COVID-19 Related Policies and Procedures

Daily COVID-19 Student Questionnaire

1. It is a university requirement to have all students fill out the daily COVID-19 questionnaire on days that they will bereporting to campus.
2. This questionnaire is emailed to you daily.
3. If you fail the daily questionnaire, please email Sydney Van Meerbergen at svanmeer@uwo.ca immediately for furtherdirection.

COVID-19 Patient Questionnaire and Protocols

1. The COVID-19 questionnaire is to be filled out in Salud at the time of appointment booking.
2. If the patient answers “yes” to any of the screening questions, the patient cannot come to the clinic.
3. The patient must wait the required 5 days (day 1 starting the day AFTER symptoms began) to return to the clinics.They must be symptom-free to return.

COVID-19 Isolation Protocols for Students, Staff and Faculty

If you are suspected or confirmed COVID-19 positive (exhibiting symptoms or have a confirmed positive test) please do not come tocampus.

You are to isolate at home for 5 days after the onset of your symptoms. Please note, that Day 1 is considered the day after yoursymptoms begin. You may return at this time, assuming that you can pass the Daily Screening Questionnaire, and are symptom-free.

Reception/Waiting Area

Patient Screening

During the COVID-19 era, patients are required to be screening upon building entrance. The patients will be asked a variety ofquestions pertaining to COVID-19 to ensure they have not “screened positive”. Any patient who answers “yes” to any of thescreening questions will not be permitted to enter the building. Patient screeners will also ensure that all patients entering thebuilding are wearing a 3-ply disposable facemask and use alcohol-based hand rub (ABHR) upon building entrance.

Students and reception staff are required to complete a COVID-19 screening questionnaire upon appointment booking, so entrance

screening acts as a second layer and “point of contact” screening.Signage

Appropriate signage posted in the reception/waiting area with expectations of patients regarding necessary PPE and COVID-19protocols. Additionally, there is signage that communicate clinic capacity numbers.

Reception Desk

IPAC Considerations:

• Tissue boxes and ABHR available at each reception desk.
• Plexiglass implemented as a physical barrier between patient and reception staff member.
• Reception staff required to wear a 3-ply disposable facemask.
• Air filtration unit placed in the reception waiting area and is kept on all day to ensure efficient air turnover.
• No magazines, books or toys are available for use in the waiting rooms.

General Environmental Cleaning

Containment of Spills of Blood and Bodily Fluids

• In the case of blood or bodily fluid spill in the dental clinic, all activity in the immediate vicinity will be suspended.
  • The covering instructor is to be immediately notified of the spill. The instructor will then notify the correctindividuals (i.e. facilities supervisor, Western care taking etc.).

General Clinic Cleaning/Care Taking

• Cleaning/caretaking is done centrally through Western University’s caretaking staff. Below is a link to theirwebsite where their cleaning protocols can be found:https://www.uwo.ca/fm/what/cleaning_caretaking/index.html

Environmental Cleaning in the Dental Care Environment

Surfaces, Chairs and Equipment

• All surfaces in operatories are cleaned following every patient appointment.
  • All surfaces are to be wiped down with a CaviCide™ wipe. This includes:
  • Counter tops
  • Light handle and arm
  • Hard plastic containers
  • Any other hard plastic or surface within the operatory
  • Chair upholstery
  • Delicate equipment
  • Sensors
• Electonics are to be wiped down with isopropyl alcohol wipes (I.e. computer screens etc.)
  • CaviCide™ wipes and alcohol wipes are available in each operatory.
  • Students are responsible for cleaning their individual operatory when they finish their patient treatment. Thisentails:
  • Removal of barriers
  • Surface cleaning
  • Emptying operatory garbage

Barriers

• Barriers are to be set-up before each patient appointment.
• Barriers are to be removed and disposed of after each patient appointment.
• All surfaces where barriers were places are to be included in the operatory disinfection/cleaning process.
• No new barriers should be placed until all surfaces have been cleaned and dried.
• Barriers required for use in operatory:

SURFACE	BARRIER REQUIRED
Keyboard	Keyboard cover
Mouse	Plastic bag
Chair Back	Large plastic bag
Saliva Ejector	Plastic bagDisposable saliva ejector
HVE Suction	Plastic bagDisposable tip
Air/H2O Syringe	Plastic bagDisposable tip
Light Toggle Switch	Baggie/over glove
Light Handles	Baggies
Chair Touch Pads	Blue barrier film
Bracket Table Handle	Plastic baggie

Bracket Table	White Paper
Countertops	Brown paper if mixing materials (e.g. cements,impression materials)

Operatory/Cubicle Storage

• No medical items/disposables are to be stored in the clinic operatory under the sink or adjacent to the sink.
  • The only items that are to be stored in the operatory/cubicle are items such as paper cups, mouthwash, tissues andpaper towel.
  • No personal items are to be stored in operatory/cubicle.
  • Gloves are stored in hard plastic enclosed containers. These containers must be wiped down after each patientprocedure with a CaviCide™ wipe.

Waste Disposal

• All disposable refuse accumulated during clinical therapy will be temporarily stored in the waste receptacles under the counters. At the end of each patient appointment, this refuse will be emptied into the chair back bag, and deposited in the central refuse bins located outside of Main Clinic dispensary. STUDENTS ARE RESPONSIBLE TO EMPTY GARBAGE CONTAINERS AFTER EVERY CLINIC SESSION.

Laundry Policy

·       Scrubs:

• Scrubs are not to be removed from the property. A lab coat must be worn when leaving the clinics.
  • Absolutely no scrubs to be worn outside.
  • Scrubs are dispensed through Dental Supply.
  • A new set of scrubs is to be worn each clinic day.
  • Laundry of scrubs is contracted out and students and faculty are not to launder their own scrubs. Scrub caps arealso to be taken home in a separate bag to be laundered,
  • Scrubs must remain on campus and are never to be removed from the property.
  • Dirty scrubs are to be kept in a separate bag in student locker until scrub exchange hours are available.

Gowns:

1. Clean gowns are available throughout the clinic.
2. A new gown is to be donned before each patient interaction.
3. When a gown is doffed, it is to be discarded in one of the biohazard laundry bags placed around the clinic.
4. The biohazard laundry bags are changed out when the bag gets full, and at the end of each day by the dental assisting team.
5. The biohazard laundry bags are collected in a large laundry cart and are brought down each day to dental supply where thebiohazard laundry bags are sent out for laundering to our contracted laundry service.
   1. Laundry service provider: https://www.canadianlinen.com/

Air Purification System Policy

In-operatory unit placement and operation:

The unit should be placed along a wall in the operatory leaving approximately 4 inches of clearance on all sides of the air purifier toallow for proper air flow through the unit’s air intake system. The clean air output can be directed along the wall or towards it, butpreferably not towards the patient treatment chair. The air filters will be turned on to the medium setting prior to the start of clinics bythe Dental Assistant. The Dental Assistant will turn off the air filters at the end of the day.

Operation of the unit during treatment:

Running the unit during patient treatment will continue to provide air changes in the operatory and scrub the air of airbornecontaminants/aerosols generated during treatment. The unit may be set to the medium level during treatment or surgery. Doing so will help to reduce transmission risk further by lowering the baseline level of contaminants at the start of the fallow period comparedto if the unit was not running during treatment.

Operation of the unit following treatment:

Units can be turned off during the evening and during extended periods when the clinic is closed. Filterchange interval:

Unless specifically outlined by the manufacturer, when an air purifier is used in a clinical setting where ACH performance is

measured to determine a fallow time, it’s best practice to change the air purifier’s HEPA filter when approximately 70% of its maximum lifespan has been reached. This is important because once a filter reaches beyond 70% capacity then the airflow rate through the filter will begin to slow. The filter’s efficiency rating remains unaffected and HEPA efficiency actually continues to increase until the filter becomes completely blocked.

For Austin Air filters, we recommend that the filters are changed once every three years in a clinical setting and once every fiveyears in a residential setting.

Disinfection & Cleaning Protocol:

The outside of the air purifier will be wiped down with a disinfectant wipe (CaviCide™) at the end of each patient treatmentappointment by the Operator.

The Dental Assistant will use a HEPA vacuum to vacuum the pre-filter from the outside of the unit. This is to be done weekly orwhere appropriate based on a visual inspection from the outside of the unit. (If you see dust clinging to the outside of the unitthen it should be vacuumed.).

Hand Hygiene

Hand hygiene is the single most important practice for preventing the transmission of micro-organisms. The term “hand hygiene” has replaced hand washing and includes the combined use of plain or antimicrobial soap with running water, and an alcohol-based handsanitizer.

Four Moments of Hand Hygiene

• Before initial patient/patient environment contact
  • Upon entry into the cubicle/operatory
  • Prior to touching the patient or any object in the patient’s environment
  • Before aseptic procedure
  • Hands must be cleaned immediately prior to beginning a procedure/treatment and donning your gloves
  • After body fluid exposure
  • Hands must be cleaned immediately after an exposure to body fluids, including after the doffing of gloves
  • After patient/patient environment contact
  • Hands must be cleaned upon completion of patient interaction
  • Hands must be cleaned after leaving the patient cubicle/operatory

Hand Hygiene Products

*Please note, that it is not appropriate to use both soap and ABHR at the same time. This will irritate skin.

• Alcohol-Based Hand Rub (ABHR):
  • ABHR products that contain 70 – 90% alcohol are to be used in the clinical setting.
  • ABHR is the preferred method of hand hygiene when hands are not visibly soiled.
  • ABHR is to be used for 15 seconds.
  • Please see below for the technique that is required when cleaning your hands via ABHR

• Hand Washing Soaps:
  • Plain liquid soaps is to be used in the clinical setting. Bar soap is not acceptable.
  • Soap acts to emulsify dirt and substances.
  • Soap and water is to be used when hands are visibly soiled.
  • Please see below for the technique that is required when cleaning your hands via soap and water:

Access to Hand Hygiene Products and Stations

• ABHR dispensers are accessible upon entry into the clinic – both student/staff/faculty entrance and patient entry.
  • ABHR dispensers are scattered around the clinic for use.
  • ABHR bottles are available in each clinic operatory.
  • ABHR bottles and soap bottles are not to be placed adjacent to one another, so not to promote simultaneous use.
  • Each operatory has a dedicated hand-washing sink with access to appropriate plain liquid soap.
  • Hand washing sinks are under no circumstances to be used for instrument cleaning. There are separatedesignated instrument cleaning sinks available for use in the clinic.
  • Disposable towels are readily available at each cubicle
  • Taps should be turned off with the aid of a paper towel to avoid recontamination of hands or better by using the

“hands off” kick plate

• Keep clean equipment away from sinks to avoid contamination
  • To avoid contamination, disposable pump dispensers of liquid products should be discarded when empty and not

“topped-up” or refilled.

• All liquid soap and ABHR containers will maintain their original label with content and safety information on it.

Hand Hygiene Impediments

For hands to be allowed to be properly kept and clean, all unnecessary impediments to hand hygiene are prohibited in clinics.Many hand impediments can act to harbour microorganisms making it more difficult to properly perform hand hygiene. Pleaseconsider the following:

• Nails are to be kept short and clean, and should not go past the end of the finger. Long nails are difficult to clean andcan pierce gloves.
  • Artificial nails and nail polish are prohibited in clinic.
  • All Hand/finger jewellery (i.e. rings, bracelets, watches, etc.) and necklaces are prohibited in clinic. Please also notethat necklaces are also prohibited, and stud earrings with smooth surfaces are the only earrings allowed to be wornin clinics.

Skin Care

Hand lotion to prevent dry or cracked skin is available in disposable pump dispensers. Petroleum-based hand lotions should not beused, because they can affect glove integrity. Maintenance of healthy, lesion-free, intact skin provides a barrier against infectiousmicroorganisms. Repeated washing with strong anti-microbial agents may result in drying and cracking of the skin, thus reducing itsprotective qualities. The use of skin conditioners and moisturizers (available from the Dispensary) is encouraged for everyone directlyinvolved in patient care. Severe dermatological conditions (exudative lesions, weeping dermatitis of the hands) increase the risk ofinfection to the Ontario Healthcare Worker. Individuals so afflicted must refrain from handling dental patient-care equipment until thecondition resolves.

Personal Protective Equipment (PPE)

Personal protective equipment (PPE) is worn to shield the exposed tissues of the OHCWs from exposure to potentially infectiousmaterial. PPE serves as a barrier to protect the skin of the hands and arms from exposure to splashing, spraying or spatter of blood,saliva or other body fluids, and from introducing micro-organisms into deeper tissues by traumatic injuries. Such equipment alsoprotects the conjunctival mucosa of the eyes, as well as the lining mucosa of the respiratory tract.

General Clinic PPE Policy

Our PPE guidelines and policies currently go above and beyond what is required from the RCDSO. This is to ensure that we aretaking a universal precaution approach to COVID-19

• Non-Aerosol Generating Procedures (non-AGPs):
  • Re-usable gown
  • ASTM level 3 surgical mask
  • Face shield
  • Gloves
  • Aerosol Generating Procedures (AGPs):
• Re-usable gown
• N-95 respirator (that operator is properly fit tested for)
• Bouffant or Surgical Cap
• Face shield
• Gloves

*Please note that it is always a requirement that hair is up and out of the operator’s face at all times and not touching shoulders.

**Please note that the only earrings allowed to be worn during any patient treatment is smooth stud earrings. All other earrings areprohibited.

Gown Policy

• Due to the current PPE supply chain concerns, we have moved to a re-usable gown model in the clinics.
• You are to doff your gown every time you leave a cubicle/operatory. You are then to don a new gown every time you enter a new cubicle/operatory. Due to this, we strongly encourage students to leave the cubicle/operatory as little as possible during clinicprocedures. This requires organizational skills and preparedness!
• Gowns can be found in the aisle cubbies in main clinic, or on carts in the hallways.
• Gowns are to be donned immediately prior to the start of patient treatment.
• When treatment has finished, gowns are to be doffed in the appropriate manner where the removal of the gown takes place away from the body, and you only have direct contact with the uncontaminated (clean) side of the gown. As you doff the gown, you are to roll the gown inside out so you only have direct contact with the clean/uncontaminated side of the gown (see donning/doffing).
• Once the gown has been properly doffed, you are to bring your gown to one of the many biohazard laundry hampers around clinic and dispose of the gown.

• Gowns are not to be doffed and left in the cubicle, and then re-donned when you return to the cubicle. Thiscreates a high-risk for transfer of microorganisms during the re-donning process.

Clinic Shoes

All students and clinical faculty must have a dedicated pair of clinic shoes to be worn. These chosen shoes are not to leave thebuilding for any reason. Ideally, the selected shoes can be wiped down after a patient procedure is done.

Donning and Doffing

https://www.publichealthontario.ca/-/media/documents/ncov/ipac/ppe-recommended-steps

Public Health Ontario Donning Full PPE Video: https://youtu.be/s2z1uM1fXN8

Public Health Ontario Doffing Full PPE Video: https://youtu.be/crGlUX3_4DA

Reprocessing of Dental/Medical Equipment/Devices used to Provide Patient Care

The level of processing/reprocessing for CRITICAL and SEMICRITICAL Instruments in Dentistry (see Spaulding’s Classification of

Medical Equipment/Devices and Required Level of Processing/Reprocessing) is Cleaning followed by Sterilization. Although high-

level disinfection is acceptable for SEMICRITICAL instruments and devices, this form of disinfection is rarely, if ever, used in thedental setting due to the toxicity of the chemicals required. Schulich Dentistry does not use high-level disinfection. For thoseSEMICRITICAL instruments and devices that cannot be subjected to heat required for sterilization or the chemicals required forhigh-level disinfection (such as intra-oral cameras), a disposable watertight barrier such as a plastic sleeve, must be used to coverthe device when used in the mouth.

For NONCRITICAL devices such as blood pressure cuffs, Cleaning followed by Low-Level Disinfection is the standard. The use of low-level disinfectants (i.e. CaviCide™/CaviWipes™) is used according to the manufacturer’s instructions (this includes that thesurface must remain wet for the time indicated on the manufacturer’s instructions for the surface to be considered cleaned) Pleaseensure the surface is kept wet for the recommended duration (ie: 3 minutes)

Sterilization alone is NOT a substitute for Cleaning followed by Sterilization. Cleaning is the physical removal of debris. Cleaning reduces the number of microorganisms present by removing organic matter, such as blood, tissue and other debris that act as barriers which hinder the sterilization/disinfection process.

Cleaning:

• Essential to the sterilization process
• Includes the removal of all visible soil (i.e. blood, tissue, bone, cements, etc.)
• Soil must be removed from the surface, crevices, serrations, joints, lumens, etc.
• Completed with a detergent and water
• Done manually at the designated reprocessing sink and mechanically by ultrasonic cleaners/washer/disinfector machines (in the reprocessing area)
• All instruments and burs must be manually pre-cleaned by the dental student before being sent for reprocessing (in mainclinic)

Personal Protective Equipment (PPE) such as utility gloves, eye protection, and a procedural gown are to be worn while cleaning.Brushes for cleaning are readily available for use at identified cleaning areas as well as Main Clinic’s Dispensary. Utility gloves mustbe worn when manually cleaning contaminated instruments. Instruments are to only to be cleaned at sinks labelled “reprocessingsink”. DO NOT use the sinks labeled “hand washing only.” Once items are cleaned and dry, they are to be placed in the appropriatecassette or sterilization pouch. Utility gloves must also be worn to transport contaminated instruments to the DispensaryContaminated/Dirty Window in Main Clinic. Utility gloves and cleaning brushes must be disinfected with CaviCide™ and returned tothe appropriate cubicle.

Contaminated instrument cassettes will be run through a washer/disinfector machine for another cleaning cycle after cleaning hasbeen completed. Contaminated instruments in sterilization pouches such as hand pieces and bur blocks that have been cleaned donot go through a washer/disinfector.

Sterilization:

Sterilization is the process that kills all microbial life including viruses, bacteria, fungi and bacterial endospores. These organismscause infections such as Hepatitis A, B, C, HIV and potentially serious bacterial or fungal infections. If you have properly sterilized,no microorganisms will survive.

All instruments classified as CRITICAL or SEMICRITICAL must be sterilized in sterilization pouches or wrapped cassettes thatcorrectly fit the instruments. More than one instrument can be placed in a sterilization pouch, but they must not touch each other.Items such as forceps, scissors, hemostats, and any other hinged instruments must be packaged with the hinges open. Pleaseensure separation of mouth mirror from handle.

Methods of sterilization include steam under pressure (steam sterilizer), dry heat and unsaturated chemical vapor. Steam underpressure is the method of sterilization utilized at the Schulich School of Medicine and Dentistry.

NOTE: DISPENSARY STAFF MONITOR ALL DENTAL INSTRUMENTS SUBMITTED FOR STERILIZATION. INSTRUMENTS THAT ARE NOT

CLEAN WILL NOT BE STERILIZED. THIS MAY RESULT IN INSTRUMENTS NOT BEING PREPARED FOR A STUDENT’S NEXT REQUIRED

SESSION. VIOLATIONS WILL BE DOCUMENTED IN THE FORM OF A DEFIECIENCY REPORT FORM AND SUBMITTED TO THE ASSISTANT DIRECTOR, CLINICAL AFFAIRS FOR DISCIPLINARY ACTION IF REQUIRED.

Instrument Sterilization and Disinfection:

Students will utilize metal instrument cassettes for sterilization and storage of their hand instruments. Cassettes should containinstruments specific to ONE clinical discipline (i.e. Operative, Endodontics, Periodontics, etc.). Sterilized cassettes will be stored inthe Main Clinic Dispensary. Please do not add additional instruments to your cassette.

ALL SHARP INSTRUMENTS MUST BE SUBMITTED FOR STERILIZATION IN METAL TRAYS.

The following is a list of instrument categories and instructions for sterilization:

1. HEAT STABLE HAND INSTRUMENTS: Heat sterilization (hot water pre-wash followed by steam under pressure) will be done to ALL reusable heat stable instruments used in patient therapy. Cements (i.e. IRM™) are difficult to remove once they are set,therefore, it is recommended to wipe instruments free of these materials before they set using gauze.
2. INSTRUMENTS IN STERILIZATION POUCHES: The student must clean Items prior to sterilization (i.e. impression trays, burs, anaesthetic syringes, etc.)
3. HANDPIECES: Heat sterilize after cleaning and lubricate according to the manufacturer’s recommendations.
4. ROTARY CUTTING INSTRUMENTS: Heat sterilize all burs. Burs must be free of debris, pre-scrubbed with a bur brush, dry andstored in the appropriate bur block. Burs must be sterilized prior to use unless they are specified by the manufacturer as “SterilePackaged”.

If you receive sterilized instruments from Dispensary that are contaminated with debris, do not use these instruments. Clean andsterilize before use. Inform Dispensary staff of any problems with sterilized instruments. They can offer guidance and equipment toaid in proper cleaning of instruments.

Use of unclean instruments will be reported to the Assistant Director, Clinical Affairs and may result in suspension of clinicprivileges.

Intraoral Devices:

Several dental devices that come into contact with mucous membranes are attached to the air or waterlines of the dental unit, including:

• Highspeed and slowspeed handpieces
• Prophylaxis angles
• Ultrasonic and sonic instruments
• Air/water syringe tips

These devices have the potential of retracting oral fluids into their internal compartments, which can then be expelled into the oralcavity of another patient during subsequent use. In order to flush out any patient material that might have entered the turbine or air and waterlines, these devices should be activated to discharge air and water for a minimum of 20 seconds after each patient use.

NOTE: This is in addition to the 2-minute purge of all water lines before each clinic session.

Dental handpieces and other intraoral devices that are attached to air or waterlines must be sterilized after each patient use.

Manufacturer’s instructions for cleaning/lubricating/sterilization of these devices must be followed:

1. AIR/WATER SYRINGE: Change disposable tips between patients. Once installed, the syringe must be protected with a plasticbarrier placed over the entire syringe. The barrier should be punctured to only allow the tip to protrude.
2. DENTAL CHAIR & LIGHT HANDLES: The back of the dental chair and light handles must be covered by disposable plastic barriers of the appropriate size. Barriers must be changed between patients. Arms, back, chair and light switches must be disinfected with CaviCide™ saturated paper towels between patients. Do not spray disinfectant directly onto chair. Wipe dental chair, operator and assistant stools with paper towels saturated with water only.
3. COUNTER TOPS: Before each patient arrives, countertops and work surfaces must be wiped with CaviWipes™. A minimumwaiting period of THREE minutes is necessary before disinfection becomes effective. Ensure the surface is kept wet for the timeperiod.

Dental Unit Water Lines (DUWL)

Dental unit waterlines can act as an environment to house waterborne microorganisms. Therefore, special attention must be taken toensure they stay clean and bacteria-free.

Schulich dental clinics use mostly a closed water systems. This means that there is no reliance on direct municipal water supply.Water is obtained in a water bottle from one of the carboys placed around the clinic. There is an iodine water filter that is placed in this water bottle to help filter any impurities as water is absorbed from the water bottle into the dental unit water lines for patient care use.

Pre and Post Procedure Protocols

• Students are to purge all water lines for 2 minutes prior to patient appointment.
  • Students are to purge all water lines for 30 seconds following patient appointment (for handpiece lines, make surehandpiece is still attached).

Water Testing Protocols

• The infection control coordinator performs water testing.
  • Water is tested to ensure clean dental unit water lines in two different ways:
    • In-house dip slide testing
      • Used when dental water lines have sat stagnant for long periods of time or as a routine sampling test for 3months straight when there is any change in material or process.
      • Maxill water culture dip slide tests are the products used.
      • One dip slide test represents the water lines for a given dental chair.
      • The dip slide test must then sit in an incubator at 33 degrees Fahrenheit for 96 hours. The dip slide will showmicroorganism/bacteria growth if there is any via red spots on one side, and spores/fungus will grow on theother side if they are present in the water sample.
    • Microbiology testing through LHSC labs
  • When >500 cfu/ml are present in a given water test, water line shocking is done.

Dental Unit Water Line Shocking

Procedure Purpose	This procedure describes the standard operating procedures with regards tochemically cleaning the lines of a dental chair. It also outlines the steps required for monitoring microbial contamination of dental unit water lines using Maxill Dip slide Culture Tests and disposal of used tests.
When Does Chemical Cleaning Need to beDone?	The standard for water cleanliness in DUWL is the same as the standard fordrinking water. PHO stipulates that municipal drinking water can contain nomore than 1000cfu/ml (colony forming units). If a dental chair samplecontains

	>1000cfu/ml, the chair must be removed from service and chemical cleaningneeds to take place. If a sample contains >500cfu/ml but <1000cfu/ml,chemical cleaning and re-sampling of the chair needs to take place, but the chair can remain in service.
When Does Dip Slide Sampling Need to beDone?	There are two types of sampling: routine and non-routine. Routine Sampling: when there is a change in process or material, every chair impacted by the change(s) must be sampled monthly for 3 consecutive months. If, after 3 months there is 100% pass rate (i.e. under 500cfu/ml), sampling can go back to quarterly (follow the LHSC sampling plan). The LHSC sampling plan is to befollowed in conjunction with the routine dip slide testing.Non-Routine Sampling: when a sample from LHSC or our internal dip slide samples comes back above 500cfu/ml, every line from the impacted chair needs to be sampled to determine source ofcontamination. If the re-check is above 500cfu/ml, chemical cleaning and re-sampling needs to take place, but the dental chaircan remain in service. If the sample is above 1000cfu/ml, the chair needs to be removed from service, chemically cleaned, and re-sampled. If after cleaning, the sample is below 500cfu/ml, the chair can be put back in service.
PPE for ChemicalCleaning	The following PPE is to be worn when mixing chemicals and when chemically cleaning dental unit water lines: Neoprene GlovesFace ShieldFace Mask
Preparation ofChemicals	The chemical cleaning of dental unit water lines requires preparation of twoseparate solutions, an enzymatic cleaner (Zymax) and a chemicaldisinfectant (AquaFX). Zymax Preparation: Zymax 128 Enzymatic Cleaning Solution (Maxill item #60035) is used for the pre-treatment of water lines. Measure 8ml of Zymax 128 and add to an empty carboy. Fill the carboy with1L of water. Keep the same ratio if more than 1L of solution is required.AquaFX Preparation: AquaFX (Maxill item #60084) is used to disinfect the water lines. Measure 10ml of AquaFX and add to anempty carboy. Fill the carboy with 1L of water. Keep the same ratio if more than 1L is required.
DUWL CleaningProcess	The DUWL cleaning process is made up of ten steps. Each step is recordedon the DUWL Chair Shocking Checklist (see Appendix 1). Ensure the DentaPure DUWL Cartridge is removed and replaced with a standardplastic pickup straw (available from Dental Repair). The chemicals will damage the DentaPure cartridge. Step 1 – Air Purge: turn the dental chair off and remove the waterbottle. Empty the water bottle, reattach, turn the chair back on andrun each water line (primary air water, assistant air water, highspeed andCavitron [C row and D row only]) until all water is removed.

·       Step 2 – Zymax Quick Purge: Fill the water bottle approximately ¼ full with the Zymax solution. Run the solution through each lineonly until the lines are filled and stop. Leave the Zymax in the lines for 10-15 minutes.Step 3 – Zymax Purge: Run Zymax through each line for 10-20 seconds. To save time, continue running the lines until the bottle is empty.·       Step 4 – Air Purge: Purge lines with air to ensure Zymax is removed.Step 5 – AquaFX Quick Purge: Fill the water bottle approximately ¼ full with the AquaFX solution. Run the solution through each lineonly until the lines are filled and stop. Leave the AquaFX in the lines for 5-7 minutes.Step 6 – AquaFX Purge: Run AquaFX through each line for 20-30 seconds. To save time, continue running the lines until thebottle is empty.Step 7 – Air Purge: Purge lines with air to ensure AquaFX is removed.Step 8 – Water Purge: from a separate carboy filled with tap waterfrom room DSB 0142B, rinse the water bottle and dump in a cubicle sink. Fill the water bottle and run through each line for approximately 20-30 seconds.·       Step 9 – Acid Test: spray a small amount (approx. 10ml) of water from each line into separate paper cups. Dip a peracetic acid(PAA) test strip (LaMotte Insta-Test Analytic High Range Peracetic Acid Test Strip, LaMotte Item #3000), pad face up, in the water and let it sit for 10 seconds. Remove the strip and compare any colour change to the PAA ppm scale on the test strip container. If there is any colour change, purge water for 30 more seconds andre-test.·       Step 10 – Culture Test Collection: Fill a paper cup with water from each water line so that the sample is inclusive of the entire chair (unless troubleshooting to determine if there is a problem with a specific line). Using a Maxill Dip slide Culture Test (Maxill Item#81135), open the test and submerge in the water, so that all of the media is covered. Gently rotate the dip slide for 30 seconds. Gently shake off excess water, and re-seal the media to the test tube. The test should be slightly less than “hand tight”, to allow any potentialbacteria growth to respire.Replace the standard plastic pickup straw with a new DentaPurecartridge (Crosstex Item #DP365B) and purge each line for 2 minutes. Validate iodine levels using CrossTex SenSafe Iodine Check (Crosstex Item #480018). To test, fill a paper cup with approximately 20 ml of water. Dip a test strip into the water andgently move it back and forth for 10 seconds. Remove the strip and wait 30 seconds. Compare the test strip to the colour range on the container. The test should register above 0.5ppm iodine. DentaPure cartridges are replaced annually, but there is a small inventory of them in Dental Supply, if one-off replacement isrequired throughout the year.

Incubation and Interpretation of Samples

On each sample to be incubated, record the chair number, date and time ofcollection on the test. Place the test in the incubator in HSA H5. After 48 hours, bacteria counts can be read (the “clear” side of the media). Bacteriacolonies will be coloured red. 1 visible colony = 100cfu/ml. After 96 hours, yeast/mold can be read (the “beige” side of the media). These colonies can be difficult to see. To properly read them, remove the media from the test tube (wear appropriate PPE), and look at the media on an angle. Colonies may be cloudy in colour or can take on the appearance of a water droplet. One (1) visible colony = 100cfu/ml.                                                                        Tests need to be removed from the tube because condensation on theinside of

the tube can lead to interpretation errors. Record results on the Maxill Dipslide                                                                                 Results sheet (AppendixB).

Disposal of Samples

Used dip slides are considered hazardous waste and need to be autoclavedbefore disposal. The autoclave in DSB 0032A can be used to process samples and there is a signup sheet in the room. Samples should be put inautoclave bags with a piece of autoclave tape on the outside of the bag. Bags and tape are in HSA H5, under the incubator. When more bags and tape are needed, notify Dental Supply for re-order. Allow ~4 weeks for orders to be fulfilled. Once samples are bagged, they can be placed in a bin (located in DSB 0032A), then put in the autoclave. Do not overtighten the door of the autoclave as this can damage the door seal. Hand tighten the door until you feel resistance, then tighten ½ turn more. Once closed, press “3” twice on the autoclave to start the cycle. Ensure no steam leaks out of the door and the autoclave reaches temperature. If there is a small leak, tighten the door more. If the leak persists, notify the power plant (number located on the autoclave). When the cycle is complete, use the gloves in DSB 0032A to remove the tray holding the samples. Place a “Treated Biological Waste Sticker” on the bag and put the bag on the ground beside the garbage bin in the hallway. Stickers are under the incubator in HSA H5.When more stickers are needed, contact Anne Marie McCusker in OH&S for more supply.

Dental Handpieces and other Intraoral Devices

Several dental devices that contact mucous membranes are attached to the air or waterlines of the dental unit, including:

• High and low-speed handpieces
• Prophylaxis angles
• Ultrasonic and sonic instruments
• Air/water syringe tips

These devices have the potential of retracting oral fluids into their internal compartments, which can then be expelled into the oralcavity of another patient during subsequent use. To flush out any patient material that might have entered the turbine or air andwaterlines, these devices should be activated to discharge air and water for a minimum of 20 seconds after each patient use. Notethis is in addition to the 2-minute purge of all water lines before each clinic session.

Dental handpieces and other intraoral devices that are attached to air or waterlines mustbe sterilized after each patient use. The manufacturer’s instructions for cleaning, lubricatingand sterilizing these devices must be strictly followed.

• Water/Air Syringe: Change disposable tips between patients. Once installed, the syringe must be protected with a plasticbag placed over the entire syringe. The plastic bag should be punctured to only allow the tip to protrude.
  • Dental Chair and Light Handles: The back of the dental chair and light handles must be covered by disposable plastic bagsof the appropriate size. Bags must be changed between patients. Arms, back, chair and light switches should be disinfected with CaviCide™-saturated paper towels between patients. Do not spray disinfectant directly onto chair. Wipe dental chair, operator and assistant stools with paper towels saturated with water only.
  • Countertops: Before each patient arrives, countertops and work surfaces must be wiped with a CaviCide™ wipe. A minimumwaiting period of THREE minutes is necessary before disinfection becomes effective. Again, ensure the surface is kept wetwith the product for the entire time.

For certain procedures, e.g. treatment involving removable prosthetics, brown lab paper sheets are available on cart underAssistance hand piece lube machine in Main Clinic, and must be used to cover countertops under water baths, mixing pads, etc.These must be discarded after each patient.

Dust producing procedures such as plaster or acrylic resin trimming must only be performed in the laboratories.

Suction Lines

High volume suction must be used during any aerosol generating procedures. This includes both high speed and ultrasonic use. Thisis ideally done by the assistant such that the primary operator is able to hold a mouth mirror or retractor, as well as, the hand piece.

Medication Room/Area (applicable to practices with sedation and/or anesthesia)

Not Applicable to Schulich Dental Clinics.

Injectable Medication Vials or Solutions

Not Applicable to Schulich Dental Clinics.

Multidose Vials

Not Applicable to Schulich Dental Clinics.

Aseptic Technique

Not Applicable to Schulich Dental Clinics.

Sharps Safety Program

Exposure Prevention

The primary method of preventing the transmission of blood-borne pathogens (e.g. HBV, HCV, and HIV) to OHCWs is by avoidingoccupational exposures to blood. In the dental setting exposures may occur through percutaneous injuries (e.g. needle puncture orcuts with sharp objects), or by contact with the mucous membranes of the eyes/nose/mouth, or by contact with non-intact skin (e.g.exposed skin that is abraded, chapped or has signs of dermatitis).

The majority of exposures are preventable by following best practices, which include the use of personal protective equipment(PPE), such as gloves, protective eyewear, masks, protective clothing, and safe work habits for the handling and disposal of sharps.

Percutaneous injuries pose the greatest risk of transmission of blood-borne pathogens to OCHWs. Best practices to prevent suchinjuries include the following:

1. Always use extreme caution when passing sharps during four-handed dentistry.
2. Needles should remain capped prior to use.
3. Needles must not be bent, recapped or otherwise manipulated by using both hands.
4. Following use, needles must be recapped as soon as possible by using one-handed scoop technique or a commercialrecapping device. Your large instrument cassettes also have a circular cut out in one corner that is meant for retaining thecap during recapping.
5. When suturing, and while using any other sharp instruments in the mouth including needles, scalpels and scalers, tissuesmust be retracted using appropriate instruments (e.g. retractor, dental mirror), rather than fingers.
6. Burs must be covered with disposable cups when not in use. Remove burs from hand pieces immediately following theprocedure.
7. Identify and remove all sharps from trays before cleaning instruments.
8. Used sharps must be collected in a clearly labelled puncture-resistant biohazard container. Each operatory contains one.
9. When cleaning contaminated instruments by hand, heavy-duty utility gloves, appropriate clothing and long-handledbrushes should be used.

Needle Puncture Protocol

This protocol is to assist any student, staff or faculty member who receive a percutaneous blood borne injury (needle stick injury). Itis the responsibility of the injured party to report their injury quickly to follow the steps outlined below.

10.   During Workplace Health operating Hours (8:30am – 4:00pm):

1. Wash the area immediately after the puncture has occurred (10 – 15 seconds with soap and water) and place abandage on site if required.
   1. Report the injury to your supervisor (student’s supervisor = faculty instructor; staff supervisor= direct supervisor;faculty= assistant director, clinical affairs).
   1. Complete Western’s Accident/Illness/Incident (All) Reporting Form and Investigation Report
   1. Submit the completed report to the Clinic Coordinator. This report will be sent to Workplace Health.
   1. Contact Kristine Brown, R.N. at Workplace Health – 519-661-2111, extension 85472 to inform her of the injury.Kristine will provide instructions for the injured party to come to Workplace Health. If Kristine is unavailable, pleasecontact Workplace Health Reception at 519-661-2111, extension 82047. When possible, the source patient shouldaccompany the injured party to Workplace Health.
   1. If the source patient is unable to accompany the injured party to Workplace Health, provide them with the SourcePatient Package (available in Dispensary) to obtain the recommended blood tests.
   1. Workplace Health will continue to follow-up with the injured party.

11.   Outside of Workplace Health Operating Hours (After 4pm):

• Wash the area immediately after the puncture has occurred (10 – 15 seconds with soap and water) and place a bandageon site if required.
• Report the injury to your supervisor (student’s supervisor = faculty instructor; staff supervisor= direct supervisor; faculty=assistant director, clinical affairs).
• Complete Western’s Accident/Illness/Incident (All) Reporting Form and Investigation Report
• Submit the completed report to the Clinic Coordinator. This report will be sent to Workplace Health.
• The injured party will proceed to University Hospital to obtain the necessary blood tests. When possible, the sourcepatient should accompany the injured party to the hospital.
• If the source patient is unable to accompany the injured party to the Hospital, provide them with the Source PatientPackage (available in Dispensary) to obtain the recommended blood tests.
• The Clinic Coordinator will email Kristine Brown R.N. to inform her of the injury to allow her to follow-up with the injured partythe next business day.
• Workplace Health will continue to follow-up with the injured party.

Biohazard Collection Protocol

Collection of biohazard materials takes place every Thursday at 10:15am. The pickup location is down the hallway adjacent to the

Facilities and Supply Supervisor’s office (DSB 0017).

Biohazard containers including, but not limited to Sharps containers, Mercontainers, etc. can be brought to the biohazard/bloodfreezer storage room (DSB H5) at anytime. All containers MUST be accompanied with the proper biohazard form. Containers andcompleted forms can be left on the metal rack located inside of DSB H5.

A combination key lock has been installed on the door of DSB H5. To gain access to the room enter the code ‘5555’ to open the lockand obtain the key. Return the key to the storage lock and close the lock before leaving the storage room. The storage room is to bekept locked at all times.

One dental assistant from Dispensary will gather the biohazard pick up each Thursday using a cart. The items and correspondingforms are to be brought to the pickup location each Thursday. Once the pickup is complete the Dental Assistant will disinfect boththe cart used for transport as well as the metal rack located in DSB H5.

In the event of a staffing shortage in Dispensary, a dental assistant from another clinic may be called upon to gather the biohazarditems from the storage room and deliver the biohazard containers (and corresponding forms) to the pickup location.

WHMIS practices must be followed at all times when handling biohazard materials. Appropriate PPE must be worn during the transportof these items (gloves, eye protection & a level 1 mask) according to WHMIS regulation.

Empty sharps containers can be included in each department’s weekly order from Dental Supply. Replacement Mercontainers and

any other specialty containers need to be ordered via a special order.

Responsibilities

ResponsibleParty	Duties
Faculty	Follow the outlined protocol.Ensuring the students follow the outlined protocol.
Student	Follow the outlined protocol.Report any accident or injury immediately.Ask Faculty or Staff to clarify protocol when questions arise.
Staff	Follow the outlined protocol.Report any accident or injury immediately.Ask the Clinic Coordinator to clarify protocol when questionsarise.Collection & disposal of sharps containers

Specimen Handling

Not Applicable to Schulich Dental Clinics.

Blood Collection and Testing Devices

Not Applicable to Schulich Dental Clinics.

Dental Radiography

1. Students work in pairs or with an assistant while taking radiographs to reduce the potential for cross- contamination. One freshly gloved individual will be responsible for placing and removing the films intraorally. The assistant will obtain the film, set and operate the controls, and perform all other tasks associated with taking the radiographs, except placement and removal of films. The assistant will work with freshly washed hands.
2. CCD sensors (Schick sensors) are to be covered with plastic sleeve barriers before being used to capture intraoral images. After use, the plastic barrier is removed and the sensor and cable are wiped with CaviWipes and allowed to air dry before being returned to their storage area. These tasks are to be completed while wearing clean gloves.
3. Phosphor plate sensors and analogue films are to be handled as follows. Completed films will be placed on acaviwipe on the countertop by the student or staff member working directly with the patient. When all exposures are taken, the assistant will follow the routines for disinfecting the x-ray bay, and assist the patient to return to the waiting room. The operator will follow the standard routine for developing x-ray film.
4. A single operator will observe the following procedures for obtaining radiographs:

1. Prior to entering the x-ray bay, gloves must be removed and thehand washing routine must befollowed.
   1. The patient must be seated and protected with a lead apron, then the controls are set, and thenecessary films and film holders are obtained.

• Place a facial tissue on the countertop and caviwipe. Re-glove, place the film intraorally and position the x-rayhead, then operate the control.

• Avoid contaminating the controls by covering them with blue barriertape and/or plastic fitted coveringssupplied for each component.

• Place exposed film on the caviwipe on the countertop.

• Upon successful completion of the radiographs: remove lead apron, re-wash your hands, dismiss the patient to the clinic or waiting room, and follow the routines for film developing and x-ray bay disinfection.
• The x-ray bay is disinfected by wiping the x-ray tube and controls, chair switches, film dispenser, countertop,lead apron and chair armrests with the disinfectant disposable clothsavailable in each bay.
• To process the digital (phosphor plate) film, begin by removing moisture from film packets with the facial tissue. Openeach film packet and dispose of the empty film packets in the appropriately basket. Place film in the conveyor slot ofthe automatic film scanner. Remove gloves after feeding all the films into the processor.
• 18.   The process for analogue film is virtually the same except the film is developed in the dark room as it must not be exposed to light, and it is inserted into the automatic chemical processor for development. All other steps are thesame.

Dental Laboratory

Due to the nature of dental prostheses and appliances, the potential of microorganism transmission is high. Therefore, all dentalprostheses and appliances along with all laboratory tools and items used to adjust dental prostheses and appliances must be properly disinfected as per manufacturer’s guidelines and recommendations. The tools and items that must be considered include but are not limited to: burs, polishing points, rag wheels, lab knives, and dental lathes.

General Policies and Procedures

Written IPAC policies and procedures are to be found in the Schulich Dental Clinics IPAC Policy manual. This IPAC policy manual willbe an addendum to the general Student Policy Manual for the Dental Clinics.

The IPAC manual has been written and created to follow the best practices outlined by both Public Health Ontario and the RoyalCollege of Dental Surgeons of Ontario.

Education

Clinic-Specific Education

• New students to Schulich dental clinics receive clinic-specific IPAC education during orientation week. IPAC topicscovered in orientation week include:
• Required PPE
• N-95 respirator policy
• PPE donning and doffing
• Sharps safety
• Blood pressure monitoring
• Cubicle/operatory set-up and clean-up
• Cleaning products
• Reprocessing and dispensary protocols
• COVID-19 specific protocolsOngoing/Continued IPAC Education
• All Schulich Dental students who enter the clinic are expected to complete the Public Health Ontario InfectionPrevention and Control Core Competency modules (10 in total).
• Students are given a deadline at the start of the academic term for when the expected completion date is for the IPACcore competency modules. This deadline is monitored, and students who do not meet the deadline for this are penalizedvia a deficiency report stating lack of professionalism.

Occupational Health and Safety

*Schulich Dental Clinics are subject to Occupational Health and Safety Policies and Standards set forth by Western University.Information on the matter can be found here:

https://www.uwo.ca/hr/safety/index

Additional Resources

• RCDSO – Standard of Practice IPAC

https://az184419.vo.msecnd.net/rcdso/pdf/standards-of-practice/RCDSO_Standard_of_Practice_IPAC.pdf

• Public Health Ontario IPAC Checklist

https://www.publichealthontario.ca/-/media/documents/c/2019/checklist-ipac-dental-core.pdf?sc_lang=en

• Public Health Ontario Reprocessing of Medical Equipment/Devices

https://www.publichealthontario.ca/-/media/documents/c/2019/checklist-clinical-office-reprocessing.pdf?sc_lang=en

• RCDSO Latest COVID-19 Updates

https://www.rcdso.org/en-ca/standards-guidelines-resources/2019-novel-coronavirus/covid-19–managing-infection-risks-during-in-person-care

• MLHU COVID-19 Page

https://www.healthunit.com/novel-coronavirus