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TRANSCRIPT
COVID-19 Urgent Dental Care in Yorkshire and Humber
Webinar 04.06.2020
Contents
1. General overview of Y&H COVID-19 urgent care
2. Good practice examples of implementing guidance
3. Preparation for the resumption of dental services
Introduction
• Delivered initial education package in relation to the provision of urgent dental care
• Ongoing education requirements
• Preparing practices for the resumption of care 8th June 2020
James Spencer
Postgraduate Dental Dean, HEE YH
Where we are now
• Population – 5.5M
• Area – 15,500 km2
Yorkshire and Humber
Cluster Practice & UDC System
UDC/HUB
UDC Maps – Yorkshire and Humber
WYSY&B NY&H
Regional Data
Cluster & UDC
System
Two-stage triage
Localisation for face to face care
Future roles:• Phased reopening –AGP/non AGP
• Delivery of localised programmes
• Peer Review
https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/06/C0575-dental-transition-to-recovery-sop-4-June.pdf
An example of practice led transition
https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/06/C0575-dental-transition-to-recovery-sop-4-June.pdf
UDC
https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/06/C0575-dental-transition-to-recovery-sop-4-June.pdf
Cluster Practice Future Role
Triage
http://www.sdcep.org.uk/published-guidance/acute-dental-
problems-covid-19/
COVID-19 Assessment and Triage
1. COVID-19 +ve or Suspicious
2. Shielded 3. Vulnerable
4. Non-vulnerable
and
non-shielded
Asymptomatic
Vulnerable definition https://www.gov.uk/government/publications/staying-alert-and-safe-social-distancing/staying-alert-and-safe-social-distancing#clinically-vulnerable-people
‘Shielded’ AKA Extremely Vulnerable definition https://www.gov.uk/government/publications/guidance-on-shielding-and-protecting-extremely-vulnerable-persons-from-covid-19/guidance-on-shielding-and-protecting-extremely-vulnerable-persons-from-covid-19#who-is-clinically-extremely-vulnerable
Referral to UDC Centre
Cluster Practice Role
Cluster UDC/Hub Role
Discharge Proforma (Following Referral)
NHSE UDC SITE DATA COLLECTION
Photos of UDC treatment Centres
“The referral trauma patient today was extremely complimentary about the practice and how it was all being run. He was very impressed. He said he'd be clapping for us on Thursday. It's nice all the hard work everyone has put in to the UDC is appreciated”
Current UDC examples
Video overview• Introduction
Video overview• Outdoor triage
Video overview• Reception
Video overview• Donning PPE
Video overview• Instrument Storage
Video overview• Entrance and Surgery
Video overview• Doffing PPE
Video overview• Summary
From a UDC’s perspective:“Decontamination Survey”
Reducing the riskNicola Eades
Bridge Street Dental Surgery Tadcaster
Selby UDC
Understanding COVID-19 provides you the ability to survey your practice
“The transmission risk is not just from the patient”
Ways of Transmission:Contact: direct contact or indirectly from the persons immediate
environment
Droplet: from the respiratory tract of one individual to another
Airborne: possibly via aerosol generating procedures
Q: Waiting Roomsare they source of Infection?
“Walk through your practice as if you are a potential buyer, starting at the front
door with fresh eyes”
✓ Remove leaflets, leaving clear and clutter free environments in all areas including corridors
✓ Remove sundry items and any points of additional contact
✓ Ensure multiple points to access alcohol hand gel
✓ Take pre payments over the phone, no handling of cash or card in practice if possible
✓ Triage patients prior; less contact on reception and in surgery. Consider phone or video consultation platform
✓ Encourage patients to use home toilet facilities before attending and bring minimal belongings
Next phase:
- Space seating in waiting areas
- A reception desk screen
- Contactless payments
Survey the surgery’s and the decontamination roomContinue to follow the
“HTM01-05 guidelines”
We are highly trained professionals
✓ Make surgery’s easier and faster to decontaminate with minimal equipment. This will significantly reduce surfaces for contamination
✓ Reduce stock and materials
✓ Invest in “on and off” site training. Helping provide knowledge and reassuring the team making the “new world” slightly easier
Survey “Instrument and team work flow”look at what may work for you?
Consider:
✓ Removing instruments out of the surgery if possible?
We use “really useful” containers, providing safe transport and storage
✓ Team role structures: use of Buddy Nurse and organization structure, change and adaptation?
Key points to recommend:
✓ Excellent communication with patients and team members…
Motivated and trained team members will provide organization and preparedness
“Efficient workflow and reducing cross infection risks”
Donning and Doffing surveyQ: Donning and Doffing areas where
do I put them?A: We have converted our waiting room for
“Donning” “Doffing” in the spare surgery.
Consider your practice space it has to be practicable.
Key points to recommend:Walk through team training sessionsPrint “GOV” guides on “Donning & Doffing” for working areas and trainingQ: Do I need a practice washing machine? A: At home washing is acceptable, its about the handling process. Scrubs must be placed in either a pullcord pillowcase or disposable bag.
Cross Infection survey among team members the forgotten one?
Our team see many people a day and live their own life's out of work.
We must set the same standard for the team:✓ Temperature check the team on a morning
✓ Ask them to alcohol hand gel on entering the building
✓ Bring minimal belongings to work
✓ Social distance with colleagues where possible consider split start and lunch times
Key points to recommend:
✓ Ensure you have staff risk assessments and updated policy’s “Audit trail”
✓ Stress the important of self and family isolation amongst the team
✓ Encourage the importance of social distancing out of work
✓ Regular communication; consider “Zoom” meetings and training less direct contact
Patient Flow
• Patient has already been prepped by reception
• Payment (if required) has been taken by telephone. No signature required on FP17
• Outside door is unlocked by the runner nurse at the agreed time
• Temperature taken using infra red thermometer and recorded. If below 37.2 then escort patient to surgery
Patient Flow
• All doors open so patient doesn’t have to touch anything
• Once in surgery door is closed the runner nurse stays within earshot on outside
• Patient assessed and treatment confirmed with patient
• Once completed call for runner nurse to open door and guide patient outside and close door.
Your first patient… and our experience to make it easier
Andy Tannahill BDSScarborough UDC
Your First Patient…
• Find an easy patient known to the staff and dentist and familiar with the practice
• Use role play to rehearse the donning and doffing procedure.
• Be very critical of each other as mistakes will be made
• Use another dentist as surgical/buddy nurse, then swap over as this will give you more confidence
Your First Patient…
• Help the nurse to prepare the patient
• Tissues in spitoon will reduce them using it
• Consider using a funnel in the aspiration unit to rinse as reduces splatter
• Practice using rubber dam on a study cast if appropriate
• Ask the patient if they gag with intraoral radiographs and have a smaller film ready
Patient Flow
• We found standing to treat the patient better as distancing is increased
• Ensure the buddy nurse knows what to do and is at close call
• Efficient entry for the patient meant an efficient exit
• If another patient in the vicinity we held the exiting patient in the surgery until all clear
Our Findings
• Patients were familiar with PPE as seen in the media
• Pleased that we took precautions to keep them safe as many worried about full waiting room
• We got letters of thanks and presents from quite a few who were very grateful as they felt they were made very important
Peer Led Learning and Education
o Utilise existing Hub/Cluster arrangements and Communication Channels
o Encourage local collaboration and peer learning during COVID Period (Whatsappgroups and local virtual meetings)
o Involve all practice team members including management teams
o Focus on local challenges with reference to National directives and policies
o Shared learning and training resources
Outcomes
• Learning from each other
• Dissemination of best practice
• Development of local S.O.Ps
• Appointment of COVID-19 lead
• Self-certification of compliance
What is going well?
What is going well?
• Cluster & Hub development
• Rapid mobilization
• Collaboration with ProDental CPD to deliver the e-learning modules
• Professional networking
• Communication
What is going well?
• Working / referring across boundaries
• Mask fitting / testing (Over 600 tested to date)
• Clear process & systems
• Some aspects of PPE supply
• HEE support
https://www.yorksandhumberdeanery.nhs.uk/dentistry/covid-19-urgent-dental-care-
education
What could we improve?
What could we improve?
• Clarification on PPE supplies
• Fit test training and supplies
• Risk assessment of workforce inc. BAME
• OS pathways and access to GA
• Antibiotic prescribing
Key updates to guidance
and resources
• Workforce risk assessments
• Legionella Risk
• Infection control
https://www.yorksandhumberdeanery.nhs.uk/dentistry/covid-19-urgent-dental-care-education
Key updates to guidance
and resources
• Workforce risk assessments
• Legionella Risk
• Infection control
• Ventilation
• Reusable Gowns
• Fit testing
• CPR protocols
https://www.yorksandhumberdeanery.nhs.uk/dentistry/covid-19-urgent-dental-care-education
Preparing your practice
What does the new guidance mean?
Red• Urgent Dental Care in designated
centres only
Amber
• Re-introduction of care
• SOP, IPC, PPE
• Risk based care
Green• Resumption of routine dental care
Minimise Your Risk
Social Distancing
Infection Control
PPE (Donning /Doffing)
Systems / SOP
Risk assessment
Training
Key things to access
National SOP
CDO – Prompt to Prepare
FGDP Guidance
ProDental CPD resource
HEE site
BDA Toolkit
https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/06/C0575-dental-transition-to-recovery-sop-4-June.pdf
First steps…
How to access course:
https://www.prodentalcpd.com/module1205/covid-19-and-urgent-dental-care
https://www.yorksandhumberdeanery.nhs.uk/dentistry/covid-19-urgent-dental-care-
education
https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/06/C0575-dental-transition-to-recovery-sop-4-June.pdf
Considerations
Practice
• Patient Flow and environment
• Surgeries and communal areas
Workforce / Staff
• Training
• Staff health, risk and well being
Patient
• Communication and patient journey
• Individualised care – identification and prioritisation
https://www.fgdp.org.uk/sites/fgdp.org.uk/files/editors/2020.05.28%20CDO%20England%20Prompt%20to%20Prepare%20Statement.pdf
FGDP guidance
• Risk and evidence-based approach to providing care in the current circumstances
• Adjust measures depending on their individual risks and those of their patients.
• Patients and staff with particularly high risks must be suitably protected.
• Risk stratification of AGP and AGEs
Thereafter…..
• Liaise with local UDC centre/Peer review
• SOP checklists and examples• Develop your own as a team
• Don’t forget Legionella Risk!
Teamwork
• Human factors
• Errors are a result of poor systems
• Key that all the team are involved in helping to develop it▪ Test it and implement it for it to work
▪ There are a lot of changes to implement!
Returning to Work
Prioritising Care
Management options
Patient options Clinical options
Risk Category
Red Amber Green
Risk Rating Domains
Pain Caries Risk Periodontal Disease H&N cancer risk Medical History
Patient Assessment
Triage + COVID-19 Clinical records Radiographs Remote consultation
Clinical Intervention
Management options
Clinical Intervention Non-Clinical Intervention / Delay
Risk Category
High risk Low risk
Risk Rating Domains
Individual staff risk Procedural risk Patient/Population risk PPE availability Practice capacity
Consider options for intervention
Clinical records Radiographs Face to face consultation
COVID-19 Testing & Track and Trace
Now
• Antigen testing
The future
• Antibody testing
Track & Trace considerationshttps://self-referral.test-for-coronavirus.service.gov.uk/test-type
Summary
• We have collectively delivered UDC effectively
• We need to work through the best way forward regionally
• UDC sites will remain a critical part of the system
• Cluster sites will be supported to meet requirements to return to safe working practices
– This may be limited by PPE/ Mask testing.
Contact email:- [email protected]
Summary
• All sites will continue to offer UDC to "registered" " non –registered patients"
• Capacity will be reduced – We need to prioritise care
• Resources will be available on the HEE webpage
• We will develop some Peer Learning resources
• Protocols will change with COVID-19 alert level
• We will continue to keep everyone informed.
Contact email:- [email protected]
Questions?
Please note, we are unable to answer any questions regarding NHS contractual obligations or payments. Questions to Yorkshire and Humber NHSE commissioning
team can be directed to [email protected]
Question Options
Reusable half mask Respirators
Reusable Gowns
Ventilation
Non AGP - PPE
Sessional PPE
CPR
Beards/failed fit testing
Do N95/FFP2/FFP3 need fit testing?
Staff Risk Assessment
Fit testing
Can you reuse Visors?
Team member gets COVID
Reusable respirator half masks• Need to meet minimum technical
specification – P3 Filtration• Need to have adequate
disinfection protocol• Check with manufacturer first
and local IPCT• REQUIRE FIT TEST BEFORE USE• Full face masks cannot be
qualitatively fit tested due to size
Disinfection of half mask respirators
Remove and wipe filters with adequate disinfectant and submerse mask and straps in detergent/ disinfectant solution -Air dry
• Filters that are exposed and not disinfectable = single use!
NON- AGP PPE
• Visor or goggles• Fluid Resistant Surgical mask IIR
• NOT type I or type II• Apron• Gloves (non-sterile)• Bear below elbow – wash to elbows
AGP PPE
• Full face Visor • FFP3 Respirator (fit tested)
• Where there are shortages FFP2 or N95 (fit tested)
• Alternative also includes reusable half mask respirator with P3 filters (Fit tested)*
• Alternatives available for those with beards or failed fit tests
• Fluid Repellant gown• Where there are shortages, reusable
gowns are ok• Gloves (non-sterile)• (No requirement for head covers or shoe
covers)
Fallow timePHE are currently reviewing fallow times
FGDP discuss reducing fallow time based upon AGE risk and mitigation measures
Non-AGP no fallow time required, can immediately decontaminate room
AGP neutral pressure room 1 hour fallow time
Sessional use of PPE
• Single use is best practice• Sessional use possible with risk assessment• Session = staying within a specific environment (clinical area/dental surgeries)
• BUT – discard if soiled, contaminated, compromised or uncomfortable• KEY – avoid touching any part of sessional PPE (hand hygiene!)
• Single use PPE – if taken off – ideally discard• Reusable PPE – if taken off – disinfect appropriately• Surgical/reusable gowns – per patient only within dentistry (AGPs), unless covered
with long sleeve apron
CPR
Beards or failed fit testing
Powered respirator hoods do not need fit testing• Must be disinfectable• Filters must be adequately
protected (not exposed)
HSE HSG 53“If workers have beards, or are unable to be clean-shaven, a tight-fitting device will not be suitable so an appropriate loose-fitting device should be chosen.”
“Loose-fitting facepieces rely on enough clean air being provided to the wearer to prevent contaminant leaking in (only available as powered respirators)”
Fit testing – is it required?
• Note full face masks with P3 filters cannot be tested via the qualitative method. They require the quantitative method, of which access is limited in primary care
• Remember, people come in different shapes and sizes, so facial differences will mean that one kind of RPE is unlikely to fit all. The differences are even more significant between men, women, and people of different ethnicity. If the RPE does not fit, it will not protect the wearer.
• The COSHH (Control of Substances Hazardous to Health) Regulations and HSE HSG 53 guidance include a requirement that the initial selection process for all tight-fitting facepieces should include face-fit testing to ensure the wearer has a correctly fitting device.
• RPE Fit Testing is required for all tight-fitting facepieces including all filtering facepieces (disposable FFP2/FFP3), half masks with P3 filters
The UK recommends the use of FFP3 respirators when caring for patients in areas where high risk
aerosol generating procedures (AGPs) are being performed. When FFP3 respirators are not available,
then FFP2 respirators may be used.
The World Health Organisation(WHO) recommends FFP2 and N95 respirators for AGPs and these
are widely used in other countries. The N95 respirator is not CE marked but has been tested against
standards similar to European standards.
When does fit testing need repeating?
Fit testing – When should it be repeated?
From HSE:
A fit test should be repeated whenever there is a change to the RPE type, size, model or material or whenever there is a change to the circumstances of the wearer that could alter the fit of the RPE; for example: • Weight loss or gain; • Substantial dental work; • Any facial changes (scars, moles, effects of ageing etc) around the face • Seal area; • Facial piercings; • Introduction or change in other head-worn personal protective equipment (PPE).
Reusable gowns
• Where there is a shortage of disposable gowns, reusable gowns may be used. If used gowns need to be transported they should be transported in a disposable plastic bag. This bag should be disposed of into the household waste stream. Reusable gowns should be laundered: separately from other household linen, in a load not more than half the machine capacity and at the maximum temperature the fabric can tolerate, then ironed or tumbled-dried.
Additional information
• https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-control/managing-shortages-in-personal-protective-equipment-ppe
• I would also draw attention to Guidance on decontamination of linen for health and social care.
https://www.gov.uk/government/publications/decontamination-of-linen-for-health-and-social-care
• We have checked that hospital laundry service does not have to be used.
Indemnity for fit testing
• A dental professional can be appropriately trained and supported through practical mentorship in safely gaining experience & competency in performing facepiece fit testing.
• Dental professionals conducting fit-testing should seek independent advice from their indemnity organisation to ensure adequate and suitable professional indemnity and employer’s liability cover is in place.
• This is being looked into nationally regarding crown indemnity, but no clarification has been received yet
AIR FILTRATIONDevices that remove viable microbes from air, either by filtration or microbicidal action, will be highly variable:
1) The rate they pass air through the device will vary
2) The removal or inactivation will vary according to filtration or microbicidal efficacy
3) Over time – Filters will become progressively blocked. Microbicidal treatment such as UV can get obscured by a build-up of dust and the spectrum of UV emission, critical for microbicidal efficacy, can change over time.
It is often unclear from manufacturers’ descriptions (e.g. “multi filtration system, air filtration system, HEPA filters”) what the precise mechanism of a particular device is. If there are test data, it is usually with the device in a small test chamber that may be poorly representative of an intended area of application.
Can you re-use visors?
• In the Context of acute PPE shortages, PHE state:
• Visors can be reused
• They should be cleaned with detergent/disinfectant as per IPCT advice, rinsed to remove residue and left to dry
• This may compromise the visual clarity of the prouduct
What happens if a member of the dental team gets symptoms of COVID-19?
• Staff with symptoms of COVID-19, or who live with someone with symptoms, should stay at home as per advice for the public.
• If staff become unwell with symptoms of COVID-19 while at work, they should stop work immediately and go home.
• Staff should self-isolate for 7 days or longer if they have symptoms after this time. After this time, as long as they are symptom free, they can return to work.
• If staff live with someone who has COVID19 symptoms, staff must self-isolate for 14 days from the day of onset in their household member.
• All staff should be risk assessed on an ongoing basis to protect them and keep possible cases, household contacts, staff who should be shielded, or those at increased risk, away from work.
Reusable gowns
From PHE:Where there is a shortage of disposable gowns, reusable (ideally water resistant) gowns may be used.
“If used, gowns need to be transported in a disposable plastic bag. This bag should be disposed of into the household waste stream. Reusable gowns should be laundered: separately from other household linen, in a load not more than half the machine capacity and at the maximum temperature the fabric can tolerate, then ironed or tumbled-dried. There is no need currently to use healthcare laundry facilities with these.”
Staff Risk Assessments
https://www.nhsemployers.org/covid19/health-safety-and-wellbeing/supporting-our-most-vulnerable-people
https://www.yorksandhumberdeanery.nhs.uk/dentistry/covid-19-urgent-dental-care-education
What should staff do if they live with someone who needs to shield themselves?
If living with someone who is advised to shield, other household members are not required to adopt shielding measures for themselves, however, the guidance suggests that they would need to stringently follow the advice on social distancing to minimise the risk of the virus spreading within the home. Staff members should discuss any concerns with their manager and employers should make every effort make adjustments where possible.This includes minimising time in shared spaces, keeping shared spaces well ventilated, and keeping two metres away from people who you live with. For detailed information please see the guidance on shielding.Staff members should discuss any concerns with their manager and employers should make every effort make adjustments based on individual circumstances . Adjustments may include working from home or temporarily moving into hotel accommodation. Where employees feel unable to attend work due to living with someone who is shielding, employers should follow guidance on pay for this situation .For staff members in this category, the NHS will support staff to stay well, protect their families and continue to work where national guidance allows and where reasonable adjustments can be made where required. Some staff may also be carers for extremely vulnerable people, friends, family members or neighbours.-