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ADDENDUMTOINTERIMGUIDANCEDURINGCOVID-19

RETURNTOROUTINEPATIENTCARE

AMERICANSOCIETYOFDENTISTANESTHESIOLOGISTS

PUBLISHEDON5/8/2020

OVERVIEW

ThispandemichasbroughtthedentalcommunitytogetherandtheASDAiscommittedtosharinginformationandmakingrecommendationsbasedonthemostcurrentscienceandtheguidanceoftheAmericanDentalAssociation(ADA),AmericanSocietyofAnesthesiologists(ASA),AnesthesiaPatientSafetyFoundation(APSF),SocietyforAmbulatoryAnesthesia(SAMBA)andgovernmentalagenciessuchastheCentersforDiseaseControlandPrevention(CDC)andtheOccupationalSafetyandHealthAdministration(OSHA).

Thisaddendumtotheinterimguidancewaswrittentofacilitatedentistanesthesiologistsprovidingscheduledcareintheoffice-basedsetting.Manyintricatedetailswillvarybygeographicareaandindividualdentalpracticessothisiswrittenasabroadoverviewandwillrequireprofessionaljudgmentofeachpractitioner.Pleaserefertotheoriginaldocumentformoreextensiveexplanations.

TheCOVID-19pandemicwillcontinueasweprovidecaresoitisessentialtoimplementCOVID-safepractices.Wemustcontinuetoadapttoourcircumstancesandprioritizethesafetyofourcolleaguesandpatients.

TIMINGOFRESUMPTION

• Authorizationbytheappropriatestateorcountyhealthauthority.• SustainedreductionintherateofnewCOVID-19casesfor14days(oneincubationperiod)inyourimmediate

area.• Abilityoflocalhospitalstosafelytreatpatientswithoutresortingtocrisisstandardsofcare.• StatecapabilitytotestallpeoplewithCOVID-19symptomsandcapacitytoconductactivemonitoringofall

confirmedcasesandtheircontacts.• AdequateavailabilityofPPEandotheressentialresourcesatthelocalhospitalsforfrontlineworkerswithout

jeopardizingsurgecapacity.• Availabilityofanestheticagents,whichmaybeinshortsupplyfortheforeseeablefuture.

DENTALHEALTHCAREPERSONNELSAFETY

• Assesstheworkforceavailabilityateachoffice(e.g.,healthstatus,exposuretoCOVID-19,underlyingmedicalconditions).

• Wearamaskatalltimesinthedentaloffice.• EnsureadequateavailabilityofappropriatePPEforallpersonnel.

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SCREENINGRECOMMENDATIONSFORPROSPECTIVEPATIENTSANDESCORTS

• Inthepast14days,haveyou

o TestedpositiveorbeendiagnosedwithCOVID-19?

o Beenunderinvestigationforpossiblecoronavirusinfection?

o Experiencedalossoftasteorsmellorflu-likesymptomssuchasfever,cough,shortnessofbreath,bodyachesordiarrhea?

o HaveyoubeeninclosecontactwithanotherpersonwhohasbeendiagnosedwithorunderinvestigationforCOVID-19?

Patientswhorespond‘yes’toanyofthesequestionsshouldnotcomeintothedentalofficeandshouldbeencouragedtocontacttheirprimarycarephysician(PCP)fortreatmentrecommendations.Theycanalsobereferredtodentalfacilitieswithairborneprecautions(e.g.,dentalschoolsorhospitaldentalservices)foremergencydentalcare.

• Onthedayoftheprocedure,askscreeningquestionsagainandtakethetemperatureofthepatientandtheescort.

o If99-100.4°F(37.2-38°C),considerthesourceofthefever(e.g.,dentalinfection)anddecideclinicalcourse.

o If≥100.4°F(38°C),assessanydifficultywithbreathing.

! Ifnone,defertreatmentandhavethepatientfollowupwiththeirPCPifthingsworsen.

! Ifbreathingdifficultyisobserved,considercalling911orreferringthepatienttotheemergencyroom.

PPERECOMMENDATIONSFORDENTISTANESTHESIOLOGISTS

Theminimumrecommendedequipmentforaerosol-generatingprocedures(AGP)includes:

• N95orhigher-levelrespirator

• SurgicalmaskwornovertheN95

• Eyeprotection-faceshieldorgoggleswithsideshields(nopersonalglasses)

• Disposableheadcovering(e.g.,bouffant,surgicalcap)

• Disposablefluid-resistantlong-sleevedgown

• Non-sterilegloves(doubleglovesarerecommendedduringanesthesiaprocedures)

• Shoecoverings

• Provideadequatepatientscreeningpriortoschedulingtheappointmentandpriortotheenteringthedentaloffice(seeAppendix).Patientswillbeaskedtosociallydistanceandwearafacecoveringonceinthedentaloffice.

• Strictadherencetohandhygiene.o uponentryintotheworkplaceo beforeandaftercontactwithpatientso aftercontactwithacontaminatedsurfaceorpieceofequipmento beforedonningandafterdoffingPPE

• Implementastrategytofollowupwithallpatientswithinatleast7daysandupto14daysaftertheprocedureregardingCOVID-19symptomstodetermineifdentalanesthesiapersonnelmayhavebeenexposed.AplanwillneedtobedevelopedforthosepatientswithCOVID-19symptoms.

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WHENAPATIENTSHOWSSYMPTOMSORTESTSPOSTIVEFORCOVID-19FOLLOWINGAPROCEDURE

• Havethepatientseekmedicaltreatmentimmediatelyifsymptomsworsen.

• TrytodeterminewhomayhavehadcontactwiththeindividualwhoisCOVID-19positive.

• Notifyanystafforotherpatientswhowerepotentiallyexposed.

• Monitorthesymptomsofallexposedstaffmembersandpatients.

• Conductariskassessmenttodeterminetheneedforquarantine,testingand/orimplementationofanyworkrestrictions.

ENVIRONMENTALINFECTIONCONTROLRECOMMENDATIONSFORDENTISTANESTHESIOLOGISTS

• Waitatleast30-60minutesfortheaerosolizedparticlestodescendbeforeroutinecleaninganddisinfectionofanesthesiaequipmentandsupplies.Theactualtimeneededtowaitbeforeroutinecleaningisvariablebasedonroomsize,roomisolation,ventilationandotherparameters.Useprofessionaljudgment.

• Allsurfacesshouldbedisinfectedinatop-downformatwithanEPAapproveddisinfectant,includingthefloors.

• Theuseofdisposabletransparentplasticdrapestocoveranesthesiaequipmentlikelylimitscontamination.

• Keepadditionalairwaysuppliesinanesthesiacartuntilnecessaryforuse(unlessadifficultairwayisanticipated).

• Single-useanddisposableequipmentarepreferred.

• Unusedbutpotentiallyexposedconsumablesshouldbediscardedorappropriatelydisinfected.

• Utilizeahigh-qualityviralfiltertoprotecttheanesthesiamachinefromcontamination.

• Gassamplingtubingshouldbediscardedaftereachpatient.Theviralfiltershouldbeplacedinalocationtopreventvirustransmissionviagassamplingtubing.

PATIENTSAFETY

Manydentalpatientswillexpecttransparencywithnewcontrolstoassuretheirsafety.

• Establishandimplementnewinfectioncontrolguidelineswitheachdentaloffice.• Ensureproperfunctioningofmobileequipmentandallfixedequipmentateachoffice.• Considersimulatedcaseswithstafftobecomefamiliarwithanynewguidelinesandmaterials.• PlacePPEintheemergencykitincaseofacomplication.• Continuewithdistancingstrategiesinthewaitingroomandwithsubsequentpatients.• Whenadequateandreliablepoint-of-caretestingisavailable,eachpatientshouldbetestedbeforeeach

procedure.• ImplementspecialconsiderationsforpeopleathighriskforseverecomplicationswithCOVID-19.

PRIORITIZATIONOFPROCEDURES&RESCHEDULINGCASES

• ContinuetoprioritizeurgentcasesbecauseoftheriskofapotentialresurgenceofCOVID-19.• WhenschedulingapatientwhowasdiagnosedwithCOVID-19,adequatetimeaftertheresolutionof

symptomsshouldpassanditmaybeprudenttoobtainamedicalconsultationpriortoscheduling.• Considertheuseofanadditionaladvisory/consentform(SeeAppendix)todiscusstheriskoftransmissionin

thedentalsetting.

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AIRWAYMANAGEMENTRECOMMENDATIONSFORDENTISTANESTHESIOLOGISTS

• Considerapre-proceduralmouthrinse(1.5%hydrogenperoxideor0.2%povidone-iodine)forcooperativepatients.Ifthisisnotpossible,considerswabbingtheoralcavitypriortothedentalprocedure.

• Intubationwithacuffedendotrachealtubewillresultindecreasedexhalationofpatientgasesandisconsideredthemostcertainwaytominimizevirusaerosolizationfromexhaledpatientgases.

• Forshortcases,especiallyifaerosolizationwillbekepttoaminimum,anaturaloropenairwaycanbeconsidered.

• Nasalintubationisnotcontraindicated.

• Doublegloveswillenableonetoshedtheouterglovesafterintubationandminimizesubsequentenvironmentalcontamination.

INDUCTIONRECOMMENDATIONSFORDENTISTANESTHESIOLOGISTS

• Considermoderatesedationinsteadofgeneralanesthesia(orbriefgeneralanesthesiaforlocalanestheticadministrationfollowedbymoderatesedation)ifpossible.

• Preoxygenateforanadequateperiodoftimewith100%O2priortoinductionwhenpossible.

• Dependingontheclinicalconditionandplannedairwaymanagement,therecommendedrapidsequenceinductionwillneedtobemodified.Ifmanualventilationisnecessary,applysmalltidalvolumes.

• Ensurethereisahigh-qualityviralfilterateithertheexpiratorylimbconnectiontotheanesthesiamachineand/orbetweenthefacemaskandbreathingcircuit.Ensurethegassamplinglineisalsoprotected.

• Videolaryngoscopesmayallowfurtherpatientdistancing.Othershavesuggestedclearplasticdrapesorotherbarriersoverthepatientduringintubation.

• Re-sheaththelaryngoscopeimmediatelypostintubation(useoutergloveindoubleglovetechnique).

• AfterremovingPPE,avoidtouchingyourhairorfaceandperformhandhygiene.

ANESTHETICMANAGEMENTRECOMMENDATIONSINPREVIOUSDOCUMENT

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RECOVERYRECOMMENDATIONSFORDENTISTANESTHESIOLOGISTS

• Keepafullcoveragemaskoverthepatient’sairwayduringemergenceandrecoveryandremainvigilanttoensureadequateventilation.

• Usetheprocedureroomforrecoverytoavoidcontaminatinganotherspace.

• Iftheescortcomesintothecontaminatedprocedureroom,besuretheyarepartofthepatient’squarantinedcircle(duringthistimeofsocialdistancing).

• Waitatleast30-60minutesfortheaerosolizedparticlestodescendbeforedisinfectinganesthesiaequipmentandsupplies(aswellastheprocedureroombyDHCP)withanEPAapproveddisinfectantwhilewearingappropriatePPE.Theactualtimeneededtowaitbeforeroutinecleaningisvariablebasedonroomsize,roomisolation,ventilationandotherparameters.Useprofessionaljudgment.

• DoffingallPPE(exceptfortheN95)shouldbedonepriortoleavingtheprocedureroomwhenrecoverytakesplaceinthetreatmentroom.

• Ifthedentistanesthesiologistneedstoleavetheroombeforefinaldisinfection,consideradedicatedroomadjacenttothetreatmentareawheredoffingofPPEcantakeplace.

• BesuretocontinuewearingallnecessaryPPEifthepatientistransferredtoadedicatedrecoveryarea.

MAINTENANCEANDEMERGENCERECOMMENDATIONSFORDENTISTANESTHESIOLOGISTS

• Ifanon-intubatedgeneralanestheticischosenandthepatientrequiresairwaysupporttomaintainadequateventilation,thisplacesthedentistanesthesiologistclosetoaerosolgenerationandconsiderationforintubationshouldbemade.

• Awell-fittedrubberdamwithindividualholespunchedforteethintheareaofoperationwillminimizevirusaerosolizationandlimitpatientgasescapeinanopenairwaycase.Otherisolationdevices(e.g.,Isolite®)likelyprovidesomeminimizationofvirusaerosolizationbutthedegreeofbenefitisunclear.

• Highvolumeevacuationshouldbeusedmeticulouslythroughoutthedentalproceduretominimizeaerosolspread.

• Ifdeepextubationisanoption,itshouldbeconsidered.Ifawakeextubationisplanned,adequateanalgesiamaypreventbucking,coughingandpost-operativesorethroat.

• Inordertominimizevirustransfertosurfaces,haveareceptacleclosetothepatientwheretheextubatedendotrachealtubecanbeimmediatelydiscarded.

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APPENDIX

APPENDIXA:ADA®PATIENTSCREENINGFORMAPPENDIXB:ADA®DAILYSCREENINGLOGAPPENDIXC:LIMITEDTOONLYEMERGENT/URGENTPROCEDURES

EXAMPLE1:DISCLOSURE/CONSENTEXAMPLE2:ADVISORY/ACKNOWLEDGMENT(FROMMEDPRO)

APPENDIXD:DENTALOFFICESOPENTOSCHEDULEDCASES

EXAMPLE1:DISCLOSURE/CONSENT

EXAMPLE2:ADVISORY/ACKNOWLEDGMENT(FROMMEDPRO)

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Patient Screening Form

Patient Name:

PRE-APPOINTMENT IN-OFFICE

Date:

Date:

Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?

Yes No Yes No

Are you/they having shortness of breath or other difficulties breathing? Yes No Yes No

Do you/they have a cough? Yes No Yes No

Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?

Yes No Yes No

Have you/they experienced recent loss of taste or smell? Yes No Yes No

Are you/they in contact with any confirmed COVID-19 positive patients? Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.

Yes No Yes No

Is your/their age over 60? Yes No Yes No

Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?

Yes No Yes No

Have you/they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)

Yes No Yes No

Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.

• For testing, see the list of State and Territorial Health Department Websites for your specific area’s information.

CourtesyoftheAmericanDentalAssociation(ADA®)2020

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COVID-19 Daily Screening Log

DATE NAME TEMPERATURE <100.4°F COUGH

NEW SHORTNESS OF

BREATH

ASKED TO GO HOME (Note Time Dismissed)

Yes No Yes No Yes, Time:

No

Yes No Yes No Yes, Time:

No

Yes No Yes No Yes, Time:

No

Yes No Yes No Yes, Time:

No

Yes No Yes No Yes, Time:

No

Yes No Yes No Yes, Time:

No

Yes No Yes No Yes, Time:

No

Yes No Yes No Yes, Time:

No

Yes No Yes No Yes, Time:

No

Yes No Yes No Yes, Time:

No

Yes No Yes No Yes, Time:

No

Yes No Yes No Yes, Time:

No

Yes No Yes No Yes, Time:

No

Yes No Yes No Yes, Time:

No

Yes No Yes No Yes, Time:

No

Yes No Yes No Yes, Time:

No

Yes No Yes No Yes, Time:

No

Yes No Yes No Yes, Time:

No

CourtesyoftheAmericanDentalAssociation(ADA®)2020

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COVID-19 (Coronavirus) Disclosure/Consent

PatientName:______________________________________________________________________

TheCentersforDiseaseControlandPrevention(CDC),theAmericanDentalAssociation(ADA),andthestatedentalboardhaveallissuedastrongrecommendationtopostponeanynon-emergentdentalcareuntilfurthernoticeduringtheCOVID-19pandemic.

Currentstudiesindicatethatsomedentalprocedurescreateaerosolizedparticles(similartoasneeze),whichcanlingerintheairforminutestosometimeshours,whichcanresultintransmissionofCOVID-19.IunderstandandacknowledgetheserecommendationsandherebydeclarethatIhaveanemergentorurgentdentalconditionthatrequirespromptcare(orIhaveachildwithanemergentorurgentdentalcondition).___________(Initial)Iherebyaffirmthatmydentist/surgeonandanesthesiologisthaveofferedmetheopportunitytorescheduledentaltreatmentundergeneralanesthesiatoasubsequentdatependingrecommendationchanges.___________(Initial)IalsoaffirmthatIhavefreelyelectedtoproceedwiththeprocedureduetopain/infectionthatareunmanageableathomewithmedications.Ihaveconsultedthetreatingdentistforotheralternatives.___________(Initial)Ifullyunderstandthatproceedingwiththetreatmenttodayincreasesmyexposure/mychild’sexposureandthereforeriskofcontractingcommunityacquiredCOVID-19(Coronavirus)infection. Acquiringsuchinfectioncanleadtosymptomssuchasfever,chestpain,shortnessofbreathandfurtherrespiratorycomplications.Severediseasecanalsoleadto:prolongedhospitalization,intensivecareadmission,mechanicalventilation,and/orpossibledeath.

IalsoaffirmthatneitherI/mychild,noranyofmyfamilymembershavebeenexposedtoorhadanyofthefollowingsymptomsinthepast14days:

1)Fever(≥100.4°F) 2)Shortnessofbreath 3)Drycough 4)Fatigueandbodyaching5)Chestpain6)ConfirmedorsuspectedCOVID-19(Coronavirus)infection

Iamconsentingtothisprocedurewithfullunderstandinganddisclosureofsuchrisksandalternatives,andallmyquestionswereansweredtomysatisfaction.Name(printed):_______________________________________________________________________Signature:____________________________________________________________________________Relationshiptopatient(ifapplicable):______________________________________________________Date:___________________________

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PATIE NT/RESPONSIBLE PART Y DATE

ARE YOU CURRENTLY AWAITING THE RESULTS OF A COVID-19 TEST? YES NO

DO YOU HAVE A FEVER? YES NO

DO YOU HAVE ANY SHORTNESS OF BREATH? YES NO

DO YOU HAVE A DRY COUGH? YES NO

DO YOU HAVE A RUNNY NOSE? YES NO

DO YOU HAVE A SORE THROAT? YES NO

DO YOU HAVE SNEEZING, WATERY EYES, AND/OR SINUS PAIN/PRESSURE

THAT IS UNUSUAL AND NOT RELATED TO SEASONAL ALLERGIES? YES NO

HAVE YOU EXPERIENCED HEADACHES, FATIGUE, OR WEAKNESS? YES NO

HAVE YOU LOST YOUR SENSE OF TASTE AND/OR SMELL? YES NO

WITHIN THE LAST 14 DAYS, HAVE YOU TRAVELLED TO ANY FOREIGN COUNTRY? YES NO

WITHIN THE LAST 14 DAYS, HAVE YOU TRAVELLED WITHIN THE UNITED STATES? YES NO

IF SO, WHERE?

PLEASE ANSWER “YES” OR “NO” WITH YOUR INITIALS, TO THE FOLLOWING QUESTIONS:

Patient Advisory and Acknowledgment Receiving Dental Treatment During the COVID-19 Pandemic

Dear Patient:

You have presented to the office today because you have an urgent dental condition which must be treated at this time and cannot be postponed until the current COVID-19 risk period abates. Please be advised of the following:

While our office complies with State Health Department and the Centers for Disease Control and Prevention infection control guidelines to prevent the spread of the COVID-19 virus, we cannot make any guarantees.

Our staff are symptom-free and, to the best of their knowledge, have not been exposed to the virus. However, since we are a place of public accommodation, other persons (including other patients) could be infected, with or without their knowledge.

In order to reduce the risk of spreading COVID-19, we have asked you a number of “screening” questions below. For the safety of our staff, other patients, and yourself, please be truthful and candid in your answers.

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COVID-19 (Coronavirus) Disclosure/Consent

PatientName:______________________________________________________________________

Currentstudiesindicatethatsomedentalprocedurescreateaerosolizedparticles(similartoasneeze)ofthevirusthatcausesCOVID-19,whichcanlingerintheairforminutestosometimeshours,whichcanresultintransmissionofCOVID-19(Coronavirus)fromaninfectedperson.IunderstandandacknowledgethisinformationandherebydeclarethatIhaveadentalconditionthatrequirespromptcareorIhaveachildwithadentalconditionthatrequirespromptcare.___________(Initial)Iherebyaffirmthatmydentist/surgeonandanesthesiologisthavediscussedwithmethepreventativemeasuresbeingtakentominimizetheriskofCOVID-19(Coronavirus)transmission.___________(Initial)Ifullyunderstandthatproceedingwiththetreatmenttodayincreasesmyexposure/mychild’sexposureandthereforemyriskofcontractingcommunityacquiredCOVID-19(Coronavirus)infection. Acquiringsuchinfectioncanleadtosymptomssuchasfever,chestpain,shortnessofbreathandfurtherrespiratorycomplications.Severediseasecanalsoleadto:prolongedhospitalization,intensivecareadmission,mechanicalventilation,and/orpossibledeath.

IalsoaffirmthatneitherI/mychild,noranyofmyimmediatefamilymembershavebeenexposedtoorhadanyofthefollowingsymptomsinthepast14days:

1)Fever(≥100.4°F) 2)Shortnessofbreath 3)Drycough 4)Fatigueandbodyaching5)Chestpain6)ConfirmedorsuspectedCOVID-19(Coronavirus)infection

I am consenting to this procedure with full understanding and disclosure of such risks and alternatives, and all my questions were answered to my satisfaction.

Name(printed):_______________________________________________________________________Signature:____________________________________________________________________________Relationshiptopatient(ifapplicable):______________________________________________________Date:___________________________

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PATIE NT/RESPONSIBLE PART Y DATE

ARE YOU CURRENTLY AWAITING THE RESULTS OF A COVID-19 TEST? YES NO

DO YOU HAVE A FEVER? YES NO

DO YOU HAVE ANY SHORTNESS OF BREATH? YES NO

DO YOU HAVE A DRY COUGH? YES NO

DO YOU HAVE A RUNNY NOSE? YES NO

DO YOU HAVE A SORE THROAT? YES NO

DO YOU HAVE SNEEZING, WATERY EYES, AND/OR SINUS PAIN/PRESSURE

THAT IS UNUSUAL AND NOT RELATED TO SEASONAL ALLERGIES? YES NO

HAVE YOU EXPERIENCED HEADACHES, FATIGUE, OR WEAKNESS? YES NO

HAVE YOU LOST YOUR SENSE OF TASTE AND/OR SMELL? YES NO

WITHIN THE LAST 14 DAYS, HAVE YOU TRAVELLED TO ANY FOREIGN COUNTRY? YES NO

WITHIN THE LAST 14 DAYS, HAVE YOU TRAVELLED WITHIN THE UNITED STATES? YES NO

IF SO, WHERE?

PLEASE ANSWER “YES” OR “NO” WITH YOUR INITIALS, TO THE FOLLOWING QUESTIONS:

Patient Advisory and Acknowledgment Receiving Dental Treatment During the COVID-19 Pandemic

Dear Patient:

You have come to our office today for a routine dental evaluation and/or treatment that will be done during the COVID-19 pandemic. Please be advised of the following:

While our office complies with State Health Department and the Centers for Disease Control and Prevention infection control guidelines to prevent the spread of the COVID-19 virus, we cannot make any guarantees.

Our staff are symptom-free and, to the best of their knowledge, have not been exposed to the virus. However, since we are a place of public accommodation, other persons (including other patients) could be infected, with or without their knowledge.

In order to reduce the risk of spreading COVID-19, we have asked you a number of “screening” questions below. For the safety of our staff, other patients, and yourself, please be truthful and candid in your answers.