SOP and RRR

• To provide a written reference document for our patients, colleagues and practice team outlining in detail all practice policy at RDC relating to reopening for routine patient care after the COVID-19 coronavirus world pandemic has started to subside in the UK.
• To collate as far as is possible all of the available evidence, key opinions and regulatory advice into one working document. Whilst covering all aspects in detail, we wish for this information to be as concise and easily referenceable as possible.
• To make clear our responsibilities and decision processes based on the above to provide a safe but pragmatic approach to reopening RDC to routine and specialist dental care as the pandemic numbers decline.
• This document supersedes all previous advice and position statements and versions will be updated.

For feedback or comments please contact me on [email protected]

Casey Holbrow

Practice Manager

Royston Dental Care

• For the first time in our professional lives, it has been necessary to cease practicing routine dentistry for more than two months upon advice from our regulators. COVID-19 was declared a pandemic by the World Health Organisation on 11th March 2020.

• RDC acknowledges that as a healthcare provider and an employer we have a duty of care to the team and to our patients to ensure that the environment at RDC is safe to work in and that everybody is clear about the actions and procedures that have been put into place to protect everyone attending RDC from infection by coronavirus.

• This document will be updated as required in light of developing advice and knowledge.

• RDC accepts the following regulatory bodies as having ultimate control and influence over when and to what extent we are able to return to work. Most of these have issued guidance in relation to dental practice rather than absolute regulations.
  • The Government of the United Kingdom and Public Health England
  • Office of the Chief Dental Officer of England (OCDO)
  • The General Dental Council
  • NHS England
  • The Care Quality Commission (CQC)
  • The Faculty of General Dental Practitioners (FGDP)
  • Dental Indemnity Companies
  • The British Dental Association
  • British Orthodontic Society (BOS)

• All primary dental care services were asked to establish a remote urgent dental care (UDC) service. For RDC this consisted of access to emails and our emergency line 24/7, 7-days a week, to ask patients who required urgent dental assistance to email or telephoning the practice in the event of an emergency. To date we have fortunately had very few incidences where urgent emergency care has been required reflecting our attention to quality care in the past.

• We were advised by our Chief Dental Officer (CDO), the CQC, GDC and indemnifiers to manage dental emergencies using the AAA protocol (Analgesics, Antibiotics, Advice). Where there was a severe infection which could not be managed using AAA, we should refer patients to a UDC. Whilst UDC centers have been set up under the NHS, referral to them requires a complex process.

• COVID-19 is still at “alert level 4” (out of 5) in the UK which indicates that it is still a disease with a severe risk of transmission. This is calculated using the R-number (the Reproduction number or the number of infected individuals infected by an infected patient) which has regional variations.

• On 28^th of May, the Chief Dental Officer for England Sara Hurley And Director of Primary Care and System Transformation Matt Neligan released an official document (Publications approval reference: 001559) addressed to “Dental practices” and CC’d to “Regional dental commissioning leads” . It stated that this correspondence “now sets out next steps for delivery of NHS dental services in England, as the NHS moves into the second phase of the COVID-19 response.”
  • It goes on to state that “we have consensus on the commencement of reopening services. We support the full resumption of routine dental care, in a way that is safe, operationally deliverable and allows dental practices flexibility to do what is best for patients and their teams. Central to this is the acknowledged clinical judgement of practitioners and their ability to risk manage the delivery of dental care, as service provision is recommenced”
  • It continues to acknowledge that clear safety standards including personal protective equipment (PPE) and infection prevention and control (IPC) protocols are required to safely deliver dental care as recommended by Public health England.
  • It states “Today, we are asking that all dental practices commence opening from Monday 8th June for all face-to-face care, where practices assess that they have the necessary IPC and PPE requirements in place”

• It is our view that as a leading, quality private dental practice with already the most stringent cross infection control procedures woven into our pre-COVID-19 standard operating procedures, we will be in a position to reopen the practice for patient care early in June using a staged approach, managing emergencies and non aerosol generating procedures as priority, followed by routine dental care.

• We would like to acknowledge that this document has been adopted and customised from the original publication, Standard Operating Procedure and Risk Reduction Recommendations written by Mr Koray Feran at the LCIAD.

• It is highly unlikely that COVID-19 will be eradicated as a disease for the foreseeable future. Like common cold or influenza viruses, the coronavirus responsible for COVID-19 will remain at large in the population to some extent.
• It is highly unlikely that the current lockdown or similar restriction in social contact will be in force for a length of time until a vaccine or suitable targeted medication against SARS-CoV-2 will become readily available. The UK government is therefore proposing a phased reopening of venues over the next few weeks or months to allow the economy to resume functioning. The population will therefore gradually be exposed to this virus in the coming months.
• This means that there will always remain a risk that coronavirus infection can be contracted during normal day-to-day activity and it is impossible for RDC to control the environments in which our patients and staff circulate outside the practice. However, we can do a considerable amount to reduce the risk of exposure to this virus at RDC itself.
• There have been many suggestions to reduce risk and we have adopted as many of them as possible while still allowing us to carry out dental procedures to a high standard. We have also questioned and researched rationale behind advice given.
• We often read that many of these additional procedures have no evidence to support their efficacy in reduction of cross infection. However, absence of evidence is not necessarily evidence of absence, especially for a disease that is so new. We must keep an open mind and learn from similar outbreaks.
• Our advice aims for the best possible combination of safety and practicality so that we can provide necessary dental care for our patients without increasing their risk of contracting coronavirus infection beyond that already present in the general population and indeed ideally providing a lower risk environment by controlling as many risk factors as possible within the practice.
• Research is continuing at a rapid pace and regular updates in our information and procedures will undoubtedly occur.
• It is clear that we cannot completely eliminate all risk of infection absolutely and any risk of cross infection of coronavirus at the dental surgery will need to be weighed against the risks and benefits of not providing required dental treatment. To weigh up the balance of risks and whether to take this risk is entirely at the discretion of the individual patient attending the clinic.
• Our starting point is the list of the government’s basic social distancing and personal precaution guidelines on https://www.gov.uk/coronavirus which all team members and patients should be familiar with and comply with for day to day protection.
• Further measures specifically custom written for RDC are listed below in more detail but are based around:
  • Risk assessment of our entire team prior to commencing reopening
  • Pre-appointment triaging of risk levels for individual patients
  • Reduction in incidences of contact between staff and patients as far as possible
  • Reduction in risk of transmission whilst on RDC premises.
• Many of the protocols that provide safety to patients and staff alike at RDC are already in place and are tried and tested over the years. A dental practice is one of the best controlled and cleanest environments alongside operating theatres and food production facilities.
• We are regulated by a bewildering array of professional bodies and guidance documents as indicated in this document and with which we must keep up to date as part of our compliance to maintain an up to date and safe dental practice.
• Whilst this may seem like an onerous document to tread through, please be assured that it is the culmination of many days of work and consideration and will hopefully relay to the reader that we take this issue seriously.

• Between 23^rd March 2020 and 2^nd June 2020, the entire practice was cleaned and all water lines were disinfected on a weekly basis.

• On Friday 5^th June 2020, the entire practice was deep cleaned and disinfected by RDC staff (with appropriate social distancing based on personal assessment of risk) from top to bottom including removal of all non-essential items, removal of all objects from drawers and cupboards and interior cleaning, servicing of all chairs and internal water lines by RPA Dental and disinfection and wiping of all surfaces inside and outside the surgeries.

• Replacement of suction motor HEPA (high efficiency particulate absorbing) filters in each surgery to filter exhaust air from dental suction units have been arranged prior to opening.
• Air-conditioning filters will be replaced and all air-conditioning units were serviced recently.
• Legionella testing which is also due as per routine practice protocols will also be carried out prior to practice opening in accordance with HTM 01-05, HTM 04-01 part 2 (2014), and Approved Code of Practice (ACOP) L8 (2013).

4.1. RRR and SOP training and confirmation of understanding – role play and step by step staff training

• It is important that all practice steps in this document are practiced before implementation. These steps will be rigorously tested by all staff prior to re-opening to ensure all processes run smoothly. This will give us important information:
  • An idea of the practicalities of the recommendations
  • A time and motion study of patient care and flow through the practice under the new recommendations
  • Required modifications to procedures to adapt to the recommendations
  • Ironing out issues in the protocols and finding solutions where issues present themselves.
  • Assessment of additional time and costs involved with additional procedures to build into the business plan of the practice to ensure viability
  • Refining and where possible simplifying the protocols as required

4.2. Confirmation of standard infection control procedures (HTM 01-05) plus supplemental post-COVID 19 risk-reduction modifications

• All standard pre-COVID-19 standard infection control processes as outlined under Health Technical Memorandum 01-05 (HTM 01-05): decontamination in primary care dental practices will remain in force as before lockdown.

• RDC is also aware of and has incorporated aspects of “COVID-19: infection prevention and control guidance” for additional aspects and current guidelines over and above HTM 01-05.

• Our regular decontamination, cleaning and sterilisation procedures already have a proven track record of being effective at prevention of cross infection of previous respiratory and blood-borne viruses.

• These procedures, already second nature to our team, will continue to be used until superseded by any modifications that may come into force following the pandemic.

4.3 Hand and Respiratory Hygiene

• All persons entering and leaving RDC should thoroughly wash their hands in the changing room scrub sinks as soon as they arrive at the practice.

• Handwashing should follow standard pre-operative techniques used routinely before surgery to include forearms. All sinks will have step-by-step images of the ideal handwashing process and videos are available at https://www.nhs.uk/live-well/healthy-body/best-way-to-wash-your-hands/.

• Hands should be washed at every reasonable opportunity with antibacterial hand soap provided and especially at the following times:
  • Immediately before attending to patient treatment and donning personal protective equipment (PPE)
  • After any activity that may lead to hands becoming contaminated such as opening doors, receiving packages, typing on keyboards, before and after eating etc.
  • After removal of PPE before leaving surgery
  • After equipment decontamination in the sterilisation room before leaving the sterilisation room.
  • After handling and disposal of waste
  • At the start and end of every clinical procedure
  • Always after using the toilet facilities
• Alcohol based hand rub should be used adjunctively for 30 seconds after each handwashing session allowing access to all of the same surfaces of the hands and wrists as during handwashing

• Respiratory hygiene should follow the principle of “catch it, bin it, kill it”. Tissues are available in all areas of the practice and should be used to sneeze or cough into when required. The tissue should then be immediately discarded into the nearest bin and hands and face washed and decontaminated as above.

• If you need to sneeze or cough, please make every effort to distance yourself from anyone in close proximity by at least 2 metres and turn away to direct the cough or sneeze onto a tissue and away from any individual. If no tissue is immediately available, please catch in the crook of your elbow and ensure that your skin or clothing covering this area is washed as soon as possible.

4.4 Staff Protocol and Clothing

• Jewellery
  • All staff at RDC should refrain from wearing any jewellery in the form of rings, necklaces, earrings or piercings in the facial region.
  • The only exception are small stud earrings to prevent closure of pierced ears.
  • Plain wedding bands which should be removed at the start of each day and kept locked in the staff members locker after decontamination with alcohol hand gel disinfectant.

• Alarm Panel and light switches
  • The practice alarm panel should be covered in clear protective adhesive film by the last person to leave in the evenings and the alarm activated through the clingfilm.

• The first person to arrive at and unlock the practice should turn off the alarm through the clear protective adhesive film and then remove the clear protective adhesive film. The clear protective adhesive film should be disposed off in clinical waste and proceed directly to the nearest handwashing sink as soon as the alarm has been turned off but before touching any light switches. Upon washing their hands and using alcohol hand rub, they should return to the alarm panel, decontaminate the surface with suitable alcohol wipes and close the alarm panel cover. They should only then turn on all lights and equipment / electricals in the practice as normal.

• The same person should unlock the staff room fire escape gate and staff room door and the RDC WhatsApp message the rest of the practice to say that the practice is open for staff to enter.

• Staff Personal Hygiene
  • Staff should shower each morning and wear clean and ideally easily washable clothes to work each day. Male staff members are required to be clean shaven every day.
  • Nails should be kept short, neat and tidy with no nail varnish.

• Staff are required to bring two pillow cases to work, one for their clean clothes and one for their dirty scrubs and re-usable PPE

• Please avoid the use of public transport where possible. Where this is necessary, use a face mask and disposable gloved during the course of your journey.

• Staff should arrive at least 30 minutes before the first patient. Their temperatures will be checked at the door and logged daily by the practice manager, Jenny Corrigan. The practice manager will also check the temperature of the infection control nurse and vice versa.

• Staff will then proceed to the changing area via the staircase on the left to reduce street clothing exposure to the remainder of the practice.

• Please proceed directly to the staff room where they should wash their hands and faces as above after having removed any wedding ring and prior to changing into work scrubs.

• Hands should be dried on disposable paper towels or via Hand dryer Air blades. Tea towels or other non-disposable fabric items must not be used.

• Street clothes should be regarded as contaminated from exposure and stored folded in your first pillow case, in the personal lockers and not left in view or hung in the wardrobes.

• Lockers should be cleared of all non-essential items and decontaminated with surface disinfectant at the end of each clinical day after street clothes are re-donned prior to leaving the practice. Street clothes must not be worn anywhere in the practice other than the changing area.

• Shoes must be stored in the shoe lockers and not left anywhere else.

• Lunch should be brought in sealed Tupperware containers and left in the fridge after hands have been washed. Staff should try to limit exiting the practice during the day as far as possible to reduce risks of carrying infection in either direction. The Microwave will be out of use until further notice. Please bring cold sandwiches which can be easily consumed without the need to heat it.

• Mobile phones should be switched off and left in lockers provided with all other personal property and should only be used during break and lunch periods after having thoroughly washed and disinfected hands.

• Scrub uniforms or practice clothing should be worn by all staff including administrative staff during working hours. Further clinical PPE measures are outlined below. Scrub uniforms must never be worn outside the practice other than in the practice quadrangle and must not come into contact with street clothing.

• Used Scrub uniforms should be placed directly into the second pillowcase, at the end of each day (or each session if soiled) and street clothes donned immediately prior to leaving the practice.

• If scrubs need to be removed to exit the practice during the day, they can be stored over lunch hour in your washable bags/pillowcases, which should also be laundered at the end of the clinical day.

• Used work scrubs should be put on the most suitable wash cycle for the fabric at the end of each working day at home (usually at 60 degrees). We recommend you do separate cycles for the clinical scrubs and pillow case and do not mix this with your clothing you wore to and from work. Hands should be washed, and the washing machine surfaces at home wiped down with surface disinfectant after this process.

• Work shoes / clogs / Crocs should be sprayed with surface disinfectant or machine washed with scrubs if appropriate and stored in your lockers.

• Street clothes should be removed and washed as soon as you return home and a similar protocol to the practice adopted for handwashing and antimicrobial alcohol hand rubs when arriving home after work. All staff should shower as soon as you return home.

• Avoid touching your face at all times when changing outside donning and removing mask, eye protection and visor PPE.

• All staff are required to adhere to strict protocol outside of work, to minimise the risk of exposing themselves to the virus and therefore risking the spread to our patients. The staff protocol outside of work needs to be strictly adhered to the government guidance.

• • Where we suspect that you have been not following the government guidance outside of work, we will have no choice but to advise you to self-isolate for a period of 2 weeks under SSP.

4.5. Practice risk assessment and updated checklists

• Updated practice risk assessments have been prepared by the Practice Manager and Senior Nurse.

• All staff should familiarise themselves with these documents during the staff training days.

4.6. Changes to non-clinical patient and common areas

• Non-clinical patient areas are defined as:
  • The practice entrance hallway
  • The ground floor corridor
  • The ground floor treatment coordinator room
  • The staircase and first floor landing and corridor
  • The first floor bathroom

• The common areas for RDC staff only are defined as\
  • The ground floor offices
  • The first floor office
  • The first floor locker room area
  • The basement vaults
  • The outside quadrangle beyond the kitchen is regarded as open air and outside RDC premises.

• A rota for cleaning and disinfection of all communal areas must be reinforced especially for often-touched areas such as door handles, using proprietary surface cleaners. This should ideally be handled by the greeting and runner nurse as below.

4.7. Changes to surgeries / operatories

• All clinical and disinfection and sterilisation areas are normally subject to sessional, daily, weekly and monthly hygiene routines. These will be reinstated as normal prior to surgery opening and continue with our normal high standards as per HTM 01-05

• All surgeries and operatories have been cleaned by removal of all objects from inside cupboards and drawers, surface disinfection of the insides of the cupboards and drawers and surfaces of all items and packing way of all non-essential or rarely used items into lidded boxes which will be stored within the basement of the practice.

• All chair water lines have been fully run through and disinfected with hydrogen peroxide or hypochlorous acid (HOCl) solution as appropriate for the manufacturer. This will be repeated immediately prior to reopening and as per our normal HTM 01-05 procedures at the end of each patient treatment session. We have ordered further equipment to increase production for use in disinfection of the whole practice.

• All non-essential items from worktops have been removed and placed into cupboards or drawers

4.8. Changes to decontamination and sterilisation room

• Similarly, to the operatories, the contents and interiors of all cupboards and drawers have been sorted, cleaned and disinfected in the same way.

• All autoclaves, purified water and hypochlorous acid (HOCl) production machinery will be thoroughly cleaned, put through at least three cycles and serviced where required to ensure that they are cleaned, disinfected and fit for purpose immediately before opening.

4.9. Personal Protective Equipment (PPE) definitions, aerosol-generating or non-aerosol-generating procedures (AGP and non-AGP), standard, FFP2 and FFP3 masks, fit testing of masks, staff PPE requirements, donning and removal of PPE training

PPE Definitions

• PPE is defined as any item that is worn by a healthcare worker or indeed any person for the purposes of protecting the user against health and safety risks.

• In this context it includes additional precautions that may reduce the risk of cross infection of coronavirus, the causative agent of SARS COVID-19 to those normally used in primary dental care such as face masks or respirators, eye protection, visors and surgical gowns and hoods.

• The question of personal protective equipment is highly topical and presents the greatest challenge for dental practices that plan to reopen due to a global level of demand which far outstrips supply especially for higher level protection. We regard personal protective equipment as the following:

• • Work scrubs made of high temperature washable polycotton as basic uniform within the practice for both clinical and, from 1st June, also non -clinical staff.

• • Suitable respirator (Respiratory Protective Equipment or RPE) matched to the risk level of the patient and the procedure and certified fit tested by qualified fit tester where appropriate.

• • Respirators contain multiple layers of fine filters that not only physically trap tiny droplets and particles but are also electrostatically charged to attract particles to be caught within the mesh of the filters rather than allowing them to pass through unimpeded.

• • Respirators are classified as “filtering face piece” respiratory protective equipment (RPE) – FFP1, FFP2 or FFP3 and can be valved or un-valved.

• • • FFP1 – standard surgical face mask loop or tied. Protection against large solid particles or droplets with a minimum filter efficiency of 78%.

• • • FFP2 – protection against solid and liquid aerosols with minimum filter efficiency of 92% to 95%

• • • FFP3 – protection against solid and liquid potentially toxic aerosols with a minimum filter efficiency of 98% to 99% when fit-tested.

• • • • Valved versus non-valved –
        • Valved masks protect the wearer from aerosol generated from the patient but allows exhalation of unfiltered air to escape through the valve. i.e. it is protective in one direction only by protecting the wearer i.e. the healthcare worker from the patient. It makes wearing the mask more comfortable but does not prevent cross infection from the wearer to other people.
        • Un-valved masks protect both the wearer and anyone close to them from aerosol by filtering inhaled and exhaled breath equally in both directions, i.e. both the healthcare worker and the patient are protected from each other. However, they are considerably more uncomfortable to wear especially for prolonged periods and in hotter environments.

• • It should be noted that valved respirators are not fully fluid resistant unless they are also “shrouded” where the valve is covered by additional fabric to protect it from splatter or aerosol or is protected by a second standard surgical mask for the same purpose.

• Eye protection against direct splatter and aerosol compatible with magnifying loupes and coaxial lights vital for the practice of fine dentistry.

• Face visors to complement eye and facial protection from direct splatter and reduce aerosol and direct splatter contamination of eye protection and loupes.

• Hair nets or surgical hoods to reduce aerosol and direct splatter contamination of hair and exposed forehead skin.

• Disposable or washable water-resistant gowns to reduce aerosol and direct splatter contamination of working scrub suits and exposed forearm skin.

• Plastic aprons and heavy-duty gloves during the decontamination and sterilisation processes outside the surgery.

• RDC is of the opinion that shoe covers do not add any further protection from a respiratory virus. It is unlikely that the presence of any particles that have settled to the floor are likely to be kicked up into an aerosol or droplet form after settling and shoe covers would also not prevent this.
• The action of placing shoe covers introduces additional risk of patients touching a potentially more contaminated part of their attire than they normally would (i.e. the soles of one’s footwear) and may also increase the risk of losing balance or leading to slipping or falls for more elderly or infirm patients. It will also create a substantial amount of additional unjustified plastic waste. We have therefore not included additional foot covers in our PPE list after suitable risk assessment but will continue with normal established daily floor decontamination and disinfection routines to maintain a hygienic floor environment as far as possible in the practice.

Fit testing of respirators

• FFP2 and FFP3 respirators come in a variety of designs, shapes and sizes and consequently, in the UK, these need to be fit tested by law by a registered fit tester to ensure that they maintain a proper seal during normal movements for any given individual. All of our staff have been through fit testing prior to return to work by Dakatra in compliance with Health and Safety Executive guidance found here:

• • https://www.hse.gov.uk/respiratory-protective-equipment/fit-testing-basics.htm

• • https://www.hse.gov.uk/pubns/indg479.htm

Important statement:

• At the time of writing there is a global shortage of reputable, CE-marked and quality-checked FFP3 respirators. Recognised high standard FFP3 respirators by companies such as 3M or Uvex are simply unobtainable in adequate quantities to most small practices due to all reputable suppliers being out of stock until well into the autumn.

• Governments, larger health organisations and large buying groups have tied up most stock with bulk order purchases primarily for the National Health Service but to which the private dental sector in the UK has extremely limited access.

• Whilst our regulators have indicated that dental practices can open with “suitable” or “appropriate” PPE in the form of respirators, they are fully aware that this will not be possible for the vast majority of both private and NHS dental practices who will require substantial stocks of consistent quality fit-tested FFP2 and FFP3 respirators.

Current recommended PPE for primary dental care

• The current Recommended Personal Protective Equipment for primary, outpatient, community and social care by setting, NHS and independent sector in the UK endorsed by Public Health England, The Academy of Medical Royal Colleges, Public Health Wales, Health Protection Scotland, Public Health Agency and the National Health Service is given in the table below (please click image for hyperlink to full PDF document).

• It is our view that it is impossible to know whether any of our patients or indeed staff are infected with coronavirus. Whilst we will go through a screening procedure as detailed below for both staff and patients before they commence work and attend the practice, it is entirely possible that anyone can become infected with coronavirus on the way to the practice or in the 72 hours prior to attending after having completed their updated medical and dental questionnaire.

• It is therefore our policy at RDC that all patients are treated as being possibly infected and all procedures regarded as aerosol generating, though to different degrees. This is supported by the recent document by the British Association of Oral and Maxillofacial Surgeons.

• This means that the following PPE will be used for all operative dentistry procedures:

• • Single-use disposable gloves
  • Single-use disposable fluid repellent coverall or gown (or high-temperature washable equivalent)
  • A filtering face piece respirator conforming to fit-tested FFP2 or FFP3 for all operative dentistry.

• Whilst there are multiple references that dental aerosol does contain microorganisms from the oral cavity, that there is no evidence in the literature that general dental aerosol has resulted in the infection of dental healthcare workers or their patients in any centre or with any disease. Were dental aerosols a significant transmitter of airborne pathogens, this would surely have come to light. The paucity and almost lack of publications in the extensive dental and medical literature on the subject suggests that whilst it is theoretically a high risk activity, dental aerosol does not in fact appear to be a significant source of bacterial or viral cross infection when one considers the millions of aerosol producing dental procedures that are carried out every year in this country let alone the rest of the world.

• In summary, it is our professional opinion that the aerosol generated in dental practice through dental operative procedures is formed mainly of treated water containing potent virucidal components such as hypochlorous acid (HOCl) or other proprietary antibacterial and antiviral chemicals placed to protect dental water lines from bacterial and viral contamination. The aerosol produced from the patient’s mouth during dental operative procedures is therefore substantially diluted and formed mainly of clean water with a virucidal activity and is not, in our opinion from the paucity of evidence over many years, a major risk or source of cross infection of infective agents between patients and dental healthcare professionals.

• The bacterial load carried by the aerosol created during dental procedures is also substantially reduced by preoperative mouth rinses, gargles and nasal sprays and the use of dental dam which is already part of our routine as seen below. Thus, we feel that the risk of transmission by dental aerosols in dental practices is the same or even less than the risk outside the surgery, despite the fact that bacteria and viruses are still detectable within these aerosols.

Staff Requirements

• Despite the above viewpoint, it is in the interest of all of our staff and patients and our profession that everyone attending RDC is kept as safe as possible with a belt and braces approach.

• All staff at RDC are required to wear personal protective equipment depending on the environment in which they work and the procedures that they are expected to carry out.

• This list is modified from our normal procedures and should be adopted upon reopening of RDC on 8th June as planned. It is based on the document COVID 19: guidance and standing operating procedure – Delay phase 18 May 2020

All staff should comply with the recommendations under item 4.4 upon arrival at the practice.

• Back office staff – (Practice manager Jenny Corrigan).
  • The staff are unlikely to have direct contact with patients to the practice. Where they need to have direct contact with patients or third parties attending the practice then they should adopt the same protocols as front office staff below.
    • Polycotton scrubs or similar machine washable practice attire to be worn only within the practice.
    • Normal surgical face masks to be worn in common areas where social distancing is not possible. No mask is required if alone in a room or if social distancing is possible within the same room as a colleague.

• Front office staff – receptionist.
  • No reception services available during threat levels 3,4,5. All admin work will be undertaken from the back office. Once we enter threat level 2 or 1, reception services will resume.
  • RDC polycotton scrubs or similar machine washable practice attire to be worn only within the practice.
  • Normal surgical face masks to be worn in common areas where social distancing is not possible, changed at least every hour. A mask is still required even if social distancing is possible within the same room as a or patient.

• Patient greeting and escort/ runner nurse. (Alice Elbourn)
  • This nurse will be responsible for greeting of patients that arrive at the practice, going through patient arrival protocols and escorting the patient to the appropriate surgery directly upon arrival at the practice.
  • This nurse will also be responsible for disinfecting common areas after passage of patients to and from the surgeries. This nurse should not enter operative areas and should be the only nurse wearing full protective gear in common areas.
  • PPE may be removed and placed in a dedicated lidded container when there are likely to be extended periods of time between patient arrival and departure to the practice. This practice member will be responsible for providing enough time to re-don PPE in time for patient departure or patient arrival at the practice. Further details are listed under item 7 below.
  • RDC polycotton scrubs, protective water-resistant gown, FFP2 mask, visor, nitrile gloves, hairnet.

• Clinical staff including dental surgeons, hygienist/therapist and assisting dental nurses within the surgeries.
  • RDC polycotton scrubs, protective water-resistant gown, single use FFP2 or fitted FFP3 masks depending on procedure (see below), multiple use disinfectable safety goggles or spectacles (normal loupes for clinical operators), multiple use disinfectable or disposable visor, nitrile or latex single-use disposable gloves, single use hairnet or surgeon hat depending on hair length.

Donning and removal of PPE training for staff at RDC 

• As a clinic that regularly carries out surgical procedures, all of our clinical staff are trained and proficient in sterile gown and draping as it is a daily activity within the practice.

• Putting on and removing (donning and doffing) of personal protective equipment so that contaminated surfaces are contained within removed gloves, gowns, hoods and disposable visors immediately prior to disposal in clinical waste bags for incineration and good hand hygiene before and after this process is already part and parcel of our daily work.

• However, additional training has also been received during fit testing of our FFP3 respirators to revise the procedure to ensure that contaminated surfaces are not allowed to come into contact with clean surfaces or be the source of cross infection following patient procedures.

• We will be following the following guidelines:

• • NHS / Public Health England / Health and Safety Executive

• • Prepare and protect – putting on (donning) and removing (doffing) personal protective equipment (PPE)
  • Putting on (donning) of PPE
  • Removal (doffing) of PPE

• Upon reopening, RDC will be responsible for prioritising patient attendances at RDC based on infectionrisk versus clinical need. We will prioritise patients who require urgent attention or who were undergoing current treatment phases abandoned after 23rd March and where further delay may result in significant deterioration of their dental

• We would ask patients with non-urgent problems or requiring check-up appointments to please bepatient and await appointments towards the end of the

• The most effective way of reducing risk of cross infection between individuals attending RDC is to assessrelative risks and recent past experience and ensure those attending RDC are low

• All of our staff will be asked to complete a COVID-19 return to work questionnaire which will also confirm that they have read, understood and agree to abide by this RDC Standard Operating Procedure (SOP) and Risk Reduction Recommendations (RRR) dated 1st June as well as asking for their recent experience and exposure to potential infection.

5.1. Patient risk groups.

• The NHS has provided a list of patients who are at high risk (clinically extremely vulnerable) and atmoderate risk (clinically vulnerable) of COVID-19 and potential Please refer to this list to assess ifyou are at risk and try to defer your dental appointment until the end of the summer if your dental conditiondoes not require immediate attention.

• For patients who are in one of these risk groups but still require urgent dental attention please do contact the practice and we will make arrangements to alleviate your emergency in the safest possible

5.2  Medical and Dental Questionnaire (MDQ) completion

• All patients to RDC are already asked to complete a comprehensive medical and dental questionnaire. You will receive a link to complete this online via Text. This questionnaire must be updated every time the patient attends   Our current  system  now  allows  the  existing  form  data  to  be recalled and edited onlywhere circumstances have changed rather than having to re-complete the entire form each time. We knowthat this will be a relief for all of our patients who hate filling in forms every time they attend.

• We have added a further section on assessment of COVID-19  We must respectfully insist that this is carried out without fail.

• Please note that we reserve the right to decline to book appointments or to postpone appointments ifthe fully completed questionnaires are not returned in time or we feel that  you  are  at  high  risk  of  having been  exposed  to  coronavirus in  the  last  2  to 3

• Our practice manager Jenny Corrigan will guide you through the questionnaire by telephone or Zoom video meeting if you have

• Please note that we are going through extra efforts to screen every patient to protect the staff, clinicians and patients we are treating. We thank you for your patience and cooperation in filling these forms.

5.3.  Individual patient screening / risk assessment and prioritisation of patients 

• Upon receipt of a patient’s completed or updated MDQ, the clinician involved with their  care  will  make  an assessment  of  COVID-19  risk  versus  dental  needs  priority and advise reception and patient coordination as to thelevel of risk and

• Patients will  be classed as  high,  medium or low  COVID-19  risk  or  as  already having been infected and recovered pending proof of documentation. A copy of such documentation should be emailed to [email protected] for  your  

• Patients will then be classed as high, medium or low priority in terms of the requirement for theirimmediate dental

• The clinician will then make an assessment of the balance between these two risks to prioritise available appointments. For example, a low Covid-19 risk patient with a high dental priority will receive and appointment before a high Covid-19 risk patient with medium dental priority.

• Patients with high or medium COVID-19 risk will normally be asked to self-isolate and refrain fromattending the practice for at least three weeks before they are asked to update and resubmit their questionnaire prior to requesting a new dental appointment.

• Patient bookings will be made into the diary based on a new staggered diary control system to reduce contact between patients arriving and leaving the practice and allow for longer periods between

• Where possible we will be seeing reduced number of patients per session per surgery for dental treatmentor a maximum of three patients per session for dental hygiene and minimal aerosol generating

• We will also be operating only 2 out of the 4 surgeries at any point and swapping clinicians between rooms to allow for sufficient fallow times between procedures.

5.4. Patient communication/ phone or video contact / patient consent

• The processes for patient communication, consultation,  reporting  and  consent will continue as normal. Further information can be found on our website royston-dental-care.co.uk.

• It is likely that we will make more use of video consultations, especially to answer patient questions or go overtreatment reports and phases of treatment which we would normally do face-to-face at the Ourpractice manager Jenny Corrigan will arrange for Zoom or telephone meetings where required.

5.5. Diary management and changes to scheduling

The following changes will be introduced into the diary management system for RDC from 8^Th June 2020 which will be our first “soft opening” day after lockdown:

• The diaries for the surgeries will commence with 15 minutes staggered start times at the beginning of the appointment. This is to ensure that patients arriving for dental appointments can be greeted in isolation without other patients also being present.

• All minimally aerosol generating procedures as listed below will have an additional 15 minutes buffer period introduced after the appointment. This will cover the following procedures and there will be no charge for this additional 15 minutes of time:
  • Dental consultations and examinations
  • Removal of sutures
  • Fitting of removable dental appliances such as whitening trays, occlusal deprogramming devices and fitting of dentures
  • Fitting of orthodontic appliances and routine orthodontic adjustments

• All other procedures including hygiene visits and all operative dental procedures will have an additional 60 minutes buffer period introduced after the appointment.

• Whilst we will not be charging additional fees for the donning and doffing times, RDC will need to introduce a surcharge for the PPE that we need to invest in for the safety of our patients and staff. The table below outlines the additional charges, per visit. We will encourage, where possible, to have longer appointments to have treatments done in one visit to reduce the number of surcharges you will incur.

5.6. Appointment bookings and treatment slots

• RDC is already a practice whose protocols are based on efficient full mouth dental care. Rather than seeing multiple patients per day for short procedures, we tend to have longer half day or full day appointments to maximise efficiency and control of the cases we treat.

• Therefore, for patients requiring multiple procedures, we will strongly recommend that longer appointments to get multiple procedures completed as far as is possible be prioritised. This is not a great change from what we normally do.

• Our receptionist Alice Elbourn and practice manager Jenny Corrigan will inform you of the available treatment times required for your particular case and we would be most grateful if you could follow their lead and allow them to arrange your appointments as most appropriate for your case at the times they recommend. Your flexibility on this subject to allow RDC to maintain social distancing between patients and keep a tight control of diary times will be most appreciated.

5.7. Changes to payment methods

• RDC already works by a system where each treatment phase with our specialist dentists is paid in advance. This will not change and will continue as normal.

• Payments for routine appointments like exam, hygiene visits, fillings, crowns, etc were collected on the day of the appointment after your appointment has finished. We shall now start collecting the fees for these appointments in advance.

• Appointments that are normally paid at the front desk on the day of the appointment such as for hygiene visits, examination appointments and occasional treatment will need to be paid in advance when the appointment is booked and no later than three days prior to the appointment at the same time as submission of the patient is completed or updated Medical and Dental Questionnaire.

• We would be grateful for your cooperation in ensuring that all fees are paid in advance prior to attending for your appointment. This is to reduce the need for use of payment terminals and prolonged time spent at reception before or after your appointment.

• Please note that our normal terms and conditions continue to apply.

• We should be most grateful to all of our patients to consider the following points before coming for your appointment. Please note that all of these are measures taken to minimise the risks of transmission at RDC as far as possible. They are logical precautions and should not worry you unduly in their stringency.

6.1. Preparations by patients 

Three days before your appointment

• Please ensure that your Medical and Dental Questionnaire, Covid-19 risk assessment and consent forms are completed at least three full working days prior to your appointment. Please be sure to indicate if you feel that you are at any risk of having been exposed to a patient with COVID-19 in the last three weeks.

• You will be contacted and reminded to submit the paperwork above for your visit prior to arrival.

• You must also inform us if any of the information you submitted changed prior to your arrival.

On the day of your appointment

• Please let us know immediately on 01763247533 or via email if you have developed any symptoms or have come into contact with anybody that may have COVID-19 in the 72 hours since completing your medical and dental questionnaire or if you feel in any way unwell.

• Please shower and wear clean, light and easily washable clothing that has not been worn elsewhere. We will recommend that this clothing is washed immediately after you get home.

• You should arrange to go directly home from the practice and not visit anyone.

• Please do not wear heavy make-up or jewellery. Small stud earrings and a wedding band are acceptable.

• Please tie your hair back if you have long hair.

• Please ensure that you have thoroughly brushed your teeth as normal before attending and that your mouth is as clean as possible.

• Please minimise what you bring to the practice – for example shopping bags.These will not be allowed into clinical areas and you will be asked to leave all belongings at reception.  As no patients will be allowed in the waiting room the receptionist on duty will over look all personal belongings however no responsibility can be taken by Royston Dental Care for lost, damaged or stolen belongings.  The practice has a CCTV in place.

• Please be well hydrated but do not over-drink water or fluids. We will have decommissioned our normal water cooler and removed it from the waiting room.

• Please visit the bathroom before you set out as the WC facilities at RDC will not be available for use.

6.2. Transport

• We strongly recommend reducing the risk of COVID-19 infection by avoiding public transport wherever possible. If you are obliged to use public transport, please find the best rated mask that you are able to get hold of and wear at all times from leaving home until arriving at the practice. Try to maintain social distancing of at least 2m at all times. We appreciate that this may not be easy or indeed possible.

• If possible, please drive to the practice in your own vehicle and park at the Warren Car park, SG8 9EG.

• If it is not possible for you to drive in your own vehicle then please ask someone with whom you have been isolated to drive you and pick you up afterwards.

• If this is not possible then we would recommend taking a taxi from a which has installed a Perspex shield or similar between the passenger and driver compartments. We would recommend booking the same driver to return home at the end of your appointment if possible, to reduce the number of people to whom you are exposed travelling to and from the practice.

• It is of course possible to cycle, walk or use an electric scooter or similar to arrive at the practice. We would be happy to provide you with space to park your bicycle or electric scooter at the courtyard of the practice. Our staff will direct you as to where to go if you wish to leave your bicycle or electric scooter. Please inform them that this is how you will be arriving at the practice and they will be ready for you. Please be aware that RDC will not take any responsibility for theft, damage to your bicycle or electric motor while is parked on our premises. Please lock the bicycle/scooter/bike safely using your own locks.

6.3.  Accompanying patient escorts

• If you are being accompanied by an escort, partner or carer, please be aware that they will not be permitted to wait at the practice and should be prepared to drop you off at the door and return to accompany you at the end of your appointment time. Please inform our receptionist and patient manager if you will be arriving at the practice with an accompanying person.

Children (unless they are patients and are attending for an appointment) and pets should under no circumstancesshould be brought to the practice and should be left with suitable carers. We regret that we are unable to accommodate or look after children or pets especially in the current circumstances.

It is our objective that by staggering diary start times and allowing buffer time between appointments, we will minimise the chances of patients coming into close proximity with other patients at the practice and hopefully eliminate this altogether.

7.1.  Procedures prior to entering the practice

We have started the following protocols for patients arriving at the practice:

• Please complete any telephone calls that you need to make before entering the practice and switch off your mobile phone and put it safely in your bag or pocket before you ring the practice bell. You will not be permitted to take your mobile phone into the surgery.

• We will ask you to remain outside the practice until it is time for your appointment. Please only arrive five minutes before your appointment is due. Please bring an umbrella in case it is raining. If we are running late, our reception will call you on your mobile when we are ready for you. 

• After you ring the practice doorbell and are allowed in you will be met at the entrance by one of our infection control nurses. They will be in full PPE so please do not be surprised.

7.2. Procedures upon entering the practice and personal property

• Your temperature will be taken using a remote contactless temperature sensor. If your temperature is above 37.5°C over three consecutive attempts, you will not be permitted to enter the building and we will request that you rebook your appointment for at least three weeks later.

• You will be asked again verbally to confirm that there are no changes to your COVID-19 status since completing your medical and dental questionnaire three days before. If your temperature is below 37.5°C and you have not exhibited any of the symptoms associated with coronavirus infection in the last three days, you will be admitted for your appointment.

• If you have an elevated temperature or have developed one or more of the COVID 19 symptoms on our medical and dental questionnaire (MDQ) we would strongly recommend that you self-isolate and inform those around you that you may have COVID-19. Please let your GP know and click on the link here to initiate a test and trace.

• You will be asked to put all your personal belongings including your switched off mobile phone into a disinfected, clear, lidded plastic box which will be stored safely in a clear sealed bag until the end of your appointment. RDC will not be responsible for any damage, theft to your personal property.

• If an escort is due to pick you up at the end of your appointment, please let reception know their mobile number and we will call them near to the end of your appointment for them to be ready to collect you.

• You will be given hand sanitiser to rub into your hands for at least 30 seconds.

• Our meet and greet nurse will accompany you to the dental surgery directly without stopping in the waiting room and hand you over to your dental surgeon and his or her nurse in the surgery.

• You will then be ready to commence normal dental appointment as arranged.

7.3. Procedures before leaving the practice

At the end of your appointment, we would like you to be able to leave the practice directly without having to visit reception.

• If someone is due to pick you up, we will give reception notice to call them in good time to be able to arrive at the practice towards the end of your appointment. They will not be permitted to enter the practice but should arrange to meet you outside the front door at the allotted time.

• Your belongings can be collected from the plastic box which will be ready for you at the entrance to reception on your way out of the practice. This box will then be thoroughly disinfected ready for the next patient 30 minutes later.

7.4. Follow up contacts

• Reception will give you your usual TLC follow-up call either later the same day or the following day as we normally do after operative procedures.

• Where required, further appointments can then be arranged via telephone or email.

• Please note that the same process starting with the updating of your medical and dental questionnaire will repeat for your next appointment and all of the steps above will apply for your next appointment as well.

• RDC already has strict dental surgery and operatory protocols as part of its day-today functioning. These will continue as normal.

• However, in addition we will be introducing the following protocols whilst the Covid-19 pandemic is still at significant levels in the UK.

8.1. Aerosol generating procedures (AGP)s

• RDC would reiterate that we regard all patient contact generates some level of droplet or aerosol production.

• Our normal dental suction removes over 90% of aerosol generated during dental procedures.

• If patients and staff are at lower risk of exposure to SARS-CoV-2 based on pre-attendance questionnaires and maintenance of social distancing and self-monitoring, we maintain that there is scant evidence to suggest that aerosol generated by dental instrumentation in any way increase the risk of viral transmission. The references given at the end of this Standard Operating Procedure document referred to potential risk of aerosol- borne infection from dental procedures but have documented no such confirmed case.

• However, to mitigate any potential risk we will have adopted at least FFP2 and wherever possible FFP3 fit tested masks as well as face visors, hair nets and protective waterproof gowns plus eye protection as normal.

• It should be remembered that most of the aerosol produced by dental instrumentation will be virucidal and have a diluting effect on droplets and on any aerosol from the patient. This will include 10% hydrogen peroxide-based (H2O2) and hypochlorous acid (HOCl)-based solutions which are safe for ingestion but are potently virucidal.

• Air-conditioning units will operate minimally and have recently been serviced. There is no evidence to suggest that well-maintained air conditioning units harbour or transmit the virus. However, airborne transmission does seem to be associated with areas of greater presence of particles in the air such as in polluted or smoggy atmosphere.

• Immediately after each operative procedure, the surgery will be vacated and the door of the surgery closed for at least 30 minutes. We have called this the aerosol settling period. All airborne aerosol droplets should then have hit the floor.

8.2. Operatory preparation protocols 

• Normal surgery preparation at the start of each day and at the end of each session will continue as normal as per our established protocols based on HTM 01-05 protocols and standard protocols for running through and disinfection of dental water lines.

• All non-essential items have been removed from the surgeries and placed into cupboards or into storage.

• All treatment is planned well in advance and any laboratory work that has been received from the laboratory will have been processed as under item 10 below.

• All items to be used for a procedure should be prepared in advance on the worktop to avoid having to open drawers or cupboards during operative procedures.

• All computers and other equipment that cannot be removed should be covered with disinfected or disposable covers such as polythene for items such as the operating microscope and disposable clingfilm for computers and photographic and video cameras. 

• The operatory nurse should not leave the surgery during treatment and should, similarly to the patient, be well hydrated and have visited the bathroom prior to donning PPE for that session.

• Nobody should enter the surgery where patient treatment is continuing without donning suitable PPE even if it is for only a very short period of time. Similarly, the PPE should be removed upon exiting the surgery. All nurses and clinicians should ensure that they have everything they need and should not need to enter another surgery during a procedure.

8.3. Clinical protocols 

• Following a full clinical assessment, we will be classifying procedures into non-AGPs and AGPs. Risk stratification for aerosol generating procedures was published by the FGDP, adapted by RD-UK, as follows:

• The following points should be considered when treating patients:
  • Rubber dam should be used for all restorative operative procedures as normal. This is already something that is carried out at RDC as routine.
  • The spittoon tap should be turned on prior to patients rinsing to reduce the amount of droplet or aerosol deflected from the spittoon. The number of times a patient needs to rinse should be minimised to reduce droplets and spatter. We do not feel it is realistic to stop patients rinsing entirely but they should be made aware of the need to minimise this activity.
  • High-volume suction with or without additional saliva ejector should be used for all procedures including use of piezon/cavitron.
  • Water flow to the piezon/cavitron and handpieces should not be reduced in an attempt to reduce aerosol. This would have the following effects:
    • reduction in virucidal and bactericidal dilution
    • greater tendency for overheating and therefore patient discomfort or even pulpal damage when drilling
    • reduction in efficiency of cleaning or drilling which prolongs the procedure and therefore the exposure time.
    • It is therefore advised that coolant water is turned up to its full extent as we would normally do.

• Excellent airway protection to reduce the chances of patients coughing or sneezing during the procedure should be insured as always.

• As soon as the patient has completed treatment, the assisting nurse should guide the patient through how to doff their PPE at the exit to the surgery and wash and disinfect their hands. The patients PPE should be gathered outside in by the assisting nurse and placed into the clinical waste bin.

• The assistant nurse should maintain all of their current PPE and remain in the surgery for the moment but distant from the patient once the patient’s PPE has been removed. 

• The dental surgeon should remove their gloves only and also wash and disinfect their hands remembering that the remainder of their PPE remains contaminated.

• The patient should leave the surgery into the outside corridor some distance from the surgery door wearing only their normal street clothes.

• The dental surgeon should exit the surgery closing the door behind him or her and immediately doff all personal protective equipment into a clinical waste container that will be positioned outside the surgery door for the end of the treatment session by the runner/greeting nurse.

• They should handover the patient to the infection control nurse to escort the patient towards the exit whilst maintaining social distance of 2m. 

• The infection control nurse should prepare the patient’s personal belongings box and open the lid and step back so that they are 2 m away.

• The patient can then remove their personal belongings from the clear bag and put them on in the area of the entrance hall. They are then free to leave the practice.

• The runner/greeting nurse should then wipe down the exit door handle inside and outside the front door and also the entry phone button by the front door. The wipes and disposable gloves should be immediately disposed in clinical waste.

• In the meantime, the surgery nurse should also have removed her gloves and thoroughly washed and disinfected her hands.

• An aerosol settling period of at least 60 minutes should then be allowed with the surgery door closed whilst the nurse has a break outside the surgery or carries out any duties in the sterilising room. A “no entry” sign on the door should be placed to indicate that this is now a no entry zone and a clock with a 60-minute alarm set on the door to indicate how much time has elapsed (10 minutes for minimal AGP procedures). It should be remembered that this 60 minute is in addition to any time elapsed from the last aerosol generating dental activity ceasing during the treatment session, during which time aerosol and particle settling will have already started.

• The dental surgeon should then use this time to write up contemporaneous notes, right up lab dockets, check emails, optimise name and tag photographs from the previous session or day and carry out all the administrative tasks required by standard RDC protocols. This is still regarded as an integral part of the patient’s appointment.

• After each treatment session, the surgery nurse will then re-enter the operatory 10 minutes before the next patient is due. They will don new PPE plus plastic apron and heavy duty gloves and wipe down all surfaces using regular proprietary antimicrobial cleaning solution and wipes, changing and replenishing as required, starting at high level and working downwards to include the following in order.

• • All clinical items to be decontaminated and sterilised to be placed into a lidded lockable box normally stored in the sterilisation room and brought to the surgery by the runner/patient greeting nurse at the end of the session.
  • Any small items or material containers or equipment to be put away at the end of the procedure (e.g. Implant motor, endodontic motor, dental loupes etc) removing all clingfilm on items such as computers and cameras with the contaminated surface being collected inwards and the clingfilm discarded into clinical waste.
  • Light, camera and light arm on the dental chair
  • Dental chair bracket table and arm
  • Handpiece motors and cabling
  • Nurses station and spittoon
  • Dental chair and base and foot pedals
  • Clinician and dental nurse tools
  • Wall cabinet façades and handles, work surfaces and base cabinet façades and handles
  • Wall mounted x-ray
  • Alcohol and soap dispensers
  • Paper towel dispenser
  • Sharps bin surface taking care that no sharps project out of the bin
  • Computers and mice ensuring no excess fluid gets under the keys onto the screen and PC speakers
  • Trios scanner
  • Taps and hand wash basins
  • Light switches and x-ray machine switches
  • Door handle (inside and on other side of door facing outwards)
  • Floor
• Discard all cleaning items and solutions as clinical waste

• Doff all PPE at the end of the cleaning session into clinical waste

• Carry out full hand hygiene prior to the next procedure

• Plug-in clinical camera to upload photographs from the surgery to the clinician’s folder.

Sterilising room procedure

• No changes should be required to normal HTM 01-05 protocols apart from the following considerations. The cat sat on the mat (this is just a test sentence to check whether people have read through the entire document – if they do not spot this then they will be made to re-read it under supervision).

Outgoing work

• All laboratory work due to go to the laboratory should be placed on and covered by a disposable bib/surface cover for the duration of the aerosol settling and air purification period (ASAPP). Alginate should not be used and instead substituted with silicone based impression materials.

• The lab work should be left away from direct sunlight so that they are not distorted and are not warped.

• The nurse entering the room with clean PPE to decontaminate the room after the aerosol settling period should then immerse laboratory work into the decontamination solution for the 10 minutes it takes to wipe down the surgery. A timer should be set as normal (timers should be being stored within a cupboard rather than on the side).

• Laboratory work can then be rinsed, dried, wrapped and boxed normally using new gloves and bags and boxes stored away from aerosol within the cupboards after surgery decontamination has been completed.

• A sticker to indicate decontamination of contents has been completed should be stuck to the packaging.

Incoming work

• Standard procedures apply for incoming work which is steam cleaned and disinfected in the laboratory and then re-disinfected prior to fitting in the clinical environment. No changes to protocols are required other than those for packages being received as below under item 11.

Cleaning services 

• Cleaning services should continue as normal. A minimum of one hour should elapse between the last patient being completed and the cleaner attending the practice to allow for ASAPP after all staff have left the practice.

• All clinical areas down to floor level will have been decontaminated by the assisting nurse in the surgeries.

• The colour-coded mops for clinical and non-clincal areas will remain and the efficacy of the floor cleaning solutions in being virucidal should be verified.

• Cleaning staff should be trained to be knowledgeable about the virus and wear masks while wiping the floors and carrying out cleaning of the common areas.

• They should be trained to minimise droplet and spatter when mopping clinical areas to reduce the risk of viable viral droplets being re-distributed around the surgery.

11.1. Handling of packages to the practice 

• Delivery men including the postman should not enter the practice but leave all items just inside the front door on the main mat. The outside of the door and the door buzzer and grill should always be regarded as contaminated and outside the practice.

• It should be remembered that coronavirus can survive for up to a day on cardboard and paper and therefore all packaging coming to the practice should be regarded as being potentially contaminated.

• The runner/greeting nurse should undertake opening of all letters and boxes whilst wearing a fit tested mask, protective gown and gloves as well as eye protection. When the boxes are opened the contents should be removed by a second nurse also wearing PPE and with alcohol wipes to disinfect or items that can be wiped down.

• Paper or cardboard boxed items that cannot be read wiped down without causing damp damage to the box or wiping of surface ink due to the alcohol content should be transferred to a decontaminated really useful box and left for at least 24 hours for the virus to die before the items are removed from the box and distributed to their storage places in the practice.

• The runner/greeting nurse who first opened the delivery boxes or envelopes should place them into a recycling bag the back should then be sealed, the outside surface sprayed with hypochlorous vapour or alcohol wiped at the end of each day and left for the cleaner to dispose of.

11.2. Information pack for third-party contractors attending the practice

• A copy of this standard operating procedure and risk reduction recommendations document will be available on the website and can be forwarded to any party working with RDC upon request

11.3. Feedback mechanism for third party contractors

• Any third-party contractor concerns or comments should be directed to the Practice Manager Jenny Corrigan at [email protected] We will endeavour to respond to them within 24 hours.

• At all times, we will be undergoing staff training and updating the SOP and RRR document as we receive further advice and guidance from our governing bodies
• The following points will also be reviewed on a daily and weekly basis by the clinical directors and practice manager.
  • Risk assessments for all staff and patients
  • Identify members of staff to fulfil specific duties in line with the demands of the practice
  • Health and wellbeing lead of staff and patients
  • Facilities will be prepared to support social distancing with appropriate signage and demarcation
  • Risk assessment of staff prior to recommencement of work on a daily basis.
  • Ensure there is appropriate training in place, including medical emergencies
  • Stock control reviewed and ensure appropriate PPE available