The Compliance Divas Podcast
Our podcast covers current topics such as infection prevention and control, OSHA and HIPAA compliance for dentistry. We discuss the latest regulatory information, answer frequently asked questions and give suggestions for dental practices to make compliance easy and sustainable. The Compliance Divas are a trusted source for consistent, accurate information based upon current guidelines, standards, science, and recommendations.
The Compliance Divas Podcast
Episode #23 Breaking News: CDC September 10, 2021 Updates Part 2
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In this follow up episode, the Divas further discuss the CDC's September 10, 2021 updates and what this means for your practice. This episode in conjunction with Part 1 will assist you in implementing the latest requirements so you can maintain a safe environment for your dental team and patients alike.
Welcome. I'm Leslie Cannon. I'm Mary Gavoni. I'm Linda Harvey.
SPEAKER_02I'm Olivia Juan. And together we are the Compliance Divas.
SPEAKER_03Welcome to the Compliance Divas Podcast. My name is Mary Gavoni, and I will be the moderator for this episode. We bring clarity and simplicity to compliance by navigating the regulatory environment to keep you on course. You can subscribe to the Compliance Divas podcast through your favorite podcast channel or on our website, thecompliancedeevas.com. Throughout this episode and other episodes, we mention many resources from the CDC and other groups. And we always make those resources available on our website, thecompliancedivas.com. You can also submit questions if you have them to support at compliancedevas.com. You can send email those questions to us there. So in a previous episode, we discussed the general provisions for healthcare settings in the September 10th, 2021 CDC Interim Guidance. This is now the document, the go-to document for everyone in healthcare settings, and specific information that applies just to dentistry is included in this document. So we're going to continue that conversation in this episode with information about the CDC's guidance for treating patients with COVID-19 symptoms or healthcare personnel who may be exposed to COVID-19 or have COVID-19 infections, since some of the testing and quarantine protocols have changed. Most notably, if a healthcare worker is exposed to an individual with a known case of COVID-19, that healthcare worker needs to be tested within two to five days of the exposure, even if they are vaccinated or they have no symptoms. And this is primarily because we have a number of asymptomatic cases. This is because of the spread of the delta variant from vaccinated and unvaccinated individuals. We're also going to address the sections in this document that are specific to dentistry. So as we start out today, Linda, can you talk about what agencies or organizations, in addition to the CDC, that dental practices need to monitor or interact with to make sure they're up to date on specific state or local recommendations?
SPEAKER_01Sure, Mary, thank you. That's an important piece that we don't want our listeners to overlook. We sometimes can get focused on one agency or one organization and forget there are other agencies and organizations and governing bodies that we need to be mindful of. For example, all dental health care personnel should continually consult and check with their state dental boards as well as their state or local health departments for any other current information or recommendations or any specific requirements for their state or jurisdiction. And so on top of that, when we think about state level, there may be state requirements related to COVID that apply to all businesses, including healthcare. And on top of that, I'm going to add a fourth layer, and that is to determine whether or not a particular state has a state-approved OSHA plan. And there are quite a few states over 20 that do. You know, there's Cal OSHA, there's MyOSHA in Michigan, you know, Tennessee has Tennessee OSHA. So there's quite a few states that do. And so it's important to understand how these agencies all come together. If we likened it to patient care, it would be like putting together a treatment plan. We'd have to look at every quadrant of the mouth. So we also look at every quadrant of areas of agencies and organizations and governing bodies that would relate to what we need to be mindful of. Now, with our state dental boards, I know that uh some states didn't have any uh rules they promulgated related to COVID-19. They simply defer or leave the CDC and OSHA primarily in charge. But if there's a state OSHA plan, then of course there is going to be some additional guidance and documents to be mindful of. Now, one of the things to bear in mind about staying in touch with your community or local health department is the fact that you need to be monitoring what's going on in your particular geographic area. You need to understand what your caseload is for positive cases and also understanding the percentage of eligible population fully vaccinated is another important factor. We also mentioned that we have the COVID CDC COVID tracker that we're going to have that link on the resources for all of our listeners. So when you click on this area and you look at your state and drill down to your county, you'll see that primarily the majority of the country is in the high zone. We're in high risk. So when you look at this, take a look at the percentage of eligible population fully vaccinated. And that will help you determine what's the likelihood of the patients coming in your practice that may or may not be vaccinated. So, for example, in Northeast Florida, in Duval County, everyone is there's 61% of the pop eligible population is fully vaccinated. So we've tipped the 50% mark. I've looked in some counties and other states that may be a little bit more rural or smaller population, and they've been as low as 25 or even 11%. So I think that's important when we start thinking about uh whether we're seeing patients and trying to screen patients who are suspected or COVID-posit, that we have some different variables to bear in mind. And over the years, it's interesting how when we think about referring our clients to the CDC documents and we refer to them as guidelines, and the word guideline can be misinterpreted or misunderstood because we always look for what's required. And sometimes we tease out guidelines as something that's recommended. And while the CDC itself is not a governing body, an agency with enforcement authority, like OSHA is, or state dental board or just state, then but the ghost guidelines are the guidelines that OSHA uses with their COVID enforcement. And it's very clear at all of the OSHA guidelines and documentations, rather not guidelines, but all their publications and all their standards and all their enforcement documents, as well as their compliance directives, that they are they're clearly have been always enforcing the CDC guidelines. This is nothing new. So I'd like to make sure that our listeners are aware of those two ideas as well, Mary, because it's really important just not just to just pay attention to the four different agencies and groups that I talked about, but to also understand that these are all requirements. They're not nice to know anymore. It's must-do. And now that this crisis, it's important that we stay abreast of those, these changes on an ongoing basis because the CDC is monitoring these variants at four different levels. And right now there are 10 different COVID variants that are being monitored. There's no variants of interest, which is the second category, and the variant of concern are the delta variants. And right now, none of the variants have been labeled as variants of high consequences, but you know, the CDC is monitoring those closely. So there could be changes at any time. So stay in close touch with your state health department, Mary.
SPEAKER_03Absolutely. Thank you so much, Linda. That clarification is so important. And um I know that collectively we have all been teaching the groups that we work with that just because their CDC documents are guidelines or recommendations doesn't mean that they're not um enforceable or they're not important. And I would not want to be the dental practice that perhaps gets um has an allegation from a patient that they may have contracted not just COVID, but any infectious disease in the practice. And their question is, well, what guidelines are you following? What are your infection control practices? And the answer would be, well, they're just recommendations. And I'm sure that any astute attorney would pick up on that and saying, why aren't you following the recognized standard of care? So in a previous podcast, we talked about um the importance of having a response plan for what a dental practice should do if there is an exposure, especially to a healthcare worker. And in addition to the September 10th, 2021 interim guidance for healthcare facilities, the CDC also released on the same day interim guidance for managing healthcare personnel with SARS-CoV-2 infection or exposure to SARS-CoV-2. So we will link this document in the references or the resources section on our website. And I think it's important for our listeners to make sure that they download that document and review it so they know what to do in conjunction with their local health department if they do have an exposure, what is the quarantine period, when is the testing period, and so forth. That is very, very important information. But the document we're discussing this morning also addresses issues of what to do if you have a patient who has symptoms of COVID-19 or they have a confirmed case of COVID-19. If they need non-urgent care, meaning elective procedures, those should be postponed until that patient is no longer an infectious disease threat to everyone else in the dental practice. But if it's a medically necessary emergency treatment that needs to be done, practices need to think over what their plan would be, whether they will treat that patient in the dental office, which according to the CDC is not the ideal situation, that they should be treated in a facility with airborne infection isolation facilities, meaning a closed room and most likely with negative air pressure and so forth, especially because of the increased transmissibility of the current prevalent delta variant. The other thing to remember is that if you are treating patients who have symptoms of COVID-19, who have confirmed cases of COVID-19 in your facility, then that immediately puts you under the auspices of the OSHA Emergency Temporary Standard. Because remember, one of the qualifications or disqualifications from having to comply with that standard is that no patients with COVID-19 symptoms or known cases are treated in your facility. So what you may need to do then is refer that patient to perhaps an oral surgeon who has hospital privileges where that patient could be treated. And of course, it it really boils down to protection from aerosols, which Olivia is going to talk to us about. So, Olivia, can you give us a good sort of definition of what the CDC and what OSHA considers to be aerosol generating procedures? And what else do we need to be aware of?
SPEAKER_02Sure, Mary, thank you. So aerosol generating procedures have been specifically defined as using the high-speed handpieces, the ultrasonic scalers, air water syringe, air polishing, and other procedures that might generate splash and splatter. Now, what we do understand in dentistry is that hands down, aerosols are an occupational hazard in dentistry. So when we look at this new guidance, Mary, in section two, not to confuse our listeners, section two deals specifically with serving a patient with suspected or confirmed SARS-CoV-2 infection. So when we look in that section, it discusses aerosol generating procedures and it clearly states that procedures that could generate infectious aerosols should be performed cautiously and avoided if there's alternatives. And then notice it indicates that aerosol generating procedures should take place in airborne infection isolation room if possible. Now, I've not been in any private practices that had airborne infection isolation rooms. So as you pointed out, it would be appropriate for hospitalized dentistry. Now, let's look deeper. We understand that it should not aerosol generating procedures should not be performed on a suspected COVID patient or confirmed COVID patient. Obviously, that's going to trigger the emergency temporary standard published by OSHA. But even in our day-to-day practice, we look at OSHA's federal guidance, and this relates to what Linda was pointing out, we have to assess the risk of our community. So in looking at the PPE ensembles that OSHA published, which is uh reiterated in the CDC's guidance, that if you are practicing in a community where COVID has subsided, that uh at a minimum face mask and a face shield, but it points out that a NIOSH certified disposable N95 filtering face piece respirator offers more protection to the worker who may encounter asymptomatic or pre-symptomatic patients who can spread COVID. And then additionally, OSHA points out that for procedures known to generate aerosol, where COVID continues to be transmitted in communities, it clarifies that NIAS certified disposable N95 filtering face piece respirator, or better, should be used. And the same is true in areas where COVID continues to be a high transmission rate. And so it appears that the N95s continue to be very important, even if we are not serving patients known to have COVID or confirmed to have COVID due to the asymatic patients that may come into our office that do not know they have it. So, just as a little summary, section two of this new guidance applies if we are treating suspicious COVID or confirmed COVID patients, and we should not be performing uh aerosol-generating procedures. But even in our practices where we don't serve those types of individuals, we still should wear an IR certified N95. So I think that this is important guidance for us to embrace and get up to date with.
SPEAKER_03Absolutely, Olivia, and thank you for making that distinction because um the reality is right now we don't necessarily know. As you stated, there may be asymptomatic patients who don't know that they've even been exposed. So those N95s are important for us for protection, um, not only for ourselves, but for our patients as well, because it could be a healthcare provider. Olivia.
SPEAKER_02And one more thing I wanted to point out, Mary, that in the guidance, it indicates that we should minimize the number of healthcare workers in the room if we are treating a known COVID or suspected COVID patient to only those who are essential. And this is even true in practice settings where we're serving a patient that is not known to have COVID or not confirmed to have COVID, we should still minimize individuals who are in the room because they do not have respiratory protection in place. So it's a safety issue for those visitors or caregivers.
SPEAKER_03Absolutely. Thank you again for that clarification. Leslie, can you help us bring this all home and talk about the provisions within this September 10th, 2021 document about our treatment areas? What do we need to know about the layout of facilities? And what are some other considerations for environmental disinfection that we should be aware of?
SPEAKER_00Sure, Mary. Well, first of all, our listeners should know that in the guidance document under section three, we have what's called setting specific considerations. And that's where we're going to find the dental practice setting. As we had heard from Olivia, there are aerosol generating procedures, and we talked about what those are. There's a small section that talks about mitigation strategies such as four-handed dentistry and high evacuation section and dental dams to minimize droplets and aerosols. But there are some other recommendations that are related to the layout of dental practice and the environmental infection control, as well as surfaces and air quality. The recommendation is that dental practices should have treatment rooms in individual patient treatment areas if possible. Now, that is a little tough. In some dental practices, we have open base style seating, such as pediatric and orthodontic type practices. So when an individual treatment room can be used, if there is going to be an aerosol generating procedure, perhaps in a pediatric or an orthodontic setting, if they could use that individual treatment room for that procedure, that would be ideal. It's also stated that dental facilities should at least have chairs with open floor plans that are six feet apart. So we're still looking at that six-foot social distancing. It's because in uh with aerosol generating procedures, studies have shown that aerosols fall as far as six and a half feet away from the patient's mouth. Physical barriers between patient chairs, such as easy-to-clean floor-to-ceiling barriers, will enhance the effectiveness of what's called HEPA filters or portable uh air filters. And I'll talk a little bit more about that uh in the next part. And also to check to make sure that the extending barriers to the ceiling will not interfere with a fire sprinkler system. So when you're setting up these temporary temporary barriers, you want to make sure that they're safe as well as effective in preventing splashes and spatters and potentially aerosols from traveling to other locations. Operatory should be oriented parallel to the direction of air flow if possible. And where feasible, consider patient air orientation carefully. Now, this is a part that's a little bit confusing. When I first read it, I misread it and I understood it incorrectly. It states that placing the patient's head near the return air vent and away from pedestrian corridors and toward the rear wall when using vestibule style office layouts. So if you have individual treatment rooms, it doesn't mean that your patient should have their feet toward the patient corridor. It means that their head is uh positioned at the patient corridor and their mouth is positioned the other direction. So aerosols would clearly go away from open corridors where they could uh travel to other places, other people that are passing through those areas. And again, I'll spend a little bit more time on uh the recommendations for air quality. But there's another part that we should uh look at here too. And let me just go ahead and provide you with some information on other engineering controls that will help and enhance air quality. The use of engineering controls to reduce or eliminate exposure by shielding healthcare workers from other patients and infected individuals. And we don't know always who's infected. We can do our screening, but many times there are people who are asymptomatic in our practice. And so uh the direction of traffic in which we escort our patients to and from the treatment room is still important. We should also stage our treatment room. Uh pardon me, we should stage our reception area where we allow to accommodate six feet apart for patients should they have to stop and wait in our reception area prior to treatment. Then we want to make sure that we explore other options, and this is where it's key. In consultation with facility engineers, improve ventilation delivery and indoor air quality in all shared spaces. They give some references and links to various different uh documents that give guidance to HVAC technicians that will help to improve ventilation. And it's something that you can check with your uh if you own the building, then it would be the owner's responsibility to uh contact the HVAC technician and have a consultation. If the building is owned by another person or another company and the dental practice either rents or leases the office space. Then that question regarding consulting with the HVAT tech should be elevated to the appropriate person. The guidance that ensures ventilation systems are operating properly are available in three different resources that are provided. If the building is not owned by the dentist, but owned by a company other than the dentist, then the dentist should consult with that authority, whoever is uh owns the properties, and find out if they would be willing to assist in improving air quality. And the guidance documents are located in the CDC recommendations. Uh, so that would be something to look at the three different resources that are available there. Now, uh coming back to us, we want to talk about a little bit about what we can do, regardless of whether we bring in an HVAC tech or not. We want to make sure that our systems that handle the air conditioning and heating ventilation are maintained and cleaned properly. We want to make sure that we uh take advantage of additional measures, like if we can open windows and doors during work hours when outdoor climate allows that. And that includes not only weather, but uh, for us in California, we have fires. So smoke can be a concern if we have our windows open and smoke is coming in. That can be quite irritating to sensitive individuals. We can look at placement of fans in windows, but not where potentially contaminated airflow flows directly from one person to another. Another suggestion that has been made is that running an HVAC system or your air conditioning heating ventilation system for at least two hours before and after the building is occupied. So your own suite, if you have controls of your HVAC, that would be something to consider. And then I mentioned earlier HEPA filters using portable, high-efficiency particulate air fan filtration systems. That's what HEPA stands for. That can greatly reduce the uh amount of irritants that are not only in the air, but also uh helps a little bit with dental office odors and can be effective in cleaning the air and improving air quality. Now there's another section that uh deals with the patient's environmental infection control, like making sure that we ensure enough time to clean and disinfect operatories between patients when we calculate our daily patient volume, which is important for those at the front desk who are scheduling those appointments to make sure that we allow adequate time, not only for the extra time it's going to take for donning and doffing the PPE that we need to wear, but also for making sure that we have time to clean and disinfect operatories properly. And with cleaning and disinfecting properly, I remember that in the older guidance, uh in the uh 2020 guidance for infection control and dental settings, there was mention of an amount of time that an examination room should be left to settle before bringing another patient in. And they have not uh included that information in the new guidance, but the amount of time really is not known, and they depend on a number of factors, including the size of the treatment room, the number of air exchanges per hour, how long a patient was in the room, if a patient was coughing or sneezing, and if an aerosol generating procedure was performed. So for a patient who was not coughing or sneezing or did not undergo an aerosol generating procedure, and the room was occupied for a short period of time, like a few minutes, then it's likely that uh that anything in the air, a virus or otherwise, would dissipate over a few minutes. However, for a patient who was coughing or remained in the room longer period of time or underwent an aerosol generating procedure, the risk period is likely longer. And this is uh document that information that I was able to pull from March 4th, 2021, uh in the CDC guidelines. So you can refer to that and we'll include that link in our resources in the compliance diva's website. And just before we go uh further, I wanted to mention air exchanges. Now, air exchanges uh normally are listed at six air exchanges per hour for a treatment room when there were not aerosol generating procedures performed. But if an aerosol generating procedure was performed, the air exchanges should be bumped up to 12 air changes per hour. And again, that information is listed in the CDC guidelines, and we'll provide that link for you as well. It's a rather technical document, but it it's used by hospitals and other settings that are required to have certain air exchanges in every location, including the sterilization area of a dental of a hospital setting.
SPEAKER_03Mary. Thank you so much, Leslie. That's a lot of information. Um, I cannot emphasize enough the importance of um accessing these documents, having them on hand in your practice facility so that you can actually read for yourself what the documents say and what the recommendations are. Um, Divas, are there any particular points that we want to re-emphasize or um add to our information from this episode? Okay, well, I think we have covered it. Well, I think we've covered it well. And again, the resources and Leslie, you mentioned a wealth of resources that we will make available on the Compliance Divas website. Thecompliancedivas.com under the resources tab. And you can click on the links for any of those documents and download them and review them. Remember that if you ever have questions from any of our episodes, you can email them to us at support at thecompliancedivas.com. So we thank you for joining us for this episode. And the Compliance Divas purpose, again, is to bring clarity and simplicity to regulatory compliance by navigating the regulatory environment to keep you on course. Thank you again for joining us, and we hope you'll join us on a future episode.