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Online COVID-19 Manual

CONTENTS

  1. Preparing the office
  2. Providing Dental Care
  3. Provision of In-Person Care of Patients Who Are COVID-19 Positive
  4. COVID-19 Exposure in the Practice
  5. Appendices
  6. Printables

1. PREPARING THE OFFICE

Prior to reopening the practice, take an inventory of personal protective equipment (PPE) and use this inventory to help inform the volume and scope of care that can be safely provided.

a. Use PPE appropriately to prevent unnecessary use of limited supplies and other PPE resources (eg, N95 respirators or the equivalent as approved nby Health Canada).

b. N95 respirators (or the equivalent) should be reserved for situations where risks are highest, especially aerosol-generating procedures (AGPs).

1A. GENERAL STAFF REQUIREMENTS

Have a team meeting and thoroughly review and explain any new office policies and procedures.

Wear procedure-appropriate PPE according to Table 1.

Change into office clothes and footwear immediately upon reporting to work.

a. Clothes worn in the office must not be worn outside of the office and should be laundered after every shift.

b. Laundry bins/containers should be lined with a barrier to avoid cross contamination during storage and transportation.

The number of staff in the practice at any one time will be limited, to avoid the spread of COVID-19.

Consider staggering shifts and lunch/coffee breaks when possible to support physical distancing.

Staff Screening. A daily log of staff screening and self-monitoring will be kept. The log will include answers to whether or not particular symptoms are experienced as well as a record of staff temperature readings twice daily; this will be signed at each entry. Please see the Dental Office Return-to-Work Screening Form.

Pregnant staff members should seek and follow medical guidance from their physician regarding returning to work.

Staff must conduct hand hygiene frequently by using an alcohol-based rub (ABHR) or soap and running water (especially before and after any contact with patients, after contact with high-touch surfaces or equipment, and after removing PPE).

Staff must maintain physical distancing of at least of 2 meters except as required to provide patient care.

Staff must self-monitor for any symptoms of COVID-19 (eg, By using the COVID-19 screening questions developed by the Ontario Ministry of Health).

Staff experiencing symptoms of COVID-19 must immediately go home and not return to work until after consulting with their physician and/or after they are symptom-free following 14 days of self-isolation.

1B. OFFICE SETUP

Limit points of entry into the office (eg, By designating a single entrance door)

Ensure the operatories are clean and disinfected.

Ensure magazines, toys, and any other non-essential items are removed from the office.

Post signage in common areas (eg, At the main entrance and in the waiting area) communicating relevant expectations for patients, including any requirements for:

a. Hand hygiene (eg, A requirement to wash and/or sanitize hands upon entry to the practice),
b. Respiratory hygiene (eg, A requirement to wear a mask within the practice),
c. Physical distancing (eg, a requirement to maintain a minimum distance of 2 meters, except as required for the provision of care).
d. Signs and symptoms of COVID-19; posted at the entrance to the office and/or at reception.

Ensure the availability of 70-90% ABHR at all entry points to the office and at the reception area for use by staff.

Ensure that patients and staff have access to tissues and receptacles lined with garbage bags.

Consider installing physical barriers at key contact points to reduce the spread of droplets, including reception (eg, a plexiglass shield).

Specific additional preparations for the delivery of AGPs can be found in the section regarding Provision of In-Person Care for Patients who are COVID-19 Positive (see Section 3).

2. PROVIDING DENTAL CARE

In accordance with the CMOH Directive #2, dentists are permitted to provide in-person care for all deferred, non-essential, and elective services, in addition to emergency and urgent care.

Exercise professional judgment when deciding how to triage and manage patient care.
This includes deciding which patients to triage and manage remotely (eg, via teledentistry), which patients to treat in-person, and which patient appointments to defer until the risks posed by COVID-19 are further mitigated.

These decisions must be made with careful consideration for the following principles:

a. The need to maintain physical distancing as a general risk mitigation tactic.
b. The possibility of using technology to provide guidance and care to patients via teledentistry.
c. The imperative to reduce risks to patients. This includes weighing the risks of not receiving treatment or deferring treatment against the risks of attending at the office.
d. The imperative to defer in-person care for patients who have screened or tested positive for COVID-19 wherever possible.

2A. SCHEDULING APPOINTMENTS

In order to schedule in-person appointments for assessment and/or treatment, ensure that the office can meet the appropriate PPE and operatory requirements, use professional judgement for the enhanced protection of others.

If we are unable to meet the applicable PPE and operatory requirements, the appointment(s) must be deferred until the PPE and/or operatory requirements can be met, or the patient must be referred to another available practitioner.

Ensure that appointments are scheduled and managed to avoid or limit direct, face-to-face interaction with others, including staff and other patients (eg, by staggering appointment times).

Ensure that patients are triaged and appointments are scheduled by phone or via teledentistry (not in person or via walk-in).

Prior to scheduling an appointment, ensure that patients are screened by phone for COVID-19 using the COVID-19 screening questions developed by the Ontario Ministry of Health. They may or may not be asked to sign and return the Patient COVID-19 Screening Form as well as the Patient Acknowledgement: COVID-19 Pandemic Emergency Dental Risk Form.

Patients who have screened or tested positive for COVID-19 must not be treated in-person except as needed for emergency or urgent care that cannot be delayed. If care must be provided without delay, dentists must adhere to the additional guidance and enhanced precautions set out in the section of this manual regarding Provision of In-Person Care of Patients who are COVID-19 Positive (see Section 3).

Patients who screen positive for COVID-19 should be advised to contact their primary care provider to determine next steps (which may include testing).

Make are report to the MOH of the health unit in which the treatment is provided, if any patient is discovered to be COVID-19 positive. This is mandated under the Health Protection and Promotion Act.

Record the results of the patient’s screening in the patient’s record (a written notation summarizing the conversation and screening results is sufficient for record keeping purposes).

2B. ENVIRONMENTAL CLEANING

Keep a daily log of cleaning procedures, indicating that particular areas were cleaned and who cleaned them.

a. Reception and waiting area: minimize contact, encourage physical distancing, remove fabric surfaces and replace with surfaces that can be easily wiped, remove unnecessary items and provide hand sanitation. Disinfect common areas and touch surfaces according to use.
b. Common areas: encourage physical distancing or wear a mask, disinfect high-contact surfaces often.
c. Clinical areas: only patients and necessary attendants allowed in clinical areas, clean according to IPAC manual and perform enhanced cleaning for COVID-19 positive patients.

Deliveries: have the delivery person knock to announce the delivery. Wear gloves when accepting all mail and/or packages. Disinfect/wipe the exterior of each box and allow it to remain untouched for 15 minutes prior to opening.

Contractors and dental technicians: screen the same as patients.

2C. PATIENT ARRIVAL PROTOCOL

Prior to permitting entry to the office, patients (and anyone else entering the office) should be screened a second time for COVID-19 using the screening questions provided by regulatory bodies.

If a patient reports or exhibits symptoms of COVID-19, dentists are advised to defer the appointment until the patient has consulted with their physician and/or after they are symptom-free following 14 days of self-isolation.

Patients and visitors must wear their own mask at all times while in the office except during the provision of care.

Patients who arrive without a mask must be provided one by staff prior to entering the office or be required to schedule a new appointment.

Require individuals accompanying a patient to wait outside the practice unless absolutely required (eg, a parent accompanying a young child or a patient who requires accommodation).

Patients (and guests) must perform hand hygiene with either 70-90% ABHR or soap and running water upon initial entry to the office.

Minimize patient contact with all surfaces.

Except as needed when providing care, a physical distance of at least 2 meters should be enforced between all people in the office. No handshaking or other unnecessary physical contact.

2D. DURING DENTAL CARE

The following guidance reflects the CMOH COVID-19 Operational Requirements Health Sector Restart document which specifies actions based on whether a patient has screened or tested positive or negative for COVID-19.

In keeping with this approach, the guidance set out below includes Routine Practices as well as Contact and Droplet Precautions that apply to all patients, whether they have screened or tested positive or negative for COVID-19.

Specific additional guidance for patients who have screened or tested positive for COVID-19 is contained with in the section regarding Provision of In-Person Care of Patients who are COVID-19 Positive (Section 3).

If the CMOH’s approach to specifying actions based on screening and/or testing changes, the RCDSO may provide guidance that may be updated accordingly.

All clinical staff must wear PPE that is appropriate for the anticipated procedure or activity (see Table 1).

Table 1A: Required Personal Protective Equipment (PPE) by Setting and Procedure/Activity when the patient has screened COVID-19 NEGATIVE.

Operatory or other treatment area: Non-AGP

·ASTM level 2 or 3 mask
·Gloves
·Eye protection OR face shield

Operatory or other treatment area: AGP

·Fitted N95 or equivalent, OR ASTM level 2 or 3 mask
·Gloves
·Eye protection OR face shield
·Optional gown

Reprocessing area

·ASTM level 2 or 3 mask
·Heavy DutyGloves
·Eye protection OR face shield
·Gown

Reception area

·ASTM level 1 mask or physical barrier
·Physical distancing

Common and staff areas

·ASTM level 1 mask OR physical distancing

Table 1B: Required Personal Protective Equipment (PPE) by Setting and Procedure/Activity when the patient has screened COVID-19 POSITIVE.

Operatory or other treatment area: Non-AGP

·ASTM level 2 or 3 mask
·Gloves
·Eye protection OR face shield
·Gown

Operatory or other treatment area: AGP

·Fitted and tested N95 respirator or equivalent
·Gloves
·Eye protection OR face shield
·Gown

Clinical staff must be trained in and familiar with proper donning and doffing procedures for PPE (eg, review Public Health Ontario’s Recommended Steps for Putting on and Taking Off Personal Protective Equipment).

Ensure that operatories are cleaned and disinfected between each patient appointment.

Following an AGP involving a patient who has screened NEGATIVE for COVID-19, wait 15 minutes after completion of the clinical care and exit of each patient before cleaning and disinfection.

Following an aerosol-generating procedure involving a patient who has screened or tested POSITIVE for COVID-19, cleaning and disinfection of the operatory must only be undertaken following the necessary fallow period, as described in Section 3.

2E. PATIENT DEPARTURE PROTOCOL

Ask the patient to disinfect their hands with 70-90% ABHR before leaving the office.

Patients should be asked to inform office staff if they experience any symptoms of COVID-19 within 14 days of their appointment.

Operatories must be cleaned and disinfected between each patient appointment.

In addition to the cleaning procedures outline in our IPAC manual, disinfect all touch surfaces as used and perform enhanced cleaning if there has been potential exposure to a patient or staff member who has been screened or tested positive for COVID-19.

Keep surfaces clear of items as much as possible and wipe down common areas frequently according to usage.

2F. END OF DAY SANITIZATION

Ensure the general office housekeeping, including cleaning and disinfection of high-touch surfaces, occurs at least twice per day (eg, door knobs, plexiglass barriers, hand rails, counters, and the arms of chairs). Enter this in the cleaning log.

3. PROVISION OF IN-PERSON CARE OF PATIENTS WHO ARE COVID-19 POSITIVE

The following guidance is specific to the in-person care of patients who have screened or tested positive for COVID-19.

Patients who have screened or tested positive for COVID-19 must not be treated in-person except as required for emergency or urgent care that cannot be delayed.

Where in-person care must be provided to patients who have screened or tested positive for COVID-19, enhanced precautions must be used as set out below and in Table 1B.

Except as unavoidable for the treatment of emergency or urgent care that cannot be delayed, avoid AGPs on patients who have screened or tested positive for COVID-19 unless the additional requirements set out below are met.

3A. PATIENT ARRIVAL PROTOCOL FOR PATIENTS WHO HAVE SCREENED OR TESTED POSITIVE FOR COVID-19

Where the in-person care of a patient who has screened or tested positive for COVID-19 cannot be avoided, the patient must be required to perform hand hygiene with a 70-90% ABHR upon entering the office.

Patients who have screened or tested positive for COVID-19 must don a surgical / procedure mask prior to entering the office.

a. Where the patient does not have their own surgical / procedure mask, they must be given one.

We must ensure that patients who have screened or tested positive for COVID-19 do not remove their mask, except as required for treatment, and do not leave their mask in waiting areas or anywhere else inside the office.

Patients who have screened or tested positive for COVID-19 must immediately be placed into an operatory alone with the door closed.

a. Patients who have screened or tested positive for COVID-19 must not be placed within 2 meters of any other patients in the office (eg, in the waiting room).
b. Where an operatory is not available and/or physical distancing cannot be maintained, patients who have screened or tested positive for COVID-19 must be instructed to return outside (eg, to their vehicle or a parking lot if available and appropriate), and informed they will be notified when a room becomes available.

3B. USING AN ORAL RINSE

While there is a lack of documented evidence, we should still require patients who have screened or tested positive for COVID-19 to rinse with 1% – 1.5% hydrogen peroxide or 1% providone-iodine for 60 seconds prior to examination of the oral cavity, as this may help decrease oral pathogens.

3C. INTRA-ORAL RADIOGRAPHS

When possible, minimize the use of intra-oral radiographs and consider using extra-oral radiographs when a patient has screened or tested positive for COVID-19.

3D. AGPs

When a patient undergoes an AGP, high concentrations of droplets smaller than 5µm (droplet nuclei) are generated that may remain suspended in the air for significant periods of time, move with air currents, and come in contact with others. It is thought this creates a risk for opportunistic airborne transmission of COVID-19, even if the virus is not otherwise able to spread by the airborne route. While there is no conclusive evidence at this time that opportunistic airborne transmission of COVID-19 occurs after AGPs, and the thought may always be at least apocryphal or perhaps just complete bullshit, given how clean we keep our clinics, some powers that be have adopted a precautionary approach that prioritizes safety.

Again, when treating patients who have screened or tested positive for COVID-19, avoid AGPs whenever possible and use the lowest aerosol-generating options when necessary.

Aerosols may be generated by high-speed, low-speed and other rotary handpieces, ultrasonic and other similar devices, and air-water syringes. Basically everything we do.

3E. PREPARING THE OPERATORY FOR AGPs

Preparing the Operatory for Aerosol-Generating Procedures
Minimize the contents of all operatories in which AGPs may be performed on patients who have screened or tested positive for COVID-19, including unnecessary equipment, supplies, plants, and artwork. Artwork? Yes, artwork, too.

When performing AGPs on patients who have screened or tested positive for COVID-19, the procedure must be performed in an operatory that is capable of containing the aerosol. This requires floor-to-ceiling walls and a door (or other barrier) that must remain closed during and after such procedures. Temporary walls and doors are permitted, provided they create an area to contain aerosols and are constructed of materials that can withstand repeated cleaning and disinfection.

3F. USE OF PPE DURING AGPs

When performing AGPs on patients who have screened or tested positive for COVID-19, ensure that treatment is provided using enhanced PPE precautions for all clinical staff, including:

a. fit-tested and seal-checked N95 respirators (or Health Canada-approved equivalent),
b. gloves,
c. eye protection and face shields,
d. gown.

Ensure that clinical staff are trained in and use proper donning and doffing procedures for PPE.

3G. MITIGATING HIGH RISK AEROSOLS

If possible, dentists performing AGPs on patients who have screened or tested positive for COVID-19 should use a rubber dam with high-volume suction to minimize aerosols and possible exposure to infectious agents.

3H. CLEANING AND DISINFECTION FOLLOWING AGPs

Following AGPs involving patients who have screened or tested positive for COVID-19, cleaning and disinfection of the operatory must only be undertaken following the necessary fallow period outlined in Table 2.

Following the appropriate fallow period, ensure that operatories (including all clinical contact surfaces and equipment) are cleaned and disinfected prior to treating a new patient. Cleaning and disinfection must be undertaken using appropriate hospital-grade low-level disinfectant (i.e. has a DIN from Health Canada).

3I. CLEARING THE AIR OF AEROSOL (FALLOW TIME) FOLLOWING AGPs

Following an AGP involving a patient who has screened or tested positive for COVID-19, the operatory must be left empty (with the door closed) to permit the clearance and/or settling of aerosols.

The length of time that the operatory must be left empty (the fallow time) is determined by the air changes per hour (ACH). The aim is to achieve 99.9% removal of airborne contaminants.

Consult an HVAC professional to assess the existing HVAC system and calculate the actual ACH for the dental practice. Dentists may use the actual ACH to calculate a fallow time using Table 2.

Retain copies of any documentation supporting the HVAC assessment and any need for engineering controls.

If the rate of ACH is unknown, assume that a fallow time of 3 hours is required between patients in that particular operatory.

Table 2: Time Required for Removal or Settling of Aerosols by Air Changes per Hour (ACH) in minutes for 99.9% efficiency.

ACH                   Time in minutes for 99.9% effeciency

2                         207
4                         104
6                         69
8                         52
10                       41
12                       35
15                       28
20                       21
50                        8

Adapted from: Centers for Disease Control and Prevent, Guidelines for Environmental Infection Control in Health-Care Facilities (2003): Table B.1. Air changes/hour (ACH) and time required for airborne-contaminant removal by efficiency. Available at: https://www.cdc.gov/infectioncontrol/guidelines/environmental/appendix/air.html#tableb1

Options to improve ACH may include:
a. consult an HVAC professional to determine whether changes to the existing system may be improved.
b. In-operatory air cleaners with HEPA filtration.

4. COVID-19 EXPOSURE IN THE PRACTICE

Ensure that there is a designated space for staff and/or patients to self-isolate should they experience symptoms of COVID-19 or suspect possible exposure to COVID-19.

In the event of suspected exposure to COVID-19, staff must immediately self-isolate, not present to work and contact their primary care provider or our local public health unit for further guidance.

In the event that a patient contacts the office to report symptoms of COVID-19 within 14 days of having attended an appointment, contact our local public health unit for further guidance.

5.  APPENDICES

Appendix A

Terminal cleaning for dental operatories after an AGP on a patient who screened positive for COVID-19

1. Terminal cleaning refers to the process for cleaning the dental operatory, operatory chair, chairside equipment, environmental surfaces, and sinks before another patient is allowed to enter the treatment area.

2. Terminal cleaning should primarily be directed toward items that have been in direct contact with the patient or in contact with the patient’s secretions, blood or body fluids such as during AGPs.

3. Assigned dental personnel should use the same precautions to protect themselves during terminal cleaning that they would use for routine cleaning. Respirators are not needed as long as cleaning does not begin prior to the appropriate fallow time. (Refer to table below for fallow times for AGPs).

4. All disposable items in the dental operatory should be discarded.

5. Reusable items in the room should be reprocessed as appropriate to the item.

6. Dental chairs, counters, handles, doors, sinks, electronics and X-ray equipment and all horizontal surfaces in the room should be cleaned with detergents/disinfectants as per customary protocol.

7. Routine washing of walls, and blinds is not indicated. These should be cleaned if visibly soiled.

Adapted from Routine Practices and Additional Precautions for Preventing the Transmission of Infection in
Healthcare Settings, Public Health Agency of Canada, November 2016
Page 29 of 37
ODA Return-to-Practice Toolkit (Version 2.0)

Appendix B

Steps for donning PPE for the operatory for patients who screened positive for COVID-19

Before donning, ensure hydration, use the washroom, secure your hair, and remove jewelry. Donning must be completed prior to entering the operatory.

1. Perform hand hygiene. Clean all surfaces of hands and wrists.
2. Gown (AGP). Cover torso and wrap around back, fasten behind neck and waist.
3. Surgical/procedure mask (N95 or equivalent for AGP). Secure ties in middle of head and neck, fit nose band to your nose and pull on bottom down to completely cover chin.
4. Eye protection – Place goggles or face shield over face and eyes and adjust to fit.
5. Gloves – Extend to cover wrist of gown.

Before entering the operatory, dentist and assistant should check each other to assess fit and proper coverage of PPE.

Appendix C

Steps for doffing PPE

For non-AGPs:

1. Gloves – The outside of gloves are contaminated. Grasp palm area of one gloved hand and peel off first glove. Slide fingers of hand under other glove at wrist and peel off. Discard in regular waste bin.
2. Perform hand hygiene – Clean all surfaces of hands and wrists.
3. Gown – Unfasten ties, pull gown away from neck and shoulders, touching ONLY the inside of the gown. Turn gown inside out and roll into a bundle. Place in soiled laundry hamper (if reusable) or in regular waste bin (if disposable).
4. Perform hand hygiene – Clean all surfaces of hands and wrists. If you are NOT 2 meters away from the patient, exit room now, perform hand hygiene, and finish the remaining steps.
5. Goggles or face shield – Do NOT touch the front of the eye wear. Place in receptacle for reprocessing (if reusable) or in regular waste bin (if disposable).
6. Perform hand hygiene – Clean all surfaces of hands and wrists.
7. Surgical or procedure mask – Grasp ties or elastics at back and remove WITHOUT touching the front. Place in receptacle for reprocessing or in regular waste bin.
8. Perform hand hygiene – Clean all surfaces of hands and wrists.
9. Exit room: Exit room and perform hand hygiene.

For AGPs:

1. Gloves – The outside of gloves are contaminated. Grasp palm area of one gloved hand and peel off first glove. Slide fingers of hand under other glove at wrist and peel off. Discard in regular waste bin.
2. Perform hand hygiene – Clean all surfaces of hands and wrists.
3. Gown – Unfasten ties, pull gown away from neck and shoulders, touching ONLY the inside of the gown. Turn gown inside out and roll into a bundle. Place in soiled laundry hamper (if reusable) or in regular waste bin (if disposable).
4. Perform hand hygiene – Clean all surfaces of hands and wrists.
5. Exit room: Exit room and perform hand hygiene.
6. Goggles or face shield – Do NOT touch the front of the eye wear. Place in receptacle for reprocessing (if reusable) or in regular waste bin (if disposable).
7. Perform hand hygiene – Clean all surfaces of hands and wrists.
8. N95 respirator – Grasp ties or elastics at back and remove WITHOUT touching the front. Place in receptacle for reprocessing or in regular waste bin if soiled or broken.
9. Perform hand hygiene – Clean all surfaces of hands and wrists.

6.  PRINTABLES

How to Don and Doff PPE
How to Handwash
How to use Handrub
Cough Etiquette
COVID-19 Physical Distancing
COVID-19 Cleaning and Disinfection in Public Places
How to Stay Safe at Work
Frontline Worker Safety Guide
Stop and Read Before Entering
Before Seeing Reception