COVID-19 diaries: Urgent Dental Care Hubs
So life as we know it has changed... and while I usually pick up occasional shifts at Out of Hours Dental services, this has shifted to being one of the Urgent Dental Hubs in London during the pandemic.
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| I've shared my experiences of working in an urgent hub on dentistry.co.uk |
I thought I would have more time in lock down to short my life out... but I guess it was inevitable to get my head stuck into lots of other projects! So I apologise I haven't got round to writing this blog earlier!
So since the pandemic, most of my clinical work, as most other dentists, has stopped. I am now only seeing urgent patients; either at one of the hospitals I work, or at an Urgent Care Hub.
What is an Urgent Care Hub?
These hubs are based up and down the country to provide urgent dental care during this pandemic. As per the Office of the Chief Dental Officer's preparedness letter in March, all routine dental care in the UK is suspended.
Patients will still have dental emergencies however; and we need to ensure they are able to access the appropriate care, as the alternative of presenting to A & E is completely inappropriate and increases the risk of COVID-19 spreading.
Currently, there are at least 92 sites across England & Wales identified for these hubs across Community, General Dental and Hospital Dental Services. Hubs will be designated to see 1 of 3 categories of patients (or can show they can separate these groups within their service):
- Patients who are possible or confirmed COVID-19 patients - includes patients with symptoms, or those living in their household (although in real terms, we should consider everyone to be potentially infected right now)
- Shielding patients - those who are at high risk of severe illness for the infection
- Patients who do not fit either of the above (see the latest OCDO letter for reference)
What Treatment Do I Provide?
Urgent dental conditions that I manage include:
- Facial swellings
- Trauma cases (including soft and hard tissue)
- Post-extraction bleeding that the patient cannot control with local measures
- Severe dental and facial pain that cannot be controlled with over the counter painkillers
- Fractured, painful teeth
- Suspected oral cancer
This is what I would've normally have seen in out of hours, but there are differences. We telephone assess these patients before seeing them and try manage their issue remotely using the 3 A's:
Advice
Analgesia
Anti-microbials (if appropriate)
For some patients, their GDP has already attempted the 3A's, and in these patients it is more likely we would have to see them face to face (but sometimes we try an alternative antibiotic for example).
These hubs are there to perform treatment when 3 A's haven't worked, so treatments we can perform include:
- Incision & drainage of swellings
- Management of trauma e.g. splinting, reposititioning, dressing teeth
- Extractions
- Dressing of open cavities
- Opening pulp chambers
- Suturing of soft tissue injuries, bleeding sockets
- Onward referral to secondary care for patient admission, 2WW cancers and other specialist management
It is advised that Aerosol Generating Procedures (AGPs) (i.e. use of fast hand-piece, surgical hand-piece, 3 in 1, ultrasonic scalers) are avoided unless they are absolutely necessary!
What are the Challenges?
Working during the past few weeks has needed some out-of-the-box thinking and flexibility to ensure both staff and patient safety, as well as addressing patients who have urgent problems.
1. PPE
We will all have heard of the shortages in PPE across health and social care right now. While guidance and reassurances from NHS England is that the hubs will have access to the correct PPE, our hub is finding it difficult to get the FFP3 masks in place. This means we cannot provide AGPs right now and managing patients who are in acute pain, who need their tooth opening is a really challenging situation to manage. I've had to be creative in some cases, opening teeth with hand excavators if they have an open cavity. The table below from the OCDO shows when these FFP3 masks are needed.
2. Follow-up Care
Patients who present in an emergency often need follow-up soon after their issue. Whether this be to review teeth following trauma, removing dental splints, completing a root canal treatment, or reviewing an ulcer, these patients clearly have no where to go to review or treat the cause of their dental issue. Plus we do not know how long this pandemic is going to last and when routine care will resume. I usually say to patients who I have opened a tooth for, they need to see their dentist to complete the RCT (or remove the tooth) within a couple of weeks. While I know one extirpation I did for a relative lasted 2 years (miraculously) with no symptoms, I am sure this is an anomaly. The risk of flare up or abscess of these teeth we are extirpating will certainly be higher if they are left like this for months!
3. Difficult Decisions
Following on from the above point, surely this situation will influence the dentist and the patient's decision making when treatment planning. Will people be more likely to take teeth out, rather than extirpate if they do not know when routine care will resume? Or if a patient has an urgent dental problem which should be seen, but they might be at high risk of COVID-19 infection, should the risk of bringing them out of self-isolation be taken? I saw a 83 year old, medically compromised patient this weekend. Initially I was torn getting him out of the house to come to the clinic, but the pain he was in was so severe he hadn't eaten anything solid in 4 days - and I could help by taking out the offending tooth. The relief on his face when he left was clear, but I am still haunted by the idea that what if he contracts COVID-19 because of this encounter?
4. Remote Consultations and Prescribing
Assessing and prescribing for patients without physically seeing them is weird! I've also learnt that some patients are really good at describing their issue (and some are better than I am at taking intra-oral photos!), while others are not. One lady this weekend came to see me after taking 2 courses of antibiotics and swelling under her bridge. Firstly on looking in her mouth, she didn't have any bridges (she did have a couple of crowns), and secondly the issue she was describing was with a completely different tooth! I am also so grateful for all the pharmacists I've spoken to over the past couple of weeks when organising remote prescriptions - most were super helpful, kind and friendly in a time where they must be very stressed and busy!
While there are many challenges, there are also lots of small pick-me-ups that happen throughout each day that keep me going. From walking past all the NHS rainbows chalked on the path to the hospital, to Nestle delivering hundreds of free Easter Eggs to our staff, to a patient trying her best to let us allow her to pay for the treatment we'd just given her. There are going to be even more challenges ahead for all of us, but I think we should all take the time to appreciate these small victories in the fight against this virus.
Are you working in an urgent care hub? Let me know your experiences in the comments below.
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