Standard Precautions

Background

Standard Precautions are the minimum infection prevention practices that apply to all patient care, regardless of suspected or confirmed infection status of the patient, in any setting where health care is delivered. Standard Precautions include:

1. Hand hygiene.
2. Use of personal protective equipment (e.g., gloves, masks, eyewear).
3. Respiratory hygiene/cough etiquette.
4. Sharps safety (engineering and work practice controls).
5. Safe injection practices (i.e., aseptic technique for parenteral medications).
6. Sterile instruments and devices.
7. Clean and disinfected environmental surfaces.

Each element of Standard Precautions is described in the following sections. Education and training are critical elements of Standard Precautions, because they help DHCP make appropriate decisions and comply with recommended practices.

When Standard Precautions alone cannot prevent transmission, they are supplemented with Transmission-Based Precautions. This second tier of infection prevention is used when patients have diseases that can spread through contact, droplet or airborne routes (e.g., skin contact, sneezing, coughing), and are always used in addition to Standard Precautions. Dental settings are not typically designed to carry out all of the Transmission-Based Precautions (e.g., Airborne Precautions for patients with suspected tuberculosis, measles, or chickenpox) that are recommended for hospital and other ambulatory care settings. Patients, however, do not usually seek routine dental outpatient care when acutely ill with diseases requiring Transmission-Based Precautions.

Nonetheless, DHCP should develop and carry out systems for early detection and management of potentially infectious patients at initial points of entry to the dental setting. To the extent possible, this includes rescheduling non-urgent dental care until the patient is no longer infectious or referral to a dental setting with appropriate infection prevention precautions when urgent dental treatment is needed.

Hand hygiene

Hand hygiene is the most important measure to prevent the spread of infections among patients and DHCP. Education and training programs should thoroughly address indications and techniques for hand hygiene practices before performing routine and oral surgical procedures.

For routine dental examinations and nonsurgical procedures, use water and plain soap (hand washing), or antimicrobial soap (hand antisepsis) specific for health care settings, or use an alcohol-based hand rub. Although alcohol-based hand rubs are effective for hand hygiene in health care settings, soap and water should be used when hands are visibly soiled (e.g., dirt, blood, body fluids). For surgical procedures, A perform a surgical hand scrub before putting on sterile surgeon's gloves. For all types of hand hygiene products, follow the product manufacturer's label for instructions. Complete guidance on how and when hand hygiene should be performed, including recommendations regarding surgical hand antisepsis and artificial nails, can be found in the Guideline for Hand Hygiene in Healthcare Settings.

Key Recommendations for HAND HYGIENE in Dental Settings

1. Perform Hand Hygiene:
   1. When hands are visibly soiled.
   2. After barehanded touching of instruments, equipment, materials, and other objects likely to be contaminated by blood, saliva, or respiratory secretions.
   3. Before and after treating each patient.
   4. Before putting on gloves and again immediately after removing gloves.
2. Use soap and water when hands are visibly soiled (e.g., blood, body fluids); otherwise, an alcohol-based hand rub may be used.

Personal protective equipment

Personal protective equipment (PPE) refers to wearable equipment that is designed to protect DHCP from exposure to or contact with infectious agents. PPE that is appropriate for various types of patient interactions and effectively covers personal clothing and skin likely to be soiled with blood, saliva, or other potentially infectious materials (OPIM) should be available. These include gloves, face masks, protective eye wear, face shields, and protective clothing (e.g., reusable or disposable gown, jacket, laboratory coat). Examples of appropriate use of PPE for adherence to Standard Precautions include:

• Use of gloves in situations involving possible contact with blood or body fluids, mucous membranes, non-intact skin (e.g., exposed skin that is chapped, abraded, or with dermatitis) or OPIM.
• Use of protective clothing to protect skin and clothing during procedures or activities where contact with blood or body fluids is anticipated.
• Use of mouth, nose, and eye protection during procedures that are likely to generate splashes or sprays of blood or other body fluids.

DHCP should be trained to select and put on appropriate PPE and remove PPE so that the chance for skin or clothing contamination is reduced. Hand hygiene is always the final step after removing and disposing of PPE. Training should also stress preventing further spread of contamination while wearing PPE by:

• Keeping hands away from face.
• Limiting surfaces touched.
• Removing PPE when leaving work areas.
• Performing hand hygiene.

The application of Standard Precautions and guidance on appropriate selection and an example of putting on and removal of personal protective equipment is described in detail in the 2007 Guideline for Isolation Precautions.

Key Recommendations for PERSONAL PROTECTIVE EQUIPMENT (PPE) in Dental Settings

1. Provide sufficient and appropriate PPE and ensure it is accessible to DHCP.
2. Educate all DHCP on proper selection and use of PPE.
3. Wear gloves whenever there is potential for contact with blood, body fluids, mucous membranes, non-intact skin, or contaminated equipment.
   1. Do not wear the same pair of gloves for the care of more than one patient.
   2. Do not wash gloves. Gloves cannot be reused.
   3. Perform hand hygiene immediately after removing gloves.
4. Wear protective clothing that covers skin and personal clothing during procedures or activities where contact with blood, saliva, or OPIM is anticipated.
5. Wear mouth, nose, and eye protection during procedures that are likely to generate splashes or spattering of blood or other body fluids.
6. Remove PPE before leaving the work area.

Respiratory hygiene/cough etiquette

Respiratory hygiene/cough etiquette infection prevention measures are designed to limit the transmission of respiratory pathogens spread by droplet or airborne routes. The strategies target primarily patients and individuals accompanying patients to the dental setting who might have undiagnosed transmissible respiratory infections, but also apply to anyone (including DHCP) with signs of illness including cough, congestion, runny nose, or increased production of respiratory secretions.

DHCP should be educated on preventing the spread of respiratory pathogens when in contact with symptomatic persons. Respiratory hygiene/cough etiquette measures were added to Standard Precautions in 2007. Additional information related to respiratory hygiene/cough etiquette can be found in the 2007 Guideline for Isolation Precautions. Recommendations for preventing the spread of influenza are available at: Infection Control in Health Care Facilities | CDC.

Key Recommendations for RESPIRATORY HYGIENE/COUGH ETIQUETTE in Dental Settings

1. Implement measures to contain respiratory secretions in patients and accompanying individuals who have signs and symptoms of a respiratory infection, beginning at point of entry to the facility and continuing throughout the visit.
   1. Post signs at entrances with instructions to patients with symptoms of respiratory infection to (1) cover their mouths/noses when coughing or sneezing; (2) use and dispose of tissues; and (3) perform hand hygiene after hands have been in contact with respiratory secretions.
   2. Provide tissues and no-touch receptacles for disposal of tissues.
   3. Provide resources for performing hand hygiene in or near waiting areas.
   4. Offer masks to coughing patients and other symptomatic persons when they enter the dental setting.
   5. Provide space and encourage persons with symptoms of respiratory infections to sit as far away from others as possible. If available, facilities may wish to place these patients in a separate area while waiting for care.
2. Educate DHCP on the importance of infection prevention measures to contain respiratory secretions to prevent the spread of respiratory pathogens when examining and caring for patients with signs and symptoms of a respiratory infection.

Sharps safety

Most percutaneous injuries (e.g., needlestick, cut with a sharp object) among DHCP involve burs, needles, and other sharp instruments. Implementation of the OSHA Bloodborne Pathogens Standard has helped to protect DHCP from blood exposure and sharps injuries. However, sharps injuries continue to occur and pose the risk of bloodborne pathogen transmission to DHCP and patients. Most exposures in dentistry are preventable; therefore, each dental practice should have policies and procedures available addressing sharps safety. DHCP should be aware of the risk of injury whenever sharps are exposed. When using or working around sharp devices, DHCP should take precautions while using sharps, during cleanup, and during disposal.

Engineering and work-practice controls are the primary methods to reduce exposures to blood and OPIM from sharp instruments and needles. Whenever possible, engineering controls should be used as the primary method to reduce exposures to bloodborne pathogens. Engineering controls remove or isolate a hazard in the workplace and are frequently technology based (e.g., self-sheathing anesthetic needles, safety scalpels, and needleless IV ports). Employers should involve those DHCP who are directly responsible for patient care (e.g., dentists, hygienists, dental assistants) in identifying, evaluating, and selecting devices with engineered safety features at least annually and as they become available. Other examples of engineering controls include sharps containers and needle recapping devices.

When engineering controls are not available or appropriate, work-practice controls should be used. Work-practice controls are behavior-based and are intended to reduce the risk of blood exposure by changing the way DHCP perform tasks, such as using a one-handed scoop technique for recapping needles between uses and before disposal. Other work-practice controls include not bending or breaking needles before disposal, not passing a syringe with an unsheathed needle by hand, removing burs before disassembling the handpiece from the dental unit, and using instruments in place of fingers for tissue retraction or palpation during suturing and administration of anesthesia.

All used disposable syringes and needles, scalpel blades, and other sharp items should be placed in appropriate puncture-resistant containers located close to the area where they are used. Sharps containers should be disposed of according to state and local regulated medical waste rules.

For more information about sharps safety, see the Guidelines for Infection Control in Dental Health-Care Settings—2003, the CDC Workbook for Designing, Implementing, and Evaluating a Sharps Injury Prevention Program, and the CDC Sample Screening and Device Evaluation Forms for Dentistry.

Key Recommendations for SHARPS SAFETY in Dental Settings

1. Consider sharp items (e.g., needles, scalers, burs, lab knives, and wires) that are contaminated with patient blood and saliva as potentially infective and establish engineering controls and work practices to prevent injuries.
2. 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.
3. 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 non-disposable aspirating syringe).
4. Place used disposable syringes and needles, scalpel blades, and other sharp items in appropriate puncture-resistant containers located as close as possible to the area where the items are used.

Safe injection practices

Safe injection practices are intended to prevent transmission of infectious diseases between one patient and another, or between a patient and DHCP during preparation and administration of parenteral (e.g., intravenous or intramuscular injection) medications. Safe injection practices are a set of measures DHCP should follow to perform injections in the safest possible manner for the protection of patients. DHCP most frequently handle parenteral medications when administering local anesthesia, during which needles and cartridges containing local anesthetics are used for one patient only and the dental cartridge syringe is cleaned and heat sterilized between patients. Other safe practices described here primarily apply to use of parenteral medications combined with fluid infusion systems, such as for patients undergoing conscious sedation. Unsafe practices that have led to patient harm include (1) use of a single syringe—with or without the same needle—to administer medication to multiple patients, (2) reinsertion of a used syringe—with or without the same needle—into a medication vial or solution container (e.g., saline bag) to obtain additional medication for a single patient and then using that vial or solution container for subsequent patients, and (3) preparation of medications in close proximity to contaminated supplies or equipment.

Safe injection practices were covered in the Special Considerations section (Aseptic Technique for Parenteral Medications) of the 2003 CDC dental guidelines. However, because of reports of transmission of infectious diseases by inappropriate handling of injectable medications, CDC now considers safe injection practices to be a formal element of Standard Precautions. Complete guidance on safe injection practices can be found in the 2007 Guideline for Isolation Precautions. Additional materials, including a list of frequently asked questions from providers and a patient notification toolkit, are also available.

Key Recommendations for SAFE INJECTION PRACTICES in Dental Settings

1. Prepare injections using aseptic techniqueB in a clean area.
2. Disinfect the rubber septum on a medication vial with alcohol before piercing.
3. Do not use needles or syringesC for more than one patient (this includes manufactured prefilled syringes and other devices such as insulin pens).
4. Medication containers (single and multidose vials, ampules, and bags) are entered with a new needle and new syringe, even when obtaining additional doses for the same patient.
5. Use single-dose vials for parenteral medications when possible.
6. Do not use single-dose (single-use) medication vials, ampules, and bags or bottles of intravenous solution for more than one patient.
7. Do not combine the leftover contents of single-use vials for later use.
8. The following apply if multidose vials are used:
   1. Dedicate multidose vials to a single patient whenever possible.
   2. If multidose vials will be used for more than one patient, they should be restricted to a centralized medication area and should not enter the immediate patient treatment area (e.g., dental operatory) to prevent inadvertent contamination.
   3. If a multidose vial enters the immediate patient treatment area, it should be dedicated for single-patient use and discarded immediately after use.
   4. Date multidose vials when first opened and discard within 28 days, unless the manufacturer specifies a shorter or longer date for that opened vial.
9. Do not use fluid infusion or administration sets (e.g., IV bags, tubings, connections) for more than one patient.