By Cat Edney and Tarik A. M. Shembesh
When the Chief Dental Officer for England announced that Urgent Dental Centres (UDCs) were to open during the COVID-19 pandemic, there were numerous hurdles that needed to be overcome prior to opening. One of the biggest challenges, in addition to securing a supply of appropriate personal protective equipment (PPE), was the provision of training and testing of respiratory protective equipment (RPE) and the appropriate use of PPE in order to ensure that the dental workforce is safe to deliver face to face patient care.
The issues were recognised quickly and a cohort of redeployed workforce and volunteers was assembled to support the NHS and its dental workforce. Being part of a comprehensive testing and training service helping to get the London UDCs ready has given us clear insights into how dentistry might look in the future. The operation was led by three colleagues who had identified that there was a need for the training and testing. They worked hard and efficiently to ensure that the need was met.
Within the early phase of setting up the UDCs in April, we collectively managed to visit, train and fit-test over 300 staff in London alone. We provided extensive RPE training and insights into the use of PPE alongside adapted workflows helping protect dental staff working during the pandemic. Since this team was a mobile workforce we were able to visit the UDCs in local practices and community clinics. This meant that we could work to often last-minute requests for testing, and work with teams to collectively find workflow solutions specific to the local environment of a particular UDC.
The most important aspect of working in this pandemic is to keep every individual safe. The team leaders place a significant emphasis on making sure each session was governed well, providing a pre-attendance questionnaire to ensure individuals and fit testing staff were symptomless prior to the test day. This included assessing and implementing measures locally, such as safe social distancing in the practice, marking out waiting areas, keeping distance where possible with staff and clearing all surfaces of unnecessary equipment and clutter. Further to this we addressed anxiety issues of working in a pressured environment and highlighted the need for decompression outside of the working day.
Working with support from Regional Dental Leads within NHS England and NHS Improvement, and using Public Health England (PHE) guidance on PPE, we provided training explaining the need for fit testing with respirators, outlining the legal aspects related to respirator use and the function of each respirator we fitted. We discussed the different scenarios in which respirator use would be indicated and explained how team structures may need to be adapted to fit with PPE availability. It is well known that not all respirators fit all face types and with shortages affecting every healthcare provider, the teams have faced a new challenge in sourcing and providing a range of models for staff to try. It became clear that it was important to get the most senior or experienced member of each team fitted in order to prioritise supply to those who are most adept and able to provide all the treatments that might require an AGP.
A very important aspect to understand is that fit testing will need to be repeated regularly. As new respirators become available, or with changes to the provision of the models that were supplied, each individual will need to be fit tested again with the model that is currently available to them. Moreover, there are multiple indications for repeating fit testing, including: weight-changes, facial structure changes (eg broken nose, surgery including cosmetic botox or fillers in the lower region of the face); the use of new glasses; different visor frames; and the use of loupes.
As a multidisciplinary team of dental professionals coming from across the London region, we have been able to raise awareness for the need for gold standard fit testing and highlight the requirement for local RPE programmes to develop. The skill set of the team and the willingness to learn and adapt throughout the process, due to regular new developments, the fast changing global situation and manufacturers' recommendations, has meant that we have been able to keep our advice, testing and training very up to date during the current pandemic.
The PPE and RPE training was offered as a free service to all London UDCs by the NHS. In addition to this we facilitated training and comprehensive mentoring of professionals from each UDC to become local fit testers. The latter has allowed each UDC to become independent and given them the skills required going forward to maintain their operation throughout the uncertainty of supply of differing models of PPE. This means that if staff providing care at a UDC becomes unwell the UDC is able to locate and prepare cover quickly without waiting for a remote or distant fit testing session to become available for the new member of staff.
Dental professionals are some of the best suited healthcare professionals to perform fit testing, as they are already well versed with assessing the anatomy of the lower mid face and have an understanding the limitations of qualitative taste test methods. It is because they are part of a workforce that regularly undertakes aerosol generating procedures that they understand the risks involved and what is required to mitigate the risks.
Testing RPE involves training the wearer in a pre-use Fit Check test, to ensure that each and every time they don the equipment they are personally satisfied that it works adequately. We then use a qualitative method of testing in which the wearer is asked to perform a series of standardised exercises while wearing a dosing hood over their RPE and PPE. The doses are specifically tailored to each individual. The wearer is instructed to breathe through their mouth and over their tongue. If at any point the wearer can taste the dosing solution the indication is that there is an incompetent seal being achieved by the respirator and therefore it is not going to provide sufficient protection to the wearer. The process takes approximately 40 minutes per individual, as long as they pass the test at the first attempt. With our carefully selected workforce working in parallel simultaneously, most dental practices can have all their staff tested and trained within a half-day.
Currently, the biggest obstacle to opening a dental surgery has been finding correctly fitting respirators for enough members of the team to make it operational. The supply of disposable RPE is limited and the sizes are rarely adaptable to each face shape. Collectively working with the local London Dental Network and regional leads we managed to improve the pass rates of fit-tests and even managed the initial disparity of successful tests related to gender, with women passing a fit test less frequently than their male counterparts. Furthermore, being extremely mindful of the limited and changing supply of RPEs and to minimise wastage we used our collective dental knowledge of skeletal assessment, anthropometric measurements and 3D scanning of the lower anterior face height in the selection of RPEs prior to their checking and testing.
Working with UDCs to understand how to prepare the surgery for opening also involved designating AGP rooms: often those with the best ventilation, and close to additional areas selected for donning of PPE and doffing (removing) of RPE. It is local measures like these that teams needed to come together and discuss following fit-testing once they were aware of which staff members were able to perform AGPs. The collective experience of each UDC with the guidance provided by our team ensured that primary care UDCs in London were operational within such a short time from the closure of general dental practices.
The future for dentistry is dependent on the progression of the response to COVID-19 and the limitations we face through all phases of managing the pandemic. The use of respirators on an ongoing basis may not be indicated in the distant future, but they will be required for some time. The good news is that preparing for the eventuality that respirators will be required as a routine will be relatively easily managed with a collective effort, local coordination as well as the right resources and teams, as was achieved in our early response to opening UDCs in London. An RPE programme, with a well-structured quality assured fit testing process, aims to raise awareness and helps to ensure the maximum protection is available to the wearer, while also ensuring the suitability and adequacy of the RPE being used. Adopting this approach means that opening up practices may not be as difficult as initially anticipated.
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Mobilising the primary care UDCs during the COVID-19 pandemic. BDJ Team 7, 4–5 (2020). https://doi.org/10.1038/s41407-020-0320-2