Return to Work Plan: Phase 2 Opening

The Return to work plan must emphasize safety protocols to ensure the health and well being of staff, patients and any people who come within the dental office, including cleaners, building maintenance workers, delivery people, etc. We also want to ensure that people within the community that we visit, our families, friends and general population are kept safe from exposure to COVID19 from our practice. We are currently in Phase 2 of re-opening in the province. The return to work plan could change should there be an order from the Provincial Health Officer. (PHO) Our return to work plan is based on requirements of WSBC, BCSDC, CDSBC and the BCDA. Dentistry has always emphasized the use of standard personal protective equipment, such as masks, safety glasses, uniforms, disinfecting of surfaces and sterilization of all items that can be sterilized. The aim is to keep staff, our patients and people who enter our premises safe. The following protocols have been introduced to our clinic for Phase 2 Re-opening:

Administrative:

• A screen has been placed between the reception desk and dental patients in the reception area
• Reception screens will be cleaned daily with approved sanitizer
• All cloth covered furniture has been removed from the waiting room, and the new chairs are easily disinfected and spaced two meters. All magazines or items that could be touched have been removed from the waiting room.
• Patients will be asked to wait in their cars until called for their appointments.
• Patients will come alone to their appointments unless they are infirm or children.
• Waiting time in the reception area will be kept to a minimum to maximize social distancing from other patients visiting the office. Maximum people allowed in the waiting room to allow for social distancing is 6.
• Appointments will be staggered to have less overlap at arrival and leaving times.
• Patient will be asked prior to their appointments if they have any of the symptoms of COVID19. (appendix 1) If they respond positively to any question, they will be asked to stay home to ensure that they do not have any signs or symptoms of COVID19. Upon presenting for their appointment they will be asked to clean their hands with sanitizer. They will update and sign the COVID19 symptom form. Should they have any symptoms of COVID19 on the day of the appointment they will be asked to reappoint for another day.
• Minimum interaction will happen at the front desk. If possible, payment will be processed after the patient has left and receipts emailed to them. Appointments that need to be scheduled will be done as promptly as possible. Appointments will attempt to be scheduled to allow as little overlap as possible and to maximize social distancing in the reception and clinical areas.
• Patients will be asked to sanitize their hands before leaving the dental reception area.
• Reception staff will at least twice daily, at noon and at closing time, use disinfectant wipes to clean the handles of doors and any surfaces that have been contacted in the reception area.

Provision of Health Services

Staff:

• will be required to form a return to work health questionnaire to ensure that they are healthy to return to work in Phase 2 of the re-opening after the PHO ordered province wide office closure of March 16, 2020.
• If staff feel unwell, or have a cold, cough, temperature, loss of taste or smell, conjunctivitis, have been in close contact with a person recently diagnosed with COVID19 or been out of the country in the past fourteen days they will be advised to stay home until it is determined that they do not have COVID-19.
• Staff will be required to get tested for COVID-19 if they have symptoms. Staff can not return to work until they have the results of the COVID19 test.
• Staff are not, under any circumstance, obligated to come to work with even mild symptoms of a cold or any of the above COVID19 symptoms. Should they test negative for COVID19 they can return to work.
• If a staff member feels even mild symptoms for illness, they should sanitize their hands and then place a mask on and immediately report to their employer. They will be asked to go straight home. The area the worker was in should be sanitized while wearing full PPE and an N95 or similar mask.
• If the worker is severely ill or is having difficulty breathing 911 will be called.
• Daily, all staff members will be required to have their temperature taken and sign a symptom form that evaluates for signs of COVID19. (appendix 2) This information will be stored in a private area.
• Uniforms will be worn by all clinical staff for clinical procedures and removed before leaving the office. They will be carried home in a designated bag and washed immediately upon returning home. It is recommended that a shower be taken immediately upon returning home after work. Clinic footwear should be only worn at the office and left in the office.
• Clinic jackets or isolation gowns will be worn per patient appointment. They will be donned prior to masking procedures for non-aerosol and aerosol generating procedures. Proper donning techniques as outlined by the BCSDC will be followed. They will be discarded for washing in the dirty clothes hampers in each clinical room following proper doffing techniques after each patient.
• Staff have been trained in the proper use of masks and have had two sessions of fit testing of N95 masks, KN95 and half face respirators.
• Signage has been posted of the appropriate mask to use for each procedure by the donning areas
• For non aerosol generating procedures (NAGP) a level 2 or 3 mask is required. Non aerosol generating procedures include:
1. Hand scaling and dental probing but not polishing.
2. Preventive measures such as application of topical fluorides, silver diamine fluoride, etc.)
3. Simple extraction (NAGP)
4. Oral and maxillofacial radiology
5. Cementation of previously fabricated fixed prosthodontics
6. Orthodontic procedures (NAGP)
7. Examinations and consultations
8. Removeable prosthodontic procedures
9. Temporomandibular dysfunction management and procedures
• Although NOT required by the BCCDC or the BCDA or the CDSBC we will use ENHANCED PPE for any Aerosol Generating Procedures (AGP) done within the office at this stage of the re-opening. We will use fitted N95 level masking and will cover this with an additional mask (level 2 or 3).
• Aerosol generating procedures include:
1. Ultrasonic scaling and root planning
2. Use of dental handpieces, both high and low speed during filling, crown and bridge preparations, complicated dental extractions, periodontal surgeries requiring bone removal
3. Use of sandblasters
4. Polishing procedures with slow speed handpieces intraorally
• If the clinical procedure generates aerosols safety shield or goggles will be worn in addition to clinical jacket with cuffed sleeves and full closure to the neck or isolation gown during Stage 2 of re-opening. The need for this will be re-evaluated at Stage 3.
• Proper donning and doffing techniques of all PPE will be adhered to. Training has been done in donning and doffing procedures.
• Donning of PPE will be done in an area separate from doffing. Doffing will be done in the clinical rooms and material will be disposed of in waste containers or placed in a hamper for cleaning.

Sterilization and Disinfection procedures in the clinical rooms

• Standard procedures will be followed for disinfection and sterilization as outlined in CDSBC Infection Prevention and Control Guidelines, July 2012. Approved disinfectants will be used to clean surfaces and wait times will be adhered to as required by the type of disinfectant before drying. Keyboards are covered with pads that allow surface disinfection. Plastic coating will be used on frequent contact areas (light handles, x-ray controls, unit switches). They will be removed and replaced after each patient.
• Light switches or frequent touch areas will be disinfected twice a day
• Paintings, wall art, degrees and magazines will be removed from the clinical rooms to increase ease of cleaning.
• All items that can be sterilized will be bagged and sterilized.
• Protocols will continue to be followed as outlined by the BCDA guide to Infection Control in the sterilization area. Certified Dental Assistants and Dental Hygienists will be responsible for adhering to these principles as outlined.

Our office building is fortunate to have LEED Gold certification so has excellent air exchange and filtration. Dr. Mitchell has decided to further enhance the air filtration in the clinical rooms of her practice. We have ordered and will have installed in early July 2020 (in each operatory that Dr. Mitchell practices in suite 604 ASQ) ECM Phantom by Gordon Cleanroom Products. The ECM Phantoms have very high room clearance rates. They remove the dental aerosols with 99.99% efficiency. The air in this building, which has an excellent filtration system, turns over the air once an hour. The Phantom will turn over and filter the air volume in the clinical area fifty times an hour, or about once a minute. Long term this will be a very significant enhancement for all who enter the clinical rooms. Filter change schedules will be set up once the Phantoms are installed, and the dentist will be responsible for seeing that it is adhered to.

Common Areas

• We have identified areas where staff cross over and gather (coffee room, supply room and dental laboratory) and posted occupancy limits for these rooms.
• Protocol for use of coffee maker and fridge has been developed
• Hand sanitizer is available in the coffee room as well as soap and water
• Often touched areas will be sanitized in the coffee room, supply rooms and lab.
• Laboratory room surfaces will be disinfected after use. Individual who use the lab equipment will be responsible for disinfecting it with appropriate disinfectant after laboratory procedures.
• Delivery people are screened and identified and asked to sanitize hands prior to delivering goods.
• The building management has determined maximum occupancy in the elevators will be two.

Modifications to the Return to Work Plan

Staff are encouraged to make suggestions to further enhance the safety plan outlined in the Return to Work Plan and can approach either the office manager or the dentist.