINFECTING AND STERILIZING

10.1 CARE AND HANDLING OF USED ITEMS

Complex multi component instruments are opened or dismantled prior to reprocessing
Documented standard procedures are observed for handling of used items, including protective clothing and eyewear
Tea towels are not located in the packaging area
Where brushes are used for the manual cleaning of RMD's, these are sterilised daily
There is documented evidence that the ultrasonic is filled with reverse-osmosis (RO) water
Jointed or serrated stainless steel instruments undergo ultrasonic washing with closed lid
Where manual cleaning / soaking of RMD's occurs, a medical grade neutral detergent solution is used. Detergents are diluted as per manufacturer’s instruction.
All equipment is appropriately dried. In the absence of mechanical drying, lint free disposable material is used
Instrument cleaning is validated by physical check using magnified light
Routine equipment & instrument maintenance program in place and documented. e.g. free of pitting, rusting, staining, snags, burrs, sharpness, stiffness, looseness

10.2 PREPARATION AND PACKAGING FOR STERILISATION

Instruments opened or dismantled prior to packaging
Instrument protectors are used to protect delicate or sharp instruments
A Class 6 chemical integrator is used within every sterilisation cycle
A mechanism is in place to identify unsterile packs, document non-conformance and return for reprocessing
Laminate pouches are heat sealed. Where a heat sealer is unavailable, self sealing laminate pouches may be used.
Daily testing of heat sealer integrity is documented.

10.3 STERILISATION PROCESS

The sterilizer chamber is loaded as per manufacturers instructions
Mechanism in place to validate sterilisation cycle prior to removing load from sterilizer. This process is documented. (ie. Class 6 chemical indicators & steriliser parameters)
Documented failure reporting procedure is in place (ie. non-conforming cycle)
Appropriate storage facilities for sterilized stock ensuring designated shelf life & package integrity are maintained
Segregated storage facilities for '6-month' sterilised stock is in place and appropriately labeled. This ensures package integrity and sterility is maintained.
There is a documented policy and procedure in place for the recall of RMD's
Staff are aware of the policy and procedure for the recall of RMD's.

10.4 VALIDATION

Appropriate daily/weekly/periodic tests are undertaken on pre-vacuum sterilizer and documented. This includes Helix test, vacuum test, validation and calibration
Pencil test is undertaken daily for Ultrasonic Washer and results are documented
pH test is undertaken daily for Thermal Washer Disinfector and results are documented
Soil test is undertaken weekly for Thermal Washer Disinfector and results are documented

10.5 DOCUMENTATION

Results of annual testing, validation and calibration of all equipment is available, e.g. sterilizers, ultrasonic, thermal washer disinfector
Records of sterilizer loads are maintained
Service records for all equipment in use is up to date and available. e.g. sterilizers, Handpieces, ultrasonic, thermal washer disinfector
Records maintained for all non-conforming packs returned where there is no batch label or packaging compromised

CRITERIA 11:WASTE MANAGEMENT

11.1 Signage

There is signage indicating correct segregation of waste

11.2 Waste Collection Bags

Yellow bags or containers are available for the disposal of clinical waste
Designated bags are available for the disposal of general waste
Waste storage is segregated from equipment or consumables storage
Mercury waste is separated and disposed of in adherence to clinical waste contractor instructions
Extracted teeth are wrapped in a glove or gauze and disposed in clinical waste

CRITERIA 12: ENVIRONMENTAL CLEANING

12.1 PATIENT CARE AREAS

Waiting areas and non-clinical patient zones in surgeries are cleaned at least daily and when visibly soiled
Clinical area and adjacent bench tops are decontaminated with neutral detergent wipes between cases
Clinical areas, including bench tops; are decontaminated at the beginning and end of each day with neutral detergent wipes

12.2 BLOOD AND BODY SUBSTANCES SPILLS

A spills kit is conveniently located within the dental clinic
PPE including safety eyewear mask gloves and gown are worn
Contaminants are soaked up/removed before area is cleaned
Cleaning equipment is thoroughly cleaned with detergent after use
Area is cleaned and dried as soon as practicable

CRITERIA 13: FOOD SERVICES

13.1 The following applies

Staff eating and recreational areas are separate from work areas and patient treatment areas
There is no evidence of staff eating and drinking in clinical areas
There is a dedicated staff food refrigerator, and all contents appropriately labeled with name and date
Temperature monitoring of the staff food refrigerator occurs and is documented
Unlabeled or unclaimed food/drink is disposed of at the end of the week

COMMENTS / ACTIONS REQUIRED

COMMENTS

Comments:

Actions Required - Criteria 1

Please detail the Issue(s) Identified
Please detail the Action(s) required
Please detail who is Responsible for the action(s)
Please detail the timeframe for the action(s) to occur
Action(s) Completed?
Date Competed

Actions Required - Criteria 2

Please detail the Issue(s) Identified
Please detail the Action(s) required
Please detail who is Responsible for the action(s)
Please detail the timeframe for the action(s) to occur
Action(s) Completed?
Date Competed

Actions Required - Criteria 3

Please detail the Issue(s) Identified
Please detail the Action(s) required
Please detail who is Responsible for the action(s)
Please detail the timeframe for the action(s) to occur
Action(s) Completed?
Date Competed

Actions Required - Criteria 4

Please detail the Issue(s) Identified
Please detail the Action(s) required
Please detail who is Responsible for the action(s)
Please detail the timeframe for the action(s) to occur
Action(s) Completed?
Date Competed

Actions Required - Criteria 5

Please detail the Issue(s) Identified
Please detail the Action(s) required
Please detail who is Responsible for the action(s)
Please detail the timeframe for the action(s) to occur
Action(s) Completed?
Date Competed

Actions Required - Criteria 6

Please detail the Issue(s) Identified
Please detail the Action(s) required
Please detail who is Responsible for the action(s)
Please detail the timeframe for the action(s) to occur
Action(s) Completed?
Date Competed

Actions Required - Criteria 7

Please detail the Issue(s) Identified
Please detail the Action(s) required
Please detail who is Responsible for the action(s)
Please detail the timeframe for the action(s) to occur
Action(s) Completed?
Date Competed

Actions Required - Criteria 8

Please detail the Issue(s) Identified
Please detail the Action(s) required
Please detail who is Responsible for the action(s)
Please detail the timeframe for the action(s) to occur
Action(s) Completed?
Date Competed

Actions Required - Criteria 9

Please detail the Issue(s) Identified
Please detail the Action(s) required
Please detail who is Responsible for the action(s)
Please detail the timeframe for the action(s) to occur
Action(s) Completed?
Date Competed

Actions Required - Criteria 10

Please detail the Issue(s) Identified
Please detail the Action(s) required
Please detail who is Responsible for the action(s)
Please detail the timeframe for the action(s) to occur
Action(s) Completed?
Date Competed

Actions Required - Criteria 11

Please detail the Issue(s) Identified
Please detail the Action(s) required
Please detail who is Responsible for the action(s)
Please detail the timeframe for the action(s) to occur
Action(s) Completed?
Date Competed

Actions Required - Criteria 13

Please detail the Issue(s) Identified
Please detail the Action(s) required
Please detail who is Responsible for the action(s)
Please detail the timeframe for the action(s) to occur
Action(s) Completed?
Date Competed

Actions Required - Criteria 12

Please detail the Issue(s) Identified
Please detail the Action(s) required
Please detail who is Responsible for the action(s)
Please detail the timeframe for the action(s) to occur
Action(s) Completed?
Date Competed

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