Bhanderi S – President, Thomson P – Secretary. British Endodontic Society Information and Advice on Triage and Management for Primary Dental Care and other healthcare providers during the COVID-19 Pandemic. Advice, Analgesia and Antibiotics. 2020;
British National Formulary 79.: Royal Pharmaceutical Society; 2020
Across healthcare systems stringent measures have been introduced to prevent the sustained transmission of COVID-19. With the ease of lockdown the provision of all routine, non-urgent dental care will continue to be affected in England for some time. The provision of urgent dental care (UDC) via a robust and safe service has been constructed across every NHS region. In the South West, phone triaging has been an integral part of UDC centres operating procedure. Phone triaging will be required for some time. This proforma will be a valuable resource, especially for primary care practices as they move to re-opening.
CPD/Clinical Relevance: The clinical relevance is to share the effective use of a standardized telephone triage form supported by NHS England and NHS Improvement – South West (NHSE/I SW).
Article
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), causing the disease known as COVID-19, is thought to spread via respiratory droplets mainly through close contact from person-to-person from someone who is infected.1
Stringent measures had been put in place for the dental profession to prevent sustained transmission of COVID-19 in accordance with the government guidance in England issued 15 April 2020.2 It has been advised that the dental profession is at a high risk of spreading the infection. This is due to the proximity of the provider to the patient's oropharyngeal region and the nature of dental interventions, which include a high number of aerosol generating procedures (AGPs).
Across every NHS region the provision of urgent dental care (UDC) via a robust and safe service is required.2 Currently, high numbers of people are utilizing these UDC centres and the need for them has become apparent longer term.
The initial patient contact/interphase has now moved to a remote pathway via telephone triage to assess patients needs – the new normal for the near foreseeable future. It is likely that, for the near future, restrictions on the type and amount of treatment provided will continue to be in place across primary and secondary care services.
The use of a standardized proforma across the South West aims to ensure appropriate questions are asked to gain information, allowing a clinician to assess the patient's condition remotely. This allows the clinician to provide advice and helps to ensure that patients with true dental emergencies are identified for face-to-face assessment and treatment. The aim of using a standardized form allows a unified, calibrated approach to be achieved rapidly amongst many independent clinicians and help support urgent dental care as a new normal practice for dentistry. Even with lockdown easing, these stringent measures need to continue in all dental care settings to ensure safe dental treatment. Phone triaging is likely to be the new normal for some time moving forward.
Development of the COVID-19 triage form
Figure 1 shows the dental triage form as approved by NHS England and NHS Improvement – South West. In the South West of England, the development of a dental triage form was essential to allow for a standardized approach to patient care during this pandemic to avoid any discrepancy in patient care over the region. To produce a triage form, one must think about the information needed to be obtained remotely to allow for an appropriate assessment of need and if a face-to-face assessment is required. This standardized form was created following good record-keeping advice in accordance with the General Dental Council (GDC) Standards for the Dental Team,3 and the Scottish Dental Clinical Effectiveness Programme (SDCEP) guidance.4
Figure 1. Dental Telephone Triage Form (COVID-19). Available at: https://protect-eu.mimecast.com/s/Yi8BC8qmqcXZVn7HnAXZO?domain=eur01.safe-links.protection.outlook.com.
With any history and examination of a patient, the important information required should always include:
Patient demographic details and contact information;
This is to ensure the appropriate care pathways are taken to separate patients according to agreed COVID-19 risk or shielding status.
Further information on urgent dental issues such as pain, facial swelling, trauma, bleeding.2
Analgesics (prescribed or self-administered) and antibiotics usage.
This aids in assessment of an individual's pain severity allowing a review of the analgesic routine. A concern of analgesic overdose should be acknowledged instantly, and the patient referred to the appropriate service.6 Obtaining analgesic and antibiotic information will inform the clinician of what advice prescription they may appropriately provide.
Assessing the urgency of any emergency.
Acute emergencies require immediate intervention and escalation to the appropriate service. Primary concerns are head and cervical spine injuries and should be assessed first in the emergency department and stabilized prior to any dental intervention.
Questions relating to facial swellings, trismus, restriction of tongue movement, difficulty breathing, speaking and swallowing are regarded as life-threatening and should be assessed immediately.
Sepsis of dental origin can lead to life-threatening outcomes.7 If signs/symptoms of sepsis are reported, the patient should be immediately referred to an appropriate service.
Following questioning, the form provides the pathways the clinician can follow to advise the patient.
Provision of a definitive diagnosis.
Without a clinical examination, a diagnosis is somewhat limited, thus a provisional diagnosis may be obtained in the first instance.
The triage outcome and provision of patient pathway moving forward.
This sets out to highlight the services available to the clinician and patient. To help the clinician, reference is made to appropriate guidance on analgesic and antibiotic prescribing. These include those available from the SDCEP8 and the British Endodontic Society.9 The British National Formulary (BNF)10 should be referred to for any medication prescribed.
Roll out of the telephone triage form
Subsequent to completion of the initial draft document, the form was submitted for review to the Standard Operating Procedure (SOP) Task and Finish Team of NHSE/I SW, COVID-19 UDC project group. This included Managed Clinical Network Chairs, Local Dental Committees Chairs, Health Education England and Public Health England representatives. On completion of this review, it was submitted to the clinical cell of NHSE/I SW for final assessment and approval.
Following approval of the finalized Triage proforma, all stakeholders were sent the finalized documentation for roll out. To ensure all practitioners have availability of the form for standardized use, the form has been shared on the NHS England and NHS Improvement website which can be found at https://protect-eu.mimecast.com/s/Yi8BC8qmqcXZVn7HnAXZO?domain=eur01.safelinks.protection.outlook.com.
It has also been emailed to practitioners through the Local Dental Committees in the South West.
It is worth noting that this article is informing of a telephone triage form that has been supported by NHSE/I SW. Please make sure to follow the guidance and legal requirements specified by the government and relevant institutions in your locality.
