OVERARCHING PRINCIPLES :

This document outlines the policies, guidelines and procedures that we have put into place at ARTIS DENTAL CENTRE to reduce the risk of COVID-19 transmission and protect the safety of all our patients and staff.

In-person services will only proceed when the anticipated benefits of such services outweigh the risks to the patient, the health professional, and the greater community. It is always safer for the patient and the provider to stay home if at all possible.

The dentist is accountable for prioritizing access to in-person services based on clinical judgment and with consideration given to the patient perspective and the referral source. When determining priority for in-person care, dentists should reflect upon the following: • Acuity of the patient’s condition. • Functional impor impact of the condition on health-related quality of life. • The impact of not receiving services. • Appropriateness of service provision via virtual care. • Necessity of services which can only be provided in-person. • Duration of patient wait times for care.

ThisWorkplace COVID-19 Safety Plan will be posted on the business website, and in the clinic, where it is readily available to workers, patients and others who may attend the workplace

All the modifications made are based on reducing the risk of spreading infection—from pre-appointment triage to physical distancing to personal protective equipment(PPE). The COVID-19 illness is especially challenging because infected people may not have any symptoms and do not know they are infected. For this reason, PPE measures must be followed in full because each works together with the others to reduce the risk of the spread of infection.

The health of the dental office staff is paramount and must be monitored for the continued health of the dental team. Daily staff screening focuses on this principle and includes a daily log confirming that they are not experiencing any symptoms of COVID-19.

Strict staff hand hygiene is of paramount importance. Staff have been instructed to wash or disinfect hands thoroughly: • Upon entry into the dental office. • Before and after any contact with patients. • After contact with contaminated surfaces or equipment. • In between procedures and after removing PPE depending on the procedure, following established PPE protocols.

CLINIC MODIFICATIONS MADE:

In light of COVID 19, we have modified our premises to ensure that the highest levels of infection control are maintained for everyone’s safety

All magazines and toys in waiting rooms have been removed.

No coffee service or massage chair access will be provided until the government advises that all pandemic restrictions can be lifted.

Plexi-glass screens were installed to create a divider to protect both patient and receptionist.  The receptionist conduct business from behind the plexiglass screen.

To address the issue of patients touching a contaminated surface, all light switches in our bathroom facilities have been changed so that they turn on & off automatically on entry and do not require a patient to touch to switch at all.  Additionally, foot-peddled garbage cans have been placed in the bathrooms and also in the reception areas that do not require patients to ‘touch’ anything to void or discard items of garbage.

We are fortunate that in the design of our clinic spaces, ‘closed operatories’ were ingeniously created along with ‘open concept’ operatories. Having this mix is indeed convenient at a time like this when we can now partition and assign specific procedures to specific operatories.  As such, all AEROSOL GENERATED PROCEDURES (AGPs) will be performed in ‘closed operatories’ and all NON-AEROSOL GENERATED PROCEDURES (NAGPs) will be performed in the ‘open concept’ operatories.  Furthermore, 2 operatories (OP 8 in NW & OP 3 in NV) were modified (by hiring a qualified contractor) by applying plastic screening materials to ‘close’ off all voids and hence make them useable for AGPs.

In order to prevent patient collision / unexpected meet ups, blue painters tape was used to create a ‘One-Way’ flow for traffic in the clinical space. The visible markings on the floor will clearly indicate the correct flow that both patients and office staff must use to travel within the clinic’s spaces.

TEAM TRAINING SESSIONS PRE-OPENING:

Two weeks prior to re-opening, all ARTIS Doctors, RDH’s, CDA’s and Admin personnel were invited to participate in a ZOOM PRESENTATION led by Dr. Amin Damji, entitled, “ARTIS RE-OPENING PROTOCOL:  A COVID-19 ORIENTATION & TRAINING PRESENTATION on TUESDAY May 5^th at 10:30AM. The purpose of this presentation was to ‘align’ all team members on the new protocols that will need to be implemented when we return to face our ‘new normal’.

Small group ‘In-Clinic” orientation meetings were also held at both clinics to ensure that all team members were apprised of the new protocols that we have implemented to ‘Welcome Back’ our patients to ARTIS.  Especially for meeting and greeting patients, admin staff members were also asked to ‘role play’ their newly modified roles to welcome patients and ensure that all protocols were being followed to ensure everyone’s safety.

Signage has been posted at the main entrance to restrict individuals from entering the premise should they be displaying symptoms related to Covid-19.  There is also a sign to maintain physical distancing on the patient seating bench.  Also, another sign to indicate patient entry protocol: 1. Sanitize hands; 2. Wear mask; 3. Wear gloves.

A Visitor Sign In Rosterhas also been devised and placed at the entry of the clinic for any visitors (ie. non-patients) including the mailman, delivery people, lab pick up and drop off drivers, potential new patients, etc. Admin team members have been instructed to ask them to “sign in” on entry and then proceed to partake in hand sanitizing before making their requests / drop offs.

All Team members were encouraged to give input on any health or safety concern they wish to discuss or bring to attention with either the practice owner or the office manager.

We are aware that things may change as the business opens up and operates. As the pandemic continues to unfold and close, this document will be modified as needed to keep abreast of any changes that may occur.

WORKING POLICIES FOR ALL TEAM MEMBERS:

Our team members have been advised that we will all abide by the guidance that has been issue by the provincial health officer and the BC CDC around self-isolation:

• Anyone who feels ill or unwell, should not present to work. They must immediately alert the office manager of their condition so that steps can be taken to either ill their shift with another employee or modify the schedule accordingly.
• Team members who start feeling ill while at work should immediately notify the office manager of their condition and make the necessary arrangements to travel safely from the clinic to their home. If the case necessitates, then a taxi or Uber will be arranged to take the employee safely home.
• Anyone who has had symptoms of COVID-19 in the last 10 days must self-isolate at home; symptoms include fever, chills, new or worsening cough, shortness of breath, sore throat and new muscle aches or headache.
• anyone under the direction of the provincial health officer to self-isolate must follow those instructions
• anyone who has arrived from outside of Canada, or who is a contact of a confirmed COVID-19 case, to self-isolate for 14 days and monitorfor symptoms

ADMIN TEAM PROTOCOL:

The following PROTOCOLS have been developed to ensure the highest level of safety of all working staff and patients alike.  We want to ensure that the risk of exposure to SARS COV-2, the virus that causes COVID-19 is minimized in our clinic.

Our team of professionals are experts at infection control and they want to ensure everyone complies with physical distancing and other requirements to reduce the transmission of the virus.

Administrators have been instructed to be aware that appointment times may need to be staggered.  Also they have been asked to implement a 10-30 mins “grey box” in Tracker:  time allotted to disinfection protocol, donning/doffing, etc

Patients will be reminded to:

• Return the New Patient Health History form that we emailed them – it should be completed prior to their arrival at the clinic.
• Reschedule if they become sick, are placed on self-isolation, or have travelled out of the country within the last 14 days.
• Attending appointments alone where possible, and not bring friends or children.

All admin team members have been requested to wear appropriate PPE:  including a gown, gloves, level 3 mask and face shield.

Due to the size of the administrative area (reception space), the overall number of employees positioned here will be reduced to one or two maximum so that a 2 meter physical distance can be maintained between team members.

Signs have been placed in the waiting room highlighting that physical distancing must be observed between patients who are seated. No more than 3 patients can be in the waiting room at any given time. Signs have also been posted on the entrance doors to the clinic, warning those who have symptoms NOT to enter.

Patients will be asked health screening questions when making their appointment and on the day of their appointment, and on entering the clinic, will be asked to immediately sanitize their hands, and wear a mask and gloves.  An infra-red thermometer will also be used to ensure that each patient has a ‘normal’ temperature and is not running a fever.

Pre-appointment screening or triage is critically important in assessing the risk the patient may have a COVID-19 infection. Here are typical screening questionsthe receptionist must ask the patient before the appointment:

1. Are you aware you are COVID-19 positive or are you waiting for a test result?
2. Do you have a fever or have felt hot or feverish anytime in the last two weeks (14 days)?
3. Do you have any of the following symptoms: Dry cough? Shortness of breath? Difficulty breathing? Sore throat? Runny nose? Post-nasal drip?
4. Have you experienced a recent loss of smell or taste?
5. Have you been in contact with any confirmed COVID-19 positive patients, or persons self-isolating because of a determined risk for COVID-19?
6. Have you returned from travel outside of Canada in the last 14 days?
7. Have you returned from travel within Canada from a location known affected with COVID-19?
8. Is your workplace considered high risk? (E.g. routine close contact with many people)
9. When screening results indicate a patient may be more likely to have COVID-19, defer appointments for 14 days or more if possible, treat with enhanced PPE or refer to appropriate facility for care.

Each patient will then be instructed to fill out a COVID 19 CONSENT FORM answering a variety of risk assessment questions.

Once a patient has left the waiting room, admin team staff have been instructed to clean and disinfect the space that was occupied by the previous patient. Ie. Seating site / table, etc. as well as the plastic clipboard that housed the consent form and the pen used by the patient.  Cavicide wipes and spray have been dispensed to all admin staff for this duty.

Admin team members are also responsible to clean/disinfect the patient bathroom space including the door handles between patient use.

Receiving Deliveries:  All visitors to the clinic who are not patients, must sign in on arriving to the clinic.  The VISITOR SIGN-IN ROSTER was created to ensure that all delivery personnel, etc. must sign in when making deliveries.  All deliveries will be placed in the “toy area” – since this site is empty and no longer in use.  Minimize transmission risk with procedures such as: • Consider wearing gloves when collecting and/or accepting mail or packages. • Screen delivery personnel. • Consider sanitizing the exterior of boxes delivered. • Consider sanitizing all surfaces that were touched by delivery items.

To obey the rules of physical distancing, only one person will be allowed to eat in the staff room / lunch table at a time.

CLINICAL TEAM PROTOCOL:

On returning to practice after the 6 week break, all dental unit water lines were “shocked” to ensure any unwanted biofilm was dealt with and that clean, safe water was once again available.  The product LINES was used to “shock” the system and ICX disinfectant tablets are to be introduced into the water bottles of operatory units to ensure that water levels are maintained free of infection.

All common clinical touch surfaces will be disinfected regularly by the CDA’s and RDH’s.

Upon being seated in the operatory chair, patients will be asked to rinse their mouths with a 1% hydrogen peroxide rinse for 1 min before treatment commences.

Splattermust be minimized through the choice of procedures, and any splatter must be controlled with high volume evacuation (HVE) and careful handling of splattered PPE, clothing and surfaces. Absolute care is needed to ensure any splatter is not carried outside the procedure area. Splatter is the most common infectious risk in the dental office with an infectious virus.

Aerosol Generating Procedures (AGPs)

Potentially infectious aerosols may be minimized with the following steps: • Have the patient rinse with 1% hydrogen peroxide (H2O2) for 60s. • Apply a sealed rubber dam to isolate the procedure area, then swab exposed procedure area with H2O2 prior to beginning treatment • Use of HVE

Clothing and Office Environment In the highly infective COVID-19 environment, all dental office staff should consider wearing scrubs at work. Scrubs and shoes should be only worn in the office and should be put on when entering the office at the start of the day and removed at the office at the end of the day

The following measures should be considered for AGPs

• Limit AGPs as much as possible • Have patient complete a pre-procedural rinse with 1% hydrogen peroxide, or similar, for 60 seconds. Have patient spit rinse back into cup provided, not the sink. • User rubber dam and HVE wherever possible • Where possible, increase air circulation (exchanges) and ventilation in operatories (e.g. by opening window or maintaining efficient HVAC systems). • Low risk, use standard precautions • Increased risk, use enhanced precautions

Personal Protective Equipment (PPE)

Personal Protective Equipment (PPE) is a key line of defense for dental office staff in preventing infection. In a pandemic environment, all dental office staff should be using the appropriate PPE. The necessary PPE is indicated by the CDSBC, BCCDC and WorkSafeBC and it is based on the dental care being provided, or function in the dental office (e.g. reception, room cleaning, etc.). It is also based on the risk level for the patient as determined by the pre-appointment and appointment arrival screening questionnaires.

According to the BCCDC, “Where there is low incidence and prevalence of Covid-19, additional PPE over and above that required for normal precautions is not recommended”. This assumes the patient also screens negative for COVID-19 risk.

Despite this, we at ARTIS DENTAL CENTRE feel that it is better to be proactive and protect ourselves and our patients by assuming that anyone might be a carrier of the CoV2-SARS virus – as many individuals may be ASYMPTOMATIC.  Hence, as advised by our N95 Fit Tester, we will continue (by individual choice) to wear a fit tested N95 mask whenever we perform an AGP.

Enhanced precautions, such as a fit-tested N95 respirator, goggles/face shield, and gown are only required for AGPs on patients with suspected or confirmed COVID-19. (However, these high-risk cases would most likely not be treated in a typical community dental practice.) Appropriate personal protective equipment (PPE) must be used for the safe delivery of in person care. However, all dentist must also act to conserve PPE through its judicious use.

When patient is seated in operatory:

• Chair-side staff, wash hands and don mask before entering operatory.
• No hand-shaking or physical contact.
• Wash hands and don gloves in-room.
• Review overall health history, confirming that the screening questions were asked during the check-in procedure, and review if necessary.
• Remove mask only outside operatory.
• Limit movement out of operatory as much as possible.
• Clean operatory while wearing PPE.
• Wash hands after doffing PPE
• Ensure PPE is donned and doffed appropriately. Refer to resources on the BCCDC site: http://www.bccdc.ca/health-professionals/clinical-resources/covid-19-care/infectioncontrol/personal-protective-equipment

As the patient is leaving:

• Choose a touchless payment method, if possible.
• Have the patient wash or disinfect their hands before leaving the office.