Table of Content

Title Page number

Introduction 1
Infection Control Committee MIHS 3
Organization of Infection control program 5
Administrative Measures 7

Infection Control Practices 9

 Standard Precautions
Hand Hygiene Policy 10

Personal Protective Measures 12

Needle Stick Injury Policy 18

Additional Precaution 20
 Airborne Precaution
 Droplet Precautions
 Contact Precaution
Disinfection & Sterilization 22

Dental Unit Water Quality 27

Managing Spillages 28

Dental Radiology 30

Environmental Cleaning 31

Healthcare Workers Safety 33

Appendix 34

0
Infection Prevention and control Protocol in Margalla
Institute of Health Sciences, Rawalpindi.

INFECTION PREVENTION AND CONTROL:

Purpose
For adequate cross infection control and prevention there is a need to have a common
minimal standard to which all healthcare facilities must adhere to. Secondly a common
standard allows sharing of experiences. Additionally such a program can help to;
 Ensure the well-being of both patients and staff
 Provide a forum to develop and continually update guidelines for recommended
health care surveillance, prevention, and practice.
 Harmonize initial and continuing training programs for health care professionals,
by sharing resources.
 Facilitate access to materials and products essential for hygiene and safety.

SALIENT COMPONENTS OF THE INFECTION PREVENTION AND CONTROL ARE:

1. Basic measures for infection control, i.e. standard and additional precautions
2. Education and training of health care workers
3. Protection of health care workers, e.g. immunization, post exposure prophylaxis
4. Identification of hazards (e.g., handling of sharps, amalgam wastes etc.,) and
minimizing risks
5. Routine practices essential for infection control such as aseptic techniques, use of
single use devices, reprocessing of instruments and equipment, antibiotic usage,
management of blood/body fluid exposure, handling and use of blood and blood
products, sound management of medical waste
6. Effective work practices and procedures, for the management of hospital clinical and
hazardous waste.
7. Incidence monitoring
8. Surveillance: Process surveillance: Monitoring of patient care practices and outcome
surveillance monitoring healthcare associated infections.
9. Infection control in specific situations
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They directly determine the quality and nature of the care that is provided. In addition to
implementing basic measures for infection control, health care facilities should prioritize
their infection control needs and design their programs accordingly.
For ongoing effectiveness, the infection control program should have to be
comprehensive, include surveillance and prevention activities and staff training.

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 INFECTION CONTROL COMMITTEE

Chairman:
Dr.Sadia Sajjad (Assistant Professor Community & Preventive Dentistry Dept.)

S No. MEMBERS DESIGNATION & DEPARTMENT

01 Dr Shahid Ahmad Medical Superintendent (Margalla
General Hospital, Pirwadhai)
02 Dr. Taimur Ashraf Khan Administrator Margalla Dental Hospital
03 Dr. Muhammad Afzal Associate Professor & HOD General
Medicine
04 Dr. Syed Sagheer Hussain Assistant Professor & HOD General
Shah Surgery
05 Dr. Huma Farid Associate Professor Operative Dentistry
06 Dr. Syed Amjad Abbas Assistant Professor Oral Pathology
07 Dr. Seemi Tanvir Assistant Professor General Pathology
08 Dr. Shaukat Shahzad In-Charge Central Sterilization & Store
Department (CSSD)
09 Dr Shahzad Nasir Assistant Professor, Oral Surgery
10 Dr Wasif Awan In Charge, OPD
11 Dr Ghazanfer Ali Khan Assistant Professor, DPT
12 Dr Waqar Mustafa Assistant Professor, Pharm-D

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 ORGANIZATION OF AN INFECTION CONTROL PROGRAM

Hospital Chief Administrator/Administrator and Senior

Medical Management
Infection control strategic planning & Imlementation

Infection Control Committee

Multidisciplinary clinical and non-clinical team

 It includes the senior faculty members from clinical
and basic departments

Infection Control Team

Infection prevention practitioners/assistants

 It includes one junior faculty
member/Demonstrator and one dental/lab
assistant

Fig. 1 Management and the role of various individuals in implementing Infection Control practices.

The Margalla Institute of Health Sciences (MIHS) has an Infection Control Committee
which is led by a senior faculty of Community Dentistry Department along with the
senior faculty members from basic and clinical departments and attached hospitals. The
infection control program consists of a manual which is prepared on National Guidelines
on Infection Prevention and Control in Health Care Settings. The roles and
responsibilities of Infection Prevention &Control committee are as follows:
 Responsible for developing infection control and prevention policies and
procedures based on evidence based guidelines, regulations, or standards.
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 Policies and procedures should be tailored made to our dental settings and
reassessed on a regular basis.
 Ensure supplies for standard precautions (e.g., hand hygiene products, personal
protective equipment etc)
 Provision of job or task specific infection control and prevention education and
training to all dental health care personnel.
 Must meet regularly no less than four times a year
 In an emergency (such as an outbreak), this committee must be able to meet
promptly.
 Oversee, monitor and evaluate the performance of the infection control protocols
 Review and approve a yearly program of activity for surveillance and prevention
 Enforce compliance with basic infection control standards.
 Perform audits of clinical practices related to prevention of infection, e.g., aseptic
techniques, isolation of patients, disposal of healthcare wastes
 Establish and supervene Infection Prevention & Control team.
 The Infection Control Team consisting of infection control practitioners from all
clinical departments and designated staff must have the authority to enforce
Infection Control Practices directly as needed with in their respective
departments.

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 THE INFECTION CONTROL MANUAL
A hospital-associated infection prevention manual containing instructions and practices
for patient care is an important tool. In MIHS, this manual is developed and updated by
the Infection Control Committee. It must be made readily available for health care
workers, by having at least one copy available at all patient care areas including
laboratories. It must be updated in a timely fashion.

INFECTION CONTROL ADMINISTRATIVE MEASURES

Infection Prevention & Control Policy
 Develop and maintain infection prevention and control guidelines
 Provide supplies necessary to adherence to standard precautions
 Assign at least one individual trained in infection prevention responsibility for
coordinating the program
 Develop and maintain written infection prevention & control policy and procedures.
 Allow staff time to attend the infection Prevention &Control training session, which
should include a practical aspect where appropriate.(on –site)
 Place signs to deter unauthorized persons from entering isolation areas.
 Limit staff access to patients with suspected or known infectious diseases
Education and Training of Health Care Workers
Health care workers should be equipped with requisite knowledge, skills and attitudes
for good infection control practices. The infection control team which comprises ofdental
faculty and assistants/staff should:
 Assess training needs of the staff and provide required training through awareness
programs, in-service education and on-the-job training
 Organize regular training sessions for the staff for essential infection control
practices that are appropriate to their job description
 Provide periodic re-training or orientation of staff/students
 Review the impact of training periodically
Staff/faculty/students screening
Staff /students and faculty screening is done for Hepatitis B, C & HIV before induction and
periodically if required by the college.
Vaccination
It is mandatory that all workers are vaccinated for Hepatitis B and vaccination for any
infectious diseases, e.g., Covid-19 as directed by the government agency working for
healthcare sector.

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Surveillance of Hospital associated infections
The ultimate aim of the surveillance is to prevent and/or reduce healthcare associated
infections. The main objective of surveillance are as follows:
 Implement cost-effective interventions based on local priorities, resources, and
institutional objectives.
 Identify, monitor and control outbreaks.
 Evaluate the success and sustainability of Infection Control interventions/practices.
 Process surveillance include monitoring of the Infection Control practices

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 INFECTION CONTROL PRACTICES
Infection control practices can be grouped in two categories
1. Standard precautions
2. Additional (transmission-based) precautions.
Transmission of infections in health care facilities can be prevented and controlled
through the application of basic infection control precautions which can be grouped into
Standard Precautions, that must be applied to all patients at all times, regardless of
whether a patient’s infectious status is confirmed, suspected or presumed, and
Additional (Transmission-Based) Precautions which are specific to modes of
transmission (airborne, droplet and contact).
STANDARD PRECAUTIONS
Purpose:
Treating all patients in the health care facility with the same basic level of “standard”
precautions involves work practices that are essential to provide a high level of
protection to patients, health care workers and visitors.
Responsibility:
Each unit/ward/department head MUST BE responsible for the implementation of the
policy. Following are the components of the standard Precautions:
 Hand washing and antisepsis (hand hygiene)

 Patient placement.

 Use of appropriate personal protective equipment.

 Appropriate handling of patient care equipment and soiled linen if used

 Prevention of needle stick/ sharp injuries

 Respiratory hygiene and cough etiquette

 Environmental cleaning and spills-management and

 Appropriate handling of waste

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 HAND WASHING AND ANTISEPSIS (HAND HYGIENE)
Purpose:
To protect the healthcare workers and community from cross infections
Indications
 Perform hand washing before and after treating each patient and also before
putting on gloves and again immediately after removing gloves.
 Use soap and water when hands are visibly soiled (e.g. after handling any blood,
body fluids, secretions, excretions and contaminated items) otherwise an alcohol
based hand rub may be used.
 In case of using hand rub , apply enough alcohol-based hand rub product to cover
all areas of the hands; rub hands until dry i.e. 20–30 seconds.
 Long sleeves should be rolled up to the elbow before hand washing
 All arm and hand jewelry should be removed during the delivery of healthcare as
these can act as reservoirs and disseminators of infection
 Nails should be worn short and artificial nails and nail polish of any type should
not be worn in the clinical environment
 Hand wash before and after contact with each patient

Recommendations
 Use of an alcohol based hand-rub or waterless antiseptic agent is preferable. In
unavailability of such agent washing with plain soap for a full minute is
recommended.
 All healthcare workers MUST adhere to the hand hygiene policy and non-
compliance should be communicated to the head of the department via
designated infection control team member of the department.
(Hand Hygiene Technical Reference Manual WHO 2009)
Patient placement
The main aim of triage is to assess risk and segregate suspected and/or confirmed
infected patients with transmissible infections. Implementation of the Triage system in
the Accident & Emergency (A&E) and out-patient department IS ESSENTIAL in all
healthcare facilities to prevent cross-infection due to overcrowding.

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10
 USE OF PERSONAL PROTECTIVE EQUIPMENT
Purpose
To protect healthcare workers, patients and community from cross infections
Indication
Personal protective equipment include gloves, protective eye wear (goggles), mask,
apron, gown, boots/shoe covers and cap/hair cover. These SHOULD BE used by:
 Health care workers who provide direct care to patients and who work in
situations where they may have contact with blood, body fluids, excretions or
secretions
 Support staff including medical aides, cleaners, and laundry staff in situations
where they may have contact with blood, body fluids, secretions and excretions
 Laboratory staff, who handle patient specimens
Staff MUST be adequately trained in proper use and be aware that use of personal
protective equipment does not replace the need to follow basic infection control
measures such as hand hygiene.
The following principles guide the use of personal protective equipment:
 Personal protective equipment must be made available for use at ALL times
 Do not share personal protective equipment.
 Change personal protective equipment completely and thoroughly wash hands
each time you leave a patient to attend to another patient or another duty.
 Personal protective equipment SHOULD BE chosen according to the risk of
exposure.
 Avoid any contact between contaminated (used) personal protective equipment
and surfaces, clothing or people outside the patient care area.
Gloves
When to wear
 Wear gloves (clean, non-sterile) when touching blood, body fluids, secretions or
mucous membranes.
Application
 Change gloves between contacts with different patients.
 Change gloves between tasks/ procedures on the same patient to prevent cross
contamination between different body sites.
 DO NOT touch any surface ,item or another patient with contaminated gloves
 Remove gloves immediately after use and before attending to another patient.

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  Used gloves SHOULD BE placed directly into clinical waste bin
 Wash hands immediately after removing gloves.
 Use a plain soap, antimicrobial agent or waterless antiseptic agent.
Masks
When to wear
 Wear a mask to protect mucous membranes of the mouth and nose when
undertaking procedures that are likely to generate splashes of blood, body fluids,
aerosols and secretions.
 Wear surgical masks rather than cotton material or gauze masks. Surgical masks
have been designed to resist fluids to varying degrees depending on the design
of the material in the mask.
 DO NOT reuse disposable masks.
Masks with or without face shield
 Assess risk and wear to protect the mouth and nose from inhalation of respiratory
droplets or splashing or spraying of bodily fluids into the mouth or nose.
 Wear a face shield (eye visor, goggles) to protect mucous membranes of the
eyes, nose, and mouth during activities that are likely to generate splashes or
sprays of blood, body fluids, aerosols & secretions.
 Staff who may be required to wear a respirator mask MUST BE trained on how to
fit the mask to their face for maximum benefit. The FFP2 or N95 particulate
respirators SHOULD BE used when caring for patients with known/ suspected
open pulmonary or laryngeal tuberculosis. It should also be used when managing
patients with highly infectious respiratory tract infections when aerosol generating
procedures (AGPs) are performed.
Protective eyewear/goggles
When to wear
 Wear protective eyewear/goggles to protect the mucous membranes of the eyes
when conducting procedures that are likely to generate splashes of blood, body
fluids, aerosols & secretions. If they are reusable, decontaminate them according
to the manufacturers’ instructions.
Gowns and plastic aprons
When to wear
 Wear a gown (clean, non-sterile) to protect the skin and prevent soiling of
clothing during procedures that are likely to generate splashes of blood, aerosols,
body fluids & secretions. Impermeable gowns are preferable.
 Remove a soiled or wet gown as soon as possible.

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  A plastic apron may be worn on top of the gown to protect exposure to blood,
body fluids & secretions.
 DO NOT reuse disposable gowns and apron.
Caps and boots/ shoe covers
 Caps and boots/shoe covers SOULD BE worn when there is a likelihood of
patient’s blood, body fluids, secretions, splashing, spills or leak onto the hair or
shoes.
 DO NOT reuse disposable caps/shoe covers. They should be discarded
according to the health care facility protocol.
Patient care equipment
 Handle patient care equipment soiled with blood, body fluids, and secretions with
care in order to prevent exposure to skin and mucous membranes, clothing and
the environment.
 Ensure all reusable equipment is cleaned and reprocessed appropriately before
being used on another patient.

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14
15
(Centers for Disease Control and Prevention. Preventing Healthcare- Associated Infections. Available at:
cdc.gov/HAI/prevent/prevention.html. Accessed February 17, 2015.)

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 NEEDLE STICK/SHARPS INJURIES POLICY
Purpose
 To prevent injuries when using needles, scalpels and other sharp instruments or
equipment.
Prevention
 Resheathing needles represents a significant hazard and should be avoided, if
possible, by using safe needle systems.
 If needles are to be re-sheathed then, single-hand Resheathing of needles
(Bayonet Technique) should be practiced.
 NEVER handle sharp instruments by the working end.
 Safe disposal of sharps is essential and they SHOULD BE disposed of at point of
use.
 Needles MUST NOT be bent, sheared, broken, recapped, removed from
disposable syringes, or otherwise manipulated by hand before disposal.
Responsibility
 All staff MUST be aware of sharps disposal and needle stick injury policy
 The Head of departments SHOULD carry out inspection of health care workers
 Needles SHOULD NOT be recapped, bent, broken or disassembled.
 DISPOSE all used needles and sharps instruments in a designated puncture-
resistant sharp container
Management of needle stick injury:
In the event of a skin puncture by a contaminated instrument (needle prick),
 Report the incident IMMEDIATELY.
 Wash the area immediately under running tab water
 DO NOT scrub or suck the wound, encourage bleeding by applying gentle
pressure for three to four minutes whilst continuing to wash the area. Dry area
with paper towel.
 Cover the wound with a water-impermeable sticking plaster and consider double
gloving any hand injury, if continuing to work.
 Seek appropriate medical advice.
 The source patient SHOULD BE identified and arrangements made for a blood
sample to be obtained, with informed consent. This should be tested for the
presence of the blood borne viruses’ hepatitis B, hepatitis C and HIV.
 Arrangements should be made for blood samples to be taken from the staff
member (victim) with informed consent for hepatitis B antibody level.
 Document the incident

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18
 ADDITIONAL (TRANSMISSION-BASED) PRECAUTIONS
Additional (transmission-based) precautions SHOULD BE taken while ensuring
Standard Precautions are maintained. Additional precautions include:
1. Airborne precautions
2. Droplet precautions
3. Contact precautions.
AIRBORNE PRECAUTIONS
 Proper PPE MUST BE maintained
 Proper Ventilation MUST BE ensured.
 Environment surfaces cleaning MUST BE done
 Respiratory hygiene and cough etiquette MUST BE practiced.
Application
 To prevent the spread of microorganisms dispersed as respiratory secretions into
the air, all persons with respiratory symptoms MUST cover their nose and mouth
when coughing or sneezing or wiping and blowing noses with a tissue or mask.
 Ensure education of health workers, patients and visitors regarding respiratory
hygiene.
 POST VISUAL ALERTS at the entrance to healthcare facilities, instructing
persons with respiratory symptoms to practice respiratory hygiene/ cough
etiquette.
DROPLET PRECAUTIONS
Diseases, which are transmitted by this route, include pneumonias, pertussis,
diphtheria, influenza type B, mumps, meningitis and Covid -19 etc. The following
precautions need to be taken:
Application
 Standard precautions MUST BE implemented
 Place patient in a single room (or in a room with another patient infected by the
same pathogen).
 Wear a surgical mask when working within 1-2 meters of the patient
 Place a surgical mask on the patient if transport is necessary.
 Special air handling and ventilation are required to prevent droplet transmission
of infection.

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CONTACT PRECAUTIONS
Diseases which are transmitted by this route include colonization or infection with
multiple antibiotic resistant organisms, enteric infections and skin infections.
Application
 Standard precautions MUST BE implemented.
 Place patient in a single room (or in a room with another patient infected by the
same pathogen). Consider the epidemiology of the disease and the patient
population when determining patient placement
 Wear clean, non-sterile gloves when entering the room.
 Wear a clean, non-sterile gown when entering the room if substantial contact with
the patient, environmental surfaces or items in the patient’s room is anticipated
 Limit the movement and transport of the patient from the room; patients should
be moved for essential purposes only. If transportation is required, use
precautions to minimize the risk of transmission.

(Centers for Disease Control and Prevention. Preventing Healthcare- Associated Infections. Available at:
cdc.gov/HAI/prevent/prevention.html. Accessed February 17, 2015)

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 DISINFECTION AND STERILIZATION
Purpose
To limit the spread of infectious agents through instruments
Cleaning
Prior to any reprocessing to achieve disinfection or sterility all instruments and
equipment MUST BE cleaned. If not cleaned properly, organic matter may prevent the
disinfectant from having contact with the instrument/equipment and may also bind and
inactivate the chemical activity of the disinfectant. If an instrument/equipment is unable
to be cleaned then it is unable to be sterilized or disinfected. After an instrument has
been used, prior to it drying, it should be washed to remove any gross soiling. At this
stage, detergent and water is appropriate to use.
There are different methods used for cleaning of instruments and equipment:
1. Manual cleaning
 All surfaces of the instrument/equipment MUST BE cleaned taking care to
reach all channels and bores of the instrument. If instruments are being
washed manually the following procedure should be followed:
 Wear personal protective equipment (plastic apron, thick rubber gloves, eye
protection, surgical mask and/or face shield),
 Any gross soiling MUST BE cleaned on the instrument by rinsing in tepid
water (15-18 degrees),
 Take instrument apart – fully and immerse all parts in warm water with a
biodegradable, non-corrosive, nonabrasive, low foaming and free rinsing
detergent or use an enzymatic cleaner if necessary,
 All visible soil MUST BE removed from the instrument – follow manufacturers’
instructions, • Rinse in hot water (unless contraindicated),
 Dry the instrument either in a drying cabinet, or hand dry with clean lint-free
cloth,
 Inspect to ensure the instrument is clean.
2. Ultrasonic cleaners and automated washers
Ultrasonic cleaners and automated washers are recommended for cleaning basic
instruments that can withstand this process. Using a machine to wash the instruments
will cut down on the handling of the instruments. These cleaners must be used
according to the manufacturers’ instructions. Ultrasonic cleaners do not disinfect the
instruments. By causing high frequency, high-energy sound waves to hit the
instrument/equipment, the soiling matter drops off the instrument, or becomes easy to
remove during the rinsing process.

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DISINFECTION
Purpose
Disinfection removes micro-organisms without complete sterilization. Disinfection is
used to destroy organisms present on delicate or heat-sensitive instruments which
cannot be sterilized or when single use items are not available. Disinfection is not a
sterilizing process and MUST NOT be used as a convenient substitute for sterilization.
Certain products and processes will provide different levels of disinfection.
These levels are classified as:
1. High-level disinfection: Destroys all micro-organisms except some bacterial spores
(especially if there is heavy contamination).
2. Intermediate disinfection: Inactivates Mycobacterium tuberculosis vegetative bacteria,
most viruses and most fungi, but does not always kill bacterial spores.
3. Low-level disinfection: Can kill most bacteria, some viruses and some fungi, but
cannot be relied on to kill more resistant bacteria such as M. tuberculosis or bacterial
spores.
The two methods of achieving disinfection are thermal and chemical disinfection

1. Thermal disinfection (pasteurization)

If an instrument is able to withstand the process of heat and moisture and is not
required to be sterile, then thermal disinfection is appropriate. By using heat and water
at temperatures that destroy pathogenic, vegetative agents, this is a very efficient
method of disinfection.
The level of disinfection depends on the water temperature and the duration the
instrument is exposed to that temperature.
2. Chemical disinfection
The performance of chemical disinfectants is dependent on a number of factors
including: temperature, contact time, concentration, pH, presence of organic or
inorganic matter and the numbers and resistance of the initial bio burden on a
surface. Disinfectants are classified as high, intermediate or low level. When used
according to the manufacturers’ guidelines, disinfectants will fall into one of these
levels.

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Level of Disinfection
Activity against microbes

High level chemical disinfectant

Inactivates all microbial pathogens except where there are large numbers of bacterial
spores
Intermediate level disinfectant
Inactivates all microbial pathogens except bacterial spores
Low level disinfectant
Rapidly inactivate most vegetative bacteria as well as medium sized lipid-containing
viruses, but may not destroy bacterial spores, mycobacteria, fungi or small non-lipid
Selection of disinfectant
There is no single ideal disinfectant. Different grades of disinfectants are used for
different purposes. Only instrument grade disinfectants are suitable to use on medical
instruments and equipment. Hospital grade or household grade disinfectants must not
be used on instruments, they are only suitable for environmental purposes. Monitoring
of the disinfectant is important if it is a multi-use solution.
It is important that it is stored correctly and according to the manufacturer’s instructions.
Be sure not to contaminate the solution when pouring out for use.
Glutaraldehyde is generally the most appropriate chemical disinfectant that will provide
high-level disinfection. This chemical must be used under very strict controlled
conditions and in a safe working environment. Glutaraldehyde 2% is an appropriate high
level disinfectant for endoscopes, respiratory therapy equipment and for material that is
destroyed by heat. An immersion time of > 20 min is required. It is extremely important
that meticulous mechanical cleaning must always precede sterilization or disinfection
procedures. For the selection of disinfectants see APIC Guideline for selection and use
of disinfectants (1996.)
STERILIZATION
Sterilization is the destruction of all micro-organisms and can be achieved by either
physical or chemical methods. Sterilization is necessary for medical devices penetrating
sterile body sites. Cleaning to remove visible soiling in reusable equipment SHOULD
ALWAYS precede sterilization. All materials must be wrapped before sterilization. Only
wrapped/packed sterilized materials SHOULD BE described as sterile. Before any

23
instrument or equipment goes under the process of steam sterilization, the following
should be checked:
1. Ensure that the instrument can withstand the process (e.g. steam under pressure),
2. Ensure that the instrument has been adequately cleaned
3. Ensure that the instrument does not require any special treatment
Instruments and equipment will only be sterile if one of the following sterilizing
processes is used:
1. Steam under pressure (moist heat)
2. Dry heat
3. Ethylene oxide
Sterilization in M.I.H.S
Initial debridement done in the departments by placing the instruments in a tray full of
disinfectant for preventing them from drying.
Instruments are carried to CSSD (Central sterilization services department) in sealed
red bucket
In CSSD they are cleaned in an ultrasonic bath cleaner then rinsed with tape water.
Instruments are dried, pouched and sealed and are sterilized in an autoclave for 15
mins at 121˚C & 15 lbs pressure. This is the most efficient and reliable method to
achieve sterility of instruments and equipment. This method sterilizes and dries the
sterile package as part of the cycle.
Wrapped instruments MUST BE stored in a clean and dry location such as a drawer or
in an enclosed area.
From Storage & Distribution counter sterilized instruments are distributed to the
respective departments in blue buckets
(National guidelines infection Prevention & Control, NIH 2020)

Surface Asepsis
Purpose
Surface Asepsis Surface asepsis is a set of procedures that prevent or remove
contamination from surfaces. Uncovered surfaces within the confine of the dental
operatory are prone to be contaminated by splatters, aerosols, direct touch, etc. Eating,
drinking and handling of contact lenses are therefore not advisable in the operative
areas.

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Limit of Contamination (Zoning)
The area for cleaning and processing used instruments (Dirty Zone), the area for
holding sterilized and clean instruments (Clean Zone), and the area for patient
treatment (Working Zone) MUST BE clearly delineated from one another. It is essential
to ensure a unidirectional flow of items from the Clean Zone to the Dirty Zone.
Surface barriers
 Impervious barriers MUST BE employed to protect equipment and areas that are
difficult to decontaminate and are vulnerable to contamination during patient
treatment. Caution should be exercised when removing these barriers to prevent
contamination of the area or equipment protected.
Aspiration and ventilation
 The use of high volume aspiration will reduce any risk of cross-infection from
aerosols.
 Good ventilation SHOUL BE used to avoid hazard risk.
 The tubing of high volume aspirators and saliva ejectors SHOULD BE flushed
with water between patients and with disinfectant (sodium hypochlorite, 0.1%)
regularly or according to the manufacturer’s instructions.
Surface Disinfection
Surface disinfection can be achieved with either intermediate-level or low-level
disinfectants. Intermediate-level disinfectants are those registered with the US
Environmental Protection Agency (EPA) as "hospital disinfectants" with "tuberculocidal"
activity. They include phenolics, iodophors, and chlorine-containing compounds. Low-
level disinfectants are those registered with EPA as “hospital disinfectants” exclusive of
“tuberculocidal” activity e.g. alcohol, quaternary ammonium compounds.
Decontamination of impressions and prosthetic appliances
 Impressions and appliances SHOULD be rinsed thoroughly to remove all visible
blood and debris.
 Gloves SHOULD be worn when handling impressions and pouring models.
 Certain types of impression material (silicone, polysulphur) can be disinfected by
total immersion in Sodium hypochlorite (0.1%).
 Other materials (alginate, polyether) may be disinfected by submerging for several
seconds in Sodium hypochlorite (0.1%), which should then be wrapped in a
hypochlorite saturated paper towel and kept in a closed container for the
recommended disinfectant time.
 Prosthetic appliances received from a laboratory SHOULD be disinfected prior to
insertion into the patient’s mouth.

25
 (2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare
Settings www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf)

26
 DENTAL UNIT WATER QUALITY
Purpose
To ensure safe water supply during the procedures and limit cross infection.
Recommendation
 Use water which meets drinking water criteria for routine dental treatment output
water
 Follow the recommendation for monitoring water quality provided by the
manufacturer of the unit or waterline treatment product.
 Use sterile saline or sterile water as coolant during surgical procedures

(CDC Dental Unit Water Quality http://www.cdc.gov/oralhealth/infectioncontrol/questions/dental-

unit- water-quality.html

27
 MANAGING SPILLAGES GUIDANCE
Purpose
To avoid spillage in healthcare facility and limit hazardous effect in case accidental
spillage occurs
Steps to manage spillage
 Use other absorbent granules or absorbent pads to contain the spill.
 Put on appropriate PPEs. Use plastic scoop or other mechanical means to
remove any broken glass or other sharp objects from the spill area, and dispose
into the sharp container
 Sprinkle absorbent granules over the spill and leave for two minutes or as per the
manufacturer’s recommended contact time. Allow the spill to solidify before
removing.
 Remove the solidified waste material using the scoop and scraper and carefully
dispose all contaminated materials into the infectious waste bag.
 If there are no available absorbent granules, contain the spill by placing
absorbent pads (i.e. paper towel) on top of the spill and apply the appropriate
disinfectant.
 To avoid creating aerosols, never spray disinfectant directly onto the spilled
material. Instead, gently pour disinfectant on top of paper towels covering the
spill or gently flood the affected area, first around the perimeter of the spill, then
working slowly toward the spilled material. If sodium hypochlorite solution (5.25%
household chlorine bleach) is used, prepare a fresh solution on a daily basis.
Leave for the recommended contact time.
 Pick up all absorbent material and carefully place in the infectious yellow bag for
disposal. Remove PPEs and place in a yellow bag for disposal. Seal the yellow
bag.
 Wash hands thoroughly with soap and water. Contact housekeeping to clean the
affected area with hospital-approved disinfectant.
(CDC guidelines of infection control in dentals settings, 2016.)

Dental Amalgam:
The following are best management practices for amalgam waste:
 Amalgam waste, amalgam capsules and extracted teeth that contain amalgam
restorations MUST NOT BE placed in biohazard containers, infectious waste
containers or regular garbage.
 Amalgam waste MUST NOT BE flushed down the drain or toilet.
 Devices containing amalgam SHOULD NOT BE rinsed under running water over
drains or sinks as this could introduce dental amalgam into the waste stream.
 Encapsulated alloys and a variety of capsule sizes SHOULD BE used to
minimize the amount of amalgam waste generated.

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  Bulk mercury SHOULD NOT be used. Chair-side traps, vacuum pump filters, or
amalgam separators should be used to retain amalgam.
 Line cleaners that minimize dissolution of amalgam should be used. The use of
bleach or chlorine-containing cleaners to flush wastewater lines should be
avoided.
 All contact and non-contact scrap amalgam should be salvaged and stored in
separate, appropriately labeled containers.
 Amalgam waste SHOULD BE stored in wide-mouthed, covered, rigid plastic
container.
 After mixing amalgam, the empty capsules SHOULD BE placed in a wide-
mouthed, container that is marked “Amalgam
 Capsule Waste for Recycling.” The container lid SHOULD BE well sealed. When
the container is full, it should be sent to a recycler.
 Any defective capsules that cannot be emptied should be placed with the non-
contact scrap amalgam so they can be recycled (the amalgam recycler should be
asked if they will take capsules with scrap amalgam).
Application
 The department Head along with the member of infection control team (Junior
faculty member/assistant) MUST train staff to prevent any spillage or how to
handle if faced by this situation
 There MUST be documentation of spillage in the department
 There MUST be availability of spillage kit in the facility.

(Guidelines for Infection Control in Dental Health-Care Settings—2003 (available at: www.cdc.
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gov/mmwr/PDF/rr/rr5217.pdf)

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 DENTAL RADIOLOGY PROTOCOL
When taking radiographs for patients, ensure that;
 Workplace SHOULD BE properly designed
 Prevent contamination of the processing equipment
 Appropriate shielding (lead apron) MUST BE used.
 Gloves MUST BE used to position film, holder and tube
 Tube head and surfaces MUST BE disinfected
 Bite blocks and holders can be sterilized.
Film processing in clinics using darkrooms
 Remove any saliva/blood on the film pack with paper towels.
 Open the film pack (dirty) inside the dark room and let the exposed film drop onto
a clean paper towel or surface barrier.
 Be sure not to contaminate the film.
 Put on a new pair of gloves and take the clean film for development.

Processing of digital radiographic plates

 Wrap and seal the digital plate with barrier(s) before exposure.
 Remove the barrier(s) and let the clean plate drop onto a clean surface afterward.
 These plastic barriers are carefully removed to maintain asepsis and are
discarded between patients
 Put on a new pair of gloves and take the plate for scanning. In case of plate
contamination, follow manufacturers’ instructions for disinfection

(American Dental Association Council on Scientific Affairs. The use of dental radiographs: update
and recommendations. J Am Dent Assoc. 2006;137:1304–1312)

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 ENVIRONMENTAL CLEANING
Purpose:
To ensure clean hospital environment for patient safety and decrease in hospital
associated infections.
The constant contamination of the environment with microorganisms occurs from
infected and/or colonized patients, staff, and visitors. Therefore, regular and thorough
cleaning of environmental surfaces, items and equipment is essential to reduce bio
burden, to minimize transfer of pathogens directly via hands touching the contaminated
environmental surface or indirectly via contaminated hands, items, and equipment.
Various types of products are used for the cleaning and disinfection of environmental
surfaces. For effective disinfection of surfaces, after thorough cleaning, apply
disinfectants using the manufacturer’s recommendations for dilution and contact time
The following products are used in environmental cleaning:
 Neutral detergent
 Alcohol 60–70% (ethanol or isopropanol)
 Chlorine releasing agents (for example, sodium hypochlorite,
bleach 0.5%-1% available
 Hydrogen peroxide
 Clear soluble phenolics (1-2%)
 Quaternary ammonium

Measurements of cleanliness

 Visual inspection
 For microorganisms like HBV, HCV, HIV and CCHF, terminal cleaning are
done with a detergent followed by hypochlorite.

Application
 The designated staff of all the department to perform environmental disinfection
daily
 The sanitary workers Should be cleaning the hospital surfaces daily

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Figure 6: Showing source of cross infection and steps to break the chain of transmission

(Centers for Disease Control and Prevention. Preventing Healthcare- Associated Infections. Available at:
cdc.gov/HAI/prevent/prevention.html. Accessed February 17, 2015)
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 HEALTHCARE WORKERS SAFETY
Staff
Safety
Purpose
To ensure safety of staff in clinical settings by applying administrative and engineering
controls
Hazards control
Chemical disinfectants are hazardous substances and may cause damage on contact
with the skin, eyes, or mucous membranes by inhalation of vapours or by absorption
through the skin. The following points should be kept in mind when using chemical
disinfectants:
 All chemical disinfectants MUST BE clearly labelled and used before the
expiry date. They SHOULD BE freshly prepared and must be used at the
correct concentration and stored in an appropriate container.
 Disinfectants can be corrosive and may damage fabrics, metals, and plastics.
 Manufacturers’ instructions must be consulted on compatibility of materials
with the method of sterilization or disinfection.
(IPC Guidelines, National institute of health)

Screening
MIHS providing screening to all the staff, faculty and students of hepatitis B & C and
HIV
Vaccination
Healthcare workers are at risk of acquiring and transmitting infections through
occupational exposure with potential contact with patients, their blood or body
substances in health care settings. Protection against some infectious diseases can be
achieved through vaccination.
MIHS Policy on Vaccination
 All the administrative, healthcare staff, faculty and students are vaccinated
against hepatitis B & C and covid -19.
 Vaccination is mandatory for new employer induction
 Record of screening and vaccination is maintained with HR department and
student affair Department.

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 APPENDIX
Checklists for Implementation and Monitoring I: Hand

Hygiene checklist
Elements To Be Assessed Yes No
When hands are visibly soiled then perform hand hygiene
After barehanded touching of instruments, equipment,
materials and other objects likely to be contaminated by
blood, saliva, or respiratory secretions, hand hygiene
performed
Before and after treating each patient
Immediately after removing gloves
Surgical hand scrub is performed before putting on sterile
surgeon’s gloves for all surgical procedures

II: Personal Protective Equipment (PPE) is Used Correctly

Elements to be assessed Yes No

PPE is removed before leaving the work area (e.g., dental
patient care, instrument processing, or laboratory areas)
Hand hygiene is performed immediately after removal of
PPE
DHCP wear surgical masks during procedures that are
likely to generate splashes or sprays of blood or other body
fluids
DHCP wear eye protection with solid side shields or a face
shield during procedures that are likely to generate splashes
or sprays of blood or other body fluids
DHCP change masks between patients and during patient
treatment if the mask becomes wet
DHCP wear puncture- and chemical-resistant utility gloves
when cleaning instruments and performing housekeeping
tasks involving contact with blood etc
DHCP wear protective clothing (e.g., reusable or disposable
gown, laboratory coat, or uniform) that covers personal
clothing and skin (e.g., forearms) likely to be soiled with
blood, saliva

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III: Respiratory Hygiene checklist
Element to be assessed Yes No
Signs are posted at entrances (with instructions to patients
with symptoms of respiratory infection to cover their mouths /
noses when coughing or sneezing, use and dispose of tissues,
and perform hand hygiene after hands have been in contact
with respiratory secretions)
Resources are provided for patients to perform hand hygiene
in or near waiting areas
Face masks are offered to coughing patients and other
symptomatic persons when they enter the setting

IV: Sharp Safety Checklist

Elements to be assessed Yes No

Work practice controls (e.g., one-handed scoop
technique for recapping needles, removing burs
before disconnecting handpieces) are used to prevent
injuries
DHCP do not recap used needles by using both
hands or any other technique that involves directing
the point of a needle toward any part of the body

DHCP use either a one-handed scoop technique or a

mechanical device designed for holding the needle
cap when recapping needles (e.g., between multiple
injections and before removing from a reusable
aspirating syringe)

All sharps are disposed of in a puncture-resistant

sharps container located as close as possible to the
area in which the items are used

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V: Sterilization and Disinfection of Patient-Care Items

Elements to be assessed Yes No

Single-use devices are discarded after one use and not
used for more than one patient
Items are thoroughly cleaned according to manufacturer
instructions and visually inspected for residual
contamination before sterilization
Work-practice controls that minimize contact with sharp
instruments (e.g., long-handled brush) are used and
appropriate PPE is worn (e.g., puncture- and chemical-
resistant utility gloves) if manual cleaning is necessary
After cleaning and drying, instruments are appropriately
wrapped/packaged for sterilization
A chemical indicator is used inside each package. If the
internal indicator is not visible from the outside, an exterior
chemical indicator is also used on the package
Note: The chemical indicators may be integrated into
the package design.

Sterile packs are labeled at a minimum with the sterilizer

used, the cycle or load number, the date of sterilization,
and if applicable an expiration date
A biologic indicator (i.e., spore test) is used at least weekly
and with every load containing implantable items
Logs for each sterilizer cycle are maintained
After sterilization, dental devices and instruments are
stored so that sterility is not compromised
Reusable heat sensitive semi critical items that cannot
be replaced by a heat stable or disposable alternative
are high-level disinfected according to manufacturer’s
instructions
Dental hand pieces (including the low-speed motor) and
other devices not permanently attached to air and
waterlines are cleaned and heat-sterilized according to
manufacturer instructions

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VI: Environmental Infection Prevention and Control

Element to be assessed Yes No

Clinical contact surfaces are either barrier-protected or
cleaned and disinfected with an EPA-registered hospital
disinfectant after each patient
Cleaners and disinfectants are used in accordance with
manufacturer instructions (e.g., dilution, storage, shelf-life,
contact time, PPE)
Regulated waste disposal is done
DHCP engaged in environmental cleaning wear appropriate
PPE to prevent exposure to infectious agents or chemicals
(PPE can include gloves, gowns, masks, and eye protection)

(https://www.cdc.gov/oralhealth/infectioncontrol/summary-infection-prevention-practices/appendix-a-
section2.html)

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