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

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:

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.

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:

All HCWs should ensure that:

Active screening and notification

Prompt identification of all individuals (including inpatients) with signs or symptoms of infection should occur via active screening.

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:

Organizational controls

It is essential that acute healthcare settings have the following engineering and administrative controls in place.

Engineering controls

Facility design should include:

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:

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:

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:

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.

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:

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.

A PCRA includes determining if there may be:

Patient factors may include:

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:

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:

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.

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:

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:

Inpatient management

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

Placement and accommodation

The following are important considerations for patient placement and accommodation:

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:

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.

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:

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