- Between 23rd March 2020 and 2nd June 2020, the entire practice was cleaned and all water lines were disinfected on a weekly basis.
- On Friday 5th 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
- 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- These procedures, already second nature to our team, will continue to be used until superseded by any modifications that may come into force following the pandemic.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.
- 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
- 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 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:
- 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.
- 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