ANNIVERSARY Fortune Management extraordinary practice. extraordinary life.? CLINICAL SAFETY GUIDE fortune@fortunemgmt.com 800-628-1052 CLINICAL & SAFETY PROTOCOL Clinical Guidelines for Returning to the Dental Practice Table of Contents Personal Protective Equipment............................................................3 Suggested PPE.............................................................................3 CDC strategies to optimize your Supply of PPE.........................3 In Office Safety Procedures..................................................................4 Procedures to safeguard health for patients and team................4 Preventive Protocols once patient arrives to dental office..........4 Team Members in facility.............................................................5 Scheduling Protocols .............................................................................6 Questions to ask patients during confirmation calls...................6 Setting expectations.....................................................................6 Scheduling of patients .................................................................8 Sterilization Protocols Between Appointments..................................10 Clinical Technique Recommendations........................................11 Patient Check-Out Protocols......................................................11 Before Returning Home after a Workday..........................................14 Addendum - CDC Guidelines..............................................................16 References: ADA: https://success.ada.org/en/practice-management/patients/infectious-diseases-2019-novel-coronavirus CDC: https://www.cdc.gov/coronavirus/2019-nCoV/hcp/index.html Clean Room Technology: https://www.cleanroomtechnology.com/news/article_page/The_science_of_chlorine-based_disinfectant/93824 HIPAA: https://www.hhs.gov/hipaa/for-professionals/special-topics/hipaa-covid19/index.html OSHA: https://www.osha.gov/Publications/OSHA3990.pdf EPA: https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2 Disclaimer: All information contained within these guidelines are merely suggestions. Fortune Management recommends that all clients review suggestions and proposals with the client’s entire advisory team (HR, attorney, accountant, etc.) and act accordingly. Ultimately, it is the client’s responsibility to decide to incorporate some, none, or all suggestions presented. Some pre-existing documents are included for reference (i.e. CDC PPE Factsheet, CDA Teledentistry Consent Forms, etc.). It is the doctor’s responsibility to evaluate the source material and adjust to the doctor’s specific local/county/state laws and regulations. All information offered within was researched utilizing any/all of the above agency websites. All suggestions were based on available information as of April 15, 2020. CLINICAL & SAFETY PROTOCOL Personal Protective Equipment Suggested PPE ● ● ● ● ● ● ● Proper Aerosol PPE Eye Wear with side shields Gown (disposable or white lab coats knee length, cuffed) Head/Beard Cover (worn to cover the mask; contact restaurant suppliers) N95 mask Gloves Booties (fabric or silicone) CDC strategies to optimize your Supply of PPE For N-95 masks https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirators-strategy/index.html For Facemasks https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/face-masks.html For Isolation gowns https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/isolation-gowns.html For Eye Protection https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/eye-protection.html Page 3 CLINICAL & SAFETY PROTOCOL In Office Safety Procedures Procedures to safeguard health for patients and team Our goal is to maintain safety for patients and team members and to reduce unnecessary risk of exposure. No one is allowed in the building if they have a fever, cough or have had contact with a COVID-19 positive person within the past 14 days. Proper signs have been posted at all entrances along with appropriate hand-sanitizing stations with posters from the World Health Organization on proper hand washing techniques at every station and sink. ● ● ● ● ● ● ● Pre-screening via Telephone or Video Conferencing – the dentist decides if the concern can be alleviated without coming in or waiting until the Shelter in Place Order is removed. General medical history questions COVID-19 risk questions - recent cough, cold, flu or fever? Same for immediate relatives Any known exposure to anyone positive for COVID-19? We ask patients to take their temperature at home evening before and before coming to office. We review “what to expect COVID-19 protection procedure protocols” that they will go through when they arrive. They are also told that we prefer to not have anyone beside the emergency patient in the facility. If they are coming with someone, we ask they stay in the car whenever possible. Preventative Protocols once patient arrives to dental office ● ● ● ● ● ● ● ● ● ● Office outside doors remain locked throughout the business day. Patients are instructed to call the office or doctor’s cell phone when they arrive and to wait in the car until the team is ready for them to enter the facility. Patients could sign an additional COVID-19 Treatment Waiver in addition to treatment proce dure consent forms. Dental team member meets patients outside the facility with Proper PPE to take their temperature and we record temperature in their chart. Patient sanitizes their hands upon entering our facility and follows the World Health Organi zation protocol. We ask patients to not touch their face with their hands. Patient is immediately seated in their personal operatory and they are asked to rinse with OraCare (anti-viral, anti-microbial) mouth rinse for one minute (or other approved anti-viral, anti-microbial mouth rinse). If treatment rooms have doors, they should remain shut through the procedure. No one sits in waiting area. To minimize aerosols, consider utilizing rubber dam isolation or Iso-Dry when possible and HVE. For maximum sterilization, you may consider using a hypochlorous acid fogger* and have a 3-hour latency between operatories. This is in addition to Universal Precautions and Standard Bloodborne Pathogen Protocols. For more information on hypochlorous acid, please visit https://www.cambridge.org/core/journals/epidemiology-and-infection/article/studies-on-the-disinfecting-action-of-hypochlorous-acid-gas-and-sprayed-solution-of-hypochlorite-against-bacterial-aerosols/ 9091A7D64D2E4489B7B918B758AEEA75 Page 4 CLINICAL & SAFETY PROTOCOL Team Members in facility ● ● ● ● ● Wash Hands with soap and water upon entering our facility and hand sanitizer frequently. All team members wear proper PPE of masks when anyone is in the building; additionally, social distancing of 6 ft. is maintained at all times when possible. All internal doors remain open throughout the office whenever possible, except for active treatment rooms. In this case, team member will wipe all doorknobs and surfaces touched. Administrative desk surfaces, keyboards and pens are wiped before and after use. All mail and supply deliveries are sprayed with Birex and allowed to dry upon entering the facility. It is recommended to have team members announce out loud the safety protocols as they are performing them. This gives the patient reassurance to what is being done and helps team create habits for these new protocols. Example A. “Mrs. Jones, you will be hearing me say out loud the safety precautions we are taking in the office throughout your appointment today.” Example B. “Per our guidelines on Hand Hygiene in accordance with the CDC, I am washing my hands for at least 20 seconds with soap and water.” Scheduling Protocols The office should call, not email, to confirm patients. Hopefully, doctors and their teams have been in contact with all patients during this time. Why call patients? The office needs to pre-screen to ensure the patient poses little to no risk of infecting the doctor, team and any other patients. Explain that the office is following all these steps to keep their patients and team safe and healthy. It’s also recommended that whichever team member is making the calls should reassure all patients that the dental office is one of the safest places to be. We have been diligent about infection control for decades. We are supremely positioned and educated in how to handle this situation. Questions to ask patients during confirmation calls 1. Within the past 2-3 weeks have you experienced any of the following: a. Fever b. Dry cough c. Sore throat d. Shortness of breath e. Muscle aches f. Pink eye (conjunctivitis) If the patient answers “yes” to any of the above, he/she should be referred to his/her MD to discuss the severity of the symptoms. The patient’s physician will determine if the patient should be tested and/or treated. 2. Within the past 2-3 weeks have you: a. Traveled outside our shelter-in-place area/city/state/country? b. Come into contact with anyone who has either tested positive for COVID-19 or has experienced any of the symptoms listed above? If the patient answers “yes” to any question in group #1 or 2, he/she should be rescheduled for at least one month out. Scheduling coordinator should plan to follow up with the patient in 2 weeks to see how he/she is progressing and re-evaluate the appointment schedule. Page 5 CLINICAL & SAFETY PROTOCOL Questions to ask patients during confirmation calls (Continued) 3. Review and update patient’s existing medical history. Make a note in the patient chart regarding any predisposing conditions for COVID (asthma, cancer, immune-compromised, etc.) 4. Ensure patient’s emergency contact information is up to date. 5. Tell the patient to take his/her temperature the night before the appointment and the morning of the appointment. If the patient registers a fever, he/she should call the office immediately to reschedule. Setting Expectations Inform the patient of changes in office appointment protocol 1. Patients should arrive 15 minutes EARLY for their appointment time. They should also not be LATE. This is especially important. 2. The office has scheduled “disinfection and sterilization” time in between appointments. To ensure that all patients can be protected and seen on-time, they must all be considerate of the time parameters. 3. Patients must wait in their cars once they arrive. The office will call or text to inform the patient when he/she may enter the building. If the patient is not driving, he/she must wait outside the office, keeping social distancing in mind, until the office alerts him/her to enter. 4. Once the patient enters the building (or outside the office, if possible), a team member will check the patient’s blood pressure (see below for guidelines) and temperature with a no-contact thermometer to ensure that the patient is not running a fever. Temperature Guidelines: https://www.khealth.ai/article/normal-body-temperature Page 6 CLINICAL & SAFETY PROTOCOL 5. If the office is comfortable with the patient waiting in the reception area, ensure that: a. All chairs are positioned at least 8 feet apart from each other b. If any chairs, couches, etc. have soft surfaces, remove them and replace with plastic or metal seats that are easily disinfected. If this is impossible, cover all seating areas with plastic (clinical chair covers could work well here) and replace after each use. c. All magazines, pillows, blankets, toys, etc. are removed from the reception area. These items all pose a greater risk for cross-contamination d. All “public” refreshments and coffee stations, etc. should be removed. The office may provide individual, sealed water bottles to patients if desired. 6. The patient should arrive wearing a mask, if possible. The office can establish its own protocol for patient masks: a. Either discard the patient’s mask when he/she enters and replace it with a new mask. The patient should wear a mask, while in the office, until a team member advises otherwise. b. Have the patient wear his/her own mask until treatment starts. i. If the patient’s mask is disposable, throw it out. ii. If the mask is not disposable, place in a plastic bag until the patient is ready to leave. iii. Supply the patient with a new mask when treatment is completed. 7. The patient should plan to arrive by him/herself to the appointment. a. If the patient requires a companion (i.e., minor child, elderly patient, or disabled patient), inform the guardian that no companions will be allowed in the treatment rooms. b. The guardian should wear a mask (or will be provided with one) while in the office. c. The guardian should wait for the patient outside the office. The office can call or text the guardian when the patient is ready to leave. Page 7 CLINICAL & SAFETY PROTOCOL 8. To minimize the chance of cross-contamination, ask the patient to use the restroom at his/her house right before he/she leaves the house for his/her appointment. (Of course, patients can use the restroom in the office. We are just trying to minimize the chances of potential inter-personal contact and cross-contamination as much as possible). 9. Suggest a no- contact payment system – asking for a Credit Card number on phone and entering it into the Encrypted Credit Card terminal to have on file. Preferred payments include credit card or third-party electronic financing (CareCredit, Lending Club, etc.) to minimize chances of cross-contamination. a. If the patient is using third-party financing, ensure that the patient has sufficient funds in his/her account to cover treatment costs for that appointment 10. Pre-frame how the clinical team will appear to the patient. a. Explain that the recommended PPE includes N-95 masks (whenever appropriate), face shields, gowns, head cover, and booties. b. This is important especially for pediatric practices. The parents can prepare the pediatric patient, so he/she won’t be frightened when entering the office. c. Mention again how the office has always gone above and beyond the CDC infection control standards. While this is the “new normal”, the office is fully prepared. Scheduling of patients 1. Review existing schedule blocks. If the office schedules in 10-minute increments (recommended), leave at least 10 open minutes of “disinfection and sterilization” time in between each appointment. The clinical team needs this time to perform disinfection and sterilization, between patient contacts, according to CDC guidelines. 2. Consider adding 10 minutes to the start of each appointment. It is likely that patients will want to talk more with both the doctor and team member before starting treatment. 3. Adhere to scheduling-to-goal protocol as much as possible 4. Book most dire emergency patients first (See Safety Protocols for more detail on how to classify emergency patients) 5. Book highest production appointments next. If a patient has multiple procedures outstanding, try to block book as many as feasibly possible in each appointment 6. Utilize the “Ghost Hygiene” column 7. Book 10 minute teledentistry appointments (follow up, general check-in) for both the doctors and hygienists during the 10-20 minute “open” time between patients Page 8 CLINICAL & SAFETY PROTOCOL 8. Book longer (30 minute) teledentistry appointments (limited exams for doctors, OHI for hygienists) for both the doctors and hygienists during any open time that occurs within the following 48 hours. See “Teledentistry Protocols” section for more guidance on booking these appointments. 9. Consider which team members will see which patients, depending on each team member’s risk factors a. Team members with higher risk factors should not treat patients who also have higher risk factors b. Team members who have tested positive to an antigen test may be scheduled to treat patients with higher risk factors If the office can process patient check-outs in the treatment room, add 10 minutes to the end of the appointment time (see “Patient Check-Out Protocols” for more information) 10. Page 9 CLINICAL SAFETY PROTOCOL Triage ln-Person Visit Triage Questions: Have you been diagnosed with If yes, when were your last 0 More than 14 days ago} follow steps for "Any Dental Treatment? 0 Less than 14 days ago, follow steps for ?Emergency or Urgent Care Only? Have you traveled outside of the USA in the last 14 days? Have you been in close proximity to someone who has been diagnosed with Are you over the age of 70? I ?i?to any above question I Emergency or Urgent Care Only Patient washes hands when he/she Any Dental Treatment may be Performed Patient washes hands when he/she enters treatment room Patient wears mask until clinician starts treatment enters treatment room Patient wears mask until clinician starts treatment Patient rinses with OraCarrelor similar anti-viral mouthripnsg \m?nmm Patient rinses with Q?raCareor similar 1 111m"; anti-viral 1,1199% [rinse Clinical Team May Wear CDC Recommended PPE (See CDC Flowsheet Protocol) At a minimum, clinical team should wear: Surgical Mask wear with side shields Gown Nitrile gloves Clinical Team Should Wear CDC Recommended PPE (See CDC Flowsheet Protocol After Treatment: I Disinfect/Sterilize as outlined in Sterilization Protocols 0 Start process while patient is in room to demonstrate office protocols for infection control Page 10 fortune@fortunemgmt.com 800-628-1052 CLINICAL & SAFETY PROTOCOL Before caring for patients with confirmed or suspected COVID-19, healthcare personnel (HCP) must: • Receive comprehensive training on when and what PPE is necessary, how to don (put on) and doff (take off) PPE, limitations of PPE, and proper care, maintenance, and disposal of PPE. • Demonstrate competency in performing appropriate infection control practices and procedures. Remember: • PPE must be donned correctly before entering the patient area (e.g., isolation room, unit if cohorting). • PPE must remain in place and be worn correctly for the duration of work in potentially contaminated areas. PPE should not be adjusted (e.g., retying gown, adjusting respirator/facemask) during patient care. • PPE must be removed slowly and deliberately in a sequence that prevents self-contamination. A step-by-step process should be developed and used during training and patient care. Donning (putting on the gear): Doffing (taking off the gear): More than one donning method may be acceptable. Training and practice using your healthcare facility’s procedure is critical. Below is one example of donning. 1. Identify and gather the proper PPE to don. Ensure choice of gown size is correct (based on training). 2. Perform hand hygiene using hand sanitizer. 3. Put on isolation gown. Tie all of the ties on the gown. Assistance may be needed by another HCP. 4. Put on NIOSH-approved N95 filtering facepiece respirator or higher (use a facemask if a respirator is not available). If the respirator has a nosepiece, it should be fitted to the nose with both hands, not bent or tented. Do not pinch the nosepiece with one hand. Respirator/facemask should be extended under chin. Both your mouth and nose should be protected. Do not wear respirator/facemask under your chin or store in scrubs pocket between patients.* » Respirator: Respirator straps should be placed on crown of head (top strap) and base of neck (bottom strap). Perform a user seal check eachtime you put on the respirator. » Facemask: Mask ties should be secured on crown of head (top tie) and base of neck (bottom tie). If mask has loops, hook them appropriately around your ears. 5. Put on face shield or goggles. Face shields provide full face coverage. Goggles also provide excellent protection for eyes, but fogging is common. 6. Perform hand hygiene before putting on gloves. Gloves should cover the cuff (wrist) of gown. 7. HCP may now enter patient room. More than one doffing method may be acceptable. Training and practice using your healthcare facility’s procedure is critical. Below is one example of doffing. 1. Remove gloves. Ensure glove removal does not cause additional contamination of hands. Gloves can be removed using more than one technique (e.g., glove-in-glove or bird beak). 2. Remove gown. Untie all ties (or unsnap all buttons). Some gown ties can be broken rather than untied. Do so in gentle manner, avoiding a forceful movement. Reach up to the shoulders and carefully pull gown down and away from the body. Rolling the gown down is an acceptable approach. Dispose in trash receptacle.* 3. HCP may now exit patient room. 4. Perform hand hygiene. 5. Remove face shield or goggles. Carefully remove face shield or goggles by grabbing the strap and pulling upwards and away from head. Do not touch the front of face shield or goggles. 6. Remove and discard respirator (or facemask if used instead of respirator).* Do not touch the front of the respirator or facemask. » Respirator: Remove the bottom strap by touching only the strap and bring it carefully over the head. Grasp the top strap and bring it carefully over the head, and then pull the respirator away from the face without touching the front of the respirator. » Facemask: Carefully untie (or unhook from the ears) and pull away from face without touching the front. 7. Perform hand hygiene after removing the respirator/facemask and before putting it on again if your workplace is practicing reuse. Page 11 CLINICAL & SAFETY PROTOCOL Sterilization Protocols Between Appointments 1. Clean [PPE] with soap and water, or if visibly soiled, clean and disinfect reusable facial protective equipment (e.g., clinician and patient protective eyewear or face shields) between patients. 2. Non-dedicated and non-disposable equipment (e.g., handpieces, dental x-ray equipment, dental chair and light) should be disinfected according to manufacturer’s instructions. Handpieces should be cleaned to remove debris, followed by heat-sterilization after each patient. 3. Routine cleaning and disinfection procedures (e.g., using cleaners and water to pre-clean surfaces prior to applying an EPA-registered, hospital-grade disinfectant to frequently touched surfaces or objects for appropriate contact times as indicated on the product’s label) are appropriate for SARS-CoV-2 in healthcare settings, including those patient-care areas in which aerosol-generating procedures are performed. 4. Surfaces such as door handles, chairs, desks, elevators, and bathrooms should be cleaned and disinfected frequently. Clinical Technique Recommendations 1. Now recommended to rinse and gargle with OraCare for 60 seconds prior to treatment to minimise aerosol spray of potential COVID-19 or equivalent anti-viral mouth rinse 2. Use of extraoral dental radiographs, such as panoramic radiographs or cone beam CT, are appropriate alternatives to intraoral dental radiographs during the outbreak of COVID-19, as the latter can stimulate saliva secretion and coughing. 3. Reduce aerosol production as much as possible, as the transmission of COVID-19 seems to occur via droplets or aerosols, and DHCP should prioritize the use of hand instrumentation. 4. Use rubber dams or Iso-dry, Isolite, etc. if an aerosol-producing procedure is being performed to help minimize aerosol or spatter. 5. Use a 4-handed technique for controlling infection. 6. Anti-retraction functions of handpieces may provide additional protection against cross-contamination. 7. Use high-volume evacuators. DHCP should be aware that in certain situations, backflow could occur when using a saliva ejector, and this backflow can be a potential source of cross contamination. 8. Use resorbable sutures (i.e. sutures that last 3 to 5 days in the oral cavity) to eliminate the need for a follow up appointment. Page 12 CLINICAL & SAFETY PROTOCOL Clinical Technique Recommendations (Continued) 9. Minimize the use of a 3-in-1 syringe as this may create droplets due to forcible ejection of water/air. 10. Disinfectants (hypochlorite, ethanol) in the handpiece and 3-in-1 syringe water supplies have been reported to reduce viral contaminants in splatter, but its action on human coronavirus is unknown. 11. Fog treatment rooms with hypochlorous acid mist after use (See “Safety Protocols” for more information). Patient Check-Out Protocols If the office has two separate entrances, assign one door as “entrance” and one as “exit”. If the patient needs to use the restroom before he/she leaves, try to time it so that he/she uses it on the way out of the office. This will minimize excess patient contact from treatment room to restroom and back to treatment room. If the office has a consult room or private office, consider changing this to the “check-out” area. 1. 2. 3. 4. Designate one team member to handle all patient check-outs to limit interpersonal contact. This team member should wear a mask. Team member should wear gloves when handling patient payments (see no-contact payment suggestion above). Disinfecting spray, nitrile gloves, and Alcohol Based Hand Sanitizer should be available in this area. Ideally, a closed trash receptacle should be available in this area. If the office has practice software networked in all treatment rooms: 1. Once treatment is completed, give patient a new mask or return his/her non-disposable one. 2. Start appointment check-out in treatment room. 3. Accepting Payments in the treatment room: a. Credit Card i. If the office has a practice management portal that processes credit cards electronically, process payment in the treatment room ii. If not, a team member will take the patient’s credit card, disinfect it, remove gloves, wash his/her hands, and bring the card to the check-out area. iii. Once payment is processed, the team member returns to the treatment room, washes his/her hands, puts on gloves, disinfects the card, and returns it to the patient. b. Third-Party Financing (CareCredit, Lending Club, etc.) i. Patient should already have sufficient funds in his/her account to pay for treatment costs. (See “Scheduling Protocols” for more details) ii. Team member can process patient’s appointment balance through the appropriate patient financing portal Page 13 CLINICAL & SAFETY PROTOCOL c. 4. 5. 6. 7. 8. Check or Cash i. Least desirable due to greater chance of cross-contamination. ii. Suggested guidelines include storing cash and checks in a sealed plastic bag and depositing all items at the end of each business day. iii. Ensure that anyone handling checks or cash washes his/her hands after, following the recommended CDC guidelines on hand-washing iv. Individual offices can set specific policies on whether or not they will accept these forms of payment. Schedule next appointment. Ask for referrals. a. This is the perfect time to ask for feedback on what the patient thought about the “new” appointment protocol. b. Make notes if the patient has suggestions to improve/change any aspect (if reasonable) c. Thank the patient for his/her feedback. d. Ask the patient to share her positive experience with her friends, family, co-workers. If the patient must be escorted out by a guardian, alert the scheduling coordinator to notify the guardian that the patient is ready for pick up. Walk the patient to the exit door. Disinfect any doorknobs, keyboards, credit card processing machines, etc. If the office does NOT have practice software networked in all treatment rooms 1. Once treatment is completed, give patient a new mask or return his/her non-disposable one. 2. Bring patient to designated “check-out” area. Team member should put on gloves in front of patient. 3. Start appointment check-out. 4. Accepting Payments: a. Credit Card i. If the office has a practice management portal that processes credit cards electronically, use this ii. If not, the team member will take the patient’s credit card and process payment. b. Third-Party Financing (CareCredit, Lending Club, etc.) i. Patient should already have sufficient funds in his/her account to pay for treatment costs. (See “Scheduling Protocols” for more details) ii. Team member can process patient’s appointment balance through the appropriate patient financing portal c. Check or Cash i. Least desirable due to greater chance of cross-contamination. ii. Suggested guidelines include storing cash and checks in a sealed plastic bag and depositing all items at the end of each business day. iii. Ensure that anyone handling checks or cash washes his/her hands after, following the recommended CDC guidelines on hand-washing. iv. Individual offices can set specific policies on whether or not they will accept these forms of payment. 5. Schedule next appointment. Page 14 CLINICAL & SAFETY PROTOCOL 6. 7. 8. 9. Ask for referrals. a. This is the perfect time to ask for feedback on what the patient thought about the “new” appointment protocol. b. Make notes if the patient has suggestions to improve/change any aspect (if reasonable). c. Thank the patient for his/her feedback. d. Ask the patient to share her positive experience with her friends, family, co-workers. If the patient must be escorted out by a guardian, alert the scheduling coordinator to notify the guardian that the patient is ready for pick up. Walk the patient to the exit door. Disinfect any doorknobs, keyboards, credit card processing machines, etc. Before Returning Home after a Workday Besides performing normal end of day office shut down during this interim period with Covid-19 please consider the following and see links attached for further investigation. The ADA, the CDC, State and local agencies are in constant update mode right now. Constantly look for updates to this area. 1. Thoroughly clean your office before leaving may include reduction of aerosols in clinical areas by a fogging process with hypochlorous acid. For more specific guidelines, refer to www.ADA.com and www.cleanroomtechnology.com 2. How to Take Off (Doff) PPE Gear More than one doffing method may be acceptable. Training and practice using your healthcare facility’s procedure is critical. Below is one example of doffing. a Remove gloves. Ensure glove removal does not cause additional contamination of hands. Gloves can be removed using more than one technique (e.g., glove-in-glove or bird beak). b. Remove gown. Untie all ties (or unsnap all buttons). Some gown ties can be broken rather than untied. Do so in gentle manner, avoiding a forceful movement. Reach up to the shoulders and carefully pull gown down and away from the body. Rolling the gown down is an acceptable approach. Dispose in trash receptacle. c. Healthcare personnel may now exit patient room. d. Perform hand hygiene. e. Remove face shield or goggles. Carefully remove face shield or goggles by grabbing the strap and pulling upwards and away from head. Do not touch the front of face shield or goggles. f. Remove and discard respirator (or facemask if used instead of respirator). Do not touch the front of the respirator or facemask. Respirator: Remove the bottom strap by touching only the strap and bring it carefully over the head. Grasp the top strap and bring it carefully over the head, and then pull the respirator away from the face without touching the front of the respirator. Facemask: Carefully untie (or unhook from the ears) and pull away from face without touching the front. Page 15 CLINICAL & SAFETY PROTOCOL g. 3. Perform hand hygiene after removing the respirator/facemask and before putting it on again if your workplace is practicing reuse. Laundry in a healthcare facility may include blankets, personal clothing, uniforms, scrub suits, gowns and drapes. PPE may include disposable or reusable apparel. Care should be taken in handling and proper labeling. Laundry areas should have handwashing facilities readily avail able to workers. Care should be taken to not contaminate clean apparel from soiled apparel. Take note that sleeves , cuffs, and pockets will have heaviest contaminated load. Do not leave wet items in washer overnight. a. For laundry going to a facility bags containing contaminated laundry must be clearly identified with labels, color coding and other methods so workers may handle items safely. b. CDC background information https://www.cdc.gov/infectioncontrol/guidelines/environmental/background/laundry.html Page 16 CLINICAL & SAFETY PROTOCOL ADDENDUM Key Points to Understand in Reducing Dental Aerosols & Transmission of COVID Main Source CDC”: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html As always in dental infection control, we must utilize universal precautions and presume everyone is infected. Considering that patients who are asymptomatic may still be COVID-19 infectious, it should be assumed that all patients can transmit disease. ● CDC: “Reduce facility risk. Cancel elective procedures, use telemedicine when possible, limit points of entry and manage visitors, screen everyone entering the facility for COVID-19 symptoms, implement source control for everyone entering the facility, regardless of symptoms.” Solution: Business Operational changes- incorporate paperless office, perform teledentistry for anything and all things to reduce patient in person contact. Institute patients to pay for procedures at the time of booking over the phone. Remove all magazines, self-serve beverage centers and implement a sanitation regimen that includes frequent wiping down of surfaces and door handles. Ask patients to text when they are in the parking lot and text them back when their room is ready. Ask patients to wash hands upon entering the building and before leaving. Utilize frequent Hypochlorous Acid (HOCl) Fogging of reception area. Encourage patients to come into the office on their own and to utilize video chat during appointment to reduce exposure. ● CDC: “Patients should wear a facemask or cloth face covering 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.” Solution: Encourage all patients to wear their cloth masks from home and to remain on throughout the time in the office and if they arrive without a mask give them a surgical mask to wear throughout the visit except when they are not being worked on. ● CDC: “Mode of transmission: Current data suggest person-to-person transmission most commonly happens during close exposure to a person infected with the virus that causes COVID-19, primarily via respiratory droplets produced when the infected person speaks, coughs, or sneezes. Droplets can land in the mouths, noses, or eyes of people who are nearby or possibly be inhaled into the lungs of those within close proximity. Transmission also might occur through contact with contaminated surfaces followed by self-delivery to the eyes, nose, or mouth. The contribution of small respirable particles, sometimes called aerosols or droplet nuclei, to close proximity transmission is currently uncertain. However, airborne transmission from person-to-person over long distances is unlikely.” Solution: Mandate frequent hand washing and masks to be worn by all team members including administration and patients at all times. Team members exposed to Aerosol Generating Procedures (AGPs) should wear N95 or higher masks, gloves, eye protection, face shields, head/beard covers over masks, lab coats or disposable gowns during all procedures. All patients must do pre-rinse OraCare (activated Chlorine Dioxide) or Povidone Iodine. Implement AGP’s requirement for patient care to use internal vacuum devices (dryshield, Isolite) and external vacuum together the room aerosol exposure is almost all removed. After procedure use Universal Protocol for wiping down surfaces and treat the air and room with HOCl fog. Page 17 CLINICAL & SAFETY PROTOCOL ● CDC: “Put on a clean isolation gown upon entry into the patient room or area. Change the gown if it becomes soiled. Remove and discard the gown in a dedicated container for waste or linen before leaving the patient room or care area. Disposable gowns should be discarded after use. Cloth gowns should be laundered after each use. If there are shortages of gowns, they should be prioritized for: aerosol generating procedures.” Gowns and other PPE will need to be disinfected between patients, this provides a particular challenge with hygiene checks. It’s cost prohibitive to put on a disposable gown for every patient throughout the day not to mention the impact this would have on the environment. Solution: Disinfect PPE between patients with Hypochlorous acid Fog with a wall mounted ULV fogger. (prototype design is currently being tested) • CDC: “The number of healthcare providers (HCP) 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. Limit visitors to the facility to only those essential for the patient’s physical or emotional well-being and care (e.g., care partners). Encourage use of alternative mechanisms for patient and visitor interactions such as video-call applications on cell phones or tablets.” Solution: Restrict administration team exposure to patients by prepaying at time of scheduling over the phone and pre-appointing next visits from the clinical room, if treatment changes during appointment consider video conferencing with an ipad your administrative team. • CDC: “As part of routine practice, HCP should be asked to regularly monitor themselves for fever and symptoms of COVID-19. HCP should be reminded to stay home when they are ill. If HCP develop fever (T≥ 100.0oF) or symptoms consistent with COVID-19* while at work they should keep their cloth face covering or facemask on, inform their supervisor, and leave the workplace. Screen all HCP at the beginning of their shift for fever and symptoms consistent with COVID-19* Actively take their temperature and document absence of symptoms consistent with COVID-19*. If they are ill, have them keep their cloth face covering or facemask on and leave the workplace. *Fever is either measured temperature >100.0oF or subjective fever. Note that fever may be intermittent or may not be present in some individuals, such as those who are elderly, immunosuppressed, or taking certain medications (e.g., NSAIDs). Clinical judgement should be used to guide testing of individuals in such situations. Respiratory symptoms consistent with COVID-19 are cough, shortness of breath, and sore throat. Medical evaluation may be warranted for lower temperatures (<100.0oF) or other symptoms (e.g., muscle aches, nausea, vomiting, diarrhea, abdominal pain, headache, runny nose, fatigue) based on assessment by occupational health. Additional information about clinical presentation of patients with COVID-19 is available.” Solution: Follow the CDC recommendation of recording all team members on a daily basis and do not allow anyone ill to come to work. Documentation should be maintained of who was present in the office with when each patient was in the office. Payroll time clocks can be used to match who was present in the building but also maintain a visitor’s log for anyone who is working in the office for maintenance and get their temperatures as well. Receive all deliveries outside of the building to avoid documenting the name of the delivery person and taking their temperature. Page 18 CLINICAL & SAFETY PROTOCOL • CDC: “Routine cleaning and disinfection procedures (e.g., using cleaners and water to pre-clean surfaces prior to applying an EPA-registered, hospital-grade disinfectant to frequently touched surfaces or objects for appropriate contact times as indicated on the product’s label) are appropriate for SARS-CoV-2 in healthcare settings, including those patient-care areas in which aerosol generating procedures are performed. Refer to List Nexternal iconon the EPA website for EPA-registered disinfectants that have qualified under EPA’s emerging viral pathogens program for use against SARS-CoV-2.” Solution: Confirm your products are listed on the “N” list https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2 • CDC: “Management of laundry, food service utensils, and medical waste should also be performed in accordance with routine procedures.” Solution: As always do laundry and clean the office utilizing PPE. Consider using Ziploc gallon bags to place food items in communal refrigerator with individual names on them. • CDC: During AGPs “Room doors should be kept closed except when entering or leaving the room, and entry and exit should be minimized.” Solution: Close doors in operatory whenever possible to contain the aerosol transmission. If you have openbay design, consider plexiglass or curtain isolation. Page 19