Practice Risk Assessment For Covid-19

This assessment has been prepared by David Guppy BDS MSc MRD RCS (Lon). It has been circulated to all clinical staff for comment and any necessary update. It will be reviewed on a monthly basis or when any major announcement is made by professional bodies or regulators.

Individual risk assessment must take place by the clinician in respect of any procedure that might be carried out on that individual.

All members of staff will receive a copy in advance of return to work. Copy will be posted on our website and is available to the public. Patients who plan to attend the practice will be directed to this and it will form one layer of consent prior to them entering our premises.

Context

In Wales practices were asked to close by the Chief Dental Officer (CDO) on March 24th 2020 as part of wider measures known as lockdown with the intention of slowing down transmission and thereby relieving pressure on critical care in hospital.This is known as the RED phase.

The advice was further updated by the CDO on May 21st 2020.

Our practice is closed but has responded to emergencies as advised by the CDO of Wales. This advice has not materially changed and we continue to deal with dental emergencies with the AAA (Advice, Analgesia, Anti biotics) strategy. Onward referral to Urgent  Dental Care (UDC) has not been necessary.

Her current advice which as yet has not been franked for private practice by the Health Inspectorate of Wales (HIW) still precludes the use of Aerosol Generating Procedure (AGP) outside of the UDC.

It is my view that this is no longer sustainable or advisable. As a private practice we have been happy to follow the guidance of the CDO, Public Health Wales and HIW but we now feel the dental needs of our patients warrant a different approach. I state this opinion as part of this assessment and it is informed by the limited amount of peer reviewed science, best practice protocols and review of measures being taken in other parts of Europe who would have comparable standards of health care.

We now have a cohort of patients in pain and another with incomplete treatment.
These patients need to be stabilized as far as possible avoiding AGP but not precluding that intervention with the appropriate Personal Protection Equipment (PPE) in place.

Specifically we have patients within our practice who have unrestored teeth and implants which we believe cannot be asked to tolerate further delay or temporization as this will endanger their dental health generating the possibility of further  unwarranted intervention that we are trying to avoid. Other patients in the midst of orthodontic or endodontic treatment will be evaluated and where we feel further delay will be damaging they can also be seen at the discretion of the dentist treating them.

We will not carry out any elective procedures, routine dentistry or invite any referral for such. We will carry out remote or virtual consultation where required.

Initially no hygiene procedures will be carried out.

We aim to re-open for appropriate and abbreviated treatment from June 8th 2020.

In formulating this risk assessment we have acknowledged the views of Chief Dental Officer of Wales, HIW and the General Dental Council. We have also taken a view from literature produced by the British Association of Private Dentistry and the British Dental Association. Verbal soundings have also been taken from Dental Defense Union.

We will briefly reference these resources and update as necessary.

This assessment supplements but does not replace  all other documentation that has been put in place to satisfy the requirements of HIW. The practice was last inspected 2016.

We identify three main areas of risk.

a) Close physical contact within 2 metres of clinicians, DCP and the patient that might provoke casual transmission.

b) Risk of contact with droplets via surface contamination and transmission via AGP.

c) A transmission cluster emanating from a dental practice.

We recognize that the level of risk at any time or setting is calibrated against the number of cases, rate of transmission, morbidity or mortality of Covid-19 within the community at large. This is referenced in public.tableau.com. Due to the nature of triage we are likely to encounter individuals who asymptotic and is not clear how strong transmission is among these patients.

We see the direction of risk as follows.

  1. Staff members are aware of the risks of Covid 19. They are at risk of infection casually from other staff members, patients and other members of the public. The nature of their work places them at heightened risk. The additional but as yet unproven effectson pregnancy have been further explained and acknowledgedby two staff members who are 15 and 20 weeks pregnant. We have directedall staffto theOffice of National Statistics (ONS) survey that shows that dental workers are at greater potential riskof transmission. A supplementary study by the same group shows that transmission and infection amongst the same workers is the same as the general population. We invite all staff to approach their own professional bodies independently to acquaint themselves fully with the risks that pertain specifically to them. So farand in response to their concerns we have made the following assurances

    Staff training to review updated Standard Operating Procedures (SOP)will take place prior to re-opening and they have received assurance that we have sufficient and sustainable stock of PPE. We have informed that they must constantly monitor their own health status and we have made them aware of where and how to get tested.

  2. Entry of patients or any other members of the public who enter the practice represent a risk of transmission to staff or other patients. They are at risk themselves from the same vector in the opposite direction. The nature of patient, clinician and nurse interaction places them all at heightened risk. There is a risk that AGP might be a significant vector of transmission.

    Certain members of the public are deemed to be at greater risk to the consequences of infection with Covid 19 and have been asked to self-isolate. This is a group of patients whose clinical dental needs are high. Whilst the chanceof contractingCovid 19 is the same the morbidity factor puts patients in this group at higher risk and we discourage attendance.

  3. It is possible that any infection acquired at our practice could be spread further by clinical staff or patients. Testing and contact tracing is not yet in place and this in itself is a greater risk and one over which we have no control. At this point we include some mitigation that will be expanded upon in our SOP docs.

    We will make it clear to patients that should they develop symptoms they must inform us immediately as our appointment book data will show any contacts generated by that visit to us. Staff members who encountered that individual will be asked to test. To redouble that effort we will commit to contacting patients who have been through the practice 14 days post treatment to confirm their wellbeing as there is risk that they would not associate transmission with a visit to the dentist. The Government anticipates that the contact tracing will be in place by the end of June. We will attempt to make sure that our patient’s understand that uptake of this technology is essential.

Additional Risks

We do not believe that use of FFP3 masks will be useful to us in the long term though these are currently in use for active treatment in the UDC. They can only be worn for limited periods of time and require a complicated fitting procedure.We will attempt to have a member of staff enrolled on the fit testing course as soon as practicable possible and commit to their professional standards.

We are concerned with the valves which blow expired air out in the direction of the mask which we feel are a major risk of transmission. Repeated donning and doffing of the above also represents risk in our view.

We will be using the existing surgical masks and FPP2 in combination with barriers and you will be trained when and how to use these.This is in line with advice from the Health and Safety Executive.

Supply issues are a worldwide issue and this has the potential to undermine our best efforts to mitigate risk.

Mental Health

We support mental health in the workplace. We recognize that the issues around Covid 19 will place individuals at greater risk.

BAME, Vulnerable and Pregnant Staff

We acknowledge additional risks to these groups and will adapt SOP appropriately.

Resuscitation/Cardiac Arrest

We have to assume that should this medical emergency arise that the patient before us is asymptomatic Covid 19

References

Resucitation Council UK V1. 11/05/2020

www.ons.gov.uk/causesofdeathhiw.org.uk/coronavirus-covid-19statementgdc-uk.org/information-stanards-guidance/covid

HTM 01-05 (DH) 2013

hse.gov.uk/respiratory-protective-equipment

Wales de-escalation plan for dentistry 21/05/2020

www.guysandstthomas.nhs.uk/occupational-health pdf