The agency offers a range of training programs and resource materials to the dental profession in the areas of infection control and occupational health and safety. These include hands on training programs, seminars, lecture programs, in house surgery training programs and consultancy services.

The first of the education programs were run at Fairfield in October 1992. Since then over 5,000 dental workers have attended one of the education sessions provided by the program, and in excess of 200 programs have been run in Victoria and in other States of Australia.

The Association, which is a non - profit organisation, is funded partly by the Department of Human Services Victoria, partly through industry sponsorship and also through participant course fees.

Funding from the Victorian Department of Human Services is provided to subsidise training programs for dental nurses and a significant component of the association's activities are directed towards the education of nurses in both metropolitan and rural areas of Victoria.

The program produces regular newsletters which are kindly sponsored by Oral B and are distributed to all dental practices within Victoria. The newsletters look at new developments in infection control practices and materials and occupational health and safety issues. 3M sponsors our rural programs and we are grateful for this ongoing support.

In addition to the newsletters the program also produces a resource manual which is distributed to participants of our training programs but may also be purchased through the projects offices. The manual, which is regularly updated, looks at infectious diseases of concerrn in dentistry, safe work practices and infection control protocols and practices which are appropriate to the practice of dentistry.

 The agency is happy to assist with simple enquiries by telephone or by e-mail and we endeavour to respond to these requests for assistance or information as quickly as is practicable.

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Infectrol Infectious Disease and Infection Control Update

"From the Editors Desk"		Validation Of Sterilisation Procedures
Waterlines and Antiretraction Valves		Instruments Which Are Difficult To Clean
Packaging and Drying Cycles		Consultancy and Surgery Sessions
City Seminars  and Tutorials		Practical Programs
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From the Editor's Desk

This extra edition of the newsletter has been produced specifically to look at some of the changes which have been included in the Australian/New Zealand Standard 4815 "Office-based health care facilities not involved in complex patient procedures and processes - Cleaning, disinfecting and sterilising reusable medical and surgical instruments and equipment and maintenance of the associated environment."

While I am sure a number of practices will look at the changes as an unwelcome additional burden in infection control I think they are quite simple and necessary changes and will improve both the reliability and demonstrability of the cleaning, disinfection  and sterilisation processes.  Although some initial work will be required in areas such as load validation, I believe the changes will not significantly impact on those practices who are already complying with the existing infection control guidelines and, in some areas, I believe less effort will be required.

This edition of the newsletter addresses some of the major changes which are likely to impact on infection control in dentistry but it is not intended to be a comprehensive discussion of the document as a whole. I would urge all practitioners to obtain this publication, read it thoroughly and ensure that they comply with the recommendations that it contains. The publication is available on the internet at www.standards.com.au or ring Standards on 96933555.

VALIDATION OF STERILISATION PROCEDURES

 Given the high level of reliance placed on sterilisation in preventing cross infection in dentistry it is necessary to have in place validation procedures to verify the effectiveness of both the autoclave and the protocols related it’s operation.
Validation Protocols

A written protocol for validation is required. The information in the protocol should include the autoclave being validated, time, temperature and pressure of operation and the frequency and type of monitoring utilised in validation procedures. Cleaning protocols and packaging should also be included in the written protocols.

The protocol should also include details which relate to load size and type and the validation protocol used for load validation including the types and numbers of indicator used. The protocol should also include all details of autoclave instrument calibration and testing and the certified results of these tests.
 All test results should be included in a log specific to the machine tested and test result failures must also be included in the log. Where a test has failed the results of investigation of the fault should be included, as well as the action taken to rectify the fault.
 A range of validation procedures need to be in place and these procedures are described in terms of both the type and frequency of validation testing recommended in Standard 4815.
 

1. Gauge Operation

This involves the observation of key physical parameters such as temperature, time and pressure of operation. Where a printer is installed these parameters are recorded as part of printer function and direct observation is not required for each cycle. The printout of the relevant parameters should be checked and  signed at the end of the cycle and the printout should be retained for future reference for a five year period. Where no printout is available the results of each cycle need to be manually monitored and recorded. Practitioners who do not have an autoclave fitted with a printer may want to review their equipment needs. While it is possible to monitor gauge operation manually for every cycle this will be an extremely labour intensive process and the option of fitting a printer will be far more economic in the long term.

2. Load Validation

This involves validating the load capacity of the autoclave and should be conducted for each machine in use in the surgery. The load size and type needs to be selected and recorded and the cycle should be challenged using either a biological, enzymatic or class 4, 5, or 6 emulator indicator system. Three separate cycles must be performed for verification of load validation. The indicator used should be placed central to the load in the coldest area of the autoclave to ensure that adequate penetration of steam to all areas of the load has occurred. Load validation should be conducted at commissioning, with changes in load size or type, following repair and as part of any  revalidation process.

3. Routine Autoclave Monitoring

This involves validation of autoclave function using either a biological, enzymatic or class 4,5, or 6 emulator indicator system. This monitoring procedure should be conducted at commissioning, following repair and at validation and, routinely,  at six monthly intervals. Results should be checked and recorded in the log book.

4. Instrument Calibration and Monitoring

This procedure involves checking gauge calibration, thermocouple testing and autoclave performance throughout the cycle. This process should be performed six monthly by a technician skilled in the procedures and the results should be certified. For further information on instrument calibration contact your autoclave supplier or Craig Komene at Calitec will be happy to advise you. Craig can be contacted on 94848509.

5 Chemical / Color Monitoring

This method relies on a colour change in an indicator placed inside the autoclave or oven. Sterilisation bags should incorporate a colour indicator which indicates subjection to a sterilisation process. Tests strips serve a similar function. The use of test strips only indicates that a cycle was performed and not that sterilization was achieved.  N.B. While certain types of chemical and color indicators can be a useful indicator of steriliser function, they do not indicate that sterilisation has occurred. The storage of test strips or bags can affect the result if they are incorrectly stored. Exposure to sunlight, heat or chemical contamination may affect the test agent.

Please note that  validation protocols utilising indicators such as biological, enzymatic or emulators require that the indicator is subjected to the same cycle as the autoclave load. Thus, if the items in the load are packaged it is necessary to also package the indicator. The indicator should also always be placed in the most inaccessible position within the load to  ensure that appropriate penetration has occurred.

(For further information on validation procedures and requirements see AS 4815 Appendix H ).
 
 

Water Lines and Anti - Retraction Valves

 Dental water lines are a potential source of microbial contamination. Biofilms form in water lines and the microbial count found in the water lines in dentistry is significantly higher than that found in tap water.
 The potential for cross infection or  infection of dental personnel resulting from contaminated aerosol spray is not clear, but dental workers have been infected with Legionella. Herpes Simplex Virus can survive aerosolisation and may be infective if  introduced into dental water lines.
 
Dental units must be fitted with an anti-retraction valve or valves to prevent the aspiration of contaminated fluids into the water lines. Anti-retraction valve testers are available to monitor the function of these valves. The test should be conducted on a regular basis and test results recorded. Consult manufacturers to determine the appropriate method of testing.

 Independent water supply systems are available which allow for the use of distilled water in water lines and this may have the effect of reducing microbial levels in water lines. These systems are also amenable to line drainage and disinfection procedures both of which can assist in reducing microbial levels in water lines. Protocols for drainage and disinfection should follow the manufacturers instructions.
 

Packaging of instruments and equipment for autoclaving  preserves the sterile status of the object while the packaging is intact. This is important where equipment and instruments are to be stored for a period of time prior to use. Where instruments are to be used immediately after autoclaving the need for packaging is open to question.  However the best way to maintain sterility is in sealed, impervious packages and bags. This is the best protocol to employ when even short term storage is envisaged. Packaged items should be checked for integrity before being dated and stored. Storage is limited to a 12 month period and packages  must then be reprocessed.

 All instruments with invasive potential should be sterile at the point of service delivery and pack integrity should be maintained up to the point of use. Incorrect sealing of packages will compromise sterility. Check all packages to ensure that they are properly sealed according to manufacturers instructions and that there is no possibility of air circulation through open areas underneath the seal.

 Packaging of equipment is contingent on the autoclave used having a drying cycle. Wet packages may permit the entry of microorganisms and as such constitute a risk of recontamination of the package contents.  As a result wet packages cannot be   considered sterile and drying through residual heat is not deemed an adequate procedure by Standards Australia.
 Packages which are wet on removal from the autoclave must be reprocessed. Given the increasing need for packaging, practitioners who do not have autoclaves with a drying cycles may need to review their equipment needs.
 

Instruments Which Are Difficult To Clean

 Instruments such as reamers and files and certain burs are difficult to clean. If the instrument cannot be properly cleaned then sterilisation procedures may not be effective and there is a risk of cross infection.
 While these instruments are not designated single use, it is recommended that reuse is limited to a single patient. Reamers and files may be used for a specific treatment program for that patient, these instruments should be packaged, labelled with the patients name and procedure and then reserved for use with that patient. At the end of the treatment program the instruments  should  be discarded.

They allow for discussion and debate about the issues involved in infection control and can lead to significant increases in both the efficiency and efficacy of the protocols utilised in infection control. A three and a half hour session is costed at $660.00 per session inc. GST.

Consultancy is also available, a minimum session of 2 hours is costed at $385.00.

City Based Seminars At Le Meridien   June - September 2001- Tutorial Programs Mont Albert

Once again we have had a great response to our city based seminars which are held at Le Meridien. Over 140 people have attended the last three programs and we have found ourselves unable to satisfy the demand for places. As a result we are offering two more mixed seminars to be held in July and September. These  seminars will be  open to all dental workers.   Both seminars will cover the usual topics of infectious disease, infection control, and will also include practical tips and demonstrations. We will also be discussing the new Standard 4815 and it’s implications for dental practice. Useful materials, techniques, and safe handling practices will also be discussed. The seminars will run from 1 pm – 5 pm.
 
Numbers for the seminars are limited to 50 participants so book early. Fees for the program are $77.00 for auxiliary staff and $88.00 for dentists. This fee includes an excellent afternoon tea and course materials.  We are also offering a door prize for one lucky participant!   We will be sending circulars in the near future, however if you are keen to secure a firm booking ring Russell on 9890 - 1068 for an advance copy.
    

 

Code	Venue	Date
Melbourne MS4	Le Meridien	Saturday 28th July 2001
Melbourne MS5	Le Meridien	Saturday 8th September 2001
Melbourne TT1	Mont Albert	Saturday 14th July 2001
Melbourne TT2	Mont Albert	Saturday 18th August 2001

PRACTICAL WORKSHOP PROGRAMS

Our new full day practical workshop programs are now up and running and judging by feedback from participants they are a welcome and  necessary addition to our other programs. While the seminar programs continue to be highly successful and in demand, they are limited in the material that can be covered in the available time. Infection control is a practical science and I believe that to excel in infection control  requires practical training. These programs provide an opportunity to explore the field in a broader sense and provide a practical opportunity for problem solving. The next program will be held on August 4th.
 
 $143.00 for Nurses and  Auxiliary Staff  and $176.00 for Dentists. Course code is FD6 and bookings can be made on the form on this page.
 

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Can We Help?

 It remains our policy to help when we can but it may not always be possible to respond on the same day as enqueries are received. So if you want information or resources we will do our best to meet your needs but please be patient if it takes a little time .

From the Editor's Desk

 Welcome to the January 2001 edition of Infectrol and a Happy New Year. In this edition of the newsletter we will ook at some of the infection control issues which are likely to arise out of the revision of Standards AS 1478 and the N.H. & M.R.C. document Infection Control In the Health Care Setting.

I have also detailed the new format for the hands on programs to be conducted in the first half of 2001. These will be essentially practical programs for those who have already completed one of our programs and will look at a large range of procedures commonly practiced in dentistry.

Our new programs for the first half of 2001 are included in the newsletter. As you will see we are offering five full day hands on programs which are limited to fifteen participants per course, and four tutorials, three in the city, one in the country. This will provide places for a further one hundred and twenty participants in total. In the last series of programs many people missed out on places in the programs so I would suggest that early booking is the order of the day if you wish to attend a program in 2001.
 

The introduction of the new versions of Standards AS 4178 and the N.H. & M.R.C. Guidelines in 2001 will, I believe, see a significant change in the way infection control is practiced in dentistry. These  publications form the major component of the  infection control requirements as set down by the Dental Board of Victoria and must be seen in this context. They are not simply recommendations they are regulations enforceable by law. Date for the release is not yet known.
     Previous versions of these publications have been with us for a number of years but it remains the case that many practices don't own a copy of either publication and where a copy is available it has often not been read or understood sufficiently to guide infection control procedures. Practitioners need to be aware that the Dental Board has and will continue to be diligent in enforcing appropriate infection control guidelines within the dental profession. The Board and it's officers are to be applauded for their commitment to the highest level of infection control within the profession.
    I still receive enquiries about "Cold Steri" when in fact the process of immersion disinfection is being described and I still hear a casual swipe with an alcohol wipe referred to as surface disinfection! We really do need to understand the meanings of the terms we use and the usefulness of the procedures we employ in preventing cross infection.  My own belief is that there is little need for disinfection procedures of either variety in dentistry and we should be looking instead at effective barrier techniques and autoclave sterilisable preventing cross infection.  My own belief is that there is little need for disinfection procedures of either variety in dentistry and we should be looking instead at effective barrier techniques, decontamination procedures, and autoclave sterilisable products. It is both a more effective and more efficient way to work.
     Similarly the notion of zoning is poorly understood although it is absolutely integral to good infection control. I frequently see a dirty zone plonked in the middle of two clean zones with not a single indicator of where one begins and the other ends. Not only does this pose a risk of cross infection, it also usually results in inefficient work flow patterns.
     I could go on. The reuse of items clearly marked "single use only", breaches of occupational health and safety guidelines, are both legally indefensible! The failure to address stock materials dispensed with dirty gloves and entry into drawers without first removing dirty gloves.
     We need to bite the bullet and address the issues of infection control professionally. It may require some retraining, it may be as simple as reading the guidelines carefully and ensuring compliance. But be assured that there is a vigilant public out there who expect us to provide optimal care and that includes infection control.

    I have received a number of calls from practitioners who have heard that autoclave printers may not be necessary under the new N.H.&M.R.C.Guidelines. The bush telegraph in action! My understanding is that they are quite right, the use of printers will not be mandatory. However, the new guidelines will still require that a record be kept for each load passed through the autoclave so the effect will be the same. Unless you are very well endowed with staff so that there is someone available to monitor temperature, pressure and time for each autoclave cycle, you will need a printer to verify each cycle anyway. I wouls suggest this is a much more economical way to manage autoclave cycle monitoring. So while the printer may not be mandatory it is likely that you'll need one.
    There will be other changes to the way in which we manage our sterilisation processes included in the new Guidelines too. It will be necessary to have the autoclave checked and validated every six months rather than annually, as is now the case. This will mean two visits per year from the technicians to ensure that the autoclave is performing to set standards. However I understand that in house validation testing will be required less frequently, however, it will also be necessary to perform load validation procedures. I think this is a sensible idea given that many dental workers have a relatively poor understanding of the sterilisation process. Sterilisation is a function of load size, packaging, and the distribution of the load within the autoclave chamber. Autoclaves do not have infinite capacity and overloaded poorly packed autoclaves may not sterilise everything in the chamber.
    Poor autoclave loading is often also the underlying problem in adequately drying packaged items during a set drying cycle. It is still the case that bags which are not fully dry will need to be reprocessed. Wet packaging is porous and micro-organism can traverse the wet surface. All instruments which are not dry on removal from the autoclave should be reprocessed and fully dried prior to storage.
 
 

Packaging and Storage of Instruments

 I have been to a great many dental surgeries during my work with the Program over the past nine years. I think I could count on the fingers of one hand how many of those surgeries were using appropriate packaging techniques! Generally at least some of the self seal bags had been folded in such a way as to leave them open to the atmosphere and therefore not sterile.  In order to maintain sterility bags MUST be correctly sealed. To do this requires that the bag be folded along the perforated line indicated on the bag. If this is not done and there is space at the sides for entry of air then the whole procedures constitutes a  complete waste of time because the contents simply cannot be maintained in a sterile state! It is worth considering the medico-legal implications of poor bagging technique where situations such as post operative infection occurs.

 Storage of sterile bags is also an important issue. Bagged instruments need to be stored in a clean dry area which is not subject to environmental or other types of contamination. The storage area should be regularly cleaned and bags inspected for soiling or damage before use. While contamination of bagged instruments is event related rather than time related, good management suggests that bags which have been stored for a year be repackaged and reprocessed.   Validation of packaging techniques has already been mentioned but where different methods of packaging are used in different situations it is necessary to ensure that the packaging method used has undergone an appropriate validation procedure.

Autoclave Testing and Monitoring

What To Bag?

 I believe that under the new N.H.& M.R.C. guidelines there will be a greater emphasis on the packaging of instruments and sterile storage of instruments up to the point of use. Exceptions may apply where the instrument is used directly from the Autoclave but, where there is even limited storage of instruments, packaging and sterile storage will be required.
 I believe that this will include instruments used in conservative procedures, as well as more specialised invasive instruments and that burs which have been previously used will also need to be sterile at the point of use also. New stainless steel burs which have not been previously used will not need to be packaged.