RDHM Infection Control Clinical Compliance Audit: Dental

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Criteria 1: Resources- Manuals and Guidelines

• The following resources are available

  Yes

  No

  N/A

• RDHM Infection Control Policies and Procedures are accessible via LRH Intranet

  Yes

  No

  N/A

• Infection Control Guidelines for the Prevention of Transmission of Infectious Diseases in Healthcare setting: online or hard copy

  Yes

  No

  N/A

• ADA Guidelines for Infection Control 2012

  Yes

  No

  N/A

Criteria:2 Single Use Items & Administration of Injectables

• There are Policy and Procedures in place and no evidence of:

  Yes

  No

  N/A

• Reuse of single use items

  Yes

  No

  N/A

• Single use vials of injectable agents being used for multiple patients

  Yes

  No

  N/A

• Multiuser creams and solutions are dispensed into individual containers for each patient

  Yes

  No

  N/A

• There is correct labelling of dispensed items

  Yes

  No

  N/A

Criteria:3 Personal Protective Equipment

• 3.1 Gloves

  Yes

  No

  N/A

• Gloves are available in a size of ranges

  Yes

  No

  N/A

• Latex free alternatives are available for staff with latex allergies

  Yes

  No

  N/A

• Storage system protects gloves from contaminants i.e. aerosolation of water and secretions

  Yes

  No

  N/A

• Gloves worn for all procedures involving contact with mucous membranes, blood or body substances fluid

  Yes

  No

  N/A

• 3.2 Gowns

  Yes

  No

  N/A

• Long and short sleeved gowns are available for staff during procedures

  Yes

  No

  N/A

• Gowns are changed at each case/meal break and or at least when soiled

  Yes

  No

  N/A

• 3.3 Protective eyewear

  Yes

  No

  N/A

• Should have side protection

  Yes

  No

  N/A

• Where possible staff should have their own dedicated safety eyewear OR wash between each use

  Yes

  No

  N/A

• Is available and readily accessible for staff to use when there is a risk to aerosols and splashing

  Yes

  No

  N/A

• Is available for patients to wear and washed between each patient use

  Yes

  No

  N/A

• Is clean and in good condition

  Yes

  No

  N/A

• 3.4 Face masks

  Yes

  No

  N/A

• Fluid resistant masks are available

  Yes

  No

  N/A

• Respirators (P2) masks are available for specific cases

  Yes

  No

  N/A

• Masks are dispensed from original container at point of use and disposed of on removal and are NOT reused

  Yes

  No

  N/A

Criteria 4: Hand Hygiene

• 4.1 Products

  Yes

  No

  N/A

• Neutral soap hand wash solutions are available at all hand basins

  Yes

  No

  N/A

• Anti microbial hand wash solutions are available at specified clinical basins

  Yes

  No

  N/A

• Hand washing solutions is dispensed from non refillable, disposable containers

  Yes

  No

  N/A

• Alcohol based hand rubs are available in all clinical area sat a safe height

  Yes

  No

  N/A

• There is comparable moisturiser available for all staff

  Yes

  No

  N/A

• There is no evidence of soaps or moisturisers that are not provided or endorsed by RDHM

  Yes

  No

  N/A

• 4.2 Hand hygiene practices

  Yes

  No

  N/A

• Staff consistently demonstrates sound hand hygiene practices with posters available in clinical areas

  Yes

  No

  N/A

• Staff have had education on hand hygiene and undertake annual updates

  Yes

  No

  N/A

• Alcohol based hand rubs are used when hands not visibly soiled otherwise they are washed with soap and water

  Yes

  No

  N/A

• 4.3 Sinks

  Yes

  No

  N/A

• Nominated clinical hand washing sinks are available and accessible

  Yes

  No

  N/A

• 4.4 Towels

  Yes

  No

  N/A

• There is paper towel in working dispensers at all hand basins

  Yes

  No

  N/A

• Waste bins are available and not overfilled in areas paper towels are used

  Yes

  No

  N/A

• Paper and hand towels are single use only

  Yes

  No

  N/A

• 4.5 Jewellery and nail polish

  Yes

  No

  N/A

• There is no evidence of staff wearing nail polish and/or artificial or gel nails

  Yes

  No

  N/A

• There is no evidence of staff wearing hand or wrist jewellery (single plain band excepted)

  Yes

  No

  N/A

Criteria 5: Management of Instruments in Treatment Areas

• 5.1 Sterile instrument packs

  Yes

  No

  N/A

• Instruments are protected from potential for environmental contamination e.g. Moisture, dust and soil

  Yes

  No

  N/A

• They are checked for sterility integrity - packaging is intact, clean, dry, not expired

  Yes

  No

  N/A

• Packages are not opened in advance of procedure

  Yes

  No

  N/A

• Opening the packs is in a manner that facilitates aseptic removal of instruments

  Yes

  No

  N/A

• Chemical indicators located inside the 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

  Yes

  No

  N/A

• 5.2 Batch Labels

  Yes

  No

  N/A

• All critical instruments have batch labels to facilitate tracking

  Yes

  No

  N/A

• When instruments are opened and used on a patient this is removed and placed in the patient's Dental Record

  Yes

  No

  N/A

• RDHM has a shelf life of 28 days and this is verified prior to instrument use

  Yes

  No

  N/A

• If a batch label is missing, critical items are not used but returned to CSD for reprocessing

  Yes

  No

  N/A

• When an item is opened and not used the item is returned to sterilising area the batch label is placed on the non conforming record sheet

  Yes

  No

  N/A

• 5.4 Aseptic Technique

  Yes

  No

  N/A

• Instrument sets used during any critical dental procedure are packaged and standardised within cassette / auto plans tray and have undergone steam sterilisation before use

  Yes

  No

  N/A

• Additional critical instruments are maintained in a sterile manner, packaged in cassettes or laminate pouches

  Yes

  No

  N/A

• A no touch technique is used during retrieval of additional instruments

  Yes

  No

  N/A

• Zoning is used within treatment areas prevent the contamination of multi use items or environment

  Yes

  No

  N/A

• 5.5 Barrier wraps

  Yes

  No

  N/A

• Wraps are single use and can be used to cover equipment that is difficult to clean

  Yes

  No

  N/A

• They are not left on the equipment overnight

  Yes

  No

  N/A

• They are removed at end of each case and the surfaces are wiped with a neutral detergent

  Yes

  No

  N/A

• 5.6 Rubber dams

  Yes

  No

  N/A

• Alternative non latex dams are available for anyone with latex allergies

  Yes

  No

  N/A

• Rubber dams are routinely used for restorative procedures

  Yes

  No

  N/A

• 5.7 Specialised Equipment

  Yes

  No

  N/A

• All hand pieces are packaged and undergo a validate sterilisation process

  Yes

  No

  N/A

• Cannulated equipment is thoroughly cleaned, packaged and undergoes a validated sterilisation process

  Yes

  No

  N/A

Criteria 6: Management of Dental Chair Equipment

• 6.1 Waterlines

  Yes

  No

  N/A

• Lines are flushed for two minutes at the beginning of each day

  Yes

  No

  N/A

• Lines are flushed for 30 seconds between each patient

  Yes

  No

  N/A

• Lines are purged at the end of each day and dry bottle installed

  Yes

  No

  N/A

• Chair water bottles are filled each morning with distilled / treated water

  Yes

  No

  N/A

• There is documented evidence that daily management of Waterlines occurs

  Yes

  No

  N/A

• There is documented evidence that weekly disinfection of Waterlines, including bottles has occurred

  Yes

  No

  N/A

• Appropriate disinfection is available to manage lines and dental chair equipment

  Yes

  No

  N/A

• 6.2 Anti retraction mechanisms

  Yes

  No

  N/A

• Weekly testing following manufacturers instructions occurs

  Yes

  No

  N/A

• Testing of devices is documented

  Yes

  No

  N/A

• 6.3 Evacuation systems

  Yes

  No

  N/A

• Staff can identify which type of evacuation system is used in their clinic.i.e. wet or dry system

  Yes

  No

  N/A

• Evacuation lines are flushed with water between each patient

  Yes

  No

  N/A

• There is documented evidence that lines are flushed

  Yes

  No

  N/A

• Wet system-disinfectant is flushed through the system at completion of each clinic day

  Yes

  No

  N/A

• Appropriate disinfection is available for use within the dry system

  Yes

  No

  N/A

• 6.4 Suction tips

  Yes

  No

  N/A

• Suction tips are changed between patients

  Yes

  No

  N/A

• Single use / disposable triplex syringe, saliva ejector, HVE are discarded between each patient

  Yes

  No

  N/A

• 6.5 Cuspidor

  Yes

  No

  N/A

• Where a Cuspidor is in use they are cleaned daily with hot water and detergent

  Yes

  No

  N/A

• 6.6 Surface management

  Yes

  No

  N/A

• Surfaces are cleaned with detergent and water between in each patient

  Yes

  No

  N/A

• Disposable cloths are used and disposed of after each use

  Yes

  No

  N/A

• If used for cleaning detergent is made fresh each day<br>

  Yes

  No

  N/A

• Remaining detergent is discarded end each day and the container is washed and left dry

  Yes

  No

  N/A

• A clean dry container is used if more detergent required

  Yes

  No

  N/A

• Containers have appropriate legible labels describing product, usage and material safety.

  Yes

  No

  N/A

• Material safety data sheets are available for all chemicals in use

  Yes

  No

  N/A

Criteria 7: Management of sharps and clinical waste

• 7.1 Positioning of containers

  Yes

  No

  N/A

• Position at a height of between 1.1-1.2 metre

  Yes

  No

  N/A

• Opening visible

  Yes

  No

  N/A

• They are not overfilled

  Yes

  No

  N/A

• They are accessible for use

  Yes

  No

  N/A

• Free standing units are attached to trolley or fitted on product specific stand

  Yes

  No

  N/A

• They are NOT position above waste bins

  Yes

  No

  N/A

• 7.2 Sharps

  Yes

  No

  N/A

• Sharp once used is disposed at point of into a sharps container

  Yes

  No

  N/A

• The user of the sharp disposes of the sharp

  Yes

  No

  N/A

• Local anaesthetic needles are removed by supplied forceps and disposed in sharps container

  Yes

  No

  N/A

• Needles are not recap at any time

  Yes

  No

  N/A

• Fingers ARE NOT to be used for retraction when administrating LA.

  Yes

  No

  N/A

Criteria 8: Management of Prosthetic Materials and Equipment in Clinical Environments

• Reusable containers are washed in warm water and detergent

  Yes

  No

  N/A

• Study models and articulated models are regarded as client records and are not handled with contaminated gloves

  Yes

  No

  N/A

• Impressions or other prosthetics appliances, e.g. Wax rims are cleaned immediately after removal from the mouth by rinsing with running water, washing with enzymatic detergent and further rinsing, until traces of blood and debris are removed. Items are dried

  Yes

  No

  N/A

• Reusable metal trays, rubber bowls and spatulas are washed rinsed, dried and at a minimum thermally disinfected or sterilised

  Yes

  No

  N/A

• All materials going to the dental laboratory are decontaminated and and placed into a sealed container. the prosthetic equipment and materials are managed so that contamination of other areas does not occur

  Yes

  No

  N/A

• There is a laboratory form documenting client information and procedures

  Yes

  No

  N/A

• The method of decontamination is documented on the laboratory form

  Yes

  No

  N/A

• On the completion of the laboratory work, the items are thoroughly washed, rinsed and dried. This procedures documented prior to returning the material to the clinical site.

  Yes

  No

  N/A

• Impressions or other prosthetic appliances being returned to Clinician or patient is transported in a container to prevent contamination of other areas

  Yes

  No

  N/A

• Impressions or other prosthetic appliances arriving at the clinical area are rinsed in running water, washed, then rinsed before placing in the patient's mouth

  Yes

  No

  N/A

• Minor adjustments are made at the chair side away from the patients. Major adjustments occur at the denture adjustment area.

  Yes

  No

  N/A

• Minor adjustments, the dental assistant positions the high speed evaluator near the procedure to minimise the dispersion of acrylic and other particles. On completion of the adjustment the compliance is cleaned, prior to polishing and returning to the patient

  Yes

  No

  N/A

• Hand pieces and burs are rinsed, washed with detergent, rinsed, dried and sterilised. Burs are placed in the ultra sonic cleaner after cleaning before sterilisation

  Yes

  No

  N/A

Criteria 11: Waste Management

• 11.1 Signage

  Yes

  No

  N/A

• There is signage indicating correct segregation of waste

  Yes

  No

  N/A

• 11.2 Waste Collection

  Yes

  No

  N/A

• Yellow bags / containers are available for clinical waste

  Yes

  No

  N/A

• Black / white bags are available for general waste

  Yes

  No

  N/A

• Sharps containers comply with AS/NZS 4031 or AS/NZS 4261

  Yes

  No

  N/A

• Waste storage is separate from equipment store

  Yes

  No

  N/A

Criteria 12: Environmental cleaning

• 12.1 Floor surfaces

  Yes

  No

  N/A

• Floor surfaces are non slip

  Yes

  No

  N/A

• Floors are easy to clean and in good condition

  Yes

  No

  N/A

• 12.2 Cleaning tools

  Yes

  No

  N/A

• Ordinary household brooms are not used in clinical areas

  Yes

  No

  N/A

• Floor mops are laundered as per AS 4146

  Yes

  No

  N/A

• Buckets are emptied and washed after use and stored dry

  Yes

  No

  N/A

• Vacuum cleaners at fitted with particulate retaining filter

  Yes

  No

  N/A

• Walls are not visibly soiled and wiped when soiled

  Yes

  No

  N/A

• Sinks are cleaned with suitable detergent at least daily

  Yes

  No

  N/A

• 12.3 Patient care areas

  Yes

  No

  N/A

• They are cleaned at least daily and when visibly soiled<br>

  Yes

  No

  N/A

• Clinical area and horizontal areas are wiped down with neutral detergent between cases

  Yes

  No

  N/A

• If barriers are used they are removed and area wiped down between cases

  Yes

  No

  N/A

• Clinical area is cleaned at end of each day as per current Policy and Procedure

  Yes

  No

  N/A

• 12.4 Blood and Body Substance Spills

  Yes

  No

  N/A

• Contaminants are soaked up/removed before area is cleaned

  Yes

  No

  N/A

• Area is cleaned and dried as soon as practicable

  Yes

  No

  N/A

• PPE including safety eye wear, mask, gloves and gown are worn

  Yes

  No

  N/A

• Any cleaning equipment used is thoroughly cleaned with detergent after use

  Yes

  No

  N/A

Criteria 13: Food Services

• Staff eating and recreation areas are separate from work areas and patient treatment areas

  Yes

  No

  N/A

• There is no evidence of staff eating or drinking in clinical areas

  Yes

  No

  N/A

• There is a dedicated staff refrigerator

  Yes

  No

  N/A