Infection prevention and control for COVID-19: Interim guidance for outpatient and ambulatory care settings

Table of contents

This document provides guidance specific to the COVID-19 pandemic in outpatient and ambulatory care settings. Outpatient and ambulatory care settings are defined here as those providing health care on an outpatient basis and can include hospital-based and non-hospital based clinics, physician offices, community health centers and urgent care centers.

Individuals responsible for policy development, implementation and oversight of infection prevention and control (IPC) measures in outpatient and ambulatory care settings should be familiar with relevant IPC background documents on Routine Practices and Additional Precautions and occupational health and safety legislation. The term "staff" is intended to include anyone working in outpatient and ambulatory care settings, including but not limited to healthcare workers.

Measures to control COVID-19 in outpatient and ambulatory settings should be based on local and regional epidemiology. Provinces and territories may have IPC and testing guidance that is specific to their local context.

Important measures to prevent introduction and spread of COVID-19 in outpatient and ambulatory care settings are:

Background

In December 2019, a cluster of cases of pneumonia of unknown origin was reported from Wuhan, Hubei Province in China. On January 10, 2020, a novel coronavirus that causes a disease now referred to as COVID-19 was identified as the cause of this cluster of pneumonia cases. A pandemic was declared on March 11, 2020.

For current information, staff working in outpatient and ambulatory care settings should refer to the Public Health Agency of Canada Coronavirus disease (COVID-19): Outbreak update at and to local, provincial or territorial public health authorities.

Over the last few months, our understanding of COVID-19 has rapidly expanded. Person-to-person transmission is occurring in Canadian communities. COVID-19 is most commonly spread from an infected person through respiratory droplets generated through cough or sneezing, close personal contact such as touching or shaking hands, or touching something with the virus on it and then touching one's mouth, nose or eyes before washing one's hands. COVID-19 may also be spread through the air during aerosol-generating medical procedures (AGMPs).

There is asymptomatic, pre-symptomatic or pauci-symptomatic transmission of this virus. Both staff and patients in ambulatory care settings may have COVID-19 infection without symptoms, or with undetected mild or atypical symptoms at the time of visits.

Introduction

The Public Health Agency of Canada (PHAC) develops evidence-informed infection prevention and control guidelines and recommendations to complement provincial and territorial public health efforts in monitoring, preventing, and controlling healthcare-associated infections.

The purpose of this document, Infection Prevention and Control for COVID-19: Interim Guidance for Outpatient and Ambulatory Care Settings, is to provide interim guidance to operators and staff of outpatient and ambulatory care settings to prevent transmission of COVID-19. The guidance in this document is not intended to apply to specialized medical settings such as hemodialysis or sleep medicine clinics. 

This interim guidance is based upon Canadian guidance developed for previous coronavirus outbreaks, experience with COVID-19 in other countries, as well as interim guidance from other Canadian and international bodies. It has been informed by technical advice provided by members of the PHAC National Advisory Committee on Infection Prevention and Control (NAC-IPC).

IPC strategies to prevent or limit transmission of COVID-19 in outpatient and ambulatory care settings are similar to those used for the IPC management of other acute respiratory infections and include:

This guidance has been developed for Canadian outpatient and ambulatory care settings and staff and may differ from guidance developed by other countries. It should be read in conjunction with relevant provincial, territorial and local legislation, regulations, and policies.

This guidance is informed by currently available scientific evidence and expert opinion, and is subject to change as new information becomes available.

Infection prevention and control preparedness

Outpatient and ambulatory care settings must ensure that:

All staff should ensure that:

Screening and management

Outpatient and ambulatory care settings must ensure that there are processes in place to conduct active screening of staff, external service providers, and patients (and their essential companions) for signs and symptoms of COVID-19. 

Outpatient and ambulatory care settings should liaise with jurisdictional public health authorities to have COVID-19 testing of staff and patients completed and reported, and for guidance on the indications for COVID-19 testing of staff and patients and where this should be conducted.

Access points

Outpatient and ambulatory care settings should minimize access points and ensure that:

Staff

Staff screening must include daily self-assessment for exposures, signs and symptoms of COVID-19.

Facility operators should work with public health authorities to manage exposed staff.

Staff should try to maintain a minimum 2-metre distance between each other throughout their shifts when feasible, and certainly during any breaks or meal periods when they are not masked.

External service providers (including delivery personnel, lab personnel, and contractors)

External service providers should be screened for signs and symptoms of COVID-19 at every visit. If signs or symptoms are present, or if they are on self-isolation or quarantine as per relevant public health directives, they should not enter the ambulatory care setting, and should be advised to follow up with local public health or their healthcare provider.

External service providers should:

Patients and essential companions

Telephone screening and triage

Telephone screening of patients should be conducted to ensure:

Screening and management at presentation

Patients (and their essential companions) presenting directly to ambulatory care settings should be passively (with signage) and actively screened for signs and symptoms of COVID-19, even if already pre-screened via telephone.

Patient care and infection control measures

Point-of-care risk assessment (PCRA)

Prior to any patient interaction, all staff have a responsibility to assess the infectious risks posed to themselves, the patient, and any others from a patient, situation or procedure.

Hand hygiene

Staff are required to perform hand hygiene:

External service providers and essential patient companions should be trained and expected to perform hand hygiene under the same circumstances outlined above for staff.

Patients should be instructed to perform hand hygiene and assisted with this if they are physically or cognitively unable to do so.  Patients should perform hand hygiene:

Hands may be cleaned using ABHR containing 60-90% alcohol or soap and water.  Washing with soap and water is preferable if hands are visibly soiled, or when caring for patients with Clostridioides difficile infection.

Routine Practices

Routine Practices apply to all staff and patients, at all times, in all outpatient or ambulatory care settings and include but are not limited to:

Masking/eye protection for all staff providing or participating in patient care for duration of shifts

The rationale for full-shift masking of outpatient and ambulatory care staff is to reduce the risk of transmitting COVID-19 infection from staff to patients or other facility staff, at a time when no signs or symptoms of illness are recognized, but the virus can be transmitted. In regions where there is  community transmission COVID-19, masking for the full duration of shifts for staff working in direct patient care areas is recommended, and use of eye protection (e.g., a face shield) for the full duration of shifts should be strongly considered in order to protect staff.

Staff should refer to local, provincial or territorial guidance and facility policies on specific recommendations for use of masks, eye protection, and other PPE, and PPE conservation strategies. These may differ over time based on changing epidemiology.

When masks and face shields are applied for the full duration of shifts, staff must:

It is a foundational concept in IPC practice that disposable masks should not be re-worn. However, in the context of the COVID-19 pandemic and PPE shortages, outpatient and ambulatory care settings should follow jurisdictional guidance with regard to mask use, reuse, and reprocessing.

If re-use of masks is recommended, staff must remove their mask by the ear loops or elastics taking care not to touch front of mask, and carefully store the mask in a clean dry area and in accordance with facility and jurisdictional public health guidance, taking care to avoid contamination of the inner surface of the mask, and perform hand hygiene before and after mask removal and before putting it on again.

Masks should be disposed of and replaced when they become damaged, wet, damp, or soiled (from the wearer's breathing or external splash), or when they come in direct contact with a patient.

Staff should be informed of how to access additional masks as needed.

Droplet and Contact Precautions

Droplet and Contact Precautions should be implemented for all patients diagnosed with or presenting with signs or symptoms of possible COVID-19

Aerosol-generating medical procedures (AGMPs)

An AGMP is any procedure conducted on a patient that can induce production of aerosols of various sizes, including droplet nuclei.

Follow provincial or territorial guidance for procedures that require the use of an N95 respirator in addition to Droplet and Contact Precautions. This guidance may vary among provinces and territories.

Handling lab specimens

All specimens collected for laboratory investigations should be regarded as potentially infectious, and placed in biohazard bags. Clinical specimens should be collected and transported in accordance with organizational policies and procedures. For additional information on biosafety procedures when handling samples from patients under investigation for COVID-19, refer to the PHAC's biosafety advisory.

Handling patient care equipment

Single-use disposable equipment and supplies should be used whenever possible, and discarded into a no-touch waste receptacle after each use. All reusable equipment should whenever possible be dedicated for use by one patient. If this is not feasible, equipment should be cleaned first and then disinfected or otherwise reprocessed according to manufacturer's instructions and facility protocols.   

Environmental cleaning and disinfection

Increased frequency of cleaning high-touch surfaces in patient exam rooms and any central areas is important for controlling the spread of microorganisms. Environmental disinfectants used should be classed as hospital-grade, registered in Canada with a Drug Identification Number (DIN), and labelled as effective for both enveloped and non-enveloped viruses.

Outpatient and ambulatory care settings that are located in hospital facilities should follow established environmental cleaning and disinfection policies and procedures with approved disinfectants.

Linen management

Routine Practices are used.

Waste management

Routine Practices are used.

Bibliography

Alberta Health Services.  novel Coronavirus (COVID-19): Frequently Asked Questions – for Primary Care (16 April 2020).

Arons MM, Hatfield KM, Reddy SC, Kimball A, James A, Jacobs JR, et al. Presymptomatic SARS-CoV-2 Infections and Transmission in a Skilled Nursing Facility. N Engl J Med. April 24, 2020. DOI: 10.1056/NEJMoa2008457

BC Centre for Disease Control.  COVID-19 Care – Clinical Care: Primary Care (2020). 

Centers for Disease Control and Prevention.  Outpatient and Ambulatory Care Settings: Responding to Community Transmission of COVID-19 in the United States (7 April 2020). 

Centers for Disease Control and Prevention.  Get Your Clinic Ready for Coronavirus Disease 2019 (COVID-19) (11 March 2020). 

Centers for Disease Control and Prevention.  Healthcare Facilities: Preparing for Community Transmission (29 February 2020). 

Government of New Brunswick.  Novel Coronavirus (COVID-19) Guidance for Primary Care Providers in a Community Setting (22 March 2020). 

Ministry of Health, Ontario.  COVID-19 Guidance: Primary Care Providers in a Community Setting, Version 4 (25 April 2020). 

Nova Scotia Health Authority.  Cleaning and Disinfection of the Environment and Devices for Primary Care Practices (26 January 2019).

Public Health Agency of Canada.  Hand Hygiene Practices in Healthcare Settings (2012). 

Public Health Agency of Canada. Infection Prevention and Control for COVID-19: Second Interim Guidance for Acute Healthcare Settings (30 April 2020).

Public Health Agency of Canada.  Infection Prevention and Control for COVID-19: Interim Guidance for Long Term Care Homes (8 April 2020).

Public Health Agency of Canada.  Routine practices and additional precautions for preventing the transmission of infection in healthcare settings (2013).

Public Health England.  Recommended PPE for primary, outpatient, community and social care by setting, NHS and independent sector (2020).

Public Health Ontario.  Technical Brief: IPAC Recommendations for Use of Personal Protective Equipment for Care of Individuals with Suspect or Confirmed COVID-19 (6 April 2020).

Saskatchewan Health Authority.  Continuous and Extended Use PPE Guidelines — Primary Health Care (17 April 2020).

Shared Health Manitoba.  COVID-19 Highlights: Primary Care Providers in Community (16 April 2020).

Sutton D, Fuchs K, D'Alton M, Goffman D. Universal Screening for SARS-CoV-2 in Women Admitted for Delivery. N Engl J Med. April 13, 2020. DOI: 10.1056/NEJMc2009316

Wei WE LZ, Chiew CJ, Yong SE, Toh MP, Lee VJ. Presymptomatic Transmission of SARS-CoV-2 - Singapore, January 23 - March 16, 2020. MMWR Morb Mortal Wkly Rep 2020;69:411–415. DOI: http://dx.doi.org/10.15585/mmwr.mm6914e1

World Health Organization.  Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected, Interim guidance (19 March 2020).

World Health Organization.  Advice on the use of masks in the context of COVID-19 (6 April 2020).

World Health Organization.  Rational use of personal protective equipment for coronavirus disease (COVID-2019) and considerations during severe shortages, Interim guidance (6 April 2020).

Acknowledgments

The National Advisory Committee on Infection Prevention and Control (NAC-IPC) is an external advisory body that provides subject matter expertise and advice to the Public Health Agency of Canada on the prevention and control of infectious diseases in Canadian healthcare settings.

This guideline was prepared by: Dr. Cheryl Volling, Ms. Sabrina Chung, Dr. Marina Salvadori, and Dr. James Brooks.

NAC-IPC Members: Dr. Joanne Embree, (Chair), Dr. Jennie Johnstone (Vice-Chair), Ms. Molly Blake, Ms. Josiane Charest, Dr. Maureen Cividino, Ms. Nan Cleator, Ms. Jennifer Happe, Dr. Susy Hota, Ms. Anne Masters-Boyne, Dr. Matthew Muller, Ms. Patsy Rawding, Ms. Suzanne Rhodenizer-Rose, Dr. Patrice Savard, Dr. Stephanie Smith, Dr. Nisha Thampi.

PHAC Healthcare-Associated Infections Prevention and Control Section: Dr. James Brooks (Director), Ms. Kathy Dunn (Manager), Ms. Katherine Defalco, Ms. Toju Ogunremi, Ms. Adina Popalyar, Ms. Anna Bottiglia, Ms. Sabrina Chung, Dr. Kahina Abdesselam, Mr. Steven Ettles, and Mr. John McMeekin.

The authors gratefully acknowledge the contributions of: Dr. William Cunningham, Dr. Lee Green, Dr. Michael E. Green, Ms. Christine Moussa, and Ms. Darlene Campbell, scientific writer.

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