Infection prevention and control for COVID-19: Interim guidance for acute healthcare settings
This document was created on January 8, 2021. Please refer back for future updates.
Table of contents
- Changes in the current update
- Background
- Infection prevention and control practices at a glance
- Active screening and notification
- Organizational readiness
- Organizational controls
- Healthcare worker safety and training
- Patient care and infection prevention and control measures
- Inpatient management
- Handling laboratory specimens
- Handling patient care equipment
- Environmental cleaning and disinfection
- Management of healthcare worker exposures
- Visitor management
- Monitoring and evaluation
- Bibliography
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 acute healthcare 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.
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 workers (HCWs) 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:
- 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 an infected person; 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
- 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
- There is no evidence at this time of transmission of COVID-19 from room to room via air ducts
- 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. Acute healthcare facilities 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 HCWs, non-clinical staff, and visitors to acute healthcare facilities 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. Administrative controls such as arranging for breaks or meals to occur preferentially in larger spaces and at staggered times should be strongly considered
- Eye protection (e.g., full face shields), in addition to medical masks, is recommended for all HCWs when they have contact with patients, based on local epidemiology
- A policy of medical masks to be worn by all patients when they are within the facility but outside of their room or bedspace, or when they are within 2 metres of other individuals (e.g., when staff enter their single-bed room and in multi-bed rooms), while awake and where tolerated should be strongly considered
- 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 to ensure that barriers (e.g., plastic barriers or at least privacy curtains) are in place
- Staff should be educated that patient masking is just one layer of protection aimed at reducing overall transmission of COVID-19 within acute healthcare facilities, and that an individual patient’s inability to mask should in no way affect the care that they provide
- 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 on clean handling and storage of any masks that are expected to be re-worn
- 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 when caring for 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 HCW’s point-of-care risk assessment (PCRA)
- Heating, ventilation and air conditioning systems should be properly installed and regularly inspected and maintained
Individuals responsible for policy development, implementation and oversight of IPC measures in acute healthcare 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 and training for COVID-19 should be developed in conjunction with joint occupational health and safety committees (JOHSC).
This document builds on the foundational IPC guidance for acute healthcare settings and provides guidance specific to COVID-19 in acute healthcare settings. IPC guidance documents for other healthcare settings can be found at Coronavirus disease (COVID-19): Guidance documents.
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 updated interim IPC guidance to healthcare organizations and HCWs to prevent the transmission of COVID-19 in acute healthcare settings.
This interim guidance is based upon Canadian guidance developed for previous coronavirus outbreaks, 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.
Infection prevention and control practices at a glance
Employers must ensure that:
- Organizational risk assessments are completed to determine potential risks for contamination and transmission of COVID-19 to HCWs, other staff, patients and visitors in the acute healthcare setting
- A PCRA is conducted by all HCWs prior to any interaction with a patient or visitor
- Routine Practices, including hand hygiene, are in place for the care of all patients
- Adequate triage and facility access points are in place
- Active screening activities are in place ensuring:
- A limited number of access points designated for active screening of all HCWs and others working in the facility
- A limited number of entry points for active screening of patients and visitors
- Controls are in place to limit traffic, and to ensure physical distancing and that medical masks are worn by staff, visitors, and patients (where tolerated) on entry to acute care facilities
- Screeners are protected with transparent barriers that allow for communication between themselves and patients or others who present at screening
- Where the above controls 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)
- All staff and visitors put on a medical mask at entry and while in the healthcare facility to reduce the risk of transmitting COVID-19 infection to other staff, visitors or patients, which may occur even when signs or symptoms of illness are not apparent
- A policy of medical masks to be worn by all patients when they are within the facility but outside of their room or bedspace, or when they are within 2 metres of other individuals (e.g., when staff enter their single-bed room and in multi-bed rooms), while awake and where tolerated should be strongly considered
- 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)
- A policy of medical masks to be worn by all patients when they are within the facility but outside of their room or bedspace, or when they are within 2 metres of other individuals (e.g., when staff enter their single-bed room and in multi-bed rooms), while awake and where tolerated should be strongly considered
- Information is provided to staff, visitors, and patients who are asked to wear a mask about the importance of performing hand hygiene prior to putting on, and after removing or touching their mask, to reduce risk of self-contamination
- 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 COVID-19 transmission, such as physical distancing
- HCW IPC education and training, testing and monitoring for compliance are in place, tracked, recorded, and kept up-to-date
- All patients who are 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 infectious respiratory illness is ruled out, and until criteria for discontinuation of Additional Precautions have been met
- All HCWs who enter the patient room or bedspace, or come within 2 metres of a patient who is 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
- An N95 or equivalent respirator, along with gloves, a gown and eye protection are worn for AGMPs on patients who are considered potentially infectious with SARS-CoV-2
- All AGMPs should be performed in an airborne infection isolation room (AIIR), in a private room with the door closed, or on a designated COVID-19 ward where all HCWs are wearing an N95 or equivalent respirator
- Processes are in place to manage HCW exposures to COVID-19 and HCW illness
- All HCWs and other staff (e.g., contractors) who have signs or symptoms of COVID-19, or recent unprotected contact (as defined by facility, local, and jurisdictional public health or IPC guidance) with a person who is suspected or confirmed to have COVID-19, or who have been directed to self-isolate according to local public health directives, do not enter or return to the acute healthcare setting until they have been 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 facility policies and procedures
- Visitors are appropriately limited, controlled and managed
- Processes for monitoring and evaluating IPC processes and outcomes are in place
All HCWs should ensure that:
- They do not work with signs or symptoms of COVID-19
- They adhere to facility policies and public health guidance to prevent COVID-19 transmission
- They perform a PCRA prior to any interaction with a patient or visitor
- They know and follow facility policies
Active screening and notification
Prompt identification of all individuals (including inpatients) with signs or symptoms of infection should occur via active screening.
- 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
All confirmed cases of COVID-19 are to be reported to the relevant jurisdictional public health authorities.
Organizational readiness
Acute healthcare settings can minimize the risk of exposure to, and transmission of, COVID-19 within their facilities by conducting an organizational risk assessment for COVID-19 and by utilizing engineering controls and administrative controls.
Each acute healthcare facility should be prepared to identify and manage patients who are suspected or confirmed to have COVID-19.
Regardless of the number of COVID-19 cases occurring in a local community or region, acute healthcare facilities should conduct an organizational risk assessment of readiness for the management of cases of COVID-19 based on:
- Local or regional epidemiology of COVID-19 on an ongoing basis
- Facility readiness (e.g., availability and supply of PPE, hand hygiene supplies, private rooms, ICU beds, ventilators, ability to provide special separation in triage and at other patient access points including diagnostic imaging centres, outpatient laboratories and anywhere patients directly access health care)
- Ability to quickly identify suspected COVID-19 cases through active surveillance
- Ability to quickly and proactively identify, access and utilize alternate patient assessment and patient care sites when current facilities become overwhelmed
- Facility monitoring of the existing supply of PPE
- Coordinated procurement of supplies with provincial or territorial buying groups to maximize access
- Anticipation of an increased requirement for infection control professionals (ICPs) and OHS staff
- Status of HCW training on Routine Practices (including hand hygiene), selection and implementation of Additional Precautions, fit-testing and seal checking of an N95 or equivalent respirator
- Training for healthcare staff to screen and rapidly identify individuals, including visitors, who have signs or symptoms of or exposures to COVID-19 at entry to the facility (i.e., active screening/surveillance)
- Availability of testing for COVID-19, capacity to respond to changing indications for testing
Organizational controls
It is essential that acute healthcare settings have the following engineering and administrative controls in place.
Engineering controls
Facility design should include:
- Adjustments to the physical layout to facilitate IPC measures that prevent transmission of COVID-19 (e.g., spacing of chairs 2 metres apart in waiting rooms, cafeterias, or break rooms, and placing highly visible and accessible spacing indicators on the floors where queues may occur)
- Properly installed and regularly inspected and maintained heating, ventilation and air conditioning systems
- Private rooms with dedicated toilets and designated patient sinks
- Adequate space for donning and doffing of PPE
- Appropriate numbers and placement of ABHR dispensers, including in hallways at the entrance of each patient room, nursing stations, other communal areas and at the point-of-care for each patient
- Designated handwashing sinks for HCWs
- A sufficient supply of and ready access to all PPE and surface disinfectant agents (e.g., disinfectant wipes) at point-of-care for all HCWs
- An adequate number of no-touch waste receptacles for disposal of paper towels, tissues, masks and PPE
- Transparent physical barriers that allow for communication among HCWs and other individuals at all triage and reception areas
Administrative controls
Policies and procedures for the prevention and control of transmission of COVID-19 within the acute healthcare setting should be implemented, including those regarding:
- Regular communication with staff and patients on COVID-19 updates and facility policies and procedures for managing COVID-19
- A Respiratory Protection Program (RPP) for all HCWs (e.g., 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
- Selection, use, and stewardship of PPE
- Active and passive surveillance for individuals with signs or symptoms of COVID-19
- Available and timely access to COVID-19 testing for staff and patients
- Safe arrangements for staff to take breaks or consume meals
- How exposed, suspected and confirmed cases of COVID-19 in staff and patients will be managed within the facility
- Work exclusions for HCWs with exposure to or signs or symptoms of COVID-19
- Ensuring non-punitive sick leave
- Ensuring capacity to acquire necessary staffing in the event of shortages due to illness or work exclusion resulting from staff exposures
- Safe transportation of patients within the facility to ensure the protection of all HCWs, other staff, patients, and visitors, and to prevent contamination of the environment
- HCW IPC education and training, testing and compliance monitoring
- Visitor restrictions and essential visitors
- Ensuring that HCWs have and take sufficient time to put on PPE required for Routine Practices and Additional Precautions before providing care to patients, and to remove PPE after providing care (including donning and doffing procedures and sequences)
- Plans for obtaining different types and sizes of PPE
- Proper cleaning and disinfection of reusable PPE, and disposal of single-use PPE in no-touch waste receptacles
- Prompt removal and laundering of HCW uniforms after their work shift and prior to wearing for another work shift
Staff, patients, and visitors should be provided with printed, posted, or other forms of accessible information about COVID-19, how SARS-CoV-2 causes infection, and how to protect themselves and others, including:
- The importance of hand hygiene and how to effectively wash hands 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 upon entry into and while in the facility
- Any policies on medical masks to be worn by patients, e.g., when they are within the facility but outside of their room or bedspace, or when they are within 2 metres of other individuals (e.g., when staff enter their single-bed room, in multi-bed rooms), while awake and where 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 any masks that are expected to be re-worn
- Also provided should be information 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
- Posters illustrating the appropriate methods for putting on and removing required PPE, placed inside and outside of the 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
Triage, patient and healthcare worker access points
Wherever possible, separate triage and/or waiting areas for patients who are suspected or confirmed to have COVID-19 should be created.
Acute healthcare settings should minimize access points and ensure that physical barriers (e.g., partitions or clear transparent barriers that help to prevent spread from person to person but also allow for easy communication) are in place at triage and reception desks, screening desks and patient reception areas or desks, and in emergency departments and any areas where patients present directly for treatment or care (e.g., diagnostic imaging centres, ambulatory care, outpatient laboratory testing and clinics).
The number of access points for HCWs should be minimized and separated from access points used for patients or visitors and other individuals. Active screening of all HCWs for illness should occur prior to entry into healthcare facilities. This may be facilitated through use of web-based tools or applications, with proof of completion provided at entry.
Access points for patients, visitors or other individuals and those used for HCWs should be determined according to the organizational risk assessment.
To prevent transmission of COVID-19 at entry points, triage, and waiting areas in acute healthcare settings:
- Signage (accessible and multilingual as required) should be posted at all points of public or patient access to instruct patients and visitors to alert staff upon arrival if they have any signs or symptoms of COVID-19
- Active screening of all patients and visitors and contractors or outside care providers should be conducted, with assessment for signs and symptoms of or known exposure to COVID-19, prior to entry
- Controls should be in place to limit traffic, and to ensure physical distancing, performance of hand hygiene, and that medical masks are worn by staff, visitors, and patients (where tolerated) on entry to acute care facilities
- Screeners should be protected with transparent barriers that prevent transmission to staff but also allow for communication between themselves and individuals who present at screening
- Where the above controls and transparent barriers are not in place, screeners should be provided with appropriate PPE to be selected based on a PCRA (e.g., consistent with a minimum of Droplet and Contact Precautions)
- All staff, patients and visitors should be given a medical mask to wear with instructions for it to be worn at all times (see ‘Masking and eye protection for the full duration of shifts or visits’ below)
- Patients should be requested to put on a medical mask at entry to the healthcare facility, 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)
- If not tolerated, patients should be placed in private rooms on a minimum of Droplet and Contact Precautions if they are considered exposed to, or have any signs or symptoms consistent with COVID-19, and remain spaced a minimum of 2 metres from others regardless of any known exposures, signs or symptoms
- Triage should allow for rapid identification of individuals potentially symptomatic with COVID-19, who should be immediately escorted to a private room or designated waiting area where a space of at least 2 metres between patients can be ensured
- All staff, visitors, and patients who are asked to wear a mask should be provided with information on 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 any masks that are expected to be re-worn
- 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 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
- Signage should direct visitors not to visit if they are experiencing signs or symptoms of COVID-19 or any other infection or if they have been instructed and/or required to self-isolate
- Signage (accessible and multilingual as required) should encourage all individuals to practise respiratory hygiene (i.e., cover their cough with a tissue or cough into their elbow, followed by hand hygiene)
- ABHR, medical masks and tissues for patients or other individuals entering the facility should be available and distributed in a hygienic manner
Healthcare worker safety and training
Healthcare facilities should evaluate the potential risks posed to HCWs, and ensure that controls are in place to mitigate and manage these risks.
- JOHSCs should work with IPC professionals to identify and mitigate the risks of HCW exposure to COVID-19 by conducting an organizational risk assessment in conjunction with the healthcare facility
- Plans should be in place for managing occupational exposures (i.e., unprotected contact without wearing the PPE indicated by the PCRA or while wearing PPE improperly) while providing care to patients
- All HCWs should receive ongoing education, training, testing on, and monitoring of compliance with IPC practices
- The application of Routine Practices and Additional Precautions is based on a PCRA. Each HCW has a responsibility to perform a PCRA before 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
- HCWs 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 N95 or equivalent respirators, according to the facility's RPP
- Facilities should have specific policies and procedures for cleaning and disinfection of any reusable PPE
- Prior to working every shift, staff who have had a potential risk of exposure to COVID-19 should report (via phone) to their facility's OHS department to determine any necessary work restrictions or exclusions, as well as consult with their own healthcare provider for any necessary follow-up
- To limit the spread of COVID-19, OHS and IPC departments and JOHSCs should work together to develop policies for the safest possible work arrangements for HCWs who work in multiple healthcare settings, though efforts should be made to prevent this where it is not necessary
Patient care and infection prevention and control measures
Routine practices
Routine Practices apply to all staff and patients, at all times, in all acute healthcare 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 the elbow, followed by hand hygiene)
Point-of-care risk assessment
Prior to any patient interaction, all HCWs have a responsibility to assess the infectious risks posed to themselves, other HCWs, and other patients and visitors from a patient, situation or procedure.
- The PCRA is based on the HCW professional judgment (i.e., knowledge, skills, reasoning and education) about the clinical situation, up-to-date information on how the specific acute healthcare facility has designed and implemented engineering and administrative controls, and the use and availability of PPE
- PCRA is an activity implemented by HCWs 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, and
- Under available conditions.
- Select the appropriate actions and/or PPE to minimize the risk of exposure for the specific patient, other patients in the environment, other staff, and visitors
- Evaluate the likelihood of exposure to themselves and others to infectious agents (e.g., SARS-CoV-2)
A PCRA includes determining if there may be:
- Contamination of skin or clothing by microorganisms in the patient environment
- 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, mask use, respiratory hygiene, and 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 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 an AGMP or when frequent or unexpected exposure to AGMPs is anticipated (e.g., on dedicated COVID-19 units). 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
Acute healthcare settings should ensure that a current hand hygiene program is in place and is regularly reviewed, with improvements made as necessary.
Facilities should make every effort to achieve 100 percent hand hygiene adherence, with HCW performance of hand hygiene at least before and after contact with a patient or the patient care environment, before performing clean or sterile procedures, after risk of body fluid exposure, after removing gloves, and when hands are visibly soiled.
Hand hygiene is required before, during and after PPE removal, and between patient encounters.
Hands may be cleaned using ABHR containing 60 to 90 percent alcohol, or plain liquid soap and water when hands are visibly soiled.
Personal protective equipment
PPE should always be used in conjunction with engineering and administrative controls.
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 stored so it is readily accessible at the point-of-care for all HCWs and permitted visitors.
Training should be provided, with posters clearly outlining steps for putting on and removing PPE posted inside and outside each room of a patient who is suspected or confirmed to have COVID-19 for visual cues.
All HCWs using PPE should:
- Be trained on, tested, 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 the facility's RPP, including N95 or equivalent respirator fit-testing
- Ensure that their PPE fits properly, is worn appropriately, and provides adequate coverage
- Perform a PCRA prior to entering and ongoing while in a patient’s room
- Select and put on PPE prior to entering the room of a patient on Additional Precautions
- Consistently follow the correct standardized methods for putting on and removing PPE as displayed inside and outside each room of a patient who is suspected or confirmed to have COVID-19, so that self-contamination or contamination of the immediate environment is prevented, and perform hand hygiene
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 acute healthcare setting staff and visitors is recommended. The rationale for full-shift or visit masking of all staff and visitors is to reduce the risk of transmitting COVID-19 from staff or visitors to others, at a time when no 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 HCW shifts is also recommended in all acute healthcare settings, based on local epidemiology. This applies to all staff working within 2 metres of patients.
HCWs should refer to provincial and territorial guidance and facility policies on specific recommendations for use of medical masks, eye protection and other PPE, as well as PPE conservation strategies. When medical masks for HCWs and visitors (and eye protection for HCWs) are recommended for the full duration of shifts or visits, HCWs and visitors should:
- Perform hand hygiene before putting on a mask upon entering the acute healthcare facility (and before putting on eye protection upon entering any patient care area), before and after removing a mask or eye protection, and before re-wearing or 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 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 building, remove masks in an area where no patients, staff or visitors are present, and discard them in the nearest no-touch waste receptacle or store them in accordance with facility policy (see statement below on re-use of masks)
When an N95 or equivalent respirator is deemed necessary based on the HCW’s PCRA, they should follow facility procedures for taking off a medical mask and eye protection then put on the N95 or equivalent respirator and replace their eye protection, with meticulous hand hygiene performed at all steps.
A foundational concept in IPC practice is that disposable medical masks should not be re-worn. However, in the context of the COVID-19 pandemic and PPE shortages, jurisdictional guidance and facility IPC policies on staff mask use and reuse should be followed. Any such policies should be continually revisited and amended as supply changes, and revisions clearly communicated to all staff.
Masks or N95 or equivalent respirators should be replaced when they become damaged, wet, damp, or soiled (from the wearer’s breathing or external splash), or when they come in direct contact with a patient. Staff should be informed of how to access additional masks or N95 or equivalent respirators when needed. Local and facility IPC policies with regard to other indications to change extended use medical masks, N95 or equivalent respirators, and eye protection should be followed.
Additional precautions
A minimum of Droplet and Contact Precautions should be implemented for all patients who are considered exposed to, diagnosed with, or who are presenting with signs or symptoms of COVID-19.
- Gloves, a long-sleeved cuffed gown (covering the front of the body from neck to mid-thigh), a medical mask (which should already be worn due to masking for the full duration of shifts or visits policies) and eye protection should be worn upon entering the room of and when within 2 metres of a patient 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 or droplet spray and thus are not considered adequate protection
- Potential benefits of wearing a full face shield include coverage of the whole face, protection of an extended-wear medical mask or respirator from contamination, 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 SARS-CoV-2 or when frequent or unexpected exposure to AGMPs is anticipated (e.g., on dedicated COVID-19 units)
- Use of an N95 or equivalent respirator may be considered in other circumstances under which the risk of exposure to aerosolized virus may occur
- 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 or droplet spray and thus are not considered adequate protection
- 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
- Medical masks or N95 or equivalent respirators and eye protection should 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 with regard to other indications to change extended use medical masks, N95 or equivalent respirators, and eye protection should be followed
- Once donned, N95 or equivalent respirators may be worn for extended durations, but only after a review of manufacturer recommendations regarding duration of fit and function and local and facility IPC policies
- 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. Some examples of procedures that have been reported to pose increased risk of infectious aerosol generation and transmission of coronaviruses include:
- Intubation and related procedures (e.g., manual ventilation, open endotracheal suctioning)
- Bronchoscopy
- Sputum induction
- Non-invasive positive pressure ventilation (e.g., continuous positive airway pressure, bilevel positive airway pressure)
Guidance for other 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. As these rooms are very limited, and there has not been well-documented transmission by AGMPs when providers were in appropriate PPE, placement in AIIRs may not be required. If it is anticipated that a patient may require an AGMP, the patient should be placed in 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 HCWs 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
- Appropriate patient sedation should be used
- 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
- Closed endotracheal suction systems should be used
Inpatient management
Before each patient interaction, a PCRA should be performed to determine the appropriate practices and precautions for safe patient care.
- For any patient who develops signs and/or symptoms of COVID-19 while on an inpatient unit:
- A minimum of Droplet and Contact Precautions should be implemented
- If it is necessary to move a patient to a private room, a medical mask should be provided to the patient to wear during transport
- Any HCW(s) within 2 metres of the patient should wear gloves, a gown, a medical mask (or N95 or equivalent respirator based on the PCRA) and eye protection
- Patients may remove their mask when alone in a private room, but should continue to wear a mask while awake, as tolerated, if they are in a shared room or when others enter their room or bedspace
- Masks should not be used for patients who have difficulty breathing or who are unable to remove the mask on their own
- Visitors should be limited to only those who are essential. Visitors with signs or symptoms of COVID-19, or who have been advised to self-isolate should not enter the facility
- Accompanying individuals and visitors should be screened for signs and symptoms of COVID-19, and referred for medical assessment as appropriate. Personal contact information should be collected from all accompanying individuals or visitors so that local public health authorities can follow-up if required for contact tracing
Placement and accommodation
The following are important considerations for patient placement and accommodation:
- A patient who is suspected or confirmed to have COVID-19, or who is a high-risk contact of a person confirmed to have COVID-19, should be cared for in a single room, if available, with a toilet and sink designated for their use
- Cohorting patients confirmed to have COVID-19 in adequately ventilated specific units is encouraged. When the number of confirmed COVID-19 cases in the facility is high, consideration should be given to having teams of HCWs dedicated to caring for these patients; this may reduce the risk of transmitting infection in the acute healthcare setting, and allow highly trained HCWs to develop expertise in caring for these patients
- Roommates of symptomatic patients should not be moved to new shared rooms, but should instead be moved to a single room for isolation and symptom monitoring. If a single room is unavailable, in consultation with facility IPC and local public health guidance, a risk assessment may be performed with regard to the roommates’ degree of exposure to the symptomatic patient, and their ability to quarantine in place at a minimum of 2 metres from any other patient, with barriers in place and frequent monitoring
- Clear (multilingual as required) signage indicating a minimum of Droplet and Contact Precautions should be in place, and posted in such a way that it is clearly visible to all entering the patient room or bed space
- Posters illustrating the correct method for putting on and removing PPE should be displayed inside and outside of each room of a patient who is suspected or confirmed to have COVID-19 for easy visual cues
- HCWs should wear an N95 or equivalent respirator when working on dedicated COVID-19 units where frequent or unexpected exposure to AGMPs is anticipated
Patient flow and activity
Patients who are suspected or confirmed to have COVID-19 should be restricted to their room until they have met criteria for discontinuation of Additional Precautions in accordance with facility IPC protocols and provincial or territorial public health guidance. Patient movement or transport should also be restricted to essential diagnostic tests and therapeutic treatments. Transfer within and between facilities while patients are suspected to be infectious should be avoided unless medically necessary.
If patients must leave their room for medically necessary care or treatment, they should:
- Be accompanied by an HCW
- Wear a medical mask, as tolerated
- Be instructed to perform respiratory and hand hygiene (with assistance as necessary)
- Be provided with clean clothes and bedding before leaving their room
- Minimize touching or contact of surfaces or items outside of their room
Any surfaces that may have been touched by the patient while out of their room should be cleaned and disinfected.
A minimum of Droplet and Contact Precautions should be maintained by HCWs during patient transport, and communicated along with relevant clinical information to the transferring service and receiving unit ahead of transfer.
Discontinuing additional precautions
The duration and discontinuation of Additional Precautions for an individual patient or unit (where precautions may be universally applied during a COVID-19 outbreak) should be determined on a case-by-case basis, in consultation with the IPC program and in accordance with provincial or territorial public health guidance and organizational policies. The duration of Additional Precautions for a symptomatic patient with COVID-19 should be for a minimum of 10 days from onset of symptoms (and a minimum of 10 days from first positive testing for patients who remain asymptomatic), and may be longer dependent upon duration of symptoms, disease severity and the presence of any underlying immunocompromising conditions.
Handling bodies of deceased persons
Routine Practices should be used properly and consistently when handling the bodies of people who are deceased, including preparing bodies for autopsy or transfer to mortuary services. Federal guidance is available, and provincial and territorial communicable disease regulations should be followed.
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
All reusable equipment and supplies, along with toys, electronic games, personal belongings, etc., should be dedicated to the use of the patient who is suspected or confirmed to have COVID-19. If reuse with other patients is necessary, the equipment and supplies should first be cleaned, and disinfected with a hospital-grade disinfectant for the recommended contact time.
Upon patient transfer or discharge, items that cannot be appropriately cleaned and disinfected should be discarded. Patient-owned items should be taken home by the patient, and unwanted items discarded.
Single-use disposable equipment should be discarded into a no-touch waste receptacle after use.
Environmental cleaning and disinfection
Cleaning and disinfection of high-touch surfaces is important for controlling the spread of microorganisms. Environmental disinfectants should be classed 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.
All patient room surfaces that are considered "high touch" (e.g., telephone, bedside table, overbed table, chair arms, call bell cords or buttons, door handles, light switches, bedrails, handwashing sink, bathroom sink, toilet and toilet handles, shower handles, faucets, shower chairs, grab bars, outside of paper towel dispenser) should be cleaned and disinfected at least daily and when soiled. Hospital-grade disinfectant (e.g., disinfectant wipes) should be used with the recommended contact time to disinfect smaller patient care equipment (e.g., blood pressure cuffs, electronic thermometers, pulse oximeters, stethoscopes) after each use. Room cleaning and disinfection of low-touch surfaces (e.g., shelves, bedside 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.
All surfaces or items outside of the patient room that are touched by or in contact with HCWs (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.
In hospital rooms or common areas where there are more likely to be patients with unknown, suspected or confirmed COVID-19 infection status, multiple or high turnover over of patients (e.g., emergency departments, ambulatory clinics) or staff (e.g., cafeterias), and in cases of outbreaks, more frequent cleaning and disinfection is required.
Environmental Services staff should wear the same PPE as other HCWs when cleaning and disinfecting the patient room.
The acute healthcare facility's cleaning and disinfection protocols for cleaning and disinfection of the patient room after discharge, transfer, or discontinuation of Droplet and Contact Precautions should be followed. Toilet brushes, unused toilet paper and other disposable supplies should be discarded, and all bedside privacy curtains removed and laundered at the time of patient discharge or transfer.
Linen, dishes and cutlery
No special precautions are recommended; Routine Practices are used.
Waste management
No special precautions are recommended; Routine Practices are used.
Management of healthcare worker exposures
The organization's OHS professional(s), and ICPs should work collaboratively with public health authorities to manage exposed HCWs.
Visitor management
Visitation policies and restrictions may vary across jurisdictions and facilities depending on the degree of local transmission of COVID-19. These should be developed and implemented to balance the risk of infectious disease transmission and the promotion of patient and family-centered care.
- To minimize the risk of introducing COVID-19 into the acute healthcare setting, visitors for all patients should be limited to those who are essential (e.g., immediate family member or parent, guardian, or primary caregiver), and their movement within the facility restricted to visiting the patient directly and exiting the facility directly after their visit. They should be screened for signs and symptoms of COVID-19 at every visit, and excluded from visiting if any signs or symptoms are present
- Visitors should be instructed to wear a medical mask while in the facility (see above Masking and eye protection for the full duration of shifts or visits); on the importance of hand hygiene with ABHR; and on when (e.g., upon entering and exiting the building and the patient room, after touching the patient or any surface in the patient environment, before putting on and after removing their mask) and how to perform hand hygiene
- Before entering the room of a patient on Droplet and Contact or other Additional Precautions, visitors should speak with a HCW (e.g., patient’s nurse) for an assessment of the risk to the visitors’ health and their ability to adhere to Routine Practices and Additional Precautions. They should be advised on and supervised with appropriate PPE use for Droplet and Contact Precautions, including wearing a medical mask. If visitors are unable to adhere to the required Additional Precautions, they should be excluded from visiting
Monitoring and evaluation
Acute healthcare settings should ensure that processes are in place to monitor outcomes or occurrences related to managing patients with suspected or confirmed COVID-19. These may include:
- OHS monitoring and follow-up with HCWs for signs and symptoms of COVID-19
- Monitoring of hand hygiene practices and use of PPE for Routine Practices and Droplet and Contact Precautions
- Monitoring of IPC practices at triage and in all patient care areas
- Monitoring of adherence to IPC practices for AGMPs
- Evaluation of HCW education sessions for COVID-19
- Monitoring of environmental cleaning and disinfection practices
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