Future Sterilization - A Team Approach

Cool. All right, so we're going to go ahead and get started. For those of you that have not been on any of my webinars, I've been trying diligently to give as much information as I can to practices and doctors in regards to just a variety of topics. One that has been really, really good, had over a thousand attendees was this future in sterilization. It is. Many of you know, this. This is basic. You know, I'm going to cover it. You're going to be like, well, that's something we already. What I have found is over the years that I've consulted and having had the clinical background, I found that, you know, I see cross contamination all the time in dental offices. Do I call people out? No, that's not my job. That's not why I'm there. I'm not there to say, you're wearing your gloves to the front with a chart. What are you doing? You're, you know, you're cross contaminating all over the place. That's not my role. My role is to really, you know, coach and do what I need to on the business front. But because of COVID 19, I have found that it was my time to really come to the forefront and refresh everyone's memory on. Oh, yeah, that is the right thing to do. I do remember that. I know several of us, if not all of us, have been, you know, seeing people out in public where they're wearing masks and they're not wearing them properly and we're like, what are they doing? Or wearing gloves and, you know, still cross contaminating. But it does happen in the dental practice as well. So I want to go through. I'm going to go through a lot of things today, but please feel free to ask a question if you have it, or you can pop it in the Q and A bar and I'll answer it, you know, at the appropriate time. So the goal of today. Hold on one second. I have Elizabeth calling, who is my consultant who's supposed to be on this call.

Yes, Elizabeth.

Yeah, we're. It's the Zoom meeting. I sent you the invite. We're already on. I've already started.

Okay, bye. Okay, sorry. Okay, so the goal of today's presentation is to prepare you for reopening. Really going through, like, the administration, Cross contamination education, ppe. Sorry, I've been talking a lot about PPP too. What does it look like currently? What might it look like in the future? Donning and doffing sequences. Reviewing your infection control prevention protocols based on The CDC and then scripts for explaining the patient's new processes. If you guys can mute on your end, that'll help. Unless you want to talk. That'll help with distracting noises, phones ringing or chiming or things like that. Okay, so the first thing for reopening is we want to make sure that.

We'Re staying connected with our patients and our teams. I know that Dr. Mayer has been doing this and it's surprising to me how many dentists and if you're on any blogs in dental, you'll see so many practices, so many staff are so confused about what's happening and not knowing what their dentist plan is and what they have gotten in PPP and all of that. The other thing is, in order to really seamlessly open, I feel we all need to revisit our OSHA and HIPAA guidelines. And if you are current with that, great. If not, you need to go back and you need to look at that and see, hey, where are we at? Maybe we all need a refresher on this. Are we abiding by those guidelines properly? We're going to talk about and get into more detail, but you need to know that you're going to have to stagger your patients. I will show you. I did a webinar a couple of days ago where I talked just about scheduling post Covid or after we open type of thing. But staggering the patients leaving room in between the patients of 10 to 15 minutes has been the guide in regards to seeing that flow. Being able to have no patient cross in the exiting or entrancing of the practice. Explaining to you and then also explaining to the patients what are the safety policies that we have in place. I have been teaching the ADA American Dental association guidelines for that, which is. I'll go through it. I have the whole sheet. You have it, it's in your possession. You will have it. What you should do with patients, what questions do we ask of them, pre appointing them and then asking those same questions again when they walk in the door. The checking in process. In other words, what needs to take place when they check in. We know right off the bat that we need to have them. You know our waiting rooms have to be emptied of all magazines, all beverages, all anything at all. That's what could be construed as clutter or what is non essential. Non essential are brochures on dentistry dentatus models in the treatment rooms. The treatment rooms have to be decluttered of all the stuff, paper stuff, cardboard stuff, plastic stuff, things that are not necessary for our Day to day have to be removed. And the patient's check in process has to be told that upon checking in we will be taking their temperature. We will be recording it in a log. Every employee will have their temperature tested every day. I recommend to offices that they get a couple of oximeters that go on your finger. Why is that? I just had a conference with a pulmonologist about a half hour ago and he said to me, that's the exact advice you should be giving dental offices because it is a virus that is affecting the oxygen levels and you will be asymptomatic and, and see that your oxygen levels can go down. So normal oxygen levels 94 to 100 some. Anything in the 80s is definitely reason to be concerned. And that might be a reason to say, you know what, we're just gonna, this may be your normal, but we're gonna, for this day, we're not gonna see you today. And then restrictions in the office in regards to handing off from the back to the front. The other thing is obviously dental deliveries. What happens when those boxes come in? If you're doing this at home, and I would urge you, and you probably all are, but when boxes come in even again, the pulmonologist today said your precautions on that is very important. So holding that box with gloves, letting it sit for 24 hours before you open it on a cardboard box, using a sanitizer, if you're going to use gloves to open it, take off your gloves to get the product on the inside. Because if there's germs on your gloves from opening the box.

Really more and more there's a big. Obviously this webinar is not about what should you be doing for the aerosols. But good rule of thumb is hygienists not to be using their cavitrons, just hand scaling and in the dental chairs using rubber dams, isolites, all of that. Now is a good time to kind of look at your office and say, hey, you know, maybe we should be doing some spring cleaning. What could we be doing in our office to spruce it up a little bit? Do we need any freshening up of paint because of skid marks and scuff marks? Do we need a heavy duty down and dirty scrub, carpets cleaned, floors scrubbed, waxed, whatever you need to do.

And take steps to better organize the practice. Most dentists right now are having conversations with their staffs. How comfortable are you to come back? What's your feeling? Where are you at, you know, on your scale, on your level and everyone's at a different level. I use the analogy of we are going through grieving processes. Grieving, you know, stages go through different cycles and this is no different. And so everyone in the office may be at a different level. Some people, their anxiety is here, some people, their anxiety is here. Everyone's different. The doctor needs to determine who's going to come back to what capacity. And in that process.

If someone can mute their phone in that process, you may need to better organize your practice. What do I mean by that? I mean go into your lab, go into your sterilization area. What label things, organize. This is a time to get rid of your junk that you've been collecting for years and years and years. So if we do have new staff that comes in, it's easy to find things. You don't want things in disarray and now's a good time to do that and then obviously catching up on ce. So there is a hierarchy of safety and health controls within the practice, and those are, first and foremost, training and administrative controls. What do we need? And I'm going to go through all of that engineering controls. What do we need to do with our maintenance of our equipment? What is it? You know, what should we be revisiting? What logs do we have for that maintenance of our equipment, the practice work controls, what, you know, are we going to put hooks up in rooms so that we can hang up our lab coats or our gowns in the operatories? That's how it's supposed to be done based on the CDC guidelines and then ppe. So one of the things that I'm recommending is that you put someone in charge. I call it. Well, it's called the ICC Infection Control Coordinator. It obviously should be an existing employee. Right off the bat, it would be ideal to say to every practice, yeah, go out and hire this new person who's going to make sure that all the maintenance and the reviews of everything pertaining to the procedures of the CDC and the ADA are followed by that, you know, they identify any gaps, that they have proper documentation and permitting and renewal information, and they have binders and compliance. That's great. But the reality of it is most dentists haven't made any income for the last three months. So we have to assign a person. I generally will say assign a head assistant or, you know, someone in hygiene that is really the high. Not the high, the head. A hygienist that could really kind of make sure she's very detailed and she'd be good at this task, perhaps. So previously, the CDC Used to call this universal precautions. It's now been revised as standard precautions.

And what are those standard universal precautions or standard precautions that they're called now? One, it assumes that blood and bodily fluid of any patient could be infection infectious. It recommends that PPE and other infection control practices to prevent the transmission in a healthcare setting. And decisions need to be made about what PPE based on what type of procedure we're doing. So let's talk about the ppe. You all know what this is. There's lots of different ppe, but the description of it is, you know, it's specialized clothing or equipment worn by an employee to protect themselves against infectious materials. That's osha. So what are the regulations? Regulations say that employers must provide ppe, appropriate PPE for employees. What's the issue that we're having in dentistry and in medicine right now? Good luck getting a hold of the ppe. It's not just out there like go and buy whatever you need.

Ensure that the PPE is disposed of or reusable. PPE is cleaned, laundered, repaired, stored after use. OSHA has also said specific circumstances for the PPE when indicated, meaning you have to determine what and when and how you're going to use the ppe. So now let's go into different types of the ppe. In the current world of what we were before, the new normal was a gloves, maybe a gown or apron, mask, goggles and maybe face shields. The future is likely going to be more disposable gowns, hair, hair protection, shoe protection, N95 or N99 masks or a surgical mask. KN95. If you can't get N95 and a surgical mask over it, where you would change that surgical mask every day, but you'd leave your N95 on not changing that every patient and then leg protection. So not every practice is going to do this. This is. There is no set guideline right now by the CDC or the ADA specific for dental practices. I have all their guidelines. I'm going to share them with you. I have a COVID 19 toolkit on my website. It's free to you, but the reality of it is you have to feel comfortable in your own world what you're doing. I will tell you this. I've known for years and years that.

When I worked in the dental practice, I would wear my shoes to the practice and have my set shoes that I kept at the office, gym shoes or whatever, nurses shoes and those remained at the office. My recommendation would be that you do not come to and Fro to the office in your scrubs. You should be coming to the office in street clothes with your shoes. Get changed into your fresh scrubs once you're on site. Do not take those shoes out of the office. Put your, you know, your street shoes in a bag with your clothes. Take your used uniform off when you leave the day, put it in the bag, take it home and put your street clothes back on. Be as cautious as you can assume. Just like in the 80s we assumed that every patient was HIV positive. We didn't think anything different of it. We just always have operated that way. It's the same thing now. Assume every patient you see is COVID 19 positive. So what are some factors that influence the selection of your PPE? 1 is, you know, what's your anticipated exposure? Is it just spray and splash or is it touch or you know, what precautions should be you be having the durability and the appropriateness of the task will determine again, what are you going to use if you're going to be doing osseous surgery or oral surgery and flapping back gums and you know, using osseous surgery to reduce bone clefts within the palate or wherever you're working? Yeah, you might be using more PPE than you would if you're going to be doing a routine cleaning with no cavitron and making sure that the fit of the PPE is very important. Not everyone's all built the same. So let's talk about gloves. The purpose we know is for patient care and environmental services. When touching blood, bodily fluids, secretions, excretions, contaminated items for touching mucous membranes and non intact skin. So there's different variations of gloves material. You've got vinyl, you got latex, you got nitrile or other and you have sterile gloves or non sterile gloves. You have single use or reusable use. So one of the things we know for sure is that most offices are not using their utility gloves to the level that they should. Utility gloves? Every person should have a pair and they need to be used to transport the instruments from the operatory to the sterilization area. That's not generally happening. So what are some do's and don'ts of gloves? One is you work from the clean to the dirty area. Limit the opportunities for touch contamination. Protect yourselves and others in the environment. That's a do. Keep your gloves away from your face. Avoid touching or adjusting your ppe. The reason that people touch their PPE so much or touch their face is because their mask is not properly fit. We're going to go over that in a minute. And they tend to then touch more because it's uncomfortable or they're trying to readjust it. So changing your gloves after each patient during patient use, if they're torn or heavily soiled, obviously even if it's on the same patient, change it, discard appropriately in a receptacle, what are you not going to do? You're not going to touch your face or adjust your PPE with your contaminated gloves? Absolutely no cell phone use in the office. Period. End of discussion. Put it in your purse, lock it in the cabinet. Do not be having your cell phones on your person, in your lab coat, in your operatories, anywhere at all that can be.

Contaminated. And it's just not. We've said this all along, don't have your cell phones, but now more than ever, no cell phone use.

Don't touch environmental surfaces except as necessary during patient care. So what does this mean for an assistant? It means from an assistant standpoint, we need to make sure that you have everything you need in that operatory to do that procedure. That means that you might have to think ahead. If it's a three surface filling and it may end up going to a root canal because you get into the tooth and it's the Grand Canyon and you've now seen the pulp chamber and you need to, you know, do a pulpotomy or what have you. You need to be sure that you have that stuff in the room with you. Ideally, does the packages or do the cassettes need to be open? No, but you don't. You want to limit your leaving of the room because every time you leave that room you're taking off your ppe. You're just, it's, it's not a good thing. The other thing is, you know, you need to make a decision in the practice if you're using disposable gowns or gloves and washing them. Now we look at gowns. So obviously the use of the gown is to protect the skin and clothing from debris and aerosols and fluids and other materials use during procedures for patient care. Activities with contact with blood, exposed skin, with bloody and bodily fluids, secretions and excretions. Material is either natural or man made. It's either disposable or reusable and it's resistant to fluid penetration. So what are some do's and don'ts? We know that gloves have to be long enough to cover your knees. That's a must change disposable gowns when appropriate. There's no guidelines Right now that say you should wear gowns and, and take them off after every patient get rid of them. There's what I'm hearing from many clients is they're having a hard time getting the gowns. So one of the things we do know for sure is that you should be putting a hookup in your operatories. You should not be walking out of the operatories to the lobbies, break rooms or offices with your gowns on that you used in the treatment room. So if you're reusing the gown when you leave the operatory, you take it off and you hang it on the hook. And then when you go back in, you put it back on and garb up and down and off. Okay. Now when we're looking at face protection, obviously it's generated to help with the same thing that we've talked about all along. Splashes, sprays of blood, bodily fluids, secretions or excretions. Masks protect your nose and fully should be covered over your nose and mouth to prevent fluid penetration. Goggles protect your eyes. They should fit snugly and around your eyes. Face shields should protect your nose and your mouth and your eyes and should cover your forehead and extend below your chin. So let's look at the do's and don'ts of face protection on the right side of my screen. You're going to see that's not safe enough.

On the left side. That's what we're looking for more. So do kind of, you know, have an anti fog that helps with clarity. Use a face shield in combination with a mask or goggles. Now they do have a guideline with the ADA that says if you have a face shield you do not have to necessarily have goggles.

You know, again, I just had a conversation with a pulmonologist this morning and his recommendation is that when you, even when you as a regular citizen go out in public that you should have something covering your eyes. And glasses like this or sunglasses would constitute that a mask and gloves. Don't pull your mask down over your chin so you see it all the time. Staff go like this, don't do that. Use your face shield as a replacement for a mask or goggles. So okay, how to safely don use and doff ppe. So how to the sequence of donning putting on PPE is first you put on your gown, next you put on your mask, third you put on your goggles and or face shield, fourth you put on your gloves. A combination of PPE will affect the sequence. So depending upon again, be practical with what you're doing so how to don a gown or a lab coat. Select appropriate size and type. Make sure you have that opening is always to the back. Secure it at the neck and the waist. If the gown is too small, use two gowns. The first gown would be have the ties in the front and the second gown would be tied in the back. How to don a mask Place over your nose and mouth and chin. So you can see on this area where I have the circles, those are the areas that are really not fitting properly. So you want to make sure that your adequately doing that and trying to close all those areas of possible escape to help with prevention of any bacteria or virus getting into that area. How to don eye and face protection. Okay, on that you want to position the goggles over your eyes, secure to the head using the earpieces and headbands. So pretty much like this versus any other way. Position your face shield over and secure on your brow and headband. There are some face shields that have the capability of accommodating for loops, so that's also a possibility.

Let's look at how to don gloves. Make sure that your hands are completely dry. Don gloves Last, select the correct type and size. Insert your hand into the gloves. Extend the gloves over your isolation cuffs. So a lot of offices again are not doing that. So how do we doff the ppe? First we have to consider things contaminated and clean within our ppe. So the outside front of us is contaminated. So areas of the PPE that have or are likely to have seen contact with body sites, materials, environmental surfaces where infectious organisms may reside. The clean is the inside, outside back ties on the back of the head and the neck. The areas of PPP that are not likely to have been in contact with the infectious organism. One good thing I can tell you with my conversation with the pulmonologist today was he said that initially when this came out, none of their admin in the hospital, in the ER or the units were wearing any kind of ppe. He kind of climbed the chain and said like, come on, we need to get them in ppe. Which they did. He said the reality of it is they have seen that protecting themselves in proper PPE has protected them on the front lines, bar none. So now let's talk about doffing PPE or removing the ppe. The gloves. Let's talk about what the gloves, the face shield. So it would be gloves first, then your face shield and goggles, then your gown, then your mask. Let's go through how to doff first the Doffing should occur at the doorway before leaving the patient room or the sterilization area. Ensure that you guys have hand hygiene facilities available all over the practice. So you know either a sink or alcohol based hand rub. So when the patient comes in, ideally you want a touchless hand sanitizer. I have a practice that just. I had a conversation, a meeting with them yesterday and they have it. They've been seeing emergency patients and the assistant is going out to the front and using the patient's touchless. So they had to say, stop doing that. Use the ones that are in our clinical area. So make sure we have enough. I know what you're saying to yourself is good luck finding.

The hand rubs, alcohol based hand rubs. But ideally we want as much of that and we do need to doff in the room. So what does that look like? The first thing is you're going to grasp the outer edge nearest the wrist, pull it away from the hand, turning the glove inside out, and hold the opposite hand gloved and slide the unfinger glove underneath the wrist. For the remaining glove, peel from the inside, creating a bag for both gloves and then discard it. Okay, how do you doff goggles and face shield? Grasp the ear or head pieces. With ungloved hands. Lift away from your face and place in a designated optical. So first then the mask. I'm sorry. Then the gloves. Then doffing the gown, unfasten the ties, peel away from your neck and shoulder. Turn the, you know, outside towards the inside. Fold it and roll it into a bundle and discard it. Doffing a mask. Avoid touching the front of the mask because the front of the mask, again, anything in the front is contaminated. So untie the bottom and then the top tie. Remove from the face and discard. Okay. Hand hygiene. Perform hand hygiene immediately after removing your ppe. If hands are visible contaminated during the removal process, wash your hands before continuing to remove your PPE. Wash hands with soap and water for at least 20 seconds. The one thing that we're seeing a big.

Failure, I guess you would say, is people are not washing their hands or using hand sanitizer enough. So, you know, just to recap, you want to always wash your hands or use the sanitizer before a patient, after a patient, obviously after using the bathroom, we want to make sure that you're cleaning those bathrooms. If a patient uses it, you need to go in and sanitize that bathroom. After that patient leaves that bathroom, the doorknobs. Ideally, you want to make sure that you're having Signage. In my Covid toolkit, there is signage for what the patient needs to do coming into your office. Ideally, a lot of practices are propping their doors so the patients don't even have to grab the handle. So, so you're not having to sanitize that handle after every patient. Now let's talk a little bit about environmental surfaces and sterilization. We all know that we're going from our area of our sterilizer to our sterile end. There's different sanitizing methods that you're all using. Some of you are using cabicide, some of you are using Sanozide, Optum. It just depends on the one thing I would encourage you to do is making sure that you're not cutting corners. And that just for kicks and giggles, I know you've been using it for years and you've never, you know, you've read the manufacturer's recommendations years ago. Go ahead and reread the manufacturer's recommendations again on the product you're using. So if you're using a one step system and it's a spray, you're spraying, wiping, and you should wait. And that might be anywhere from one to three. And then if you're using wipes, you're wiping, discarding and wiping or waiting. So you don't, you know, I've seen it and I know many offices have done it where you wipe, you discard and then you wipe it with a paper towel. That's not what you should be doing. Just like many of us learned at the beginning of this. When you put on hand sanitizer, you have to rub it in until it is totally dry. You don't wipe it off. So if it's a two step sanitizing process, you need to spray, wipe, spray, wait. Or if it's a wipe with a two step process, you need to wipe, discard, wipe, wait. So you guys know what you have. I would urge you to read the manufacturer's. This is interesting. I would urge you, if you're using, you know, sterilization bags, to just do an internal experiment. When you're doing your training, purposely put some water in the bag and enough water and then do not seal the bag at the proper line where it says to fold and seal, do it wrong on purpose and then do another one and put water in and do it the correct way. And then see, turn it upside down and see where the water leaks out. That's how important it is that you do this technique properly. I know that when we get busy, you know, it's Kind of autopilot, right? You just grab it, you take off the strip and you fold it. You and you think it's right, but it's a good thing to do just to kind of see. The other thing is your chemical indicators making sure that, you know, you're checking your chem cleaves, your autoclaves properly, you're doing your indicating testing and you're logging it. The other thing is I've included in the COVID 19 toolkit an autoclave log. Most offices are not using this. Why is this important? I'm not here to scare you. I don't believe in scare tactics. I think it's stupid. I think there's a lot of information out there that's wrong. And I think it's really putting the height level of scare way up there. But I will tell you this. I think it's really important to have an autoclave indicator as to the date that we put it in, the time it was loaded, the initials of who loaded it, the date it was taken out, the time and the initials of who unloaded it. And we keep that on right above the sterilizer and we put it in, and then we take that log when we're done and put it into a binder. It's important for many reasons, but I think I don't need to go into what those are. In addition, I've included in that COVID 19 toolkit a maintenance record. So you should be keeping track and, and making sure you're logging the maintenance of all your equipment. It's an important component to infection prevention program. So, you know, making sure that we've met all the proper channels that the manufacturer is recommending with our maintenance. Now more than ever, making sure that we're keeping, you know, the instructions for use, the IFU's that they are kept. This is a recommendation by the CDC and OSHA that those be kept in a binder for how that equipment is to be maintained and the instructions for use of it and safety, adherence and regulations. So those are all things that should be kept in a binder and available to the staff. Then here's. I've given you a list, but this again, is in the COVID 19 toolkit. It just kind of goes through what you should be doing on your maintenance checkoff list. Okay, so now you see this shocked the heck out of me and Elizabeth when we did the research. And that is that OSHA has not. The cdc, I should say, has not updated their guidelines for a dental office since 2003. In 2016. They summarized some of them and tweaked them, but nothing has been changed. There is an app called the CDC Dental Check App. That is great. It's a mobile app. But I particularly, I'll go into details of what you see over here.

And what we can be using with that. And I'll go over that in a minute. This is some of the resources that I've got the data from. So the infection control, healthcare, the cdc, the ada. Here's some scripts. So if we're going to call a patient and we're going to be discussing. Hey, we want to get you in, so. Hi, Katherine, this is Paige from Dr. Marshall's office. We're resuming our care for our patients and I want to assure you our infection control and sterilization protocols are guided by the CDC osha. And you can add ADA guidelines. First and foremost, Katherine, we are taking all the precautions to protect each patient. Please know that the precautions we utilize every day.

Every day to prevent the spread of infection in our office, in our practice also prevents the spread of COVID 19. Secondly, we have altered our schedule to space patients far enough apart so that we will receive one patient at a time. May I email you our complete explanation of all our infection controls and then verify their email address? And then, Katherine, you were due for your hygiene visit last March. Whoops, hold on. Last March 10th. We have an hour appointment with Julie this Thursday at 2 or Monday, next Monday at 10. Which would work for you. So this is the COVID toolkit. I'm going to open that under a separate item. Okay. Now, if you have any questions, we can take questions. Now before I go to the next part. Part, I'm going to share a different thing right now. So.

If you have any questions, you can either pop them in the log or unmute your phone and feel free to ask.

Yes.

This was a quick question response to one of the last slides. Is the script to the patient. I wondered because it said what we do, what we utilize every day to prevent. Prevent the spread of disease is what is necessary to prevent Covid. And what I've heard before that felt good was.

Is to go beyond that to explain that because of COVID we are going. We're going beyond what we usually do so that they feel reassured that we're doing more than just what we did before.

And.

And it also will help us, the hygienist, to explain why we're not using the cavitrum.

Yes. So this next section, it's great that you're thinking that way. Because this next section takes that to the next level that you're saying that I would encourage you to share with your patients. The one thing that I will tell you is that.

I have had offices because I'm nationwide, Utah, Kansas, they are open. And I had a. My social media person, Taylor had an appointment with her dentist this past Monday and she, she shared with us the experience and she said, you know what was really weird to me was that they, the staff were very apologetic about what they were wearing and how they were dressed. She said if they would have just acted professional like this is just our everyday garb, like get over, she said I wouldn't have been a little bit taken back, she said. But I was really surprised how they were. They were literally saying sorry, we're, you know, we're all garbed up and blah blah. They weren't explaining it. And she said that if she gave any office at advice it would be act like this is business as usual. Don't. We're the professionals. If we start apologizing or making excuses or acting nervous about what we're wearing or nervous about what we're doing, we. We are going to put fear in those patients minds. So I thought that was a good tidbit, if you will. So.

Okay, can you all see my screen now?

Yes. No. Can somebody. Yes.

Yes I can.

Okay, great. Okay, there is a question. Let me get some questions out here.

I have a question. Laura, what do you think about hypochlorous acid fogging the rooms? Laura, I almost invested in a company this past weekend because I absolutely think it's an awesome thing to do. Absolutely awesome. I'll send you guys a link of a practice that did a video on it and it's really. So for those of you that are not familiar with hypochlorous acid. Hypochlorous acid is basically table salt and water and it makes hypochloric chlorous acid. And there are foggers that are used. It is essentially kills the coronavirus.

If you can imagine. It sounds crazy, right? Water and table salt kills coronavirus. Like why haven't we heard of this? You can do all the research. It's FDA approved on food, so it's been being used on our food forever. And it does.

It's basically dries in like two minutes, you know. So yes, I do have offices that are using it and I can send you some links if that's something of interest. I think the actual fogger is a couple hundred bucks. The problem is that I'm Seeing is people having a hard time getting them. But good, good question and I do think that's good. Danny, will you want the front desk to also have a change of clothes, like the back office, or can the front desk show up and leave in the same clothes? I would say since the front desk is not in the clinical area, I would say that you can come and leave in the same clothes. However, you do need ppe. I would recommend that you're wearing a mask or if you have a plexiglass that you can put up in front of the desk. If not, a face shield and don't give patients pension. Don't have a cup of pens. Either they come with their own pen or you get a bunch of cheap pens printed with your name and you give them the pen and say, no, no, no, keep it, we don't need it. Next question mark. What about PPE at the front and social distancing? Yes and yes, definitely social distancing and definitely PPE at the front. So good questions. Any other questions before I move on?

Okay, there is a chat, so let me grab that.

Marty, One office where Kathy, Lara and I work is going to use hypochlorous acid. Yeah, I agree. I have many offices that are using it and like the idea, so. Good, good point. Okay, so the next thing that you see is this can be customized for your practice, so it would be your logo on here. I have offices using this is what I have is the CDC guidelines. So the CDC guidelines are not new. I haven't tweaked them. The only thing I did was I broke the guidelines. They have put it out there as the first section and second. First section is training your staff and the second section is keeping up with the maintenance of the training of your staff. What I did was I separated it out, I took the training of the staff and I've given you an example of what that training would look like under each or several of the sections. And then I did one that is for the patients. So you can either have like this on this picture with your logo on your website, with a link that they just hit and it says, like, our COVID 19 commitment to you. And you can click that and they can go right to the list that I'll show you, or you can actually send this to patients in a PDF like. Mrs. Jones, I know you're concerned. Let me go ahead and send you what we've gone through, which is based on the CDC guidelines and we've incorporated in our practice and we've all signed It So again, this first one that I'm going to go over with you, bear with me. This is one that will be for internal use. For training. I am recommending that office spend about two days, not a half an hour. I actually had one dentist that told me they were going to come in a half hour before they opened and this was in another state and they were going to go through the training and he thought that was pretty good. And so I kind of had to gently say that's really not good. And you need to do like a day and a half to two days. We need to make sure we've gone through this and we are literally really like a well oiled machine. This is a letter that would go out to the patient. So there's two letters I'm going to show you. One is one I created. One is one the ADA created. Makes no difference. I don't have, you know my feelings aren't going to be hurt. It's what you feel comfortable with. So valued patients. We are resuming our care for our patients and are proud to inform you of our precautions we are taking to assure your safety. We have always followed CDC and OSHA guidelines and prevention of cross contamination. Additionally, we have altered our schedule to space our patients far enough apart so we will receive one patient at a time. Please know that the precautions we utilize every day to prevent the spread of infection in our practice also prevents the spread of COVID 19. To demonstrate our commitment to your health and safety to our patients and staff, we are sharing the center of Disease Control's checklist and protocol enacted by our entire office. Our staff signatures at the end of the document show our entire team's dedication to your well being. We look forward to your next visit. Now this piece that I'm showing you now is internal only. So the letter I just wanted to include that this is an internal training. So you would begin with this section Policies and practice administrative measures. So a written infection prevention policies and procedures specific for the dental setting are available current and based on the evidence based guidelines. CDC Healthcare Infection Control Practices Advisory Committee regulations and standards Policies and procedures should be appropriate for the services provided in the dental setting and should extend beyond occupational what the OSHA says. So you then check. Have you done this? In this case I'm giving you an example. The notes are policy was created and all staff trained hard copy of the logs will be kept in doctor's office. Initial training date was on and you put in the date. This is an internal document. The next one Infection preventive policies and procedures are reassessed at least annually according to the state federal requirements and updated if appropriate. All staff training. Put the date and then put the next staff training. So this is again internal for your practice. At least one individual was trained in infection prevention and assigned responsibility of coordinating the program. Name, who is your icc? Supplies and necessary adherence to the standard precautions are readily available. ICC will be responsible to verify that the necessary supplies are available to all staff. This includes, but is not limited to hand hygiene products, safer devices to reduce.

Precumptious injuries and personal protective equipment. Facility has system for early detection and management of potentially infectious persons at the initial point of patient contact or encounter. So what are we doing internally? Are you using an oximeter? Are you taking the patient's temperature? Do you have a log? I have all that. We're going to go through it in a minute internally. This again, this is a sample that you guys can use for your own. Then we go into infection prevention and training. What are the dates and the names of the training provided by the icc? What are we going to do with new hires? Where are the records going to be kept?

The dental, health care, personal safety. What are we doing with this? So you can kind of see how you go through again. I've given you examples of what you would put in those areas that you've made changes to. Save the form. This again is internal. This would go into a binder. This would be re upped every. You would print it. This would be re upped every time you do additional training by the staff with your icc.

So really important to kind of go through this and make any appropriate changes. Okay, that's this one. Now let me pull up the next which is. Let me go to my folder.

Bear with me, everyone. I'll be getting this quickly.

Okay, let me make sure you can see this.

Can you see this new one on here?

Someone can answer.

Let's see.

I see the infection prevention checklist for dental settings.

Immediately enacted.

And then. Okay, now I see valued patients.

Okay, so you guys can see it. Thank you for whoever said that. I didn't recognize your voice, but thank you, Veronica. Okay, Veronica, thank you so much. So this one would be the one that we would do for our patients. So you'd put in your name when you completed it. You can tell it's less pages. So the other one said 11 pages. But this one is actually for the front and the back covers and stuff. The actual pages of information is 9. So you know when hands are visibly soiled. Yes, we've been trained on that I have given you an example of what you could do for your patient. 1. In other words, we ideally want the patient wanted to show that we've had an assessment and we've checked. Yes, yes, yes. But if we just checked all the boxes. Yes, yes, yes. And made no notes or areas for improvement, they would know it's bs. They would know we're not doing it. So in this, after bare handed touching instruments, equipment, materials and other objects likely to be contaminated by blood, saliva or respiratory secretions, staff is trained not to touch with bare hands or anything that is likely to be contaminated. Great. Now we kind of scroll on down and we're looking. And here's the next one. PPE is removed before leaving the work area. Dental patient care, instrument processing or laboratory areas. Ongoing process. Staff needs to remember to remove their lab coats before going out into the lobby. You can change it to whatever wording you want. Doctor ordered and installed wall hooks to help with compliance. So again, I don't think that's a patient that's going to freak out. But the next thing is, let's see here.

So masks, protective eyewear and face shields, side shields and training were provided for staff members. Next.

So new chemical and puncture resistant utility gloves have been provided for each clinical staff member. Next. Area cough and etiquette. Updated signs have been posted. So there are signs that are again in that Covid toolkit that we should be posting to let patients know, like, hey, if you've got a cough, fever, stop, don't even enter. So there are signs that they are recommending that you be posting in your office. Tissues and no touch receptacles for disposal of tissues are provided. Change all receptacles. Changed all receptacles to no touch receptacles. If you have light switches that have to be turned on, you may want to consider turning it to no touch. Updated resources posted in all patient areas available at the front desk by asking a receptionist for face masks if they don't have theirs.

Persons with respiratory symptoms are encouraged to sit as far away from others as possible. We marked that no patient with respiratory symptoms will not be allowed to be seen until symptoms are cleared and patient is tested. Again, fortunate for me, I had a lengthy conversation with a pulmonologist today. He said to me, I don't understand why dental practices are not being guided to do saliva testing and swab testing. I said, tell me about it. Yeah, we would love it. He said, obviously, of course he's a pulmonologist, so he's like absolutely not letting someone in that has respiratory symptoms would be a safe thing to do for a practice.

Now when we look at all sharps are disposed in a punctured resistant sharps container located as close to possible as the area which the item was used. Staff members, I'm trying on making sure that to dispose of the sharps in the operatory.

So you can kind of see what we've done to try to help it where the patients are feeling like okay now I did a blank survey with 25 non dental people and I gave them this and I said I would like your opinion if your dentist sent you this. A, would you read it? Would you open it? B, would you read it? How far would you read it? Would you be feeling any different about going to the practice? Two people said they wouldn't probably open it. The rest said they would open it. They wouldn't know if they would read the whole thing. There was probably about seven that said they felt very reassured by it and they would read the whole thing. We don't know. Again, I kind of go through like the stages of grief. We don't know where our patients are. Just like we don't know where we're at with this. Everyone is at a different level. Sterile packs are labeled at a minimum with the sterilizer used the cycle or load number, the date of the sterilization and if applicable at expiration date. This is by the cdc. All I did was created the log. Elizabeth did actually retain staff, retrained staff on all packages to include sterilization date, sterilization number, load number and use the autoclave log is in place in the sterilization area. And again just kind of went through and did where we felt was like a good example to send to patients. You do your own, you don't have to do mine. I would encourage you to read through it, get your own comfort level. And then the very last page is where you actually print your name, put your title and type in your name and it types it out for you. So it makes it a pretty. You know.

Actually I did hold my caps is on so it looks crazy.

So and then you would date it. So that's for patients. Again, how you incorporate this. Totally up to you. I have no stock in any one company. I can customize it for you. If you want to send me your logo. I'll make sure I customize it. This will be removed.

So there's that. Now let's go through some. Let me go through some of the.

Okay guidelines for the patient. So why Is it important that we use these guidelines? Let me make sure you guys can see this.

Okay? You should be able to see what's on my screen.

I hope. Can everyone see it? Yes. Great. Okay. So before the patient comes in, this is ADA guidelines. Now. They recommend that we have a pre appointment questionnaire. I have it on my website. Sorry. On the COVID 19, which is on my website under resources. But do you or they have a fever? Have you or they felt hot or feverish recently? 14 to 21 days. Yes or no? Are they having shortness of breath or breathing difficulties? Yes or no? Do they have a cough, any other flu like symptoms, or gastrointestinal upset, headache or fatigue? Have you experienced recent loss or taste of sleep? Are you. Are they in contact with any confirmed Covid cases? Patients who are well, but who have been, who have. Sorry, but who have a family member at home with COVID 19 should consider postponing elective treatment. Okay. Is their age over 60? Do you or they have heart disease, lung disease, kidney disease, diabetes, or an autoimmune disorder? Have you or they traveled in the past 14 days to any of their regions affected by COVID 19?

So that's what you ask them before they come in, and then you ask those same exact questions when they come in. Let me go through.

Let me see you. Can you see a letter on your screen?

Yes.

Thank you. This is the ADA letter. I like it. I happen to get this letter from my personal dentist. But it's basically, we hope this letter finds you and your families in good health. Our community has been through a lot over the last few months, with all of us looking forward to resuming our normal habits and routines. While many things have changed, one thing has remained the same. Our commitment to exceptional dentistry and your safety. Infection control is always been a top priority for our office, and you may have seen this during your visits to our office. Our infection control processes are made so that when you receive care, it is both safe and comfortable. Our office follows infection control recommendations made by the American Dental association, the CDC and osha. We follow activities.

We follow the activities of these agencies so we are up to date on any new rulings and guidance that may be issued. You will see some changes when it is time for your next appointment. We made these changes to help protect our patients and team. Our office will communicate with you beforehand to ask some screening questions. You will be asked those same questions again when you are in the office, along with taking your temperature and asking you to sanitize your hands prior to being seated. In the dental chair. Now, my dentist added this. Please update your information online prior to coming to the office. Click here to get the forms. I did it and then I took a screenshot of it just so I could show the offices. But they are updating. Perfect time right now. People don't know if we have to do it or not. Update your registrations, update your hipaa. Update everything, their medical history, everything. You will see that our reception area no longer has magazines and limited seating. We may ask you to wait in your car until the time of your appointment. We will do our very best to accommodate your preferred time and day for your appointment. But due to the new parameters. Please be patient with us. As we have, we may have to move your appointment around to allow for proper social distancing. My recommendation is you have your patients wait in their car. You text them when you're ready for them.

Due to the closure of non essential services, routine dental cleanings. Please be patient and flexible when we are reappointing. Catching up on appointments. If you are unable to visit our office, we are offering virtual consults via teledentistry. Please visit virtual consultations. There will be a small fee attached to this service. We look forward to seeing you again and happy to answer any questions you may have about the steps we take to keep you and every patient safe in our office. To make an appointment, please call. Blah, blah, blah. So I think that that that's the ADA letter. Great letter. You know, don't have any issue with it. I personally like to be able to have direct them to either the website to get the CDC prevention of what we've done, our checklist or send it to them. The autoclave log looks like this. So pretty easy. Let's see. This is the daily screening. This should be done.

Obviously we want to make sure that we're doing this on our staff. Every day. I've had doctors say to me, why would we. Why do we need to screen our staff? Like, I don't understand. I just had a practice two days ago call their marketing company. The doctor was beside herself. They had just opened. The next day, her staff member called and said she tested positive for Covid. She ended up calling the doctor. The doctor called the marketing company. Why? I don't know. But like, what should I do? What do you think I should do? I believe what's happening is when you test positive, that result goes to your county health department and they are, you know, we kind of have all heard. Testing, treating, tracing. Testing, treating, tracing. The tracing is okay. Employee who Were you in contact with. So that office needs needed to contact all those patients to let them know. And the question that the doctor had is, do I need to close down for 14 days? And she was waiting to hear back from the, you know, health department, but I am assuming the answer is yes. And she just opened. So could she have prevented it by, I believe, a big indicator, not just the temperature, but the oximeter reading. Big thing. Big thing. This virus is affecting your oxygen levels before you're symptomatic. I personally would add that to your temperature column. Cough, yes or no? Shortness of breath. Asked to go home. Note time that the patient was dismissed or the employee was dismissed. So. And then you saw the patient screening. Let me go into.

Let's see here.

Here are some of the maintenance guidelines.

The instructions for the maintenance guidelines are right here. What you can be doing with your various different items that you have. In addition.

There is a whole, you know, a whole thing on letters and scripts. So scripts for infectious patients, script for PPE expense. If you're going to be having to pass on that PPE expense anywhere from, I've heard anywhere from $7 to $25 and everything in between, there is a code for billing. My experience at this point, limited, albeit, although I am in contact with some pretty. Some people that are dealing with submittals on a regular basis, insurance credentialing people. The billing code is D1999. You're, you know, I'm seeing like $7 to 25. Like I said, this is some scripting. Mrs. St. Louis, it was nice to see you again. We really appreciate all of our patients and it's nice to be back to work. I know Barb scheduled you for your next hygiene visit. Today's charge is $7 for the PPE. Oh, wait, what's that? Am I going to be have to pay every visit every time? That seems kind of high. Well, actually, our cost per patient is $25. And Dr. Marshall's accountant advised her to pass the cost onto the patient or across the board, raise all the fees to cover the cost. Thank goodness. Dr. Marshall said she would not feel comfortable doing that, but agreed that she would charge $7. Again, you do what you feel most comfortable. I don't have stock in any one particular way to do it. I do think that the cost is substantial, you know, definitely substantial. And it, and it is costing practices quite a bit to get what they need, you all know, or if you don't know, the cost has been quite a bit higher. Let me See about, I think I put in here.

So there are return to work guidelines, so inpatient registration. So again, this is by the ada, but it's all organized by how you can find it a little bit easier. Have the hand sanitizer ready at the front when they're leaving and when they're coming. Their temperature, check it. Touchless is ideal. You want to have more than one in case it breaks down. Make sure you're keeping a log of the patient's temperatures and putting it in their charts as well. I showed you the patient screening form. There is a, you know, for referring patients for testing. There is a website that gives you the guides for where to refer your patients to.

I told you about the pens. I told you about. If you're not, make sure that you have wipes for cleaning down. Clipboards, counters, keyboards. Make sure that your keyboards will get into this in the sterilization. But front should be covered with plastic. You can use plastic wrap. It doesn't have to be dental specific. Even the ADA says that. Light switches, surfaces, anything with a touch, you know, dirty surfaces, disinfecting. Post procedure, many offices are having patients rinse with peroxide, although there has been no evidence, science based evidence that says that's a definite and it's what you need to do. The reception area, I think I covered everything, but let's see. Make sure that you have tissues. Clean everything off. Make sure that your trash cans, you're putting people six feet apart. No toys. I didn't mention that.

Your knobs, your light switches, hangers, everything like that should be, you know, remember to clean them. Okay, that's done. Let me see. There's also another.

Thing here. Shopping lists, chairside checklist. So this is a good one as well. I think you're all familiar, but let's just quickly review it. Informed consent. Check with your malpractice carrier to make sure.

That you know, they have something that they may want you to have a patient sign a consent form. There is an emergency consent form that I have in the toolkit as well. Limit paperwork in the operatories. So now many of you are saying yes, no more appointment trackers. This is great. It's paper. Believe it or not. I've come up with a solution. I'd like you to get a plastic sleeve for your.

Appointment trackers. They would be kept in the treatment room. Take that appointment, that plastic sleeve with just one of the appointment trackers in it so that you have it to the front desk and hand it off. And now more than ever, we need to keep track of what's being diagnosed, what is outstanding. It's really, really important.

You're not really using paper charting, I don't think.

Keyboard cover them with a plastic wrap or barrier. Limit patients opportunity, you know. No patients in the operatory other. I'm sorry, no other. Other than the patients. Nobody else in the operatory from the family.

Keep staff level in the operatory to a minimum as required. Mask pre entry chair side. And also no shaking hands, no physical contact. Washing hands, glove in the room. Review the oral history confirming screening questions that were asked during the check in process and review if necessary. No documented evidence exist at this time to support the pre procedural rinses. Which is what I said decide on treatment based on your clinical judgment. So there are practices that are doing treatment. I have doctors that saying I feel I'm neglecting my patient if I don't do this one procedure. I'm not just gonna. If it's an emergency and I need to do beyond, I have to do that. Your call on that. Okay, so there's that and then. Let me see. Staff protection strategies. There is. We kind of went over all. Everything I went over with the donning and doffing, everything I kind of extended on what they had. So that's that.

I'm open for questions. I'm trying to think if there's anything else that I can go over with you at this point. Let me just go into my CDC quick toolkit and see if there's okay health posters. Maybe this would be helpful.

So can you see this handshake? Free zone. Stop social distance six feet. Stop the spread. Stay home, go home. If you have any symptoms, stop the spread. Wash often, cover your cough. You know, event canceled, meeting canceled. Whatever you Pretty much everything you need. If, if you. If you need it, it's here. I've given you as much as I could on that. Let's see what else. This is just a. Do not enter stop. You know, call this number if you have any of these symptoms.

Let's see. I think there's one question up. Let me make sure. I'll cover that in a minute. Sterilization, Teledentistry and building billing. I don't know if you're doing any of that, but there's some guidelines for what you should be doing with teledentistry and whatnot. And this is the most updated one from the.

Guidelines. So there's one and then I like this one actually better but I put both in there.

And this is 17 pages. So it's pretty extensive. We're not going to get into it but you know, you can basically see what you should be doing.

There's informed consent for virtual if you're doing any virtual consults. And then let me just show you one final thing of the emergency and the consent form. So this is a employee consent form and then there also is a.

What constitutes an emergency. So you've got quite a few. Let me take some of these questions. I've got quite a few of them. So 8 so Kathy asked what do you suggest a solution for keeping aerosols in the operatory. Since we have an open room layout, shower curtains, etc.

There is going to be a webinar that I'm hosting next week for it's a design dental build company. They're not, you know, it's not a promotion webinar. It's basically what giving solutions for just this. Kathy, we do know that you know using rubber dams is going to help with the aerosols in the operatories.

The fogger is definitely a thing that would help in between patients.

So that's. I can, I can. I will be recording. I have. If you go to YouTube and look up Jean St. Louis Consulting, you'll see all my recorded webinars up to this point. We are downloading them. They take a while to download onto YouTube but we're getting them downloaded I would say by the end of the week. Tomorrow will be current up to today and then today's and tomorrows will go on over the weekend. Next question mark. A couple of staff members were wondering how long this meeting is scheduled for. I had a scheduled for two hours but I'm about winding down and I'm going to go until you guys say can you please shut up. We don't want to hear you no more and we're done.

So I'll follow your guys lead on that. In regards to staggering patients, how will this work? Dr. Vs hygiene what is the plan? If Dr. Is chairside then the hygienist needs an exam. When a patient does not have a cell phone elderly and has a delivery drop them off to the care facility. If they can come to the office with a caretaker, the caretaker, I would not recommend that they come in unless they have to help them. And I would only let them help them to the door. I would take the patient's temp and I would get them in immediately. No waiting.

Do we all need to get tested for coronavirus in the office ourselves? And how and how often? Great question. Asked my pulmonologist about that. And he said, yeah, if it was available, absolutely. Get tested. The unfortunate thing is he said that out of the tests that are out there, that.

85%.

Success rate with them, meaning 15% have a little bit of a failure rate of a false negative or false positive. So I wish I had the answer for that, Mark. I don't know. I wish so bad the ADA would step up to the plate. Let Dennis come up with swab testing, saliva testing, serum testing, and let dentists do it. I think it would be a huge service to the dental patients.

What do we do and tell a helicopter? What do we do and tell helicopter parents? Okay, so great question. I get this asked a lot with pediatric practices. What I am recommending is that you are very clear with the patient. You know, I have a favorite saying. Firm in principle. Flexible and procedure. Firm in principle is. Mrs. Jones, I know you want to be in with Johnny. I understand that. And you know that we've always allowed you in the treatment room. However, we are following the ADA guidelines and the CDC guidelines and they're just not recommending it. And we are following those guidelines. We hope you respect our decision. We're trying to do this for your safety and the safety of Johnny. If they're still insistent, again, we don't know where our patients are. Maybe she's at the spike of that grief process where she's psycho. I mean, she's just intense with how she's feeling. Firm in principle is. Nope. The rule is the rule. We can't break the rule. That's it. No way. Flexible and procedure is. If this really means that much to you on this visit, we will allow it. But we want you to know, be prepared that we will not allow it. Again.

That'S kind of flexible in procedure. I feel like everyone should be doing a pre rinse prior to any dental procedure. I'm hearing hydrogen peroxide is the one to use. Jessica. Yes, that is what you are hearing and that's what everyone's saying. However, there's no efficacy, there's no research that is showing that that is a proven thing that is good. If you think it's a good thing to do and you as a practice think it's a good thing to do, then go for it. It's not going to harm anyone. And if it gives you the reassurance, by all means do it. Not a big deal. What about exams and hygiene appointments? Doctor need to put on new ppe? Yes, you need to make it think about it like this, guys. The doctor never went in to do the exam without changing his gloves. He always changed his gloves. Most dentists use the same mask. If you're using N95 with a surgical 3 over it, take off the surgical 3, throw it away, and put on a new one for that patient that you're doing the exam most. And it's not being. It's not that I can't find it printed that says you have to take off your gown at every patient.

That's your choice. That's if you have it. If not, you're keeping the same gown on and you're going in. That's your you as a clinic, clinician and your practice's choice. Hope that answered your question, Kathy. Lara, just to clarify, because my Internet is acting up, did you mention updating informed consent to include something about COVID risks? I do. There is a formed consent about emergency treatment. Yes. I would recommend you update regarding Covid risks. I would ask your medical malpractice what they have. It is not out on the CDC or the ADA website in regards that I could find. And I'm perusing this like every day. Okay. The other thing I wanted to show you, we had some questions about hygiene. Let me go to that area and get that for you.

Okay, so this is one dentist, two hygienists templated for. For how this might work in a Covid world. So we have Mary Beth Wheeler coming in at 7. She's coming into doctor's chair. Hygienist number in chair 3. Bernice Adamac is coming in at 7:20. Yo Yo Ma is coming in at chair 4 at 7:10. So you can see we're spacing them out enough to not overlap. Erin Burnett is coming in at 8:10. So Mary Beth isn't even done. Bernice isn't. Bernice is done and gone or going to be gone after Aaron gets seated. Yo Yo Mama is long gone. So you can kind of see spacing out. You guys need to decide based on your sanitizing how long it takes, where you're at, how long you need. Most practices I'm talking to are saying about 10 minutes in between should do it. Some are saying 15. Very few are saying 20 because we've always changed our PPE. So with the exception of gowns, if you have the hairnets and the boots covering shoes, those would only be changed once a day.

Okay. So then you'd have your lunch. You can also just like your staggering start times of your hygienist. So this allows for the doctor to go in and do the Exams at the right time. Most importantly, the doctor has to be being aware with the assistants directing the doctor, go do the exam now. Go do the exam now so that you're not crossing in the hallways with people. Staggering lunches is not a bad idea. It'll help you. I don't show it here, but it would help you to have some people at certain times for certain lunches and breaking it up a little bit, don't eat together, social distance.

And so then you kind of see that the next one that I wanted to show you is some. I am recommending for some offices on some days that. Because if you think about it, if you run a report right now of everyone that is past due from March 15 to current, those are your past due hygiene patients, you're already booked. If you open May 15, May 18, June 1, you're booked with patients for six months. From that point out, I'm sure. So where are you going to put all these people that are past due that maybe were coming in every three months or four months? That's a disservice. We have to figure out where we're.

Going to put them.

In addition to all the patients that were past due prior to March 15, from last March 15 to this March 15, so there's a big number. So my recommendation is that you do a super hygiene day. Doctor has no, no patients whatsoever. You may have one or two doctors there, depending upon how many operators you have. You absolutely stagger the patients and that would look something like this. So hygiene one might have 10 or, you know, 10 or 20 minutes in between each patient. Hygiene two is here. Hygiene three is here. Hygiene four is there. Depending upon how many rooms you have to accommodate some of that backlog. Again, you cannot have doctors seeing patients on those days. Doesn't make any sense. Very, very dangerous. And Dr. Would just be coming in to do exams. So I've got a couple of questions. Let me go to that.

Let's see here. I have a question. My understanding was a new gown for each patient. Unless you have been fogged, thus sterilizing the gown. Are you saying one gown per day? Okay, Kathy, I am not. If it were my practice, I would do it one way. I know that doctors are struggling to find gowns. So do we not open because we can't find gowns? The question is probably not. We have to start treating patients. It's a comfort level. Yes, I think if you can fog, absolutely. Fogging is like to me a no brainer. If you can get gowns, great. You know Maybe you change your gown. I mean, if it were my practice, I'd say, yeah, change the gown after every patient. If we had an unlimited supply of gowns, for sure. But again, it's all going to depend on the use. Even people on the front lines, the doctors and the nurses who were complaining about ppe, they know that they couldn't not treat the patient. They had to go in even though they maybe couldn't change their gown or they couldn't use a new N95. I mean, I'm not saying that you should use the same mask over and over. If the N95 is over it and you're using a surgical three, you can throw out that surgical three and use another one. Change your gloves just like you always would. The big indicator is the gown. I think that's the unknown. The face shield, you know, sanitizing it. Hope that answered your question, Kathy. I know that I had two people that raised their hands. I don't know if I answered their questions. So I have a question. Yes? How do you deal with a janitorial service coming in after hours and will he cross contaminate your office?

I think you need to talk to your janitorial service. I think you need to ask them what they are doing, how they are doing it, to what level are they doing it. You may need to change your janitorial service. If they were crappy before the COVID and now you're worried they're just going to be crappy after, you might need to change them. If you have a, you know, a fogger and you're able to fog or multiple foggers, I think the fogger itself was like a couple of few hundred bucks. My concern is that I don't know that the company has any more, but you can sure check. And if you're using the fogger, it doesn't matter. All you're doing is having the janitorial service do cleaning. We know that bleach kills it. So depending upon what they're doing. But you don't want them to be using bleach on your chairs. There's manufacturer uses, and you need to be sure you're following the manufacturer guidelines or you're going to be ruining equipment and, and you know, things that you should not be ruining. So any other questions? Good questions. Guys.

It'S Veronica. So about using a surgical mask over an N95 to preserve the N95. I understand that, and I've heard.

Practitioners or providers comment that it is so uncomfortable, it's suffocating.

That's true. That's true. I can tell you that firsthand. But I also can tell you, you know, this is another question, Jean, what do we do when our staff says they're not willing to put, they're not willing to use the ppe? I'm telling them my recommendation, contact your HR for health department company. But also that staff member better sign a disclaimer because, yes, it is uncomfortable, but this is what, you know, this is what is recommended. I mean, I kind of go back to, hey.

You know what, what about people that are on the front lines that are using it? It's, you know, you're using it to protect yourself and to protect the patient. So, yeah, that's a, that's a guideline. You're going to have to please, you know, say so.

That's. I don't know what else to say. I wish I could answer that better. So maybe.

I probably didn't make that clear enough. So is the N95 used under a shield.

Recommendations? Is that under a shield? You can use a surgical 3. Totally your comfort level.

Again, you know, totally your comfort. All the guidelines are in the COVID toolkit on my website. You can download it for free. It's available to anyone that wants it. So please don't, don't you know, it's Jean St. Louis Consulting forward slash resources. As soon as you put in your information, it downloads to your desktop and you can just open it and save them all.

Okay. Pre med. What if a patient forgets to attempt? Do we offer it or tell them to come back? I would say do what you normally do.

That could be a, you could look on the ADA and see if they have a recommendation for that.

What are we doing in regards to getting signed treatment or pre treatment? I would think if you are.

Getting a signed treatment plan, I'm assuming the question is you would do it just like you would if you were having them sign their credit card or punching in a credit card number.

Question, can we sterilize the N95? There's stuff out on the Internet that talks about that.

I, you know, ultraviolet light, UV light, that kind of thing. There, there's a lot out there. I can't answer that with any 100% certainty that yes you can or no you can't. You can do some research on that.

For some reason you, you wonderful people that are raising your hand. I can't find that, where to find that, where to go to where you're raising your hands.

I see a couple of more questions.

Let's see Here, let me see if I accidentally dismissed it.

Nope. I think I answered all the questions. If you have a question, please ask me.

You can put it in the chat. If you are worried that you want. You don't want someone to see it. I'm happy to answer anything in the chat bubble. And that pretty much.

You can say to just panelists, which is just me, or you can say to panelists and all others.

You can set the parameter when you put it in there.

Any other questions or concerns, Dr. Mark? Is this kind of what you were looking for and hoping to get?

Hello?

Hello?

Can you guys hear me? Can someone answer? Yes, I can. Okay. Okay, great. So, Dr. Mark, are you there? Did you leave? I don't think he left. Maybe he has it on mute and can't hear or something. I'm not sure.

Okay.

Does anyone text Dr. Meir?

What's that?

Maybe someone could text Dr. Meir.

Yeah, that's a good idea. Maybe he went on a bathroom break. Maybe he did.

Okay, great.

Okay, so I see a couple of more questions. My audio isn't working. He just texted me from his iPad. Well, darn it. We're sorry to hear that, Mark.

Should we have patients all wearing protective eyewear? Did we discuss this? We did not discuss this. Most practices ask patients to put on protective eyewear. I don't know if you're one of those practices. And that would be sanitized after the patient's use. Your call. I don't know if you guys typically do that or not.

Okay, any additional questions? Let me see.

So the answer is you should always have patients wear protective eyewear.

Another question here. Have offices been opening?

Offices are. I do have select. First of all, I'm all over the country. So in answer to your question, yes, in states where it's allowed, they are opening. I would say California has been the biggest state with creating mass confusion. The governor has, you know, stay in place, as has Illinois. And there is. They are saying emergency treatment only. However.

Each county, depending upon what county you live in in California, is doing different guidelines. So that is creating a lot of confusion within the state of California, within the state of Illinois as well. While I think the governors are in those states are doing some good jobs, I think there could be some better clarity. I predict that I don't have a crystal ball, but if I did, I kind of predict that we likely will see openings around maybe May 18, maybe June 1. I would hope for sure. I do have offices that are opening, doing what they're referring to as a soft Opening. So they're having patients kind of like what I would do with a startup. They're having patients come in, they're kind of getting their wiggles out, getting their nervousness out, having patients come in spaced out and not hygiene just yet, but all the kind of like getting those fillings that are getting bigger and patients are not in emergency status, but they definitely are concerned about it getting crowns cemented, bridges cemented, things of that nature that are sitting there that are need to be done. So yeah, that has been occurring.

So I hope that answered your question.

Again, anyone that has any additional questions, feel free to put it in. We're just about done. Unless you guys want some more information on something and you want me to go into my folders and find it, I'll happily share it. I wanted to know, Jean, could you send us email on your webinar schedule so we can view those? I was not aware they were occurring. And some way that we can get the documents that you presented today just for referencing. Yep. Let me just, let me just go back to my PowerPoint really quick and I can get you the.

Site right here. Can you guys all see my screen?

Let me go back. Okay, so this is the site you're going to go to to get The COVID Toolkit www.jeannesaintlouisconsulting.com resources if you would like to see your screen. You can't see my screen. Okay, hold on, let me get. I can make that happen. I can make that happen. All right. Now you should be able to, right?

Yes, yes.

Okay, so go up here. This is where you're going to get it. If you want any of the previously recorded webinars, Those are@YouTube.com and then Jean St. Louis Consulting. And you'll see all my.

Webinars that I have. And again, keep checking that I would ask you to subscribe. If you subscribe, you'll get a notice that hey, another one's been posted. So I would ask you to do that. That will help you to know when updated ones are on there. This will be recorded as well. And this will go on there. This seminar that I gave today. Webinar that I gave today. Let's see here. Besides D1999, are there any other codes or procedures that you have heard of for offices using or billing other. I'm assuming the question is pertaining to in general with the COVID crisis, D1999 is for the use of PPP. Again, PPE. Sorry again, likelihood of coverage is slim to none.

In regards to other codes. The only other one is the teledentistry code and that is in the COVID toolkit as well. I am having practices that I know are calling patients insurance to find out if they have or calling just in general like Delta specific insurance companies and saying, are you going to extend or be lenient with people with their, their recall, you know, if it's once every six months and we, you know, we're behind, how is this going to work? Are you going to cover it? So that has been. I have had offices doing that. I have had offices that are working on their, their actual, you know, obviously their ar, as you guys have as well, outstanding insurance.

Things of that nature.

So.

Okay, I think that's it, guys. It's been great. Thank you so much. If you want to be a part of the webinars, I'm sorry I said this earlier. If you want to email me.

I probably have most of your email addresses from the invite. I can go back and, and make sure you get on my mailing list. But if you did not get the invite for this webinar, then I don't have your email address, in which case I would ask you to email me and I'll make sure I get that to you. Okay.

Can I have a quick question?

Sure.

What does teledentistry look like? One example.

So one example is similar to what you're seeing now. I see you, except you would see you see me and I would see you as an example. Teledentistry has been around for years now. It just became very popular during COVID 19. Telemedicine has been around so many of you know, I had, you know, I have had lung issues for most of my adult life, ever since I lived in Arizona when I caught valley fever. So I have had four times I've had pneumonia. My last bout was around November, December.

And so my pulmonologist did a telemedicine call with me today. HIPAA guidelines are relaxed now during COVID So they're allowing us to use our FaceTime, they're allowing us to use Zoom or Join Me or anything where you can see each other. So teledentistry might be a patient is nervous about coming in, hey, I have this tooth. So they go, they shine the flashlight with their camera. They're using teaspoons to retract their cheeks. The dentist is able to get really close to the screen and there it is, it's that tooth. So you're able to assess a little bit online before you say yeah, you better comment.

Hope that answered your question.

Thank you. Perfect. I like your vision.

Yeah, for sure. So, thank you, everyone. I really enjoyed hearing your voices, and I'll be seeing you shortly, I'm sure. So I won't be flying, so I will be driving to wherever I'm going. And if I can drive, I will get there. So. So one final question. Thanks. Hey, thanks to you guys, too. I liked your input. All right, thank you very much, everyone. Be safe, be healthy. Okay, take care. Bye now. Bye. Bye.