Infection Control for the Hearing Healthcare Professional-Infection Control for the Hearing Healthcare Professional Recording

Infection Control for the Hearing Healthcare Professional Recording
Video Transcription
And me, Carrie Peterson, Professional Development Administrator. We have an awesome expert presenter today. She is Dr. Julie Purdy, Ph.D., CCCA.  She's the Manager of Audiology at Rady Children's Hospital in San Diego. Julie completed her Master's Degree in Audiology in 1985 at Brigham Young University, which  is located in Provo, Utah, and her Doctoral Degree in Audiology from the University of Utah in Salt Lake City in 1990. She specialized in multicultural and aging populations.  And prior to joining Rady Children's Hospital, she was the Director of Education for Starkey  Hearing Technologies for the Canadian office, where she provided technical and educational support.  Julie continues to teach hearing health care professionals across North America, so we are really honored to have her with us today, teaching all of you.  Before we get started, though, we do have a few housekeeping items. Please note that we are recording today's presentation so that we may offer it on demand  through the IHS website in the future. So for those of you who are looking for a recording, we will let everyone know when that's available.  This webinar is also available for one continuing education credit through the International Hearing Society.  You can find out more about receiving a continuing education credit at our website at IHSinfo.org.  You'll click on the webinar banner on the home page, or you can choose webinars from the professional development menu on the left side of the page.  There you'll find the CE quiz and information on how to submit it to IHS for credit. Also on the webinar page of the IHS site, you'll find the slides from this presentation,  which will help you gather the information you'll need for the CE quiz. Those slides went out yesterday to everyone who has registered as of yesterday, but if  you didn't get yours, you can go to the website right now and download it. Tomorrow, we'll be sending out an email with a link to a survey on this webinar.  It's very brief, and your feedback really helps us create more content and valuable content for you moving forward.  We are doing something new today we want to let everyone know about. For the first time, we are going to try some live interactive polls with the audience.  So this is a new thing for us. So bear with us if we have any glitches, but we have a couple things you guys will get to vote on during the presentation.  So let's look at the agenda. Today we're going to be covering the following topics, along with the Q&A, within a 60-minute presentation.  We're going to talk about learning the methods of infection transmission, including direct, indirect, and droplet contact transmission.  We're going to learn about evaluating clinical equipment in order to appropriately apply principles of cleaning, sterilizing, and disinfecting.  And we're going to discover the need for standard precautions in a hearing aid dispensing practice and be able to integrate them into your practice setting.  At the end, we'll move on to a Q&A session. You can send us a question for Julie at any time by entering your question in the question  box on your webinar dashboard, which is usually located to the right of your webinar screen. We'll take as many questions as we can in the time we have available.  And now I'm going to turn the presentation over to Julie, who will guide you through today's webinar. Julie? Okay, let's go ahead and get started.  Today we're going to be looking at creating an infection control program in our clinics. And so what do I mean by that?  When I talk about an infection control program, I'm talking about an organized effort to manage our environments so that we can keep ourselves and our patients from becoming sick.  And the key on this really is the organizational piece, the fact that we're really going to sit down and figure out today what are the kinds of things that we can do in our  clinic to be sure that we do not expose our patients to pathogens, or at least that we minimize that to the best of our ability.  And we are trying to do that because we really would like to have ourselves be healthy as well as keep our patients healthy. We bother for exactly the reasons I just mentioned.  We care about ourselves. We care about the people that work in our clinics. We care about the health of our practices so that we're not sued.  And we know that there's some regulatory requirements for us to practice. So there's a lot of reasons why we don't want to end up with little spots all over us.  I talk about pathogens, and this particular little comic is designed to let us know we're not going to be 100% effective at anything that we do, and we realize this.  We live in a world where we do come in contact with other people, so we're not going to be able to minimize everything that we can possibly come in contact with.  I'm not suggesting that anybody gets a little bubble and they live in their bubble. But what we are trying to do is to limit the number of pathogens in the environment so  that our own body's natural resistance can come into play and can take over and keep us and our patients from becoming ill.  And I keep using the word pathogen, and I think it's important to realize that there are lots of different things that live around us, but a pathogen has no other purpose than  to make us sick. And so I always like to think of it in many ways as a bit of a war. We have a war on these little bugs, these little creatures that are out there trying  to make us sick, and we want to do our very best to win that particular war. We care because the part of the body that we work around, the ear, has a tympanic membrane  that's very porous, and so it's very easy for us to transmit infection into the rest of our body.  And in addition, we are very close to a patient's eyes, nose, and mouth, and so we are able to have infection enter our bodies in those ways as well.  So we really are working in an environment that allows these things to take over our bodies if we're not really careful.  There are so many things that we can be exposed to, and I know that at different times, different  things have raised consciousness on infection control, and I definitely think that HIV or AIDS has been one of the things that raised a lot of consciousness, because I think for  the very first time we realized that there were things that we could catch from our patients. And at the time that we first learned about HIV, I think people were very, very worried  that this could be something that they could catch from a patient. The reality is, of course, that unless we're having, I hate to say, but unprotected sex  with our patients, which we really should not be doing, or doing a kind of a blood brother situation where we're slashing our wrists and rubbing our wrists together, HIV is not  the infection that we need to be worried about. It's not something that we're likely to catch from the kinds of activities that we do.  But some of these other things that you see here, some of the things that can grow on hearing aids, some of the fungus and bacteria we easily can transmit into our bodies.  Other things that we can easily catch are things like the cold or the flu, and although that might not seem as if that's much, having a nasty cold or having a nasty flu might just  be a disruption to our lives. We know that every year many of the sorts of folks that we see, some of our older patients, die from the flu.  And so what might just be an inconvenience to you might be something that actually kills one of your patients.  And so we definitely need to worry about things that might just seem like an inconvenience to us as well.  Hep B is a big one, and there's going to be a poll on that later, so I'm not going to talk about it, but it's one that we very much have to worry about in our clinics, as well  as, I've kind of mentioned the flu as well, as well as tuberculosis, so that's another one that we need to look at.  And so there are lots of different things that we can come in contact with, but if we take some very simple precautions, we can very much minimize our risk, and that's what  today's talk is about. So how do things get into our body? We're going to look at each of these in a little bit more detail, but let's just look at the overview.  The main ways that things enter our body are through contact, either direct, indirect, or droplet.  Vehicle, meaning that something has to get them into our body, so blood, water, or food are the most common.  Airborne, things that float around in the air, and then vector-borne, things that are transmitted via animals.  So things come into our bodies in four main ways, and we're going to look at each of these a little bit more specifically in terms of the kinds of work that we do.  So let's first start with direct contact. So in order to catch things from direct contact, we have to really be fairly close to the other  person, and the nice thing about things that are direct contact is they can't live very long outside of the body, but a cold is an example of a direct contact.  Conjunctivitis is another one. The flu is a third. So there are several different ways that we can catch things from direct contact, and  so what we're going to try to do, and we'll look at this, is to prevent as much direct contact as we possibly can.  A second method that things come into our bodies is indirect contact, and so this is the case where you touch the doorknob or you touch a computer screen and somebody else  has touched it before you, and the infection has been transmitted to that doorknob or transmitted to that computer keyboard.  And the good thing for these particular organisms is that they can live for a very long time outside of the body. That's good for them. That's not so good for us.  And so one of the biggest ones that we have to worry about is hepatitis B. We know that hepatitis B is a really problematic infection in healthcare.  We know that for every 100 people that are exposed, typically about 10% catch the virus, and for those that catch it, a good 10% of those become very, very, very ill.  So if I'm telling you that these organisms can live a long time outside of the body, what am I saying?  Am I talking about a couple of minutes, like the sorts of things we can catch from direct contact, or am I talking about longer?  Well, this is going to be our first poll, so I'd like us to take a poll to see how long we think hepatitis B can live outside of the body.  So it says that I, oh, I might not be able to make this work. Don't worry. People are voting. Oh, people are voting. Good. And people are hearing me say I don't think this can work.  Sorry about that. This one's new to me, guys, as well. I can't see what you're doing. I'm in the dark here. But, you know, normally, I'm just going to keep yammering on.  Normally I do this thing where I say, and if you were in my room, I'd make you raise your hand, and I have this pretend hand raising, so I guess it's no different than a pretend  hand raising. Okay. Okay. So, Julie, would you like to know how people voted? I would like to know how people voted. What did people say? Okay.  So 10% said it can live one day, 1% said it can live two days, 46% said it could live one week, and 23% said it could live one month. Okay.  Well, you know, the majority has it in this particular case. Hep B is typically quoted as living about a week outside of the body.  So the problem with that is if you put down an otoscope that has Hep B, let's say, on the tip on your table, and then you do your good job, and you change the tip of your otoscope,  and now you put another tip on, and you sit that otoscope down on the same table, and you didn't clean the surface in between patients, then the Hep B virus can be transmitted onto  your clean speculum, and when you put it in that patient's ear, you can transmit it to the patient.  So we need to be really super careful about where we place anything that's entered an ear canal on a surface, like a table, without cleaning.  So that's a case where for one full week, you could infect every single person if you chose not to clean your table.  So obviously I'm going to advocate table cleaning, and we'll look at that in just a minute. So droplets is another way we can catch things, and so measles is an example.  The good news is if we're a little further back from our patients, we're not likely to catch them, so if Mrs. Jones comes in and she's sneezing violently, you can pull your  chair back, and that's one way to protect yourself. Vehicle transmission we don't worry about too much, unless you're drinking the water  in a foreign country, or eating street tacos, or something along those lines, but we do worry about blood.  We have to assume that when we're taking deep ear mold impressions, or we're really any time digging around in an ear canal to, say for example, remove cerumen, or take an ear mold  impression, that we can be coming in contact with blood. So we do worry about vehicle transmission very much, and many of the guidelines that  we talk about are because of the fear of blood in an ear canal. Airborne is tricky, because we might have, for example, somebody that comes into our  clinic and we know they have tuberculosis, and then we say, oh, it's so good I took the precautions and I didn't catch tuberculosis.  But the little droplets can dry up, and they can live very, very long outside of the body.  And there was a very interesting case where a cemetery had to be moved to another location,  and so the people that had died in this particular cemetery, many of them had had tuberculosis.  So when they moved the coffins, they were able to see how long tuberculosis could continue  to live in a non-alive person. And so here's our second poll. It worked well the first time, so let's give it a try.  Poll number two is how long was the oldest coffins that they dug up did they find active tuberculosis in those coffins?  Julie, we have a lot of people voting. Are people voting? They are. Okay, let's see. We're going to close it in a second, guys. Okay. There you go.  Can you see the results on the screen? I can't see the results. I know it says to click my X, but I'm nervous. I'm nervous to click anything on my screen. No, it's okay.  Can you just tell me this? Okay, I can tell you. Thank you. Yeah, I can tell you. 5% of people said one month, 14% said one year, 41% said 10 years, and 40% said 100 plus years.  Well, you know what? It's the last category. The oldest coffin that they found in this particular case was 111 years old. The person had died 111 years beforehand.  So tuberculosis is an issue. If we work, and many of us do work around patients that have tuberculosis, we need to  realize that those particular droplets can be suspended in the air, can live a very long time, and we need to monitor ourselves periodically. We'll talk about that as we go along.  Okay. So we're not going to be super worried about the mosquitoes. I mean, we should be, but not necessarily in our clinics. Let's try to keep the mosquitoes to a minimum.  So let's see about what we can do. Well, you know, there's all kinds of things listed here in terms of what we should do,  and we are going to talk about all of these, but if we don't do anything else, if we just up our hand hygiene, we are going to be so much more healthy, and we're going to be really  preventing transmission to our patients in so many cases. So that's our biggest one. There are lots of rules in terms of when to wash your hands, and if we look at this, I  know you're going to have access to these handouts, so I'm not going to be super worried about it, but the reality is if we just look at number two there, any time we go between  a dirty and a clean activity, if we just wash our hands, any time we do that, we are going to be covered.  So if I eat, I'm going to consider that an activity that I'm going to wash my hands before because I might have dirty hands.  I'm going to eat, now my hands are dirty, I'm going to wash my hands after eating before I go back to see my patient.  If I pull something out of a patient's ear and I touch the piece that was in their ear, my hands are now dirty, I'm going to need to wash my hands before I touch my audiometer  or touch anything else. So if we just wash between every clean and every dirty activity, every single one of these falls in line.  So I always say to people, just always think that any time you touch anything that goes into an ear, it's covered in kind of nasties, goobies is what I use, I say it's covered  in goobies, and then wash your hands. And if you do that, you're covered. And how do we wash our hands?  Well, you know, we can use soap and water, but for most people in most cases, that's not very practical.  And so a lot of times people will want to use more of a pump-based or product that's perfectly good.  You want to have a good product, a good Porel product, you want to be sure that it's something that has at least 60% ethanol, and then you want to really put a fair amount into your  hand and then rub your hands vigorously together, and then let them dry for a couple of seconds before you touch your person.  Like I mentioned, we can use regular old soap and water, but if we're going to use the soap, we want it to be good soap.  It's going to need to be a soap that is an antimicrobial, so a hospital-grade soap. And once again, we need to do, just like you see on any of the television shows with  the doctors, we really need to scrub and get in there and do a good job. Another thing that I think is important is that we try to minimize the amount of stuff  that comes into our clinic. So if Mrs. Jones is having her appointment confirmed, a receptionist can easily say, and how are we feeling today, Mrs. Jones?  And if Mrs. Jones says, oh, I'm feeling horrible, I have this nasty cold, well then let's reschedule Mrs. Jones.  Mrs. Jones doesn't need to come in and infect every single person with her nasty cold. So that's a nice, easy way of trying to keep as much as we possibly can out of our clinic.  I'm going to mention that there are going to be times when we're going to want to wear gloves. Realistically, that's probably about it.  Every now and again, it might be that you work in a situation where you are going to have to do something else.  So here at the hospital, every so often we have to see a TB patient, and the person who sees them has to have a mask that's been specially fit to their face to ensure that it has a  good fit. So every so often, something like that might occur. But I do think, on the whole, the kinds of things that we're going to use are gloves,  and then in certain cases, we're going to want to use eye protection. And we'll talk about that as we get going. So gloves.  Gloves are something that we should use anytime we think we might come in contact with a possibility of blood. So when would those times be? You can see that here.  Anytime we remove an ear mold from an ear, anytime that we perform cerumen management, anytime we touch any kind of a spill of body fluids, or we're touching something that's  been contaminated, anytime we deal with an amino-compromised client. So there are going to be times when gloves are really a fabulous idea.  And if we're going to wear gloves, we want to be sure we like our gloves. And so lots of times the reason people don't like gloves is they just have crummy, one-size-fits-all  gloves. Gloves come in many, many sizes. They come with aloe vera in them. They come in many different colors and thicknesses.  And so one of the things I suggest to people is get some good gloves. Get some gloves that fit you. Make an appointment.  Go down to a medical supply store and try some things, because gloves can be actually quite comfortable.  We're going to want to change our gloves just like we're going to want to wash our hands. So anytime we move between a dirty and a clean activity, we need to change our gloves.  So if, let's say, in the time you were to see somebody, you would use gloves eight times, and you now have a person that has a bloody, drainy ear, or might wash your hands eight  times, you're probably going to need to use eight pairs of gloves. So you're not going to want to touch something nasty and then go and touch your audiometer with those gloves.  So you'd touch the nasty part, you'd take off the gloves, you'd wash your hands, you'd touch your audiometer, you'd need to use your gloves again, you'd put on another pair  of gloves. And so it's not typically going to just be one pair per person that you see. So hand hygiene is one really important thing that we need to do.  And the second one that we need to realize is how do we clean, disinfect, and sterilize? And those terms are not all the same.  Spalding is a gentleman who created a classification system that's used in all parts of health care, and he divided items into non-critical.  So those are things like our bone oscillator that touch the skin, but if they do touch the skin, it's intact skin, or they don't touch the client at all.  And then Spalding said there were semi-critical items, and these are things that come in contact with non-intact skin, but don't penetrate them.  And so in that particular case, we're going to want to use sterilization or high-level disinfecting as a minimum.  The interesting thing, as you see the list to your right there, many of the things that we use in our practices I would consider and are considered semi-critical items.  I'm going to mention this in more detail, but because there's sometimes a difficulty in deciding what is semi-critical and what is critical, in the United States, the audiology  community has determined that they're going to count all things that enter ear canals on the part of audiologists as critical items.  And so they're going to say that we're going to need to use sterilization as our method, or we need to use disposable.  So I mention this difference because it does differ a little bit from the Spalding classification,  but I think it's good for us to know what practices are being practiced in the United States.  In many of the other parts of the world, Spalding is used just as the way that you see it here, as it's used in Canada, where I've spent a considerable amount of time.  Okay, so let's talk about what those terms mean then. So cleaning is what you do when you vacuum the carpets in your office. That's good.  Cleaning is important, and sometimes if you have big chunks of things on an instrument, you're going to want to clean them first.  But cleaning is not enough for anything that we use with our patients. With our patients, we're either going to be using disinfectants, or we're going to be  using a sterilizing agent. And so a disinfectant is something that can then be classified into two different groups.  There's high-level disinfectants, and remember when you saw semi-critical, it said things needed to be using a high-level disinfectant with single-use or disposable preferred, and  sterilization as a great option. So high-level disinfectants are things that are going to kill and destroy bacteria, and  they're something that takes a little bit more energy than a low-level disinfectant. So if we're going to use a sanity wipe, or we're going to use an alcohol swab, those  are going to be considered low-level disinfectants. And they're great, but they're not enough for things that enter an ear canal.  And then sterilization is something that destroys all forms of microbial life, and I mentioned  already it's the recommendation by audiologists in the United States as the minimum standard. So how do we sterilize? Let's say we're going to take that highest level.  How do we sterilize? Well, we're going to need to use any of the things that you see here, and most commonly,  we're going to use a chemical sterilant like glutaraldehyde, with Cydex being a manufacturer of that, or hydrogen peroxide.  And hydrogen peroxide is a fabulous new introduction, at least in kind of the audiology world, and it's used very commonly with the dental world.  And when we use hydrogen peroxide, we're going to use concentrations of at least 7.5. So that's not going to be the variety that you go get at the local pharmacy.  That's a much lesser concentration. So this is going to be something that you're going to need to purchase in special locations, like a dental supply store, as an example.  So glutaraldehyde or hydrogen peroxide are the two methods that we use as chemical sterilants.  If we were to use a high-level disinfectant, we can use those same products, and the real difference is the amount of time.  So if we were using them as a high-level disinfectant, depending on the labeling of what you use, roughly you're going to be allowing the items to soak for 30 minutes, let's say,  and you want to be sure and consult your label. If you were sterilizing the items in the same solutions, in order to have them be sterilized,  they would have to soak for longer, let's say somewhere in the neighborhood of 8 to 10 hours. So the nice thing is to take a higher level or a higher standard doesn't take anything  longer than anything additional cost-wise, it just takes longer in terms of time. So the nice thing is that you can put everything in, let it soak overnight, the next morning  get up, rinse everything off, and you have used the higher level standard. So it's a nice thing to do, to use that higher standard, because it doesn't cost us any more  and things are just sitting overnight anyway, so we're not having to do anything with them.  And then I did mention low-level disinfectants, and low-level disinfectants include things like alcohol or chlorine, and some of the liquids that can go into an ultrasonic cleaner  are considered a low-level disinfectant solution, and that's great too, but they're not going  to be sufficient for things that are going to go from one ear canal to the next ear canal. And then finally, cleaning.  I mentioned some of the things that we can put in an ultrasonic cleaner are low-level disinfectants.  The vast majority, though, are more of a soap-based product, and a lot of those things are the things that go into the ultrasonic cleaner, so they're not sufficient, once again,  for things that we're going to put back into another patient's ear canal. Okay. So if we use things like glutaraldehyde or hydrogen peroxide, one of the most important  things that we need to realize is that these are chemicals and they are hazardous, and we want to be sure and know what the dangers of those are.  And we know that from our material safety data sheet that comes with the items, and we want to be sure that we have those available in case there is an accidental splash or an  accidental ingestion or whatever might happen. If something splashes into your eye, that's not the time you're going to want to go look  up on the internet to find the material safety data sheet. We want to be sure and have those posted near the chemicals so that we know what to do if something were to happen.  And so that's an important thing. I think finally, one of the things I get a lot of questions on is, what do I do if somebody does bleed?  What if I'm taking a deeper mold impression and I get a little blood, or I'm removing cerumen and I get a little blood, what do I do?  You know, there are multiple ways of – multiple kinds of waste, and most of what we would do is really very minimal.  You'd have a very minimal amount of blood, or you'd have some cerumen, and you could  really actually just throw that into just general waste into the garbage. I do recommend that you place it in a baggie or place it in something so that if then that  were to fall out onto your carpet or somebody were to drop something into the garbage or the janitor were to clean, that whatever is in that or on that is contained.  It is a good recommendation to know that anything that gets contaminated with excessive blood does need to be taken care of.  I always say, if you ever have that case where something is really being – some patient has excessive bleeding, you're not going to really need to worry about what you're going  to do with the blood. You'll be calling 911, and you can pack up all the things that you used and put that  in the patient's lap, and when the ambulance hauls them away, they can take the excessive blood with you.  I'm hoping none of you ever have that problem, but for the kinds of things that we're going  to do, simply just placing things in a separate bag and placing it in the regular trash is sufficient.  Another thing I think that's really important is that we take our own health seriously. If we take our health seriously and we don't get sick, then we can't transmit what we have  to our patients. If you ask the average adult, and I'm asking the average adult right now, this didn't lend  itself to a quiz, but I'm asking you, are your measles, mumps, and rubella shots up to date? The vast majority of you probably could not tell me that they were.  I don't think that I could know unless I work in a setting that mandates that these things are up to date. We need to be sure that our immunizations are up to date.  One of the things that I've learned the hard way is just because we are immunized as children  does not mean that there does not necessarily need to be an additional immunization to take place as we age.  Taking our immunizations very seriously and being sure that we are current and up to date is critical.  I strongly advocate that every person who does not currently have their Hep B series go and get that. That's a great thing for you to do.  I strongly advocate that every person gets the flu shot every single year. You work around patients. Patients can get ill.  If you don't have the flu, you can't give the flu to your patients. That's another thing that I strongly recommend.  I also strongly recommend TB testing and very periodic TB testing because we know that patients still do get placed in isolation if they become active with tuberculosis.  It's very simple to be tested yearly. It's kind of a pain, but it's a simple process. By pain, I don't mean it hurts.  I just mean you have to go get tested and then you have to go back and have your TB test read. If we are tested and we test positive, and I know many people are worried, as long as  you test positive and you don't have active TB, there's all kinds of things that can be done. There's medications.  There's all sorts of things, but waiting and not being tested and you are active and you then become active with TB, that process is not an easy process.  This would probably be a good quiz question, but I'm tested and I usually ask people, how often do you think I'm tested? I'm tested annually.  I think annually is a really good way to go because it ensures that you never have active TB. Even if you put it in your calendar for every other year, you still would be great.  I think these are important things, making sure that we're healthy and therefore not passing things on to our patients. I think staying home when we're sick.  I think if you're an employee and you are always sick on Fridays, your boss is going to wonder why it is that you get sick every single Friday, particularly if Thursday is  the cheap beer night in your town. Staying home when we're sick and not passing things on, I think, is important as well.  We're getting down to ... I've completed about half of the time that I'm going to talk and we want to be sure and leave plenty of time for questions, so I'm getting down to the  part where I'm going to have us look at some specific recommendations. What you will find with these is by the end, you are going to be able to predict what I'm going to say.  That is great because the nice thing about that is it means that the things that we do, we do every single time very similarly, so we don't have to think super hard about what  it is we need to do in a certain circumstance. Let's start with ear mold impressions. We're going to wash our hands because we're moving from a clean to a dirty activity, correct?  As long as we don't see gaping holes or lots of drainage or blood, we can go ahead and we can put the OtaBlock in just the normal way that we would and we can inject the impression  material. Now, the things that went into the ear, the OtaLite and the syringe are going to now be  dirty and are going to be required to have minimally high level disinfecting or they're going to be required to be sterilized. We'll talk about some ways around that in just a sec.  As the impression material is setting up, you get the ear mold box ready, you get your paperwork ready, all the kinds of things you normally do.  When you get ready to remove the impression, you're going to want to put on a pair of gloves. Now, I have many people say, I don't want to put on a pair of gloves.  I can touch my ear mold impression without ever touching the part that goes inside the patient's ear.  If you can do that, that's great because that's what you're trying to avoid, touching the part that goes in the ear.  You're going to place the ear mold in the box, you're going to remove your gloves if you wore them, you're going to close the box and you're going to disinfect your horizontal  surfaces. Anything that came in contact with the patient's ear, that came in contact with the table, you're going to want to clean that area.  I've gone to using a lot of disposable kinds of things because I don't want to have to try to remember to sterilize everything that goes into the ear.  So here's a little item you can put on the end of your syringe, and I love these. You use this, you throw this away, and now your syringe is perfectly fine because no  part of it actually touched the patient. Little Odolite tips, they're very cheap and disposable.  You can get the disposable ones and just throw that away and not have to do any kind of cleaning as well.  Of course, we're going to want to clean our splash surfaces, or disinfect our splash surfaces. So we're going to dispense a hearing aid.  We're going to take the hearing aid with our gloved hands, we're going to clean it off because we don't know what it came with from the factory.  We're going to put it in and out of the patient's ear while we're wearing our gloves, and when  we're done, we're going to go ahead and take off our gloves and we're going to disinfect the horizontal surfaces. Why are we worrying about gloves in this particular case?  Well, we're worrying because we're going to take this in and out of their ear several times, and whatever is growing in their ear is now going to be growing on our hands, and  we don't want that. We take a used hearing aid, something that's been worn from the patient. I suggest gloves.  If you don't want gloves, you can put it on a sandy cloth and you can wipe it off that way. That's fine too, but we want to clean that hearing aid, disinfect that hearing aid before  we ever touch it. We need to realize that if we're going to use little picks and dig around in our hearing  aids that we are going to get debris up into our eyes. The way to prevent that is to wear goggles.  We're going to want to clean the surface of the hearing aid when we're done, disinfect it again.  The picks and the probes that came in contact with cerumen, if they're visibly contaminated with cerumen, we're going to want to clean them and we're going to want to sterilize  them. We can then remove our gloves and we can clean our splashed surfaces again. Why do we care about what grows with hearing aids?  I've mentioned this already, but this is a fabulous study in which Benkakis looked at what was growing on hearing aids.  What you'll see here is she looked at seven different hearing aids and each hearing aid had at least a bacteria growing on it and some of them, in addition, had a fungus.  There are some pretty nasty things that live on hearing aids and we don't want those nasty things to live with us. We do a hearing aid listing check.  We pre-clean and disinfect the hearing aid. We will listen to it. When we're done, we clean it again. We clean the probe and we put everything away.  We analyze the hearing aid in a test box. We pre-clean the hearing aid. We attach the coupler. We make our measurements. We clean the coupler.  We clean the coupler again and we return it into its appropriate location. We do real ear measurements.  Once we see stuff growing in the patient's ear and blood or anything, we don't need to put on gloves because we're not actually going to come in contact at that point with anything  in their ear. We finish our measurements. We remove the probe, not touching the contaminated piece. if it's disposable, we dispose it.  If it's reusable, we clean it off to remove surface debris and then we sterilize it or high-level disinfect it. We're gonna make ear mold or hearing aid modifications.  We're gonna clean the hearing aid. Prior to buffing, we're gonna wear goggles, but now goggles we've already seen before. Remember, if we were gonna use a pick and pick things out,  we don't want things to get into our eyes. Similar kinds of things with any kind of modification that's gonna involve buffing or grinding.  Additionally, though, we're going to kick up debris and we're gonna breathe that in. So unless we want to get all of that into our lungs, we're gonna wanna wear a mask,  we're gonna put on our gloves, we're gonna go ahead and disinfect the hearing aid, clean this horizontal surfaces when we're done,  remove our gloves, clean our hands and remove our mask.  Okay, one of the things, and we're getting down to the point where I need to give you some time to ask for questions, but one of the things I think that's really important  is it's fine for us to learn about these procedures. It's fine for us to know how to protect ourselves. And yet there's our poor front office staff up there  taking hearing aids from patients, being asked to get them coffee, being asked to do a variety of different things. I think it's very, very, very important  that we be sure that our staff is safe as well. And so one of the things that I've implemented, and you can do it a variety of different ways,  but what I'd have is a nice, large manila envelope. And it's not the big eight and a half by 11 ones, but it's a pretty big envelope. It's about a four by sixer, I'd say.  And I have the staff open that up. They can, if a patient wants to drop off a hearing aid, they open it and hold it open so that the patient can drop the hearing aid  into the envelope. It's a nice, big target so that the patient has an easy time getting it into the envelope. They can secure it, not by licking the envelope  because you don't know what's there, but they can secure it by stapling it. They can put any kind of note then on the front of that envelope  or attach a paper if you have a drop-off sheet or whatever you have that's helpful. And then they can clean their hands. But this way, they have not had to touch the hearing aid  and therefore they're not transferring that to the patient's chart or to their computer screen or to the coffee mugs or anything along those lines. I think it's super critical  that everything that we do, we're certain that we're also making sure our staff is safe as well.  So I'm just about done with the things that I was gonna say and then we're gonna open it up for questions. But a lot of times, people will ask me,  fine, Julie, that was a lot of information. I need to know where I might go to get some additional information. And there are lots of sources out there.  I'm just showing you a couple of them. So for example, if you do a Google search and you type in infection control in a dispensing practice or in an audiology practice,  you'll find articles like this. So this is a nice article that's in the American Academy of Audiology's journal, American Speech Language Hearing Association  have some nice articles as well. So there's some articles that you can find that are going to give you additional information. There's some nice textbooks that are out there  that give you also additional information. The tricky part about that sometimes though is that some of this will become outdated. So if you're going to read your articles,  be sure that you're reading something that's reasonably current. Another document that I like, and this is very helpful I think for our Canadians amongst us,  is that all the audiology organizations in Canada got together and agreed upon a document. And it's called, as you see here, the Infection Prevention and Control Guidelines  for Audiology. And it's available in lots of places. I'm giving it to you on the CASELPO website, which is the Ontario audiology website. But it's another nice document  and it goes through much of the same kinds of information that we talked about today.  Okay, so I am to the part where we're ready for questions.  Awesome, thank you Julie. Okay everyone, we are opening it up to questions. A couple of people, well maybe a handful have submitted questions already, so don't be shy.  Go ahead and type in your question in the question box on your webinar dashboard for Julie and we will get to as many as we can. And by the way, I'm really excited Julie  to tell you that total attendees today reached about 240.  Wow. So we had, yes, we had quite a lot of colleagues on today. And we're gonna take our first question now. And the first question is from Jody  and she's asking, would you suggest to wipe the specula and or the surface with an alcohol swab before changing to another?  Ah, so that's an interesting question and I'm not certain I know what,  when you're asking that to take place. So I'm gonna answer it in a couple of different ways with the hope that I then answer your question  and you can, you know, resend a question if I did not. So one of the things that people will often ask is should they change it between ears? And certainly, you know,  if you have fungus on one side let's say and you put the specula in the other ear, you now are gonna have it on the other side.  So there is definitely, I think, a good case to be made for using different things between the two ears. I would say standardly people do not do that  and I think the reason that they don't is because patients themselves do not make a differentiation between ears. But if ever I were to see blood in one ear  or something that looked funny in one ear, I absolutely would not use the same specula in the other ear. And I would not use an alcohol swab in that case.  I would actually just discard it and use something different. So that might be one answer to your question. The other answer to your question might be  would I be doing that before I put it in their ear or after I took it out of their ear? And so if I was putting it in their ear, I would be using something brand new.  So I would feel fine about, you know, about not using alcohol on it prior to placing it in their ear. Now, the other thing I will say is extra infection control is never bad.  So if you have that practice and you do, you always wipe it off before you put it in their ear, continue. Nothing bad's gonna happen from that. That's just extra.  Extra's always good. So that's completely fine. When I'm finished, I would not alcohol it off. I simply would throw it away. So I'm hoping I answered your question  that I covered enough answers to answer that. If not, please resubmit the question.  Thank you, Julie. And actually, Renee had a very similar question about cleaning the probe tip from one ear to the other in the same patient.  So Renee, hopefully that answered your question as well. Okay. Okay, so we have a few others streaming in and Chris wants to know how many days  can you use the same solution to soak in?  Okay. Well, and I'm assuming you mean you're,  well, okay, there's, once again, there are two answers to that. If you're talking about your otosonic cleaner solution, you're using it as a cleaning solution,  in which case you could use that for as long  until the water looked dirty or you wanted to change it, because that would only be step one. That would be step one. And then step two would be that you would have  to be using a high-level disinfectant or you would have to be using a sterilizing agent on anything that's going to go into the patient's ear canal.  So that might be one answer to your question. The second answer to your question could be  if you're gonna use a high-level disinfectant or you're gonna use a sterilizing agent and you're gonna soak that, let's say overnight, can you reuse the solution?  And if you read your labeling, it says that you should not do that. So you would be pouring the solution into the tray or whatever, and then in the morning,  you would be disposing of that solution. The nice thing is, though, and I will tell you this, is it's not terribly expensive long-term to do that,  particularly the hydrogen peroxide is not an expensive item. And so you can have a small little tray, put that in the next day, then go ahead and dispose of it.  There's one other little caveat I will mention to you about hydrogen peroxide, even though I obviously am a big fan of it, I like it because it's not nearly as toxic  and the fumes aren't as much of a problem and it doesn't eat your fingernails if you accidentally get it on your hand, all of which I consider good.  But once you crack open the bottle of hydrogen peroxide, it can only be good for three weeks. So you're gonna wanna be sure and label when you opened it  because the solution itself is not very helpful. So once again, kind of back to your question, if you're using it every day,  you'll easily go through that bottle in three weeks. And so it's not so much of a problem.  Okay, great, Julie, thank you. To sort of continue on that line with using the ultrasonic cleaners, Todd wants to know, and you may have touched on this already  so feel free to expound or refer to your previous answer, but Todd is asking, what is the proper procedure when using an ultrasonic cleaner for ear molds?  And what is the proper solution to use in it? Is it hydrogen peroxide or something else?  So I didn't specifically get into this on my presentation  because I do want you to realize that you do have some ability to have your own thoughts  as long as you follow good infection control processes. And what I mean by that is some clinics really love their ultrasonic cleaner. And if I suggest to you,  just give up your ultrasonic cleaner, you're gonna say, no, I'm not gonna do that. I really like them. And I understand that.  So if you view whatever that goes into your ultrasonic cleaner, regardless of what it is, and there are a variety of different substances that you can buy, and some of them will say  that they are a disinfectant solution, and that's fine. They can say that, and I'm not even disputing that they are that. But what you need to think about  is if you put more than one ear mold ever into the same solution, then you can't view it as a disinfectant. So it would be similar if you were to say,  and I know alcohol is a low-level disinfectant, but let's think about that. If you had an alcohol swab and you swabbed up Mrs. Jones's hearing aid with it, you wouldn't turn around  and swab up Mr. Smith's hearing aid with it. I mean, I know they go dry, but just think about the fact that you'd be using one thing for one person  and one thing for the other person. So for the fluid or the solution in an ultrasonic cleaner, you can use it to clean. You can put more than one ear mold in it to clean it,  but when you are done, because whatever came off that hearing aid is in that solution and can go onto the next person's hearing aid, you need to view that as step number one.  So that's gonna be the way we're gonna joggle loose all of the cerumen, all of the bits in the dirt, and then whatever, and that's great. There is nothing wrong with that,  and so you absolutely can do that, but when you are finished, you are still going to need to use, if you're gonna take that and put that back into something  that somebody else's ear mold was in that solution, their debris is now in that solution. You are now going to have to use a high-level disinfectant  before you put that ear mold back into a patient. So because it's a little bit problematic, I have unfortunately just kind of decided  that my ultrasonic cleaner is more effort than it's worth, and I have gone to just using, not using anything that allows one person's dirt to get onto another person's ear mold.  I hope that makes sense. I've given up my ultrasonic cleaner, but I'm not telling you that you have to. You absolutely can, but you need to realize  that unless you change your solution  after every single person, you are going to have to high-level disinfect that ear mold before you put it back into the patient's ear.  That makes sense, Julie. And Barbie asked something very similar, but she wanted to take it a little further and ask, what would you use to clean out the ultrasonic cleaner?  The same type of solution or something different? Yeah, I mean, you can use the same kind of solution because you're once again not as worried about that as,  so you're gonna clean it out, you're gonna rinse it out, you can use soap and water, you can do all of those kinds of things. You could alcohol it out, you could sani-wipe it out.  You're not really going to be as worried about that because you know that that's just gonna be step one. That's just gonna be kind of your cleaning step,  and you're gonna go from there  in terms of if you're gonna reintroduce that back into a patient's ear. So yeah, I think just using good soap and water is probably sufficient,  and then using the same solution back into it, clean solution back into it.  Okay, we had a couple of related questions. So Denise and Teddy had very similar questions, and they wanted to know when disposing, can things be thrown away in a regular trash?  Would you have to have special trash bags and disposal service or sort of the red and white disposal containers?  What do you recommend? I think regular trash is completely fine. The only thing I would worry about or the only thing that I do think that you need to realize  is anything you throw into your regular trash, unless you're the person who takes that trash out and disposes of it of where it goes next. Let's say you have a cleaning service  and they come in at night and you throw things into the regular trash, and then they go ahead and they try to clean that and they let all of those things fall onto your carpet.  You might not realize then that big chunks of cerumen or a bloody tissue has fallen onto the carpet. And so I always say, think a little bit about what happens to the trash  once you put it in there. So if I have cerumen or I have a little bit of blood or just a little bit of something, like I mentioned before, I'm gonna put it in a Ziploc baggie  and put that in the trash. And then at the end of the night, I go ahead and tie my trash bag shut. That means that if the cleaning people come  and they take away my trash bag, it's tied shut. So I know that stuff is not gonna fall on my carpet. It's not gonna get, you know the trash can's not gonna get set,  put on the chair that I sit in and then maybe it tips over and when I come in in the morning and I sit down, unbeknownst to me,  I'm sitting on Mrs. Jones' cerumen from the day before. So I think that just realizing or being conscious of what the next step is, is fine. But the sorts of things that we have  were allowed and able to just put regularly into our trash, our regular old trash.  Okay, thank you. So we have a question from Valerie and she wants to know, do you need to ask a client if they have a known problem with alcohol or peroxide?  And if so, what kind of alternatives are there?  Yeah, so this is a very, very good question actually. And so the alternatives are disposables. And we didn't specifically talk about that.  And you know, I'm one of those gals that grew up in Seattle and we hug our trees in Seattle and we don't like the landfills in Seattle.  You know, we don't like all of this disposable stuff. But one of the things that has become, I think very common in a lot of clinics  is they don't wanna deal with a lot of this kinds of sterilization, high-level disinfecting kinds of issues. And they've gone to disposables and it does definitely decrease risk.  And so an alternative would be that you do use a, you know, everything that goes into an air is disposable. Here at the hospital, everything is disposable.  We really, we will clean and disinfect our splash surfaces.  But if it goes into an air canal, when we're done, it goes into the garbage. And that is a means that then we don't have to ask those questions and we don't have to worry  about what kinds of allergies a person might have. That I do agree with you, the hydrogen peroxide should not be one that they react to because anything that you put  into the hydrogen peroxide solution, at the end, when you read the labeling, it's gonna tell you afterwards to clean it or rinse it off with regular running water.  So you're gonna rinse the residual off of that. So that's one thing that is nice, but patients do have allergies and I do agree with you. It is tricky.  We don't ask because like I said, we just throw everything away. Every single thing that we use is disposable.  Okay, thank you. Let's see, we have a bunch of questions. Unfortunately, everyone won't be able to get through all of them, but we are gonna try to get through a few more.  And Rebecca wants to know, would audio wipes be okay to use to disinfect surfaces between patients? Yep. I'm a big fan. Yep, those are great.  All right, that was an easy one. Yay, I only had to give one sentence. I love it. Who is that? Let's have her ask another question.  Okay, Andrea wants to know, how effective is alcohol for disinfecting surfaces or specula?  So two different answers. So surfaces is fine.  So a surface comes hopefully in contact only with intact skin. I mean, it's different, I guess, if the patient comes in and they're bleeding all over,  then you know your surface is something different. But we assume that we're gonna let people sit in chairs and touch tables and all of those kinds of things.  So surfaces, alcohol is perfectly fine. That's a good one. For anything that's gonna go back into a patient's ear, so like a specula would be an example,  then alcohol is not sufficient. The minimum standard is a high-level disinfectant, a single-use item, or as I've mentioned, the audiology community is saying sterilizing.  So anything that's going back into another patient's ear, alcohol would not meet that classification because alcohol is a low-level disinfectant.  But it's perfect for the splash surfaces, absolutely fine.  Okay, so we did have a few questions on that. Hopefully that answered the question for many of you who wanted to know specifically about alcohol surfaces  as opposed to using it for something that might go into the ear. And would you recommend, Julie, that in terms of disinfecting surfaces with alcohol,  would maybe putting it in a spray bottle with a disposable paper towel or something be fine? Yes, yes, a spray bottle is great. You know, the sani-cloths that you can buy  that are the pull-ups, and you know, they don't even have to be specifically related to our field in order to, you know, be used in a splash surface.  If you're gonna use a low-level disinfectant, a lot of the commercial products that you might find even at places like Costco are gonna meet that criteria.  But those kinds of products, those pull-up cloths, are great for splash surfaces. But yes, you wanna find a way, you know, it's gonna be hard if you have a big bottle of alcohol  and you have a very large table. It's gonna be difficult to get that to the table unless you put it on a towel. And so I think some of those products  that are already pretreated are great. The other thing that I sometimes mention, and I'm gonna mention it here, because I think that this is one that's helped me a lot,  is I like using the dental bibs, and I don't have a picture, obviously, but the dental bib, you know, anybody who's been to a dentist knows  that they put a little, looks like a very large napkin around your neck that they call a dental bib. And underneath that napkin, it has a plastic surface.  So it keeps things that are sticky and gooey from soaking through. Dental bibs are not overly expensive. And I like to use those for serum and management  or for ear mold impression taking are two great examples where I would put one down, put all of the things that I need to use onto that surface.  And when I'm done, I know that everything that's on that dental bib is now considered dirty and is going to need to go in for throwing away  or for high-level disinfecting or whatever needs to be done. I know I'm gonna have to do that, but it allows me not to have to worry too much about my splashed surfaces,  because I'm not gonna sit an otoscope down anywhere else. It's only going to go onto that location. And so it keeps me from wondering where all did I place things  and how large of an area do I really have to disinfect? Because I contain myself to that little surface that's my dental bib. And so that might be something that you can do.  And I like the dental bib just because it has the plastic underneath it. Allows you to really keep things from soaking through. And we have a lot of things that do soak through  like impression material, some of the different kinds of products that we use.  Thanks, Julie. That is fantastic information. And hopefully this has given everyone some great information so that you can either tweak or implement  some different practices in your clinic for infection control. And we still have a lot of questions left over, but unfortunately we've run out of time.  So thank you, Julie, again for an excellent presentation. And we want to thank everyone for joining us today on the IHS webinar,  Infection Control for the Hearing Healthcare Professional. If you'd like to get in contact with Julie, you may email her directly at Julie at rchsd.org.  And you'll see her email up on the screen now. And for more information about receiving a continuing education credit for this webinar, please visit the IHS website at ihsinfo.org.  You can click on that webinar banner, or you can find more info on the webinar tab under professional development. IHS members do receive a substantial discount on CE credits.  So if you're not already an IHS member, you'll find out more about how to become a member at ihsinfo.org. Please keep an eye out for the feedback survey  we'll send you tomorrow via email. We ask that you just take a brief moment to answer a few questions about the quality of today's presentation.  And I just want to thank everybody again for being with us today, and we will see you at the next IHS webinar.