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

This document was updated and re-posted on June 16, 2021. Please refer back for future updates.

Changes in recent updates
Background
Infection prevention and control preparedness
Outpatient and ambulatory care staff safety and training
Management of staff exposures
Access points
Screening and management of persons entering outpatient and ambulatory care settings
Patient care and infection prevention and control measures
Discontinuing Additional Precautions
Handling laboratory specimens
Handling patient care equipment
Environmental cleaning and disinfection
Bibliography

Changes in recent updates

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.

April 9, 2021

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.

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:

Transmission of SARS-CoV-2 may occur from individuals who do not have signs or symptoms of infection (those who are presymptomatic or asymptomatic)
Transmission occurs primarily when individuals are in close contact with a person who is infected; transmission at close ranges may occur via large respiratory droplets that fall through the air and land on mucous membranes of a susceptible person's nose, mouth or eyes, and through inhalation of smaller suspensions of droplets or particles (often referred to as aerosols)
Reports of SARS-CoV-2 outbreaks in certain community settings support that aerosol transmission occurs at least under some circumstances and that effective ventilation is important to mitigate spread. The extent and quality of ventilation may vary between and within healthcare settings, including outpatient and ambulatory care settings
Some procedures have been found to be associated with increased risk of aerosol generation and transmission of respiratory viruses (often referred to as aerosol-generating medical procedures, AGPs, or AGMPs). Aerosols are also generated during other activities such as coughing, sneezing, or shouting. The infectiousness of aerosols created during different procedures or activities remains unclear. The infectiousness of aerosols also depends on the infectious dose of the virus (currently unknown for SARS-CoV-2) and likely varies during the course of illness. Contact tracing and viral studies suggest that immunocompetent individuals with COVID-19 are most infectious just before and within the first five days of symptom onset
SARS-CoV-2 may also spread when individuals touch surfaces or objects (also referred to as fomites) that have the virus on them, and then touch their mouth, nose or eyes before cleaning their hands

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.

Medical masks are recommended for all outpatient and ambulatory care setting staff and visitors at all times
- These masks can be removed for breaks or meals, during which a minimum physical distance of 2 metres from others should be maintained, along with minimal numbers of unmasked individuals in any given space. Breaks or meals should occur in larger spaces and at staggered times
Eye protection (e.g., full face shields), in addition to medical masks, is recommended for all staff when they are working in patient care areas based on local epidemiology
Medical masks are recommended to be worn by all patients (where tolerated) except when they need to be removed for provision of care (e.g., during physical examination or diagnostic testing)
- Masks should not be used for patients who have difficulty breathing or who are unable to remove the mask on their own (e.g., due to decreased level of consciousness, physical ability, young age, mental illness, or cognitive impairment)
- Where patient masks cannot be worn, every effort should be made to maximize the distance (with a minimum of 2 metres) between patients and others in the facility
- Staff should be educated that patient masking is just one layer of protection aimed at reducing overall transmission of COVID-19 within outpatient and ambulatory care settings, and that an individual patient's inability to mask should in no way affect the care they are provided
All staff, visitors, and patients who are asked to wear a mask should be informed about the importance of performing hand hygiene prior to putting on, and after removing or touching their mask, to reduce the risk of self-contamination, and of clean handling and storage of masks. Communication should be accessible and multilingual as required
- They should also be informed about the steps for proper hand hygiene, and be provided with access to a dedicated hand hygiene sink with soap or alcohol-based hand rub (ABHR), and a no-touch waste receptacle for proper disposal of the mask. It should be emphasized that wearing a mask does not lessen the need to adhere to other measures to reduce transmission, such as physical distancing
A minimum of Droplet and Contact Precautions (which includes wearing gloves, a gown, a medical mask and eye protection) should be implemented during encounters with patients who are considered exposed to or suspected or confirmed to have COVID-19; substitution of an N95 or equivalent respirator in place of a medical mask may occur based on a staff point-of-care risk assessment (PCRA)
Heating, ventilation and air conditioning systems should be properly installed and regularly inspected and maintained

May 21, 2021 Updates

PHAC is updating its interim guidance on infection prevention and control in outpatient and ambulatory care settings to consider the rollout of COVID-19 vaccines and emerging data on SARS-CoV-2 variants of concern.

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:

SARS-CoV-2 variants of concern:

Viruses naturally mutate or change over time. Mutations do not always result in increased transmissibility or virulence, or lead to suboptimal immune or therapeutic responses compared to non-variant virus
Multiple SARS-CoV-2 variants that have emerged in recent months have shown increased transmissibility when compared with non-variant SARS-CoV-2. These have been labeled variants of concern (VOCs)
The mechanism for the increased transmissibility of some SARS-CoV-2 variants has not been fully determined, though it may be related to changes in receptor binding or viral load
Some VOCs have demonstrated ability or potential to escape immune responses from previous SARS-CoV-2 infection or vaccines; the risk of reinfection or superinfection and influence on vaccine effectiveness for all known and future variants is uncertain

Vaccination:

Multiple vaccines have shown clinical trial efficacy and real-world effectiveness against COVID-19 disease and serious outcomes, and there is growing data on the real-world effectiveness of some vaccines against infection with SARS-CoV-2
There is still some uncertainty regarding the risk of transmission of COVID-19 from infected previously vaccinated individuals, durability of vaccine protection in different populations, as well as vaccine effectiveness against VOCs. However, vaccines do reduce transmission from vaccinated persons to others, although the extent of the reduction is still undetermined

In this context, the following updated recommendations have been made in this guidance. Outpatient and ambulatory care settings are also encouraged to refer to their provincial, territorial and local policies and regulations.

SARS-CoV-2 variants of concern:

Continue to adhere to, reinforce and monitor the full range of existing infection prevention and control measures and guidance
Active screening, universal masking and eye protection, physical distancing, engineering and administrative controls, Routine Practices, and if necessary Additional Precautions should be adhered to in order to prevent nosocomial transmission of SARS-CoV-2, including more transmissible variants
Patient placement:

Continued recommendation for placement in single rooms for patients who are suspected or confirmed to have COVID-19, or those who have had exposure to others with active COVID-19 infection

References to extended use of PPE have been removed from the guidance, except for extended use in the context of masks worn as source control, and eye protection worn for the duration of shifts (i.e., not when used for encounters with patients on Additional Precautions). If extended use of any disposable single-use PPE is deemed necessary under other circumstances, this should be in accordance with IPC expert consultation or guidance. As noted in previous guidance, a foundational concept in IPC practice is that disposable medical masks should not be re-worn.

Vaccination:

COVID-19 vaccines are strongly recommended for healthcare workers who do not have a contraindication
There are currently no recommended changes to IPC practices regardless of vaccination status
PHAC will continue to monitor data on vaccine effectiveness including against circulating VOCs

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:

They maintain ongoing awareness of the local and regional spread of COVID-19
Organizational risk assessments are completed to determine potential risks of COVID-19 contamination and transmission amongst staff, patients and visitors
A PCRA is conducted by all staff prior to any interaction with a patient or visitor
Routine Practices, including hand hygiene, are in place for the care of all patients
Adjustments to the physical layout are made to facilitate IPC measures to prevent transmission of COVID-19 (e.g. spacing chairs a minimum of 2 metres apart in waiting rooms and staff or break rooms, placing highly visible and accessible spacing indicators on the floors as reminders to maintain physical distancing, especially where queues may occur and with consideration for flow of traffic within the facility)
Wherever possible, furnishings and surfaces are smooth and non-porous to facilitate cleaning and disinfection
All non-essential items are removed from exposed environmental surfaces (e.g., magazines, toys)
Adequate space is available for donning and doffing of PPE
Heating, ventilation and air conditioning systems are properly installed and regularly inspected and maintained
All staff work proactively to identify cases of COVID-19 in staff, patients, and visitors, implement appropriate precautions, and advise testing where indicated and as guided by local, provincial or territorial public health guidelines
Patients and essential companions are screened for signs and symptoms of, and known exposures to, COVID-19 prior to their scheduled appointment and again on arrival
Staff conducting screening are provided with appropriate guidance on how to screen patients and essential companions for signs and symptoms of, and known exposures to, COVID-19
There are a limited number of access points designated for active screening of all staff, patients and visitors
Measures are in place to limit traffic, and to ensure adherence to physical distancing, performance of hand hygiene, and wearing of medical masks by staff, visitors, and patients (where tolerated) on entry
Screeners are protected with transparent barriers that allow for communication between themselves and patients or others who present at screening
Where the above measures and transparent barriers are not in place, screeners are provided with appropriate PPE to be selected based on a PCRA (e.g., consistent with a minimum of Droplet and Contact Precautions)
Staff have contact information for local COVID-19 assessment centres
Staff are prepared to offer virtual visits to patients via telephone or web-based communications technology, where clinically appropriate and in-person assessment is not necessary
The exchange of paperwork or any items between reception staff and patients is minimized
In facilities that conduct COVID-19 assessments, all pertinent staff are trained on how to properly and safely obtain specimens for testing
Policies and procedures are in place to prevent the introduction of COVID-19 into outpatient and ambulatory care settings and to prevent and control the spread of infection if identified, and that they are informed by regional and/or provincial/territorial directives or recommendations. These include those pertaining to:
- Regular communication with staff and patients on COVID-19 updates and facility policies and procedures to prevent and manage COVID-19
- N95 or equivalent respirator fit-testing
- A hand hygiene program
- Environmental cleaning and disinfection
- Adherence to Routine Practices
- Application of Additional Precautions based on a PCRA
- Staff having sufficient training, time, guidance (e.g., donning and doffing procedures) and support to properly put on PPE before, and remove PPE after, encounters with patients, with consideration of modifying/adapting training in cases where staff do not speak English or French as a first language
- Ensuring capacity to acquire necessary staffing or other means of referral in the event of shortages due to illness or work exclusion resulting from staff exposures
- Patient (and essential companion) pre-visit screening for exposures to, and signs and symptoms of, COVID-19
- Limiting access points, with entrance screening conducted at all
- Management of patient and staff exposures to, and those with suspected or confirmed, COVID-19
- Work exclusions for staff with exposure to or signs or symptoms of COVID-19
- Non-punitive sick leave
Staff, patients and visitors are provided with printed, posted or other forms of accessible information in multiple languages as required about COVID-19, how the virus causes infection, and how to protect themselves and others, including:
- The importance of hand hygiene and when and how to wash hands with soap and water and use ABHR
- The importance of physical distancing (maintaining a minimum of 2 metres separation) at entrances and while in the facility whenever feasible and when closer contact is not required for provision of care (including in non-patient care areas such as where breaks or meals occur)
- The importance of all staff and visitors wearing a medical mask on entry into and while in the facility
- The recommendation for patients to wear a medical mask, if tolerated
  - Masks should not be used for patients who have difficulty breathing or who are unable to remove the mask on their own (e.g., due to decreased level of consciousness, physical ability, young age, mental illness, or cognitive impairment)
- The importance of performing hand hygiene prior to putting on and after removing or touching their mask, to reduce the risk of self-contamination, and clean handling and storage of masks
  - They should also be informed about the steps for proper hand hygiene, and that wearing a mask does not lessen the need to adhere to other measures to reduce transmission, such as physical distancing
- 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 appropriate methods for putting on and removing required PPE, placed inside and outside of exam rooms of patients on Additional (e.g. Droplet and Contact) Precautions for easy visual cues
- Instructions on how and where to dispose of used supplies
Stocks of necessary PPE (e.g., gloves, gowns, medical masks, eye protection, N95 or equivalent respirators) and other supplies including disinfectant wipes and nasopharyngeal swab kits are regularly assessed and maintained (with local, regional, or provincial/territorial support as needed)
PPE, surface cleaners and disinfectants (e.g., disinfectant wipes) are available and accessible at all points of care
There are sufficient and appropriately placed ABHR dispensers, in hallways at the entrance to each patient exam room, in communal areas and at all points of care
There are sufficient and appropriately placed no-touch waste receptacles for disposal of paper towels, tissues, and PPE
Respiratory hygiene products (e.g., medical masks, tissues, ABHR, no-touch waste receptacles) are available and easily accessible to staff, patients, and visitors
Safe arrangements for staff to take breaks or consume meals are in place (e.g., in larger spaces and at staggered times, to limit unmasked individuals in any given space)
Physical distancing measures (maintaining a minimum of 2 metres spatial separation) are applied by patients, essential companions, and visitors, and additional space is reserved for those who require more room to maintain physical distancing measures (e.g., for people using wheelchairs or walkers, for caregivers with young children in strollers or infant car seats) whenever feasible, and while providing safe care
Patients considered exposed to, or suspected or confirmed to have, COVID-19 are immediately placed on a minimum of Droplet and Contact Precautions until COVID-19 or other respiratory infection is ruled out and until criteria for discontinuation of Additional Precautions are met, according to local, provincial and territorial public health and IPC guidance
All staff who enter the room, or come within 2 metres, of a patient who is considered exposed to, or suspected or confirmed to have, COVID-19 wear gloves, a gown, a medical mask or N95 or equivalent respirator, and eye protection, in addition to following Routine Practices
Signage (accessible and multilingual as required) that indicates a minimum of Droplet and Contact Precautions is placed outside of exam rooms where patients who are considered exposed to, or suspected or confirmed to have, COVID-19 are located
Staff wear a fit-tested N95 or equivalent respirator, along with gloves, gown, and eye protection for AGMPs on patients who are considered potentially infectious with SARS-CoV-2
All AGMPs are performed in an airborne isolation room (AIIR) or private room with the door closed
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, do not return to the outpatient and ambulatory care setting until cleared to do so according to local and jurisdictional public health guidance and facility IPC policies
Waste, soiled linen and the care environment are managed and adequately cleaned and disinfected according to Routine Practices and facility policies and procedures
Environmental cleaning and disinfection practices are followed

All staff should ensure that:

They adhere to facility IPC policies and procedures and public health guidance to prevent COVID-19 transmission
They support patients and visitors with IPC practices, including hand hygiene, as required
They self-monitor for new signs or symptoms of COVID-19 and immediately report any to facility management, and refrain from working with signs or symptoms of COVID-19
Prior to working any shift, they report (remotely - e.g., via phone, email or text) any recent possible exposures to COVID-19 to their facility's OHS representative or facility management (in accordance with facility IPC policies and procedures) to determine any necessary work restrictions or exclusions, or need for testing, in accordance with local public health guidance
They follow Routine Practices, including performing hand hygiene and a PCRA prior to any interaction with a patient or visitor
They are knowledgeable about the indications for use and limitations of the available PPE
They know where they and their close contacts can get tested for COVID-19 should they become symptomatic or be requested by local public health authorities or the outpatient or ambulatory care setting to do so
Their uniforms are promptly removed and laundered after their work shift

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:

Staff should be taught to perform a PCRA prior to every interaction with a patient and/or the patient's environment, and to ensure that appropriate control measures (i.e., Routine Practices and, if necessary, Additional Precautions) are taken to prevent transmission of microorganisms
Staff should receive ongoing education, training and practice in, and be monitored for compliance with, IPC practices, including proper hand hygiene and selecting, putting on, wearing and removing PPE to minimize contamination of themselves and the immediate environment
IPC education, training and compliance monitoring of staff should be tracked, recorded, and kept up-to-date
Staff should be fit-tested for an N95 or equivalent respirator, and monitored for proper wearing, seal checking and removal of their assigned size and type of respirator
Facilities should have specific policies and procedures for cleaning and disinfection of any reusable PPE
Facility plans for managing occupational exposures (i.e., unprotected contact without wearing the PPE indicated by the PCRA or while wearing PPE improperly) should be in place

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:

Signage (accessible and multilingual as required) is posted at all points of access to instruct staff, patients and visitors to:
- Not enter if they have any signs or symptoms of COVID-19, or recent unprotected exposure to someone suspected or confirmed to have COVID-19 (unless a patient has been instructed by the facility to do so and self-identifies at presentation, or the healthcare setting is a dedicated COVID-19 assessment centre)
- Not enter if they have been instructed to self-isolate or self-quarantine, until they have been cleared by public health authorities
- Practice hand hygiene and put on a medical mask on entry (where tolerated for patients)
- Practice respiratory hygiene (i.e., covering their cough with a tissue or coughing into their elbow followed by performing hand hygiene)
All staff, patients and visitors are actively screened for signs and symptoms of and recent exposure to COVID-19 prior to entry
Measures are in place to limit traffic and to ensure adherence to physical distancing, performance of hand hygiene, and wearing of medical masks by staff, patients (where tolerated) and visitors on entry
Screeners are protected by transparent barriers that allow for communication between themselves and individuals who present at screening
Where the above measures and transparent barriers are not in place, screeners are provided with PPE to be selected based on a PCRA (e.g., consistent with a minimum of Droplet and Contact Precautions)
All staff, patients and visitors perform hand hygiene and put on a medical mask (where tolerated by patients) on entry to reduce the risk of transmitting COVID-19, which may occur even when signs and symptoms of illness are not recognized
- All staff, patients and visitors who are asked to wear a mask should be informed about the importance of performing hand hygiene prior to putting on, removing, or touching their mask, to reduce the risk of self-contamination, and on clean handling and storage of masks. Communication should be accessible and multilingual as required
  - They should also be informed about the steps for proper hand hygiene, and provided with access to a hand hygiene sink with soap or ABHR and a no-touch waste receptacle for proper mask disposal. It should be emphasized that wearing a mask does not lessen the need to adhere to other measures to reduce transmission, such as physical distancing
ABHR and medical masks are available for staff, patient, and visitor use at each access point, with care taken to ensure that masks are distributed in a hygienic manner
All staff and visitors are logged on entry, and their personal contact information recorded, so that local public health authorities can follow-up if required for contact tracing purposes
Unnecessary entry is avoided and, when unavoidable, essential items are delivered through a single access point and delivery personnel are screened as per other visitors
Essential deliveries that are unable to be left outside occur through a single access point
Access points allow for rapid placement of symptomatic patients under isolation with a minimum of Droplet and Contact Precautions

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:

new or worsening cough
shortness of breath or difficulty breathing
temperature equal to or over 38°C
feeling feverish
chills
fatigue or weakness
muscle or body aches
new loss of smell or taste
headache
gastrointestinal symptoms (abdominal pain, diarrhea, vomiting)
runny nose or congested nose
sore throat
conjunctivitis
feeling very unwell

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:

If at work, immediately perform hand hygiene, keep their medical mask (or respirator) on, avoid further patient contact, inform their supervisor or facility management and leave as soon as it is safe to do so
Be tested for COVID-19 and excluded from work

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:

Patients with signs or symptoms of COVID-19 are identified and:
- their appointments are deferred if possible (depending on indication and urgency)
- they are advised to self-isolate and counseled on signs and symptoms of more severe illness that should prompt them to seek emergent care
- for non-emergent cases, they are referred to local, provincial or territorial public health guidance, testing information and test center locations, and further instruction on self-isolation and care in the home
- are asked to call ahead of presentation so that staff can be prepared for their arrival, if advised to present to the outpatient and ambulatory care facility
- if possible, arrangements are made for healthcare staff to follow up with them, particularly if at higher risk of more severe disease or worse outcomes, to ensure they are managing well at home
Patients and essential companions are instructed to self-screen prior to upcoming appointments, and report to the facility if they have signs or symptoms of COVID-19, have had an exposure to someone suspected or confirmed to have COVID-19, or have been directed to self-isolate by public health authorities
- When a patient is unable to self-screen (e.g., due to decreased level of consciousness, physical ability, young age, mental illness, or cognitive impairment), essential companions or caregivers are instructed to screen the patient prior to upcoming appointments, and report to the facility if the patient has signs or symptoms of COVID-19, or if they have had exposure to someone suspected or confirmed to have COVID-19, or have been directed to self-isolate by public health authorities
Essential companions are instructed to not accompany patients to appointments if they have had recent exposure to or signs or symptoms of COVID-19, or have been directed to self-isolate by public health authorities
Medical appointments are triaged, so that visits for patients at risk for complications from delayed care are prioritized and emergency department visits and acute care hospitalization may be prevented
Medical appointments can be conducted virtually by telephone, video, or other means of telecommunication technology, based on feasibility (i.e., patients have access to and can adequately communicate via an appropriate device) and appropriateness (i.e., in-person assessment is unnecessary)
- Any services that are time-sensitive and immunizations should continue to be provided. Where safe and feasible, a system for prescription renewal without an in-person facility visit should be implemented

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.

Patients with signs or symptoms of, or potential exposures to, COVID-19 should be instructed to perform hand hygiene and put on a medical mask, and be immediately placed under a minimum of Droplet and Contact Precautions preferably in a single room with the door closed
- Posters illustrating the correct method for putting on and removing PPE should be displayed, for visual cues, inside and outside of each room of a patient considered exposed to, or suspected or confirmed to have, COVID-19
- PPE, a hand hygiene sink or ABHR and a no-touch waste receptacle should be located outside these patient exam rooms
Essential companions who have signs or symptoms of, or potential exposures to, COVID-19 (including via the patient they accompany) should be instructed to not enter the facility, and provided with information on assessment and testing
To reduce crowding, and when patients with symptoms or signs of COVID-19 will be seen, consideration should be given to asking patients to remain outside as appropriate (e.g., weather-permitting and/or if able to stay in their vehicles) until called in for their appointment

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.

If exhibiting signs or symptoms, or having recent known exposure to someone with COVID-19, or if they are on self-isolation or quarantine as per public health directives, they should be excluded from visiting and advised to follow up with local public health and their health care provider

External service providers should:

make adjustments to reduce contact where feasible, e.g., leaving deliveries at the door
enter the outpatient or ambulatory care setting only when necessary
if required to enter the facility, be instructed to wear a medical mask on entry and on how and when to perform hand hygiene (e.g., upon entering and exiting the building, and before and after touching any surfaces in the healthcare setting environment)
be taught how to put on and remove any additional PPE as needed

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:

conducting a PCRA
hand hygiene
adhering to respiratory hygiene (i.e., covering a cough with a tissue or coughing into elbow, followed by hand hygiene)

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:

based on staff professional judgment (i.e., knowledge, skills, reasoning and education) about the clinical situation or encounter, the environment, policies and procedures in place, and the use and availability of PPE
an activity implemented by staff to:
- Evaluate the likelihood of exposure to themselves and others to infectious agents (e.g. SARS-CoV-2)
  - For a specific interaction
  - For a specific task
  - With a specific patient
  - In a specific environment
  - Under available conditions
- Select the appropriate actions and/or PPE to minimize the risk of exposure for the specific patient and others in the environment

A PCRA includes determining if there may be:

Contamination of skin or clothing by microorganisms
Exposure to blood, body fluids, respiratory secretions or excretions
Exposure to contaminated equipment or surfaces
Exposure to AGMPs

Patient factors may include:

Signs, symptoms, or clinical syndromes that require the use of Additional Precautions
The patient's volume of respiratory secretions, and ability to control behaviours (e.g., shouting), secretions and cough
The patient's ability to comply with IPC practices (e.g., hand hygiene, medical mask use, respiratory hygiene or other IPC practices)
Requirement of extensive or prolonged hands-on care

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:

on entry to and exit from the facility
before and after contact with a patient, regardless of whether gloves are worn
before putting on and after removing gloves
before and after contact with a patient's environment (e.g., medical equipment, exam table) regardless of whether gloves are worn
whenever hands are potentially contaminated (e.g., after any contact with blood, body fluids, or wound dressings)
before preparing or administering medications
before performing aseptic procedures
before putting on PPE and during and after removal of PPE, according to the facility's procedures for putting on and removing PPE
after performing personal hygiene (e.g., blowing one's nose, using the toilet, etc.)

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:

upon entering or leaving the facility
prior to eating, performing oral care or handling oral medications
after using toileting facilities or blowing one's nose
whenever hands are potentially contaminated (e.g., after contact with body fluids or wound dressings)

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:

be trained and tested on and monitored for compliance with facility procedures for selecting, putting on and removing PPE, and for cleaning and disinfection of any reusable PPE
participate in N95 or equivalent respirator fit-testing
perform a PCRA prior to entering and ongoing while in a patient's room
select and put on PPE as per the PCRA and prior to entering the room of a patient on Additional Precautions
ensure that their PPE fits properly, is worn appropriately, and provides adequate coverage
consistently follow the correct standardized methods for putting on and removing PPE as displayed by posters inside and outside each room of a patient who is considered exposed to, or suspected or confirmed to have COVID-19, so that self-contamination or contamination of the immediate environment is prevented
perform hand hygiene before putting on, and during and after removal of, PPE

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:

perform hand hygiene before putting on a mask on entry into the facility (and before putting on eye protection on entry into any patient care area), before and after removing a mask or eye protection, and before putting on a new mask or eye protection
wear the mask securely over their mouth and nose and adjust the nose piece to fit snugly
not touch the front of mask or eye protection during wear (and immediately perform hand hygiene if this occurs)
not dangle the mask under their chin, around their neck, off their ear(s), under their nose or place it on top of their head
remove eye protection when outside of patient care areas (to be disposed of or to undergo safe reprocessing according to facility IPC policies and procedures)
just prior to breaks or when leaving the facility, remove masks in an area where no patients, staff or visitors are present, and discard them in the nearest no-touch waste receptacle

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 worn as source control, and eye protection worn for the full duration of shifts (i.e., not when used for encounters with patients on Additional Precautions), may be worn for extended periods. Any extended use policies should be developed with IPC expert consultation or guidance. Masks or N95 or equivalent respirators and eye protection 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 and eye protection 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.

Gloves, a long-sleeved cuffed gown (covering the front of the body from neck to mid-thigh), medical mask (which should already be worn due to masking for full duration of shifts or visits policies) and eye protection should be worn on entering the patient exam room and when within 2 metres of a patient on Droplet and Contact Precautions
- Examples of eye protection include a full face shield that covers the front and sides of the face or well-fitting goggles; regular eyeglasses or safety glasses with gaps between glasses and the face are not sufficient to protect from all splashes and droplet spray and thus are not considered adequate protection
  - Potential benefits of wearing a full face shield include coverage of the whole face and prevention of direct contact with the face near mucous membranes
An N95 or equivalent respirator should be worn in place of a mask when an AGMP is being performed on a patient who is considered potentially infectious with COVID-19
- Use of an N95 or equivalent respirator may be considered in other circumstances under which the risk of exposure to aerosolized virus may occur
After seeing a patient on Droplet and Contact Precautions:
- gloves should be discarded into the nearest no-touch waste receptacle (they should not be re-worn)
- disposable gowns should be discarded into the nearest no-touch waste receptacle, and reusable gowns processed as per facility protocols
- eye protection should be removed (to be disposed of or to undergo safe reprocessing according to facility IPC policies and procedures) and replaced
- medical masks and N95 or equivalent respirators should be removed and replaced
Medical masks or N95 or equivalent respirators and eye protection should always be removed if there is concern about possible contamination via splash or spray, if they have come into direct contact with a patient, or if they have been damaged. Local and facility IPC policies regarding other indications for changing extended-use medical masks, N95 or equivalent respirators, and eye protection should be followed
Hand hygiene must be performed during and after PPE removal and between patient encounters
The area where PPE is put on should be separated as much as possible from the area where it is removed and discarded

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. If a patient requires an AGMP, the patient should at minimum 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:

AGMPs should be limited to those that are medically necessary and anticipated and planned for whenever possible
Strategies should be implemented to reduce aerosol generation
The number of individuals in the room should be limited to the minimum required to safely perform the procedure
The most experienced person available should perform the procedure

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