In this guest post, Emma O’Keefe, Consultant in Dental Health, NHS Fife and South East Scotland (including NHS Lothian) is keen to share her experiences in relation to managing COVID-19 incidents in the dental setting.
Who would have known when primary care dentistry closed their doors in March the situation we would be in as we approach Christmas 2020. In November 2020, the Scottish Government announced NHS dentistry would move to “Phase 4 of the remobilisation plan” and open for ‘routine’ dental care including the delivery of aerosol generating procedures. The review carried out by SDCEP[i], SDCEP’s remobilisation document[ii] and guidance developed by Public Health England[iii] provided up to date information for practice teams to consider.
Routine dentistry does not resemble the same as it was pre-COVID, with practices evolving with the pandemic, changing their full Standard Operating Procedures[iv] and formulating up to date risk assessments to manage their patients and staff with the appropriate precautions to ensure patient and staff safety.
Managing patient expectations has required some skill to get a balanced approach that ‘dentistry is open but it won’t look as it did pre-COVID-19’ as there is a significant backlog of patients requiring care. Working with NHS Communications teams has helped deliver bespoke messaging for the public but we continue to reinforce the message.
The re-opening of dental practices in phase 4 coincided with the second wave in COVID-19 and this has been seen in both the numbers of dental staff members testing positive and the number of patients who have visited the dental practice during their asymptomatic but infectious period.
Dental teams, in conjunction with dental public health colleagues, have been instrumental in helping to break the chain of transmission in the dental setting. Dental public health colleagues sit within Public Health Departments and work closely with health protection teams and have developed ‘guiding principles’ to support the management of COVID-19 incidents in the dental setting. The importance of learning and sharing our experiences will help prevent further chains in transmission. A collaborative approach with our NHS Occupational Health Colleagues, Infection Prevention Control Teams and primary care colleagues who have local intelligence regarding the dental practices has been critical to define roles and prevent duplication of effort. Our managed services, Public Dental Service and Hospital Dental Services, have also been involved in breaking the chain of transmission in their settings. Colleagues have also worked to ensure universities have mechanisms in place to manage incidents in the dental school setting and outreach student placements. Speaking with occupational health colleagues and listening to how they have conveyed the messaging inspired me to share some stories.
Stories are powerful ways to help reinforce messages and as we head towards the festive period where we celebrate with food and drink all my stories revolve around this. Dental teams are meticulous in infection prevention control in the clinical setting but our experience suggests that it is the behind the scenes where we have seen the chain of transmission.
The reality is that COVID-19 is highly contagious, can occur in anyone, patients and dental staff alike and is most contagious in the first 5 days of infection, hence the need for following advice, case interviews and contact tracing. The information can come from a variety of sources and key to using the information is having the appropriate resources in place to gather information, analyse the data, conduct risk assessment and mitigate risk as soon as possible.
Understanding who has the information is fundamental and identifying the gaps in a methodical and thorough manner is key. The multidisciplinary approach we have adopted has been successful and acknowledging the benefit of being integrated with public health/health protection teams has been invaluable.
Chocolate cake – pure indulgence
Staff were treated to an amazing cake that was delivered by a local bakery. Physical distancing measures and numbers in the staff room might have been breached as the pull to the amazing chocolate cake blew the COVID-19 principles out of the window. The investigations included who handled the cake knife, how many of the team gathered round for the calorific coffee break. Take care and think of measures where the cake can be enjoyed but in a safe and secure COVID-19 free way. An additional challenge in many dental practices is that the staff room/kitchen is often an internal room with no windows making air changes very limited and increasing the risk of transmission.
Pizza Party at a lunchtime
We are all familiar with the expression ‘when the cat is away the mice come out to play’ and this has become evident when practice principals and practice managers are away for the day. The pizzas brought a sense of Friday feeling and guards were let down, sitting round a table with staff being identified as direct contacts. Could practices develop COVID-19 champions and have an open and transparent culture to ensure that the team feel able to speak out when they don’t feel comfortable with plans or behaviours. This ability to speak out can stop the chain of transmission and therefore maintain a COVID-19 secure premises, COVID-19 aware staff and sustainable patient care.
Gifts this Christmas from patients
We know this is the season where patients often show their appreciation to their dental team and give gifts and we are all aware of the ethical implications of receiving gifts. Please can we ask that you think seriously before receiving gifts this Christmas.
We had an incident recently when an asymptomatic but COVID-19 positive patient gave the team an edible gift. This was taken into the staff room and shared. The dental team were then informed the patient had attended during their infectious period. After investigation of who could and couldn’t resist the biscuits, the staff were given ‘warn and inform’ letters in that they were not identified as contacts[v] but to remain vigilant for COVID19 symptoms.
We know that you might offend the patients but perhaps suggest that this year it is not appropriate. If the patient insists then put measures in place to wipe down the gift, an appropriate wipe and ‘quarantine’ it in a safe place for 72 hours. Be careful if you do share edible gifts that there is not contamination and potential staff to staff transmission.
Key to success
Breaking the chain is dependent on a number of factors and the number one key is adhering to guidance and protocols at all times (both front of house patient facing and in the ‘back rooms (including offices, changing facilities and staff rooms/kitchens); the second key is communication. ‘Prevention is better than cure’ is public health mantra and when it comes to COVID-19 there is nothing more important. Staff need to feel able to ring or message their boss and say they feel unwell, have COVID-19 like symptoms and get tested. ‘If in doubt get it checked out’ applies here. Getting tested quickly and accurately is vital to breaking the chain of transmission, local NHS Occupational Health Services have processes in place that NHS dental teams can access. The appropriate use of the NHS Scotland Test & Protect App is a useful tool that we encourage everyone to download and to ensure the App is ‘paused’ when wearing PPE in the clinical setting.
Constantly reinforcing the messages is also important. We hear people say that complacency has set in and the team are weary. We can get through this pandemic together. A quick morning huddle is so important, in a physically distanced way, to check in and see how people are feeling that day, reiterate key points and perhaps use it as an opportunity to reinforce staggered breaks, wiping surfaces down before and after use and the etiquette of mask wearing. Now is also a good time to review the practice risk assessments, Standard Operating Procedures and reinforce the key messages to staff to remain vigilant as we each have a part to play in stopping the chain of transmission.
Creating a culture of openness, where team members feel able to speak out and bring issues or ‘near misses’ to the forefront of everyone’s minds. The skill of bringing the team together, in a no blame situation will enable sharing, learning and improvement activity. Have you got team members who are innovative and can develop novel ideas to reinforce the messages? Can you nurture staff, with a desire to lead, to take on additional roles and responsibilities to promote the culture of everyone plays a fundamental role in breaking the chain of transmission?
The COVID-19 pandemic has been with us for over 9 months and we have certainly learned a lot and overcome a lot of the challenges through opportunities of joint working, embracing uncertainty, remaining agile to deliver timely and efficient responses in order to try and break the chain of transmission of COVID-19 in the dental setting. I wonder what 2021 will bring.
This work would not have been possible without the continued efforts of dental public health colleagues particularly my Specialty Registrars, Public Health/Health Protection colleagues, Test & Protect colleagues, Occupational Health, Infection Prevention Control Teams and Primary Care and special thanks to Dental Practice Teams.