SECTION 4: Tattoo and piercing facilities

Learning objectives: The learner will be able to

General bloodborne pathogens rules and regulations apply to anyone who may encounter contaminated materials while on the job. However, some high-risk industries have special requirements to ensure the safety of their customers and employees alike. Tattoo and piercing is one such industry.

All tattoo and piercing establishments must adhere to the rules set forth by the Occupational Safety and Health Administration (OSHA) https://www.osha.gov/ and Centers for Disease Control and Prevention (CDC). The goal of bloodborne pathogen regulations is to prevent any potential risk of exposure to blood or OPIM before, during and after tattooing or body piercing. The following will take a look at the rules and regulations that are most relevant to the industry.

Risk of infection during tattooing and piercing procedures

Anytime the skin is penetrated or punctured there is a potential risk for infection from opportunistic microorganisms entering a fresh or healing tattoo or piercing. These infections can be transmitted between two people, or from contact with an object that is contaminated, such as an instrument used to puncture the skin.

There are risk factors that are unique to the tattoo process. They include:

Many of these factors can be minimized by following some simple rules.

Join the discussion: What is the difference between a localized infection versus a systemic infection? What opportunistic microorganisms may cause a localized infection? Please share your clinical experience.Discuss on Med Talk.

Physical setup of the facility

Customers must have a waiting and/or shopping area that is separate from the section that is used to complete tattoo or piercing work. Adequate lighting and ventilation is a requirement. A utility sink and a working toilet must be present. The sink must have both hot and cold water.

There cannot be any carpet on the floor due to the inability to effectively clean this material to prevent occupational exposure. The walls must be painted a light color. Furniture must be non-absorbent (for example, a fabric chair would be prohibited), corrosive resistant and smooth—it must be easy to sanitize. All work tables, countertops, and work chairs must be smooth and free of damage such as divots or missing pieces that could prevent proper cleaning.

Each artist must have a separate workspace that includes cabinets with doors to store instruments, dyes and other items that are needed to perform their work. The area must be cleaned and sanitized between each client.

Waste disposal and sanitation

General waste from the waiting room or office personnel must have a separate waste basket from the work area. Hazardous and sharps waste must be collected and disposed of in appropriate containers (as discussed earlier in the course). This waste must be disposed of by a contractor that holds a license to handle hazardous waste products. A separate container used exclusively for sharps must be readily available for each work area. The container must be solid and puncture-resistant, have leak-proof walls and be sealable. It must be clearly marked as a sharps disposal.

Non-disposable instruments must be scrubbed with soap and hot water and then sterilized in an autoclave. If acetate reusable stencils are used, they must be sterilized using an antibacterial solution after each use. Paper stencils are one-time use only and are disposed of in the hazardous materials bin.

Markers used to draw on the client’s skin must be disposed of and a new one used for each client. New and sterile tattoo needles must be used for each client. For safety, forceps should be used to attach and remove the needle from the machine. The needle should never be manipulated, cleaned or used by hand.

Clean gloves must be used with each client and should be readily available at each workstation. Gloves are changed with each client or when they are punctured. They are disposed of in the hazardous waste bin.

Preventing infection before, during, and after tattoos and piercing

Any artist who is ill (including fever, diarrhea, and vomiting) or who has a skin rash or infection is not permitted to perform tattoos or piercing until the condition is completely gone.

The tattoo and piercing artist must ensure that they have no cuts, sores or open areas on their hands; if they are present, they must be covered with a bandage before donning gloves for the procedure. All jewelry, including rings and watches, must be removed.

The artist must wash their hands with warm water and antibacterial soap using a brush to go between fingers and around and underneath fingernails. The hands should be dried using a hand dryer. Gloves and an apron or smock are then put on; anytime they are cut or punctured they must be replaced.

If the skin must be shaved, only disposable razors should be used. They are disposed of in the sharps container.

There should be no food or drink in any of the work areas of the studio.

Cleaning and sterilization

The sterilization of reusable instruments is key to any bloodborne pathogens program. Sterilization, when done properly, kills all microorganisms and bacterial spores. Any reusable instrument that has come in contact with mucous membranes or open skin of a client must be sterilized before its next use. Passing a Biological Indicator Sterility Test is the most definitive way to ensure that sterilization has been accomplished.

Biological Indicators are performed by placing a standardized, viable amount of bacterial spores into a liquid or on a paper strip. Two samples form a test kit—one of the samples is run with a regular load of instruments to be sterilized, the other is a control sample. Growth in the control but not in the sterilized sample is a reliable way to know that the sterilization process was successful. This test should be completed monthly as part of a regular sterilization monitoring process.

Chemical Indicators may also be used. They are strips, tapes or indicating labels on bags and pouches that change color or form when exposed to heat. There are three classes of indicators.

The third way of checking whether sterilization has occurred is by monitoring the gauges on the autoclave to make sure that the pressure and temperature are correct before beginning the timing process.

Most states, including California, require the use of steam under pressure (an autoclave) for sterilization in body art shops. Steam is much more effective than dry air in delivering heat. Liquid sterilants, such as glutaraldehyde, are not approved for sterilizing tattoo, body piercing, and permanent cosmetic instruments because of the adverse effects they can have on people and the environment.

There are four essential components to effective sterilization by steam: time, contact, temperature, and high pressure. The machine must be capable of heating water to a point where it produces steam. The items to be sterilized must be arranged in a way that all surface areas are accessible to the steam. They must be exposed for an appropriate amount of time—times may vary depending on the type of instrument.

Cleaning

Instruments must be cleaned before packaging them for sterilization. The preferred method is to clean via an ultrasonic cleaner—it will lessen the exposure to contaminated materials and is more efficient than hand cleaning. Manual cleaning should be avoided whenever possible.

Packaging

Hemostats, pliers, and all instruments that have hinges must be sterilized in the open position so that the steam reaches all surfaces. Sharp objects must be packaged in a manner that ensures that the packaging will not be pierced during the process. If the packaging is pierced during the process, it must be repackaged and resterilized. The package label must include:

All packages should be loaded into the autoclave in an upright position. Never overload an autoclave as packages will block each other from being properly sterilized.

Documentation

A sterilization log must be maintained. Each load must be logged and then kept on file at the place of business for two years. The log must contain:

Storage

Sterilized instruments must be stored in an area that prevents moisture, puncture or contamination. Instruments should only be handled with clean gloves to prevent pathogens from transferring to the sterilized equipment when the package is opened. Before each use, the package should be inspected for punctures, tears or moisture; if any are present, the instrument should be considered contaminated.

Before the procedure

All paperwork must be completed and kept on file for three years. The requirements of each State differs on how long client records must be kept. Some states such as Alabama require that they be stored indefinitely, although only immediately available onsite for 3 years. It would be prudent to check with your Department of Health and other governing bodies to ensure that your recordkeeping is in compliance with your State’s requirements.

The paperwork must include:

The procedure should be reviewed with the client verbally, and all questions must be answered. Aftercare instructions should also be reviewed. When the procedure is finished, aftercare instructions and a copy of the informed consent should be given to them before they leave.

Aftercare

Aftercare is an essential part of ensuring a safe experience for both the artist and the client. The site should be gently cleansed to remove excess ink, ointments or pigments that were utilized during the procedure. After cleansing, an appropriate protective covering must be applied—the kind of coverage will change depending on the location and type of procedure. No client should be permitted to leave the facility with a tattoo that is not protected.

If fluids are weeping from the tattoo site, an absorbent dressing must be applied to avoid contaminating surfaces and other people. The client must be provided with both written and verbal instructions on how to care for the site and any restrictions on activity or bathing. They should be educated on how long the healing process is expected to take, the signs and symptoms of infection and knowing when and how to seek medical attention. A phone number must be provided for any questions they may have after leaving the facility.

Works cited

The following are helpful resources for all who are involved in the art of tattoo, body piercing or permanent cosmetics.