Using Dental Health Care Personnel During a Crisis

Abstract

The first few months of the coronavirus disease 2019 (COVID-19) pandemic challenged health care facilities worldwide in many ways. Inpatient and intensive care unit (ICU) beds were at a premium, and personnel shortages occurred during the initial peak of the pandemic. New York State was the hardest hit of all US states, with a high concentration of cases in New York City and, in particular, Bronx County. The governor of New York and leadership of hospitals in New York City called upon all available personnel to provide support and patient care during this health care crisis. This case study highlights the efforts of Jacobi Medical Center, located in the northeast Bronx, from March 1 through May 31, 2020, and its use of nontraditional health care personnel, including Department of Dentistry/OMFS (Oral and Maxillofacial Surgery) staff members, to provide a wide range of health care services. Dental staff members including ancillary personnel, residents, and attendings were redeployed and functioned throughout the facility. Dental anesthesiology residents provided medical services in support of their colleagues in a step-down COVID-19–dedicated ICU, providing intubation, ventilator management, and critical and palliative care. (Step-down units provide an intermediate level of care between ICUs and the general medical–surgical wards.) Clear communication of an acute need, a well-articulated mission, creative use of personnel, and dedicated staff members were evident during this challenging time. Although not routinely called upon to provide support in the medical and surgical inpatient areas, dental staff members may provide additional health care personnel during times of need.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes coronavirus disease 2019 (COVID-19), was identified in 2019 and began to affect the US health care system, particularly in New York, in a major way in late February/early March 2020. On March 7, 2020, New York Governor Andrew Cuomo signed an executive order declaring a disaster emergency in New York State.¹ On March 11, the World Health Organization declared that the COVID-19 outbreak had reached pandemic status.² On March 15, US Surgeon General Jerome Adams suggested that health care providers and those performing invasive procedures postpone elective surgeries.³ In a subsequent executive order on March 20, dental services in New York State were limited to urgent and emergent care only.⁴

One of the hardest-hit areas in New York State was the Bronx. The US Census Bureau considers the Bronx, with a population of 1.4 million, to be the most ethnically and linguistically diverse county in the country.⁵ The Bronx is also one of the poorest counties in New York State: 28.0% of residents had an income below the federal poverty level in 2017, which was 49.8% higher than the federal poverty level in New York State (14.1%),⁶ and it has the worst health outcomes of all 62 counties in New York State.⁷

Jacobi Medical Center (JMC), located in the Bronx, is part of the municipal hospital system of NYC Health + Hospitals. It is a 450-bed, 54 mixed intensive care unit (ICU)–bed, level 1 trauma center and part of the safety net for patients who are indigent and/or medically underserved.⁸ The hospital system credo is to take care of patients regardless of their ability to pay. JMC is also a major teaching hospital for the Albert Einstein College of Medicine and trains medical students in nearly all of its departments. In addition, postgraduate residents in many disciplines are trained at JMC, although no training program currently exists for physician anesthesiologists.

At the end of March 2020, as JMC was being overwhelmed by COVID-19 patients, Governor Cuomo called upon all licensed professionals, including dentists, to come to the aid of their colleagues who were dealing with the COVID-19 pandemic.⁹ At JMC, all vacations were canceled, and all able-bodied people were called to assist in the effort. All elective surgeries were rescheduled, and all outpatient clinics were closed. At that time, the administration and chairs of many departments requested help from their hospital colleagues who were not on the front lines or were not involved in providing urgent patient care. The situation was so dire that in mid-March, NYC Health + Hospitals administration asked the Armed Forces Medical Reserve Corps for help; by April 7, 122 Air Force and Army reservists had come to JMC to provide care.

The Department of Dentistry/OMFS serves the ambulatory and inpatient oral health needs of the medically underserved population of the Bronx and provides resident education to 53 residents in 5 accredited training programs: general practice residency (n = 17), pediatric dentistry (n = 10), dental anesthesiology (n = 12), oral and maxillofacial surgery (n = 12), and dental public health (n = 1) and a fellowship in craniofacial orthodontics (n = 1). The department has 15 full- and part-time attending dentists as well as per diem attending dentists who provide resident supervision in each division and 42 ancillary support staff members. This case study illustrates how 1 hospital-based dental practice responded to the demands of the COVID-19 pandemic.

Methods

Beginning in early March 2020, interdepartmental meetings were held with senior administrative staff members, including all department chairs, to identify service needs and to develop a plan to cope with an increasing load of patients. Daily meetings were held within the dentistry department to allay fears, provide a source of support and information, and update everyone on the current state of knowledge. An article, “If Not Now, When?”,¹⁰ was distributed to dental staff members and outlined the responsibilities of dental health care workers during the COVID-19 pandemic. It reaffirmed the need for personal protective equipment (PPE), encouraged service to those who were sick, and described the immediacy of the need to take action during the crisis.

The Department of Dentistry/OMFS offered its support to the hospital, and for the next 3 months was an integral part of the care provided at JMC. Of the 99 staff members, 12 were permitted to use the Family and Medical Leave Act and stayed at home (2 because they were aged >75 and 10 because of childcare or underlying medical concerns). A small cohort of staff members (about 8-10) were left in the Department of Dentistry/OMFS clinics to provide necessary emergency and urgent oral health care, to provide teledentistry visits, or to solicit and collect PPE donations. Most (60%-70%) dentistry attendings, residents, dental hygienists, assistants, and front desk personnel participated in and supported the hospital-wide COVID-19 effort (Table).

Table.

Roles of staff members at the Jacobi Medical Center before and during the COVID-19 pandemic, the Bronx, New York, 2020

Role	Before the COVID-19 pandemic	During the COVID-19 pandemic
Front desk associates	Clerical and office management in Department of Dentistry/OMFS	Trained to manage medical units and supervise donning and doffing of PPE
Dental assistants	Chairside assisting of dental procedures	Trained by Blood Bank as phlebotomists; assisted in proning (ie, placing patients with lung problems in a face-down position for 16 h per day) and supervised donning and doffing of PPE
Pediatric dental residents	Clinical pediatric dental care	Trained by research team to obtain informed consent and to monitor patients who were in remdesivir and sarilumab trials
General practice residents	General dentistry procedures, including restorative, prosthetic, and endodontic services	Trained by oral surgery attendings to function as junior oral surgery residents
Oral and maxillofacial surgery residents	Full-service oral and maxillofacial surgery procedures, including dentoalveolar surgery, pathology, and trauma facial reconstruction	Trained by general surgery attendings to function as critical care physicians; managed all facial trauma at the Jacobi Medical Center
Dental anesthesia residents	Anesthesiology in outpatient and operating room settings for patients undergoing operations that required moderate sedation and general anesthesia	Trained and supervised by critical care team to function and manage intubated patients in a medical intensive care unit

Abbreviations: COVID-19, coronavirus disease 2019; OMFS, oral and maxillofacial surgery; PPE, personal protective equipment.

Staff members were assigned to tasks that were most aligned with their original job functions (eg, dental front desk associates functioned as medical support staff members, and oral and maxillofacial surgeons functioned as general surgeons). Department personnel provided basic hospital services, including phlebotomy, spotting (ie, supervising the donning and doffing of PPE in COVID-19 inpatient units), proning (ie, placing patients with lung problems in a face-down position for 16 hours per day), contact tracing, patient triage, and clerical functions. As appropriate, Department of Dentistry/OMFS personnel also provided higher-level medical services as part of the medical, surgical, and ICU teams. Pediatric dental residents participated in research on developing experimental COVID-19 therapies (including remdesivir), senior general practice residents worked alongside their medical colleagues on non–COVID-19 inpatient units to alleviate the overall personnel shortages, the first drive-through nasal pharyngeal swab testing for COVID-19 at JMC was performed by oral and maxillofacial surgery residents, and oral and maxillofacial surgery residents also staffed a general surgery COVID-19 inpatient unit by working alongside surgical residents, responding to medical emergencies, and managing patients who were admitted but managing relatively well. In addition, whereas dental residents rotated with the otolaryngology and plastic surgery services for maxillofacial trauma emergency calls before the pandemic, as of March 16, the Department of Dentistry/OMFS responded to and treated all maxillofacial trauma emergency patients who came into the hospital.

The most valuable contribution was provided by dental anesthesiology residents, who became the primary staff members in a step-down ICU for the sickest COVID-19 patients at JMC. (Step-down units provide an intermediate level of care between ICUs and the general medical–surgical wards.) Dental anesthesiology skills were readily transferrable to the COVID-19 ICU. Dental anesthesiology is the newest specialty of dentistry; it was recognized as a specialty of dentistry in 2019. Dental anesthesiology training programs are 3 years in length and accredited by the Commission on Dental Accreditation. During residency, trainees perform 800 cases of deep sedation/general anesthesia with at least 300 patients intubated. The residents have medical rotations in pediatric inpatient medicine, medical consultation, emergency medicine, and critical care medicine.¹¹ Graduates provide comprehensive anesthesia care for patients undergoing dental or maxillofacial procedures in various settings (dental office, surgery center, or operating room) and for patients whose medical needs vary in complexity, including pediatric patients and patients with special needs. In most states, the scope of practice for dental anesthesiologists is providing anesthesia for oral health care.

Patients in the COVID-19 ICU had acute respiratory distress for which the management protocols were and still are evolving. However, dental anesthesiologists have the requisite skills in intubation, ventilator management, placement and management of arterial lines, and preparation of blood specimens.

Although dentistry department staff members made heroic efforts throughout the pandemic, the psychological safety of all hospital personnel was always a focus and a priority at JMC. We were particularly concerned about how dental staff members—who were performing tasks outside their regular roles—would be accepted by medical staff members. We were also concerned about whether they would experience emotional trauma from observing severe illness and perhaps death—things they would not otherwise come into contact with in a dental department. Emotional support services talked to Department of Dentistry/OMFS staff members and were made available to all staff members as part of the “Helping Healers Heal” program, which was provided by the hospital before COVID-19 to keep health care providers from burnout and secondary trauma. Staff members were reassured of the value of their service and that PPE and supervision were available during the pandemic surge. After the first 3 or 4 weeks, nearly all residents and staff members had settled into a workflow and got to know the patients, affording continuity of care.

Outcomes

Throughout their assignment, dental residents worked alongside and under the supervision of medical and surgical attending physicians. The attending physicians had ultimate responsibility for the determination of the patient’s care plan. However, dental residents managed patients in the unit, and dental anesthesia residents routinely performed intubation and resuscitation of intubated patients infected with COVID-19; they were also present when some patients died.

The director of the surgical ICU (Mel Stone, MD) reflected on the contributions of the dental anesthesia residents:

The dental anesthesiology residents worked alongside their medical colleagues at Jacobi caring for the sickest intubated patients infected with COVID-19. The sickest COVID-19 patients all required critical care management. The dental anesthesiology residents immediately took on the task of learning critical care management algorithms that usually require weeks or months for advanced health care trainees to learn, let alone master. Additionally, the dental anesthesiology residents were required to be patient advocates in regard to end-of-life and palliative issues on an almost daily basis, [which is] not commonly seen in the practice of dental anesthesiology. In sum, the anesthesiology residents overcame almost insurmountable obstacles to help the critical care team. They were integral, needed, and excellent in all aspects of patient care. We are fortunate to have them at Jacobi.

Dental anesthesia residents reflected on their time in the ICU. One resident noted the following:

I was in the unit every single day because I couldn’t afford to lose a moment with the patients. And when I wasn’t there, I was thinking about them, reading about COVID from Italy and China, and dreaming about them. Being there as much as possible gave me a false sense of security, as if I could somehow impact the trajectory of their illness. Alone, I obviously couldn’t. But as a team, we provided consistency in care, which I believe whole-heartedly became our key asset. We actually saved people with incredibly poor prognoses and celebrated those who walked out on their own two feet.

Another resident noted this:

I am there for the families. I speak to them whenever they call. I comfort them as best I can as a liaison, ensuring that their loved ones are as comfortable as they can be. The frequent updates, the distressing news that my patient—their loved one—hasn’t survived, all weigh heavily on me every night. But during these unprecedented times, we are supposed to stay strong for our patients and their families. We are on the frontlines doing our duty as health care professionals.

By the end of May 2020, the Bronx was identified as the county having had the highest prevalence of COVID-19–infected people in New York State, the state with the highest prevalence of all US states. By May 30, 2020, 38%-51% of the population in the Bronx had tested positive for antibodies, and the local area around JMC had one of the highest hospitalization rates (5.91 per 100 000 population) in the United States.¹²

From March 1 through May 31, 2020, 1255 patients infected with COVID-19 were admitted for care at JMC, and more than 1500 COVID-19–related patient visits occurred (unpublished report, JMC, 2020). A total of 319 COVID-19 patients died. During this same period, many medical staff members at JMC were redeployed to areas of need within the hospital, the staff expanded by more than 25%, the nursing staff increased from 141 to 242 full-time equivalent employees, the number of physicians increased from 347 to 516, 150 inpatient beds were added (a 33% increase), and ICU capacity more than doubled (from 54 to 120 ICU beds). From March 15 to May 31, dental anesthesiology and oral and maxillofacial surgery residents performed approximately 300 twelve-hour shifts, on ICU and inpatient wards, alongside and in collaboration with their medical colleagues. Although not all JMC dental staff members were tested for COVID-19, 20% of dental staff members, when formally asked about their own health and symptoms, reported that during the 3-month period they had “become ill with COVID-19–like symptoms.” Several members of the Department of Dentistry/OMFS said that they were not immediately accepted in their newly assigned medical locations, but it did not take long for them to become part of the team. Although the availability of emotional support was reiterated at daily morning briefings, some staff members said that the amount and severity of illness was daunting and emotionally challenging; they were offered support from JMC’s Behavioral Medicine and Helping Healers Heal programs.

Lessons Learned

One of the key lessons of this case study was that dental health care workers are a valuable resource of health care personnel during times of urgent need. They can provide support for some of the basic needs of a health care facility. Dental anesthesiologists and oral and maxillofacial surgeons also can participate and function alongside medical colleagues in the most complex health care settings. They can be integrated into the medical, surgical, emergency department, or anesthesia teams and support the operation of hospitals and other health care facilities.

The experience also reinforced the value of a clear vision and the need to honestly communicate the risks and requirements of assignments. In this case study, administrative and medical staff members demonstrated and communicated the need, which led to staff member buy-in, engagement, and commitment to the articulated mission. Thorough, honest, straightforward, and repeated communication and dialogue facilitated the effort. During the most difficult times of the crisis, almost without exception, staff members did not waver in their commitment.

New York State dental practices were allowed to reopen for routine care, as long as they adhered to published safety guidelines from the New York State Department of Health and the Centers for Disease Control and Prevention, starting on June 1, 2020.^13,14 Dentists, including those at JMC, newly armed with knowledge on COVID-19 transmission (ie, aerosol vs airborne vs droplet), viral particle size, room air exchanges, and PPE effectiveness (ie, masks, full face shields), cautiously restarted practicing dentistry according to published safety guidelines. The battle against COVID-19 is far from over, but many hospital staff members at JMC are back to their routine roles. However, the skills, courage, and bravery of the dental team members who worked alongside and gained the respect of their medical colleagues has not been forgotten. The final lesson of this pandemic is that dental health care providers are capable of and can support health care efforts during future health crises, as they did during this hospital-wide and national effort to combat the COVID-19 pandemic.

ORCID iD

Victor Badner, DMD, MPH https://orcid.org/0000-0001-9742-9951