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Appendix A: Infection Prevention Checklist Section II: Direct Observation of Personnel and Patient-Care Practices

Infection Prevention Checklist

Section II:
Direct Observation of
Personnel and Patient-Care Practices

Facility name; Completed by; Date

II.1 Hand Hygiene is Performed Correctly

Elements To Be Assessed Assessment Notes/Areas For Improvement
A. When hands are visibly soiled  Yes No
B. After barehanded touching of instruments, equipment, materials and other objects likely to be contaminated by blood, saliva, or respiratory secretions  Yes No
C. Before and after treating each patient  Yes No
D. Before putting on gloves  Yes No
E. Immediately after removing gloves  Yes No
F. Surgical hand scrub is performed before putting on sterile surgeon’s gloves for all surgical procedures

Note: Examples of surgical procedures include biopsy, periodontal surgery, apical surgery, implant surgery, and surgical extractions of teeth.

 Yes No

II.2 Personal Protective Equipment (PPE) is Used Correctly

Elements To Be Assessed Assessment Notes/Areas For Improvement
A. PPE is removed before leaving the work area (e.g., dental patient care, instrument processing, or laboratory areas)  Yes No
B. Hand hygiene is performed immediately after removal of PPE  Yes No
C. Masks, Protective Eyewear, and Face Shields

a. DHCP wear surgical masks during procedures that are likely to generate splashes or sprays of blood or other body fluids
b. 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
c. DHCP change masks between patients and during patient treatment if the mask becomes wet

 Yes No
D. Gloves

a. DHCP wear gloves for potential contact with blood, body fluids, mucous membranes, non-intact skin, or contaminated equipment
b. DHCP change gloves between patients; do not wear the same pair of gloves for the care of more than one patient
c. DHCP do not wash examination or sterile surgeon’s gloves for the purpose of reuse
d. DHCP wear puncture- and chemical-resistant utility gloves when cleaning instruments and performing housekeeping tasks involving contact with blood or OPIM
e. DHCP wear sterile surgeon’s gloves for all surgical procedures

Note: Examples of surgical procedures include biopsy, periodontal surgery, apical surgery, implant surgery, and surgical extractions of teeth.

f. DHCP remove gloves that are torn, cut, or punctured and perform hand hygiene before putting on new gloves

 Yes No
E. Protective Clothing

a. 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, or OPIM
b. DHCP change protective clothing if visibly soiled and immediately or as soon as possible if penetrated by blood or other potentially infectious fluids

 Yes No

II.3 Respiratory Hygiene/Cough Etiquette

Elements To Be Assessed Assessment Notes/Areas For Improvement
A. 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)  Yes No
B. Tissues and no-touch receptacles for disposal of tissues are provided  Yes No
C. Resources are provided for patients to perform hand hygiene in or near waiting areas  Yes No
D. Face masks are offered to coughing patients and other symptomatic persons when they enter the setting  Yes No
E. Persons with respiratory symptoms are encouraged to sit as far away from others as possible. If possible, a separate waiting area is ideal  Yes No

II.4 Sharps Safety

Elements To Be Assessed Assessment Notes/Areas For Improvement
A. Engineering controls (e.g., self-sheathing anesthetic needles, safety scalpels, needleless IV ports) are used to prevent injuries  Yes No
B. Work practice controls (e.g., one-handed scoop technique for recapping needles, removing burs before disconnecting handpieces) are used to prevent injuries  Yes No
C. 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  Yes No
D. 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)  Yes No
E. 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  Yes No
F. Sharps containers are disposed of in accordance with federal, state and local regulated medical waste rules and regulations  Yes No

II.5 Safe Injection Practices

Elements To Be Assessed Assessment Notes/Areas For Improvement
A. Injections are prepared using an aseptic technique in a clean area free from contaminants or contact with blood, body fluids, or contaminated equipment  Yes No
B. Needles and syringes are used for only one patient (this includes manufactured prefilled syringes and other devices such as insulin pens)

Note: When using a dental cartridge syringe to administer local anesthesia, do not use the needle, syringe, or anesthetic cartridge for more than one patient. Ensure that the dental cartridge syringe is appropriately cleaned and heat sterilized before use on another patient.

 Yes No
C. The rubber septum on a medication vial is disinfected with alcohol before piercing  Yes No
D. Medication containers (single and multidose vials, ampules, and bags) are entered with a new needle and a new syringe, even when obtaining additional doses for the same patient  Yes No
E. Single-dose (single-use) vials, ampules, and bags or bottles of intravenous solutions are used for only one patient  Yes No
F. Leftover contents of single-dose vials, ampules, and bags of intravenous solutions are not combined for later use  Yes No
G. Single-dose vials for parenteral medications are used when possible  Yes No
H. When using multidose medication vials

a. multidose vials are dedicated to individual patients whenever possible
b. multidose vials to be used for more than one patient are kept in a centralized medication area and do not enter the immediate patient treatment area (e.g., dental operatory) to prevent inadvertent contamination of the vial

Note: If a multidose vial enters the immediate patient treatment area it should be dedicated for single-patient use and discarded immediately after use.

c. multidose vials are dated when first opened and discarded within 28 days unless the manufacturer specifies a shorter or longer date for that opened vial

Note: This is different from the expiration date printed on the vial.

 Yes No
I. Fluid infusion and administration sets (i.e., IV bags, tubings, and connections) are used for one patient only and disposed of appropriately  Yes No

II.6 Sterilization and Disinfection of Patient-Care Items and Devices

Elements To Be Assessed Assessment Notes/Areas For Improvement
A. Single-use devices are discarded after one use and not used for more than one patient  Yes No
B. Reusable critical and semicritical dental items and devices are cleaned and heat-sterilized according to manufacturer instructions between patient use

Note: If the manufacturer does not provide reprocessing instructions, the item or device may not be suitable for multi-patient use.

 Yes No
C. Items are thoroughly cleaned according to manufacturer instructions and visually inspected for residual contamination before sterilization  Yes No
D. Food and Drug Administration (FDA)-cleared automated cleaning equipment (e.g., ultrasonic cleaner, instrument washer, washer-disinfector) is used to remove debris to improve cleaning effectiveness and decrease worker exposure to blood  Yes No
E. 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  Yes No
F. After cleaning and drying, instruments are appropriately wrapped/packaged for sterilization (e.g., package system selected is compatible with the sterilization process being performed, hinged instruments are open, instruments are disassembled if indicated by the manufacturer)  Yes No
G. 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.

 Yes No
H. 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  Yes No
I. FDA-cleared medical devices for sterilization are used according to manufacturer’s instructions  Yes No
J. A biologic indicator (i.e., spore test) is used at least weekly and with every load containing implantable items  Yes No
K. Logs for each sterilizer cycle are current and include results from each load and comply with state and local regulations  Yes No
L. After sterilization, dental devices and instruments are stored so that sterility is not compromised  Yes No
M. Sterile packages are inspected for integrity and compromised packages are reprocessed before use  Yes No
N. Instrument packs are not used if mechanical
(e.g., time, temperature, pressure) or chemical indicators indicate inadequate processing (e.g., color change for chemical indicators)
 Yes No
O. The instrument processing area has a workflow pattern designed to ensure that devices and instruments clearly flow from high contamination areas to clean/sterile areas (i.e., there is clear separation of contaminated and clean workspaces)  Yes No
P. Reusable heat sensitive semicritical items that cannot be replaced by a heat stable or disposable alternative are high-level disinfected according to manufacturer’s instructions  Yes No
Q. High-level disinfection products are used and maintained according to manufacturer instructions  Yes No
R. Dental handpieces (including the low-speed motor) and other devices not permanently attached to air and waterlines are cleaned and heat-sterilized according to manufacturer instructions  Yes No
S. If digital radiography is used in the dental setting—

a. FDA-cleared barriers are used to cover the sensor and barriers are changed between patients
b. after the surface barrier is removed, the sensor is ideally cleaned and heat sterilized or high-level disinfected according to the manufacturer’s instructions. If the item cannot tolerate these procedures, then at a minimum, the sensor is cleaned and disinfected with an intermediate-level, EPA-registered hospital disinfectant

Note: Consult with manufacturers regarding compatibility of heat sterilization methods and disinfection products.

 Yes No

II.7 Environmental Infection Prevention and Control

Elements To Be Assessed Assessment Notes/Areas For Improvement
A. Clinical contact surfaces are either barrier-protected or cleaned and disinfected with an EPA-registered hospital disinfectant after each patient. An intermediate-level (i.e., tuberculocidal claim) disinfectant is used if visibly contaminated with blood  Yes No
B. Surface barriers are used to protect clinical contact surfaces that are difficult to clean (e.g., switches on dental chairs, computer equipment, connections to hoses) and are changed between patients  Yes No
C. Cleaners and disinfectants are used in accordance with manufacturer instructions (e.g., dilution, storage, shelf-life, contact time, PPE)  Yes No
D. Regulated medical waste is handled and disposed of according to local, state, and federal regulations  Yes No
E. 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)

Note: The correct type of PPE depends on infectious or chemical agent and anticipated type of exposure.

 Yes No

II.8 Dental Unit Water Quality

Elements To Be Assessed Assessment Notes/Areas For Improvement
A. Dental unit waterline treatment products / devices are used to ensure water meets EPA regulatory standards for drinking water (i.e., ≤ 500 CFU/mL of heterotrophic water bacteria) for routine dental treatment output water  Yes No
B. Product manufacturer instructions (i.e., waterline treatment product, dental unit manufacturer) are followed for monitoring the water quality  Yes No
C. Sterile saline or sterile water is used as a coolant / irrigant when performing surgical procedures

Note: Use devices specifically designed for delivering sterile irrigating fluids (e.g., sterile bulb syringe, single-use disposable products, and sterilizable tubing).

Note: Examples of surgical procedures include biopsy, periodontal surgery, apical surgery, implant surgery, and surgical extractions of teeth.

Yes No

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