On 15 April 2020, NHS England published updated guidance for dentists which addresses the provision of urgent dental care during the COVID-19 pandemic. The full guidance can be found here.
Further to NHS England’s previous guidance, it is reiterated that the provision of all routine, non-urgent dental care has been suspended until further notice. In providing urgent or emergency dental care, the guidance states that each COVID-19 urgent dental care (UDC) system should deliver the following:
- A clear message to the public to advise that routine dental care is currently unavailable and what to do if urgent dental care is required;
- Have in place a remote consultation and triage service whose outcomes are to either:
- advise, analgesia, antimicrobials (AAA) or
- refer to a designated UDC site for a face-to-face consolation and treatment (but only if absolutely necessary)
- Face-to-face consolation and treatment service (but only following remote triage and if the correct PPE is utilised for treatment procedures).
Where face-to-face treatment is required, the designated sites involved will need to have in place separation and treatment protocols to protect the safety of staff and patients for example, by introducing physical measures such as zones, and temporal measures such as certain appointment times.
The approach for the following different types of patients should also be considered:
- Patients who are possible or confirmed COVID-19 patients, including those with symptoms;
- Higher risk (shielded) patients;
- Patients with an increased risk;
- Patients who do not fit into one of the above categories.
Standard operating procedures for urgent care services
The Guidance refers to the patient pathway for UDC consisting of two stages: remote management and face-to-face management. Whilst the standard operating procedures (SOP) for Remote Management will apply to all services providing urgent dental care, the SOP for face-to-face management will only apply to those services receiving patients in person. Therefore, all dental service providers should be familiar with the SOP for Remote Management.
- Effective communication to patients at an early stage should reduce the number of patients making inappropriate contact with the service.
- A risk assessment of each patient should be undertaken remotely and questions should be asked to ascertain which group the patient belongs to, what risk would be posed to the patient if they contracted COVID-19, and to determine any isolation requirements.
- Dental triage should also be conducted remotely to determine issues such as whether urgent dental care can be managed remotely or be delayed, appropriate referral to the relevant part of the local UDC service and the prioritisation of patients with the most urgent care needs.
- Assessment and management of each patient should be achieved by consideration of the patient’s best interests, professional opinion, local UDC arrangements and prioritisation of patients with the most urgent care needs.
- Social distancing measures should be applied as much as possible. Physical and temporal measures should be implemented to separate patients, and additional separation measures should be in place for high risk or increased risk patients. Patient escorts should also be restricted unless absolutely necessary, and the number of patients in communal areas should be minimised as much as possible.
- Covid-19 infection control procedures should be followed including the appropriate use of PPE.
Approaches for shielded and increased risk patients
NHS England has advised that these patients should not come into contact with others or attend a dental setting unless absolutely necessary. Management of these patients should be done remotely if possible, and any invasive treatment delayed. If face-to-face treatment is needed, dental teams should align with any local arrangements in place via primary, community and secondary care services for patients in these groups, and the patient’s GP should be contacted. If necessary, urgent dental care may be provided on a domiciliary visit or at a designated UDC provider if this is not possible.
Guidance for infection protection and control in urgent dental settings
A summary of the current infection and control guidance can be found here.
Patients must be triaged/assessed for infection risk to ensure they are directed to the correct urgent care dental site. If possible, patients should instead be treated with advice, analgesia, antimicrobials. Where face-to-face treatment is required, enhanced PPE must be worn for Aerosol Generating Procedures (AGPs) however, these procedures should be avoided unless absolutely necessary. Guidance on the appropriate PPE applicable for both AGP and non-AGP urgent dental care procedures can be found here.
Actions for dental services
Dental service providers should appoint a COVID-19 lead for the co-ordination of activities within a dental service, training, preparation and implementation of SOPs.
In summary, dental care services should ensure the following:
- Keep staff safe by undertaking individual risk assessments and by promoting social distancing guidelines and hygiene practices
- Inform the public and commissioners of their service status
- Communicate with the local UDC system
- Keep aware of updates, alerts and communications in respect of further and updated guidance and information.
Remote prescribing protocol
In respect of protocol, dental services should work with pharmacy colleagues and align with any local arrangements for remote prescribing. A recommended prescribing protocol can be found in the guidance here.
Preparation for incident management for unwell patients with possible/confirmed COVID-19
The guidance recommends that service providers may wish to draw on their existing protocols for dealing with medical emergencies by:
- Developing and rehearsing the service provider’s COVID-19 triage protocols and isolation procedures;
- Reviewing the Coronavirus infection control protocols;
- Anticipating an impact on service schedules.
The further guidance discussed above will certainly be welcomed by the dental community in providing some additional clarity on arrangements for care moving forward.
Victoria Mortimer, Trainee Solicitor, BLM