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

This document was posted on March 17, 2021. Please refer back for future updates.

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Changes in the current update

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

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

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

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

In this context, the following recommendations 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:

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:

Home care staff should ensure that:

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:

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:

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.

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:

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.

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:

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:

A PCRA includes determining if there may be:

Client factors may include:

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:

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:

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:

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:

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 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 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.

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:

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:

Client and household member education

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

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.

Bibliography

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