TOSHA Compliance for Dental Offices

1. TOSHA Compliance for Dental Offices

2. TOSHA believes the information in this presentation to be accurate and delivers this presentation as a community service. As such, it is an academic presentation which cannot apply to every specific fact or situation; nor is it a substitute for any provisions of 29 CFR Part 1910 and/or Part 1926 of the Occupational Safety and Health Standards as adopted by the Tennessee Department of Labor and Workforce Development or of the Occupational Safety and Health Rules of the Tennessee Department of Labor and Workforce Development.

3. TOSHA required: Safety & Health Programs For Dentistry • Bloodborne Pathogens Exposure Control Plan Sharps Injury Prevention Sharps Injury Log • Hazard Communication Plan • Hazard Assessment for Selection of PPE • TB • Emergency Action Plan http://www.osha.gov/SLTC/dentistry/control.html

4. Bloodborne Pathogens1910.1030 Written Exposure Control Program (ECP) • Engineering Controls (safer medical devices) • Personal Protective Equipment • Hepatitis-B vaccine and Antibody Test • Confidential Follow-up (Exposure Incident) • Bio-Hazard Labels • Initial and Annual Training • Sharps Injury Log / Sharps Injury Prevention http://osha.gov/SLTC/bloodbornepathogens/indes.html

5. Other Potentially Infectious Materials--OPIM • Semen • Vaginal secretions • Cerebrospinal fluid • Pleural fluid • Pericardial fluid • Peritoneal fluid • Amniotic fluid • Saliva in dental procedures • Any visibly contaminated body fluid • Any body fluid where differentiation is difficult • Any unfixed tissue or organ

6. Universal Precautions (Standard Precautions) • Must be observed • Include in Exposure Control Plan • What is/are universal precautions? • All blood and body fluids are treated as if known to be infected with HIV, HBV, HCV, etc.

7. Engineering and Work Practice Controls • Safety Engineered Devices • Hand-washing facilities • No Recapping, bending, breaking, shearing, etc. of needles • No Eating, drinking in the workplace • Handling, storing, transporting specimen

8. Personal Protective Equipment • Parenteral exposure • stick or cut • Mucous membrane • splash • Non-intact skin • spill or splash • gloves • gowns • glasses/ goggles • masks • pocket masks

9. Housekeeping • Written cleaning schedule • Decontaminate with appropriate disinfectant • http://www.epa.gov/oppad001/chemregindex.htm • EPA registered tuberculocidal disinfectant • EPA registered disinfectant with label stating it is effective against HIV and HBV • Household bleach, diluted 1:10-1:100, made fresh daily • Ensure correct contact time (let air dry w/bleach)

10. Regulated Waste • Sharps containers • Immediate Disposal • Needles • Blades • Broken glass • Red bags • Liquid or semi-liquid blood or OPIM • Items caked with dried blood or OPIM • Items that could release blood or OPIM • Pathological waste • Microbiological waste

11. HBV Vaccinations • Offer to all persons with reasonably anticipated exposure to blood or OPIM • Offered within ten working days of initial exposure • At no cost to the employee • Test for antibody to Hepatitis B surface antigen 1-2 months after completion of the three-dose vaccination series • Sign declination statement

12. Labels • Fluorescent orange or orange-red background • Letters in contrasting color • Regulated waste • Refrigerators/freezer • Containers used to store, ship, transport contaminated reusable equipment – dental “picks”

13. Training • For all employees listed in the Exposure Determination • At no cost to employees • During working hours • At the time of initial assignment • Annually--within 1 year of last training date • Must be opportunity for interactive questions and answers • Train employees on adopted safer needle devices before implementation • Bloodborne Pathogens and specifics of site Exposure Control Plan

14. Exposure Control Plan Training • What does "Universal Precautions" mean? (Universal Precautions – all human blood and certain human body fluids are treated as if known to be infectious for HIV, HBV, and other bloodborne pathogens.) • What do you do when there is a blood or OPIM spill? • What personal protective equipment must be worn during cleanup? • What cleanup and disposal procedures are used? • What disinfection procedures are used (what are the chemical hazards of the sanitizers used and what is the contact time)? (PPE worn if sprayed?) • Have you been offered an HBV vaccination series free of charge? Titer? Declination statement? Doctor’s Written Opinion? • Where is the employer's written Bloodborne Pathogen Exposure Control Plan, has it been explained to you, and have you been trained in its procedures?

15. The Needlestick Problem • Among healthcare workers, there are an estimated 600,000 to 800,000 percutaneous injuries occur each year • Many needle-sticks are not reported • 2006 – TOSHA Special Emphasis – Ambulatory Surgery Centers & Hospitals – In 2012, a 22% reduction

16. Problem with Sharps Up to 80% of All Accidental Exposures to Blood Are Caused by Needle-sticks and Other Contaminated Sharps. Source: OSHA: “Safer Medical Devices: Protecting Healthcare Workers” 1997

17. Needle sticks in Dental Practice • 1/3 of exposures - non-disposable local anaesthetic syringes, usually during removal and disposal of the needle. • “20-26” exposures within 1 million hours worked. • “0” exposures with safety occurred within 1 million man hours. • **Needle sheath prop – one handed removal technique

18. Sharps Injury Prevention Each employer must use “Safer Medical Devices” that are appropriate, commercially available, and effective: Employers can no longer refuse to buy safety devices because of cost or lack of efficacy data • Sharps with engineered sharps-injury protections; • Needle-less systems NOTE: definitions added to therevised standard January 18, 2001.

19. Sharps Injury Log / Sharps Injury Prevention • Confidential • Type and brand of device involved in the incident • Department or work area where the exposure incident occurred • Explanation of how the incident occurred • Action resulted from investigation - prevention

20. Infection Control: Recommendations • Practices for the dental laboratory • Receiving area • Incoming cases • Disposal of waste materials • Production area • Outgoing cases • CDC http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5217a1.htm

21. Hazard Communication/GHS1910.1200 • Written Program – http://www.state.tn.us/labor-wfd/Wtdbooklet.pdf • Safety Data Sheet for each product containing hazardous chemicals • All chemical products must be labeled - mixtures • Training on specific chemicals used, hazards, first aid, and prevention • GHS – December 1th, 2013

22. GHS Elements Classification A description of the hazard and its severity. For example: Reproductive Toxicity: Category 2 Standardized phrases and codes that describe the nature of the hazard. For example: H315 - Causes skin irritation Hazard Statements Standardized phrases and codes giving advice about the correct management of chemical substances and mixtures. For example: P264 - Wash hands thoroughly after handling Precautionary Statements Words that are used to emphasize hazards and indicate the relative level of severity of the hazard.  For example: Danger or Warning Signal Words Symbols that indicate the health, physical or environmental hazards. Pictograms

23. Pictograms GHS Pictograms and Hazard Classes Physical Oxidizers Flammable Self Reactives Pyrophorics Self-Heating Emits Flammable Gas Organic Peroxides Explosives (Divisions1.1 to 1.4 only) Self Reactives Organic Peroxides Corrosive to Metals Gas Under Pressure Health Environmental Acute Toxicity (severe) Irritant Dermal Sensitizer Acute Toxicity (harmful) Skin Corrosion Serious Eye Damage/Eye Irritation Aquatic Toxicity (acute) Aquatic Toxicity (chronic) Carcinogen Respiratory Sensitizer Reproductive Toxicity Target Organ Toxicity Mutagenicity Aspiration Toxicity

24. Hazard CommunicationLabels • Each container of hazardous chemicals must be labeled with the: • Identity • Hazard warning • Name/address chemical manufacturer • GHS • Label must cross-reference with the SDS and chemical inventory entry

25. Labels

26. Safety Data Sheets • For each hazardous chemical • No SDS is required for: • Drugs in solid, final form for direct administration to patients (pills, tablets) • Consumer products where the employer can show: • It is used in the workplace for the purpose intended • Duration and frequency of use is not different from that of the consumer • Must be available to employees while they are in their work areas

27. Safety Data Sheet Info • In English • New 16-section format • Sections must be in order as dictated in Appendix D • Appendix D details the information to be included under each heading • Same as ANSI Z400.1 • Compliance date for chemical manufactures, imports and distributors —June 1, 2015

28. Safety Data Sheet Sections • Section 1, Identification; • Section 2, Hazard(s) identification; • Section 3, Composition/information on ingredients; • (Section 4, First-aid measures; • Section 5, Fire-fighting measures; • Section 6, Accidental release measures; • Section 7, Handling and storage; • (Section 8, Exposure controls/personal protection; • Section 9, Physical and chemical properties; • Section 10, Stability and reactivity; • Section 11, Toxicological information. • Note 1 to paragraph (g)(2): To be consistent with the GHS, an SDS must also include the following headings in this order: • Section 12, Ecological information; • Section 13, Disposal considerations; • (Section 14, Transport information; and • Section 15, Regulatory information. • Note 2 to paragraph (g)(2): OSHA will not be enforcing information requirements in sections 12 through 15, as these areas are not under its jurisdiction. • Section 16, Other information, including date of preparation or last revision.

29. Hazard CommunicationTraining • Before employees are exposed • Initially & Annually, per Tennessee Right to Know Law • Training must be “effective,” i.e., employees must be able to recall basic information

30. Hazard Communication Training • What are the requirements of the hazard communication standard? • What hazardous chemical(s) are you exposed or may be exposed to during normal use or in a foreseeable emergency? • Where is this chemical present? • What are the short and long term effects on the body? • How can you detect if you are overexposed to the chemical? • How can you protect yourself from overexposure? • Where are the SDS, chemical list, and written program located?

31. Plus Two More for GHS •  What information must be on the label on containers of hazardous chemicals? •  What do the pictograms indicate?

32. Specific Employer Requirements for PPE Programs • Hazard Assessment • Written Certification of Assessment is Required • Workplace evaluated • Person doing the certification • Date of the assessment • Id of the document as a ppe certification • Training • Written Certification of Training • Name of employee • Dates of training • Subject of certification

33. ADA & OSHA ALLIANCE - Ergonomics • In 2005 the Alliance calls for OSHA and the ADA to explore ways to determine whether ergonomics instruction is currently being included in dental schools' educational programs, and then encourage the incorporation of sound and proven ergonomics techniques into such curricula. Both organizations will also speak, exhibit and appear at conferences, local meetings or other events, and also disseminate information for dental employees through the media and from both organization's websites. Concluded April 2010. No results posted yet…. • http://www.osha.gov/dcsp/alliances/ada/ada.html#products– ergo tools for dentistry

34. Emergency Action Plan • Must be in writing* • Minimal plan elements: • Emergency escape procedures • Procedures for critical plant operations • Accounting for all personnel • Rescue and medical duties • Means of reporting fires and other emergencies • Contacts for further information • Types of evacuations *Employers with 10 or less employees may communicate the plan orally and need not maintain a written plan.

35. Postings • “It’s the Law” Poster • Get info on starting new business at: http://www.tennessee.gov/ecd/res_guide.htm • Citations

36. Nitrous Oxide • OSHA Document-Anesthetic Gases:Guideline for Workplace Exposures • Hazard Communication • MSDS, Information and Training, chemical list and training on health effects, labels • ACGIH TLV-50ppm • Health effects-reproductive & CNS • Follow manufactures guide on machine care & maintenance • Nitrous oxide (N2O) is used to increase an engine's power output by allowing more fuel to be burned than would normally be the case

37. Nitrous Oxide • NIOSH Technical Report-Control of Nitrous Oxide in Dental Operatories • DHHS (NIOSH) Publication No. 94-129 • 1-800-35-NIOSH

38. TB • Required if treat reasonably suspect individuals – free health care clinic to homeless with three confirmed cases • Establish risk from Health Department • Establish testing – PPD two step then annual one step • Train on the signs and symptoms of TB http://www.osha.gov/SLTC/etools/hospital/hazards/tb/tb.html#RespiratoryProtection & http://www.cdc.gov/nchstp/tb/webcourses/CoreCurr/index.htm

39. TOSHA Resources • www.osha.gov www.state.tn.us/labor-wfd • www.cdc.gov • www.cdc.gov/niosh • Memphis Office 901-543-7259 • Jackson Office 731-423-5640 • Nashville Office 615-741-2793 1-800-249-8510 • Knoxville Office 865-594-6180 • Kingsport Office 423-224-2042 • Chattanooga 423-634-6424 • Consultative Services 1-800-325-9901

40. Questions?