COVID PPE Prioritization – Effective 6-1-2020

COVID PPE Prioritization

The COVID pandemic has no doubt created many challenges for the dental community. Gentle Dentistry has tirelessly strived to adjust to the every-changing guidance on PPE, policy and recommendations on an almost daily basis as we all learn more about the SARS-CoV-2 virus. Two weeks ago, we launched a hands-on infection control training under the strict PPE and policy guidance that, at the time, was required from the Minnesota Board of Dentistry, Minnesota OSHA and at the recommendations of the CDC. Since then, the CDC has learned more about how the virus spreads and how it affects people and some of those recommendations have changed.

On May 19, 2020 the CDC released a statement on new recommendations for PPE requirements for dental procedures during the COVID pandemic:

https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html#PPE

On May 22, 2020 the Minnesota Board of Dentistry released further guidance on PPE requirements in accordance with the CDC recommendations and the Minnesota OSHA requirements: https://content.govdelivery.com/accounts/MNBOD/bulletins/28d0051

Minnesota OSHA can be found here: https://www.dli.mn.gov/sites/default/files/pdf/WSC_guide_dentistry.pdf

UNDERSTANDING A TIERED APPROACH TO PPE

Utilization and selection of Personal Protective Equipment is dependent on the specific job task that is being performed. Certain job tasks do not require PPE, some require a lower level of PPE, and others require a medium or high level of PPE.

Now that we understand more about how SARS-CoV-2 is transmitted, we can understand the job tasks that pose a low, medium or high risk of exposure to the pathogen. It is important to always be prepared prior to initiating a job task to ensure that the appropriate level of PPE is in place.

The key to understanding what type of PPE to use is to anticipate whether any droplets, sprays, spatter or aerosols are going to be produced during patient care.

What kind of procedure is being performed? Will there be a chance of sprays or spatter? Will dental aerosols be generated?

Gentle Dentistry requires that all employees wear no less than the minimum required PPE when performing specific job tasks. Use the grid below to determine which task requires a level of PPE. If you are unsure which level is required, please discuss with the on-site Dentist, the Clinic Team Lead, the Systems and Compliance Manager or the Clinical Director. Safety is our top priority.

We understand that this is new and can be confusing information. We want every employee to feel comfortable at all times. We are confident that having a thorough understanding of COVID disease transmission and infection prevention can help alleviate any concerns. Please ask many questions! We are here for you at all times.

Level 0: Basic Interaction

This level does not require PPE, but instead requires heightened infection prevention during this global pandemic. In general, every person, including employees, can be a potential carrier of the SARS-CoV-2 pathogen and not know it. They may by asymptomatic (not have symptoms). While the pandemic is occurring, Gentle Dentistry employees will follow the general CDC recommendations for illness screening, source control and social distancing as much as possible.

1. All people inside the dental clinic will be required to wear a face covering. This can be a personal mask or a Level 1 surgical mask.
2. This includes patients, employees, visitors, maintenance workers, sales reps
3. Everyone who enters the clinic must take their temperature and fill out the symptom questionnaire
4. Sick employees may not work.
5. All employees must report illness symptoms immediately and go home if sick
6. All people inside the dental clinic will practice social distancing when possible, taking care to limit close contact interactions to as little time as possible

Levels 1-3 apply to patient care involving the oral cavity.

As soon as the patient’s mouth is no longer covered, it is required to use appropriate PPE. Since we know that COVID19 may be asymptomatic, employees must always have at least the minimum required PPE for the job task when interacting with a patient within close contact (6 feet).

PPE REQUIREMENTS

Remember, PPE is the last line of defense. It is important to try to reduce exposure to a hazard as much as possible using other ways first, such as

1. Elimination Controls (Do not treat known COVID patients)
2. Engineering Controls (reception barriers, high volume suction, air flow management)
3. Administrative Controls (social distancing, staggering dental appointments, prioritizing necessary dental procedures, reducing aerosol generating procedures)

Always know what type of PPE is required prior to performing the job task.

Do not perform the job task if you do not have the minimum required PPE.

PPE INVENTORY

PPE inventory must be performed daily with the DDS and the CTL. If PPE supplies are low, the dentist will screen every patient and procedure to determine necessity to ensure prioritization of PPE supplies for patients who require emergent, urgent and more necessary dental procedures over elective and routine care procedures.

Each clinic is responsible to monitor and maintain the appropriate level of PPE and schedule patients accordingly.

This will require frequent communication of ALL team members so that everyone is on the same page and can take action steps prior to running out of required PPE.

EMPLOYEE PERSONAL PPE PREFERENCE

Some employees want to use a higher level of PPE than what is minimally required because of their personal preference. It is important to understand that Gentle Dentistry is obligated to provide the minimum required PPE for each job task (Level 1 for non-aerosols, Level 3 for aerosols). If all the Level 3 masks are used up, we cannot perform those higher level procedures and will have to reschedule the patients until the appropriate PPE is available.

N95 or KN95 RESPIRATORS FOR NON-COVID PATIENTS

N95 or KN95 masks are recommended for aerosol generated procedures, but if they are not available, a Level 3 surgical mask with a face shield is acceptable. This directive is from the Minnesota Board of Dentistry and in alignment with the CDC recommendations.

Gentle Dentistry understands that employees may want the opportunity to use N95 or KN95 masks right now. We will continue to provide them on the Henry Schein formulary as they become available and continue to look for alternate vendors who may have them. We have dispersed our current inventory of N95 and provided fit testing so that each clinician has the opportunity to wear one if they are available.

We have a shipment of KN95 masks coming from Henry Schein. They have passed the NIOSH testing, but have not yet been certified by the FDA to be cleared as a medical device in the United States. Gentle Dentistry employees may elect to use them so long as they have the appropriate level NIOSH certified surgical mask over the top until they are FDA cleared.

For patients with confirmed or suspected COVID, only treat life-threatening emergencies, use the highest level of PPE including N95 or FDA cleared KN95 or consider referring to a hospital or other emergency facility.  Active or suspected COVID patients may not be treated if a N95 is unavailable. Dentists will use their professional judgement to determine whether it is appropriate to treat a COVID patient in the dental setting for a life-threatening emergency.

OPERATORY TURN AROUND FOR AEROSOL PRODUCING PROCEDURES

Per the Board of Dentistry, for all aerosol generating procedures, allow 15 minutes from the time the patient leaves the operatory before returning to clean. You may have to change the way the appointment flow works to allow for the 15 minutes to begin.

• Remove the patient from the operatory as soon as possible after patient treatment
• Utilize other spaces for non-patient treatment needs, such as post op instructions etc
• Schedule 6 month recall visits at another work station rather than in the operatory
• Complete clinical notes at another work station

Since we have to let dental aerosols settle for 15 minutes regardless of the air purification system being implemented,  GD purchased Germ Guardian HEPA air purifiers with UV-C light for each operatory which will still filter the air and turn it over every 15 minutes. Every clinic will also have one or two IQ Air purification systems (mobile) placed in the common hallways that can also be used as an additional air exchange option when doing extended-time aerosol generating procedures and the clinician would like a faster room air exchange during said procedure.