AAOMS COVID-19 WebcastApril 22, 2020

Victor L. Nannini, DDS, FACSAAOMS President

AAOMS Activities and COVID-19 Resources – Dr. Victor Nannini The University of Washington COVID-19 Experience:

Impact on Private Practice Transition – Dr. Tom Dodson Practice Management Considerations – Drs. J. David Johnson

and David Fenton Update from OMSNIC – Dr. James Swift Closing Remarks and Personal Note from Pandemic Central –

Dr. Victor Nannini

Welcome and Introductions

The American Association of Oral and Maxillofacial Surgeons is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry.The American Association of Oral and Maxillofacial Surgeons designates this activity for 1.5 continuing education credits.

AGD - Accepted Program ProviderFAGD/MAGD Credit5/1/18 – 6/30/22Provider ID# 214680

The American Association of Oral and Maxillofacial Surgeons (AAOMS) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The American Association of Oral and Maxillofacial Surgeons designates this live activity for a maximum of 1.5 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Attendees will receive a link to complete the evaluation for CE credit.

2020 COVID-19 Town Hall: CE

Victor L. Nannini, DDS, FACSAAOMS President

AAOMS COVID-19 WebcastAAOMS Activities and COVID-19 Resources

COVID-19 virus resulting in unprecedented times Decision-making based on scientific evidence, when available Forced to respond rapidly to change Fear of the unknown AAOMS continually monitoring the situation on multiple fronts Rapidly changing, sometimes by the hour Monitoring and reporting as appropriate

COVID-19 AAOMS Updates

• AAOMS Updates and Resources• Financial Relief Assistance Resources• Personal Protection Equipment (PPE) Resources• Telehealth / Telemedicine• Government Agency Updates and Resources• General COVID-19 Information• News from Health Organizations• Research

COVID-19 Updates on AAOMS.org

• From the AAOMS President: Providing you with resources during the crisis (April 15)

• Member Alert: Loss reminds us of our dedication, determination (April 5)

• Faculty Alert: OMS Full-time Faculty COVID-19 Community (April 3)

• From the AAOMS President: The latest news in an ever-changing world (April 1)

• Member Alert: Difficult times; difficult decisions. Always advocating for OMSs (March 24)

• From the AAOMS President: Spread of COVID-19 prompts request from CMS (March 19)

• Member Alert: AAOMS COVID-19 Guidance for OMS Practices (March 17)

AAOMS Statements

• AAOMS Tips for Patient Communication during the COVID-19 Pandemic

• COVID-19 Guide for OMS Practices

• FAQs: COVID-19 Guidance for OMSs

• How States are Defining Emergency Procedures

• Federal/State Orders, Decrees and Mandates Related to Dentistry and Healthcare

• OMS Full-time Faculty COVID-19 Online Community

• OMS Resident COVID-19 Online Community

AAOMS Member-only Resources

• Advocacy letters sent by OMS state societies

• Advocacy E-Newsletter - April 14, 2020

• COVID-19 OMS Volunteer Opportunities

• April 8 letter to Congress on COVID-19 concerns (April 8)

• AAOMS letter to congressional leaders re: critical access to N95 masks for OMSs (March 24)

• AAOMS letter to federal agencies re: critical access to N95 masks for OMSs (March 24)

• Letter to the National Governors Association urging access to PPE (March 23)

• Letter to the Administration-COVID-19-Physicians Organizations Coalition Request (March 18)

• Letter to Department of Labor from Dental Organizations (March 18)

AAOMS Advocacy

American Dental Association

ADA Coronavirus Resource PageAmerican College of Surgeons

ACS COVID-19: Guidance for Triage of Non-Emergent Surgical Procedures

ACS COVID-19 Update: Elective Surgery

Accreditation Council for Continuing Medical Education (ACCME)

ACCME COVID-19 Clinician Resources

Commission on Dental Accreditation (CODA)

CODA COVID-19 Updates

News from Health Organizations

Updated Telehealth Resources At-a-GlanceWith the COVID-19 outbreak, CMS and states are working to eliminate barriers to telehealth use – including telephone or “virtual” evaluations and/or treatment advice – to help patients access care remotely and reduce the strain on hospitals and clinics. AAOMS has assembled a new webpage –Telehealth Resources – with details and links that will be updated when new

information becomes available. In addition, AAOMS published AAOMS White Paper: Telehealth and Remote Treatment in January.

Telehealth / Telemedicine

• CDC Interim Infection Prevention and Control Guidance for Dental Settings During the COVID-19 Response

• CDC Oral Health Guidance

• CDC Resources

• CDC COVID-19 Website Buttons and Badges

• CDC Crisis Standards of Care Decontamination Recommendations

• CDC Handouts and Posters

• CDC Office Sign

Government Agency Updates & Resources

• Free webinar: Financial Steps to Take Now to Overcome a COVID-19 Business Downturn

• Free webinar: What the COVID-19 Stimulus Package (CARES Act) Means to You and Your Practice

• Complimentary Webinar on Infection Control

• Complimentary OMSKU Volume V

• Complimentary CE on Demand

• Complimentary On-Line Anesthesia Review for Dental Anesthesia Assistants

• Complimentary Online Coding Courses for AAOMS Members

AAOMS Continuing Education

• FDA Information on N95 masks

• CDC NIOSH Putting on and Taking off Disposable Respirator

• CDC NIOSH Putting on and Taking off Disposable Respirator (Spanish)

• CDC NIOSH Sequence for Putting on Personal Protective Equipment (PPE)

• Southern Anesthesia / Henry Schein Initiatives

• AAOMS Resources Surgical Masks and Face Shields

Personal Protection Equipment (PPE) Resources

• SAGE Journals: Most recent COVID-19 research

• SAGE Journals: All coronavirus-related articles

• International Journal of Oral Science: Transmission routes of 2019-nCoV and controls in dental practice (published March 3, 2020)

• Journal of Dental Research Coronavirus Disease 2019 (COVID-19): Emerging and Future Challenges for Dental and Oral Medicine (published March 12, 2020)

Research

Thomas B. Dodson, DMD, MPH, FACS Professor and Chair, Department of Oral and Maxillofacial Surgery

University of Washington School of Dentistry, Seattle, Wash.Associate Editor, Journal of Oral and Maxillofacial Surgery

AAOMS COVID-19 WebcastThe University of Washington COVID-19 Experience: Impact on Private Practice

Current WA state COVID-19 statsHow we manage patientsRisk of occupational exposure to SARS-CoV-2 (SC-2) Asymptomatic patients Symptomatic patients

Staff safety

Topics

First U.S. epicenter of novel corona virus disease (COVID-19) First case, first death

To mitigate spread Schools closed 3/13 Clinical services restricted to urgent/emergent conditions

from 3/13 - 5/18 Stay at home order issued 3/23 Banned non-essential activities from 3/25 – 5/5

Epidemiology of SC2

Washington State COVID-19 Stats

doh.wa.gov/Emergencies/Coronavirus

Re – number of people of infected by one personR3 – 1 to 3 to 9 to 27 to 81 to 243 . . .

Social Distancing and Disease Mitigation

Flattening the curve – SCH Enterprise Analytics

schdatascience.org

State COVID-19

Institute for Healthcare Metrics

covid19.healthdata.org/united-states-of-america/Washington

Washington State COVID-19 Resource Need

Overarching goal To provide care to the asymptomatic,

SARS-CoV-2 (SC-2) negative patient in a timely, efficient, productive and safe manner

UW OMS Office-based Clinic Patient Management

Goal – limit exposure to corona (SC-2) virus and reduce COVID risk Treatment limited to referral patients Triage using telehealth Staff schedule telehealth screening

appointment

UW OMS Office-based Clinic Patient Management

Clinician Reviews chief complaint, PMH,

COVID symptom status Limited clinical examination Swelling, trismus, body habitus, behavior

Review imaging (if available)

UW OMS Office-based Clinic Patient Management

Clinician Make a decision Elective care – defer until May 18 (WA state) Emergent care – hospital ORs

• Uncontrolled bleeding• Fractures• Fascial space infection impinging on airway

UW OMS Office-based Clinic Patient Management

Clinician Urgent care ADA guidelines for urgent procedures

• Pain of odontogenic origin• Osteitis• Localized pain and swelling

Develop a preliminary treatment plan Confirmed at time of procedural appointment

UW OMS Office-based Clinic Patient Management

• Dentoalveolar trauma• Suture removal

Order SC-2 test – faculty/resident Schedule SC-2 test - staff Staff schedules procedure 24-36 hours

after the scheduled SC-2 test Check test preoperatively

• Positive – cancel • Negative – proceed using standard precautions Face shield or goggles for AGP Should be little need for the N95 mask

UW OMS Patient Management

Calling patients 7 days postoperatively Assess COVID sx status Did an asymptomatic, test negative

patient develop COVID? And was the clinician and staff

exposed to SC2?• Median time from known exposure

to sxs – 5 days

UW OMS Patient Management

Uncertainty vs. Risk Uncertainty ≠ Risk

Uncertainty is a qualitative assessment High risk, low risk

Risk is a quantitative measure 1 in 10

Uncertainty and Risk

Uncertainty – conservative decision All patients treated as having COVID

Uncertainty and Risk

Risk – informed decisions Assess risk Assess level of comfort with riskMake a go – no go decision

Uncertainty and Risk

Asymptomatic (Sx-) patient What is the frequency of SC-2+ in Sx- patients?

Risk of SC-2 Exposure

Sx- patient – Frequency of SC-2+ 2/240 = 0.008

• upper 95% CI – 3%

Risk of SC-2 Exposure

Sx- patient – Frequency of SC-2+ = 3% Now we put on a mask Respiratory droplets – 6 microns SC-2 size 0.1 micron

Risk of SC-2 Exposure

Mask filtration effectivenessRisk of SC-2 Exposure

Sx- patients Frequency of SC2+ upper 95% CI – 3%

Leakage of Level 1 <5% leakage

0.03 x 0.05 = 0.0015

Risk of SC-2 Exposure

Asymptomatic patient Risk of SC-2 exposure 15 per 10,000 exposures

Risk of SC-2 Exposure

Exposure ≠ infection Severity of infection – asymptomatic to death Risk of death from COVID – 5% Risk of death from asymptomatic

patients and wearing a mask• 0.03 x 0.05 x 0.05

SC-2 test result – negative• untested in this model

Risk of SC-2 Exposure: Other Considerations

• 75 per million exposures

Symptomatic patient (Sx+) Frequency of SC-2+ 10% (n=1206) (upper limit = 0.11)

Leakage of Level 1 mask <0.05

Risk of SC-2 Exposure

Symptomatic patient (Sx+) Risk for SC-2 exposure (0.11 x 0.05) 55 per 10,000 (3.4-fold increased risk

compared to Sx- patient)

Risk of SC-2 Exposure

Symptomatic patient (Sx+) Risk for SC-2 exposure – 55 per 10,000 Other factors Time and type of contact

• Close contact to SC2+ patient 1 minute for a quick

followup examination Hours managing a panfacial

fracture

Risk of SC-2 Exposure

• High risk exposure – naso-or oro-pharynx

• Exposure to aerosolized generating procedure (AGPs) generating particles (not droplets)

Situation-appropriate assumptionsMath doesn’t change Brooklyn – 13% SC-2 positive in

asymptomatic patients• 0.13 x 0.05 = 0.0065 65 per 10,000 exposure

Boston homeless shelter – 37% SC-2 positive in asymptomatic subjects

Risk of SC-2 Exposure

Other considerations Physical spacing Skeleton crew Limit number of persons involved in an operation Limit number of visitors per clinic visit Remove furniture from waiting area Isolation rooms

Staff and Provider Safety

Screening, screening, screening Pre-visit, check-in, and being seated Risk of SC2 exposure from asymptomatic

patient low (<3%) People lie

Masks available at intake and on clinical floorsLimiting treatment to Sx-, SC-2- patients

Staff and Provider Safety

J. David Johnson Jr., DDSAAOMS Vice President

AAOMS COVID-19 WebcastPractice ManagementConsiderations

COVID-19 Pandemic Office Policies Emergency/Urgent Care Patient Flow, Social Distancing

& Infection Control Personal Protective Equipment (PPE)

•The Executive Board of the TSOMS,•The TDA President, Dr. Terryl Propper,•Our Lobbyist, Jack Fosbinder, and •Lt. Governor Randy McNally.

Concurrently, in order to advocate the position that OMSs should be viewed as primary and essentialproviders in the COVID-19 Pandemic, I contacted:

Office Policy: Emergency/Urgent CareEmergency and urgent care should be performed as usual following CDC guidelines (pain, swelling, traumatic injury, etc.).

With certain OMS disease states, injuries, when the patient’s conditions are symptomatic, when delaying treatment might have an adverse impact on the patient’s health (oral or otherwise, such as delaying chemotherapy) AND when the patient has no history of or little apparent risk for COVID-19 exposure, we will proceed with surgical management.

Office Policy: Emergency/Urgent CareIf the patient is asymptomatic and has no history of related signs or symptoms to planned management (such as third molars) AND when there is no risk of impairment of the patient’s condition or pending treatment (e.g., impairment of the restoration of diseased tooth when another tooth that is indicated for removal prevents access to the diseased tooth, or irreversible impairment of permanent tooth eruption, etc.), we should defer treatment. Telephone discussions, review of available radiographs and cellphone photographs, and clinical examinations can help us make these determinations. When in doubt, ASK ME.

Office Policy: Emergency/Urgent CareWe should perform biopsies and see post-biopsy patients unless there is a benign pathology report with no indication for additional management, in which case the patient will be given the option of a telephone discussion.

Routine post-operative appointment patients will be called and given the option of phone discussion or to attend the appointment, depending on the nature of the procedure that was performed.

Office Policy: Emergency/Urgent CareConsultations – We will screen to see if the patient has experienced or is experiencing symptoms related to the purpose of the consultation. If so, we will perform said consultation under the conditions that only the patient and at most one other person is with them. We should make efforts to limit the total number of persons in the office with no gathering of patients, escorts and staff in any one room to exceed 10 people. If there are no potentially related signs or symptoms or likely progress of a given state or condition, the consultation can be rescheduled or a teleconference consultation can be scheduled.

Office Policies: Patient Flow, Social Distancing, Infection Control

Staff Training and Reviews Handwashing Techniques PPE: Masks, Eye Protection,

Don/Doff Sequences

ADA Interim Guidance on PPE and Comparison of Mask Types

Office Policy: Personal Protective EquipmentCOVID-19 patients or patients under investigation (PUI) are NOT to be treated in our office. PUI include the following:• Patients who have active symptoms of fever

and/or cough who have not been tested• Patients who have been exposed to patients

who have active symptoms of fever and/or cough who have not been tested

• Patients who have been exposed to patients with confirmed COVID-19

Office Policy: Personal Protective EquipmentFor patients who are not COVID-19 confirmed or PUIs, we are now limiting our office surgical procedures to emergency care, urgent care or care that if delayed could lead to a worsened condition or permanent impairment. During these procedures, clinical staff must wear the following PPE: • Gown & Hair Covering• N95 mask covered by

a standard surgical facemask

• Gloves• Eye protection – full-face

shield (that acts as droplet barrier)

Further Developments Powered Air Purifying Respirators (PAPR) or

No-Hose Closed Air Purifying Respirators (CAPR) Point of service testing More effective medical

management of COVID-19 Effective COVID-19 vaccinations

Thank You AAOMS Staff!

David Fenton, DDS, MD, FACS

Chair, AAOMS Committee on Practice Management & Professional Staff Development

AAOMS COVID-19 WebcastPractice ManagementConsiderations

Getting Back to Work

Phases of getting back to practice Infection control considerations COVID-19 testing

Phase 1: Preparation for Return Foster your team’s wellness Get organized Know your finances and protect yourself Establish protocols and update your standard

operating procedures Grassroots activism Constant contact with your professionals: AAOMS,

accountant, payroll company, attorney, financial advisor

Phase 2: Prepare the Office for Patients Follow AAOMS, ADA, OSHA, and CDC Guidelines Expect temporary and permanent changes in our offices Decrease vectors for spread of respiratory droplets Infection control measures Consider telehealth services Staff retraining Catch up on unfinished administrative work

Phase 3: Finally Seeing Patients Again! Strict adherence to protocols Continuous use of facemasks Consider team badges with name and face

Utilization of testing when available

New Infection Control Considerations Updated protocolsMinimize aerosol-generating procedures Evacuation devices Air filtration and purification Respirator use

SARS-CoV-2 TestingPCR – Polymerase Chain Reaction Testing Nasal or throat swab, sputum Nasal swab shortage Abbott Laboratory Rapid Test: 5-15 minutes Saliva test: Rutgers clinical genomics lab

COVID-19 Antibody Testing Serum test Over 70 companies selling tests Questionable reliability and interpretation

James Q. Swift, DDS, FACSChair and Director, OMSNIC

AAOMS COVID-19 WebcastOMSNIC Update

COVID-19 Issues

In-Office Testing

Tele-Health

Volunteering

Cyber Attacks

Testing – Wait for authoritative guidance, or use your best judgment on whether to use or not if no authoritative guidance provided and document your reasoning

Tele-Health – Check state board guidelines, only use for patients in states where you are licensed and check resources at omsnic.com

Volunteering – Be sure you are covered by federal or state immunity by checking at omsnic.com

Cyber Attacks – Remain vigilant on emails and ensure timely back-ups are being made

Takeaways

Victor L. Nannini, DDS, FACSAAOMS President

AAOMS COVID-19 WebcastClosing Remarks and Personal Note

Thank You

AAOMS Board of Trustees