Infection prevention and control for COVID-19: Second interim guidance for acute healthcare settings

This document was created on April 30, 2020. Please refer back for future updates.

Table of Contents

This guidance updates and consolidates infection prevention and control guidance for managing COVID-19 in acute healthcare settings. Additional clarification is provided on certain issues (e.g., triage and facility entry points, aerosol-generating medical procedures (AGMPs), organizational readiness, and health care worker (HCW) safety and training).

Individuals responsible for policy development, implementation and oversight of infection prevention and control (IPC) measures at specific acute healthcare settings should be familiar with relevant background documents on routine practices and additional precautions and occupational health and safety 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 infection prevention and control guidance for acute healthcare settings and provides guidance specific to the COVID-19 pandemic in acute care settings. It does not address Canada's circumstances with respect to shortages of personal protective equipment (PPE) that are the subject of urgent and ongoing discussion at all levels across the country. It does not address the provision of healthcare in non-traditional settings.

Infection prevention and control (IPC) practices at a glance

Background

In December 2019, a cluster of cases of pneumonia of unknown origin was reported from Wuhan, Hubei Province in China. A pandemic was declared on March 11, 2020.

On January 10, 2020, a novel coronavirus, that causes a disease now referred to a COVID-19 was identified as the cause of this cluster of pneumonia cases.

The situation is evolving rapidly. Most countries, including Canada, are reporting community transmission of COVID-19. For current information acute care settings should refer to their provincial public health websites.

Over the last several weeks, our understanding of COVID-19 has rapidly expanded. Based on the international evidence to date, there is convincing evidence of person-to-person transmission. The primary routes of transmission for COVID-19 are by respiratory droplets and/or contact with contaminated surfaces or items. COVID-19 can also be spread through the airborne route during AGMP.

The protection of HCWs is a critical priority.

Introduction

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.

The purpose of this document, Infection Prevention and Control for COVID-19: Second Interim Guidance for Acute Healthcare Settings, is to provide interim IPC guidance to healthcare organizations and HCWs to prevent the transmission of COVID-19 in acute care settings.

This interim guidance is based upon Canadian guidance developed for previous coronavirus outbreaks, experience with COVID-19 in China and other countries, as well as interim guidance for COVID-19 published by the World Health Organization (WHO). It has been informed by technical advice provided by members of the PHAC 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 (IPC) strategies to prevent or limit transmission of COVID-19 in acute healthcare settings are similar to those used for the management of patients presenting with other acute respiratory infections and include:

This guidance has been developed for Canadian acute healthcare settings and HCWs and may differ from guidance developed by other countries. It should be read in conjunction with relevant provincial, territorial and local legislation, regulations, and policies.

Public health surveillance and notification

Provincial and territorial public health authorities must report confirmed cases of COVID-19 within 24 hours of notification in their own jurisdiction.

At this time, the primary objective for the COVID-19 outbreak is the early detection of cases and slowing the spread of COVID-19 in order to flatten the epidemiological curve.

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 (including use of adequate and proper PPE at the right time, and in the correct way, as outlined below).

Each acute healthcare facility should be prepared to identify and manage patients with potential and/or confirmed COVID-19.

In advance of COVID-19 cases occurring in a local community or region, acute healthcare settings should conduct an organizational risk assessment of readiness for the management of cases of COVID-19 based on:

Organizational controls

It is essential that, prior to managing cases of COVID-19, acute healthcare settings have the following engineering and administrative controls, including PPE, in place.

Engineering controls

Facility design should ideally include:

Administrative controls

Policies and procedures should be implemented for the prevention and control of transmission of COVID-19 including:

In addition to providing ABHR at point of care, acute healthcare settings should provide:

OHS, JOHSC and IPC departments should work together to develop policies to determine the safest possible work arrangements for HCWs who work in multiple agencies or facilities to limit the spread of COVID-19.

Triage, patient and HCW access points

Wherever possible, separate triage and/or waiting areas for COVID-19 patients should be created.

Acute healthcare settings should minimize access points and ensure that physical barriers (e.g., partitions or clear transparent barriers that prevent droplet spread from person to person and that allow for easy communication through the barrier) are in place at triage and reception desks, screening desks/tables and patient reception areas/desks, at emergency department and any areas where patients present directly for treatment or care (e.g., diagnostic imaging departments, ambulatory care, outpatient lab testing and clinics).

The number of access points for HCWs should be minimized and should be separate from access points used for patients or visitors or other persons. Consideration should be given to active screening of all HCWs for illness at HCW access points.

Determination of access points for patients, visitors or other persons and those used for HCW should be determined by the organizational risk assessment.

To ensure prompt identification and management of all patients presenting with signs and symptoms of an acute respiratory illness:

HCW safety and training

Patient care and IPC measures

Point-of-care risk assessment (PCRA)

Prior to any patient interaction, all HCWs have a responsibility to assess the infectious risks posed to themselves, other HCWs, other patients and visitors from a patient, situation or procedure.

A PCRA includes determining if there may be:

Patient factors include:

PPE should always be used as determined by PCRA for routine practices, as outlined in droplet and contact precautions and for airborne precautions when AGMPs are anticipated or are being performed.

Hand hygiene

Acute healthcare settings should ensure that a current hand hygiene program is in place and is regularly monitored with improvements made as necessary.

As always, all ABHR should contain 60-90% alcohol.

Every effort should be made to achieve 100% adherence with performance of hand hygiene (i.e., at least before and after contact with a patient or the patient care environment, before clean or sterile procedures, after risk of body fluid exposure, after removing gloves, and when hands are visibly soiled).

Hand hygiene is required when removing PPE.

Routine practices

Routine practices are for all patients, at all times, in all acute healthcare settings and include performing a PCRA, hand hygiene, use of PPE and adhering to respiratory hygiene (e.g., coughing or sneezing into an elbow or a tissue).

Droplet and contact precautions

Aerosol-generating medical procedures (AGMPs)

An AGMP is any procedure conducted on a patient that can induce production of aerosols of various sizes, including droplet nuclei. Examples include:

Follow provincial or territorial guidance for other procedures that require the use of an N95 respirator. This guidance may vary among provinces and territories.

If it is anticipated that the patient may require an AGMP, the patient should be placed in an AIIR if one is available on the unit. If no AIIR is available on the unit, the patient should be placed in a private room. The door of the room should be closed when an AGMP is being performed. Transfers between units should not occur unless medically necessary.

AGMPs on a patient suspected or confirmed to have COVID-19 should only be performed when all persons in the room are wearing a fit-tested, seal-checked N95 respirator, gloves, gown and face or eye protection.

In addition:

Nasopharyngeal Swabs

There is, as yet, no specific scientific study to inform diagnostic specimen collection using nasopharyngeal (NP) swabs in patients with COVID-19. Various jurisdictions have different guidance. Obtaining a nasal, throat or nasopharyngeal swab is a procedure which requires considerably less time than most procedures considered to be AGMPs, and in many cases does not induce significant coughing. However, at least in some cases, coughing and sneezing can be induced. All HCW who are to obtain specimens should always conduct a PCRA before the procedure.

There is debate about the extent to which some medical procedures generate droplets and aerosols. Examples include:

For these procedures, the selection of PPE should be informed by PCRA that considers the risk that each individual patient will cough or sneeze in association with the procedure, and balances patient and HCW safety.

Personal protective equipment (PPE)

All PPE (gloves, gown, masks, N95 respirators and face and eye protection) should be supplied, in all patient care areas, in adequate amounts and stored so it is readily accessible at the point of care for all HCWs.

PPE must always be used in conjunction with implementation and maintenance of engineering and administrative controls.

All HCWs using PPE must:

For more information on use, selection and fit of PPE refer to: Routine practices and additional precautions for preventing the transmission of infection in healthcare settings

Inpatient management

Before each patient interaction, a PCRA should be performed to determine the appropriate routine practices for safe patient care.

Placement and accommodation

A patient with suspect or confirmed COVID-19 infection should be cared for in a private room, if available, with a private toilet and sink for designated patient use.

Clear IPC signage (multilingual signage as required) that indicates droplet and contact precaution are in place.

Posters illustrating the correct method for putting on and removing PPE should be displayed inside and outside of each COVID-19 patient's room for easy visual cues.

If cohorting is necessary, only patients who are confirmed to have COVID-19 infection should be cohorted.

When the number of confirmed or suspected COVID-19 cases in the institution is high, consideration should be given to having dedicated teams of HCWs specific to these patients, to reduce the risk of transmitting infection in the acute healthcare setting, and to allow highly trained HCWs to develop expertise in caring for these patients.

The number of HCWs caring for individuals with suspected or confirmed COVID-19 should be minimized whenever possible. HCWs should be cohorted to work only with COVID-19 patients whenever possible.

As the numbers of patients with COVID-19 increase, a specific unit or area should be designated for COVID-19 patients. This unit or area should not be located adjacent to or near units with high risk patients (e.g., acute oncology).

Patient flow and activity

Patients with confirmed and suspected COVID-19 infection should be restricted to their room until their symptoms have resolved and in accordance with provincial and territorial guidance. Patient movement and/or transport should be restricted to essential diagnostic tests and therapeutic treatments. Transfer within and between facilities should be avoided unless medically indicated.

Patients should not be moved to access an AIIR, as this may place additional HCWs and patients at risk.

If patients must leave their room for medically necessary care or treatment, they should:

Attention should be paid to cleaning and disinfection of any surfaces that may be touched by the patient while out of the room.

Droplet and contact precautions should be maintained by HCWs during patient transport, and droplet and contact precautions communicated to the transferring service and receiving unit ahead of transfer.

Moving patients who are on CPAP or BiPAP within a facility should be avoided. If a transfer cannot be avoided, use the most direct route to the destination within the acute healthcare facility and ensure other patients or visitors are at least 2 metres from the transferring patient. Also ensure that all HCWs or accompanying persons who are within 2 metres of the transferring patient follow routine practices and droplet and contact precautions. Any HCW in contact with the patient or stretcher should also follow contact precautions and wear an N95 respirator. Any high touch surfaces such as handrails or door handles/push buttons along the route taken by patient should be immediately cleaned and disinfected.

Discontinuing additional precautions

The duration and discontinuation of precautions should be determined on a case-by-case basis, in consultation with the IPC program, and in accordance with provincial and territorial guidance or the organization's policy.

Handling deceased bodies

Routine practices should be used properly and consistently when handling deceased bodies or preparing bodies for autopsy or transfer to mortuary services. Provincial and territorial specified communicable disease regulations should be followed.

Handling lab 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 tothe 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 with suspect or confirmed COVID-19 infection. If use with other patients is necessary, the equipment and supplies should be cleaned and disinfected with a hospital disinfectant before reuse. Items that cannot be appropriately cleaned and disinfected should be discarded upon patient transfer or discharge. Patient owned items should be taken home by patient and unwanted items discarded at patient discharge. Single-use disposable equipment should be discarded into a no-touch waste receptacle after use.

Environmental cleaning and disinfection

Increased frequency of cleaning high-touch surfaces is important for controlling the spread of microorganisms during a respiratory infection outbreak. Environmental disinfectants should be classed as a hospital disinfectant and registered in Canada with a Drug Identification Number (DIN) and labelled as effective for both enveloped and non-enveloped viruses.

All 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 and shower handles, faucets or shower chairs, grab bars, outside of paper towel dispenser) should be cleaned and disinfected at a minimum of twice daily and when soiled. Hospital grade disinfectant (e.g., disinfectant wipes) should be used to disinfect smaller patient care equipment (e.g., BP cuffs, electronic thermometers, oximeters, stethoscope) after each use.

In addition, room cleaning and disinfection should be performed at least once per day including all low touch surfaces (e.g., shelves, bedside chairs or benches, windowsills, headwall units, overbed light fixtures, message or white boards, outside of sharps containers). Floors and walls should be kept visibly clean and free of spills, dust and debris.

The acute healthcare facility's cleaning protocol for cleaning of the patient's 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 should be removed and laundered at patient discharge or transfer.

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.

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 HCW exposures within the acute healthcare facility

The organization's OHS professional(s), and infection control professional(s) should work collaboratively with public health authorities to manage exposed HCWs.

Visitors

To minimize the risk of introducing COVID-19 into the healthcare facility, the number of visitors for all patients should be strictly limited to those who are essential (e.g., immediate family member or parent, guardian, or primary caregiver), and their movement within the facility limited by visiting the patient directly and exiting the facility directly after their visit. They must be instructed in the importance of hand hygiene with ABHR and how to perform hand hygiene on entering and exiting the building, the patient room, and after touching any surfaces in the patient environment or touching the patient.

Visitors should be screened for signs and symptoms of any infection at every visit. If signs and symptoms are present, the visitors are excluded from visiting.

Visitors should be instructed to speak with a nurse before entering the room of a patient on droplet and contact precautions. The nurse will assess the risk to the visitor's health and ability to adhere to routine practices and droplet and contact precautions. They should be provided with instructions on and supervision with appropriate use of PPE for droplet and contact precautions, including wearing a mask as well as eye protection. If the visitor is unable to adhere to the droplet and contact precautions, the visitor will be excluded from visiting.

Visitation policies should be developed and implemented to balance the risk of infectious disease transmission and the promotion of patient and family-centered care.

Monitoring and evaluation

Acute healthcare settings should ensure that there are processes in place to conduct surveillance and or monitor outcomes or occurrences related to managing patients with COVID-19. These may include, if feasible:

Bibliography

Acknowledgments

The National Advisory Committee on Infection Prevention and Control (NAC-IPC) is an external advisory body that provides subject matter expertise and advice to the Public Health Agency of Canada on the prevention and control of infectious diseases in Canadian health care settings.

This guideline was prepared by: Dr. Marina Salvadori, Ms. Sabrina Chung, the National Advisory Committee on Infection Prevention and Control (NAC-IPC), and the Public Health Agency of Canada (PHAC)'s Healthcare-Associated Infections Prevention and Control Section.

NAC-IPC Members: Dr. Joanne Embree, (Chair), Dr. Jennie Johnstone (Vice-Chair), Ms. Molly Blake, Ms. Josiane Charest, Dr. Maureen Cividino, Ms. Nan Cleator, Ms. Jennifer Happe, Dr. Susy Hota, Ms. Anne Masters-Boyne, Dr. Matthew Muller, Ms. Patsy Rawding, Ms. Suzanne Rhodenizer-Rose, Dr. Patrice Savard, Dr. Stephanie Smith, Dr. Nisha Thampi.

PHAC Healthcare-Associated Infections Prevention and Control Section: Dr. Gina Coleman (Director), Ms. Kathy Dunn (Manager), Ms. Sabrina Chung, Ms. Katherine Defalco, Ms. Anna Bottiglia, Ms. Toju Ogunremi, Mr. Steven Ettles, Mr. John McMeekin and Dr. Kahina Abdesselam.

The authors gratefully acknowledge the contributions of Dr. Allison McGeer, Dr. John Conly, as well as, Ms. Anne Augustin and Ms. Barbara Catt on behalf of Infection Prevention and Control (IPAC)-Canada and Ms. Patricia Piaskowski, scientific writer.

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