audiometry

Infection control in the hearing clinic


Infection control guidelines

The application of standard precautions For any infection control strategy to work everyone needs to be committed to it and work towards minimum or preferable best practice. Strategies need to be regularly reviewed, assessed and evaluated with all contributions of staff acknowledged. Quite often we may only think of major infectious diseases as being of concern to the hearing clinic team. You must remember even the common cold is an infectious disease and may result in members of the staff requiring time off work. The infection can be spread to other staff members and clients. We must consider all clients as being infectious, and this is why standard precautions are followed. To implement these principles of best practice in infection control each hearing clinic should have an infection control manual that has been designed for the education of all staff in the policies/procedures/protocol that are to be followed.

The following areas should be detailed in the manual:
• methods of hand washing
• personal protective equipment requirements
• preparation for a client
• defined areas of contamination
• clean up procedures between clients
• management of blood or body fluid spills
• handling and disposal of sharps
• waste disposal
• management of body/body fluid exposure
• processing of reusable items — cleaning, packaging, sterilisation or disinfection and storage.

Cross infection

The hearing clinic has a variety of areas where contamination and cross infection occur.
Cross infection involves coming into contact with a contaminated surface, instrument, or substance.
Diseases may be indirectly transmitted by the micro-organisms that are present on the item that has been touched. Of particular concern is the situation where cleaning of an instrument used on one client has not been carried out and that instrument is then used on another client. The micro-organisms could then be transferred from one client to another.

Diseases may be indirectly transmitted by dirty hands, towels and instruments - even dust. Other common areas of infection in the hearing clinic may include tap handles, switches, drawer handles, client charts, children’s toys even the pen used to write on the client’s chart Let's look at some specific areas and items of concern.

Waiting room and reception area
In the waiting room diseases may be indirectly transmitted by dirty hands touching furniture, magazines, children’s toys, door handles. In the reception area, telephone handsets, pens, computer terminals and keyboards, benches etc should all be cleaned regularly and kept dust-free. Frequent hand washing is an extremely important activity for all staff frequenting these areas and in particular reception staff who, in addition to frequently handling the above items also handle money, credit cards and hearing aids brought in for repair.. Of particular concern is the handling of hearing aids by reception staff at the front counter. Hearing aids handed in for repair should never be directly handed to reception staff over the counter but should be placed by the client into a receptacle (perhaps a paper bag, small box or reusable clean jar) offered to the client by reception staff.

Clinical area/ audiometrist’s office
Telephone handsets, computer terminals and keyboards, audiometry equipment including insertion gain equipment, desks and furniture, pens, client charts/files are always in frequent us in the office and must be kept clean. In addition, there are many other items such as impression making material and impression making equipment, otoscope and specula, clean and contaminated jars for specula, hearing aids, ear moulds and demonstration hearing aids that are all sources of infection. In the sound treated room, the desk top and chairs are in frequent use. There will be an audiometer and the headphones, insert earphone, bone conductor, patient response button all come into bodily contact with many people. There may be other items of audiometric equipment, eg otoscope and specula, tympanometer and ear tips as well as assorted clean and contaminated jars and maybe toys used as distractors for infants or toys used for play audiometry.

Sinks
One sink in the hearing clinic area must be specifically designated for hand washing. Hands should not be washed in a sink which is used for either instrument cleaning, or disposal of blood, body substances or chemicals or the sink in the staff room which is used in food preparation.

Technical area
The technical area of the hearing clinic should be designed to allow for the proper cleaning and repair of hearing aids. There should be frequent disinfection of all work areas and equipment. Clean and dirty areas should be established and labelled clearly in the technical area. Contaminated or dirty ear specula and tips should be rinsed and cleaned in the dirty area. The ultrasonic cleaned is located here and a mechanical dryer perhaps. Often the ear mould grinder is in this area also. Cleaned equipment is dried and relocated to the clean area for storage and re-use. There should be designated areas for incoming and outgoing hearing aid repair work. Sharps containers used for the disposal of scalpel blades, fragments of hearing aid shell should be available in this area. Hand washing should be routinely carried out after each hearing aid repair and cleaning of equipment. Gloves should be provided.

Staff lunch area
Hands must be washed before touching anything in this area. There is a great risk of infection from the incorrect stacking of food in the fridge, (raw meats should be on the bottom shelves) and from foods stored at incorrect temperatures. Coffee cups and other kitchen utensils should be properly washed and stored. The sink in the staff room is for the preparation of food and not for handwashing. You are now aware of various areas of the hearing clinic where contamination by micro-organisms can take place. Take a minute to think back on the term 'cross infection' and the possible undesirable effects this could have. Now let's have a more detailed look at how these areas become contaminated. Just think about the areas you cover in a normal working day. It is quite common for you to move through the various areas of the clinic without even thinking about it. Now take a minute to think about what could happen if, for instance, you did not wash your hands prior to leaving the clinic area to answer the phone at the reception desk. You have just taken an ear impression for a client. Suppose you are working in a clinic and you do not wash your hands all day. During the course of the day, you carry out a range of tasks (eg conducting screening tests, using the grinder, speaking on the phone, etc) so you move around all the areas of the clinic.

Patients' role in infection control

As mentioned earlier the client also has a role in the preventing of cross infection in the hearing clinic.
The client should inform you of any infectious diseases they may have presently or have had in the past. You may become aware of this information during the case history interview. The client may not be aware they have an infectious disease and this is why we must treat all clients as if they are infectious and follow standard precautions.

The two-tiered approach to infection control

NSW Health has endorsed a two-tiered approach to infection control.
  1. Standard precautions. The first and most important approach to infection control is the application of standard precautions to the care of all clients regardless of their diagnosis, disease status, or presumed infectious status. Standard precautions are the minimum acceptable level of infection control practices, and must be followed by all employees in all health and community care services.
  2. Transmission-based precautions. The second level requires that additional precautions and practices are applied to the care of clients who are known, or suspected, to be infected with diseases that are spread by airborne or droplet transmission, or contact with dry skin, or contaminated surfaces, or by any combination of these routes.

Standard precautions

Standard precautions are work practices required for the basic level of infection control. They include:
• good hygiene practices, particularly washing and drying hands before and after client contact
• the use of protective barriers which may include gloves, gowns, aprons, masks or shields
• proper handling of sharps
• use of aseptic techniques — ie cleaning, disinfecting and sterilisation.

Standard precautions apply to:
• blood
• all bodily substances, secretions and excretions except sweat, regardless of whether or not they are known to contain visible blood (ie tears, phlegm, urine, saliva, faeces, vomit etc)
• non-intact skin (eg cuts, sores, wounds)
• mucous membranes (eg mouth, nose, eyes, anus, vagina).

Standard precautions are recommended for the treatment of ALL patients, regardless of their infectious status.

Additional precautions

Additional precautions are used for clients that are known or suspected of being infected with highly transmissible pathogens that can cause infection.
They are particularly used when there is the possibility of air borne transmission, for example, tuberculosis (TB), measles or chicken pox; or droplet infection for example mumps, rubella or influenza.
Additional precautions are specific to a given situation. They are applied in addition to standard precautions.

Immunisation

Immunity is about a person’s ability to fight a particular disease or micro-organism. When we say someone is immune to a certain disease – for example measles – we essentially mean that the person cannot catch the disease because they have a resistance to the organism through their body’s ability to make antibodies to fight the disease-causing organisms.
Immunity is specific to each disease type, so while someone may be immune to Hepatitis A, for example, they are not automatically immune to Hepatitis B. Immunity can be achieved in one of two ways: inherent or acquired.
Inherent immunity basically means that you have inherited antibodies from your mother to help you fight particular diseases.

Acquired immunity means that at some stage in your life you have either been exposed to the disease or have been immunised, and have subsequently developed the antibodies to protect you against becoming infected.
As you are dealing with people in close proximity and with body fluids, adequate vaccination is required against such diseases as tetanus, mumps, measles and hepatitis B. It is highly advisable to be immunised against influenza also. Other types of vaccinations may be considered if there is a risk of potential exposure, such as tuberculosis.
Prior to vaccination it is highly advised to have a blood test to determine the need for vaccination. After some vaccinations blood tests may be needed to determine if the level of antibodies is sufficient.

Employers must offer Hepatitis B vaccine to all health care workers whose work places them at a risk. This must be made available within 10 working days of commencement of employment. Staff members should maintain a record of their immune status (NSW Health Circular 96/40). This consists of a series of 3 injections over 6 months. Immune status should be checked to ensure that the immunization has been effective.

Employers in the health care industry are obliged to provide the following safety support services to their staff:
• Procedures to facilitate access to treatment as required
• Education on immediate care of injuries
• Contact person for advice on needle stick injuries
• Expert advice available to all health care workers 24 hours a day.

Australia’s immunisation policy has prevented many people from contracting serious diseases, such as measles. Most people born in Australia started their immunisation program when they were infants and ended approximately at the end of primary school.
However, some vaccinations like tetanus or the flu vaccination are given throughout our lives, as the need arises. Health care workers are at risk of exposure to some diseases that are preventable by vaccines, just like those mentioned. It is because of the availability of vaccines that there is strong recommendation for health care personnel to be immunised. It is appreciated that the freedom of choice is an important consideration when choosing not to be immunised, however, it is an ethical responsibility to maintain a current immunisation status and can prevent legal implications.

Further information can be found NSW Health website: http://www.health.nsw.gov.au/publichealth/immunisation/ohs/

Minimising contamination of materials, equipment and instruments by aerosols and splatter

Aerosols and splatter are a common occurrence in a clinical environment. The main source of aerosols and splatter in the hearing clinic is from water from the tap. However, anything that applies force to a surface has the potential to create aerosols and splatter which might contain infective material.

Water from the tap
You might wonder why on earth I have described tap water as a source of aerosol or splatter.
Let’s think about it this way…
When you wash your contaminated hands, contaminated instruments or any article that is dirty, in the sink, there is the potential for splatter to occur.
Hands should be washed in a sink allocated for hand washing only.
Dirty instruments should be washed in a sink in the dirty zone of your clinic, and once there should be held low in the sink to eliminate as much splatter as possible.
There are numerous other causes of splatter. Each should be treated with as much care as the other.


Identifying and responding to infection risks in the hearing clinic


Standard and guidelines

If you have access to the standard relating to infection control, familiarise yourself with it:
CSA PLUS 1112:2004 :
Infection Prevention and Control in Office-based Health Care and Allied Services

You can read about the scope of the standard at: www.saiglobal.com/shop/Script/Details.asp?DocN=CSA00961-W2307
You might be able to access it at your workplace or at a TAFE library.

Other standards related to infection control: www.saiglobal.com/shop/Script/Result.asp?SearchType=simple&Sort=AS&Status=all&Gst=1&Max=15&Db=All&DegnKeyword=infection+control&Search=+Go+

Department of Health and Ageing (2004) Infection control guidelines for the prevention of transmission of infectious diseases in the health care setting. Department, Canberra www.health.gov.au/internet/wcms/Publishing.nsf/content/icg-guidelines-index.htm

Identifying infection risks and implementing an appropriate response

To identify infection risks and how we can implement the appropriate response to each risk we should first have a look at how disease can be transmitted.

Transmission of disease
Transmission of infection can potentially occur from clients to hearing clinic personnel and vice versa by a number of pathways in the hearing clinic environment. Work habits of the hearing clinic team must be developed so that the risks of cross infection are minimised.

Micro-organisms and viruses are not able to travel from one person to another or from one object to another on their own. They need a means of transportation, such as:
• people
• air, dust, food, water
• inanimate objects (eg instruments, clothing)
• insects and vermin.

Organisms can be transmitted from a source by four main modes:
• direct contact
• indirect contact
• vectors
• placenta.

Direct contact
By direct contact we mean direct physical contact between one person and another, such as:
• touching with hands, which is probably the most common way of transmitting pathogenic organisms from one place to another
• kissing or sexual activity.

Indirect contact
Transmission of organisms by indirect contact can occur by contact with:
• fabrics (eg handkerchiefs, clothing)
• used instruments and other appliances
• food, water and air
• insects and vermin.

Airborne infection
Airborne infections are caused by pathogenic organisms carried through the air by dust or droplets. Minute droplets containing organisms are projected from the mouth and nose for 1m to 2m through the air whenever a person speaks, coughs or sneezes. Large droplets may directly infect the nose, throat, eyes or a wound of a person close by. Alternatively, these droplets may fall on personal clothing, toys, and furniture (such as equipment table, which in turn contaminates specula and tips). Small droplets may evaporate, leaving in the air suspended infected particles, known as droplet nuclei, which can be carried a considerable distance.

Vectors
Vectors are animals or insects that carry pathogenic organisms from one host to another. For instance, flies commonly transfer gastrointestinal organisms from excreta to food.
So, you must bear in mind that every item in your office or testing room, which is not sterile and protected, has living organisms on it. Some of these organisms may be pathogenic. This contamination can be caused by settling of infected dust, contact with clothing, or direct contact with infected body secretions like ear discharges.
Some insects cause infections by depositing organisms on the skin surrounding bites. Scratching the site pushes the organisms into the bites. Insects such as mosquitos actually suck up organisms from an infected person and inject them into another person.

Placenta
Some pathogens are able to enter the foetal circulation from the mother via the placental blood vessels, for example, AIDS, cytolomegalovirus (CMV), rubella.
If you have not already accessed the topic on micro-organisms (microbiology), then this is a good time to do so.[link this to the resource direct]

Now that you have an understanding of how infectious diseases can be transmitted what do you think we can do to avoid the spread of infection in our hearing clinics? We need to be able to identify these hazards, assess the risks (low, medium, high) and implement appropriate prevention control.

A hazard is unavoidable danger. In the clinical context it could be seen as something that has the potential to cause harm to people and the environment. This could be physical, chemical or biological.
Document and report activities and tasks that put clients and/or other workers at risk
As a health care worker you may be exposed to potentially infectious blood and other body fluids on occasions.
Our clients may be at risk of contracting infection from a break down in correct cleaning procedures, from contaminated instruments, equipment or even from the clinic team who do not correctly wash their hands between clients and procedures. Have a think about correct waste disposal. Is it possible for the community at large to be affected by the incorrect disposal of contaminated waste or sharps?

There are many activities that we carry out in the hearing clinic that may place the staff and/or patients at risk of contracting infection. These include things like cleaning the clinic; preparing equipment for cleaning; sharps removal; waste disposal; or even patients attending the clinic with a cold or cough?

Regulatory framework

State and territory laws, regulations, standards and guidelines, and local government ordinances
To find infection control information specific to your state or territory, try the websites listed below.

New South Wales: www.health.nsw.gov.au / Look for the NSW Department of Health Acts and Regulations. Also look for the NSW Infection Control Policy—under A-Z Health topics.
Victoria: Department of Human services Infection Control Information and Publications. www.health.vic.gov.au/infcon/info.htm Also, the Health Planning, Policy, Legislation and Guidelines Topics for Victoria: www.dhs.vic.gov.au/phd/topics/policy.htm#control
Queensland: Queensland Health Infection Control: www.health.qld.gov.au/infectioncontrol/
Tasmania: Department and Health and Human Services: www.dhhs.tas.gov.au/
South Australia: Department of Health: www.health.sa.gov.au
Western Australia: Department of Health: www.health.wa.gov.au
Northern Territory: Department of Health and Community Services: www.nt.gov.au/health/
Australian Capital Territory: ACT Health: www.health.act.gov.au

Respond appropriately to situations that pose an infection risk in accordance with the policies and procedures of the organisation
Why don’t you spend some time having a look through the Australian Government document Infection Control Guidelines?
You will find this document at: www.icg.health.gov.au

Although this is a large document you will find some very useful and interesting information about the types of policies and procedures that can put in place in health care settings.
In order for infection prevention to be effective, each staff member must do his or her part.
If you have identified some areas within your workplace that may pose a risk for the transmission of infection then now is the time to discuss this with your employer and put a procedure or policy in place that deals with the particular situation.

Think about the hazards you have come up with. Can they be eliminated? Would a change in the work procedure reduce the hazard?
For example:
• What procedure do you have in place to avoid sharps injuries form occurring?
• If an injury does occur, how do you deal with this injury?

Sharps

'Sharps' is the term used for items that can cut or penetrate the skin, and in doing so, potentially cause cross-infection of micro-organisms. These include syringes, razors, scalpels etc.
Sharps must NOT be passed by hand between people, but in a puncture-resistant tray.
When sharps are being disposed of there is a high risk of an injury occurring. However, if we wear the correct PPE, then that will decrease the risk of an injury occurring. If we follow the latest guidelines for sharps disposal as well, then that will decrease the risk of an injury occurring even more. We will look at the correct procedure to follow for this particular situation later.
Generally speaking, most audiometrists have little exposure to sharps. However, some audiometrists, such as Nurse Audiometrists and Aboriginal Health Workers/Audiometrists who have dual health care roles, will have greater sharps exposure.
Syringes should not be re-sheathed (unless it is specifically required, eg dental practice).

Dealing with sharps

The person using the sharp, in clinical practice, is responsible for the proper management and disposal of the sharp.
Sharps must not be passed by hand between a health care worker and any other person. A puncture resistant tray must be used to transfer sharps.
Sharps may be disposed of in a specific, approved 'sharps' container. These are usually in the form of a clearly labelled impervious, hard plastic container.
The general understanding is that the person responsible for using the 'sharp' is also responsible for its safe removal and disposal immediately after use. (This is what it says in the document Infection Control in the Health Care Setting, NHMRC, page 23.) This would indicate the sharp would be disposed of in the clinic. At no time should a sharp, particularly an injection needle, be left on an instrument tray that is being taken from one area to another area.

What to do in the event of a sharps injury
Contact ANCA (Australian National Council on AIDS) or the representative in the state where you work to set up a procedure for your clinic. A suggested protocol is:
• encourage the bleeding
• wash the area with soap and water
• report immediately to a supervisor or OHS officer
• make sure your workplace has a policy/protocol in the event of a sharps injury, and make sure every staff member knows what to do.


Procedures for the accidental exposure to body fluids


Immediate care of the exposed health care worker
After exposure to blood or other body substances you should as soon as possible do the following:
• encourage bleeding if exposure involves a cut or puncture, then wash with soap and water
• wash with soap and water where the exposure does not involve a cut or puncture
• if eyes are contaminated then rinse them, while they are open, gently but thoroughly with water or normal saline
• if blood or other body substances get in the mouth, spit it out and then rinse the mouth with water several times
• if clothing is contaminated remove clothing and shower if necessary
• inform an appropriate person (supervisor) to ensure that necessary further action is taken.

Factors which need to be documented:
• nature and extent of the injury
• nature of the item which caused the injury e.g. gauge of needle
• nature of body substance involved
• volume of blood and body substances to which HCW was exposed.

All occupational exposures must be fully documented to meet legal requirements to ensure that workers are able to obtain the support to which they are entitled.
Click here to see the recommended infection control guideline

Process following a sharps injury

Management will ensure that you get counselling quickly, and arrange a test for infectious diseases such as Hepatitis B, C and HIV. The opportunities for counselling continue right through the process. Both you and the person who you have just used the needle on (who we call the ‘source’) should be tested. Follow-up testing continues. For the ‘source’ this continues for 3 months, or 6 months if the person is in a high risk group. The worker is retested after 6 weeks and 3 months. If at any time you start to test positive, you will be advised regarding further treatment.

There is a 24-hour needle stick hotline in NSW 1800 804823. Your employer should also provide you with a local number which can be called at any time for advice in the event of a significant exposure to body fluids.
Place appropriate signs when and where appropriate

All areas in the hearing clinic should be clearly defined as ‘clean’ zone or ‘contaminated/dirty’ zone. These areas should be clearly indicated.
Clean areas may include storage areas for materials and equipment, sterile areas and administration areas.
Contaminated zones may be areas for cleaning equipment, carrying out hearing aid repairs, grinding ear moulds.

Have a think about the areas in your workplace. Are they clearly labelled? Are all staff aware of these designated zones?


Remove spills in accordance with the policies and procedures of the organisation


Blood and body substance spills


• Put on protective apparel, including gloves.
• Confine and contain the spill.
• Cover the spill with paper towels to absorb the bulk of the blood or body substances.
• Treat debris as clinical waste.
• Clean the spill with a neutral detergent and water.
• If mop is used, it must be stored dry.

Blood and body substance spills
• Protect yourself, wear gloves (and face protection if needed).
• If possible, isolate the area.
• For a small spill, wipe immediately with paper towel, then clean with water and detergent.
• In a 'dry' area, use absorbent paper or granular chlorine to absorb the spill. (This avoids increasing the size of the spill and/or releasing contaminants into the air.) Then scrape up the absorbed material into a pan and clean the affected area with water and detergent. Dispose of spilt material, paper or granules and gloves in a sealed container.
• In a 'wet' area, wash the spill into the sewerage system. Flush area with water and detergent.

You can use hospital-grade disinfectant on the area. Wash your hands after removing gloves.

Spills kit
You should have a dedicated 'spills kit' readily available in a bucket with a fitted lid. The kit should contain:
• protective equipment – eye protection, plastic apron, disposable rubber gloves, respiratory protection (for high-risk spills)
• containers (such as leak-proof bags) for disposing of the material spilt
• a 'pooper scooper'-type scraper and pan
• sachets of granular chlorine.

The following items should also be included in the spills kit:
• mop, bucket and detergent
• leak-proof bags and containers for disposal of waste material
• scraper and pan for spills (similar to a pooper scooper) — alternatively, a few pieces of firm cardboard which can be disposed of with the waste
• paper towel to wipe up spills
• about five granular disinfectant sachets containing 10,000 ppm available chlorine or equivalent. (Each sachet should contain sufficient granules to cover a 10 cm diameter spill.) These form the spill into a gel that can be scraped up, preventing splashes.
• disposable rubber gloves that are suitable for cleaning. Note that vinyl gloves are not recommended for handling blood.
• eye protection (disposable or reusable)
• plastic apron
• mask for protection against inhalation of powder from the disinfection granules or aerosols that may be generated from high-risk spills during the cleaning process
• forceps for picking up glass, etc.

Source: Infection Control (Health) Toolbox © Australian National Training Authority (ANTA) 2004.

Non-hazardous spills


For small spills, wipe immediately with paper towel. Clean with water and detergent. Use the following steps when cleaning up a small spill.
1 Collect cleaning materials and equipment (eg spills kit).
2 Wear disposable gloves. Eyewear and a plastic apron should be worn where there is a risk of splashing occurring.
3 Wipe up the spill immediately with absorbent material (eg paper hand towelling). Place any contaminated absorbent material into an impervious container or plastic bag for disposal.
4 Clean the area with warm water and detergent using a disposable cleaning cloth or sponge.
5 Where contact with bare skin is likely, disinfect the area by wiping with sodium hypochlorite 1,000 ppm available chlorine (or other suitable disinfectant solution) and allow to dry. (To make up 1,000 ppm, 5 litres of water can be added to 125 ml of any in-date household bleach.)
6 Discard contaminated materials (absorbent towelling, cleaning cloths, disposable gloves and plastic apron) in accordance with state/territory Regulations.
7 Wash hands.
8 Clean and disinfect reusable eyewear before re-use.

For larger spills, scrape the bulk of the spill into a pan for disposal, and then clean the residue.
1 Use the following steps when cleaning up a large spill. Within each step, any instructions specific to that size of spill are shown in bold.
2 Collect cleaning materials and equipment (eg spills kit).
3 Wear disposable gloves, eyewear, mask and a plastic apron.
4 Cover the area of the spill with granular chlorine releasing agent (1,000 ppm available chlorine) or other equivalent acting granular disinfectant and leave for three to ten minutes, depending on formulation and labelling instructions.
5 Use a disposable scraper (eg cardboard) and pan to scoop up granular disinfectant and any unabsorbed blood or body substances.
6 Place all contaminated items into impervious container or plastic bag for disposal.
7 Wipe the area with absorbent paper towelling to remove any remaining blood and other body fluids place in container for disposal.
8 Use ward cleaning materials to mop up with water and detergent.
9 Discard contaminated materials (absorbent towelling, cleaning cloths, disposable gloves and plastic apron) in accordance with state/territory Regulations.
10 Wash hands.
11 Wash the mop and bucket with detergent and hot water. Rinse and allow to dry.

Clean and disinfect reusable eyewear before reuse.


Limiting contamination


If you work in an audiometry clinic, consider the layout of your workplace. You probably have areas that are set aside for specific jobs.
If you work in a large facility such as health centre or hospital, you might even have areas that are designated ‘clean’ and other areas ‘contaminated’.
We might think that a hearing clinic does not have as much risk of contamination as, say, a dental clinic where they use dental instruments or in a hospital where staff come into contact with body fluids.
It is true that in a hearing clinic we would not usually be exposed much to body fluids — compared to, say, staff in a dental surgery (unless we are in a dual role such as that of Audiometrist Nurse). However, this is not to say that a hearing clinic does not many contamination risks. It does.

The risk for the spread of infections exists in a hearing clinic—and this topic on limiting contamination is just as important to us as it is to any other health professional.
Here is an example of how real the risk of contamination is to us in our work as audiometrists: the viral gastroenteritis infection does not just spread through body fluids (or by consuming contaminated food or drink). It also spreads from the hands of an infected person, through contact with contaminated surfaces—and this is something that can occur quite easily in a hearing clinic.

In a hearing clinic, we might not need to actually mark out whole areas as ‘contaminated’ and ‘clean’. However, we still need to allocate specific areas for specific jobs, eg, we keep the area where we conduct our screening tests separate from the technician room.
We still need to be aware of the need to make sure that we carry out proper cleaning and disinfection of all our work areas and equipment. We still need to make sure that our hearing aids, ear moulds, speculae and so on are kept in a clean area. Our hand washing routine should be rigorous—and our surface areas still need to be free of contamination.
Much of the information in the rest of this topic would be applicable in a health facility where a range of services are offered, eg a health centre or hospital. However, some aspects will be applicable to a hearing clinic. As you work through the rest of the topic, bear in mind how the information applies to your workplace as well as to other types of health facilities.

Demarcating and maintaining clean and contaminated zones

The health facility should be designed to allow for proper cleaning and disinfection of all work areas and equipment. The design should allow for ease of movement for patients or clients as well as staff, free of any possible danger areas.
Areas should be designated 'clean' and 'dirty' areas for ease of cleaning and to keep the risk of cross infection low. (In a hearing clinic, we still need to allocate specific areas for specific jobs.)
Let's take a moment to define 'clean' and ‘contaminated’ (or 'dirty'.)

A 'clean' area is a specifically designated area for non-contaminated items. These would include items that are sterile, or have been disinfected. At no stage are any contaminated items to be placed in this area.
The 'contaminated' area is a specifically designated area for placement of contaminated items, such as instruments and trays that have been unused during patient treatment.
Clean and contaminated areas should be clearly marked so that all staff are aware of these areas and can follow a safe workflow. Workflow should always be from contaminated to clean areas and care should be taken to avoid contaminated items re-entering the clean area.
‘Zones of contamination’ should be clear to the staff (or work team) and barriers should ideally be used in the commonly 'touched' areas, such as light switches and handles, handpiece cords, suction tubes, chair controls etc.
Staff eating and recreation areas must be separate from patient treatment and work areas.

Designing facilities where sterilisation of instruments is required

In health facilities where there is a need for a sterilisation area, ideally you would have a separate sterilisation room, situated close to the surgery. This proximity will facilitate the transfer of instruments, trays and some equipment from the surgery to the sterilisation room.

All 'sharps' should ideally be disposed of in the surgery. Some or all of the waste material may also be removed and disposed of prior to leaving the surgery. As part of the clean-up routine, all items that have been used during the treatment procedure should be gathered and placed on a tray to be transferred from the surgery to the sterilisation room.
Before moving around with any instruments, materials and/or equipment you must check for hazards that may occur.

Check for:
• a clear walking passage from one area to another
• any patients or other staff members in your path — there may be the possibility of dropping items where injury may occur.
On arrival in the sterilisation area you must place the instrument tray and any other items, in the clearly defined 'contaminated' area in the sterilisation room.

Confine records, materials and medicaments to a well-designated clean zone
Examples of ‘clean’ areas in a health facility would be:
• storage areas for materials and equipment
• sterile storage areas
• the reception or administration area.

The facility should have designated ‘zones’ that all staff are aware of. No patient records or pens etc. should be placed in a contaminated zone.
There should be a designated area in the surgery/clinic for patient records to be placed during treatment. Gloves must be removed before writing up any hard copy records.
If computer systems are used the keyboard and monitor should be covered with a barrier that should be changed between patients.

Where possible all materials and medicaments should be pre-dispensed prior to treatment. They should be stored in a designated clean area in the surgery. If you must access these during treatment an ‘over-glove’ or de-glove/re-glove process must be used. The same procedure should be followed for accessing additional instruments that are required during a procedure. You may have ‘transfer tweezers’ that are used for this purpose.
Confine contaminated instruments and equipment to a well-designated contaminated zone

The importance of confining all contaminated items to the set contaminated area cannot be stressed enough.
Examples of ‘contaminated’ areas would be the receiving area for contaminated instruments used during patient procedures and areas that have become contaminated during the procedure, or equipment that has been touched or used during a procedure.
There needs to be bench space to allow for the processing of instruments. A sink that is stainless steel and designated for the cleaning of contaminated instruments and items is ideal.
To avoid the risk of contamination, hand washing basins should always be separate.
All cleaning materials and equipment such as brushes need to be readily accessible.

Clean and dirty areas need to be clearly marked and that there should be no cross over of contaminated items into the clean area.
In the surgery/clinic any materials and medicaments, instruments or equipment that have become contaminated during the procedure must be cleaned , disinfected or sterilised before being returned to the clean zone.