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

This document was posted on April 9, 2021. Please refer back for future updates.

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Changes in the current update

The Public Health Agency of Canada (PHAC) develops evidence-informed infection prevention and control (IPC) guidance to complement provincial and territorial public health efforts in monitoring, preventing, and controlling healthcare-associated infections. Guidance will necessarily shift with the benefit of new scientific findings and their replication, as well as with thoughtful consideration of implications for practice in areas of uncertainty. National-level guidance should always be read in conjunction with relevant provincial, territorial and local policies and regulations.

PHAC is updating its interim guidance on infection prevention and control in outpatient and ambulatory care settings to consider emerging data on the transmission of SARS-CoV-2, the virus that causes COVID-19. While reports point to the occurrence of aerosol transmission in certain community circumstances (e.g., prolonged contact in closed indoor spaces with poor ventilation), there remains uncertainty around the exact role of aerosol transmission of SARS-CoV-2 and its impact in healthcare settings, including outpatient and ambulatory care settings.

Those using this guidance are encouraged to consider the responsibility of exercising stewardship of finite personal protective equipment (PPE) during this pandemic. Encouraging optimal use of PPE, including N95 or equivalent respirators, where there are known or anticipated shortages, is not a matter of limiting access to PPE, but about trying to ensure that appropriate PPE is available to healthcare staff who, by the nature of their work, are at a higher risk of exposure.

PHAC will continue to consider new evidence as it becomes available. The following statements summarize the current knowledge used to inform updates to the guidance:

In this context, the following recommendations are being made in this guidance. Outpatient and ambulatory care settings are also encouraged to refer to their provincial, territorial and local policies and regulations, which may vary depending on local epidemiology.

Individuals responsible for policy development, implementation and oversight of IPC measures at specific outpatient and ambulatory care settings should be familiar with relevant IPC background documents on Routine Practices and Additional Precautions and occupational health and safety (OHS) legislation. Facility IPC policies and procedures, protocols, guidance, education and training referred to within this document should be informed by IPC experts and regional and/or provincial/territorial directives or recommendations, and frequently reviewed and updated as needed. Whenever possible, these should be developed in conjunction with joint occupational health and safety committees (JOHSC) or workplace health and safety representatives. All outpatient and ambulatory care settings should have ongoing access to local IPC expertise, with at least one person assigned to manage COVID-19-related prevention and response activities in the outpatient and ambulatory care setting.

Background

In December 2019, a cluster of cases of pneumonia of unknown origin was reported from Wuhan, Hubei Province in China. These cases were due to infection with a novel coronavirus, now called SARS-CoV-2, that causes a disease now referred to as COVID-19. A pandemic was declared by the World Health Organization on March 11, 2020.

For current information on the pandemic, please refer to the Public Health Agency of Canada Coronavirus Disease (COVID-19): Outbreak Update and to local, provincial or territorial public health authorities.

The purpose of this document is to provide operators and staff updated interim IPC guidance to prevent the transmission of COVID-19 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. 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 experience with COVID-19 in Canada and other countries, as well as interim guidance from other international bodies. It has been informed by technical advice provided by members of the National Advisory Committee on Infection Prevention and Control (NAC-IPC). This guidance is informed by currently available scientific evidence and expert opinion, and is subject to change as new information becomes available.

The term "staff" is intended to include anyone working in outpatient and ambulatory care settings, including but not limited to those providing health care. The term “visitor” is intended to include anyone other than staff or patients who has been permitted to enter the facility, and includes but is not limited to essential companions (e.g., parents/guardians, family members, or support workers who are needed to accompany patients unable to attend medical appointments on their own) and external service providers (including delivery personnel, laboratory personnel and contractors).

Infection prevention and control preparedness

Each outpatient and ambulatory care facility should be prepared to identify and manage or otherwise direct patients who are considered exposed to, or suspected or confirmed to have COVID-19.

Outpatient and ambulatory care setting operators should ensure that:

All staff should ensure that:

Outpatient and ambulatory care staff safety and training

Outpatient and ambulatory care facilities should evaluate the potential risks posed to staff, and ensure that controls are in place to mitigate and manage them.

The outpatient and ambulatory care facility management, in collaboration with IPC experts (and workplace health and safety representatives or JOHSCs wherever possible) should conduct an organizational risk assessment to identify and mitigate the risks of facility staff exposure to COVID-19. In addition:

Management of staff exposures

Outpatient and ambulatory care facility management, OHS professional(s), and infection control practitioners should work collaboratively with public health authorities to manage staff exposed to COVID-19.

Access points

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

Screening and management of persons entering outpatient and ambulatory care settings

Active screening should be conducted to promptly identify any individuals with signs and/or symptoms of COVID-19 or other respiratory illness.

Signs and symptoms of COVID-19 can vary from person to person. They may also vary according to age group.

Reported signs and symptoms include but are not limited to:

Older and frail adults may experience chest pain, dizziness, loss of appetite, changes in cognition, behavior, or functional status, increased frequency of falls, or delirium.

Outpatient and ambulatory care settings should liaise with local laboratories and jurisdictional public health authorities to determine the most rapid way to have COVID-19 testing of staff and patients completed and reported.

All confirmed cases of COVID-19 are to be reported to the relevant jurisdictional public health authorities.

Staff screening

Staff screening should include ongoing self-assessment for exposures to, and signs and symptoms, of COVID-19. Staff who develop any signs or symptoms of COVID-19 (of any severity) should:

Staff who have signs or symptoms of COVID-19, who have had recent unprotected exposure (as defined by facility, local, and jurisdictional public health or IPC guidance) to a person suspected or confirmed to have COVID-19, or who have been directed to self-isolate according to local public health directives, should not return to the outpatient or ambulatory care facility until they have been cleared to do so according to local and jurisdictional public health guidance and facility IPC policies.

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.

Patient (and essential companion) pre-visit screening and triage

Outpatient and ambulatory care facilities should ensure that a consistent process is in place for screening all patients and essential companions. This should include pre-visit assessment of patients and any essential companions for signs and symptoms of COVID-19, a suspected or confirmed diagnosis of COVID-19, or any recent contact with a person suspected or confirmed to have COVID-19.

Pre-visit screening should be conducted to ensure:

Patient (and essential companion) screening and management at presentation

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

External service provider (including delivery personnel, lab personnel, and contractors) screening and management

External service providers should be screened for exposure to, and signs and symptoms of, COVID-19 at every visit.

External service providers should:

Patient care and infection prevention and control measures

Routine Practices

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

Point-of-care risk assessment

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 PCRA includes determining if there may be:

Patient factors may include:

The selection and use of PPE during patient interactions should always be determined by the PCRA.

For interactions with patients who are considered exposed to, or suspected or confirmed to have COVID-19, PPE consistent with a minimum of Droplet and Contact Precautions (e.g., gloves, a gown, a medical mask and eye protection) should be worn. An N95 or equivalent respirator should be worn in place of a mask when performing or exposed to an AGMP. Use of an N95 or equivalent respirator may be considered in other circumstances under which risk of exposure to aerosolized virus may occur.

Hand hygiene

Outpatient and ambulatory care settings should have a hand hygiene program in place, with regular review and updating of staff education, training, and monitoring for adherence. Facilities should make every effort to achieve 100 percent hand hygiene adherence.

Staff should perform hand hygiene:

Hands may be cleaned using ABHR containing 60 to 90% alcohol, or plain liquid soap and water.  Soap and water are preferable for use immediately after using toileting facilities, if hands are visibly soiled, and when caring for patients with Clostridioides difficile infection.

Visitors are expected to perform hand hygiene under the same circumstances outlined above for staff and should be trained on how to do so properly.

Patients should be taught how to perform proper hand hygiene, and assisted with this if they have physical or cognitive limitations.  Patients should perform hand hygiene:

Personal protective equipment

All PPE (e.g., gloves, gowns, medical masks, N95 or equivalent respirators, eye protection) should be supplied in adequate amounts and sizes in all patient care areas, and placed so it is readily accessible at the point-of-care for all staff. Additional supplies of PPE should be stored in clean supply rooms that are clearly separated from any soiled utility areas.

Training should be provided, with posters clearly outlining the steps for putting on and removing PPE posted for visual cues inside and outside each room of a patient who is considered exposed to, or suspected or confirmed to have COVID-19.

All staff using PPE should:

Masking and eye protection for the full duration of shifts or visits

Given ongoing community spread of COVID-19 within Canada and evidence that transmission occurs from those who have few or no symptoms, masking for the full duration of shifts or visits for all outpatient and ambulatory care setting staff and visitors (e.g., essential companions or external service providers) is recommended. The rationale for full-shift or visit masking of all staff and visitors is to reduce the risk of transmitting COVID-19 infection from staff or visitors to others, at a time when no signs or symptoms of illness are recognized, but the virus can be transmitted. Staff should support visitors to ensure appropriate use of medical masks.

Use of eye protection (e.g., a face shield) for the full duration of staff shifts is also recommended in outpatient and ambulatory care settings, based on local epidemiology. This applies to all staff working in patient care areas.

Staff should refer to facility IPC and provincial and territorial guidance on specific recommendations for use of medical masks, eye protection and other PPE, as well as PPE conservation strategies. When medical masks for staff and visitors (and eye protection for staff) are recommended for the full duration of shifts or visits, staff and visitors should:

When an N95 or equivalent respirator is deemed necessary based on the staff PCRA, staff should follow local and facility IPC procedures for taking off a medical mask (and eye protection, if worn), and then put on a fit-tested N95 or equivalent respirator and replace their eye protection, with meticulous hand hygiene performed at all steps.

Masks or N95 or equivalent respirators should be 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 or N95 or equivalent respirators when needed.

Additional Precautions

A minimum of Droplet and Contact Precautions should be implemented for all patients who are considered exposed to, have been diagnosed with, or have signs or symptoms of COVID-19.

Aerosol-generating medical procedures

Some medical procedures have been reported to increase the likelihood of generating infectious aerosols, and linked to transmission of other respiratory viruses. These are often referred to as aerosol-generating procedures (AGPs) or aerosol-generating medical procedures (AGMPs). There are many knowledge gaps as to which procedures pose the greatest risk of aerosol generation and of transmission of SARS-CoV-2.  It is likely that the degree of risk may also vary depending on the patient, the operator, and the setting.

Most procedures that are reported to pose increased risk of aerosol generation and transmission of respiratory viruses are rarely performed in outpatient and ambulatory care settings.

Guidance for procedures that require the use of an N95 or equivalent respirator should be followed. This guidance may vary among provinces and territories.

AGMPs are ideally performed in AIIRs if these are available. These rooms are limited in outpatient and ambulatory care settings, and there has not been well-documented transmission by AGMPs when providers were in appropriate PPE. If a patient requires an AGMP, the patient should be placed in an AIIR or a private room with the door closed.

AGMPs on a patient who is considered potentially infectious with SARS-CoV-2 should only be performed when all staff in the room are wearing a fit-tested, seal-checked N95 or equivalent respirator, gloves, a gown and eye protection.

In addition:

Discontinuing Additional Precautions

The duration and discontinuation of Additional Precautions for an individual patient should be determined on a case-by-case basis, in accordance with local, provincial and territorial public health and IPC guidance.

Handling laboratory specimens

All specimens collected for laboratory investigations should be regarded as potentially infectious. Clinical specimens should be collected and transported in accordance with organizational policies and procedures. For proper laboratory 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 immediately after use.

All reusable equipment should, whenever possible, be dedicated for use by one patient. If reuse with other patients is necessary, equipment (e.g., blood pressure monitor, stethoscope) should first be cleaned and then disinfected with a hospital-grade disinfectant according to the manufacturer’s recommended contact time and facility protocols. Items that have been cleaned and disinfected should be clearly identified as such (e.g., with tags) and stored separately from any non-clean and non-disinfected items.

Environmental cleaning and disinfection

Cleaning and disinfection of high-touch surfaces is important for controlling the spread of microorganisms. Environmental disinfectants should be classified as hospital disinfectants, registered in Canada with a Drug Identification Number (DIN), and labelled as effective for both enveloped and non-enveloped viruses. Manufacturer’s instructions for use and required contact times should be followed to ensure adequate disinfection.

Patient exam rooms and all central areas (e.g., waiting rooms, office spaces, lunch rooms) 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 each patient. Cleaning and disinfection of low-touch surfaces (e.g., shelves, chairs or benches, windowsills, headwall units, overbed light fixtures, message or white boards, outside of sharps containers) should also be performed on a regular basis and when soiled. Floors and walls should be kept visibly clean and free of spills, dust and debris.

Single use barriers or covers (e.g., paper table covers) used on surfaces that are more likely to become contaminated should be discarded after each patient, and underlying surfaces cleaned and disinfected.

All surfaces or items outside of the patient room that are touched by or in contact with staff (e.g., computer carts, medication carts, charting desks or tables, computer screens, telephones, touch screens, chair arms) should be cleaned and disinfected at least daily and when soiled. Staff should ensure that their hands are clean before touching the above-mentioned equipment.

In areas with patients who are considered exposed to, or suspected or confirmed to have COVID-19, or shared staff or patient common spaces, more frequent cleaning and disinfection is required.

Outpatient and ambulatory care settings located in hospital facilities should follow hospital environmental cleaning and disinfection policies and procedures.

Linen management

Routine Practices should be used.

Waste management

Routine Practices should be used.

Monitoring and evaluation

Outpatient and ambulatory care settings should ensure that processes to monitor processes and outcomes related to managing patients with suspected or confirmed COVID-19 are in place. These may include:

Bibliography

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