Infection prevention and control for COVID-19: Interim guidance for long term care homes

This document was last updated on April 8, 2020. Please refer back for future updates.

Table of Contents

This document provides guidance specific to the COVID-19 pandemic in long term care homes (LTCHs).

Individuals responsible for policy development, implementation and oversight of infection prevention and control measures at specific LTCHs should be familiar with relevant infection prevention and control (IPC) background documents on Routine Practices and Additional Precautions and occupational health and safety legislation. The term "staff" is intended to include anyone working in LTCHs, including but not limited to health care workers.

Important measures to prevent introduction and spread of COVID-19 in LTCHs:

  • Essential volunteers and visitors should be restricted to those deemed essential, meaning necessary to basic personal care (e.g. feeding), medical (e.g. phlebotomy) or compassionate (e.g. end of life) resident care, and in some cases visitors may be prohibited
  • All staff and essential volunteers and visitors must be trained and monitored for compliance with putting on and wearing a mask for the duration of their shift or visit, and discarding it afterward, and also to ensure vigilance in properly assessing the need for additional personal protective equipment (PPE), putting it on, wearing and removing it to minimize contamination of themselves and the immediate environment
    • Staff must support essential volunteers and visitors in appropriate use of PPE
  • All staff will use Droplet and Contact precautions, in addition to Routine Practices, for all care of residents with suspected or confirmed COVID- 19
  • All staff and essential volunteers or visitors must be trained on other IPC measures such as proper hand hygiene and the importance of maintaining a 2 metre spatial distance between residents
  • All staff must work proactively to identify suspect or confirmed cases of COVID-19 in staff, residents, and any essential visitors, with a low threshold for testing (e.g. even mild symptoms)

Background

In December 2019, a cluster of cases of pneumonia of unknown origin was reported from Wuhan, Hubei Province in China. On January 10, 2020, a novel coronavirus, that causes a disease now referred to as COVID-19 was identified as the cause of this cluster of pneumonia cases. A pandemic was declared on March 11, 2020.

For current information, LTCHs should refer to the Public Health Agency of Canada Coronavirus Disease (COVID-19): Outbreak Update and to local, provincial or territorial public health authorities.

Over the last few months, our understanding of COVID-19 has rapidly expanded. Person-to-person transmission is occurring in Canadian communities. COVID-19 is most commonly spread from an infected person through respiratory droplets generated through cough or sneezing, close personal contact such as touching or shaking hands, or touching something with the virus on it and then touching your mouth, nose or eyes before washing your hands. COVID-19 can also be spread through the air during aerosol-generating medical procedures (AGMPs) such as open airway suctioning in patients with tracheostomies.

LTCH residents are vulnerable to infection with COVID-19 due to behavioral factors, shared spaces, and transit between other healthcare facilities. Older adults and those with pre-existing medical conditions are also at risk for more severe disease and have higher mortality when infected with COVID-19.

Introduction

The Public Health Agency of Canada (PHAC) develops evidence-informed infection prevention and control guidelines and recommendations to complement provincial and territorial public health efforts in monitoring, preventing, and controlling healthcare-associated infections.

The intended purpose of this document, Infection Prevention and Control for COVID-19: Interim Guidance for Long Term Care Homes, is to provide interim guidance to LTCHs to prevent transmission of COVID-19. The content may be adapted to other settings as appropriate (i.e. retirement homes).

This interim guidance is based upon Canadian guidance developed for previous coronavirus outbreaks, experience with COVID-19 in other countries, as well as interim guidance from other Canadian and international bodies. It has been informed by technical advice provided by members of the PHAC National Advisory Committee on Infection Prevention and Control (NAC-IPC).

Infection prevention and control strategies to prevent or limit transmission of COVID-19 in LTCHs are similar to those used for the IPC management of other acute respiratory infections and include:

This guidance has been developed for Canadian LTCHs and staff 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.

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 preparedness

Screening

Access points

LTCHs should minimize access points and ensure that:

Resident and staff screening and management

LTCHs must ensure that there are processes in place to conduct active screening of staff and residents for symptoms or signs of COVID-19.

LTCH should liaise with their local laboratories and acute care facilities to determine the most rapid way to have testing of staff and residents completed and reported

Staff

Residents

Visitors (including volunteers and contractors)

Based on public health direction or local or regional status of COVID-19 cases it may be necessary to prohibit visitors. A "no visitor" policy should be strongly considered.

If visitors are permitted, they should be strictly limited to those who are essential, meaning necessary to basic personal care (e.g. feeding), medical (e.g. phlebotomy) or compassionate (e.g. end of life) resident care. Essential visitors should be limited to one person at a time for each resident.

Visitors should be screened for signs and symptoms of infection at every visit. If signs and symptoms are present, or if they are on self-isolation or quarantine as per relevant public health directives, they should be excluded from visiting and suggested to follow up with local public health or their healthcare provider.

Visitor movement within the LTCH should be limited to visiting the resident directly and exiting the LTCH directly after their visit.

All visitors should be required to put on a mask at entry to the LTCH, to reduce the risk of transmitting COVID-19 infection to residents or LTCH staff, which may occur even when no symptoms of illness are recognized.

They must be instructed by staff on the importance of hand hygiene with ABHR and when and how to perform hand hygiene, for instance on entering and exiting the building, the resident room, and after touching any surfaces in the resident environment or the resident. They must also be instructed on how to put on and remove any required PPE when visiting or caring for residents who are on Droplet and Contact precautions. If the visitor is unable to adhere to appropriate precautions, the visitor must be excluded from visiting.

Resident care and infection control measures

Point-of-care risk assessment (PCRA)

Prior to any resident interaction, all staff have a responsibility to assess the infectious risks posed to themselves, other staff, other residents and visitors from a resident, situation or procedure.

Hand hygiene

Staff are required to perform hand hygiene:

Essential visitors should be trained to perform hand hygiene, and expected to perform hand hygiene under the same circumstances outlined above for staff.

Residents should be trained to perform hand hygiene, and assisted with this if they are physically or cognitively unable. Residents should perform hand hygiene:

Hands may be cleaned using ABHR containing 60-90% alcohol, or soap and water. Washing with soap and water is preferable for use immediately after using toilet facilities, if hands are visibly soiled, when caring for a resident with norovirus or Clostridioides difficile infection, or during an outbreak of norovirus or Clostridioides difficile.

Routine Practices

Routine Practices apply to all staff and residents, at all times, in all LTCHs and include but are not limited to:

Masking for all staff providing or participating in resident care, and any essential visitors (Mask for duration of shifts)

Given the rapid increase in community spread of COVID-19 within Canada and increasing evidence that transmission may occur from those who have few or no symptoms, masking for the full duration of shifts or visits for all LTCH staff and any essential visitors is recommended. The rationale for full-shift masking of LTCH staff and essential visitors is to reduce the risk of transmitting COVID-19 infection from staff or visitors to residents or other LTCH staff, at a time when no symptoms of illness are recognized, but the virus can be transmitted. Staff must support essential visitors to ensure appropriate use of masks.

Droplet and Contact precautions

Droplet and Contact precautions should be implemented for all residents presenting with new signs or symptoms of possible COVID-19

Aerosol-generating medical procedures (AGMPs)

An AGMP is any procedure conducted on a resident that can induce production of aerosols of various sizes, including droplet nuclei. AGMPs are rarely performed in LTCHs, though potential examples in this setting may include open suctioning in patients with a tracheostomy, or use of non-invasive positive pressure ventilation (CPAP) machines.

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

Nasopharyngeal swabs

There is, as yet, no specific scientific study to inform the taking of nasopharyngeal 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 AGMP, 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.

Resident placement and accommodation

A resident with suspect or confirmed COVID-19 infection, or who is a high-risk contact of a confirmed COVID-19 positive person, should be cared for in a single room if feasible, with a dedicated toilet and sink designated for their use. If this is not possible, a separation of 2 metres must be maintained between the bed space of the affected resident and all roommates with privacy curtains drawn. The resident should be restricted to their room or bed space.

Clear (multilingual signage as required) signage that indicates Droplet and Contact precautions needs to be in place, posted in such a way that it is clearly visible to all entering the resident room or bed space.

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

Roommates of symptomatic residents should not be moved to new shared rooms, and instead should be moved to a new single room for isolation and monitoring for symptoms, or maintained in place if a 2 metre separation and privacy curtains can be implemented.

Resident activity

Non-essential outings should be canceled. All group activities should be reassessed for their potential to unnecessarily bring residents in close proximity to each other. If group activities take place, the number of residents should be limited to the smallest feasible groups, and residents spaced as far from one another as possible, maintaining a minimum distance of 2 metres between them. Group activities should wherever possible be restricted to a single unit and floor. Any resident activities in the LTCH should ensure that any materials (e.g. electronic tablets or other devices, craft supplies, bingo cards, magazines, books, cooking utensils, linens, tools) are not shared among residents unless they are cleaned and disinfected between uses for each resident. If the items cannot be easily cleaned and disinfected, they should not be shared among residents.

Residents with confirmed or suspected COVID-19 infection should stay in their room unless there is essential need for movement and/or transport, and until their symptoms have resolved and in accordance with provincial and territorial guidance. Transfer within and between facilities should be avoided unless medically indicated.

If residents with confirmed or suspected COVID-19 must leave their room for medically necessary care or treatment, they should be provided with clean attire, be accompanied by staff, wear a mask, be instructed to perform hand hygiene (with assistance as necessary), and avoid touching surfaces or items outside of the room. Wheelchairs or transport stretchers should be cleaned and disinfected prior to exiting the resident's room. Attention should be paid to cleaning and disinfection of any surfaces that may be touched by the resident while out of the room.

Droplet and Contact precautions should be maintained by staff during resident transport, and the need for Droplet and Contact precautions should be communicated to the transferring service and receiving unit ahead of transfer.

Moving residents who are on CPAP or BiPAP within a LTCH should be avoided.

IPC measures to control COVID-19 include physical distances of 2 metres between asymptomatic individuals. Distancing measures in LTCHs can include:

Refer to relevant jurisdictional authority for the most recent IPC measures applicable to LTCHs.

Outbreak management

A single confirmed case of COVID-19 is justification to apply outbreak measures to a unit or facility. Please refer to jurisdictional public health guidance for specific definitions. Refer to relevant jurisdictional authority for directives on case reporting and outbreak management. Outbreak management strategies include:

Discontinuing additional precautions

The duration and discontinuation of Droplet and Contact precautions for an individual resident or unit on outbreak should be determined on a case-by-case basis, in consultation with local public health authorities and infection prevention and control experts, if available, and in accordance with regional and provincial and territorial directives/guidance.

Handling of 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, and placed in biohazard bags. Clinical specimens should be collected and transported in accordance with organizational policies and procedures. For additional information on biosafety procedures when handling samples from residents under investigation for COVID-19, refer tothe PHAC 's biosafety advisory.

Handling resident care equipment

All reusable equipment and supplies, electronics, personal belongings, etc., should be dedicated to the use of the resident with suspect or confirmed COVID-19 infection. If use with other residents 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 resident transfer or 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 in resident rooms and any central areas is important for controlling the spread of microorganisms during a respiratory infection outbreak. Environmental disinfectants should be classed as a hospital grade disinfectant and registered in Canada with a Drug Identification Number (DIN) and labelled as effective for both enveloped and non-enveloped viruses. In the event that commercially-prepared hospital disinfectants are not available, LTCHs may use a diluted bleach solution to disinfect the environment. The concentration of chlorine should be 5000 ppm or 0.5% (equivalent to a 1:9 dilution of 5% concentrated liquid bleach). When using bleach, cleaning must precede disinfection.

All resident room and central area 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) using the recommended contact time should be used to disinfect smaller resident 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 on 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. Environmental services staff should wear the same PPE as other staff when cleaning and disinfecting the resident room.

All reusable equipment should be dedicated to the use of the resident with suspect or confirmed COVID-19 infection. If this is not feasible, equipment should be cleaned and disinfected with a hospital grade disinfectant before each use on another resident. Single-use disposable equipment and supplies should be discarded into a no-touch waste receptacle after each use.

The LTCHs cleaning protocol for cleaning of the resident'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. Privacy curtains should be removed and laundered upon a resident's discharge or transfer.

At discharge, room transfer or death of a resident any resident-owned items (e.g. clothing, photos, televisions, furniture, cards and ornaments) should be removed, any items with hard surfaces cleaned, and placed in a bag for family or representative. While risk of transmission of COVID-19 via these items is likely low, at this time best practice may be for families to store for 5 days prior to handling. If the family wishes to donate any of the resident's items to the LTCH or another resident they must first be thoroughly cleaned and disinfected.

All surfaces or items, outside of the resident room, that are touched by or in contact with staff (e.g., computer carts and/or screens, medication carts, charting desks or tables, computer screens, telephones, touch screens, chair arms) should be cleaned and disinfected at least daily and when soiled. Staff should ensure that hands are cleaned before touching the above-mentioned equipment.

Linen, dishes and cutlery

No special precautions are recommended; Routine Practices are used.

Waste management

No special precautions are recommended; Routine Practices are used.

Bibliography

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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. Cheryl Volling, Ms. Adina Popalyar, Ms. Katherine Defalco, Dr. Marina Salvadori, Dr James Brooks, Dr. Peter Uhthoff, and Ms. Yung-En Chung.

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. James Brooks (Director), Ms. Kathy Dunn (Manager), Ms. Katherine Defalco, Ms. Toju Ogunremi, Ms. Adina Popalyar, Ms. Anna Bottiglia, Ms. Sabrina Chung, Dr. Kahina Abdesselam, Mr. Steven Ettles, and Mr. John McMeekin.

The authors gratefully acknowledge the contributions of Dr. Allison McGeer, Dr. Jerome Leis, Dr. Paddy Quail, Dr. Fred Mather, Dr. Ben Robert, Ms. Laura Farrell, Ms. Eva Skiba, Dr. Liane Macdonald, Ms. Sandra Callery, Dr. Lynn Johnston, as well as, Ms. Barbara Catt on behalf of Infection Prevention and Control (IPAC)-Canada, Dr. Marianna Ofner and Ms. Patricia Piaskowski, scientific writer.

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