Spa Creek Dental COVID-19 Infection Control Policy and Protocol
Note: Virginia Elder Care Dentistry PLLC is a subsidiary partner of Spa Creek Dental, and will be adopting and adhering to these policies and protocols.
This page will be updated as needed with any additional infection control policies and protocols 

1.               Purpose
2.               General Guidelines Policy
3.               Conducting Self-Assessment
4.               PPE Requirements
5.               Putting on and Removing PPE
6.               Entering Senior Communities and Operatory Preparation
7.               Infection Control During Appointment
8.               Operatory Maintenance Between Patients
9.               Exiting Senior Communities
10.              Statement on Treatment of Patients Who Have Recovered from COVID-19
11.              Statement on Clinicians who Have Recovered from COVID-19
12.              FAQ

 
Purpose: To reduce the risk of exposure to contagious agents that are spread by droplet contact, such as the coronavirus SARS-CoV-2, by expanding on our current infection control procedures which are based on “Standard Precautions”. The goal of these new measures is to mitigate risks and protect our clinicians and patients. This includes the use of proper Personal Protective Equipment (PPE) in all patient encounters including, but not limited to, the management of aerosol producing procedures. This protocol should allow for a gradual return to “normal operations” and the continuation of providing a reasonable level of care and services to our patients. We will continue to monitor recommended updates by official bodies such as the CDC, OSHA, and ADA and update our protocols accordingly.

General Guidelines: Spa Creek Dental will be following CDC recommendations for risk assessment of clinicians, staff, and patients, as published in the “Interim U.S. Guidance for Risk Assessment and Public Health Management of Healthcare Personnel with Potential Exposure in a Healthcare Setting to Patients with Coronavirus Disease (COVID-19)” 

• All Spa Creek Dental clinicians will have training on these guidelines to ensure established protocols are understood and compliance is adhered to.
• All Spa Creek Dental clinicians will complete daily self-assessments prior to attending any clinic as outlined in the sections below.
• All clinicians, community staff, and patients who enter a Spa Creek Dental clinical room must have body temperature measured. Those with body temperature of 100.4°F or above will be turned away.
• All clinicians, community staff, and patients who enter a Spa Creek Dental clinical room must undergo screening and must be wearing masks at all times. Removal of masks is permitted for patients during treatment.
• All clinicians, community staff, and patients must observe social distancing at all times except for patient transport and patient care
• Spa Creek Dental will not treat any patients who are experiencing symptoms of COVID-19. These symptoms include: fever >100.3 ˚F, cough, sore throat, shortness of breath, flu-like symptoms, diarrhea, recent and abrupt loss or reduction of sense of smell and/or taste. 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. 

 
Conducting Self-Assessment: All Spa Creek Dental clinicians must self-assess their health daily before reporting to Spa Creek Dental clinic. They must respond “No” to all the following screening questions:

• Fever >100.3˚F
• Cough
• Sore throat
• Shortness of breath
• Flu-like symptoms, Muscle ache, Chills, Tiredness
• Diarrhea
• Recent and abrupt loss or reduction of the sense of smell and/or taste
• Close personal contact (without PPE) with a suspected or laboratory-confirmed COVID-19 patient in the past 14 days

 
Honest self-assessment of health and exposure protects families and others from exposure to the COVID-19 virus and to other communicable diseases. If clinicians do not meet the above criteria, they are instructed not to come to a Spa Creek Dental clinic for ANY REASON.
Clinicians who answer YES to any of the questions mentioned above MUST notify their supervisor and follow CDC recommendations by not reporting to work and following up with their primary health care provider. If in reporting to their primary health care provider, a Spa Creek Dental clinician is diagnosed as positive with COVID-19, Spa Creek Dental will adhere to the following contact tracing and precautionary protocols:

• Spa Creek Dental will contact any and all communities that the exposed clinician has visited in the last 14 days
• Spa Creek Dental will contact any and all patient families for whom the exposed clinician has treated in the last 14 days
• Clinician will not be permitted to return to work until all symptoms have ceased and clinician has tested negative for COVID-19 and documentation of this test has been provided.
• Spa Creek Dental will notify communities of any clinicians who have contracted and recovered from COVID-19 and will be able to provide negative test documentation upon request.

PPE Requirements

• All Spa Creek Dental clinicians will be required to wear the following to treat patients: Bonnet Head Cover, N95 (or KN95) Mask, Surgical Mask, Full Surgical Face Shield, Full Length Disposable Gown, Gloves and Shoe Covers
• All senior living community staff will be required to wear the following when transporting patients to clinical room: Facial Mask, Gloves
• All patients will be required to wear the following while being transported in and out of clinical room: Facial Mask, Gloves

Putting On and Removing PPE
When donning (putting on) PPE, Spa Creek Dental clinicians will:

1. Identify and gather the proper PPE to don: Inspect equipment for any damage prior to donning each piece. 
2. Put on shoe covers (booties), making sure that all areas of the foot are covered, and the shoe covers are snug. Clinicians will try not to touch the floor or other areas with their hands while putting the shoe covers on. 
3. When performing hand hygiene using hand sanitizer- 3 to 4 pumps into palm and continue rubbing hand sanitizer between and around hand, fingers, and fingertips until dry
4. When performing hand hygiene with soap and water- hands must be visibly soiled all around hands, inner palm and fingertips washing for at least 20-30 seconds.
5. Put on clinical gown. Tie all of the ties on the gown. 
6. Put on a head cover (bonnet). All hair must be tied back tucked under head cover and/or gown at all times. No jewelry may be worn.
7. Put on N95 (or KN95) respirator. If the respirator has a nosepiece, it should be fitted to the nose with both hands, not bent or tented. Do not pinch the nosepiece with one hand. Respirator should be extended under the chin. Both mouth and nose should be protected. Respirator straps should be placed first at the base of the neck (bottom strap), and second on the crown of the head (top strap). Ensure good fitting and perform a user seal check each time they put on the respirator. N95 (or KN95) mask will remain on during the duration of the clinical day.  
8. Place additional surgical mask on top of N95 (or KN95) mask. Clinicians must wear a new surgical mask for each patient.
9. Put on Goggles or loupes.
10. Put on face shield: Face shields provide full face coverage (the top of the face shield should be resting in the middle of the forehead).
11. Perform hand hygiene before putting on gloves. Gloves must cover the cuff (wrist) of gown.

 
When doffing (removing) PPE, Spa Creek Dental clinicians will:

1. Remove disposable gown by reaching up to the shoulders and carefully pull gown down and away from the body towards hands (by either pulling or breaking the ties of disposable gown). Do so in gentle manner, avoiding a forceful movement. Roll the gown down always touching only the inside of the gown. Be careful not to let the gown touch their clothes, remove contaminated gloves while folding them into the gown, then dispose in trash receptacle.
2. Perform hand hygiene at this time if there is any concern their hands became contaminated during the glove removal. (If doubled gloved, remove the rest of PPE with second pair of clean gloves.)
3. Re-glove and remove face shield, then goggles or loupes carefully. Remove face shield by grabbing the strap with two hands and pulling upwards and away from head while leaning forward. Do not touch the front of face shield or goggles or loupes. Wipe face shield with antimicrobial agent in between patients and dispose in trash receptacle at the end of the day. Remove hat (bonnet), surgical mask (do not remove N95 mask), remove surgical mask carefully untie (or unhook from the ears) and pull away from face without touching the front, remove shoe covers (booties) lift the shoe cover over their heel, pull it off their foot and dispose in trash receptacle.
4. Perform hand hygiene, re-glove
5. Wash goggles with soap and water and afterwards disinfect with appropriate disinfectant wipes. For loupes, use disinfectant wipes.
6. At end of day when removing N95 (or KN95) mask that was used during clinic, they must first clean hands before removing mask. Then place N95 (or KN95) mask in a designated bag or container with each clinicians name for storage.  

Entering Senior Communities and Operatory Preparation
Prior to each Spa Creek Dental Clinic, Spa Creek will communicate with each senior living community to review the following:

• Confirmation over the clinical room to be used. Each clinical room must have working air/and or heat, proper ventilation system, access to a sink with running water, functioning electrical outlets, table and/ or countertop, chairs for patient and clinical staff, and access to a trash receptacle.
• Confirmation on patient transport procedure. In order to prevent the risk of spread, Spa Creek Dental requires communities to arrange for a nursing aid or community staff member to transport patients to and from appointments. Community staff members will be expected to adhere to certain PPE requirements as a part of entering and exiting the clinical room.
• Spa Creek Dental will review if any scheduled patients have shown any symptoms of COVID-19. If so, patients will be rescheduled.
• Spa Creek Dental will review any additional infection control policies and protocols or any additional assessments required by each senior community beyond this packet and will ensure feasibility to adhere to additional requirements prior to holding a scheduled clinic.
• Spa Creek Dental clinicians will complete the above self-assessment along with any other additional assessment required by the community, as necessary.

When Entering Senior Communities, Spa Creek Dental clinicians will:
        -All clinicians who are transporting equipment from the Spa Creek Dental office will have their temperature taken at beginning of day, prior to loading equipment. 
        -All clinicians will arrive at the community, will have their temperatures checked prior to starting the clinical day, either by Spa Creek or the community (depending on the community guidelines).

• Clinicians will enter the community wearing a surgical mask and clean scrubs. All personal items (keys, cell phones, purse) will be placed in a sterile plastic bag for the remainder of clinic.
• Clinicians will proceed to the clinical room with the necessary equipment (note: this may take up to 3-4 trips). Clinicians will sanitize hands, elevator buttons, and door handles prior to opening and closing.
• Clinicians will provide for the community staff a written list of who is scheduled for an appointment and will confirm patient transport procedure and timing.

 
Prior to seeing the first patient, Spa Creek Dental clinicians will prepare the room by:

•   Starting the Hepa filter, prepping the room with pre-wipe and covering all exposed equipment (ie: countertops, salon chairs, desks etc) in the room as well as clinical equipment (ie: laptops, x-ray machine, x-ray sensor etc).
• Using Barrier film and plastic tarp to protect the room and all Spa Creek Dental equipment from unnecessary exposure to germs and bacteria. 
• While wearing gloves and a surgical mask, spraying/wiping down surfaces in the entire room; chair, light, computer, cabinets, tubing, etc. with antimicrobial agents. 
• Covering overhead light switch/handles and bracket table handle/control unit with the appropriate barrier film. 
• Covering computer unit, suction, air water syringes and handpiece lines with appropriate barrier covers. 
• Clinician will not bring anything into the room that is not needed for the individual patient they are prepping for. All other equipment is to be left outside the room. Equipment and PPE cart should be covered with plastic barrier. PPE is put on outside of clinical room.
• Sanitizing hands with 3-4 pumps of sanitizer for 20-30 seconds, rubbing until dry. Items which are unrelated to patient care must not be present in the operatory. This includes patient bags, coats and storage boxes (such as gloves, masks and bur boxes).
•  Each patient will have their own individual sterilized kit in a sealed plastic container for their dental appointments. 

 
Infection Control During Appointments

• Clinicians will remove gloves and perform hand hygiene: When performing hand hygiene using hand sanitizer- 3 to 4 pumps into palm and continue rubbing hand sanitizer between and around hand, fingers, and fingertips until dry. When performing hand hygiene with soap and water- hands must be visibly soiled all around hands, inner palm and fingertips washing for at least 20-30 seconds.
• Clinicians will don appropriate PPE as outlined in protocol above.
• Patients must wear a mask at all times until examination and/or direct intraoral care is administered. 
• Patient will be instructed/guided through performing hand hygiene: When performing hand hygiene using hand sanitizer- 3 to 4 pumps into palm and continue rubbing hand sanitizer between and around hand, fingers, and fingertips until dry. When performing hand hygiene with soap and water- hands must be visibly soiled all around hands, inner palm and fingertips washing for at least 20-30 seconds.
• A mouthwash pre rinse will be required of all patients as we begin their appointment. Intraoral decontamination: Patients must rinse with 1.5% hydrogen peroxide for one minute. 
• All intraoral appliances, such as dentures occlusal splints etc., must be disinfected when adjustment is being performed on them. 
• To reduce aerosol; electric hand piece speed must be reduced to 100,000 revolutions or below and the air supply to the hand piece must be turned off completely cooling will be done by water stream only. 
• All aerosolized procedures must be performed under rubber dam, when possible, and with the utilization of high-speed evacuation. No cavitron ultrasonic scalers will be used until the foreseeable future.

-          Clinicians should not leave room for any supplies once treatment has started. 

• At the conclusion of active dental care, the patient must be asked to perform hand hygiene with hand sanitizer, and they must continue to wear their mask after treatment is done and as they leave the clinical area. 
• After each patient appointment, clinicians will remove all barriers and wipe area with disinfectant spray or cloth.
• RP/POA (s) are NOT allowed to attend the clinical visit with patient. If further assistance is needed, a facility/community nurse will attend. If a facility/community nurse is called into a clinic for extra support, they must comply with previously stated Spa Creek Dental’s guidelines. 
• Use ABHR with 60-95% alcohol or wash hands with soap and water for at least 20 to 30 seconds. If hands are visibly soiled, use soap and water before returning to ABHR.
• PT will not receive handpiece tooth polish at the end of the appointment.  All polishes will be done using a toothbrush that will be provided by Spa Creek Dental.

 
Operatory Maintenance Between Patients:
20 minutes will be added between all patients appointments to allow our clinicians time to properly sterilize and disinfect the rooms up to the CDC and ADA guidelines.

• Clinicians will wipe/spray goggles or face shield
• Disposable gloves and gowns will be changed in between patients
  • Clean gloved hands with Sanitizer, 20 to 30 seconds.
  • Remove gown and gloves in one movement.
  • Roll gown inside out and discard.
  • Hand hygiene
  • Remove face shield from the sides. Wash off with soap and water.
  • Remove surgical mask and discard
  • Hand hygiene.
  • All dirty PPE to be put in trash bag in room after room is cleaned and all trash is together, and tie shut per pt.
  • N95 (or KN95) mask stays on.
  • Clinicians will leave dirty space and wait 15 minutes before returning to clean room. A small timer is used to ensure 15 minutes have passed.
• Dentist will continue to enter charting notes and after 15 min. call for next patient
• The assistant wears surgical mask and gloves to clean room… no gown or face shield needed.
  • Enter room.
  • Wipe all surfaces. and change coverings as needed.
  • Instruments will be wiped and scrubbed before placing in sterilization bags
  • Seal sterilization bags and place in autoclave
  • Clinical team will run autoclave when they return to office
  • Remove dirty gloves and surgical mask
  • Hand hygiene.
  • Reset room using clean gloves and clean surgical mask.
• Once room is clean, dentist notifies community staff member to bring next patient.
• Clinical team redons their PPE

 
Exiting Senior Communities

• All disposable items are thrown away into trash receptacle and trash bag tied shut.
• All non-disposable instruments will be wiped, scrubbed and placed into sterilization bags. Sterilization bags will go into autoclave to sterilize.
• Clinical team will autoclave instruments when they return to the office.
• At end of day after the room has been cleaned, remove the N95 (or KN95) mask that was used during clinic, they must first clean hands before removing mask. Then place N95 (or KN95) mask in a designated bag or container with each clinicians name for storage. 
• Equipment and supply cart should be covered under plastic tarp before proceeding to leave the facility.
• Clinical team should wear surgical mask as they are leaving the facility/community.
• Clinical team will use hand sanitizer after placing equipment in vehicle before driving.

Statement on Treatment of Patients Who Have Recovered from COVID-19
Any patients who have recovered from COVID-19, and are no longer symptomatic, and have proof of a negative test, will be eligible to receive care. Further background may be requested to ensure safety.
 
Statement on Clinicians who Have Recovered from COVID-19
Any clinicians who have recovered from COVID-19, are no longer symptomatic, and have proof of a negative test, will be eligible to return to work. Further background will be made available upon request from communities.
 
FAQ

• What are you doing to make sure patients/community staff/clinical staff are staying safe? Safety is our first priority. We have ordering additional PPE including N95 masks, HEPA filtration systems, and unique dental equipment to reduce droplet transmission. We have updated our protocols, and conducted additional staff training to ensure that everyone is safe.
•  What testing will you be performing on your own staff, our staff, patients? Our clinicians will be tested once a week for COVID19 virus.  Our clinicians will have their temperature taken at the start of each work day. We base all our testing protocols off of the recommendations of UPenn Dental School, which follow all of the guidelines of the CDC and the American Dental Association. A complete list of those protocols has been made available online or upon request. 
•  I’ve heard about aerosol being a big concern with providing dental procedures. What is your practice going to be doing about it? We have previously used an aerosol-reliant machine called a Cavitron to help us thoroughly perform cleanings. We will be decommissioning those machines for the foreseeable future. Instead, we will be using more traditional methods for removing plaque and calculus, primarily through manual hand scalers to give our patients the best service available while in this climate.
•  What’s going to happen to the room you work in (Community)? Due to the nature of our business and how we travel this will change per community.  We will have conversations with each community before entering to make sure we have the proper materials and procedures to hold the clinic while living up to our guidelines. The most important thing is that we are able to effectively disinfect the room before and after every appointment.
•  Will I need to be there (RP)? At this time we are requiring no RPs to be present at the time of the visit.  If a patient requires extra care during an appointment we will seek an appointed nurse from the community to assist.  The nurse will have to have proper PPE and have their temperature taken prior to the appointment.