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/Institutions/University-of-Maryland-School-of-Dentistry/json/Clinic-Manual/Clinic-Manual.json

General Patient Care Protocol

General Patient Care Protocol
Subject: III. Clinical – G. Infection Control
Effective Date: July 20, 2021
Reviewed or Revised Date: 08/17/2021, 02/25/2022

UMSOD adheres to OSHA and CDC Guidelines: CDC Guidance for Dental Settings
OSHA Guidance on Preparing Workplaces for COVID-19

Hand Hygiene

Ensure HCP practice strict adherence to CDC Hand Hygiene in Healthcare Settings, including:

• Before and after all patient contact, contact with potentially infectious material, and before putting on and after removing personal protective equipment (PPE), including gloves. Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process.
• Use Alcohol-Based Hand Sanitizer (ABHS) with 60-95% alcohol or wash hands with soap and water for at least 20 seconds. If hands are visibly soiled, use soap and water before returning to ABHS.

Facility Considerations

• Take steps to ensure patients and staff adhere to respiratory hygiene and cough etiquette, as well as hand hygiene, and all patients follow triage procedures throughout the duration of the visit.
• Post visual alerts (e.g., signs, posters) at the entrance and in strategic places (e.g., waiting areas, elevators, break rooms) to provide instructions (in appropriate languages) about hand hygiene and respiratory hygiene and cough etiquette. Instructions should include wearing a cloth face covering or facemask for source control, and how and when to perform hand hygiene.
• Provide supplies for respiratory hygiene and cough etiquette, including alcohol-based hand rub (ABHR) with 60– 95% alcohol, tissues, and no-touch receptacles for disposal, at healthcare facility entrances, waiting rooms, and patient check-ins.
• Install physical barriers (e.g., glass or plastic windows) at reception areas to limit close contact between triage personnel and potentially infectious patients.
• Place chairs in the waiting room at least three feet apart.
• Remove toys, magazines, and other frequently touched objects that cannot be regularly cleaned or disinfected from waiting areas.
• Minimize the number of persons waiting in the waiting room.
• Patients may opt to wait in a personal vehicle or outside the dental facility where they can be contacted by mobile phone when it is their turn for dental care.
• Minimize overlapping dental appointments.
• Ideally, dental treatment should be provided in individual patient rooms whenever possible.
• For dental facilities with open floor plans, to prevent the spread of pathogens there should be:
  • At least 3 feet of space between patient chairs.
• Patient volume - Ensure to account for the time required to clean and disinfect operatories between patients when calculating your daily patient volume.

Universal Source Control

As part of source control efforts, Healthcare Providers (HCP) should wear a facemask at all times while they are in the dental setting.

• HCP whose job duties do not require PPE (such as clerical personnel) will wear regular facemasks for source control while in the dental setting.
• Other HCP (such as dentists, dental hygienists, dental assistants) will wear regular facemasks for source control when they are not engaged in direct patient care activities and then switch to UMSOD approved respirator when PPE is required.
• HCP should remove their respirator, perform hand hygiene, and put on their cloth face covering when leaving the facility at the end of their shift.
• HCP should also be instructed that if they must touch or adjust their mask or cloth face covering, they should perform hand hygiene immediately before and after.

Because facemasks and cloth face coverings can become saturated with respiratory secretions, HCP should take steps to prevent self-contamination:

• HCP should change facemasks and coverings if they become soiled, damp, or hard to breathe through.
• Cloth face coverings should be laundered daily and when soiled.
• HCP should perform hand hygiene immediately before and after any contact with the facemask or cloth face covering.

Using Personal Protective Equipment (PPE)

For all dental procedures, HCP should wear:

• Gown
• Head Cover
• N95 Respirator or Equivalent with Surgical Mask Over the Respirator Mask
• Full-Face Shield
• Gloves

Sequence for HCP includes:

Before entering a patient room or care area:

1. Perform hand hygiene.
2. Put on head cover
3. Put on a clean gown or protective clothing that covers personal clothing and skin (e.g., forearms) likely to be soiled with blood, saliva, or other potentially infectious materials.
   • Gowns, protective clothing, and head cover should be changed:
     • If they become soiled
     • Between patients if exposed to aerosol
4. Put on N95 respirator or equivalent.
   • Mask ties should be secured on the crown of the head (top tie) and the base of the neck (bottom tie). If mask has loops, hook them appropriately around your ears.
   • Respirator straps should be placed on the crown of the head (top strap) and the base of the neck (bottom strap). Perform a user seal check each time you put on the respirator.
   • A surgical mask should be worn over the N95 mask
5. Put on eye protection.
   • Personal eyeglasses and contact lenses are NOT considered adequate eye protection. 
   • Put on face shield (full-face shield is also required for all procedures
   • Eye
6. Perform hand hygiene.
7. Put on clean non-sterile gloves.
   • Gloves should be changed if they become torn or heavily contaminated.
8. Enter the patient room. After completion of dental care:

After completion of dental care:

1. Exit the patient room or care area.
2. Remove gloves and discard in medical waste.
3. Remove face shield carefully by grabbing the back and pulling upwards and away from head. Do not touch the front of face shield.
4. Remove gown and discard in a dedicated container for waste or linen.
   • If they become soiled
   • Between patients if exposed to aerosol
5. Perform hand hygiene.
6. Remove eye protection (loupes) carefully by grabbing the back and pulling upwards and away from head. Do not touch the front of any eye protection.
7. Remove respirator.
   • Do not touch the front of the respirator.
   • Surgical mask: Carefully untie the mask (or unhook from the ears) and pull it away from the face without touching the front.
   • Respirator: Remove the bottom strap by touching only the strap and bring it carefully over the head. Grasp the top strap and bring it carefully over the head, and then pull the respirator away from the face without touching the front of the respirator.
8. Remove head cover and discard in a dedicated container for waste or linen.
   • If they become soiled
   • Between patients if exposed to aerosol
9. Perform hand hygiene.
10. Put on clean non-sterile gloves to disinfect reusable face shield and loupes according to manufacturer’s instructions prior to reuse.
11. Remove gloves and discard in medical waste.
12. Perform hand hygiene.

Pre-Appointment Screening

• Contact all patients prior to dental treatment.
  • Telephone screen all patients for symptoms consistent with COVID-19. If the patient reports symptoms of COVID-19, avoid non-emergent dental care and use the Phone Advice Line Tool for Possible COVID-19 patients. If possible, delay dental care until the patient has recovered.
  • Telephone triage all patients in need of dental care. Assess the patient’s dental condition and determine whether the patient needs to be seen in the dental setting. Use tele dentistry options as alternatives to in-office care when possible.
  • Inform patient of the limit of visitors accompanying the patient to the dental appointment to only those people who are necessary.
  • Advise patients that they, and anyone accompanying them to the appointment, will be requested to wear a cloth face covering or facemask when entering the facility and will undergo screening for fever and symptoms consistent with COVID-19.

Arrival at School

• Patients should not attempt entry into the school until 15 minutes before appointed time
• Entry – first floor entrance; need physical distancing in the line
• Screening at School Entrance - Systematically assess all patients and visitors upon arrival. Step by step procedure, see COVID Screening - Triage Procedure 
  • Ensure that the patient and visitors have donned their own cloth face covering. Provide a facemask if supplies are adequate.
  • Screening questions; temperature taken; mask required; UMSOD will provide mask as needed; hand gel available.
    • Pass – patient permitted to enter school and proceed to proper clinic
    • Fail – patient referred to personal physician for evaluation; medical clearance will be required for future appointments
  • Ask about the presence of fever or other symptoms consistent with COVID-19.
  • Actively take the patient’s temperature.
  • If the patient is afebrile (temperature < 100.4˚F)* and otherwise without symptoms consistent with COVID-19, then dental care may be provided using appropriate engineering and administrative controls, work practices, and infection control considerations (described below).
    • *For the general population, fever is measured as a temperature ≥100.4˚F. Fever may be subjective or confirmed. If the patient has a fever strongly associated with a dental diagnosis (e.g., pulpal and periapical dental pain and intraoral swelling is present), but no other symptoms consistent with COVID-19 are present, care can be provided with appropriate protocols.
  • Escorts – must wear mask
    • One escort is permitted if patient has need
      • Language interpreter
      • Guardian or parent (one parent only)
  • Children are not permitted to accompany patients past the front door entrance; patient will need to re-schedule appointments if they have children.
  • Spouse / partner – may accompany to clinic wait room; may not go into treatment area.

Reception Area

• Rearrange seating to ensure 3-foot social distancing. For seats that cannot be split up, block off neatly ensuring 3-foot social distancing.
• Remove all magazines, books, etc.
• Patients and escorts must wear masks.
• Hand sanitizer is available.
• Arm rests and tables wiped down every morning and periodically during the workday.
• Goal is to be timely with appointments to minimize presence in reception areas.

Patient Check-in at Reception

• Physical distancing in effect – need to mark floor
• Students / residents should be ready to receive patient as soon as they arrive.
• Patients can sit in reception room chairs – avoid chairs that are marked off.
• Restrooms – patient restrooms with physical distancing marked; recommend that patient use facilities if they need as they will not be able to leave treatment area.

Operatory Protocol

• Ensure that environmental cleaning and disinfection procedures are followed consistently and correctly after each patient. Clean and disinfect the room and equipment according to the Guidelines for Infection Control in Dental Health-Care Settings – 2003.
• Limit clinical care to one patient at a time whenever possible.
• Set up operatories so that only the clean or sterile supplies and instruments needed for the dental procedure are readily accessible. All other supplies and instruments should be in covered storage, such as drawers and cabinets, and away from potential contamination. Any supplies and equipment that are exposed but not used during the procedure should be considered contaminated and should be disposed of or reprocessed properly after completion of the procedure.
• Avoid aerosol-generating procedures whenever possible. Avoid the use of dental handpieces and the air/water syringe.
• If aerosol-generating procedures are necessary for dental care, use four-handed dentistry, high evacuation suction and dental dams to minimize droplet spatter and aerosols. The number of Healthcare Providers (HCP) present during the procedure should be limited to only those essential for patient care and procedure support.
• If possible, all aerosolizing procedures should be performed with the Ajax Extraoral Evacuation Device.
• Preprocedural mouth rinses (PPMR) - All patients will rinse with 20 ml of Listerine for 30 seconds prior to every dental appointment.
• Clean and disinfect room surfaces.
  • ALL clinical contact surfaces will be disinfected with EPA approved surface disinfectant.

Treatment Areas

• Patients should continue to wear masks until instructed to remove mask
• Patients may not leave treatment area once procedure begins
• Student or Resident provider should remain in treatment bay until procedure is completed
• Employ runners to bring additional supplies – students not involved in active treatment can perform that function

Additional Precautions or Strategies for Treating Patients with Suspected or Confirmed COVID-19

• If a patient arrives at your facility and is suspected or confirmed to have COVID-19, defer dental treatment and take the following actions:
• If the patient is not already wearing a cloth face covering give the patient a facemask to cover his or her nose and mouth.
• If the patient is not acutely sick, send the patient home, and instruct the patient to call their primary physician.
• Provide patient with handout INFORMATION FOR INDIVIDUALS DENIED ACCESS TO SCHOOL OF DENTISTRY DUE TO COVID SCREENING.
• Patient will have to provide written medical clearance from their physician that their patient is clear of the virus before the patient can be treated in any clinic in the school.
• If the patient is acutely sick (for example, has trouble breathing), refer the patient to a medical facility, or call 911 as needed and inform them that the patient may have COVID-19.

Guidance for Risk Assessment and Work Restrictions for Healthcare Personnel (HCP) with Potential Exposure to COVID-19.

CDC Guidance for Risk Assessment and Work Restrictions for Healthcare Personnel with Potential Exposure to COVID-19.

• “Prolonged” is defined as a time period of 15 or more minutes.
• Any duration of exposure should be considered prolonged if the exposure occurred during performance of an aerosol-generating procedure.
• The time period that should be used for contact tracing after exposure to asymptomatic individuals who test positive for SARS-CoV-2 is 2 days. Recent data suggest that asymptomatic persons may have a lower viral burden at diagnosis than symptomatic persons.
• Work Restrictions
  • Exclude from work for 14 days after last exposure
  • Advise HCP to monitor themselves for fever or symptoms consistent with COVID-19.
  • Any HCP who develop fever or symptoms consistent with COVID-19 should immediately contact their established point of contact (e.g., occupational health program) to arrange for medical evaluation and testing.

Monitor and Manage Health Care Personnel

• As part of routine practice, HCP should be asked to regularly monitor themselves for fever and symptoms consistent with COVID-19.
  • HCP should be reminded to stay home when they are ill.
  • If HCP develop fever (T≥100.0˚F) or symptoms consistent with COVID-19 while at work, they should keep their cloth face covering or facemask on, inform their supervisor, and leave the workplace.
• Screen all HCP at the beginning of their shift for fever and symptoms consistent with COVID-19.
  • Actively measure their temperature and document absence of symptoms consistent with COVID-19.
  • Clinical judgement should be used to guide testing of individuals in such situations.
  • Medical evaluation may be warranted for lower temperatures (<100.0˚F) or other symptoms based on assessment by occupational health personnel. Additional information about clinical presentation of patients with COVID-19 is available.
• If HCP experience a potential work exposure to COVID-19, follow CDC’s Healthcare Personnel with Potential Exposure Guidance.
  • If HCP suspect they have COVID-19:
  • Do not come to work.
  • If HCP are ill at work, have them keep their cloth face covering or facemask on and leave the workplace.
  • Notify their primary healthcare provider to determine whether medical evaluation is necessary.
  • HCP with suspected COVID-19 should be prioritized for diagnostic testing.
  • Information about when HCP with suspected or confirmed COVID-19 may return to work is available in the Interim Guidance on Criteria for Return to Work for Healthcare Personnel with Confirmed or Suspected COVID-19.
• For information on work restrictions for health care personnel with underlying health conditions who may care for COVID-19 patients, see CDC's FAQs.