Getting Back to Normal

April 22, 2020

An infection control checklist for reopening the practice after Coronavirus closures.

The dental profession is so focused on social distancing, limited access to patients, and closures that it may be easy to forget that when this is all over, the doors have to reopen, and business must return to normal.

But what will “normal” look like? Will (or can) things go back to the way they were before the world was placed on hold? And, even when the doors do reopen, is it as simple as flipping on the light switches and filling your schedule with appointments?

An anti-climactic event

When practices do start seeing patients on a routine basis, “Safe Practices” infection prevention consultant and speaker Jackie Dorst, RDH, BS, doesn't expect everything to look just the way that it did before everything was put on pause.

“I don't see there will be one big opening of the gates and saying that everything's all clear,” Dorst says. “I really perceive that it's going to be a gradual thing. There may be some rural areas or some states that are not so densely populated where the dental boards and the health departments say, ‘It's okay for medical and dental offices to resume seeing patients and practice precautions for the possible transmission of COVID-19’.  Rural areas and less densely populated areas may open first as the curve flattens and the number of new cases declines. Densely populated areas may be a little bit slower to resume medical and dental services.

“For the dental offices, it's going to be a gradual resumption of seeing patients,” she continues. “They're going to have to take so many more precautions, because the SARS-CoV-2 virus is an airborne transmission. So, standard precautions, which protects us against body fluids - and has protected us as dental professionals for years - now we're going to have to add additional airborne precautions, because of the aerosol droplets that potentially can transmit the SARs-CoV-2 virus.”

Other changes are going to effect to how the front desk schedules and greets patients. Dorst believes that waiting rooms will need to be reorganized to limit exposure for both patients and staff.

“The patient should be met at the door, greeted, temperature taken, given a mask, a wellness screening, and patient hand hygiene with that patient before they're even seated in the operatory,” she says. “It's going to require schedule planning and time on the dental team's part.”

Housekeeping

When practices are given the all-clear to start seeing patients again, in whatever form that takes, most practices will have to get back to a certain level of functionality.

“For many, the term ‘housekeeping’ isn’t typically associated with infection control,” Karen Daw, “The OSHA Lady”, speaker and consultant, observes. “However, the Centers for Disease Control and Prevention, in their 2003 and 2016 guidelines, reference cleaning and disinfection of non-clinical surfaces. Though they are not likely to be a cause of disease transmission, they are still part of the overall infection control protocol, so much so that the CDC recommends maintaining a written housekeeping Operating Procedure on hand to address walls, floors, sinks and other non-clinical, low-touch surfaces.”

This will mean revisiting basic, Infection Control 101 practices, starting with a good, thorough cleaning.

“If you think back to disinfection of clinical surfaces and instrument processing, cleaning is always the first step,” Daw says. “It removes organic matter and just a good old-fashioned scrubbing with soap and water is going to remove micro-organisms. If these areas have been neglected before, now is the time to include a written process and to train on how to clean and disinfect clinical and non-clinical surfaces, alike. This should include the use of an EPA-registered disinfectant. Plus, if it’s been a few weeks, the place could use a nice dusting, anyway.”

She advises practices to ensure that they have the proper cleaning and disinfecting products on hand. Unfortunately, these days, those items may be scarce.

“With the recent disruption and reallocation of dental supplies, it’s imperative to have the proper supplies, even before the doors open,” Daw says. “Now is the time to determine if you need a disinfectant effective against a particular pathogen or not. The EPA does maintain a list of disinfectants effective against COVID-19.”

PPE

Personal protective equipment has always been an important component of infection control efforts at the dental practice. But, in a COVID-19 world, that equipment becomes even more important-along its proper use and availability.

One likely change is the type of PPE worn by staff, Dorst says, and the guidelines surrounding PPE could become more stringent.

“In the past, a dental assistant might wear glasses and a surgical mask,” Dorst says. “Now they're going to wear an N95 respirator mask, with a full-face shield over it, and then an isolation gown, rather than just the clinic jacket or scrubs that they might've worn.”

Access to necessary PPE has been limited throughout this crisis. As a result, practices may have to be creative and industrious with their equipment usage.

“There are all sorts of resources that are popping up, both FDA-approved and not-approved, let's say, ‘in the gray area’,” Dorst observes. “And even at this time, CDC said that if you couldn't find N95 respirator masks, you can use an FFR filtering respirator mask.  It’s like what you would refer to as a dust filter mask that they might sell at Home Depot or Lowe's. These are not moisture-resistant masks, so the CDC added to wear a shield over the FFR respirator mask, since the FFR is not fluid resistant.”

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Dorst notes that the CDC has a series of substitution options if the ideal product is not available.

“The CDC went down a tree of what's effective, like a Level 3 surgical mask with a full-face shield over it,” Dorst says. “If you can't get that, then the next would be a Level 2 with a full-face shield. And then, if you can't get any of those, the CDC states that you shouldn't treat patients. So that's where the anxiety comes.”

Equipment

This downtime has given practices the opportunity to address the proper preparation and availability of dental instruments and equipment. Taking inventory and getting the input of hygienists and assistants could go a long way in making sure the office is ready for a full schedule post COVID.

“This is the perfect time to meet with the team and ask if there are any infection control considerations, before the doors open. I know they’d appreciate being heard and the practice will be in great shape when things are full swing again.”

Putting that equipment back into use shouldn’t be especially difficult, but keep in mind it has been sitting unused and unmaintained for weeks. This equipment should be properly serviced according to manufacturer instructions.

“For dental units and equipment, follow the manufacturer’s IFU, or Instructions for Use, regarding maintenance,” Daw says. “For example, dental unit water lines should be shocked and tested to ensure the removal of harmful bacteria that may have built up in the lines. The current standard from the Environmental Protection Agency is no more than 500 cfu/mL of heterotrophic bacteria. In all honesty, the water in the practice should be nowhere near that level, and that is to be considered the upper threshold.  Perform routine maintenance on handpiece cleaners, instrument washers, ultrasonics, and sterilizers so they are functioning properly. If any major repair must be performed on the sterilizer, run three consecutive biological indicator tests and do not use until passing tests have been received.”

Skills refresher

Before patients walk through the door, now is a great time to brush up on infection control policies and procedures, Daw says.

“Now, not after the doors open, is the perfect time to train on OSHA and Infection Control,” she says. “In fact, when I offered this as a virtual option for practices, I sold out every week. Many practices shared that they were concerned about updates and any new standards from CDC or OSHA they should know about. And because we used video chat, everyone was able to see and interact with their co-workers in their pajamas while earning CE credits. If the practice didn’t cover this during the ‘break’, I recommend tackling this sooner, rather than later. And no matter how you choose to fulfill the mandatory training requirement, educate not just for the sake of educating, but educate for competency.

“Written programs, like the Exposure Control Plan, and hopefully your newly written Respiratory Hygiene and Protection plan, should be reviewed,” she continues. “Some items from the CDC include printing and posting signage in the waiting area, isolating patients suspected of having a respiratory illness, and offering no-touch waste receptacles in the waiting area. If you have a process in place for screening for tuberculosis and other aerosol transmissible diseases, then it can be modified to include conditions like COVID-19.”

It's also important to ensure that the practice has people in their proper safety roles, such as an infection control coordinator or a safety officer, Daw says.

“This is recommended by the CDC and OSHA. I can’t stress this enough: Safety and infection control is not just one person’s job, it is everyone’s job. However, this person will be charged with overseeing the program. Set this person up for success in the role. Encourage attendance of Infection Control continuing education, work with a consultant to help train the team and with written documentation, and join a group like the Organization for Safety Asepsis and Prevention (OSAP).”

Some of the preparation, ideally, should have begun even before operations slowed down.

“Hopefully, before closing the doors, the practice had the biohazardous waste collected,” Daw says. “Almost all states have guidelines on storage of medically regulated waste and will include language as to how long, or it might be more qualitative, like to a state of putrescence, for example. Become familiar with your local waste guidelines and have a written program in place. However, if this was overlooked, some practices may want to manage this before seeing patients again as odor can be a concern.”

The “grand” (re)opening

When patients to start returning, en masse, it isn't just policies, procedures, and PPE that must be addressed. Practices must look at patients’ overall flow into the office, including pre-screening patients as they walk through the door.

“They should look at their schedule cautiously and prioritize the patients that they're going to need to immediately get back into the office,” Dorst says. “They're going to have to put a chair, either in the foyer or the anteroom or the hallway, that's a plastic chair or a chair that can be wiped down with a disinfectant. They also need a small table, because when that patient first arrives at the office, they're going to have to be met at the door and their temperature should be taken. If the temperature is above 100.4 degrees, then dismiss the patient and reschedule in 14 days. Once they've taken their temperature, then the patient puts on a mask. If they have their own mask, they can be used for the patient to help preserve the other PPE for the dental team.”

Additionally, patients should be given a wellness screening with questions around their exposure to COVID-19, any traveling, shortness of breath or dry coughing, Drost says.

“And, once they've done that, then the next step is to get them to sanitize their hands. They're coming into your office, you don't know what surfaces the patient touched before arriving at the office. So, we either offer them an alcohol hand rub or have them wash their hands, and then at that point they're ready to be escorted back to the operatory.”

She recommends performing a few dry runs just to ensure everything goes smoothly before actual patients arrive at the practice.

“I would highly recommend practicing it,” Dorst says. “Get all your supplies together, get it positioned, and then practice it with the team members. And when the patients do show up at their office, you welcome them with a smile and say, ‘We are so happy to see you. We have missed you. We've missed caring for your beautiful smile. Welcome back.’”