The media has been full of stories over recent years about the current and likely future scale of the spread of ‘swine flu’ and the possible severity and consequences of these infections. As always, some of these articles have been well researched and factually accurate while others have adopted a more extreme and sensationalist approach.
‘Swine flu’ is just one type of influenza among many others and it is the potential summative effect of all types of influenza – including seasonal varieties – that has been causing such widespread concern in terms of preparing ourselves for a pandemic.
Alongside this, bodies such as the Department of Health and Children, the Irish Dental Association, the Dental Council, the Irish Healthcare Occupational Physicians Society and the HSE have all issued policy statements, guidance and position papers. Dental Protection and its parent organisation the MPS have had discussions regarding the arrangements for managing pandemic influenza with many of these bodies over a considerable period, and in some (but not all) cases the published advice already reflects our earlier input.
Dental Protection has had experience of advising and assisting its members in similar situations in other parts of the world, such as members in Hong Kong and Singapore who were badly affected by the SARS outbreak and the C5N1 avian flu epidemic. This experience heightens our awareness of the kind of issues and risks that need to be considered.
Acting responsibly
It is in the public interest that everyone should play their part in limiting the spread of pandemic influenza. This includes taking every reasonable step to maintain your own health and that of those around you. It is irresponsible to continue treating patients when you have reason to believe that you may be infectious; this may apply to your professional colleagues as well as to yourself. In such situations you should monitor your own health (including your temperature), take medical advice when necessary and appropriate, and act upon this advice. It is equally irresponsible to expect or require your employees to attend the workplace and come into contact with colleagues and patients when you have reason to believe that they may be infectious. The temptation may be greatest when you are already short-staffed, but it must be resisted.
On the other hand, those healthcare professionals who are fit and well can make a valuable contribution by covering for colleagues who are unwell and unable to work. The severity and duration of any pandemic will determine the extent to which this will become vital in the delivery of healthcare services, but it is likely that additional demands will be placed upon a reduced workforce, especially at the height of any outbreak.
Those who are in positions of responsibility and leadership – including practice owners and those with management responsibilities in all branches of dentistry – should plan in advance for a range of possible scenarios so they know how they would deal with many of the likely contingencies. This will make it easier to make good decisions under pressure at a later stage.
Acting ethically
The Dental Council’s Ethical Guidance emphasises our professional (ethical) duty to safeguard the health of patients and to provide treatment for medically compromised patients. If we are prevented from providing treatment safely and to an acceptable standard for any reason, we should consider alternative courses of action, including postponing the provision of treatment altogether, or referring the patient.
The Dental Council expects all registered dental health professionals to provide treatment within their competence. The dental treatment should be carried out to a satisfactory standard and if a recommended treatment is beyond the competence of a dentist, for whatever reason, the patient should be referred.
Situations may arise where the availability of secondary care (e.g. places to which a patient might be referred for certain types of treatment) is limited. Clinics or theatre lists might be cancelled, waiting lists might become longer and/or specialists may become infected themselves. In these and other situations a clinician may be tempted to carry out treatment for which they are neither trained nor competent, but consideration should instead be given to whether or not the treatment can safely be deferred to a later date.
Similarly, clinicians may find themselves treating patients without the same level of chairside and back-up support that would normally be available to them – the same consideration applies. Our duty of care is unaffected by the existence of a pandemic, and we will remain accountable for the decisions we make and for our acts and omissions.
Legal considerations for practice owners and employers
Employers have a duty, among other things, to maintain a safe workplace and to make adequate provision for the health, safety and welfare of their employees. They also have a legal obligation to provide staff members with appropriate Personal Protective Equipment (PPE).
Infection control and decontamination is important at all times, of course, but its importance is self-evident when significant numbers of patients attending for treatment will be capable of transmitting the infective agent(s). Team members should wear good quality, well-fitting masks and adequate surgery ventilation and high-volume suction will all help to minimise the risks inherent in the dental environment.
An effective infection control policy should be maintained in accordance with best practice guidelines and recommendations. The Dental Council’s paper on the Code of Practice relating to Infection Control in Dentistry provides good examples of effective precautionary measures.
The Safety, Health and Welfare at Work Act 2005 imposes a duty on employers to take steps reasonably practicable to ensure the health, safety and welfare of all their employees.
It is essential that employers review and update all policies and procedures which may be affected by a swine flu outbreak. Existing sickness/absence reporting procedures should be emphasised to employees and any amendments made to take account of the swine flu threat should be clearly communicated.
Contingency plans may involve the sharing of staff between primary and secondary care, within primary care and between practices. Employers are generally vicariously liable for the negligent acts and omissions of their employees whether or not they are directly or indirectly supervising them at the time. Similarly one might be working with, directing and supervising someone who is employed by someone else.
All registered dental health professionals should maintain adequate and appropriate professional indemnity at all times. Dental Protection recommends all its members to ensure that those with whom they work (regularly or in exceptional circumstances) do have such indemnity.
Continuity of the provision of dental services
In general, the Government’s aim is that as far as possible, it should be ‘business as usual’ as far as the delivery of dental services is concerned. Dentistry would hardly be overwhelmed by the kind of additional demand that would be likely to be faced by our medical colleagues; instead the challenge for dentistry is to maintain continuity in the provision of dental services in the face of patients, colleagues and family members becoming infected and unwell.
The SARS and C5N1 avian influenza experience in South East Asia was that patients stayed away from dental surgeries because of the perceived risk of infection if they attended. The provision of dentistry creates the dual problem of close proximity not just between patient and dental team members, but also that of the risk of droplet infection from the aerosols created during dental procedures.
Extended role(s) in healthcare provision during an influenza pandemic
Strategic plans have been developed by the various bodies with responsibilities for public health to deal with a wide variety of alternative scenarios, assuming different levels of severity of pandemic influenza.
In some of these models, dental health professionals (and other staff members) may be asked to carry out unfamiliar role(s) in order to maintain and support the wider HSE and the local community. At one level you could be asked to give advice to patients and to assist in triaging; at the other end of the scale you could be asked to do something that you have never been trained to do, and/or do not believe that you are competent to do.
As stated above, the existence of a pandemic does not alter the Dental Council's standard guidance that all registered dental health professionals should only provide treatment within the limits of their competence. The Dental Council’s paper on Scope of Practice should be referenced for a comprehensive list of procedures which dental practitioners and staff are competent and qualified to carry out.
If you are asked to carry out any procedure which is beyond your training, skill and competence, you are encouraged to speak to one of our team of dento-legal advisers.