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Infection prevention and control for acupuncture practice Stephen Janz Chair, Policy Codes and Guidelines Advisory Committee, Chinese Medicine Board of Australia

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Overview Background to guidelines Methodology used to develop guidelines Guidelines structure Specific guideline discussion Conclusion 2

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Background Primary objective of Chinese Medicine Board (CMBA) is to protect public health and safety Potential risk of infection with skin penetration and related techniques No uniform national standard in place for acupuncture prior to these guidelines State requirements vary Registered practitioners exempt from some states skin penetration regulations Need for nationally consistent, evidence based guidelines 3

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Australian guidelines for prevention and control of infection in healthcare CMBA adopted the National Health and Medical Research Council (NHMRC) Australian guidelines for prevention and control of infection in healthcare (the Australian Guidelines). The Australian Guidelines uses a risk management approach to infection prevention and control based on the best available evidence Not all areas of acupuncture practice are adequately covered in the Australian Guidelines 4

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Aim of CMBA Guidelines CMBA initiated a project to identify specific requirements for the prevention and control of infections in acupuncture practice that are not covered in the Australian Guidelines 5

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Method The Australian Guidelines were examined to identify areas requiring further acupuncture specific guidance Literature search conducted to identify other literature regarding acupuncture infection prevention and control. Very little acupuncture specific literature (mainly case reports of infections) and one set of guidelines identified 6

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Method continued... A further search was conducted for evidence based guidelines for established procedures with a similar procedural risk profile to acupuncture. NHMRC immunisation guidelines WHO guide to best practice for injections and related procedures 7

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Method continued... Draft guidelines were developed by the Policies, Standards and Guidelines Advisory Committee Revised and approved by the CMBA for stakeholder consultation Stakeholder feedback was reviewed prior to finalising the document http://www.chinesemedicineboard.gov.au/News/Past- Consultations.aspx 8

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The CMBA Guidelines Consists of three parts, with hyperlinks to take the reader directly to reference material: Part 1: How to use NHMRCs Australian Guidelines in conjunction with the CMBAs guidelines Part 2: Additional CMBA requirements for the prevention and control of infection in acupuncture practice Part 3: State and territory guidelines and regulations relevant to acupuncture practice 9

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Part 1 How to use the NHMRC Australian Guidelines The Australian Guidelines provide guidance for: Basics of infection prevention and control Standard precautions Transmission-based precautions Recommended cleaning routine Organisational support http://www.nhmrc.gov.au/book/html-australian-guidelines- prevention-and-control-infection-healthcare-2010 10

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Part 2 - Additional CMBA requirements Six specific areas identified: A)Reprocessing of reusable instruments and equipment B)Hand hygiene and special precautions when using alcohol-based hand rub C)Appropriate use of gloves D)Requirements for routine skin preparation and post- treatment procedures E)Requirements for non-sharp waste disposal F)Prevention and management of sharps Injuries 11

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Reprocessing of reusable instruments and equipment All items must be reprocessed according to the Australian Guidelines except single use of: Acupuncture needles and dermal hammers Glass cups, scraping spoons and other equipment that comes into contact with blood or non-intact skin unless sterilisation in accordance with Australian Standards AS/NZ 4187 and AS/NZS 4815 Bamboo cups in all cases not constructed of a material suitable for sterilisation in accordance with the Australian Guidelines 12

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Hand hygiene and special precautions when using alcohol-based hand rub A clinic must contain at least one hands-free sink which is dedicated for hand washing only Hand hygiene performed with alcohol-based hand rub is more effective against microbes than plain soap or antiseptic soap and water However, when hands are visibly soiled and after using the toilet, they must be washed with soap and water Either of these must be located close to acupuncture treatment area and must be readily accessible 13

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Special precautions when using alcohol- based hand rub Alcohol-based hand rub must be stored, and used, away from heat and naked flames No tasks should be attempted until hands are completely dry Procedures involving exposure to a naked flame such as moxibustion or cupping must not be attempted until alcohol has evaporated and hands are completely dry 14

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Requirements for appropriate use of gloves Gloves do not need to be worn if the patient and practitioner both have intact skin and excessive bleeding is not expected Single-use gloves may be required if excessive bleeding is anticipated Direct contact with blood or body substances is unlikely when inserting an acupuncture needle into intact skin 15

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Examples of procedures which may require glove use: removing needles from an area which has been pre-treated with heat or massage using a dermal hammer cupping applied after dermal hammering vigorous needle technique electro-stimulation applied to acupuncture needles acupuncture point injection 16

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More on glove use: Any break in the practitioners skin must be adequately covered or a fingercot or gloves used In acupuncture practice, gloves do not need to be sterile but must be changed after every individual patient contact The use of gloves is not an alternative to hand hygiene Some states and territories require gloves to be used when inserting and/or removing acupuncture needles - refer to Part 3 of these guidelines for more information 17

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Requirements for routine skin preparation Provided the skin is visibly clean, there is no need to swab it with an antiseptic before inserting needles An antiseptic (such as isopropyl alcohol) must be used if the skin is visibly soiled, or has been pre-treated with massage oil or other topical preparations An antiseptic (such as isopropyl alcohol) should be used before treating potentially immunocompromised patients 18

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Requirements for post-treatment management A clean, dry cotton wool swab should be placed over the site of needle withdrawal immediately after withdrawal - to control any pinpoint of blood which may be evident, whether or not gloves have been used Massage should not be applied to a site which has just received acupuncture due to the potential for an increased risk of infection at the site 19

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Requirements for non-sharp waste disposal The Australian Guidelines do not make specific recommendations about waste disposal Where specific state or territory requirements are not in place the following guidance applies: clinic waste such as used swabs which do not contain expressible blood can be treated as general waste, and used swabs must be: discarded into a leak-proof plastic bag kept out of reach of children, and disposed of as general waste Standard precautions should be used when handling or disposing of all waste 20

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Sharps disposal containers Containers that comply with AS4031 or AS/NZ 4261 must be located close to each patient receiving acupuncture and must be kept out of reach of children Sharps containers must not be filled beyond three- quarters full and must be disposed of by a waste disposal contractor according to respective state, territory or local government regulations 21

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Prevention and management of sharps injuries Incorrect handling of sharps can result in a sharps injury and associated health risks to the practitioner The requirements for the handling of sharps : acupuncture needles should not be reinserted into guide tubes after use, and when injection techniques are used, needles must never be recapped See CMBA guidelines on how to manage a sharps injury 22

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Part 3 - State and territory guidelines and regulations relevant to acupuncture practice The CMBA Guidelines contains a list of each state and territory acupuncture guidelines or regulations subject to change Where there is an inconsistency between the CMBA Guidelines and state or territory guidelines, the state or territory guidelines must be followed Practitioners are responsible in keeping up to date with state or territory requirements 23

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Summary All registered acupuncturists must comply with: the NHMRC Australian Guidelines the CMBA Guidelines, and relevant state, territory and local government requirements which apply to their place of business 24

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Conclusion These guidelines took effect from 20 May 2013 The CMBA will monitor these guidelines for effectiveness and review them at least every three years All acupuncturists registered with the CMBA must comply with the guidelines 25

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For more information CMBA Guidelines are available at: http://www.chinesemedicineboard.gov.au/ http://www.chinesemedicineboard.gov.au/ For an example of how to apply a risk management approach to infection control and acupuncture see: http://www.acupuncture.org.au/Publications/Infection_ Control.aspx www.ahpra.gov.au 26