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AAOMS COVID-19 WebcastAAOMS COVID-19 Webcast April 22, 2020 Victor L. Nannini, DDS, FACS AAOMS...
Transcript of AAOMS COVID-19 WebcastAAOMS COVID-19 Webcast April 22, 2020 Victor L. Nannini, DDS, FACS AAOMS...
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