10 steps back to practice – vulnerable patients

Bindiya Thakrar explores how dentists might have to change the way they practise to accommodate vulnerable patients in a post COVID-19 world.

From 8 June 2020, dental practices across England were given the go ahead to gown up and get on with it – well, sort of! As part of this series covering the 10 steps back to practice, this article will focus on how we can manage vulnerable patients as we navigate our way through the ‘new normal’ of dentistry.

In the context of COVID-19 and dental care, the conversation surrounding the management of vulnerable patients is likely to include groups of people that we hadn’t previously considered.

It is worth noting here that even though practices have been given the go ahead to open from the 8 June, they should not be seeing any patients who are displaying symptoms of COVID-19 or live with someone who is. If these patients require emergency dental treatment, they should be referred to an urgent dental care centre (UDC).

Medically compromised patients

As we know, there are patients who fall under the ‘extremely clinically vulnerable’ and ‘clinically vulnerable’ risk categories of contracting COVID-19.

Those in the highest risk categories will have received a letter that they should be shielding for 12 weeks. However, as we begin to emerge from that time, those patients will still need to take extra precautions.

Should they require dental treatment, you should triage them in much the same way as before. Carry out an assessment over the phone to ascertain their dental needs. If a trip to the surgery can be postponed, then take this option.

We can do what is necessary to minimise risks within the surgery setting. But give consideration to the fact that transmission can occur at any point along the patient’s journey to the surgery and back.

It isn’t unreasonable to ask about the patient’s mode of transport and factor this into the decision making process as well. Domiciliary visits are an option and the practice should be aware of the local referral systems in place for this.

Face-to-face appointments

However, if a face-to-face appointment is required, the team should make a choice as to whether to manage the patient in primary practice or to refer to a UDC.

If seeing the patient in general practice, you should see them first thing in the morning to allow for maximum ventilation of the surgery overnight.

Also, take care to ensure the waiting room allows for two metres social distancing rules. It may be prudent to allow some extra time after seeing a shielded patient before booking the next patient in. This will ensure there is no crossover within the practice.

The same rules should apply whether providing aerosol generating procedures (AGPs) or non-AGPs. However, of course, the PPE requirements and length of time between appointments will vary depending on the type of procedure.

Here are some practical tips provided by FGDP for seeing any patient in general practice:

Communicate arrangements and protocol for social distancing
Minimise contamination of public areas by:
- Offering storage of bags, coats, etc
- Provide antiseptic hand gel on entrance and exit
- Minimise waiting times in common areas
- Discourage use of toilet facilities
- Adoption of high level of infection control and prevention
Protection of reception staff by social distancing, wearing of appropriate PPE, and or barrier screens
Appointment times tailored to new ways of working
Temporal and spatial zoning for vulnerable patients
Temperature checks deemed unreliable
Testing seen as aspirational
Ongoing training for all staff.

Management of medical emergencies

Most of the guidelines on the management of medical emergencies remains the same as before, unless it is something that involves the airway or breathing. The Resuscitation guidelines have been amended slightly in view of the pandemic and are as follows:

Do not put your face near the patient’s face to listen or feel for breath
Call 999
Attach a defibrillator as soon as possible, which may negate the need for chest compressions and ventilations
Cover the patients nose and mouth with a cloth if chest compressions are to be carried out
If no PPE is available, the person must decide on the course of action. But ideally wear non-AGP PPE at the very least
Begin chest compressions as usual
Ventilation should only begin once assistance has arrived donning AGP PPE
If you have been involved in chest compressions, wash your hands thoroughly and contact NHS 111 for further advice.

Other risk factors

Aside from the medical factors, there are other considerations that can impact a patient’s risk category.

You should note the age, gender and ethnicity of the patient, as well as if they are pregnant, when making decisions about patient care.

None of these factors mean you cannot see a patient, but they can certainly shape the way we manage our diaries and the time that we allow for appointments.

It’s not within the scope of this article to discuss each risk factor in detail other than to draw attention to them and the way we can manage them. However, here are some useful links that have further information on the risk factors mentioned above.

Children and vulnerable adults

Healthcare workers have a duty to recognise and respond to any safeguarding concerns. This is of heightened importance during this pandemic.

The lockdown may force vulnerable members of society to spend time in toxic situations. We should remain extremely vigilant to this as we begin to see more patients face to face.

There is advice in a previously published article about how to recognise and manage cases of domestic abuse. Much of this applies to the suspected abuse or neglect of children and vulnerable adults.

When in doubt, always seek advice from your practice safeguarding lead. Do not be afraid to report what you have seen to your local safeguarding team. We assess patients from the moment they enter our doorway. And we probably notice more than we realise. But the chances are, if you question something untoward, we should investigate it further.

Oral health lessons

It’s not only cases of abuse or neglect that we should be vigilant for. The lockdown has meant children (and adults of course) have been spending more time indoors. This is likely to impact their diet in some way, be it negative or positive.

There is a chance that we will see patients experiencing an increased rate of caries. In these instances, we should use the opportunity to focus on preventative measures as well as treatment.

Educating patients and their families about the cause of decay can help them to make well-informed decisions going forward. This is especially important for those who are undergoing orthodontic treatment and are likely to see their treatment times go up.

Once the capacity of dental practice increases, it is prudent to prioritise booking those who are already on shorter recalls due to high caries or periodontal disease risk.

Attendance

Whilst the advice is that patients should attend alone to minimise the risk of spreading infection, of course children will need to attend with a parent/guardian. Vulnerable adults may require the assistance of a family member or care worker and this should be permitted.

Be mindful of surgery size so that anyone else attending can remain in the surgery whilst at a safe distance. You should also provide them with PPE if in surgery. And if they choose to remain in the waiting room, it should be big enough in order to social distance from others present.

You should consider a patient’s access to and familiarity with technology. When booking appointments, it is worthwhile calling patients instead of relying on text or email reminders. Especially if you feel they need extra support.

Preparing for appointments

Lastly, as we progress through the phases of our return to care, the level of PPE will also change. By now we’ve all seen the FFP3 masks that conjure visions of Bane from Batman or Hannibal Lecter.

For children, vulnerable adults or indeed any nervous patient, this is unlikely to be a reassuring sight. It is worth setting up a video consultation with these patients or having a pre-recorded video available on your website so they can familiarise themselves with the set up.

At least they’ll know it’s a human being under the mask and not a flesh-eating psychopath!

Here are some great resources that can help children in particular prepare for their dental visit.

Vulnerable staff

This article is here to shed light on some of the considerations for managing vulnerable patients. However, in planning our return, we should be mindful of those of us in our team who may also fall into the same categories.

Carry out personalised risk assessments that take into account age, sex, ethnicity, co-morbidities and if pregnant or not. Here are some useful tools to carry out such risk assessments:

10 steps back to practice after COVID-19 – vulnerable patients