CONTINUED Professional Development
Accreditation Number: ODO 002/04/02/20143
Infection prevention and control in optometric practice ABSTRACT KP Mashige BSc BOptom CAS MOptom Discipline of Optometry, School of Health Sciences, University of KwaZuluNatal, Westville Campus, Private Bag X54001, Durban, 4000 South Africa mashigek @ukzn.ac.za
Infection prevention and control procedures in optometric practice are essential to protect both the optometrist and the patient from infection. With the expanded scope of optometric practice in South Africa, the use of certain techniques and procedures may increase the risk for transmission of infections. The use of appropriate office hygiene procedures and universal precautions to prevent exposure to and/or transmission of disease are presented in this article. The article concludes by recommending to the Professional Board for Optometry and Dispensing Opticians (PBODO) that guidelines on infection prevention and control be published as part of the code of conduct for optometrists undertaking clinical care. Key words: Infection, infection control, sterilization, vaccination, universal precautions, disinfection INTRODUCTION Microorganisms such as bacteria, viruses and fungi, are tiny life forms that can only be seen with a microscope and are found in the environment, dust, dirt and body fluids. Although most microorganisms have beneficial effects for humans, such as in digestion and the recycling of waste, some can cause problems when they become too many or spread to places in which they should not be. Patients may present to the optometrist in practice with an infectious illness, either knowingly or unknowingly, and pose a risk of cross infecting the optometrist or passing on the infection to other patients through use of optical devices. Optometrists themselves may also be harbouring infectious disease, which they may be at risk of passing on to their patients. In addition, the practice environment may pose a microbiological hazard and infection risk to both staff and patients. The main routes through which infections may be transmitted are through physical contact, contact with body fluids and via airborne particles.
This CPD educational initiative proudly sponsored by GUESS Eyewear
Distributed by SDM Eyewear: (011) 334-7020
Although the risk of transmission of blood borne viruses (e.g. HIV, hepatitis B and C) in optometric practice is low, the risk of transmission of skin infections (e.g. staphylococcus, herpes simplex, or enteric infections) is more likely, and ophthalmic infections (e.g. bacterial and adenoviral conjunctivitis) are more common1. Most optometric procedures are considered to be low risk for the transmission of disease. However, under some circumstances, such as when instruments coming into direct contact with an infected patient, when exposure to blood occurs, or when cultures are taken, there is the potential for the transmission of disease. There is therefore a need to treat all patients in a uniform manner, including the use of universal infection control precautions. HAND WASHING Hand hygiene is one of the most effective ways to control the spread of infection. Mandatory hand washing is recommended before and after examinations and procedures, as many eye diseases are manually transmittable.
There are two ways to keep hands clean and reduce the risk to patients and the optometrist. Firstly, social hand washing with liquid soap is indicated before and after patient contact, before eating, after cleaning equipment and secondly, after using the toilet. Hygienic hand wash with antiseptic hand cleaner, such as chlorhexidine, is indicated before and after contact lenses patients, after contact with contaminated articles, as well as before and after dealing with patients with known infectious agents1. Cuts and abrasions should be covered with a waterproof plaster, nails should be kept short and clean, and artificial nails should be avoided, as they are a reservoir of gram-negative bacteria even after hand washing1. The use of moisturizers is recommended to avoid dryness that can lead to breaks in the skin. The soap or antiseptic should be dispensed into cupped hands, which should be rubbed vigorously and thoroughly for 10-15 seconds without adding more water. Bar soaps and non-disposable towels should not be used in a clinical setting. PERSONAL PROTECTIVE EQUIPMENT Medical gloves protect the skin from contamination by microorganisms during patient evaluation1. For example, it may be necessary to handle the eyelids or surrounding facial tissue, thus bringing the examiner into contact with potentially infected surfaces. Certain patients and workers may be sensitive to latex allergens, which should be taken into consideration when choosing medical gloves, as they can cause either type 1 or type 4 allergic reactions, including anaphylactic reaction that can be fatal2-4. Powder used in powdered examination gloves can also be toxic to body tissues4, and it is therefore recommended that all medical gloves be powder-free2, 5. Hands should always be washed after removing the gloves. Although gowns are not necessary for routine optometric procedures, masks may be necessary to protect the patient if an optometrist or a staff member is infected with a pulmonary or other disease that is transmittable via airborne means1. Disposable plastic aprons can protect the optometrist’s uniform or clothes from contamination with blood or other infectious material1. Protective eyewear is usually unnecessary. However, face and eye protection, such as goggles or face visors, protect the optometrist’s face in situations of splashes of hazardous liquid or infected blood or body fluid. A respiratory protection, for example a particulate filter respirator (PFR), protects the optometrist from breathing in infectious airborne particles1. HANDLING OF SHARP INSTRUMENTS Precautions should be taken to prevent injuries caused by needles, syringes, or other sharp instruments1. In case of accidental inoculations, the area should be washed with soap and running water, and the injury encouraged to bleed freely. Sucking of the wound should be avoided and a waterproof dressing should be applied1. In the case of intact-skin exposure, the area should be washed immediately with hot soapy water. Non-intact skin exposure should follow similar steps as inoculation injury, while mucous membrane exposure to the mouth should be washed out with copious amounts of water and those to the eyes should be irrigated with sterile water1. It is essential that first aid is carried out quickly for all needle-stick injuries.
Proud sponsors of this CPD Educational Initiative www.sdmeyewear.co.za
Accreditation Number: ODO 002/04/02/20143
Continued Professional DEVELOPMENT
Infection prevention and control in optometric practice INSTRUMENT CLEANING Cleaning involves the removal of organic and inorganic debris from a surface that might support micro-organisms and provide insulation that reduces the efficiency of disinfecting or sterilisation procedures. Detergents and ultrasonic cleaners are frequently used for cleaning purposes and the equipment should not come into close contact with mucous membranes or sterile body areas e.g. trial frames and refractor heads need to be cleaned1. INSTRUMENT DISINFECTION Instruments that come in close contact with body surfaces of intact mucous membranes, such as tonometer heads, gonioscopes and fundus contact lenses, should be wiped and disinfected by chemicals (3% hydrogen peroxide, 0.5% sodium hypochlorite or 70% ethanol or isopropyl alcohol)1. These devices should be rinsed thoroughly with sterile saline and air dried before reuse. INSTRUMENT STERILIZATION Sterilization is a treatment that completely kills or removes all kinds of micro-organism including spores. It can be achieved by ionising radiation, gaseous ethylene oxide, low stream pressure, dry heat or moist heat (Autoclave)1. Sterilization is suitable for equipment introduced into a sterile body area or in contact with a break in the skin or mucous membrane. CONTACT LENS DISINFECTION Contact lens fitters should be familiar with all infection prevention and control guidelines, including proper hand washing and disinfection techniques for in-office use. Trial contact lenses should be disinfected after each use by chemical/hydrogen peroxide or heat disinfection. However, the best practice is the use of single-use trail lenses. Wherever practicable, a contact lenses or ophthalmic device that comes into contact with the ocular surface should not be used on more the one patient. Where it is impractical, suitable items should be decontaminated using a recognized method. Soft contact lenses can be disinfected with an approved hydrogen peroxide system, and some soft lenses can also be heat disinfected1. Gas-permeable lenses can be disinfected with hydrogen peroxide system but not with heat due to the possibility of warping. Hard (PMMA) lenses can be disinfected with hydrogen peroxide system and most can be heat disinfected using the standard heat treatment regimen used for soft lenses (78 to 800 C) for 10 minutes1. Hydrogen peroxide is the only recommended and approved disinfection system for HIV6. Shoff et al7 showed that multipurpose system and hydrogen peroxide have reduced ability to kill ancathamoeba. SPILLAGES Spillages should be cleared up immediately using gloves and aprons, with paper towels being used to absorb the liquid. The use of sodium hypochlorite for blood spills is recommended, and the area should be cleaned with detergent and hot water1. GENERAL CLEANING All surfaces used as a preparation area for dealing with patients must be cleaned regularly. Surfaces should be cleaned with detergent and water, and those contaminated with body fluids surface should be cleaned with detergent and water followed by a chlorine-based disinfectant1. All consulting rooms should have access to a wash hand basin and it is good practice for this to be within the consulting room.
Exclusive Distributors of GUESS Eyewear www.sdmeyewear.co.za
CONCLUSION Workplace infections add to the cost the healthcare industry every year. However, it is possible to significantly reduce the rate of healthcare-associated infections in an optometric practice through effective infection prevention and control measures. Understanding and knowing how and when to apply the basic principles of infection prevention and control is critical to the success of an infection control programme. This responsibility applies to everybody working and visiting an optometric practice, including administrators, staff and patients. Implementing infection control practices in a workplace can break the chain of infection and minimize illness in the office, creating a better working environment. The Health Professions Council of South Africa’s (HPCSA) main mandate is to regulate the profession and protect the public. Through its board, Professional Board for Optometry and Dispensing Opticians (PBODO), it has published a number of registration standards, codes and guidelines to provide guidance to the profession. Effective infection prevention and control for optometrists should be part of the Board’s code of conduct to minimize the risks to patients and the associated costs to the healthcare system from poor infection control practices. The author recommends that the HPCSA, through its professional body, the PBODO, sets infection prevention and control guidelines for optometrists and monitor compliance to the guidelines.
References 1. Tyhurst KN, Hettler DL. Infection control guidelines – An update for the optometric practice. Optometry 2009; 80: 613-620. 2. Miri S, Pourpak Z, Zarinara A, et al. Prevalence of type I allergy to natural rubber latex and type IV allergy to latex and rubber additives in operating room staff with glove-related symptoms. Allergy Asthma Proc 2007; 28:557-563. 3. Reinikka-Railo H, Kautiainen H, Alenius H, et al. Latex allergy: the sum quality of four major allergens shows the allergenic potential of medical gloves. Allergy 2007; 62: 781-786. 4. Lieberman P. Anaphylatic reactions during surgical and medical procedures. J Allergy Clin Immunol 2002; 110: S64-69. 5. Edlich R, Woodard C, Pine S, et al. Hazards of powder of surgical and examination gloves: a collective review. J Long Term Eff Med Implants 2001; 11: 15-27. 6. Centre for Disease Control and Prevention. Recommendations for preventing possible transmission of human T-lymphocytes virus type 111/lymphadenopathy-associated virus from tears. MMWR 1985. 7. Shoff M, Rogerson A, Schatz S, et al. Variable responses of Acanthamoeba strains to three multipurpose lens cleaning solutions. Optom Vis Sci 2007; 84: 202-207.
This CPD educational initiative proudly sponsored by GUESS Eyewear
Distributed by SDM Eyewear: (011) 334-7020
Questionnaire:
INFECTION PREVENTION AND CONTROL IN OPTOMETRIC PRACTICE - VIS59
Accreditation Number: ODO 002/04/02/2014
Available online @ www.visionmag.co.za Multiple choice: Select the most appropriate correct answer
Questionnaire: VIS59
CPD Certificates available online www.visionmag.co.za
Infection prevention and control in optometric practice
Compulsory!!! HPCSA Post test/evaluation form
Published: October 2014
1. The following situations may expose the optometrist to infection: a. Routine contact lens fitting b. Assessment of patients with conjunctivitis c. Assessment of patients with microbial keratitis d. Lacrimal lavage e. All of the above
2. Identify the incorrect statement:
a. A pathogen is any biological agent capable of causing disease b. A reservoir is any place or thing, where an infectious organism can live and multiply, so it can be transmitted to a susceptible host c. Tears are considered infectious body fluids for HIV transmission d. Hand washing is an important means of reducing the transmission of infectious organisms e. None of the above
3. The following statements are true about alcohol-based antiseptics EXCEPT:
Vol.23 No.5 Name:
Title:
Practice address:
PO Box address:
a. They contain isopropanol, ethanol, n-propanol or a combination of two agents b. They are effective against gram positive and gram negative bacteria c. They are effective against bacterial spores, protozoan cysts and certain non-enveloped viruses d. They are effective against mycobacterium and fungi e. They denature proteins and are effective against enveloped viruses (HSV, HIV, influenza)
City:
E-mail address:
Cell:
4. Universal precautions include:
Signature:
Date:
Tel: (
Province: )
Code: Fax: (
a. Assume everybody has everything b. Assume all body secretions and excretions are infectious c. Hand washing before and after every procedure d. Clean spills promptly e. All of the above
Fill in the correct answer below: (One correct answer only)
5. Personal protective equipment to be worn to protect against a hazard include:
1
a. Masks b. Gowns c. Gloves and eye protection d. Respirator e. All of the above
Age:
A B C D E
2
)
(Example: 1.
A B C D E
)
3
4
5
6
7
8
9
A B C D E
10
6. The following are recommended for the applanation tonometer tip disinfection EXCEPT: a. Wipe the tonometer probe clean with a non-abrasive contact lens cleaner b. Disinfect with a 5-minute soak in a 1:10 dilution of bleach, 3% hydrogen peroxide or 70% isopropyl alcohol c. Rinse the tonometer probe with Opti-Kleen wipes d. Air dry the tonometer probe e. Rinse the tonometer probe with tap water
7. The most current recommendations for disinfecting the gonio lens include:
a. Clean the entire lens with mild soap (e.g. dishwashing liquid) b. Disinfect with 2% aqueous glutaraldehyde or 1:10 dilution of household bleach for 25 minutes c. Rinse thoroughly with room temperature water, dry with lint-free soft cloth d. Clean both sides of the anterior glass element and inside of the ring with Volk Precision Optical Cleaner or a Volk LensPen e. All of the above
8. The following cleaning and disinfection procedures apply to RGP contact lenses EXCEPT: a. Should be stored dry b. Should be inspected visually for defects before each use c. Should be cleaned with approved RGP cleaner via digital cleaning for 20 seconds after each use d. Avoid contact with patient’s lids before each use e. Should be cleaned with ultrasonic cleaner for 15 seconds after each use 9. The following cleaning and disinfection procedures apply to softcontact lenses EXCEPT: a. Store disinfected lenses in saline in tightly sealed vials b. Soak the lens in 3% hydrogen peroxide for a minimum of 3 hours after each use c. Clean the lens with a hydrogel lens cleaner via digital cleaning for 20 seconds per side after each use d. Rinse with sterile preserved/aerosol saline after each use e. Inspect visually for defects before each use
10. The recommended cleaning and disinfection procedures for trial disposable contact lenses after use are:
a. Clean contact lenses with a hydrogel lens cleaner via digital cleaning for 20 seconds per side b. Clean the lenses in ultrasonic cleaner for 15 seconds c. Discard lenses d. Clean the lenses
Exclusive Distributors of GUESS Eyewear www.sdmeyewear.co.za
Guidelines for Vision magazine CPD activity submissions 1. All submissions must be completed in full (HPSCA#s, postal and e-mail addresses, telephone number, etc.). Submissions without these details will not be considered for marking. 2. No submissions will be accepted after the article’s closing date. 3. Please allow 4-6 weeks after postage (it must reach our offices no later than closing date) before lodging any queries. 4. Faxed, photocopied, scanned and emailed submissions will NOT be accepted !!! 5. For any queries during office hours, please contact: Ansie e-mail:
cell:
083 4508294
[email protected]
What articles or topics of interest would you like featured in future editions? Suggestions:
Post answer sheet to: Vision magazine CPD, PO Box 308 Magaliessig, 2067
Closing date: 31 JANUARY 2015 Activity valid for 3 months ONLY!! www.visionmag.co.za
