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

Table of Contents

• Background
• Introduction
• Infection prevention and control preparedness
• Screening
  • Access points
  • Resident and staff screening and management
    • Staff
    • Residents
• Visitors (including volunteers and contractors)
• Resident care and infection control measures
  • Point-of-care risk assessment (PCRA)
  • Hand hygiene
  • Routine Practices
    • Masking for all staff providing or participating in resident care, and any essential visitors (Mask for duration of shifts)
  • Droplet and Contact precautions
  • Aerosol-generating medical procedures (AGMPs)
  • Nasopharyngeal swabs
• Resident placement and accommodation
• Resident activity
• Outbreak management
• Discontinuing additional precautions
• Handling of deceased bodies
• Handling lab specimens
• Handling resident care equipment
• Environmental cleaning and disinfection
• Linen, dishes and cutlery
• Waste management
• Bibliography
• Acknowledgments

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:

• Prompt identification of all persons with signs and symptoms of possible COVID-19
  • Signs or symptoms may include:
    • Fever (temperature of 37.8°C or greater), OR
    • Any new or worsening respiratory symptoms (cough, shortness of breath, runny nose or sneezing, nasal congestion, hoarse voice, sore throat or difficulty swallowing), OR
    • Any new onset atypical symptoms including but not limited to chills, muscle aches, diarrhea, malaise, or headache
• Institution of IPC measures to prevent infections (e.g., Routine Practices including hand hygiene, point of care risk assessment (PCRA), implementation of Droplet and Contact precautions, use of an N95 respirator for AGMPs, and increased environmental cleaning of frequently touched surfaces)
• Determination of the causal organism

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

• LTCH operators must ensure that:
  • They maintain awareness of data on the local and regional spread of COVID- 19
  • Staff receive ongoing training and monitoring of compliance with Routine Practices, including hand hygiene, and implementation of additional precautions, including Droplet and Contact precautions, and use of an N95 respirator, in addition to Droplet and Contact precautions, if AGMPs are performed
  • Staff IPC training, testing and monitoring for compliance and education are in place, tracked, recorded, and kept up-to-date
  • AGMPs are only performed if deemed medically necessary
  • If AGMPs are performed,
    • There is appropriate training and N95 respirator fit-testing for all staff who may be required to participate in or who may be exposed to these procedures
    • The fewest staff necessary to perform the procedure are present
    • These procedures are performed in a single room with the door closed
  • Policies and procedures are in place to prevent the introduction of COVID-19 into LTCHs, and to prevent and control the spread of infection if identified, and that these are informed by regional and/or provincial/territorial directives or recommendations. This includes policies and procedures pertaining to:
    • Communication with staff, residents and families on COVID-19 updates
    • Limiting access points and conducting entrance screening at all access points
    • Visitor restriction
    • The need for PCRA to be conducted by all staff prior to any interaction with a resident, Routine Practices, including hand hygiene, applied in the care of all residents, and when and in what circumstances to implement additional precautions (e.g. Droplet and Contact precautions or use of an N95 respirator for AGMPs)
    • Routine scheduled and additional environmental cleaning with attention paid to high touch, high risk surfaces (e.g. bed rails, bed headboard and footboard, chair arms, light switches, hand and support rails, toilets, sinks and grab rails, shower chairs, call bell cords and buttons, telephones, white boards)
    • Responsibility for cleaning and disinfection of resident care equipment
    • Proper cleaning and disinfection of any reusable PPE and disposal of single-use PPE in a no-touch waste receptacle
    • Review of scheduling and restriction of staff work assignments to specific units or areas wherever feasible and safe, to limit potential spread within facilities, even before COVID-19 is detected in a LTCH
    • Identifying staff who work in more than one location (e.g., other LTCHs or health care settings), and ensuring efforts are made to prevent this where possible, to limit spread between facilities and to inform investigations during an outbreak
    • Ensuring capacity to acquire necessary staffing
    • Active screening of residents, staff and essential visitors for new signs or symptoms of COVID-19
    • How to manage resident or staff exposures, symptoms, or confirmed COVID-19
    • How to safely transport residents within and outside of LTCH when necessary
  • Residents, staff and essential visitors are provided with printed or posted information about COVID-19, how the virus causes infection, and how to protect themselves and others, including:
    • The importance of hand hygiene and how to wash hands and how to use alcohol-based hand rub (ABHR)
    • Instructions on appropriate respiratory hygiene (i.e., covering their cough with a tissue or coughing into their elbow followed by performing hand hygiene)
    • Posters illustrating the current methods for putting on and removing required PPE placed inside and outside of resident rooms for easy visual cues
    • Instructions on how and where to dispose of used supplies
  • Regular assessment to determine stock of necessary PPE (e.g. gloves, gowns, masks, face or eye protection) and clinical supplies including nasopharyngeal swab kits
  • Every effort is made to make PPE available and accessible at the point-of- care with each resident
  • PPE is stored to avoid pilfering while not inhibiting staff from accessing PPE
  • Coordinated procurement of supplies with provincial or territorial buying groups to maximize access
  • Appropriate number and placement of ABHR dispensers, in hallways at entry to each resident room, communal areas and at point of care for each resident
  • Respiratory hygiene products (e.g. masks, tissues, ABHR, no-touch waste receptacles) are available and easily accessible to staff and residents
  • Environmental cleaning and disinfection practices are monitored for compliance
  • Physical distancing measures (maintaining 2 metres spatial separation) are utilized for staff wherever feasible, and while providing safe care
  • Physical distancing measures (e.g., use of single rooms when available, maintaining 2 metres spatial separation between residents in hallways, all recreation, activity, activation or dining or other communal areas) are utilized for all residents
  • All residents with suspect or confirmed COVID-19 are immediately placed into Droplet and Contact precautions (e.g., use of gloves, gown, mask and face or eye protection) for all staff or visitors who enter the resident room or who are within 2 metres of resident until COVID-19 or other respiratory infection is ruled out
    • Single rooms and dedicated bathrooms are preferred, and separation of 2 metres must be maintained between the bed space of ill resident and all roommates with privacy curtains drawn
  • Signage indicating Droplet and Contact precautions is placed on the outside of rooms or areas where resident(s) with suspected or confirmed COVID-19 are located
  • Strategies are developed to manage a high volume of residents with COVID- 19 (e.g. cohorting staff to work only with suspect or confirmed COVID-19 residents, potential need for cohorting of residents with confirmed COVID-19)
  • A fit-tested N95 respirator, gloves, gown, and face or eye protection are worn for all AGMPs
  • Staff ill or with an exposure to someone with confirmed COVID-19, as defined by occupational health or their local public health department, or those otherwise determined to require self-isolation according to public health directives, must not enter the LTCH for at least 14 days from last exposure unless local public health authorities have other policies (e.g., regarding health care workers who perform critical operational functions), which may include self-monitoring at work (if asymptomatic, using appropriate PPE, and continuing to self-isolate at home). Self- monitoring at work (or working while self-isolating) policies should include the following:
    • Maintaining physical distancing from other staff during breaks
    • Minimum twice daily screening and if staff develop fever or symptoms they are removed from duty and should be tested for COVID-19
    • LTCH operators should work with public health authorities to manage exposed staff
  • Waste, soiled linen and the care environment are managed and/or adequately cleaned and disinfected according to LTCH policies and procedures
• All staff should ensure that:
  • They adhere to LTCH IPC policies and procedures and public health guidance
  • Twice daily, they self-monitor for new signs or symptoms and immediately report any new symptoms to the LTCH
    • Signs or symptoms may include:
      • Fever (temperature of 37.8°C or greater), OR
      • Any new or worsening respiratory symptoms (cough, shortness of breath, runny nose or sneezing, nasal congestion, hoarse voice, sore throat or difficulty swallowing), OR
      • Any new onset atypical symptoms including but not limited to chills, muscle aches, diarrhea, malaise, or headache
• Prior to working every shift, they report to LTCH management if they have had potential exposure to a case of COVID-19 to determine whether restrictions are necessary (which may depend on local jurisdictional guidance), as well as consulting their own healthcare provider for any needed follow-up
• They are knowledgeable about:
  • How to conduct a PCRA prior to all interactions to determine what IPC measures are needed to protect residents and themselves from infection
  • Where to get tested if they become symptomatic or if requested by local public health authorities or the LTCH
  • Routine Practices followed for all resident interactions, e.g. hand hygiene
  • The use and limitations of the specific PPE available for their use
• They understand and participate in programs to conserve PPE

Screening

Access points

LTCHs should minimize access points and ensure that:

• Screening of all staff, residents, and essential volunteers, visitors and contractors or outside care providers is conducted at all LTCH access points, with signage, and assessment for symptoms or known exposure to COVID-19 prior to entry
• Screeners are protected with transparent barriers which prevent droplet transmission to staff and allow for communication between the screener and residents or other persons who present at screening
  • If a transparent barrier is not in place, screeners should be provided with appropriate PPE (e.g., gloves, gown, mask and face or eye protection)
• All staff and any essential visitors are required to put on a mask at entry to the LTCH to reduce the risk of transmitting COVID-19 infection from staff or visitors to residents, which may occur even when symptoms of illness are not recognized
• Masks, tissues, ABHR and a no-touch waste receptacle are available for staff, resident, and essential volunteer or visitor use at screening at each entrance. Consideration should be given to the security of supplies of PPE to prevent pilfering, but this should in no way inhibit or prevent necessary access to PPE
• Signage (multilingual as required) is posted at access points instructing staff and essential volunteers and visitors:
  • NOT to enter if they have any new signs or symptoms of illness
    • Signs or symptoms may include:
      • Fever (temperature of 37.8°C or greater), OR
      • Any new or worsening respiratory symptoms (cough, shortness of breath, runny nose or sneezing, nasal congestion, hoarse voice, sore throat or difficulty swallowing), OR
      • Any new onset atypical symptoms including but not limited to chills, muscle aches, diarrhea, malaise, or headache
  • NOT to enter if they have been instructed to self-isolate or self-quarantine, unless due to staff shortages public health authorities and LTCH permit self- monitoring (or working while self-isolating) and have provided clear guidance for this (see Staff section Resident and staff screening and management)
  • To practice hand hygiene and put on a mask on entry
• All staff and visitors should be logged at entry and exit if feasible
• Food and essential items should be delivered through a single access point. Every effort should be made to avoid unnecessary entry into LTCHs, and if entry is required delivery personnel screened as per other visitors

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

• Staff screening must include a self-assessment for exposures, symptoms of COVID-19 and a temperature check twice daily
  • Signs or symptoms may include:
    • Fever (temperature of 37.8°C or greater), OR
    • Any new or worsening respiratory symptoms (cough, shortness of breath, runny nose or sneezing, nasal congestion, hoarse voice, sore throat or difficulty swallowing), OR
    • Any new onset atypical symptoms including but not limited to chills, muscle aches, diarrhea, malaise, or headache
• If a staff develop symptoms of COVID-19 at work they should immediately perform hand hygiene, ensure that they do not remove their mask, inform their supervisor, avoid further resident contact and leave as soon as it is safe to do so
• Staff with any symptoms (including mild respiratory symptoms) must be tested for COVID-19 and excluded from work, and follow local public health guidance with regard to testing and further management
• In the context of the COVID-19 pandemic, a single laboratory-confirmed case of COVID-19 in a staff member (or resident) in a LTCH defines an outbreak
• 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
• Staff without symptoms but with exposure to COVID-19 as defined by occupational health or their local public health department should ideally be in self- isolation. If they are deemed critical to ensure continued operations in LTCHs, public health authorities may give consideration to staff self-monitoring at work which could include the following:
  • Minimum twice daily screening and if staff develop fever or symptoms they are removed from duty and tested for COVID-19
  • LTCH operators should work with public health authorities to manage exposed staff
• Staff should make every effort, where feasible, to maintain a minimum 2 metre distance between each other throughout their shifts, especially during any breaks or lunch when they are not masked

Residents

• Access points should allow for rapid placement of residents being admitted from the community or returning from another facility, and they should be given a mask during transfer and ideally placed under isolation with Droplet and Contact precautions for 14 days on arrival to the facility. They should be preferentially admitted to a single room if available or semi-private with curtains drawn between beds, maintaining at least 2 metres between residents
  • The LTCH should be called in advance and screening conducted to rule out symptoms
  • If a resident is to be transferred from a unit with a known outbreak of COVID-19 or is a known contact of a COVID-19 case, Droplet and Contact precautions must be implemented for 14 days
    • These residents should be met by a health care worker who is wearing PPE for Droplet and Contact precautions (e.g. gloves, gown, mask, and face or eye protection) and immediately escorted to a single room or a space where at least 2 metres between residents can be ensured
  • The resident and any accompanying staff should have access to ABHR
• Resident screening should include daily assessment for symptoms of COVID- 19
• Residents with signs or symptoms or potential exposures to COVID-19 should be immediately placed under Droplet and Contact precautions, and if symptomatic tested for COVID-19 as per local, provincial or territorial public health guidelines
  • Signs or symptoms may include:
    • Fever (temperature of 37.8°C or greater), OR
    • Any new or worsening respiratory symptoms (cough, shortness of breath, runny nose or sneezing, nasal congestion, hoarse voice, sore throat or difficulty swallowing), OR
    • Any new onset atypical symptoms including but not limited to chills, muscle aches, diarrhea, malaise, or headache
  • Symptoms in elderly residents may be subtle or atypical, and screening staff should be sensitive to detection of changes from resident baseline
• 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
• In the context of the COVID-19 pandemic, a single laboratory-confirmed case of COVID-19 in a resident (or staff member) in a LTCH defines an outbreak

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.

• Signs or symptoms may include:
  • Fever (temperature of 37.8°C or greater), OR
  • Any new or worsening respiratory symptoms (cough, shortness of breath, runny nose or sneezing, nasal congestion, hoarse voice, sore throat or difficulty swallowing), OR
  • Any new onset atypical symptoms including but not limited to chills, muscle aches, diarrhea, malaise, or headache

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.

• The PCRA is a routine practice that should be applied before every clinical encounter regardless of COVID-19 status and is based on the staff professional judgment (i.e. knowledge, skills, reasoning and education) made regarding the likelihood of exposing themselves and/or others to infectious agents (e.g., COVID- 19), for a specific interaction, a specific task, with a specific resident, and in a specific environment, under available conditions.
• The PCRA helps staff to select the appropriate actions and/or PPE to minimize the risk of exposure to known and unknown infections (e.g. asking oneself, will I be performing an AGMP?).

Hand hygiene

Staff are required to perform hand hygiene:

• On entry to and exit from the LTCH
• Before and after contact with a resident, regardless of whether gloves are worn
• After removing gloves
• Before and after contact with the resident's environment (e.g. medical equipment, bed, table, door handle) regardless of whether gloves are worn
• Any other time hands are potentially contaminated (e.g. after handling blood, body fluids, bedpans, urinals, or wound dressings)
• Before preparing or administering all medications or food
• Before performing aseptic procedures
• Before putting on PPE and during removal of PPE according to the facility procedure for putting on or removing PPE
• After other personal hygiene practices (e.g. blowing nose, using toilet facilities, etc.)

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:

• Upon entering or leaving their room
• Prior to eating, oral care, or handling of oral medications
• After using toileting facilities
• Any other time hands are potentially contaminated (e.g. after handling blood, body fluids, bedpans, urinals, or wound dressings)

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:

• Conducting a PCRA
• Hand hygiene
• Appropriate use of PPE
• Adhering to respiratory hygiene (i.e., covering a cough with a tissue or coughing into elbow followed by performing hand hygiene)

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.

• Staff and essential visitors will perform hand hygiene before they put on a mask when they enter the LTCH, before and after removal, and prior to putting on a new mask
• Staff and essential visitors will wear a mask securely over their mouth and nose and adjust the nose piece to fit snugly while mask is worn
• Staff and essential visitors should not touch the front of mask while wearing it
• Staff and essential visitors should not dangle the mask under their chin, off the ear, under the nose or place on top of head
• Masks should be removed just prior to breaks or when leaving the building, while in an area where no residents, staff or visitors are present, and discarded in the nearest no-touch waste receptacle
• Generally it is a foundational concept in IPC practice, that masks should not be re-worn. However, in the context of the COVID-19 pandemic and PPE shortages please follow jurisdictional guidance with regard to mask use, reuse, and reprocessing
• Example approach:
  • Providing a supply of one or two masks per shift is one strategy aimed at protecting staff and residents while trying to conserve supplies of PPE
  • If re-wearing of masks is recommended, staff must remove their mask by the ties or elastics taking care not to touch front of mask, and carefully store the mask in a clean dry area and in accordance with institutional and jurisdictional public health guidance, taking care to avoid contamination of the inner surface of the mask, and perform hand hygiene before and after mask removal and before putting it on again
  • Masks should be disposed of and replaced when they become wet, damp, or soiled (from the wearer's breathing or external splash), or when they come in direct contact with a resident
    • In the context of an outbreak of COVID-19, consideration should be given to wearing a face shield in addition to a mask for the full duration of shifts
    • Staff should be informed of how to access additional masks if needed

Droplet and Contact precautions

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

• Signs or symptoms may include:
  • Fever (temperature of 37.8°C or greater), OR
  • Any new or worsening respiratory symptoms (cough, shortness of breath, runny nose or sneezing, nasal congestion, hoarse voice, sore throat or difficulty swallowing), OR
  • Any new onset atypical symptoms including but not limited to chills, muscle aches, diarrhea, malaise, or headache
• Gloves, long-sleeved cuffed gown (covering front of body from neck to mid- thigh), mask (which should already be worn due to mask during all shifts) and face or eye protection should be worn upon entering the resident's room or when within 2 metres of the resident on Droplet and Contact precautions
  • Examples of face or eye protection (in addition to mask) include full face shield, mask with attached visor, non-vented safety glasses or goggles (regular eyeglasses are not sufficient)
• PPE (except mask when mask during all shifts is practiced) should be removed in the correct order and discarded prior to exiting the resident's room or ante-room in the nearest no-touch waste receptable
• The area where PPE is put on should be separated as much as possible from the area where it is removed and discarded
• Hand hygiene should occur according to best practices for putting on or removing PPE

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.

• AGMPs on a resident suspected or confirmed to have COVID-19 should only be performed if:
  • The AGMP is medically necessary and performed by the most experienced person
  • The minimum number of persons required to safely perform the procedure are present
  • All persons in the room are wearing a fit-tested, seal-checked N95 respirator, gloves, gown and face or eye protection
  • The door of the room is closed
  • Entry into a room of a patient undergoing CPAP is minimized

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.

• Collecting diagnostic specimens (e.g., NP swab) from a coughing or sneezing patient can be mitigated by placing a medical mask over the patient's mouth. Persons in the room during the procedure should, ideally, be limited to the patient and the HCW obtaining the specimen.
• Specimens should be obtained by a HCW experienced in their collection. Patients should be provided with tissues to contain coughs and sneezes after the procedure. Persons performing the testing should stand to the side of the patient, not directly in front of them, and should move away from the patient (to more than 2 meters distant) when the procedure is complete.

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:

• If there are no cases of COVID-19 identified in the LTCH:
  • Staggering mealtimes if maintenance of this minimum distance can be ensured
  • Cancellation of any group activities where a minimum 2 metre distance between residents cannot be maintained
• If there are suspected or confirmed cases of COVID-19 in the LTCH:
  • Serving residents individual meals in their rooms while ensuring adequate monitoring and supervision for all residents
  • Cancellation of all in-person group activities

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:

• Determination of whether a COVID-19-positive staff member or essential visitor exposed other staff or residents during the period of communicability
• Notification of the transferring hospital and local public health authorities if a resident develops symptoms and/or is diagnosed with COVID-19 within 14 days of transfer from another facility
• Determination of applying outbreak precautions to the affected unit or entire LTCH should be made based on knowledge of the LTCH and staffing, and in accordance with jurisdictional public health guidance and directives
• Increased frequency of cleaning with a focus on high-touch surfaces
• Further restriction of movement of residents within the LTCH, with discontinuation of all non-essential activities, including communal activities
• Arrange for the use of portable equipment to help avoid unnecessary resident transfers (e.g. portable x-rays), while ensuring that this is cleaned and disinfected between residents
• New resident admission is generally not recommended in the context of an outbreak of COVID-19
• Increased frequency of active screening for COVID-19 symptoms in residents
• Contact tracing of individuals (staff and residents) with potential exposure to the infected individual (either staff or resident)
• Staff exclusions until completion of home isolation, though in some cases due to staff shortages LTCH may, with guidance from public health authorities permit self-monitoring (or working while self-isolating) (see Staff section Resident and staff screening and management)
• Return-to-work policies for staff with COVID-19 whose symptoms have resolved (refer to jurisdictional public health guidance)
• Reviewing and reinforcing visitor restrictions
• LTCHs in consultation with jurisdictional public health authorities should consider resident and staff cohorting, including:
  • Residents who are confirmed to have COVID-19
  • Staff assignment between multiple units should be limited
• When the number of confirmed or suspected COVID-19 cases in a LTCH is high, consideration should be given to having dedicated teams of staff specific to residents with suspected or confirmed COVID-19, where feasible, to reduce the risk of further transmitting infection in the LTCH
• Ensure that when isolating residents and restricting visitors that consideration is given to the potential impact these may have on resident physical, social and emotional well-being. Consider use of one-on-one programs, and use of technology to allow resident contact with family or friends

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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Centers for Disease Control and Prevention. Coronavirus Disease (COVID-19) Preparedness Checklist for Nursing Homes and other Long-Term Care Settings (2020). https://www.cdc.gov/coronavirus/2019-ncov/downloads/novel-coronavirus-2019-Nursing-Homes-Preparedness-Checklist_3_13.pdf

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Institut national de sante publique. Mesures exceptionnelles pour les équipements de protection individuelle lors de pandémie (April 1 2020). https://www.inspq.qc.ca/publications/2957-mesures-exceptionnelles-protection-individuelle-covid19

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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.