Troubleshooter: Can dentist ask patients about vaccine status?

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QUESTION: I’m a dental hygienist of 43 years. One of the two offices where I work still has cuspidors, which I refuse to use. I use a high-speed evac with a cone for people to spit into. I did not allow patients to use the cuspidor during the pandemic. Now that some of the COVID-19 restrictions are easing, this dentist wants to ask patients if they’ve been vaccinated, which I disagree with. If they offer the information, that’s fine, but I don’t think it’s right or even legal to ask this question. The dentist wants two sets of rules for patients who are vaccinated and those who are not. He’s telling me I must let patients use the cuspidor if they want to, which the Occupational Safety and Health Administration does not recommend. This dentist also won’t let us bag instruments; they’re sterilized loose and put in the drawers loose. To me, that’s not sterile.

I’ve stood my ground, but I’m not happy with the protocols we’re asked to follow. Not only can vaccinated patients use the cuspidor if they want to, they can refuse to rinse or use hand sanitizer. If they have not been vaccinated, then I can ask them to use those things and the high-speed suction. The dentist's decision probably came about because a patient complained. I think my safety and comfort level should have some bearing here as well. Your thoughts? I know, find another job, right? That’s not so easy.

ANSWER FROM KAREN DAW, KarenDaw.com:
As I understand your question, it is not OSHA-related as patient medical information does not fall under the OSHA purview. Even if you ask as part of patients’ medical updates, they could lie about their vaccination status. Let me give an example. Let's say we ask patients if they are HIV-positive. Would they necessarily reply truthfully? There are so many reasons why patients might not be forthcoming—embarrassment, unsure of status, or they don't know why their dental health-care professional needs to know. That’s why the Centers for Disease Control and Prevention asks that offices apply "standard precautions," meaning you treat every patient as if they are potentially infectious. So, even if you ask them to update medical history, patients could decline or lie.

Some of you might ask, "We've been asking patients to be truthful about symptoms related to COVID-19 and we conducted temperature checks as part of screening. Could a patient lie about travel history and symptoms?" Yes, yes, they could. In fact, a recent study in the Journal of Health Psychology concluded that people who had tested positive for COVID-19 or had symptoms were not always honest.

But a fever is more difficult to conceal. So, while not perfect, the screening system does help identify potentially infected individuals. If you must provide emergency care to someone who is suspected or known to have COVID-19, then there are extra precautions you should take, such as performing aerosol-generating procedures in a negative-pressure room. Unless this is the case, there should be only one set of infection control protocols for patients who are not currently infected with COVID-19, regardless of vaccination status, and you should adhere to the highest level of safety for patients and employees.

Also, I'd like to clarify that OSHA does not ban the use of cuspidors. The Organization for Safety and Asepsis Procedures says, "While OSHA does not prohibit the use of cuspidors, they do pose infection control concerns. Patient materials are continually expelled into the basin, so cuspidors are continually contaminated. For this reason, many practices have opted to eliminate them, instead using high-volume evacuation (HVE, suction) to clear away oral fluids." So, to not use a cuspidor would be considered best practice.

Finally, with regards to instruments not being bagged, the only way to ensure sterility of instruments (after all, it is going through a sterilizer) is the presence and integrity of the pouch or wrap surrounding the instruments as they are removed from a successful sterilization cycle. By not doing so, this practice is opening itself up to liability and potential lawsuits in the event of an infection control breach as they are not following the standard of care. Plus, several states mandate following CDC guidelines. The CDC states, "Cleaned instruments and other dental supplies should be inspected, assembled into sets or trays, and wrapped, packaged, or placed into container systems for sterilization"

ANSWER FROM AMANDA HILL, BSDH, RDH, AmandaHill.com:
There’s a lot to unpack here, but the big thing is you have answered your own question. You and this dentist do not see eye to eye.

As far as asking patients about their vaccine status, we all know how forthcoming (or not) patients are about their medical histories. So, who's to say if a patient is truthful about their status? It makes me think of standard/universal precautions. Would we wear less personal protective equipment based on a patient’s HIV status? Of course not! It’s been drilled into our heads to treat every patient the same, and this just doesn’t feel much different to me when it comes to health care, not to mention there are more viruses out there besides COVID-19. 

I will affirm you by saying it looks like you are following the rules and trying to do what's best for your health and your patients’ health. As a licensed professional who took the dental hygiene oath to “promote high standards of quality care,” I understand your dilemma. It’s hard when the office protocols don’t follow the rules. As hygienists, we love rules and standard operating procedures. It’s what keeps the day moving along and ensures everyone’s safety.

Only you can decide if you should leave or stick it out at this office for a few more years. But you are correct that your safety and comfort matter. In the meantime, continue to do what you know is right. Good luck!

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