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

On this page

• Changes in recent updates
• Background
• Infection prevention and control preparedness
• Home safety risk assessment
• Home care staff safety and training
• Management of staff exposures
• Screening
  • Staff screening
  • Client (and household member) screening
• Client care and infection prevention and control measures
  • Routine Practices
  • Personal protective equipment
  • Masking and eye protection for the full duration of home visits
  • Additional Precautions
  • Aerosol-generating medical procedures
• Discontinuing additional precautions
• Handling of client care equipment and laundry
• Environmental cleaning and disinfection
• Client and household member education
• Handling laboratory specimens
• 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.

March 17, 2021

PHAC is updating its interim guidance on infection prevention and control in home 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.

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
• 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 have been made in this guidance. Home care organizations 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 home care staff in home care settings at all times
• Eye protection (e.g., full face shields), in addition to medical masks, is recommended for all home care staff when working with clients, based on local epidemiology
• A policy of medical masks to be worn by home care clients when home care staff are in their home, while awake and where tolerated should be strongly considered
  • Masks should not be used for clients 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)
  • Staff should be educated that client masking is just one layer of protection aimed at reducing overall transmission of COVID-19 in home care settings, and that an individual client’s inability to mask should in no way affect the care they are provided
• Wherever possible, only household members who are essential for communication with home care staff or to assist staff with care should be in the same room as home care staff during visits. If their presence is essential, household members should be asked to maintain a minimum 2 metre distance from home care staff and to wear a medical mask
• All home care staff, clients, or household members 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 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 have access to a hand hygiene sink with soap or alcohol-based hand rub (ABHR), and plastic-lined waste receptacles for proper disposal of the mask, including at the door exiting the home. 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 when caring for clients 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)
• Clients should optimize home ventilation where feasible, e.g., by opening a window prior to and during the home care visit if safe and weather permits, particularly if anyone in the home has had exposure to, or is suspected or confirmed to have COVID-19

May 21, 2021 update

PHAC is updating its interim guidance on infection prevention and control in home 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. Home care organizations 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 (when feasible), engineering controls, administrative controls, Routine Practices, and if necessary Additional Precautions should be adhered to in order to prevent transmission of SARS-CoV-2, including more transmissible variants

Vaccination:

• COVID-19 vaccines are strongly recommended for home care staff 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 in home care settings should be familiar with relevant background documents on Routine Practices and Additional Precautions and occupational health and safety (OHS) legislation. 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. Wherever possible, these should be developed in conjunction with joint occupational health and safety committees (JOHSC) or workplace health and safety representatives. All home care organizations should have ongoing access to local IPC expertise, with IPC-trained personnel assigned to manage COVID-19-related prevention and response activities within the homecare organization.

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 interim IPC guidance to home care organizations and staff to prevent the transmission of COVID-19 in home care settings. Home care organizations and staff provide comprehensive services to clients in their homes and other community settings and therefore play a key role in preventing unnecessary hospital and long-term care admissions. Home care is used to describe formal medical or personal care that is delivered in the home, though home care staff may in some circumstances provide care in community congregate settings and clinics. This care includes, but is not limited to, care delivered by nurses, physicians, physiotherapists, occupational therapists, respiratory therapists, and personal support workers. The PHAC has published additional interim guidance on infection prevention and control for COVID-19 in long-term care homes and ambulatory and outpatient care settings.

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 who provides formal medical or personal care in the home. The term "client" is intended to refer to people who are receiving home care services. The term “household member” is intended to refer to family members or others who live with the client, as well as anyone else who may be in the home care setting during a home care visit.

Infection prevention and control preparedness

Home care organizations and staff should be prepared to identify and manage clients who are considered exposed to, or suspected or confirmed to have COVID-19, and require home care services.

Home care organizations 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 for contamination and transmission of COVID-19 amongst home care staff and clients
• They have capacity to call and pre-screen clients and household members for signs and symptoms of or known exposures to COVID-19 prior to scheduled home care visits
• Staff conducting telephone screening are provided with appropriate guidance on how to screen for signs and symptoms of or exposures to COVID-19
• A home safety risk assessment is completed for each client to determine whether the client environment is suitable for home care services
• Policies and procedures are in place to prevent the introduction of COVID-19 into client homes, and to prevent and control the spread of infection between client homes, and that these are informed by regional and/or provincial/territorial directives or recommendations. These include those pertaining to:
  • Regular communication with staff, clients, and household members on COVID-19 updates and on the home care organizational policies and procedures to prevent and manage COVID-19
  • N95 or equivalent respirator fit-testing
  • A hand hygiene program
  • Adherence to Routine Practices
  • Application of Additional Precautions based on a PCRA
  • Ensuring that staff have sufficient training, time, guidance (e.g., donning and doffing procedures) and support to properly put on PPE before, and remove PPE after, providing home care to clients
  • Review of scheduling and restriction of staff work assignments to the same clients (i.e., limiting cross-coverage) wherever feasible and safe, to limit potential spread between home care settings (applicable regional, provincial and territorial guidance should be followed with regard to working in multiple healthcare settings)
  • Ensuring capacity to acquire necessary staffing in the event of shortages due to illness or work exclusion resulting from staff exposures
  • Active screening of staff for exposures and signs and symptoms of COVID-19
  • Client (and household member) screening for exposures to, and signs and symptoms of, COVID-19 prior to home care visits
  • Management of client and unprotected staff exposures to COVID-19, and clients and staff with suspected or confirmed COVID-19
  • Work exclusions for staff with exposure to or signs or symptoms of COVID-19
  • Available and timely access to testing for SARS-CoV-2 for clients and staff
  • Non-punitive sick leave for staff
  • Monitoring and evaluation of IPC practices and outcomes (e.g., screening practices, hand hygiene adherence, PPE use)
  • Workflow practices to mitigate the risk of IPC breaches (e.g., advance preparation of supplies needed for hygiene practices to prevent cross-contamination)
  • Limiting equipment brought into the home to that which is essential. Dedicating re-usable medical equipment to the client for the duration of care if possible, and if reusable medical equipment will be removed following a visit, minimizing contamination during the visit, and properly cleaning and disinfecting this before removing from the home
  • Environmental cleaning, disinfection and laundry practices to be used by home care staff when this is part of their plan of service, and provided as guidance to clients and household members
  • Proper storage of PPE (e.g., staff should bring adequate PPE with them to each visit, PPE should not be stored in a client's home, and a plastic-lined waste receptacle for PPE disposal should be placed at the point-of-care and at the door exiting the home)
• Staff and clients/households are provided with printed, digital 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) from other home care staff, clients and household members whenever feasible and when closer contact is not required for the provision of care
  • The importance of all staff, clients (where tolerated), and household members (when present) wearing a medical mask while staff are within the client home
    • Masks should not be used for clients or household members 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 risk of self-contamination, and clean handling and storage of masks
    • Information should also be provided on 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
  • Respiratory hygiene (i.e., covering their cough with a tissue or coughing into their elbow, followed by hand hygiene)
  • How and where to dispose of used supplies
  • How to properly put on and take off PPE to avoid self-contamination
• Clients, household members and staff (when this is part of their plan of service) are directed to resources on environmental cleaning and disinfection
• Staff have necessary PPE and cleaners and disinfectants (e.g., disinfectant wipes) available to them at the point-of-care for all home care visits
• Stocks of necessary PPE (e.g., gloves, gowns, medical masks, eye protection, N95 or equivalent respirators) and other supplies including ABHR and disinfectant wipes are regularly assessed and maintained (with local, regional, or provincial/territorial support as needed)
• Staff implement a minimum of Droplet and Contact Precautions when entering a home in which an individual is considered exposed to or suspected or confirmed to have COVID-19, until COVID-19 or other infectious respiratory illness is ruled out and until criteria for discontinuation of Additional Precautions have been met according to local, provincial and territorial public health and IPC guidance
• Staff wear a fit-tested N95 or equivalent respirator, along with gloves, gown, and eye protection when performing or in the presence of AGMPs (e.g., CPAP) on clients who are considered potentially infectious with SARS-CoV-2
• Staff who have signs or symptoms of COVID-19, who have had recent unprotected exposure (as defined by organizational, 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 enter the home care organization premises or a client’s home until cleared to do so according to local and jurisdictional public health guidance and the home care organization’s IPC policies

Home care staff should ensure that:

• They adhere to the home care organization’s IPC policies and procedures and public health guidance to prevent COVID-19 transmission
• They support clients with IPC practices, including hand hygiene, as required
• They self-monitor for new signs and symptoms of COVID-19, immediately report any to the home care organization management, and refrain from working with signs or symptoms of COVID-19
• Prior to each shift, they report (remotely, e.g., via phone, email or text) any recent possible exposure to COVID-19 to the home care organization management or OHS representative or management (in accordance with organizational 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 client or household member
• 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 home care organization to do so
• Their uniforms are promptly removed and laundered after their work shift

Home safety risk assessment

Trained home care staff should conduct a home safety risk assessment to verify that the environment is suitable for home care services. The assessment should verify that:

• The presence of household members and visitors within the home is communicated to the home care staff
  • Wherever possible, only household members who are essential for communication with home care staff or to assist with care will be in the same room as home care staff during visits. If their presence is essential, household members are asked to maintain a minimum 2 metres distance from home care staff and to wear a medical mask
• Screening of client and household members occurs at each visit
• The client and household members are capable of adhering to recommended practices such as hand hygiene, respiratory hygiene, environmental cleaning and disinfection, and movement limitations within the home
• Known COVID-19 risks and any need for Additional Precautions is communicated to all home care staff going into the home
• Any requirement to perform AGMPs or potential for exposure to AGMPs occurring within the client home during visits or just prior to visits is communicated to staff
• Safety concerns such as fire hazards and potential for accidental ABHR ingestion are addressed
• The client has a means to communicate with their primary healthcare provider or paramedic services should their condition worsen

Home care staff safety and training

Home care organizations should evaluate the potential risks posed to home care staff, and ensure that controls are in place to mitigate and manage them.

The home care organization 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 home care staff exposure to COVID-19. In addition:

• Home care staff should be taught to perform a PCRA prior to every interaction with a client and/or the client’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
• Home care 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 home care staff should be tracked, recorded, and kept up-to-date
• Home care staff should be fit-tested for an N95 or equivalent respirator, and carry a supply of respirators, and be monitored for proper wearing, seal-checking and removal of their assigned size and type
• Home care organizations should have specific policies and procedures for cleaning and disinfection of any reusable PPE
• Organizational 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

The home care organization management, OHS professional(s), and infection prevention and control practitioner(s) should work collaboratively with public health authorities to manage home care staff exposed to COVID-19.

Screening

Home care organizations should ensure that processes are in place to conduct active screening of staff and clients (and household members) for signs and symptoms of COVID-19.

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

Home care organizations should liaise with their local laboratories and jurisdictional public health authorities to determine the most rapid way to have COVID-19 testing of staff completed and reported, and for guidance on the indications and locations for COVID-19 testing of clients.

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

Staff screening

Active screening of staff for illness should occur prior to working each shift. This may be facilitated through use of web-based tools or mobile applications. Staff screening should also include ongoing self-assessment for exposures to and signs and symptoms of COVID-19. Staff who develop signs or symptoms of COVID-19 of any severity should:

• If at work, immediately perform hand hygiene, keep their mask (or respirator) on, avoid further client contact, inform their supervisor and leave the work site 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 organizational, 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 home care organization or a client’s home until cleared to do so according to local and jurisdictional public health guidance and the home care organization’s IPC policies.

Client (and household member) screening

Home care organizations should ensure that a consistent process is in place for screening all clients and their household members. This should include calling before every home care visit to ask whether the client or any household member has signs or symptoms of or has been confirmed to have COVID-19, or has had recent contact with a person suspected or confirmed to have COVID-19. If telephone screening is not possible, screening may be conducted upon arrival to the client’s home while maintaining a minimum distance of 2 metres from the client and household members.

• Clients or household members with signs or symptoms of COVID-19 should be advised to self-isolate, refer to local public health for guidance on testing, and contact their primary care provider as needed
• Those with more severe symptoms of COVID-19 should be referred to emergent care when indicated
• Clients and household members should be instructed to screen themselves on an ongoing basis, and report to the home care organization if they have signs or symptoms of COVID-19, have been tested for COVID-19, or if they have had an exposure to someone with COVID-19 and/or have been directed to self-isolate by public health authorities

Client care and infection prevention and control measures

Routine Practices

Routine Practices apply to all staff and clients, at all times, in home 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 (PCRA)

Prior to any client interaction, all home care staff have a responsibility to assess the infectious risks posed to themselves, the client, and any others in the home care setting from a client, 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
• is an activity implemented by home care 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 client
    • In a specific environment
    • Under available conditions
  • Select the appropriate actions and/or PPE to minimize the risk of exposure for the specific client and others in the environment

A PCRA includes determining if there may be:

• contamination of skin or clothing by microorganisms in the client environment
• exposure to blood, body fluids, respiratory secretions or excretions
• exposure to contaminated equipment or surfaces
• exposure to AGMPs

Client factors may include:

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

The selection and use of PPE during client interactions should always be determined by the PCRA and in accordance with public health direction when clients are on isolation or quarantine.

For interactions with clients 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

Home care organizations should have hand hygiene programs in place, with regular review and updating of staff education, training, and monitoring for adherence. Home care organizations should make every effort to achieve 100 percent hand hygiene adherence.

Staff should perform hand hygiene:

• on entry to and exit from the client's home
• before and after contact with a client, regardless of whether gloves are worn
• before putting on and after removing gloves
• before and after contact with the client's environment (e.g., medical equipment, bed, table, door handle) regardless of whether gloves are worn
• whenever hands are potentially contaminated (e.g., after any contact with blood, body fluids, bedpans, urinals, or wound dressings)
• before preparing or administering all medications or food
• before performing aseptic procedures
• before putting on PPE and during and after removal of PPE according to organizational 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 60-90% alcohol, or plain liquid soap and water. Soap and water is preferable for use immediately after using toileting facilities, if hands are visibly soiled, and when caring for clients with Clostridioides difficile infection.

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

• upon entering or leaving their home
• 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 wound dressings or bodily fluids, etc.)

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 to all staff conducting home care visits. PPE should be stored in clean conditions that are clearly separated from any soiled items.

Training should be provided, along with printed, digital or other forms of accessible materials that clearly outline the steps for putting on and removing PPE to be worn with a client who is considered exposed to, or suspected or confirmed to have COVID-19.

All home care staff using PPE should:

• be trained, tested, and monitored for compliance with organizational 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 client’s home
• select and put on PPE as per the PCRA and prior to entering the home of a client 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 when entering the home of a client 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 home visits

Given 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 visits for all home care staff is recommended. The rationale for full-visit masking of staff is to reduce the risk of transmitting COVID-19 infection from staff to clients or other household members, at a time when no signs or symptoms of illness are recognized, but the virus can be transmitted.

Use of eye protection (e.g., a face shield) for the full duration of visits is also recommended, based on local epidemiology.

Staff should refer to organizational 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 and eye protection are recommended for the full duration of visits, home care staff should:

• perform hand hygiene before putting on a mask and eye protection when they enter the home, 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 a 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 leaving the home, in an area where the client or household members are not present (to be disposed of or to undergo safe reprocessing according to the home care organization's IPC policies and procedures)
• remove masks when leaving the home, in an area where the client or household members are not present, and discard them in a plastic-lined waste receptacle followed by hand hygiene

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

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 client. Staff should be equipped with a daily supply of PPE and 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 clients who are considered exposed to, have been diagnosed with, or have signs or symptoms of COVID-19.

• Gloves, a long-sleeved cuffed gown (covering front of body from neck to mid-thigh), a medical mask and eye protection should be worn upon entering the client's home and when within 2 metres of the client on Droplet and Contact Precautions
  • Examples of eye protection (in addition to a medical mask) 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 client 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 client on Droplet and Contact Precautions:
  • gloves should be discarded into a plastic-lined waste receptacle after providing care and when exiting the client’s home (they should not be re-worn) *Clients should be asked to place plastic-lined waste receptacles at the point-of-care and at their home entrance
  • disposable gowns should be discarded into a plastic-lined waste receptacle, and reusable gowns processed as per the home care organization’s protocols
  • eye protection should be removed, to be disposed of or to undergo safe reprocessing according to organizational IPC policies and procedures
  • medical masks or N95 or equivalent respirators should be removed and discarded
  • 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 client, or if they have been damaged
• Hand hygiene must be performed during and after PPE removal and between client 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 transmission of SARS-CoV-2. It is likely that the degree of risk may also vary depending on the client, 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 home care settings (e.g., intubation, bronchoscopy, sputum induction), though potential examples in this setting include open endotracheal suctioning in clients who have a tracheostomy or use of non-invasive positive-pressure ventilation (e.g., continuous positive airway pressure or CPAP) machines.

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

AGMPs should only be performed on a client considered to be potentially infectious with SARS-CoV-2 when all home care 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 should be 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 should perform the procedure
• Entry into a room of a client undergoing CPAP should be minimized

Discontinuing additional precautions

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

Handling of client care equipment and laundry

Single-use disposable equipment and supplies should be used whenever possible, and discarded into a plastic-lined waste receptacle after each use. All reusable equipment and supplies, along with toys, electronics, games, etc. should be dedicated for use by one client whenever possible and stored at the client’s home.

Only essential equipment and devices should be brought into the home. A disposable barrier (i.e., plastic bag) should be used to avoid placing equipment and devices directly onto surfaces in the home. This equipment may be kept in a plastic bag and hung from a hook while not in use.

Reusable client care equipment (e.g., blood pressure monitor, stethoscope) and devices should be cleaned first and then disinfected after use with each client, with a hospital-grade disinfectant (e.g., disinfectant wipes) according to the manufacturer's recommended contact time and organizational protocols for cleaning and disinfection of reusable equipment.

Linen, towels, and clothing should be dedicated for use by the client. Care should be taken to avoid shaking dirty laundry. All laundry should be machine-washed with regular laundry detergent at 60 to 90°C and dried thoroughly.

Environmental cleaning and disinfection

The client, household members, and home care staff (when this is part of their assigned plan of service) should be informed about proper environmental cleaning and disinfection practices. Surfaces that are frequently touched (e.g., bedside tables, bedframes, door handles) should be cleaned and disinfected at least once daily and whenever soiled.

For high-touch surfaces, it is recommended to use regular household cleaner, followed by an approved hard-surface disinfectant that has a Drug Identification Number (DIN) for the recommended contact time. If these products are unavailable, household soap or detergent can be used first to clean, with a diluted bleach solution used afterward to disinfect, the environment:

• Clean surfaces initially and then disinfect with diluted bleach prepared according to the instructions on the label or in a ratio of 1 teaspoon (5 mL) per cup (250 mL) or 4 teaspoons (20 mL) per litre (1000 mL), assuming bleach is 5 % sodium hypochlorite, to give a 0.1 % sodium hypochlorite solution (Health Canada's Hard-surface disinfectants and hand sanitizers for COVID-19)

Client and household member education

Clients and household members should be directed to appropriate national, provincial, territorial, and/or local COVID-19 resources on:

• Hand hygiene (e.g., its importance, when and how to use soap and water and ABHR)
• Respiratory hygiene (i.e., covering their cough with a tissue or coughing into their elbow, followed by hand hygiene)
• How to isolate or quarantine when indicated
• How to safely care for someone in the home who is suspected or confirmed to have COVID-19
• The importance of not sharing personal hygiene items (e.g., soap, cream or lotion, toothpaste, toothbrush, razor (or electric shaver), towel, skin, nail and other oral care items)
• Safe handling and laundering of linens, towels and clothing
• How and where to dispose of used supplies, and on safe handling of contaminated waste, e.g., by placing in a lined container for disposal in accordance with local, and provincial or territorial regulations)

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 additional information on biosafety procedures when handling samples from clients under investigation for COVID-19, refer to the PHAC's biosafety advisory.

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