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

This document was posted on February 26, 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 long term-care homes (LTCHs) 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, including LTCHs.

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

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

In this context, the following recommendations are being made in this guidance. LTCHs 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 at specific LTCHs should be familiar with relevant IPC background documents on Routine Practices and Additional Precautions and occupational health and safety (OHS) legislation. Facility IPC policies and procedures, protocols, guidance, education and training referred to within this document should be informed by IPC experts and regional and/or provincial/territorial directives or recommendations, and frequently reviewed and updated as needed. Wherever possible, these should be developed in conjunction with joint occupational health and safety committees (JOHSC) or workplace health and safety representatives. All LTCHs should have ongoing access to local IPC expertise, with at least one IPC-trained person assigned to manage COVID-19-related prevention and response activities in the LTCH.

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 prevent the transmission of COVID-19 in Canadian homes/facilities for adults who require continuous supervised care, including professional health services, personal care and other services such as meals, laundry and housekeeping. These facilities may have different names, including but not limited to care homes/facilities, residential care homes/facilities, continuing care homes/facilities, personal care homes/facilities, nursing homes/facilities, centres d'hébergement et de soins de longue durée (CHSLDs), or other long-term care homes/facilities, hereafter all referred to as LTCHs. Some of the content may be adapted to other settings as appropriate (i.e., retirement homes).

This interim guidance is based upon experience with COVID-19 in Canada and other countries, as well as interim guidance from other international bodies. It has been informed by technical advice provided by members of the National Advisory Committee on Infection Prevention and Control (NAC-IPC). This guidance is informed by currently available scientific evidence and expert opinion, and is subject to change as new information becomes available.

The term "staff" is intended to include anyone working in LTCHs, including but not limited to those providing health care. The term “visitor” is intended to include anyone who is not employed directly by the LTCH but has been permitted entry into the facility, and includes but is not limited to volunteers, delivery personnel or contractors, outside care providers or consultants, family caregivers and general visitors.

Infection prevention and control preparedness

Each LTCH should be prepared to identify and manage residents who are considered exposed to, or suspected or confirmed to have COVID-19.

LTCH operators should ensure that:

All staff should ensure that:

LTCH staff safety and training

LTCHs should evaluate the potential risks posed to staff, and ensure that practices are in place to mitigate and manage them. 

Management of staff exposures

The LTCH's management, OHS professional(s), and infection prevention and control practitioner(s) should work collaboratively with public health authorities to manage staff exposed to COVID-19.

Access points

LTCHs should minimize access points and ensure that:

Screening and notification

Active screening should be conducted to promptly identify any individuals with signs and/or symptoms of COVID-19 or other respiratory illness.

Signs and symptoms of COVID-19 can vary from person to person. They may also vary according to age group (please see below Resident screening section for additional signs and symptoms reported in older adults).  Reported signs and symptoms include but are not limited to:

LTCHs 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.

In the context of the COVID-19 pandemic, a single laboratory-confirmed case of COVID-19 in a staff member or resident of a LTCH defines an outbreak.

All confirmed cases of COVID-19 are to be reported to the relevant jurisdictional public health authorities, and LTCHs should liaise with their affiliated laboratories for screening for variants of concern.

Staff screening

Staff screening should include a twice daily self-assessment for exposures, signs and symptoms of COVID-19, including a temperature check.  Staff who develop any signs or symptoms of COVID-19 (of any severity) should:

Staff who have signs or symptoms of COVID-19, who have had recent unprotected exposure (as defined by facility, local, and jurisdictional public health or IPC guidance) to a person suspected or confirmed to have COVID-19, or who have been directed to self-isolate according to local public health directives, should not return to the LTCH until they have been cleared to do so according to local and jurisdictional public health guidance and facility IPC policies.

Designated staff should initiate and maintain a line listing of staff with suspected or confirmed COVID-19, as required by local, provincial or territorial public health guidelines, or as directed by facility occupational health and IPC policies.

Resident screening

Resident screening should include regular and thorough assessments for signs and symptoms of COVID-19. The frequency of assessment may vary by region and over time based on local COVID-19 epidemiology, but in areas with ongoing community transmission, assessments should occur at least daily.

Residents with signs or symptoms of COVID-19 should be placed immediately on a minimum of Droplet and Contact Precautions, and tested for COVID-19 as per local, provincial or territorial public health guidelines. Signs or symptoms of COVID-19 are listed above but considerations for older adults include:

Results of recent and serial resident assessments should be recorded and easily retrieved, in order to facilitate comparison and identification of changes in resident status.

Designated staff should initiate and maintain a line listing of residents with suspected or confirmed COVID-19, as required by local, provincial or territorial public health guidelines, or as directed by facility occupational health and IPC policies.

Visitor management

The term “visitor” is intended to include anyone who is not employed directly by the LTCH but has been permitted entry into the facility, and includes but is not limited to volunteers, delivery personnel or contractors, outside care providers or consultants, family caregivers and general visitors.

LTCHs should have visitor policies in place. Based on public health direction, outbreak status, or local or regional COVID-19 status, it may be necessary to restrict some visitation. Facilities should refer to local and jurisdictional public health guidance when establishing visitor policies; these should aim to balance the physical, psychological, emotional and spiritual needs of residents with the risk of introduction and transmission of COVID-19, and may vary over time, depending on local COVID-19 epidemiology.

Visitors should:

Resident care and infection prevention and control measures

Routine practices

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

Point-of-care risk assessment

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

A PCRA includes determining if there may be:

Resident factors may include:

The selection and use of PPE during resident interactions should always be determined by the PCRA.

For interactions with residents 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 or exposed to an AGMP. Use of an N95 or equivalent respirator may be considered in other circumstances under which risk of exposure to aerosolized virus may occur.

Hand hygiene

All LTCHs should have a hand hygiene program in place, with regular review and updating of staff education, training, and monitoring for adherence. LTCHs should make every effort to achieve 100 percent hand hygiene adherence. 

Staff should perform hand hygiene:

Hands may be cleaned using ABHR containing 60 to 90% alcohol, or plain liquid soap and water. Soap and water is preferable for use immediately after using toilet facilities, if hands are visibly soiled, and when caring for a resident with Clostridioides difficile infection.

Visitors are expected to perform hand hygiene under the same circumstances outlined above for staff and should be trained on how to do so properly.

Residents should also be taught how to perform proper hand hygiene, and assisted with this if they have physical or cognitive limitations. Residents should perform hand hygiene:

Personal protective equipment

All PPE (e.g., gloves, gowns, medical masks, N95 or equivalent respirators, eye protection) should be supplied in adequate amounts and sizes in all resident care areas, and placed so it is readily accessible at the point-of-care for all staff and visitors. Additional supplies of PPE should be stored in clean supply rooms that are clearly separated from any soiled utility areas.

Training should be provided, with posters clearly outlining the steps for putting on and removing PPE posted for visual cues inside and outside each room of a resident who is considered exposed to, or suspected or confirmed to have COVID-19.

All staff 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 LTCH staff and visitors is recommended. The rationale for full-shift masking of LTCH staff and visitors is to reduce the risk of transmitting COVID-19 infection 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 staff shifts is also recommended in LTCHs, based on local epidemiology. This applies to all staff working in resident care areas. Eye protection is also recommended for visitors in close proximity to residents in a LTCH that is experiencing an outbreak.

LTCHs should refer to facility IPC and provincial and territorial guidance on specific recommendations for use of medical masks, eye protection and other PPE, as well as PPE conservation strategies.  When medical masks and eye protection are recommended for the full duration of shifts or visits, staff and visitors should:

When an N95 or equivalent respirator is deemed necessary based on the staff PCRA, staff should follow facility procedures for taking off a medical mask (and eye protection, if worn), and then put on a fit-tested N95 or equivalent respirator and replace their eye protection, with meticulous hand hygiene performed at all steps.

Masks or N95 or equivalent respirators should be replaced when they become damaged, wet, damp, or soiled (from the wearer's breathing or external splash), or when they come in direct contact with a resident.  Staff should be informed of how to access additional masks or N95 or equivalent respirators when needed.

Additional precautions

A minimum of Droplet and Contact Precautions should be implemented for all residents who are considered exposed to, diagnosed with, or who have signs or symptoms of possible COVID-19.

Aerosol-generating medical procedures

Some medical procedures have been reported to increase the likelihood of generating infectious aerosols, and linked to transmission of other respiratory viruses. These are often referred to as aerosol-generating procedures (AGPs) or aerosol-generating medical procedures (AGMPs). There are many knowledge gaps as to which procedures pose the greatest risk of aerosol generation and transmission of SARS-CoV-2. It is likely that the degree of risk may also vary depending on the resident, the operator, and the setting. Most procedures that are reported to pose increased risk of aerosol generation and transmission of respiratory viruses are rarely performed in LTCHs, though potential examples in this setting may include open endotracheal suctioning in residents who have a tracheostomy, or use of non-invasive positive-pressure ventilation (e.g., continuous positive airway pressure or CPAP) machines.

Guidance for procedures that 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. These rooms are rarely found in LTCHs, and there has not been well-documented transmission of COVID-19 by AGMPs when providers were in appropriate PPE. If a resident requires an AGMP, the resident should be placed in an AIIR or a private room with the door closed.

AGMPs on a resident who is considered potentially infectious with SARS-CoV-2 should only be performed when all staff in the room are wearing a fit-tested, seal-checked N95 or equivalent respirator, gloves, a gown and eye protection.

In addition:

Resident placement and accommodation

The following are important considerations for resident placement and accommodation:

Resident activity

IPC practices to prevent introduction and transmission of COVID-19 into and within LTCHs during resident activity should include:

Residents who are considered exposed to, or suspected or confirmed to have COVID-19 should stay in their room until they have met the criteria for discontinuation of Additional Precautions in accordance with facility IPC protocols and provincial and territorial public health guidance. Those undergoing CPAP or Bilevel Positive Airway Pressure (BiPAP) should not be moved. Movement or transfer within and between facilities of residents who are suspected to be infectious should be avoided unless medically necessary.

If residents who are considered exposed to or suspected or confirmed to have COVID-19 must leave their room for medically necessary care or treatment, they should:

A minimum of Droplet and Contact Precautions should be maintained by staff during resident transport, and communicated along with relevant clinical information to the transferring service and receiving unit ahead of transfer.

Wheelchairs or transport stretchers should be cleaned and disinfected prior to exiting the resident's room and after being used.  Any surfaces outside the room that the resident may have touched should be cleaned and disinfected.

Outbreak management

A single confirmed case of COVID-19 is justification for applying outbreak measures to a unit or facility (with detailed consideration for the LTCH layout and potential transmission routes between units, e.g., staff cross-coverage or shared communal spaces). LTCHs should refer to local and jurisdictional public health and IPC authorities for specific definitions and directives on case reporting and outbreak management.

When an outbreak occurs in a facility, an emergency operations team should be established; this should involve the LTCH administrators/directors, local and regional public health and administration, IPC practitioners, and other external supports for resident and staff testing, PPE acquisition, personnel/staffing, and communications as needed.

Once COVID-19 has been confirmed in a LTCH:

Outbreak management strategies may include but are not limited to:

Discontinuing additional precautions

The duration and discontinuation of Additional Precautions for an individual resident 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 IPC expertise and in accordance with local, provincial and territorial public health guidance.

The duration of Additional Precautions for a symptomatic resident with COVID-19 should be a minimum of 10 days from onset of symptoms (and a minimum of 10 days from the first positive test for residents who remain asymptomatic), and may be longer depending upon the duration of symptoms, disease severity and the presence of 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 residents under investigation for COVID-19, refer to the PHAC'biosafety advisory.

Handling resident care equipment

All reusable equipment and supplies, electronics, personal belongings, etc., should be dedicated to the use of the resident who is considered exposed to, or suspected or confirmed to have COVID-19. If reuse with other residents is necessary, the equipment and supplies should first be cleaned and disinfected with a hospital-grade disinfectant for the recommended contact time. Items that have been cleaned and disinfected should be clearly identified as such (e.g., with tags) and stored separately from any non-clean and non-disinfected items.

Single-use disposable equipment should be discarded into a no-touch waste receptacle immediately after use.

Upon resident discharge, items that cannot be appropriately cleaned and disinfected should be discarded. Resident-owned items with hard surfaces should be cleaned and disinfected, and all items placed in a bag for family or a representative to take. Resident items and laundry should be handled with gloves and then cleaned and disinfected or laundered with regular laundry soap and hot water (60-90°C) followed by handwashing and prior to subsequent use. Unwanted items should be discarded.

Environmental cleaning and disinfection

Cleaning and disinfection of high-touch surfaces is important for controlling the spread of microorganisms. Environmental disinfectants should be classified 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. If commercially-prepared hospital-grade disinfectants are not available, LTCHs may use a diluted bleach solution to disinfect the environment. The concentration of chlorine should be 1,000 ppm or 0.1% (equivalent to a 1:50 dilution of 5% concentrated liquid bleach). When using bleach, cleaning must precede disinfection.

All resident 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 or 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 resident 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 resident room that are touched by or in contact with staff (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. Staff should ensure that their hands are clean before touching the above-mentioned equipment.

In rooms of residents who are considered exposed to, or suspected or confirmed to have COVID-19, shared staff or resident common spaces, and in cases of outbreaks, more frequent cleaning and disinfection is required.

Environmental services staff should wear the same PPE as other staff when cleaning and disinfecting the resident room.

The facility’s 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, and all bedside privacy curtains removed and laundered at the time of resident discharge or transfer.

Linen, dishes and cutlery

Routine Practices should be used.

Waste management

Routine Practices should be used.

Monitoring and evaluation

LTCHs should ensure that processes to monitor processes and outcomes related to managing residents with suspected or confirmed COVID-19 are in place. These may include:

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