Zaro University COVID-19 Prevention Guidelines for Dental Settings - PDF

Prevention of Coronavirus Disease 2019 (COVID-19): Guidance for Dental Settings Course Dr. Sanabel Barakat Semester / year BDOS., MSc., PhD., JDC. Week  Introduction Respiratory hygiene/cough etiquette infection prevention...

Prevention of Coronavirus Disease 2019 (COVID-19): Guidance for Dental Settings Course Dr. Sanabel Barakat Semester / year BDOS., MSc., PhD., JDC. Week  Introduction Respiratory hygiene/cough etiquette infection prevention measures are designed to limit the transmission of respiratory pathogens spread by droplet or airborne routes. The strategies target primarily patients and individuals accompanying patients to the dental setting who might have undiagnosed transmissible respiratory infections, but also apply to anyone (including DHCP) with signs of illness including cough, congestion, runny nose, or increased production of respiratory secretions. 2  Respiratory hygiene/cough etiquette ✓Implement measures to contain respiratory secretions in patients and accompanying individuals who have signs and symptoms of a respiratory infection, beginning at point of entry to the facility and continuing throughout the visit. ✓Educate DHCP on the importance of infection prevention measures to contain respiratory secretions to prevent the spread of respiratory pathogens when examining and caring for patients with signs and symptoms of a respiratory infection. 3  Respiratory hygiene/cough etiquette 1. Post signs at entrances with instructions to patients with symptoms of respiratory infection to (1) cover their mouths/noses when coughing or sneezing; (2) use and dispose of tissues; and (3) perform hand hygiene after hands have been in contact with respiratory secretions. 4  Respiratory hygiene/cough etiquette 2. Provide tissues and no-touch receptacles for disposal of tissues. 3. Provide resources for performing hand hygiene in or near waiting areas. 4. Offer masks to coughing patients and other symptomatic persons when they enter the dental setting. 5. Provide space and encourage persons with symptoms of respiratory infections to sit as far away from others as possible. If available, facilities may wish to place these patients in a separate area while waiting for care. 5  Prevention of Coronavirus Disease 2019 (COVID-19): Guidance for Dental Settings 6  Precautions before the patient enters the clinic 7  Recommended Infection Prevention and Control Practices When Providing Dental Health Care for a Patient With Suspected or Confirmed COVID-19 Infection Surgical procedures that might pose higher risk for infection transmission if the patient has COVID-19 include those that generate potentially infectious aerosols or involve anatomic regions where viral loads might be higher, such as the nose and throat, oropharynx, and respiratory tract 8  Prevention of Coronavirus Disease (COVID-19): Guidance for Dental Settings It is recommended to use additional infection prevention and control practices during the COVID-19 pandemic, along with standard practices recommended as a part of routine dental health care delivery to all patients. 9  Consider if Elective Procedures, Surgeries, and Nonurgent Outpatient Visits Should Be Postponed in Certain Circumstances Provide dental treatment only after you have assessed the patient and considered both the risk to the patient of deferring care and the risk to DHCP Ensure that you have the appropriate amount of personal protective equipment (PPE) and supplies to support your patients. If PPE and supplies are limited, prioritize dental care for the highest need, most vulnerable patients first— those at most risk if care is delayed. 10  Consider if Elective Procedures, Surgeries, and Nonurgent Outpatient Visits Should Be Postponed in Certain Circumstances DHCP should consider the framework for providing non-COVID-19 Clinical Care During the COVID-19 Pandemic, to determine how and when to resume nonemergency dentalcare. DHCP should stay informed and regularly consult with the state or local health department for region-specific information and recommendations. Monitor trends in local case counts and deaths, especially for populations at higher risk for severe illness. 11  Implement Teledentistry and Triage Protocols Contact all patients before dental treatment. Telephone screen all patients for symptoms consistent with COVID-19. If the patient reports symptoms of COVID-19, avoid nonemergent dental care and use the Phone Advice Line Tool for Possible COVID-19 patients. 12  Implement Teledentistry and Triage Protocols If possible, delay dental care until the patient has ended isolation or quarantine. Telephone triage all patients in need of dental care. Assess the patient’s dental condition and determine whether the patient needs to be seen in the dental setting. 13  Implement Teledentistry and Triage Protocols Use teledentistry options as alternatives to in-office care. Request that the patient limit the number of visitors accompanying him or her to the dental appointment to only those people who are necessary. 14  Implement Teledentistry and Triage Protocols Advise patients that they, and anyone accompanying them to the appointment, will be requested to wear a facemask when entering the facility and will undergo screening for fever and symptoms consistent with COVID-19. 15  Screen and Triage Everyone Entering a Dental Health Care Facility for Signs and Symptoms of COVID-19 Take steps to ensure that everyone (patients, DHCP, visitors) adheres to respiratory hygiene and cough etiquette and hand hygiene while inside the facility. Post visual alerts icon (e.g., signs, posters) at the entrance and in strategic places (e.g., waiting areas, elevators, break rooms) to provide instructions (in appropriate languages) about hand hygiene, respiratory hygiene, and cough etiquette. 16  Screen and Triage Everyone Entering a Dental Health Care Facility for Signs and Symptoms of COVID-19 Instructions should include wearing a facemask for source control, and how and when to perform hand hygiene. Provide supplies for respiratory hygiene and cough etiquette, including alcohol-based hand rub (ABHR) with at least 60-70 % alcohol, tissues, and no-touch receptacles for disposal, at health care facility entrances, waiting rooms, and patient check-ins. 17  Screen and Triage Everyone Entering a Dental Health Care Facility for Signs and Symptoms of COVID-19 Install physical barriers (e.g., glass or plastic windows) at reception areas to limit close contact between triage personnel and potentially infectious patients. Remove toys, magazines, and other frequently touched objects from waiting room that cannot be regularly cleaned and disinfected. 18  Screen and Triage Everyone Entering a Dental Health Care Facility for Signs and Symptoms of COVID-19 Ensure that everyone has donned their own cloth face covering , or provide a facemask if supplies are adequate. Screen everyone entering the dental health care facility for fever and symptoms consistent with COVID-19 or exposure to others with infection. Actively take their temperature. Fever is either measured temperature at 100.0°F (or above) or subjective fever. 19  Screen and Triage Everyone Entering a Dental Health Care Facility for Signs and Symptoms of COVID-19 Ask them if they have been advised to self-quarantine because of exposure to someone with SARS-CoV-2 infection. Properly manage anyone with symptoms of COVID-19 or who has been advised to self-quarantine Document absence of symptoms consistent with COVID-19. 20  Screen and Triage Everyone Entering a Dental Health Care Facility for Signs and Symptoms of COVID-19 If a patient is found to be febrile, has signs or symptoms consistent with COVID-19, or experienced an exposure for which quarantine would be recommended, DHCP should follow all precautions recommended. Assess urgency of dental treatment 21  Precautions during dental treatment 22  Recommended IPC practices when providing dental health care for a patient with suspected or confirmed SARS-CoV-2 infection ✓People with COVID-19 who have ended home isolation can receive dental care following Standard Precautions. 23  Recommended IPC practices when providing dental health care for a patient with suspected or confirmed SARS-CoV-2 infection ✓If a patient has a fever strongly associated with a dental diagnosis (e.g., pulpal and periapical dental pain and intraoral swelling are present) but no other symptoms consistent with COVID-19 are present, dental care can be provided following the practices as recommended 24  Implement Universal Source Control Measures Source control refers to use of facemasks (surgical masks or procedure masks) to cover a person’s mouth and nose to prevent spread of respiratory secretions when they are talking, sneezing, or coughing. Because of the potential for asymptomatic and presymptomatic transmission, source control measures are recommended for everyone in a health care facility, even if they do not have signs and symptoms of COVID-19. 25  Implement Universal Source Control Measures Patients and visitors should, ideally, wear their own facemask covering upon arrival to and throughout their stay in the facility. If patients do not have a facemask covering, they should be offered a facemask or cloth face covering, as supplies allow. 26  Implement Universal Source Control Measures Patients may remove their facemask covering when in their rooms or patient care area but should put it back on when leaving at the end of the dental treatment. Facemasks should not be placed on young children under age 2 years, anyone who has trouble breathing, or anyone who is unconscious, incapacitated or otherwise unable to remove the mask without assistance. 27  Implement Universal Source Control Measures on suspected DHCP case If DHCP suspected to have Covid 19, they should wear a face mask at all times while they are in the dental setting, including in breakrooms or other spaces where they might encounter co-workers. Respirators with an exhalation valve are not currently recommended for source control, as they allow unfiltered exhaled breath to escape. If only a respirator with an exhalation valve is available and source control is needed, the exhalation valve should be covered with a facemask that does not interfere with the respirator fit. 28  Implement Universal Source Control Measures on suspected DHCP case Some DHCP whose job duties do not require PPE (such as clerical personnel) may continue to wear their facemasks for source control while in the dental setting. Other DHCP (such as dentists, dental hygienists, dental assistants)may wear their face covering when they are not engaged in direct patient care activities, and then switch to a respirator or a surgical mask when PPE is required 29  Implement Universal Source Control Measures on suspected DHCP case DHCP should remove their respirator or surgical mask, perform hand hygiene, and put on their face covering when leaving the facility at the end of their shift. Educate patients, visitors, and DHCP about the importance of performing hand hygiene immediately before and after any contact with their facemask. 30  Encourage Physical Distancing Dental health care delivery requires close physical contact between patients and DHCP. However, when possible, physical distancing (maintaining 6 feet between people) is an important strategy to prevent COVID 19 transmission. 31  Examples of how physical distancing can be implemented for patients include: Limiting visitors to the facility to those essential for the patient’s physical or emotional wellbeing and care (e.g., care partner, parent). Encourage use of alternative mechanisms for patient and visitor interactions, such as video-call applications on cell phones or tablets. Scheduling appointments to minimize the number of people in the waiting room. Minimize overlapping dental appoint 32  Examples of how physical distancing can be implemented for patients include: Patients may opt to wait in a personal vehicle or outside the dental facility where they can be contacted by mobile phone when it is their turn for dental care. Arranging seating in waiting rooms so patients can sit at least 6 feet apart. 33  Administrative Controls and Work Practices for patient treatment Avoid aerosol generating procedures whenever possible, including the use of high-speed dental handpieces, air/water syringe, and ultrasonic scalers. Prioritize minimally invasive/atraumatic restorative techniques (hand instruments only). If aerosol generating procedures are necessary for dental care, use four-handed dentistry, high evacuation suction, and dental dams to minimize droplet spatter and aerosols. 34  Administrative Controls and Work Practices for patient treatment The number of DHCP present during the procedure should be limited to only those essential for patient care and procedure support. Preprocedural mouth rinses (PPMR) There is no published evidence regarding the clinical effectiveness of PPMRs to reduce viral loads or to prevent transmission. Although PPMRs with an antimicrobial product (chlorhexidine gluconate, essential oils, povidone-iodine, or cetylpyridinium chloride) may reduce the level of oral microorganisms in aerosols and spatter generated during dental procedures. 35  Create a Process to Respond to SARS-CoV-2 –Covid 19 Exposures Among Dental Health Care Personnel and Others Request that patients contact the dental clinic if they develop signs or symptoms or are diagnosed with COVID-19 within 2 days following the dental appointment. If patients or DHCP believe they have experienced an exposure to COVID-19 outside of the dental health care setting, including during domestic travel, they should inform the dental office. 36  Recommended Infection Prevention and Control Practices When Providing Dental Health Care for a Patient With Suspected or Confirmed COVID-19 Infection If emergency dental care is medically necessary for a patient who has, or is suspected of having, COVID-19, DHCP should do the following Dental treatment should be provided in an individual patient room with a closed door 37  Implement Universal Use of Personal Protective Equipment DHCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use an approved N95 or equivalent or higher-level respirator (or facemask if a respirator is not available), gown, gloves, and eye protection. 38  Recommended Infection Prevention and Control Practices When Providing Dental Health Care for a Patient With Suspected or Confirmed COVID-19 Infection Protective eyewear (e.g., safety glasses, trauma glasses) with gaps between glasses and the face likely do not protect eyes from all splashes and sprays. Avoid aerosol generating procedures (e.g., use of dental handpieces, air/water syringe, ultrasonic scalers) if possible. If aerosol generating procedures must be performed, they should ideally take place in an airborne infection isolation room. 39  Recommended Infection Prevention and Control Practices When Providing Dental Health Care for a Patient With Suspected or Confirmed COVID-19 Infection The number of DHCP present during the procedure should be limited to only those essential for patient care and procedure support. Visitors should not be present for the procedure. Clean and disinfect procedure room surfaces promptly as described in the section on environmental infection control. 40  Recommended Infection Prevention and Control Practices When Providing Dental Health Care for a Patient With Suspected or Confirmed COVID-19 Infection Limit transport and movement of the patient outside of the room to medically essential purposes. Patients should wear a facemask to contain secretions during transport. If patients cannot tolerate a facemask or cloth face covering or one is not available, they should use tissues to cover their mouth and nose while out of their room or care area. 41  Recommended Infection Prevention and Control Practices When Providing Dental Health Care for a Patient With Suspected or Confirmed COVID-19 Infection Consider scheduling the patient at the end of the day. Do not schedule any other patients at that time. To clean and disinfect the dental operatory after a patient with suspected or confirmed COVID-19, DHCP should delay entry into the operatory until a sufficient time has elapsed for enough air changes to remove potentially infectious particles 42  Patient placement Ideally, dental treatment should be provided in individual patient rooms, whenever possible. For dental facilities with open floor plans, to prevent the spread of pathogens there should be: - At least 6 feet of space between patient chairs. - Physical barriers between patient chairs. - Easy-to-clean floor-to-ceiling barriers will enhance effectiveness of air filtration systems 43  Patient placement - Operatories should be oriented parallel to the direction of airflow if possible. - Where feasible, consider patient orientation carefully, placing the patient’s head near the return air vents, away from pedestrian corridors, and toward the rear wall when - Ensure to account for the time required to clean and disinfect operatories between patients when calculating your daily patient volume. 44  If a patient arrives at your facility confirmed to have COVID-19, defer nonemergent dental treatment and take the following actions: If the patient is not already wearing a face covering, give the patient a facemask to cover his or her nose & mouth. If the patient is not manifesting emergency warning signs for COVID- 19, send the patient home, and instruct the patient to call his or her primary care provider. If the patient is manifesting emergency warning signs for COVID-19 (e.g., has trouble breathing), refer the patient to a medical facility, or call 911 as needed and inform them that the patient may have COVID-19 45  WHAT ABOUT DHCP???? 46  Encourage Physical Distancing for DHCP For DHCP, the potential for exposure to Covid 19is not limited to direct patient care interactions. Transmission can also occur through unprotected exposures to asymptomatic or presymptomatic co-workers in breakrooms or co- workers or visitors in other common areas. Emphasize the importance of source control and physical distancing in nonpatient care areas. 47  Examples of how physical distancing can be implemented for DHCP include: Providing dental team members meeting areas where all individuals (e.g., visitors, DHCP) can remain at least 6 feet apart from each other. Designating areas for DHCP to take breaks, eat, and drink that allow them to remain at least 6 feet apart from each other, especially when they must be unmasked. 48  Administrative Controls and Work Practices If a DHCP is found to be febrile or has signs or symptoms consistent with COVID-19, he or she should immediately return home, should notify occupational health services or the infection control coordinator to arrange for further evaluation, or seek medical attention. Implement sick leave policies for DHCP that are flexible, and consistent with public health guidance. 50  Administrative Controls and Work Practices As part of routine practice, DHCP should be asked to regularly monitor themselves for fever and symptoms consistent with COVID-19. DHCP should be reminded to stay home when they are ill and should receive no penalties when needing to stay home when ill or under quarantine. 51  Optimize the Use of Engineering Controls Properly maintain ventilation systems. Ventilation systems that provide air movement in a clean-to-less- clean flow direction reduce the distribution of contaminants and are better at protecting staff and patient Understand clinical air flow patterns and determine air changes per hour. Increase filtration efficiency to the highest level compatible with the HVAC system without significant deviation from designed airflow. 62  Please refer to appendix B & appendix C in designated book for more information 67 68