2018 COMOM Guidelines Greeley, Colorado

Transcription

1 2018 COMOM Guidelines Greeley, Colorado COMOM MISSION To provide quality dental services, at no cost, to individuals of all ages who cannot afford and access dental care; eliminating dental pain, promoting oral health, creating smiles, and providing oral health education. Patient Care Philosophy Most Urgent Need Overall Patient Flow Clinic Opening Patient Treatment Form Patient Treatment Priority Process Treatment Coding Colored Signaling Cards Prescriptions Instrument Sterilization Infection Control Needle Stick or Sharp Instrument Cut Emergencies DENTAL CLINIC DEPARTMENTS Health Triage Dental Triage Imaging Anesthesia Endodontics Hygiene Oral Surgery Pediatrics Prosthodontics Restorative ATTACHMENT: Patient Treatment Form Patient Care Philosophy Most Urgent Need COMOM s goal for treatment is to relieve a patient s pain and to address his/her most urgent needs. A patient s identified priorities are to be addressed in a stepwise progression. Limiting treatment to a patient s urgent need enables COMOM to serve more individuals. Patient Treatment Priorities. In triage, patients will be asked about their dental care concerns and together the patient and triage dentist will determine the appropriate treatment priorities. (Note treatment form) At most, two treatment priorities will be identified, each of which are to take roughly 45 minutes. Dentists/Dental Hygienists are to initially treat a patient s first priority only. Dentists/Dental Hygienists are to treat a second priority only if a patient s treatment record is copied onto a yellow sheet. The colored sheet amplifies for the patient that s/he must follow the patient flow process for treatment. During the course of the dental clinic, if the number of patients waiting to be treated diminishes, a decision will be on whether patients are to be offered treatment for their second priority. This will be a joint decision of Alex VanAcker, DDS, Chuck Schonberger, DDS, and Pam Dinkfelt, PhD in consultation with the department leads.

2 Overall Patient Flow As patients enter the building, they will be given an envelope containing registration materials. The outside of the envelope will show a patient identification number, and envelopes will be passed out in numeric order (Friday: ; Saturday: ). The number of patients to be seen (envelopes to be passed out) will be based on clinic capacity. This will be a joint decision of Alex VanAcker, DDS, Chuck Schonberger, DDS, and Pam Dinkfelt, PhD in consultation with the department leads. As patients, and those individuals who accompany patients, enter the building, they will be given a COMOM wristband. The wristband is to be worn throughout their stay at COMOM, and only patients who are wearing a wristband will be treated. One colored wristband will be used for Friday; another color for Saturday. In patient registration, patients will complete the upper portion of the COMOM treatment form related to contact information, and sign the patient waiver. Children and teenagers under the age of 18, whether they are patients or accompanying patients, will be given a wristband with an onsite, responsible parent/guardian s name and cell phone number. In health triage, health professionals will review patients health history, take pulse and blood pressure, and check glucose levels of patients with diabetes. In dental triage, patients will be asked about their dental care concerns and then the patient and triage dentist together will determine the COMOM treatment priorities. At most, two treatment priorities will be identified, each of which are to take roughly 45 minutes. Based on a patient s established dental treatment priorities, a patient will receive a numbered routing card(s) for his/her first-priority treatment (e.g., restorative, oral surgery, endodontics). Patients will receive treatment based on the number shown on the routing card. Patients will be escorted throughout the dental clinic by COMOM volunteers. The patient envelope will identify the patients preferred name and preferred language. Volunteers who speak Spanish will be wearing green vests. A lead for interpreters will facilitate assistance for patients who speak other languages. After a patient is treated, a treatment coder will come to the patient s chair and review the patient s chart with the dentist/hygienist to ensure all care provided is coded on the patient treatment form and a department spreadsheet. The treatment coder will walk with the patient away from the dental chair and identify an escort to walk with the patient to the Clinic Exit Area. Once within the Clinic Exit Area, the patient will be guided to the following departments: Pharmacy Flu Shots Oral Health Instruction Patient Interviews Friend/Family Waiting Page 1 of 4

3 Clinic Opening The published start of the dental clinic is 6:00 am. In an effort to provide oral healthcare services to the most patients: Volunteers assigned to patient registration, health triage, and dental triage will report to the dental clinic by 5:00 am. If the leads for these departments jointly determine that they are sufficiently staffed, clinic doors will open prior to 6:00 am. Designates from Crown Town, Denture City, and Flipperville are to be in dental triage by 5:00 am to be available for procedure approvals. Veteran COMOM dentists who are assigned to restorative will be encouraged to arrive at the clinic by 5:00 am to assist in the dental triage of patients. Before helping in triage, restorative dentists are to have their operative station set-up and have informed the restorative department leads of their whereabouts. Once patients begin to enter the restorative area for treatment, restorative dentists will return to their stations. The initial group of patients entering the clinic will undergo imaging prior to dental triage. Once patients begin to enter imaging from dental triage, this process will end. Patient Treatment Form (Attachment) Information is to be printed on the patient treatment form and in particular, clinician s surname is to be printed. Only dentists and dental hygienists, with active licenses in good standing, are to have their name and signature on the treatment form. BLUE INK or GREEN INK is to be used on treatment forms NO BLACK INK. Dental care provided is to be listed on the treatment form and on the department s coding spreadsheet. Coders will assist clinicians. Documentation is important for patient tracking and integral to the COMOM s evaluation process. Patient Treatment Priority Process After the patient receives first priority treatment, s/he is to be escorted to the clinic exit area and will be checked-out through the exit area departments. During the exit interview, if the patient would like a second priority treatment performed, s/he will: Be referred to a dentist in the Exit Area to determine availability of second-priority treatment, Receive a copy of treatment form on yellow paper, Be escorted to the end of the line for entrance to patient registration, Be escorted to the patient routing table, Be routed for second priority care, Receive dental care, and then will, Be escorted to the Clinic Exit Area. Treatment Coding Treatment coders will be assigned to each clinical department. After a patient is treated, a treatment coder will come to the patient s chair and review the patient s chart with the dentist/hygienist to ensure all care provided is coded on the patient treatment form and department spreadsheet. Coding will be similar to that done at dental office with tooth/teeth number(s) and surface(s) recorded. The treatment coder will walk with the patient away from the dental chair and identify an escort to walk with the patient to the Clinic Exit Area. Page 1 of 5

4 Colored Signaling Cards Clinicians at each dental operatory will have colored signaling cards to help communicate with escorts, treatment coders, and department leads: The Green Card is raised when the clinician is ready for the escort to bring the next patient to the dental chair. The Red Card is raised when the clinician is finished treating the patient and is ready for the treatment coder to review patient treatment form. The Yellow Card is raised if the clinician has a question or needs assistance. Prescriptions COMOM will have pharmacists onsite. As shown below, the patient treatment form displays the medications available at the dental clinic. Dentists are to initial prescriptions to be filled. A dentist s signature on the treatment form is required for a patient to obtain medications. Dentists should bring their DEA number for prescription writing purposes. COMOM prescription forms, printed on security paper, are to be used for writing prescriptions for medications not available at the clinic site. The prescription forms are available from department leads and from the pharmacy. Instrument Sterilization Disengage all needles, sharps and anesthetic carpules, and discard them in the red containers nearest dental operatory. No needles or sharps are allowed in the sterilization area. For your personal items, a sterilization bag must be labeled with your chair number and name. Help COMOM make sure sterile instruments make it back to their rightful owners! Place your labeled sterilization bag (or bags) underneath the closed plastic container provided for sterilization of instruments. Instruments will remain together throughout the sterilization process, and then the sterile, bagged instruments will be returned to dentist/dental hygienist s chair when finished. Infection Control Across the dental clinic including nonclinical areas (e.g., patient registration, exit interviews) frequently: Use hand sanitizer and offer to patients, and Wipe table surfaces and ink pens with germicidal wipes. Follow infection control best practices including, but not limited to: Wearing masks and protective eye wear, Wearing and changing of gloves between patients, Using hand sanitizer before donning gloves and after removing gloves, Sterilizing all instruments (including handpieces), and Thoroughly wiping down patient chair, equipment, and surfaces between patients. Page 1 of 6

5 Infection Control (continued) Dispose of sharps in the nearest sharps container to your station. Do not travel the clinic floor with sharps on a tray. Place only biohazardous waste (e.g., blood-soaked gauze, teeth) in red biohazard bags. No general trash in the red bags. Place extra amalgam and amalgam capsules in the amalgam waste containers nearest your station. In addition, the following must be adhered to: Do not allow patient to form a lip seal on the HVE/saliva ejector. Before turning off HVE/saliva ejector, remove it from the patient s mouth, point it at the ceiling, and then turn it off. A vacuum line cleaner solution will be provided to you. After each patient, the solution should be sucked through the HVE/saliva ejector line. After the solution is sucked through the line, the HVE/saliva ejector should be held up for a count of 10 seconds. Place new air/water syringe tip between each patient. Place new saliva and/or HIVAC tip between each patient. Needle Stick or Sharp Instrument Injuries If an individual is cut, stuck or skin is broken by a contaminated needle or sharp instrument, please follow these instructions: Have one person stay with the injured person and have him/her immediately clean the wound with soap and water. Have another person advise the department lead of the incident, and they in turn will notify the COMOM dental director (Alex VanAcker, DDS). If the patient for which the instrument was used on is known, have the patient remain within the area. The dental director will make determination if there is a need for the injured person and patient to be tested. Emergencies All COMOM volunteers should be familiar with the location of the paramedic/ems professionals who will be onsite. If a patient has a medical emergency, have one person stay with the patient, have one person contact the department lead, and another person contact the paramedic/ems professionals. Page 1 of 7

6 DENTAL CLINIC DEPARTMENTS Health Triage The Health Triage Department will be separated into two sections: one for adults and a nearby section for children. The Health Triage Team will review patients health history and medications being taken. The team will specifically inquire whether patients are taking anticoagulant meds (e.g., Warfarin, Coumadin, Xarelto) or bisphosphonates (e.g., Fosamax, Zometa, Aredia). Patients will have their blood pressure and pulse taken, and also have their blood glucose level checked if they have a history of diabetes. The Health Triage Team will also inquire whether the patients have a current illness. Dental Triage Special-circumstance treatment. Patients: Taking ASA or Plavix may undergo extractions. Taking Warfarin or other anticoagulant medication may not undergo extractions. Taking Bisphosphonates May be provided routine dental care. May have local anesthetic. May have atraumatic scaling and prophylaxis with gentle soft tissue management. May have endodontic treatment. Cannot have dental extractions. Other special circumstances. Patients: With blood pressure readings of more than 180/110 cannot be treated. With blood glucose readings of more than 300 may not be treated. With heart stents may not have treatment within three months of surgery. Who have undergone heart surgery may not have treatment within six months of the procedure. Who are pregnant and have acute dental problems may be treated throughout pregnancy. Elective-type care should be provided to pregnant women only if they are in their second trimester. Page 1 of 8

7 Dental Triage (continued) The Dental Triage Department will be separated into two sections: one for adults and a nearby section for children. Priority charting Patients are to be asked about their dental care concerns and then the patient and triage dentist together determine the COMOM treatment priorities. The triage dentist is to print name and sign treatment form. At most, two treatment priorities are to be identified, each of which are to take roughly 45 minutes. The priorities are to be written in the priority boxes on the patient treatment form shown on page 6. Within a given priority, if necessary, interdepartment treatments can be indicated for interrelated dental care. For example: Priority 1 A. Impression B: Extract Teeth # 8, 9 C: Flipper #7, 8, 9 OR Priority 1 A: Endo #8 B: Restorative #8 Special Department Approval Crown Town (CT), Denture City (DC), Flipperville (FV) If a patient is a potential candidate for the preparation of a crown, denture, or a flipper a designate from the department is required to approve the treatment plan. These individuals will be wearing pinkish purple vests. Patients who have been approved for either a crown, denture or a flipper will be given a Fast Track card. The Fast Track card enables the patient to have priority across departments enabling the patient to arrive to his/her destination department as quick as possible. Treatment Crosscheck / Routing Subsequent to dental triage and imaging, patients treatment plan will undergo a final crosscheck by COMOM dentists. Based on a patient s established dental treatment priorities, a patient will receive a numbered routing card(s) for his/her first-priority treatment (e.g., restorative, oral surgery, endodontics) Oral Cancer Screening Order oral cancer screening if: A patient is using tobacco at the time of the dental clinic or has used tobacco in the past, and/or Patient s health history and/or dental triage exam indicates a closer exam by screening modality. If post-comom follow-up is indicated, patient is to be encouraged to see a dentist or physician near his/her home and identify a low-cost dentistry clinic from sheet enclosed in the patient envelope. Contact information for the Dental Lifeline Network will also be available. Page 1 of 9

8 Premedication Indicate whether premedication (Amoxicillin or Clindamycin) is needed or not needed. Premedication is indicated if a patient has any of the conditions listed below. Joint replacement History of infective endocarditis Artificial heart valves Cardiac transplant that develops a problem in a heart valve Certain specific, serious congenital (present from birth) heart conditions, including: Unrepaired or incompletely repaired cyanotic congenital heart disease, including those with palliative shunts and conduits A completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first six months after the procedure Any repaired congenital heart defect with residual defect at the site or adjacent to the site of a prosthetic patch or a prosthetic device The signature of a dentist onsite is required for a patient to obtain premedications. A wristband indicating that premedication was taken, and the time in which it was taken, is to be worn by the patient. Before beginning treatment, depending on treatment timing, dental clinicians should determine whether further premedication should be administered. Imaging If imaging is indicated, the type is to be specified on the treatment form. If an oral surgery patient is to have two or more teeth extracted, order panoramic radiograph. In addition to the Nomads in the Imaging Department, Anesthesia, Restorative/Endodontics and Oral Surgery will have dedicated Nomads for their departments. Anesthesia As patients become ready to enter a treatment area, they will proceed to the Anesthesia Department. The time that an anesthetic is administered is to be noted on the patient treatment form. The goal is to have patients anesthetized before they sit in the treatment chairs. Patient flow, however, can affect the timing of this process and patients may need to be administered additional anesthetic. At the start of each clinic day, patients will go directly to treatment chairs for anesthetizing. Anesthetic for children will be administered by dentists in the Pediatric Department. Anesthetic for endodontic patients will be administered by dentists in the Endodontic Department. Endodontics Treatment of anterior teeth and premolars take precedence. Molar endo procedures are to be performed only in special circumstances in which the tooth is considered critical, the majority of the tooth structure is intact, if time permits, AND as assessed by the Endodontic Lead. Endodontic procedures are to be performed only on those teeth that have a good restoration prognosis. Placement of a ceramic crown onsite may be an option for patients undergoing root canal treatment. Approval by the lead for crown preparation is required. If there are questions about an endodontic procedure, please consult the Endodontic Department Lead, who in turn may choose to contact a Restorative Department Lead. Page 1 of 10

9 Hygiene Dental Hygienist may use anesthesia if licensed to do so and comfortable with it. Procedures performed: Adult and child prophy Debridement Sealants Fluoride varnish Procedures not performed Deep scaling Root planning Curettage Gross debridements after extractions Patients taking bisphosphonates or anticoagulation meds may have atraumatic scaling and prophylaxis with gentle soft tissue management. Oral Surgery Extractions performed: Visibly nonrestorable teeth. Painful or infected teeth that are not amenable to endodontic treatment. Teeth that would complicate prosthetics fabrication if left in place. Third molars only if visible on clinical examination and/or carious or causing acute pain. If indicated, alveoloplasty may be performed on patients with COMOM extracted teeth. Procedures not performed: Extraction of third molars requiring hand piece (mandibular). Extraction of full-bony impacted maxilla or mandible third molar. Extraction of partial bony mandibular third molar. To minimize postoperative follow-up, only absorbable suture materials are to be used. Patients taking bisphosphonates or anticoagulation meds cannot undergo dental extractions. Pediatrics A pediatric patient is defined as a child 12 years or younger (or special need person up to 18 years). If a back-up exists of adolescent patients waiting for restorative services and pediatrics is in need of patients, patients up to 18 years may be sent to the pediatric department. Pediatric dentists will administer anesthetic to pediatric patients. Procedures performed: Extraction of nonrestorable teeth. Extraction painful or infected teeth that would require pulpectomy treatment. Restoration of moderately decayed teeth with composite or amalgam. Stainless steel crowns. Pulpectomy treatment when carious exposure occurs on previously asymptomatic teeth. Procedures not performed: Esthetic stainless steel crowns. Space maintainers / fixed or removable appliances. Page 1 of 11

10 Prosthodontics Flipperville/Denture City Flipperville services provided: Anterior acrylic removable partial dentures ( flippers ) will be provided Flipperville services not provided: Posterior teeth flippers. Fixed prosthesis work or repairs. Dentures will be prepared onsite on a limited basis for individuals whose mouth structure is amenable to the fast denture protocol. Only preclinic, edentulous patients with healed mouths are candidates for dentures. Generally, the patient should be two-months since last tooth extraction. Relining full dentures may be available on a preapproved basis. Preapproval by Flipperville or Denture City Lead is required for patients to be seen. Restorative Services provided: Basic composite and/or amalgam restorations. CAD/CAM ceramic crowns are available on limited basis, but patient must receive preapproval for crown preparation. If a patient s tooth is compromised to the point that a reasonable restoration cannot be achieved, contact a Restorative Lead to determine if it would be better to extract the tooth. If a patient has a pulp exposure, contact the Restorative Lead to determine if endo or extraction is the best option. BE FLEXIBLE, and Thank You for Making a Difference!! Page 1 of 12

11 Page 1 of 11 ATTACHMENT Patient Treatment Form