STANDARD OPERATING PROCEDURES
The following Standard Operating Procedure (SOP) is applicable in the planning and operating of Lighthouse Dental Practice during the COVID-19 Pandemic. This SOP aims to encourage a consistent approach, recognising the importance of staff and patient safety in this time while still enabling access to patients. It is essential to minimise the number of patients to reduce the risk of transmission of COVID-19 to staff and patients. To provide the best care service to our patients in this unprecedented time.
All patients at Lighthouse Dental Practice will be treated as potentially COVID-19 positive, however those who answer yes to the following questions may be at higher risk and will be treated at different times or different locations.
- Do you have a new or continuous dry cough?
- Is temperature above 37.8?
- Have you been diagnosed with COVID-19?
- Have you or a member of your household been told to self-isolate?
If the patient has COVID-19 symptoms or is self-isolating, then they will be directed to an appropriate site.
Triage Within LHD
The expectation is that face to face contacts within Lighthouse Dental Practice are kept to a minimum. In doing so non-essential contact and travel is reduced, cross-infection risks are minimised, and essential PPE is protected.
The patient pathway for Lighthouse Dental Practice is considered to have two broad stages – remote management and face-to-face management. As far as possible, patients should be managed remotely and exit the pathway at the end of this stage. Those patients who cannot be managed remotely will enter the face-to-face stage of the pathway.
Video conferencing is an extremely useful tool, particularly in relation to the assessment of swellings.
If, following this stage of triage, it is found that the patient can in fact be managed remotely, the patient should be given the appropriate advice, analgesia or antibiotics (as appropriate).
A face to face contact must only be made following this triage and conduction of risk assessment on an individual basis for each patient and it is confirmed that the patient cannot be managed remotely.
The safety, health and wellbeing of our team and patients are of paramount importance and is the primary concern and purpose of this document.
It sets out principles and practical steps that are vital to keep our workplaces safe;
- Employees have a legal responsibility to their employer and each other to follow instructions regarding safe working practices.
- Everyone should approach the health, safety and wellbeing of each other in the workplace with compassion and understanding. Employers are advised to have regular and meaningful engagement with their employees and/or their recognised trade union or other representatives (including their health and safety committee, where this exists) about the Covid-19 emergency. These engagements provide additional opportunities to remind everyone about safe working practices, necessary precautions, and to share concerns.
- Employers are advised to circulate safety messages regularly to all employees using mobile technology, such as WhatsApp groups. The use of posters and other visual aids around the workplace will also help reinforce safety messages.
Patient gets triaged by receptionist prior to booking appointment. These steps must be completed:
- Covid questionnaire asked and Medical History updated.
- Book urgent care only. Shielding patients will be advised of the risks to see the dentist, but will be given priority for first appointment of the day, along with the vulnerable patients.
- Communicate our new protocol with the patient for their arrival at the Practice.
- Asked to attend at the exact time of their appointment.
- Pay by Card (If possible pay before the appointment to avoid them coming in contact with reception staff)
- Arrive alone, unless they are a minor or require a carer
- Ring the disabled bell to inform the staff they have arrived and are waiting.
- Wait by the clear doors until they are triaged by the nurse who will supply them with hand sanitiser and take their temperature. (If temperature is not okay, patient will be asked to return home and rebook after self-isolating for 7 days.)
- Nurse escorts them into surgery (If stair lift is required, nurse will assist in PPE)
- In surgery the Dentist will ask the patient to rinse with 1% Hydrogen peroxide.
- If patient requires a follow up appointment they will be asked to rebook over the phone or via email depending on timings.
- If patient pays with the card in surgery, the machine is wiped immediately.
- Receptionist will open the door for patient and allow patient their distance to exit the surgery.
- Door will be locked again.
Journey with Hygienist
The Patient Journey with the hygienist will be similar as above, only difference is that the Hygienist will be welcoming their patient at the door.
- Opening the door.
- Taking patients temperature.
- Giving patient hand sanitiser before entering.
- Requesting them to use the hydrogen peroxide mouth wash before starting any treatment.
- Hand scaling ONLY
Patient and care plan identification & prioritisation
Although an approach has not yet been agreed, in anticipation of the need to prioritise patients on return to practice, Lighthouse Dental Practice will be identifying and allocating patients and care plans into one of the following groups:
- Shielded patients;
- Patients at increased risk from COVID-19;
- Patients with urgent dental care needs;
- Patients who have contacted the COVID-19 UDC system and already been triaged for urgent dental care or require follow up care;
- Patients with incomplete care plans;
- Patients with frequent recall according to NICE recall guidelines (e.g. children, high oral disease risk, those who have been through stabilisation and need review);
- Patients with routine dental care needs, not applicable to any of the above cohorts.
As far as possible, the management of these patient groups should be carried out remotely and invasive treatment delayed.
The referrals will specifically identify those patients who are shielded (Individuals at the highest risk of severe illness from COVID-19 who are advised to shield themselves and stay at home for 12 weeks) and patients at increased risk. The DERS referral pathway will contain specific questions in drop down format in order to identify these patients. The system is therefore reliant on the input of specific and accurate information from the referring dentist to ensure reliable identification.
Following input of this information, the algorithm will ensure that shielded patients (defined in guidance) in particular are separated from other patient groups by directing these patients to the local CDS services.
The patient’s GP and/or other dedicated health and social care professionals should be consulted as necessary to arrange face-to-face care in a way that aligns with the patient’s overall care needs and minimises contact risk.
Where appropriate, urgent dental care may be provided on a domiciliary visit by a dedicated dental team. If there is limited capacity for domiciliary care provision, consideration should be given to prioritising patients at highest risk (i.e. shielded patients).
In the event that a dental team identifies a shielded patient or patient at increased risk as having possible COVID-19 symptoms, refer to a medical practitioner for further assessment.
Train Staff on the Advice for Managing Dental Pain
The delivery of advice on managing dental pain requires suitable training.
Patients who are waiting for dental appointments might require basic advice on the effective management of their dental pain. Give the patient the following advice on the use of self-help measures, including appropriate analgesia to relieve pain.
- Avoid stimuli that precipitate or worsen the pain such as hot or cold foods or cold air.
- Holding cooled water or crushed ice around the tooth can help some types of dental pain.
- Severe pain from the mouth or teeth sometimes feels worse when lying flat; therefore, try lying propped up as this might ease the pain.
- Use painkillers that have successfully provided pain relief for you in the past without adverse effects.
- Avoid taking aspirin as a painkiller if there is bleeding.
- Ensure patients are reminded to follow the directions on the packet for advice on precautions in some medical conditions e.g. patients with asthma should avoid non-steroid anti-inflammatories.
- Advise the patient to call back if symptoms persist or worsen.
- The Practice ensures that there are facilities for everyone, including patients to wash hands with soap and hot water for at least 20 seconds, and/or hand sanitiser.
- Everyone should wash their hands. when they get home or into work, and while at work after blowing their nose sneezing or coughing, eating or handling food.
- The Practice ensures that there are adequate washing facilities and/or hand sanitiser at the workplace, e.g. entrances, reception/waiting rooms, break rooms, and in surgeries.
- Everyone must keep two metres apart, wherever possible. For working practices which necessitate closer working than the recommended public health advice, these will be facilitated with appropriate safety measures, such as PPE or protective screening.
- The need for all employees to social distance applies equally to work and break areas as well as changing facilities.
- The Practice will consider ways of ensuring that all movement around the premises and between sites supports social distancing. Recommended measures include, taking patient straight into surgery, and making entrances, corridors, stairways and aisles ‘one-way’ to prevent the risk of congestion.
- Employers will, where appropriate, stagger start/finish times, shift patterns, and lunch, tea and smoking breaks to reduce the number of employees in an area or using entrances/corridors at any given time.
- Employers will, where appropriate, keep the same team rosters every day to minimise contact with wider groups.
- Regular cleaning of touch points, such as door handles, hand rails, telephones, card machines and reception surfaces, using cleaning methods and products in line with the manufacturer’s guidance. Cleaning frequency would reflect how often touch points are used.
- Washing facilities and hand sanitiser supplies are kept stocked up.
- All waste bins are pedal operated.
- Bathroom sink has been updated with sensor tap and automatic soap dispenser.
- Minimise the use of shared tools, if this is not possible, then the equipment must be cleaned between each user.
- To be conducted via Zoom, whenever possible. Where physical meetings cannot be avoided, effective social distancing measures will be ensured.
Keeping Staff Safe
All staff are risk assessed on an ongoing basis to protect them and keep possible cases, household contacts, staff who should be shielded, or those at increased risk, away from work.
In line with government advice, it is recommended that as part of risk assessment, dental services review resource requirements for service operations and commitments. Where appropriate, this would allow staff to stay at or work from home if possible, to avoid non-essential travel and contact; or to participate in local workforce redeployment efforts in line with local arrangements.
Social distancing and good hygiene practice is promoted in the workplace.
Employees with suspected symptoms of Covid-19:
- Employees who have symptoms of the virus must let their employer know immediately, follow public health advice and stay at home. If the symptoms come on while at work, go home immediately. Where possible, an ‘isolation room’ should be designated if the employee cannot leave immediately – this must be cleaned thoroughly afterwards in line with public health advice.
- Employees who are designated as extremely vulnerable, and subject to shielding’ are strongly advised to stay at home at all times. They should also avoid any face to face contact. These measures are in place for a period of at least 12 weeks from the day they are informed by the NHS or their GP that they fall into this category.
To reduce cross contamination, consider:
- Use of a pre-operative 1% Hydrogen peroxide or 0.2% povidone-iodine mouth rinse if available.
- Rubber dam should be used where possible to reduce aerosol. After placing rubber dam decontaminate the operative field with sodium hypochlorite.
- Access into the pulp chamber only without instrumentation of the root canal system.
Alternative treatments to be considered:
- Dental extractions.
- Dressings only with caries removal.
- Using hand excavation.
- Avoid endodontic procedures.
- Avoid use of ultrasonic scaler.
Management of Aerosol Generating Procedures (AGP)
High-speed dental drills are accepted as AGPs. Using high-speed drills to open an access cavity or surgical high-speed drills to undertake surgical extraction of a tooth/root will necessitate use of enhanced PPE.
Particular care is to be taken to avoid surgical extractions at this time. Where it is necessary to remove bone, slow handpieces should be used with irrigation to reduce the risk.
The use of 3-in-1 syringes, ultrasonic scalers or other pieces of dental equipment powered by air compressor is to be avoided at this time. If, however, they are used as an adjunct to treatment with high-speed drills, staff will already have donned PPE for AGPs.
Non-AGP treatment of all patients involves compliance with standard infection control procedures. This will ensure there is no contact or droplet transmission of COVID-19. Eye protection, disposable fluid-resistant surgical mask, disposable apron and gloves should be worn.
As seen below hand-scaling is not considered an AGE
Non-aerosol generating procedures are listed here:
- Remote consultations
- Oral health assessment
- Preventative and self-care measures delivered in
line with Delivering Better Oral Health, non-AGP
- Hand instrumentation/scaling
- Simple dental extractions
- Caries excavation with hand instruments
- Caries removal with slow speed and high-volume
- Placement of restorative material
- Orthodontic treatment
- Removable denture stages (if patient has normal
- Paediatric oral health
For all AGPs, to prevent aerosol transmission, disposable, fluid-repellent surgical gown (or waterproof long-sleeved protective apron), gloves, eye protection and an FFP3 respirator should be worn by those undertaking or assisting in the procedure.
All AGPs are to be given 1 hour to settle before decontaminating the surgery.
Where patients cannot come to a dental surgery, dental professionals may be asked to provide advice remotely and to work with patients to defer the need for active treatment using pain control and antimicrobial treatment. The basic principles of the GDC’s guidance on remote consultation and prescribing apply (see GDC Guidance on remote consultations and prescribing).
- Make an appropriate assessment of your patient’s condition, prescribe within your competence and keep accurate records.
- Have an understanding of your patient’s current health and medication, including any relevant medical history, in order to prescribe medicines safely.
- Only prescribe medicines to meet the identified dental needs of your patients.
- Only use remote means to prescribe medicines for dental patients if there is no other viable option and it is in their best interests.
In the specific circumstances of COVID-19, the key requirement is to make an appropriate risk assessment. That risk assessment should be recorded by the dentist and should take into account the infection risk of COVID-19, both from and to the patient, as well the apparent seriousness of the need for treatment and the extent to which it has been possible to make a clinical assessment via telephone/video consultation.
Patients should have access to the 3A’s such as Advice, Analgesia and Antimicrobials and should not be advised to contact 111 as this is inappropriate. With the exception of patients that consider they have COVID-19 and require advice relating to COVID-19 symptoms (and not for dental advice), patients should not be advised to contact 111 and you should manage them yourself or refer to the hub if their system cannot be controlled.
National guidance can be found at: https://www.fgdp.org.uk/news/open-letter-prescribing-antibiotics-during-covid-19-%C2%A0
Antibiotics still need to be prescribed appropriately for the patient’s condition and should follow choice, dose and duration of antibiotic recommended in FGDP(UK) or SDCEP guidance.
- SDCEP: Drug prescribing for dentistry
- SDCEP: Drugs for the Management of Dental Problems During COVID-19 Pandemic
- The dental AMS toolkit also includes patient information leaflets that could be used to provide or reinforce key messages to patients.
Antibiotics should be prescribed in the following situations:
- If it is considered that the patient has a bacterial infection which requires antibiotics. This would include the treatment of acute apical or periodontal abscess and acute pericoronitis, necrotising ulcerative gingivitis/periodontitis.
- after discussion with the patient about the benefits and risks associated with the treatment options offered.
- with advice on what to do if symptoms continue to progress.
- with consideration of a follow-up call to the patient after a few days to check how their infection has responded to the antibiotics.
- Consider prescribing an antibiotic if there is any swelling even if it is only localised. In these situations, the prescription has a prophylactic role as ideal treatment which could be incisional drainage, extraction or opening the tooth up cannot be carried out.
Antibiotics should not be prescribed in the following situations:
- Because of a patient request.
- Routinely as part of a pathway to care.
- Acute pulpitis should still be managed only with painkillers with regimes described above – refer to analgesic advice section. Prescribing antibiotics is inappropriate as they are of no clinical benefit in managing dental pain from this inflammatory issue.
- Pain on biting in the absence of swelling should be treated with pain killers only.
Provision of a prescription
- During the current COVID-19 pandemic it may be appropriate to use a remote medium to prescribe analgesics and antimicrobials for patients. Pharmacists can supply medication through remote prescribing provided they receive a physical prescription within 72 hours. This applies to prescription only medication.
- Confirm patient details and obtain consent (or follow principles of the Mental Capacity Act 2005).
- Explain how the remote prescription process will work and what to do if the patient has any concerns.
- Explain that prescription will only be provided if it is safe to do so.
- Explain that it is not safe to prescribe without sufficient information about the patient’s health or if remote care is unsuitable to meet their needs.
- Explain it may be unsafe if relevant information is not shared with other healthcare providers involved in their care.
- If it is unsafe to prescribe then signpost to other appropriate services; see above triage SOP.
Prescribing via DERS
- Log onto DERS with your normal log in details.
- Add in the patient details, i.e. name, address, telephone number DOB to create a record and URN for the patient.
- Check medical history, medications, allergies, any contraindications and interactions.
- Answer the prompts as to the patients COVID-19 status – this is important. If the patient or a member of their family is symptomatic or self-isolating, they MUST not attend the pharmacy to collect the medication and must arrange for someone else to collect it.
- Shielded patients should also be advised to ask someone else to pick up the prescription. In some cases, the pharmacy may also deliver, but this will incur an additional charge to the patient and is up to the patient to arrange.
- Follow normal prescription guidelines and give patient any advice relevant to the medication prescribed.
- Select Prescription Pathway from the drop-down menu. Follow the prompts on the screen to create a record of the prescription. Select the appropriate medication, dose, route and frequency. Ensure items below have been completed.
- Check the opening times of the patient’s preferred pharmacy you are sending the script to via their profile on the NHS website
(https://www.nhs.uk/service-search/find-a-pharmacy) as some pharmacies may have needed to close because of COVID-19 related illness. Try to select the pharmacy local to the patient (after discussion with the patient as to which one they would like to use).
- You should telephone the pharmacy to confirm they have current access to their pharmacies NHS net mail shared account and to alert them that a dental prescription will be sent. Agree whether this is necessary each time a dental prescription is sent.
- Select the pharmacy from the list on DERS/REGO screen and then transmit the prescription to the pharmacy.
- Check the opening times of the patient’s preferred pharmacy you are sending the script to via their profile on the NHS website
- Send the referral. The system will save the referral in the prescribing tab visible from the front screen.
- The dentist should then write an identical FP10D and sign it prior to posting or otherwise delivering it to the pharmacy. Please remember to sign and print the prescribers name clearly, along with GDC number, as well as using the practice stamp showing the provider contract number if appropriate.
- To help manage patient expectations
- When you have sent the email to the pharmacy, contact your patient and advise them when to go to the pharmacy. This should ideally be 3 hours after the sending of e-mail to allow for dispensing, however if the patient has a large swelling, medication should be collected and taken as soon as possible.
- Remind the patient to check pharmacy opening times before travelling.
- Some pharmacies may be extremely busy and therefore enforcing social distancing, and in addition their workloads may result in some pharmacies having 2-3-hour queues at peak times.
The patient or whoever collects the medication must be made aware to tell the pharmacist they have come to collect a dental prescription which has arrived via the pharmacy nhs.net shared email account and will be available in their inbox. They should advise the pharmacist this is not via the usual method that GPs use (EPS) but from a dentist.
- It is the dentist’s responsibility to post the original hand-written prescription (FP10D) to the pharmacy by FIRST CLASS POST to arrive within 3 working days. The pharmacy address can be found on the DERS/REGO screen or on the NHS UK website (link shown above). It is a legal requirement to ensure the prescription arrives at the pharmacy within 72 hours.
- Give an email address on an enclosure in the envelope with the FP10D prescription to which, the pharmacy can acknowledge receipt of the prescription original.
- Ask the patient to contact you if they are unable to obtain the prescription.
- All pharmacies have been advised to accept dental prescriptions via these mechanisms, under the “urgent supply at the request of a prescriber” as included in the pharmacy’s terms of service. It is also a requirement that pharmacies have access to their nhs net mail shared account. Dentists can refer pharmacies to their Local Pharmaceutical committee website where this information has been posted. Dentists experiencing difficulties with a specific pharmacy which cannot be resolved locally can email Southeastcommunitypharmacy@nhs.net. Dentists should send any other queries on this process, not relating to the use of DERS to England.firstname.lastname@example.org.
- All records to be kept in accordance with guidelines to include justification for remote prescription (see Record Keeping section of this document).
- Make an entry of any prescription in the prescription log.
- Keep a record of paper prescription sent and confirmation of receipt by pharmacy.
- Keep a record of the URN associated with the prescription for entering onto patients notes. Await confirmation of receipt by pharmacy.
The patient should be advised that antibiotics will not be effective immediately but if their condition does not improve, they should seek further dental advice.
This document is subject to change as new NHS guidelines are released.
Document completed on 27/05/2020 by T Hale