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

Table of contents

• Background
• Introduction
• Infection prevention and control preparedness
• Screening and management
  • Access points
  • Staff
  • External service providers (including delivery personnel, lab personnel, and contractors)
  • Patients and essential companions
    • Telephone screening and triage
    • Screening and management at presentation
• Patient care and infection control measures
  • Point-of-care risk assessment (PCRA)
  • Hand hygiene
  • Routine Practices
  • Masking/eye protection for all staff providing or participating in patient care for duration of shifts
  • Droplet and Contact Precautions
  • Aerosol-generating medical procedures (AGMPs)
• Handling lab specimens
• Handling patient care equipment
• Environmental cleaning and disinfection
• Linen management
• Waste management
• Bibliography
• Acknowledgments

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:

• Staff must follow current IPC guidelines for use of personal protective equipment (PPE) in outpatient and ambulatory care settings
• Active screening of patients for signs and symptoms of COVID-19 and triage of medical appointments should occur by telephone when possible
• Telephone, web-based, or other means of telecommunication technology should be used to conduct virtual assessments when in-person assessment is not necessary
• All staff must be trained in assessing the need for PPE, based on a point-of-care risk assessment (PCRA), and putting it on, wearing and removing it to minimize contamination of themselves and the immediate environment
• If there is community spread of 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 duration of shifts should be strongly considered
• All staff must use Droplet and Contact Precautions, in addition to Routine Practices, for all care of patients with suspected or confirmed COVID-19
• All staff must be trained on other important IPC measures such as proper hand hygiene and maintaining a 2-metre spatial distance between themselves and patients and other staff when closer contact is not required for provision of care and when unmasked
• All staff must work proactively to identify suspect or confirmed cases of COVID-19 in staff and patients, implement appropriate precautions, and advise testing where indicated and as guided by local, provincial or territorial public health guidelines

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:

• Prompt identification of all persons with signs and symptoms of possible COVID-19
  • Signs and symptoms may include:
    • Fever (temperature of 38.0°C or greater), or
    • Any new or worsening respiratory symptoms (cough, shortness of breath, runny nose or sneezing, nasal congestion, hoarse voice, sore throat or difficulty swallowing), or
    • Any new onset atypical symptoms including but not limited to chills, muscle aches, diarrhea, malaise, or headache
• Institution of IPC measures to prevent infections (e.g., Routine Practices including hand hygiene, point-of-care risk assessment (PCRA), implementation of Droplet and Contact Precautions, use of an N95 respirator for AGMPs, and increased environmental cleaning of frequently touched surfaces)

• For more information, staff can refer to PHAC's guidelines on Routine Practices and Additional Precautions for Preventing the Transmission of Infection in Healthcare Settings 

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:

• They maintain awareness of data on the local and regional spread of COVID-19
• They conduct both passive and active screening of staff, patients, essential patient companions, and external service providers for signs and symptoms of COVID-19
• They have capacity to call and pre-screen each patient within 48 hours prior to their scheduled appointment
• Staff conducting telephone screening are provided with appropriate guidance on how to screen for signs and symptoms of COVID-19, when to advise patients to self-isolate at home, how to counsel them on signs and symptoms of more severe or critical illness that should prompt them to seek emergent care, and on the indications and locations for testing
• They are prepared to offer virtual visits to patients via telephone or web-based communications, where this is clinically appropriate
• On-site screeners will be behind a transparent barrier that prevents droplet transmission and allows for communication between staff and patients, or if this is not in place, that they will be 2 metres away or wear PPE (i.e., gloves, gown, mask and eye protection)
• The exchange of paperwork between reception staff and patients is minimized
• All non-essential items are removed from exposed environmental surfaces
• Staff receive ongoing training in conducting PCRAs, Routine Practices, including hand hygiene, and implementation of Additional Precautions, including Droplet and Contact Precautions, and use of an N95 respirator, in addition to Droplet and Contact Precautions if AGMPs are performed
• Staff IPC training, education, and testing are in place, tracked, recorded, and kept up-to-date
• In facilities responsible for assessment and testing of patients for COVID-19, all staff conducting these assessments are trained on how to properly obtain specimens for testing
• Policies and procedures are in place to prevent the introduction and spread of COVID-19 in outpatient and ambulatory care settings, and that these are informed by regional and/or provincial/territorial directives or recommendations.  This includes policies and procedures pertaining to:
  • Communication with staff and patients on COVID-19 updates
  • Self-screening of staff for exposures or signs or symptoms of COVID-19
  • Conducting telephone patient (and essential companion) screening for signs and symptoms of COVID-19 prior to visits
  • Limiting access points and conducting entrance screening at all access points
  • The need for PCRAs to be conducted by all staff prior to any interaction with a patient; Routine Practices, including hand hygiene, applied in the care of all patients; and when and in what circumstances to implement Additional Precautions (e.g., Droplet and Contact Precautions or use of an N95 respirator for AGMPs)
  • Identifying staff who work in other healthcare settings/facilities, and ensuring efforts are made to prevent this where possible, to limit spread between facilities and to inform investigations during an outbreak
  • How to manage patient or staff exposures, signs and symptoms, or confirmed COVID-19
  • Routine scheduled and additional environmental cleaning with attention paid to high-touch, high-risk surfaces (e.g., door handles, exam tables, desks, chair arms, light switches, hand and support rails, toilets, sinks, telephones)
  • Environmental cleaning and disinfection of waiting rooms, patient care equipment, patient exam areas, office spaces, lunchrooms
  • Proper cleaning and disinfection of any reusable PPE
• Staff and patients are provided with printed or posted information about COVID-19, how the virus causes infection, and how to protect themselves and others, including:
  • The importance of hand hygiene and how to wash hands and how to use alcohol-based hand rub (ABHR)
  • Instructions on appropriate respiratory hygiene (i.e., covering their cough with a tissue or coughing into their elbow followed by performing hand hygiene)
  • Posters illustrating the correct methods for putting on and removing required PPE placed inside and outside of patient exam rooms for easy visual cues
  • Instructions on how and where to dispose of used supplies
• Every effort is made to make PPE available and accessible at the point-of-care with each patient
• PPE is stored to avoid pilfering, while not inhibiting staff from accessing PPE
• There is regular assessment to determine stock of necessary PPE (e.g. gloves, gowns, masks, eye protection) and necessary supplies including ABHR and cleaning supplies
• Appropriate number and placement of ABHR dispensers, at entry to the outpatient and ambulatory care setting, in hallways at entry to each exam room, communal areas and at point-of-care for each patient
• Respiratory hygiene products (e.g., masks, tissues, ABHR, no-touch waste receptacles) are available and easily accessible to staff and patients
• Environmental cleaning and disinfection practices are monitored for compliance
• Physical distancing measures (maintaining a minimum 2-metre spatial separation) are utilized for staff and patients wherever feasible, and while providing safe care
• All patients with suspected or confirmed COVID-19 are immediately placed on Droplet and Contact Precautions (i.e., use of gloves, gown, mask and eye protection) for all staff who enter the patient exam room or who are within 2 metres of the patient until COVID-19 or other respiratory infection is ruled out
• Signage indicating Droplet and Contact Precautions is placed outside of patient exam rooms or areas where patient(s) with suspected or confirmed COVID-19 are located
• A fit-tested N95 respirator, gloves, gown, and eye protection are worn for AGMPs according to provincial and territorial guidance
• Staff ill, or with an unprotected exposure to someone with confirmed COVID-19, as defined by occupational health or their local public health department, or those otherwise determined to require self-isolation according to public health directives, must follow the policies of jurisdictional public health authorities to determine restrictions and when they can return to work
• Waste, soiled linen and the care environment are managed and/or adequately cleaned and disinfected according to facility policies and procedures

All staff should ensure that:

• They adhere to the facility IPC policies and procedures and jurisdictional public health guidance
• Once daily, they self-monitor and immediately report any new signs or symptoms to facility management
• Prior to working every shift, they report to facility management if they have had potential unprotected exposure to a case of COVID-19 to determine whether restrictions are necessary (which may depend on local jurisdictional guidance), as well as consulting their own healthcare provider for any needed follow-up
• They are knowledgeable about:
  • How to conduct a PCRA prior to all interactions to determine what IPC measures are needed to protect patients and themselves from infection
  • Routine Practices and Additional Precautions
  • Where to get tested if they become symptomatic or if requested by local public health authorities or facility management
  • The use and limitations of PPE available for their use
  • They understand and participate in programs to conserve PPE

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:

• Efforts are made to screen all patients and essential companions for signs and symptoms or exposure to COVID-19 prior to visits
• On-site screeners and administrative personnel are protected with transparent barriers which prevent droplet transmission to staff and allow for communication between the screener and patients or other persons who present at screening
  • If a transparent barrier is not in place, screeners should be provided with PPE (i.e., gloves, gown, mask and eye protection)

• Signage (multilingual as required) is posted at access points to instruct:
  • Staff and external service providers not to enter if they have any new signs or symptoms of illness or if they have been instructed by public health authorities to self-isolate or self-quarantine
    • Signs and symptoms may include:
      • Fever (temperature of 38.0°C or greater), or
      • Any new or worsening respiratory symptoms (cough, shortness of breath, runny nose or sneezing, nasal congestion, hoarse voice, sore throat or difficulty swallowing), or
      • Any new onset atypical symptoms including but not limited to chills, muscle aches, diarrhea, malaise, or headache
  • Patients (and essential companions) not to enter if they have signs or symptoms of COVID-19 unless they have been instructed by the facility to do so, or the ambulatory care setting is a dedicated COVID-19 assessment centre
  • All symptomatic patients to put on a mask at entry to the facility
  • All staff, and any external service providers expected to come within 2 metres of others, to wear a mask on entering the facility to reduce the risk of COVID-19 transmission, which may occur even when signs and symptoms of illness are not recognized
  • All those entering to perform hand hygiene with ABHR and to practice respiratory hygiene (i.e., covering their cough with a tissue or coughing into their elbow followed by performing hand hygiene)
• Access points allow for rapid placement of symptomatic patients under isolation with Droplet and Contact Precautions
• Masks, tissues, ABHR and a no-touch waste receptacle are available for staff, patient, essential companion, and external service provider use at screening at each entrance. Consideration should be given to the security of supplies of PPE to prevent pilfering, but this should not inhibit or prevent necessary access to PPE
• All staff and external service providers are logged at entry to the facility
• Essential deliveries that are unable to be left outside occur through a single access point

Staff

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

• If a staff member develops signs or symptoms of COVID-19 at work they should immediately perform hand hygiene, ensure that they do not remove their mask, inform facility management, avoid further patient contact and leave as soon as it is safe to do so
• Staff with any signs or symptoms consistent with COVID-19, including mild or atypical symptoms, should be tested for COVID-19 and excluded from work, and advised to follow local public health guidance with regard to testing and further management
• Designated staff should initiate and maintain a line listing of staff with suspected or confirmed COVID-19 as required by local, provincial or territorial public health guidelines or as directed by facility occupational health and IPC policies

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:

• Only enter the ambulatory healthcare setting when necessary
• Make adjustments to reduce contact where feasible, e.g., leaving deliveries at the door
• When entering, perform hand hygiene and put on a mask if a 2 metre distance from staff and patients cannot be ensured
• Be instructed by staff on the importance of hand hygiene with ABHR and when and how to perform hand hygiene, e.g., when entering and exiting the setting, and after touching any surfaces in the ambulatory care environment 
• Be taught how to put on and remove any additional PPE as needed

Patients and essential companions

Telephone screening and triage

Telephone screening of patients should be conducted to ensure:

• Patients with signs or symptoms of COVID-19 are advised to self-isolate at home for mild symptoms, and counseled on signs and symptoms of more severe or critical illness that should prompt them to seek emergent care
  • For non-emergent cases, staff should refer to local, provincial or territorial guidance for duration of self-isolation and whether testing is indicated
  • If indicated, testing should be performed at dedicated COVID-19 assessment centres if they exist in the area
• Patients without signs or symptoms are advised to call back if they develop any new signs or symptoms before their appointment
• Screening is conducted for all essential companions (e.g., parents/guardians, family members, personal support workers) who are required to accompany patients to medical appointments, and that they are instructed not to attend if symptomatic (and to make other arrangements if needed)
• Medical appointments are triaged, prioritizing visits for patients for whom emergency department visits and acute care hospitalization may be prevented
• Medical appointments are conducted virtually by telephone, web-based, or other means of telecommunication technology when feasible (i.e., patients have access to and are able to adequately communicate via an appropriate device) and in-person assessment is not necessary
• Non-essential visits are postponed (and deferred services are tracked in order to ensure proper follow-up when appropriate)
• Any services that are time-sensitive, and immunizations should continue to be provided
• A system for prescription renewal without an office or clinic visit is implemented

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.

• Patients with signs or symptoms or potential exposures to COVID-19 should be instructed to perform hand hygiene and to put on a medical mask and be immediately placed under Droplet and Contact Precautions in a single room or where a minimum 2-metre distance between them and other patients can be ensured
  • Outside each patient exam room should be:
    • Clear (multilingual as required) signage to indicate Droplet and Contact Precautions are in place
    • Posters illustrating the correct method for putting on and removing PPE (these should be inside the room as well)
    • PPE, hand hygiene sink or ABHR and a no-touch waste receptacle
• Companions who have signs or symptoms or potential exposures to COVID-19 (including via the patient they accompany) should be instructed to perform hand hygiene and put on a medical mask and asked to wait outside or return to pick up the patient after their appointment
• Patients and their essential companions who do not have signs or symptoms or potential exposures to COVID-19 do not require masking; however, they should be instructed to perform hand hygiene and should  maintain a  2-metre distance from others at entrances and in any designated waiting areas
• The physical layout of outpatient and ambulatory care settings should be adjusted to facilitate IPC measures to prevent transmission of COVID-19 (e.g., spacing chairs 2 metres apart in waiting rooms, and placing indicators on floors where queues may occur), and the volume and timing of appointments should take into consideration available space
• To reduce crowding, consideration should be given to asking patients waiting to be seen to remain outside if appropriate (e.g., stay in their vehicles) until they are called in for their appointment

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.

• The PCRA is a routine practice that should be applied by all staff before every clinical encounter regardless of COVID-19 status and is based on the staff professional judgment (i.e. knowledge, skills, reasoning and education) made regarding the likelihood of exposing themselves and/or others to infectious agents, for a specific interaction, a specific task, with a specific patient, and in a specific environment, under available conditions  
• The PCRA helps staff to select the appropriate actions and/or PPE to minimize the risk of exposure to known and unknown infections

Hand hygiene

Staff are required to perform hand hygiene:

• On entry to and exit from the outpatient or ambulatory care setting
• Before and after contact with a patient, regardless of whether gloves are worn
• After removing gloves
• Before and after contact with the patient's environment (e.g., medical equipment, exam table) regardless of whether gloves are worn
• Any other time hands are potentially contaminated
• Before preparing or administering all medications
• Before performing aseptic procedures
• Before putting on PPE and during removal of PPE according to the facility procedure for putting on or removing PPE
• After other personal hygiene practices (e.g., blowing nose, using toilet facilities, etc.)

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:

• Upon entering or leaving the facility
• Prior to eating, oral care or handling oral medications
• After personal hygiene practices or use of toileting facilities
• Any other time hands are potentially contaminated (e.g. after handling wound dressings or bodily fluids)

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:

• Conducting a PCRA
• Hand hygiene
• Appropriate use of PPE
• Adhering to respiratory hygiene (i.e., covering a cough with a tissue or coughing into elbow followed by performing hand hygiene)

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:

• Perform hand hygiene before they put on their mask and face shield when they enter the outpatient or ambulatory care setting, before and after removal, and prior to putting on a new mask or face shield
• Wear a mask securely over their mouth and nose and adjust the nose piece to fit snugly
• Not touch the front of mask or face shield while wearing or removing it (and immediately perform hand hygiene if this occurs)
• Not dangle the mask under their chin, around their neck, off the ear, under the nose or place on top of head
• Remove their mask and face shield just prior to breaks or when leaving the facility, while in an area where no patients or other staff are present, and discard them in the nearest no-touch waste receptacle, or otherwise store in accordance with facility policy (see statement below on re-use of masks). Reusable shields should be processed as per facility protocols
• Perform hand hygiene during and after PPE removal and between patient encounters

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

• Gloves, long-sleeved cuffed gown (covering front of body from neck to mid-thigh), mask (which should already be worn due to masking during all shifts) and face shield or eye protection should be worn upon entering the patient exam room or when within 2 metres of the patient on Droplet and Contact Precautions
  • Examples of eye protection (in addition to mask) include full face shield, mask with attached visor, non-vented safety glasses or goggles (regular eyeglasses are not sufficient)

• PPE should be removed in the correct order and discarded prior to exiting the patient exam room or ante-room in the nearest no-touch waste receptacle
  • Gloves should be discarded in the nearest no-touch waste receptacle, and should never be re-worn
  • Disposable gowns should be discarded in the nearest no-touch waste receptacle, and reusable gowns processed as per facility protocols
  • Full face shields should be removed (to be reprocessed or disposed of as per facility IPC guidance). If masks with attached visors are used these should be removed and discarded in the nearest no-touch waste receptacle, and a new mask and eye protection put on. Reusable safety glasses or goggles must be reprocessed per facility IPC guidance.
  • Masks do not necessarily need to be replaced after seeing a patient on Droplet and Contact Precautions if a full face shield is worn over this

• The area where PPE is put on should be separated from the area where it is removed and discarded
• Hand hygiene should occur according to best practices for putting on and removing PPE

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.

• Patient exam rooms and all central areas should be kept free of clutter to facilitate cleaning

• All patient exam room surfaces that are considered "high-touch" (e.g., examination tables/bed, bedrails, bedside table, chair arms, charting desks or tables, touch screens, keyboards, handwashing sink handles) should be cleaned and disinfected between every patient
• Hospital-grade ready-to-use disinfectant wipes with the recommended contact time should be used to disinfect smaller patient care equipment (e.g., blood pressure cuffs, electronic thermometers, oximeters, stethoscopes) after each use
• All central area surfaces that are considered "high-touch" (e.g., telephone, chair arms, door handles and buttons, light switches, handwashing sink, bathroom sink, toilet and toilet handles, grab bars, outside of paper towel dispensers) should be cleaned and disinfected a minimum of twice daily and when soiled
• Cleaning and disinfection should be performed at least once per day on all low-touch surfaces (e.g., shelves, chairs or benches, windowsills, headwall units, overbed light fixtures, message or white boards, outside of sharps containers)
• Surfaces that are visibly soiled with blood or other body fluids should be cleaned and disinfected immediately
• Floors and walls should be kept visibly clean and free of spills, dust and debris

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.

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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.