On March 19, 2020, Governor Jay Inslee issued Proclamation 20-24 in order to ensure hospitals and the health system would have sufficient surge capacity and personal protective equipment (“PPE”) to manage an influx of patients with COVID-19. The Proclamation applies to services delivered in hospitals, ambulatory surgical facilities, and dental offices in Washington state. It remains in effect through May 18, 2020.

In response to the advocacy efforts of WSDA and other stakeholders, the Governor issued “Interpretive Statement Related to Proclamation 20-24, Restrictions on Non-Urgent Medical Procedures” on April 29, setting forth additional guidance for providers to determine whether to provide or delay care. 

Background

The Interpretive Statement clarifies that all services considered emergent or urgent for which delay would result in worsening a debilitating or life-threatening prognosis are allowed. For procedures considered to be non-urgent or elective, the Interpretive Statement defers to clinicians to use their clinical judgment in determining whether to perform procedures or surgeries. It directs clinicians to consider the “relative harm to patients of treatment versus deferment, in terms of potential patient and provider contraction of COVID-19.”

Considerations in Determining “Harm” to the Patient

The Proclamation limits healthcare services, procedures, and surgeries that, if delayed, are “not anticipated to cause harm to the patient within the next three months…”

A definition of “harm” is not included in Proclamation 20-24. Rather, as indicated in the Interpretive Statement, the Governor leaves the assessment of harm to the individual clinician and directs the clinician to consider whether a patient’s illness or injury is:

• Causing significant pain;
• Causing significant dysfunction in the patient’s daily life or work; or
• Progressing or at risk to progress.

Additionally, clinicians should assess the risk of harm that could be experienced by a patient as a result of undertaking the surgery or procedure during the COVID-19 pandemic.

The decision to perform any surgery or procedure should be weighed against the following criteria when considering potential harm to a patient’s health and well-being:

• Expected advancement of disease process;
• Possibility that delay results in more complex future surgery or treatment;
• Increased loss of function;
• Continuing or worsening of significant or severe pain;
• Deterioration of the patient’s condition or overall health;
• Delay would be expected to result in a less-positive ultimate medical or surgical outcome;
• Leaving a condition untreated could render the patient more vulnerable to COVID-19 contraction, or resultant disease morbidity and/or mortality;
• Non-surgical alternatives are not available or appropriate per current standards of care; and
• Patient’s co-morbidities or risk factors for morbidity or mortality, if infected with COVID-19 after procedure is performed.

Diagnostic imaging, procedures and testing should continue in all settings if disease is suspected, based on clinical judgement in accordance with the above criteria.

Prerequisites to Performance of Healthcare Services, Procedures and Surgeries

Dental offices performing any non-urgent or elective healthcare services, procedures, and surgeries are required to meet infection control processes, maintain appropriate PPE supplies, and follow Department of Health-issued guidance on the use of PPE.

Specifically, the following PPE prerequisites are required before facilities can perform procedures, surgeries, or services permitted under the Proclamation:

• Facilities must provide health care workers with appropriately sized and sufficient quantities of PPE to perform essential job functions;
• Facilities must be aligned with the Department of Health’s PPE Usage Guidelines - PPE Conservation Strategies (Yellow), which states that PPE is discarded and replaced when it is soiled, damaged, or hard to breathe through;
• Facilities must follow the Washington State Department of Health’s Guidance on Extended and Re-use of PPE by Healthcare Personnel;
• Facilities must have on-hand and in the facility 7 days of appropriate PPE;
• Facilities must report accurate counts of PPE available and in the facility daily, as well as PPE on order, to the WA Health system;
• Facilities must report following required DOH guidelines for PPE use and conversation to the WA Health system;
• Health care workers have access to COVID-19 testing and to timely notification (within 8 hours of awareness) of exposure to COVID-19; and
• Facilities must report on COVID-19 positive health care workers by facility and profession/position to the WA Health system.

Several of the above prerequisites require communication with the “WA Health system.” Currently, access to the “WA Health system” is only available to hospitals. WSDA is obtaining clarification on how dental offices can communicate with a system only accessible by hospitals. In the meantime, WSDA advises that dental offices should keep records of the information required to share with “WA Health system” and share this information if or when state authorities have communicated guidance on how to comply.

Another of the above prerequisites relates to COVID-19 testing. The Interpretive Statement clearly states that COVID-19 testing must be accessible to health care workers. It does not state that testing must be available on site. WSDA advises dental offices to reach out to local laboratories, your local health department, hospitals, and other appropriate organizations for COVID-19 testing locations in your area.

Penalties and Enforcement

The Proclamation states, “Violators of this order may be subject to criminal penalties pursuant to RCW 43.06.220(5),” making anyone found to be in willful violation of the order guilty of a gross misdemeanor. However, documented clinical decision-making reflecting application of the Proclamation and the Guidance to the clinical matters or cases “will serve as evidence that performance of the health care services, procedures or surgeries was not a willful violation of the proclamation.” (Emphasis added.)

Conclusion

Decisions about increasing care during the COVID-19 pandemic should be made by each dentist using their best clinical judgement.

Dentists may now perform timely dental treatment that would reduce the risk of harmful dental or medical consequences, as determined by the patient’s dentist, as outlined in the Interpretive Statement. To help guide your decision-making process, WSDA strongly encourages you to include a diagnosis in your treatment notes for every patient visit performed. The diagnosis should be consistent with other documentation in your chart and reasonably demonstrate why a delay in treatment would cause harm to the patient. Meaning, that the care provided prevents a worsening condition that would have caused additional or more complicated care in the near future.