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Novel coronavirus (COVID-19) standard operating procedure Urgent Dental Care (East Midlands)
This guidance was written at pace on 2nd April, 2020 to support the quick mobilisation of urgent dental care sites across the East
Midlands and is subject to change.Do not print hard copies but keep live links to the document to
ensure that the information you are receiving is as up-to-date as possible.
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Contents1. Background.........................................................................................32. Generic principles for the urgent dental care system.................53. Standard Operating Procedure for Tier 1 Urgent Dental Care
remote triage and referral by primary dental care......................64. Standard Operating Procedure for Tier 2 Urgent Dental Care
remote triage and referral by a Dental-led Triage Service........95. Standard Operating Procedure for Urgent Dental Care services
............................................................................................................126. Standard Operating Procedure for Infection Prevention and
Control...............................................................................................187. Standard Operating Procedure for Remote Prescribing...........258. Standard Operating Procedure for Resilience and continuity of
service................................................................................................27
Appendix 1: East Midlands Urgent Dental Care Triage Pathway for COVID-19.............................................................................................29
Appendix 2: Routine decontamination of reusable non-invasive patient care equipment...................................................................................32
Appendix 3: Categories of vulnerable patient groups.............................33Appendix 4: Categories of shielded patient groups................................34Appendix 5: Feedback.............................................................................35
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1. Background Coronavirus disease (COVID-19) is an infectious disease caused by
a newly discovered coronavirus. The transmission of COVID-19 is thought to occur mainly through
respiratory droplets generated by coughing and sneezing, and through contact with contaminated surfaces. The predominant modes of transmission are assumed to be droplet and contact. This is consistent with a recent review of modes of transmission of COVID-19 by the World Health Organization (WHO).
The current national approach is to ensure that social distancing measures are observed to reduce social interaction between people in order to reduce the transmission of coronavirus (COVID-19).
Stringent social distancing measures are required for those in vulnerable and shielded population groups.
From international data, the balance of evidence is that infectivity has significantly reduced 7 days after the onset of symptoms.
Those with symptoms of coronavirus illness (COVID-19), however mild, need to stay at home for 7 days from when their symptoms started. Any household members who remain well must stay at home and not leave the house for 14 days. The 14-day period starts from the day when the first person in the house became ill.
COVID-19 for most individuals causes mild to moderate illness, but in addition may result in pneumonia or severe acute respiratory infection. The median time from symptom onset to clinical recovery:
o mild cases - 2 weekso severe or critical cases - 3-6 weeks
Human coronaviruses can survive on inanimate objects and can remain viable for up to 5 days at temperatures of 22-25°C and relative humidity of 40-50% (which is typical of air-conditioned indoor environments).
Frequent hand washing for 20 seconds is central to preventing and delaying the spread of coronavirus (COVID-19).
Interrupting transmission of COVID-19 requires contact, droplet and aerosol precautions depending on procedures undertaken:
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The most common symptoms of coronavirus (COVID-19) are recent onset of
new continuous cough and/orhigh temperature
During Aerosol Generating Procedures (AGPs), there is an increased risk of aerosol spread of infectious agents irrespective of the mode of transmission (contact, droplet, or airborne), and airborne precautions must be implemented when performing AGPs, including those carried out on a possible or confirmed case of COVID-19.
Urgent dental care centres operating under contract to the NHS in other parts of England should refer to guidance and Standard Operating Procedures (SOPs) produced for their specific areas.
This guidance was written at pace on 2nd April, 2020 to support the quick mobilisation of urgent dental care sites across the East Midlands and is subject to change. Do not print hard copies but keep live links to the document to ensure that the information you are receiving is as up-to-date as possible. The evidence base on COVID-19 is rapidly evolving. Further updates may be made to this document as new detail or evidence emerges.
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Contact
Prevent and control infection transmission via direct contact or indirectly from the immediate environment (including equipment). This is the most common route of infection transmission.
Droplet
Prevent and control infection transmission over short distances via droplets (>5μm) from the patient to a mucosal surface or the conjunctivae of a dental team member. A distance of approximately 1 metre around the infected individual is the area of risk for droplet transmission which is why dental teams routinely wear surgical masks and eye protection for treating patients.
Airborne
Prevent and control infection transmission via aerosols (≤5μm) from the respiratory tract of the patient directly onto a mucosal surface or conjunctivae of one of the dental team without necessarily having close contact.
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This guidance is applicable in the East Midlands and covers: Northamptonshire
Leicester, Leicestershire and Rutland Lincolnshire
Nottinghamshire Derbyshire
2. Generic principles for the urgent dental care system
The collaborative endeavours of the dental workforce in supporting the national strategy on social distancing are an essential element of the NHS measures and our national response to the risk presented by COVID-19.
This document is intended to support dental teams working within the urgent dental care system in supporting the pandemic response.
Consistency in adopting the recommended actions will ensure the safety of patients, staff and the population, while maintaining access to quality healthcare for members of the public in the East Midlands.
Generic principles for urgent dental care settings and providers
o Stop and defer all routine dental treatment and careo Ensure all members of staff observe social distancing measures with
regards to symptoms and/or in contact with those with symptomso Ensure any vulnerable and shielded members of staff are isolated
and protectedo Observe social distancing measures by minimising face-to-face
patient contacto Provide remote triage for all patients to assess risko Provide urgent dental care, as appropriate, avoiding AGPs which
must only be used in when absolute necessary and in order to alleviate pressure on the wider NHS
o Observe stringent infection prevention and control measureso Provide dedicated service for vulnerable and shielded population
groups
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3. Standard Operating Procedure for Tier 1 Urgent Dental Care remote triage and referral by primary dental care
1. Establish a remote urgent dental care service, either as an individual dental practice or as part of a collaborative group by local arrangement.
2. Practices should adopt a full triage-first model that supports the management of patients with urgent dental needs remotely where possible. This should be the first point of access by patients. In practice, this means using telephone, video and online consultation technology. This is irrespective of the patient’s dental attendance status at the practice. For further information on remote triage see: BMJ article , Information Commissioner’s guidance and GDC guidance
3. Undertake a COVID-19 assessment for all patients and provide self-isolation advice to those with the following:
a high temperature a new, continuous cough
a. Determine if patient is within vulnerable or shielded group or is self-isolating
b. Obtain relevant medical historyc. Ask every patient if they are a smoker and advise that the Chief
Medical Officer has highlighted that smokers are at increased risk from COVID-19, with the infection being more likely to last longer and be more severe.
4. During remote triage and wherever possible, all patients to be offered the following in the first instance:
Advice Analgesia Antimicrobial means where appropriate (patient to designate
pharmacy for collection)It is essential that a dentist is present when patients are being triaged remotely as a dental nurse will not be able to prescribe, if this is needed.
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General Dental Practitioners (GDPs) are responsible for triaging all patients, regardless of whether they have a regular dentist.
This service is required Monday to Friday from 9am to 5pm. If the NHS dental practice contracted opening hours are less than 9am to 5pm or
over and above this requirement, buddying arrangements are required.
5. It is advisable to liaise with local pharmacy colleagues to ensure that the products you might be recommending are available to your patients. Click on the link to locate the nearest pharmacy.
6. Patients should be advised that treatment options are severely restricted at this time and to call back in 48-72 hours if their symptoms have not resolved.
7. Dental conditions that cannot be managed by the patient and require emergency or urgent dental care should be referred via local pathways as below.
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TIER 1 Urgent Dental Care Remote triage
EMERGENCY CARE(alert A&E in advance
for all possible or confirmed COVID-19
cases, including household contacts)
REFER VIA RMS (REGO/FDS) TO
TIER 2 DENTAL-LED TRIAGE SERVICE
ADVICE, ANALGESIA AND ANTIMICROBIALS (as appropriate)
Useful information regarding triaging can be found in SDCEP: Management of Acute Dental Problems During COVID-19 Pandemic
(2020) – see pages 5 to 11.
Adapted from SDCEP: Managing of Acute Dental Problems During COVID-19 Pandemic (2020)
8. Appropriate records should be kept of all patient contacts, including care management and onward referrals.
9. The form below is to help provide some structure to the remote triaging process in line with the definitions for urgent dental treatment. It can then be used as a record of the remote consultation. It has been set up to be as straightforward as possible but it is recognised that it may not directly match every clinical situation directly.
10. When completing the form on the FDS system, please ask the patient if the clinical team receiving and triaging the referral for their dental care can view a summary of their GP record, which will include allergies and medications as well as COVID-19 information. This information will be helpful to the Urgent Dental Care team for dental treatment planning purposes. The permission from the patient to view (PTV) their Summary Care Record (SCR) needs to be recorded on the form and there is a simple box to indicate this. Clinicians involved in delivering care for the patient will then have access to the SCR.
11. Any onward referrals will need to be made via the FDS/Rego Referral Management System (RMS) to the Tier-2 Dental-led Triage Service where a basic referral form has been embedded. This will require patient details, medical history, medications and COVID-19 status plus presenting complaint, diagnosis and treatment request which can be recorded on the triage form. Previous appropriate radiographs and photographs can also be added to the referral.
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Please click on the link for more information on SCR.
4. Standard Operating Procedure for Tier 2 Urgent Dental Care remote triage and referral by a Dental-led Triage Service
1. Receive referral via the RMS (primary dental care) or direct patient contact via NHS 111 (out of hours, weekends and Bank Holidays)
2. Acknowledge and process the referral within 24 hours of receipt3. Undertake a COVID-19 assessment for all patients and provide
self-isolation advice to those with the following: a high temperature a new, continuous cough
a. Determine if patient is within vulnerable or shielded group or is self-isolating
b. Obtain relevant medical historyc. Ask every patient if they are a smoker and advise that the Chief
Medical Officer has highlighted that smokers are at increased risk from COVID-19, with the infection being more likely to last longer and be more severe.
4. During remote triage and wherever possible, all patients to be offered the following in the first instance:
Advice Analgesia Antimicrobial means where appropriate (patient to designate
pharmacy for collection)It is essential that a dentist is present when patients are being triaged remotely as a dental nurse will not be able to prescribe, if this is needed.
12. It is advisable to liaise with local pharmacy colleagues to ensure that the products you might be recommending are available to your patients. Click on the link to locate the nearest pharmacy.
5. Patients should be advised that treatment options are severely restricted at this time and to call back in 48-72 hours if their symptoms have not resolved.
6. Inform all patients referred to Urgent Dental Care sites that access is restricted to patient only. If parent/carer access is required, COVID-19 assessment needs to be undertaken.
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The Tier 2 Dental-led Triage Service is available from8am to 8pm, 7 days a week
Useful information regarding triaging can be found in SDCEP: Management of Acute Dental Problems During COVID-19 Pandemic
(2020) – see pages 5 to 11.
7. Dental conditions that cannot be managed by the patient and require emergency or urgent dental care should be referred via local pathways as below.
Adapted from SDCEP: Managing of Acute Dental Problems During COVID-19 Pandemic (2020)
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TIER 2 CLINICAL TRIAGE SERVICE
EMERGENCY CARE (alert A&E in advance
for all possible or confirmed COVID-19
cases, including household contacts)
ADVICE, ANALGESIA AND ANTIMICROBIALS (as appropriate) AND
FEEDBACK TO GDP
ONWARD REFERRAL VIA RMS TO APPROPRIATE URGENT DENTAL
CARE SITE
HOT: URGENT DENTAL CARE SITE FOR
POSSIBLE/CONFIRMED COVID-19 PATIENTS AND
THEIR HOUSEHOLD CONTACTS
COLD: URGENT DENTAL CARE SITE
FOR ASYMPTOMATIC
PATIENTS
COLD: DEDICATED URGENT DENTAL CARE
SETTING FOR VULNERABLE AND
SHIELDED PATIENTS
8. Appropriate records should be kept of all patient contacts, including care management and onward referrals.
9. The form below is to help provide some structure to the remote triaging process in line with the definitions for urgent dental treatment. It can then be used as a record of the remote consultation. It has been set up to be as straightforward as possible but it is recognised that it may not directly match every clinical situation directly.
10. When completing the form on the FDS system, please ask the patient if the clinical team receiving and triaging the referral for their dental care can view a summary of their GP record, which will include allergies and medications as well as COVID-19 information. This information will be helpful to the Urgent Dental Care team for dental treatment planning purposes. The permission from the patient to view (PTV) their Summary Care Record (SCR) needs to be recorded on the form and there is a simple box to indicate this. Clinicians involved in delivering care for the patient will then have access to the SCR.
11. Any onward referrals will need to be made via the FDS/Rego RMS to the Tier-2 Dental-led Triage Service where a basic referral form has been embedded. This will require patient details, medical history, medications and COVID-19 status plus presenting complaint, diagnosis and treatment request which can be recorded on the triage form. Previous appropriate radiographs and photographs can also be added to the referral.
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Please click on the link for more information on SCR.
5. Standard Operating Procedure for Urgent Dental Care services
1. Receive referral via RMS.2. Acknowledge and process referral within 24 hours of receipt.3. Undertake a COVID-19 re-assessment for all patients and provide
self-isolation advice to those with the following: a high temperature a new, continuous cough
a. Ask every patient if they are a smoker and advise that the Chief Medical Officer has highlighted that smokers are at increased risk from COVID-19, with the infection being more likely to last longer and be more severe.
b. Confirm correct urgent dental care site designation and make onward referral to appropriate site (e.g. if patient has become symptomatic since referral).
4. Patient considerations (assume application if it does not specifically state a hot or cold site) Access to site should be restricted to patient only. ‘Cold’ sites: COVID-19 re-assessment should be undertaken
again to ensure that there have not been any changes since last assessment – ensure 2 metres social distance. If a patient is now symptomatic and meets the case definition, they should be supported in accessing ‘hot’ urgent care site.
Only one patient to enter the practice at any given time. Any additional attendees (carer/parent) should be asked to wait outside, potentially in their car, if possible. If carer/parent need to accompany patient, COVID-19 assessment needs to be undertaken on them.
All patients should be segregated in place or time from other patients.
Patient flow through the site should conform to 2 metres social distance requirements.
Where possible, patients should be taken straight to the clinical area and not wait in communal areas.
Avoid the need for patients to contact any surfaces, including doors.
All patients (and carer/parent) should decontaminate their hands with alcohol-based hand rub when entering and leaving urgent dental care site/s.
If a patient uses toilet facilities whilst on the premises, it must be cleaned immediately.
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All sites are required to undergo an approval process to ensure that practice protocols conform with the East Midlands guidance requirements. A virtual site assessment will be undertaken.
‘Hot’ sites: Symptomatic patients may wear a fluid-resistant (Type IIR) surgical face mask (FRSM), if tolerated, to minimise the dispersal of respiratory secretions and reduce both direct transmission risk and environmental contamination. They should be placed at end of clinical list, if possible.
5. Staff considerations : Instruct all members of staff (including redeployed staff) to
personally undertake regular COVID-19 assessments and if symptomatic, to stay at home and not come to work until period of isolation is over.
Undertake risk assessment to ensure that members of staff who are in vulnerable and shielded groups are isolated and protected.
All staff should be supported in looking after their wellbeing and physical health during this time.
Reception staff: a. ‘Hot’ sites: sessional use of FRSM is required.b. ‘Cold’ sites: every effort should be made to maintain
social distancing of 2 metres. Where this is not practical, sessional use of FRSM is recommended.
All members of staff should be trained to understand PPE requirements for urgent care sites operating during pandemic. All surgery staff should be fit-tested and fit-checked for FFP3 respirators if AGPs are undertaken. AGPs should be avoided and only provided when absolutely necessary.
Consider the use of scrubs for staff who do not usually wear a uniform. It is best practice to change into and out of uniforms at work and not wear them when travelling; this is based on public perception rather than evidence of an infection risk.
6. Practice consideration : There should be appropriate signage and adequate car parking
facility at the premises for patients to wait in their cars prior to being seen (avoid using waiting areas).
Avoid any air conditioning or fans that re-circulate the air. Ensure good ventilation of premises, particularly for surgeries Respiratory and cough hygiene should be observed by staff and
patients/carers. Disposable tissues should be available and used to cover the nose and mouth when sneezing, coughing or wiping and blowing the nose – ‘Catch it, bin it, kill it’.
Avoid using waiting rooms where possible but where in use, allow for 2 metre separation between waiting area and reception. The care environment should be kept clean and clutter free. All non-essential items including toys, books and magazines should be removed from reception and waiting areas.
Designate rooms/areas as don and doff areas. AGPs must only be used when absolutely necessary and if
undertaken, the room will need to be stood down to allow for time for aerosols to be cleared before it can be decontaminated.
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7. Treatment considerations : It is for each Urgent Dental Care service to determine how many
patients are seen in a session and the length of time for each patient’s appointment. The important consideration which needs to be taken into account is to factor in longer appointment times for the pandemic situation.
Hand hygiene must be performed immediately before every episode of direct patient care and after any activity or contact that potentially results in hands becoming contaminated, including the removal of PPE, equipment decontamination and waste handling.
Any procedures should be carried out with a single patient and only staff who are needed to undertake the procedure present in the room with the doors shut.
Where possible, AGPs should be avoided and should only be used when absolutely necessary.
‘Hot’ sites: A long sleeved disposable fluid repellent gown (covering the arms and body), a filtering face piece class 3 (FFP3) respirator, a full-face shield or visor and gloves are recommended during AGPs.
AGPs potentially required for urgent dental care during
pandemic
Non-AGPs potentially required for urgent dental care during
pandemicAll procedures in which a high-speed handpiece/air rotor/air turbine is used. Urgent care does not include other aspects of dental treatment that may generate aerosols such as
Examination Radiograph Use of local anaesthetic Smoothing rough edges with
slow hand piece Extirpation of open pulp Placing dressings/temporary
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What is an aerosol generating procedure (AGP)?AGPs are described/defined as medical and patient care procedures
that result in the production of airborne particles (aerosols) that create the potential for airborne transmission of infections that may otherwise
only be transmissible by the droplet route.Please click on the link to read a review of the extant scientific
literature regarding AGPs in the healthcare environment which has formed the evidence based recommendations for practice.
If undertaking a non-AGP which does not go according to plan, before embarking on full AGP process please consider:a) Why does the AGP need to be undertaken?
b) What will it achieve?c) Does it need to be done immediately?
d) Is there an alternative route?
ultrasonic scalers. Please note that although not defined as an AGP, the use of high pressure 3 in 1 syringes could potentially create an aerosol mist and therefore this should be avoided.
fillings Extractions Surgical extractions not
requiring use of high speed drill
Suturing sockets Treatment of avulsed teeth Incision of an abscess Smoothing dentures
Use of dental aspirator, saliva ejector or slow-speed handpiece does not constitute an AGP dental procedure.
Chest compressions and defibrillation (as part of resuscitation) are not considered AGPs; first responders (any setting) can commence chest compressions and defibrillation without the need for AGP PPE while awaiting the arrival of other clinicians to undertake airway manoeuvres.
Follow local protocols for onward referral to 2-week wait for all possible oral cancer cases.
When assessing patients with dry sockets: People who smoke and use tobacco are at a much higher risk of developing dry socket after tooth extraction. Provide additional specific advice to patients who smoke and use tobacco that they are at increased risk from COVID-19, with the infection being more likely to last longer and be more severe. Inform them that even if they only pause smoking during this crisis, this will not only be a huge benefit to their lungs but it will reduce their risk of potentially developing COVID-19 if they were to be unfortunately exposed to the coronavirus.
When assessing patients with trauma: For many people who are enduring domestic abuse, limited opportunities to leave their homes mean that they may be feeling even more vulnerable and isolated than usual. Many abusers will use this situation to further control, isolate and abuse. It is important that the dental profession is vigilant towards possible cases of domestic abuse when cases of trauma are presented in this pandemic.
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Advise patients that if they are affected by domestic abuse and are unable to leave their home to access support, they can call the 24-hour National Domestic Abuse Helpline on 0808 2000 247, or the 24-
hour Victim Support line on 0808 16 89 11
Women’s Aid have webchats available Monday-Friday between 10am-12pm.
In an emergency please call 999The Police are still working hard to keep people safe
8. Patient discharge Provide usual post-operative instructions to all patients who have
had a tooth extracted, with additional specific advice to smokers about the increased risk of COVID-19 infection. Signpost patients who smoke for support:
Smoke free appThis is a stop smoking app that follows NICE guidance for smoking cessation. Counsellors are available from 6am to midnight, five days a week and for most of the weekend. The chatbot and automated features are available whenever a user wants.
Quit ClinicA twitter ‘Quit Clinic’ has launched where every evening between 7.30 and 8.30pm people can put their questions to leading cessation expert Louise Ross.
Patients discharged without definitive treatment, for example those for whom temporary dressings have been placed, should be advised of the definitive treatment they require but that all routine dental treatment has been stopped. Therefore, the time scale for them in
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Advise patients that if they are affected by domestic abuse and are unable to leave their home to access support, they can call the 24-hour National Domestic Abuse Helpline on 0808 2000 247, or the 24-
hour Victim Support line on 0808 16 89 11
Women’s Aid have webchats available Monday-Friday between 10am-12pm.
In an emergency please call 999The Police are still working hard to keep people safe
gaining dental treatment is protracted due to the COVID-19 outbreak.
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6. Standard Operating Procedure for Infection Prevention and Control
1. Adequate ventilation systems and effective environmental decontamination will physically reduce exposure to COVID-19 infection.
2. Current guidance (as of 2/4/20) states the following PPE requirements as follows for all urgent dental care settings (i.e. ‘hot’ and ‘cold’ sites):
3. Hand Hygiene Hand hygiene must be performed immediately before every
episode of direct patient care and after any activity or contact that potentially results in hands becoming contaminated, including the removal of PPE, equipment decontamination and waste handling.
Always perform hand hygiene before putting on PPE.
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All members of staff should read PHE Infection Prevention and Control guidance to familiarise themselves with specific requirements during the pandemic regularly. Please note that this guidance is constantly revised and updated and therefore live links should be kept, and no hard copies
printed.In addition, HTM01-05 and NICE guidance on infection prevention and
control measures should be used by all staff, in all settings, always, for all patients.
Best practice on how to hand-wash:
All staff, patients and visitors (including escorts) should decontaminate their hands with alcohol based hand rub when entering and leaving clinical area and when possible and confirmed COVID-19 patient is being delivered. Best practice on how to hand-rub:
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4. Eye and face protection Disposable, single-use, eye and face protection is recommended.
Re-usable eye and face protection is acceptable if decontaminated between single or single sessional use, according to the manufacturer’s instructions or local infection control policy.
Eye and face protection can be achieved by the use of any one of the following:
o surgical mask with integrated visoro full face shield or visoro polycarbonate safety spectacles or equivalento Please note that regular corrective spectacles are not
considered adequate eye protection. While performing AGPs, a full-face shield or visor is
recommended. There are specific requirements of the FRSM for COVID-19 and it
should:o Be well fitted covering both nose and moutho Not be allowed to dangle around the neck of the wearer after
or between each useo Not to be touched once put ono Be changed when they become moist or damagedo Be removed after patient has left the clinical area or 1 metre
away from the patient with possible/confirmed COVID-19o Be worn once and then discarded as clinical waste (hand
hygiene must always be performed after disposal) The process for donning and doffing PPE is critical to ensure its
effectiveness. Information is as follows for non-AGPs:
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This video shows how to safely don and doff the PPE for non-AGPs, specific to COVID-19: Video
There is no evidence that respirators add value over FRSMs for droplet protection when both are used with recommended wider PPE measures in clinical care, except in the context of AGPs. When used, FFP3 respirators must:
o be well fitted, covering both nose and moutho not be allowed to dangle around the neck of the wearer
after or between each useo not be touched once put ono fit tested on all healthcare staff who may be required to
wear an FFP3 respirator to ensure an adequate seal/fit according to the manufacturers’ guidance
o fit checked (according to the manufacturers’ guidance) by staff every time an FFP3 respirator is donned to ensure an adequate seal has been achieved
o compatible with other facial protection used i.e. protective eyewear so that this does not interfere with the seal of the respiratory protection. Regular prescription glasses are not considered adequate eye protection
o FFP3s should be removed outside the dental surgery where AGPs have been generated in line with doffing protocol.
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o disposed of and replaced if breathing becomes difficult, the respirator is damaged or distorted, the respirator becomes obviously contaminated by respiratory secretions or other body fluids, or if a proper face fit cannot be maintained. In effect this means that FFP3s will be worn once for dental AGPs and then discarded as clinical waste (hand hygiene must always be performed after disposal)
The HSE have stated that FFP2 and N95 respirators (filtering at least 94% and 95% of airborne particles respectively) offer protection against COVID-19 and may be used if FFP3 respirators are not available. Other respirators can be utilised by individuals if they comply with HSE recommendations. Reusable respirators should be cleaned according to the manufacturer’s instructions.
There are specific considerations for FFP3 respirators:
PPE should be donned and doffed in dedicated areas and in a systematic order that minimises the potential for cross contamination, especially when undertaking AGPs:
Donning PPE for AGP Doffing PPE for AGP
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Note that valved respirators are not fully fluid-resistant unless they are also ‘shrouded’. If a valved, non-shrouded FFP3 respirator is used then it
should be accompanied by full face protection for use in AGPs.
1. Gown2. Respirator3. Eye protection4. Gloves
1. Gloves2. Gown3. Eye protection4. Respirator (must always be
removed outside the clinical area)
The process for putting on donning and doffing PPE is critical to ensure its effectiveness. Information is as follows for non-AGPs:
Watch this video on how to safely don PPE specific to COVID-19 for AGPs:
Video
Watch this video on how to safely doff PPE specific to COVID-19 for AGPs:
Video
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After an AGP, the room needs to be stood down before it can be decontaminated:
5. Decontamination Decontamination of equipment and the environment must be
performed using either:o A combined detergent/disinfectant solution at a dilution of
1,000ppm available chlorine ORo A general purpose neutral detergent in a solution of warm
water followed by a disinfectant solution of 1,000ppm available chlorine
6. Uniforms Uniforms should be transported home in a disposable plastic bag.
This bag should be disposed of into the household waste stream. They should be laundered:o Separately from other household lineno In a load not more than half the machine capacityo At the maximum temperature the fabric can tolerate, then
ironed or tumble-dried7. Disposal
All single use or single session use PPE should be discarded as healthcare (clinical) waste. Hand hygiene must always be performed after disposal. However, re-usable eye and face protection is acceptable if decontaminated between single or single sessional use, according to the manufacturer’s instructions or local infection control policy.
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8. Standard Operating Procedure for Remote Prescribing
1. Ensure that up-to-date training on Information Governance and Data Protection is in place.
2. The risk assessment for the prescription of any antimicrobials should be recorded and include:
a. COVID-19 assessment b. Urgency of treatmentc. Patient’s medical historyd. Limitations of remote clinical assessment
REMOTE PRESCRIBING
Step 1
Complete prescription as normal, sign and scan. Take of photo/scan of the prescription and send
electronically via nhs.net to a pharmacy designated by the patient, ensuring delivery and read receipt is requested (To obtain an NHS.net email address, follow this link)
Contact pharmacy via phone to advise them you will be emailing scanned prescription.
Attach a copy of the prescription to the patient’s clinical records.
Step 2 Post the original signed prescription WITHIN 24
hours to the pharmacy. Log all sent prescriptions, confirming receipt with
pharmacy
Information for patients: All patients who are self-isolating (i.e. possible/confirmed with
COVID-19 and their household contacts as well as vulnerable and shielded patients) should be informed not to attend the pharmacy and that other arrangements are required.
Record in the notes what arrangements have been discussed and agreed for the prescription to be collected.
COVID-19 Medication considerations
For dental pain, advise:
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For adults without contraindications: Paracetamol 2 x 500mg every 4-6 hours with no more than 8 x 500mg
in 24 hours
ORIbuprofen, 1 x 400 mg tablets 4–6 hourly with no more than 3 x 400 mg
In line with social distancing measures and minimising face to face contact, remote prescribing should be adopted.
In the specific circumstances of COVID-19, the key requirement is to make an appropriate risk assessment during remote triage.
Click on the link to locate the nearest pharmacy.
For patients who are remotely triaged and diagnosed with a
dental infection and can TOLERATE penicillin
For patients who are remotely triaged and diagnosed with a
dental infection and are ALLERGIC to penicillin
Source: SDCEP Drug Prescribing for Dentistry
Please note that the BNF can be accessed at www.bnf.org. 9. Standard Operating Procedure for
Resilience and continuity of service
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For adults without contraindications: Paracetamol 2 x 500mg every 4-6 hours with no more than 8 x 500mg
in 24 hours
ORIbuprofen, 1 x 400 mg tablets 4–6 hourly with no more than 3 x 400 mg
To underpin practice resilience and continuity of service whilst protecting patients, practice staff and the public; the following practical steps are recommended.
1. Appoint a COVID-19 lead in every organisation for the co-ordination of activities, training, preparation and implementation of this document and any subsequent revisions to guidance, ensuring that as a minimum, the following as covered:
o COVID-19 risk assessment o Tier 1 and/or Tier 2 triage, as appropriateo Implementing infection prevention and control measures
required for the pandemic, including reviewing and refreshing knowledge and application of HTM 01-05 decontamination protocols, equipment and PPE
o planning and implementation of strategies for surge capacityDue to social distancing measures, training should be undertaken remotely, where possible.
2. It is vital that information channels be kept open during this time of crisis. Practices are to designate a practice nhs.net account for the timely receipt of COVID-19 information and ensure that the account details are noted by their NHS England and NHS Improvement Regional Commissioning team.
3. Practices should ensure auto forward for e-mails to an alternative nhs.net account and designated deputy in the event of the COVID-19 lead absence.
4. Bookmark and regularly review the hyperlinks to official guidance from PHE and NHS England and NHS Improvement to ensure up-to-date knowledge and any changes to protocols:
Coronavirus (COVID-19): latest information and advice Coronavirus (COVID-19) in dental settings (including update and
guidance) PHE Infection Prevention and Control guidance 5. Register online with PHE to download COVID-19 resources:
Registration Resources Translated resources:
o Stay at home guidance in various languages o Posters and booklets in various languages o Social distancing for vulnerable people in various
languages
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PHE has launched a WhatsApp chatbot tool. The new free to use service aims to provide official, trustworthy and timely information and advice
about coronavirus (COVID-19) and will further reduce the burden on NHS services. This will help combat the spread of coronavirus misinformation in the UK, as well as helping ensure people stay home, protect the NHS
and save lives. The GOV.UK Coronavirus Information Service is an automated ‘chatbot’ service which will allow the British public to get
answers to the most common questions about coronavirus direct from government. The service will provide information on topics such as
coronavirus prevention and symptoms, the latest number of cases in the UK, advice on staying at home, travel advice and myth busting. The
6. Consider reinforcing links with local NHS primary care colleagues, including the local medical, dental, pharmacy and optical practice, to share knowledge and experience, to co-ordinate and collaborate on training and mutual support.
7. Regular liaison with NHS England and NHS Improvement Primary Care Commissioning team contacts for the Urgent Dental Care services which would include (but not limited to)
Potential requirements for additional workforce Concerns regarding PPE supplies to be able to maintain
service deliveryshould be alerted to the team as soon as possible via the following
generic email address EM-PCDENTAL England england.em-
[email protected] clearly identifying the urgent dental care site at the start of the subject
narrative to ensure that it can be redirected to the appropriate team member.
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PHE has launched a WhatsApp chatbot tool. The new free to use service aims to provide official, trustworthy and timely information and advice
about coronavirus (COVID-19) and will further reduce the burden on NHS services. This will help combat the spread of coronavirus misinformation in the UK, as well as helping ensure people stay home, protect the NHS
and save lives. The GOV.UK Coronavirus Information Service is an automated ‘chatbot’ service which will allow the British public to get
answers to the most common questions about coronavirus direct from government. The service will provide information on topics such as
coronavirus prevention and symptoms, the latest number of cases in the UK, advice on staying at home, travel advice and myth busting. The
Appendix 1: East Midlands Urgent Dental Care Triage Pathway for COVID-19
NO PATIENT WALK-IN SERVICE PERMITTED
Clinical Dental Triaging
General Dental Practices (GDPs) or Community Dental Services (CDS) are responsible for triaging all patients, regardless of whether they have a regular dentist; this includes a COVID-19 assessment of the patient at their first contact and additionally as required through the triage pathway.
A COVID-19 assessment for a patient will be completed at their initial triage stage (either by a GDP or CDS).
Should the patient call 111, 111 will direct to the nearest GDP during operational times Monday to Friday (09:00-17:00) who will undertake a AAA triage (Advice, Analgesia, Antimicrobials where appropriate) with referral via Referral Management Service (RMS either FDS or Rego) as clinically appropriate to tier 2 Dental Led Triage Service.
Should the patient call 111 Monday to Friday (17:00-20:00), Weekends and Bank holidays (08:00-20:00) they will be directed to tier 2 Dental Led Triage Service who will undertake a tier 1 AAA and tier 2 dental clinical triage with referral via RMS (FDS/Rego) to a designated local urgent dental care service as clinically appropriate taking into account the patient group.
Should the patient call 111 Monday to Sunday (20:00-08:00), they will be triaged by the 111 call handler/dental nurse and requested to call the next day when necessary to be signposted to the appropriate service; however, patient will be referred to A&E should they have uncontrollable bleeding or swelling causing eyes to close or spreading to the neck.
The Tier 2 Dental Led Triage Service will undertake dental clinical triage with referral to designated local Urgent Dental Care Systems (UDCS) as clinically appropriate and taking into account the patient group (detailed below).
Tier Level
Description Operational Times
1
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GDP/CDS tier 1 AAA Triage with referral via RMS (FDS/Rego) as clinically appropriate to tier 2 Dental
Led Triage Service.
Monday to Friday (09:00-17:00)
2Dental Led Triage Service triage with referral to a
designated local Urgent Dental Care System (UDCS) as clinically appropriate.
Monday to Friday(08:00-20:00)
1 and 2
Dental-Led Triage Service:AAA Triage and dental clinical triage with referral to a designated local Urgent Dental Care System (UDCS)
as clinically appropriate.
Monday to Friday(17:00-20:00)
Weekends and Bank Holidays(08:00-20:00)
N/A
Patient to be triaged by 111 call handler/111 dental nurse to arrange call back the next day to access tier
1 or tier 1&2 dental triage services.
Refer to A&E if patient has bleeding or swelling causing eye to close or spreading to neck.
All days(20:00-08:00)
The patient will be categorised by the DLTS into one of four groups below:
Patient Groups/DLTS Site:a) HOT - Patients who are possible or confirmed COVID-19 patients-
including patients with symptoms, or those living in their household.b) COLD - Patients who are shielded- those who are at most significant
risk from COVID-19c) COLD - Patients who are vulnerable/at increased risk from COVID-19d) COLD - Patients who do not fit one of the above categories
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Appendix 2: Routine decontamination of reusable non-invasive patient care equipment
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Appendix 3: Categories of vulnerable patient groupsWe are advising those who are at increased risk of severe illness from coronavirus (COVID-19) to be particularly stringent in following social distancing measures.
This group includes those who are: aged 70 or older (regardless of medical conditions) under 70 with an underlying health condition listed below (i.e. anyone
instructed to get a flu jab as an adult each year on medical grounds): chronic (long-term) respiratory diseases, such as asthma, chronic
obstructive pulmonary disease (COPD), emphysema or bronchitis chronic heart disease, such as heart failure chronic kidney disease chronic liver disease, such as hepatitis chronic neurological conditions, such as Parkinson’s disease, motor
neurone disease, multiple sclerosis (MS), a learning disability or cerebral palsy
diabetes problems with your spleen – for example, sickle cell disease or if you
have had your spleen removed a weakened immune system as the result of conditions such as HIV
and AIDS, or medicines such as steroid tablets or chemotherapy being seriously overweight (a body mass index (BMI) of 40 or above)
those who are pregnant
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Appendix 4: Categories of shielded patient groupsPeople falling into this extremely vulnerable group include:
1. Solid organ transplant recipients.2. People with specific cancers:
people with cancer who are undergoing active chemotherapy people with lung cancer who are undergoing radical radiotherapy people with cancers of the blood or bone marrow such as leukaemia,
lymphoma or myeloma who are at any stage of treatment people having immunotherapy or other continuing antibody
treatments for cancer people having other targeted cancer treatments which can affect the
immune system, such as protein kinase inhibitors or PARP inhibitors people who have had bone marrow or stem cell transplants in the
last 6 months, or who are still taking immunosuppression drugs3. People with severe respiratory conditions including all cystic fibrosis,
severe asthma and severe COPD.4. People with rare diseases and inborn errors of metabolism that
significantly increase the risk of infections (such as SCID, homozygous sickle cell).
5. People on immunosuppression therapies sufficient to significantly increase risk of infection.
6. Women who are pregnant with significant heart disease, congenital or acquired.
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Appendix 5: FeedbackThis is a dynamic document that will be reviewed as the situation changes and will respond to evidenced feedback and lessons identified.
Feedback should be annotated in the template below and sent to [email protected]
Subject Line for your e-mail: COVID-19-URGENT-DENTAL-CARE-SOP-FEEDBACK- INSERT YOUR ORGANISATION-YOUR INITIALS
COVID-19 Standard Operating Procedure for Urgent Dental CareV1 – April 2020
No. Name Dental Practice
Observations and commentsSuggested amendmen
ts
Rationale for
proposed amendmen
t
Location:Page
numberParagraph
number
Original text Comments
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