10 steps back to practice after COVID-19 – PPE
Neel Kothari explores the different options of PPE available to practices and the dental team as they look to reopen.
Let me start by making a small admission – before lockdown I had almost forgotten the word ‘doffing’. I had also forgotten that using a fast handpiece was regarded as an aerosol generating procedure (AGP).
In my opinion, the cross infection measures we have as dentists are amongst the best in the world. But in the face of a viral pandemic and the news that some healthcare workers have contracted and passed away from COVID-19, it’s understandable that enhanced measures are put in place to keep ourselves, our staff and our patients as safe as possible.
In the recent guidance by the FGDP, it suggests that enhanced PPE measures are likely to be needed for high-risk procedures (generating aerosols) until the UK COVID alert level drops to two.
We are currently at level four, transitioning to level three.
In this article I will discuss my thoughts on a range of PPE such as masks, gowns and visors.
There is a particularly good reason I start with visors. In my opinion, I suspect that this is the most effective way of protecting us from exposure to various droplets, splatter, and aerosols.
It is a simple barrier, but the larger wrap around ones seem to significantly keep us protected. Potentially we could consider disposable eyewear when carrying out AGPs. But this seems the most effective.
NHS England’s SOP guidance on masks states:
- For non-AGP care the PPE required is: eye protection, disposable fluid-resistant (type IIR) surgical masks, disposable apron and gloves
- Avoid AGP where possible. For AGP care, the PPE required is: disposable, fluid-repellent gown or approved equivalent, gloves and eye/face protection. All team members involved in the procedure must wear an FFP3 respirator (it filters 98% of airborne particles).
There are further options too. A standard dental mask offers a simple barrier protection. A respirator is a device to protect the wearer from inhaling harmful substances. For it to be effective it must be fit tested to demonstrate its seal. Respirators must meet a specific standard and the HSE has stated that whilst FFP3 masks are desirable, dental practices can also use FFP2 and N95 masks.
Not every person passes a fit test and, due to availability issues, many look for reusable versions. Without entering into a debate into the rights and wrongs of how respirators are used, some have suggested a means of preserving stock by using a standard dental mask over it, which is disposed of between patients.
The evidence behind the use of fluid repellent gowns in preventing transmission of disease is inconclusive. However, it recommends during the higher alert levels (three to five) the use of full-sleeve fluid-resistant gowns for high-risk aerosol procedures.
The undergarments such as scrubs must be washed daily at high a minimum of 60 degrees. Where there is a low risk of aerosols, the policy of ‘bare below the elbows’ still applies.
Hat and shoe covers
You can use hat and shoe covers, but these are not an absolute requirement. In our practice we use hats, but decided to avoid foot coverings as having tried various brands I had concerns with staff members potentially slipping. The risk of transmission here seems low.
Donning and doffing
Within the various published guidelines, ‘doffing’ PPE carries a higher risk to us as dental healthcare workers as we potentially encounter contaminated surfaces.
As we have progressed through lockdown its clear that due to shortages in PPE, many have understandably resorted to methods of preserving stock. Such as placing a standard surgical mask over a less available respirator, reusable respirators, and reusable gowns. These may pose additional concerns as the face may be repeatedly touched during the working day.
Whilst reusable masks provide a sustainable solution, it is not yet clear how to decontaminate them between patients.
Regardless, frequent washing of our hands both before, during and after the donning/doffing procedures are incredibly important to minimise risks.