COVID-19: Staging environment

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Personal protective equipment (PPE)

The fundamental method of protecting workers is through the application of the hierarchy of hazard controls (NIOSH, January 13, 2015). Although PPE is the most visible of the hierarchy of controls, it is the last tier and should not be relied on as a standalone primary prevention program. The PPE tier refers to the availability, support and appropriate use of physical barriers between healthcare workers and an infectious agent/infected source to minimize exposure and prevent transmission (PHO, May 20, 2021).

An Organizational Risk Assessment should be performed in order to assess the efficacy of an organization’s hierarchy of controls, including the protocols for prioritizing and distributing PPE (PHO, May 20, 2021).

See Delivering patient care in-person and Delivering patient care remotely for information about logistics for different visit types.

*Image: The National Institute for Occupational Safety and Health (NIOSH)*

See Delivering patient care in-person and Delivering patient care remotely for information about logistics for different visit types.

What to wear, when

There are no changes to IPAC measures for COVID-19 variants of concern, as current evidence does not indicate that they are transmitted in different modes from other variants. However, due to the higher transmissibility of these variants, adherence to current IPAC measures remains especially important, with a lower margin of error (PHO, May 20, 2021).

Before every patient interaction, conduct a point-of-care risk assessment to determine the PPE required. See PHO’s advice on performing a risk assessment. At this time, vaccination status does not impact what PPE is required for HCWs or patients.

All patients (and those accompanying them) should wear a mask and perform hand hygiene while at the office/clinic, regardless of COVID-19 status. Patients who are symptomatic for COVID-19 or have a recent exposure MUST wear a surgical/procedure mask (MOH, July 28, 2021). A sample patient handout on wearing and disposing of masks is available on the OCFP’s Clinical Care – Office Readiness page.

For patients who screen negative for COVID-19: HCWs should wear a surgical/procedure mask for all interactions with and within 2 metres. If the patient is unmasked, eye protection (goggles or a face shield) is required. If the patient is masked for the entirety of the visit, eye protection may be used based on clinical discretion.

For patients who screen positive for COVID-19 (suspected or confirmed COVID-19 infection or contact): HCWs should follow Droplet and Contact Precautions for all interactions with and within 2 metres of patients this includes wearing the following PPE:

Surgical/procedure mask
Isolation gown
Gloves
Eye protection (goggles of face shield)

If HCWs are not able to follow droplet and contact precautions or are not knowledgeable on how to properly don and doff PPE, they should divert the care of the patient (e.g., to the emergency department, or to an assessment centre) as appropriate (MOH, July 28, 2021).

The circumstances in which airborne transmission is possible are not clearly established, however, it is recommended that airborne precautions be used when performing aerosol generating procedures (AGMPs) on patients with suspected or confirmed COVID-19 (OH, February 25, 2021). An N95 mask (not a medical/procedural mask) is used as part of airborne precautions, all other PPE is identical to droplet and contact precautions.

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Surgical mask

When to use
- Use for all patient encounters that involve less than 6 feet of separation, regardless of COVID-19 status.
When to discard
- Extend use as long as possible.
- Discard if wet, damaged, soiled, or removed (e.g. to eat or drink), or you exit the patient care area.
Eye protection (goggles or facemask)

When to use
- Use when providing care to a patient who has suspected or confirmed COVID-19.
- Consider using for all patient encounters that involve less than 6 feet of separation, regardless of COVID-19 status.
When to discard
- Extend use as long as possible if caring for multiple patients using contact and droplet precautions.
- Discard or sterilize according to manufacturer guidance after exiting patient room.
Isolation gown (disposable or cloth)

When to use
- Use when providing care to a patient who has suspected or confirmed COVID-19.
When to discard
- Discard after each patient encounter. Do not extend use of disposable isolation gowns between multiple patients with cofirmed COVID-19 infection unless gown supplies are limited.
- Launder cloth gowns according to routine practices (CDC). Do not take PPE home to launder.
Latex or nitrile gloves

When to use
- Use when providing care to a patient who has suspected or confirmed COVID-19.
When to discard
- Discard after any of the following: immediately after the activity for which they were used; when moving from a contaminated body site to a clean body site for the same patient; after touching a contaminated environmental surface; or when integrity of glove is compromised.
N95 mask*

* Not part of Droplet and Contact precautions (Medical/procedural masks suffice and should be used if available)

When to use
- Use when performing aerosol generating procedures (AGMPs) on a patient who has suspected or confirmed COVID-19
When to discard
- Discard after performing an AGMP on a patient who has suspected or confirmed COVID-19 (i.e. do not reuse for multiple AGMPs)
- Discard if wet, damaged, soiled, or removed (e.g., to eat or drink), or you exit the patient care area.

Adapted from:
IPAC Recommendations for Use of Personal Protective Equipment for Care of Individuals with Suspect or Confirmed COVID 19 (PHO, May 20, 2021
Optimizing the Supply of Personal Protective Equipment During the COVID-19 Pandemic (OH, February 25, 2021)
COVID-19 Guidance: Primary Care Providers in a Community Setting (MOH, November 9, 2020)
Non-Hospital Medical and Surgical Facilities Accreditation Standards: Hand Hygiene (College of Physicians & Surgeons of British Columbia, 2019)

See Extended use and reprocessing guidance for information on contingency and crisis strategies for optimizing PPE.

PPE inventory and quality control

Accessing PPE

Ontario Health has implemented the Pandemic PPE Transitional Support (PPTS) program, which will temporarily allow free access to PPE for primary care providers who do not have established PPE supply chains or whose supply chains have failed. This allows providers to effectively skip Step 3 of the escalation process below. For more information, see Pandemic PPE Transitional Support (PPTS) FAQs (OH, August 4, 2020).

The following escalation process provides steps for you to access PPE for your practice/organization (OH, 2020):

Step 1: Implement conservation and stewardship strategies to reduce the need for resupplying PPE.
Step 2: Use existing supply chain processes and collaboration with local partners to obtain supplies.
Step 3: Explore alternate inventories to obtain supplies.
- See the Ontario Workplace PPE Supplier Directory.
- See OMA’s Guide to PPE Drives.
- See the COVID-19 Personal Protective Equipment category of OMA’s eMarketplace.
Step 4:
- For Providers in Toronto, Central, North and East Regions: Use Ontario Health’s Critical PPE Intake Form to escalate to your Regional Lead.
- For Providers in West Region: Use the Urgent Pandemic Supply Request form to escalate to your Area Hubs, who may in turn escalate to your Regional Lead. As long as the PPTS program is active, use the PPE Pandemic Transitional Supports Order Form to obtain free PPE from the Ontario Health West Supply Chain.

Regional Leads – PPE and Critical Supplies

Toronto

Leads

Rob Burgess (Robert.Burgess@sunnybrook.ca)
Nancy Kraetschmer (Nancy.Kraetschmer@tc.lhins.on.ca)

Central

Leads

Susan Gibb (Susan.Gibb@lhins.on.ca)

North

Leads

Matthew Saj (sajm@tbh.net)

East

Leads

Paul McAuley (Paul.McAuley@3so.ca)
Shelley Moneta (Shelley.Moneta@lhins.on.ca)

West

Lead

Toby O’Hara (Toby.OHara@hmms.on.ca)

Inventory management initiatives

The MoH has issued an order for Mandatory Reporting of PPE Inventory, once per week, between Thursday and Monday. To report your PPE supply to the ministry, access the inventory reporting tool. The tool is open from 8 a.m. to 5 p.m. daily. Instructions for participation are published on the Ontario Health website.

Ontario Health has asked for healthcare providers to save and store used, unsoiled N95 unsoiled N95 respirators for decontamination using validated sterilization and disinfection methods. Store N95 respirators separately in labelled and dated storage containers.

To help extend the supply of PPE, Ontario Health suggests that providers switch to reusable PPE options wherever they can be safely implemented (OH, February 25, 2021).

Quality control

Health Canada is warning Canadians about counterfeit 3M N95 respirators in light of recent seizures of counterfeit products in Canada and at the United States border (Health Canada, April 15, 2021). Visit the 3M website for a hotline and published information on how to identify, prevent and report suspected fraud.

Health Canada is warning not to use masks labelled to contain graphene or biomass graphene, due to the potential for wearers to inhale graphene particles (Health Canada, April 2, 2021).

Confirm NIOSH approval # in the NIOSH database.

Ensure package and respirator have markings & details, as required by NIOSH.

Check for obvious signs of counterfeit (i.e. incorrect spelling).

Refer to the Government of Canada Specifications for COVID-19 Products site to confirm quality standards for other PPE.

Consult the PPE Supplier Validation Checklist (OMA, June 6, 2020) if you are purchasing PPE from a new supplier.

Donning and doffing PPE

The CDC recommends an additional handwashing step before putting on gloves. Frequent handwashing with or without adjunct antiseptics is a vital component of infection control.

Incorrect doffing is very common and leads to contamination of the healthcare worker, their clothes or the environment.

Common doffing errors:

Doffing gown from the front.
Removing face shield of the mask.
Touching potentially contaminated surfaces and PPE during doffing.

How to don PPE properly (Public Health Ontario, video, 2 minutes).

How to doff PPE properly (Public Health Ontario, video, 1 minute).

Putting it into practice

Donning

Doffing

Reducing discomfort associated with PPE use

Frequently asked questions (FAQs)

Maintain cool environment.
Topical moisturizers and petroleum jelly or baby napkin cream (only if use does not interfere with proper fit).
Use alternate mask type if one type is particularly irritating.
Take breaks from respirator use, with careful attention used when donning and doffing (especially when the respirator is being re-used).
Caps, headbands or fabric with buttons for straps of masks may reduce ear irritation but may increase pressure on front of face. This should only be done if it does not interfere with the proper fit of the PPE. These items must be integrated into proper donning/ doffing cycle and reprocessed or laundered appropriately with other PPE.

Use full face-shield.
Change to shorter, rotating shifts.
Lubricants to reduce friction between skin and goggles.
Avoid tight equipment.
Wet compression for severe skin indentations.
Avoid irritating agents when washing face.

For overheating: Avoid plastic gowns, maintain hydration, use shorter, rotating shifts and over-tight equipment.
For irritation: wear a barrier between body and PPE (unless overheating is issue) and avoid over-tight equipment.

Ensure hands are dry before donning gloves.
Choose non-irritating gloves (avoid latex).
Choose correct glove size.
Moisturize often, but avoid moisturizing immediately prior to donning gloves. Moisturizer is not sterile and can interfere with glove integrity.

Avoid hot water.
Rinse soap well.
Use hypoallergenic products (including at home).
Pat hands dry with paper towel instead of rubbing.
Moisturize often using a fragrance-free lotion or cream that contains humectants, fats and oils at least twice a day for prevention, and as often as feasible (including at work) for treatment.
Barrier cream efficacy unclear, such products are expensive, not removed by handwashing, and may = glove breakdown.
Avoid use of hand sanitizer immediately before or after handwashing.
Hand sanitizer is less likely to cause initial skin irritation than soap and water, but is more likely to cause acute pain once irritation occurs.
Ensure hands are dry before donning gloves.

Adapted from:
Gheisari et al., 2020.
Ong et al., 2020.
WHO Guidelines on Hand Hygiene in Health Care: First Global Patient Safety Challenge Clean Care is Safer Care (WHO, 2009).
Public Health Ontario Hand Care Program (PHO, 2009).

Emerging evidence

PPE extended use, reuse and reprocessing

Extended use involves wearing the same PPE across multiple patient encounters WITHOUT taking it off. Extended use carries less risk of self-contamination and is therefore preferred to reuse.
Reuse involves removal, storage, re-donning, and reuse of the same, potentially contaminated PPE items WITHOUT reprocessing in between. This is one of the principal sources of risk to health care workers (WHO, December 23, 2020).
Reprocessing involves sterilizing equipment for reuse. In the context of PPE shortages, re-processing refers to sterilizing single-use equipment that was not designed to maintain integrity during cleaning or across multiple uses. If available and intact, expired stockpiles of single-use PPE are preferable to reprocessing single-use PPE. (PHO, April 4, 2020).

Please note that extended use of surgical/procedural masks and eye protection (e.g. goggles or face shields) is now recommended in Ontario.

Do not combine extended use and reuse practices.
Take extra care when removing PPE, as this is when self-contamination may occur. If you touch or adjust PPE, immediately perform hand hygiene with soap and water or sanitizer for 20 seconds.
During Crisis capacity, unused, expired PPE items that have been stored in accordance with manufacturers’ storage conditions may be used, following inspection and testing to ensure they are not damaged (OH, February 25, 2021).

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Surgical mask

Contingency capacity
- Extend use of masks for repeated close encounters with several different patients without removing in between.
- Restrict facemasks to use for HCP rather than for patients for source control.
- When to discard: when the mask is wet, damaged, difficult to breathe through, soiled or removed.
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Crisis capacity

Implement limited reuse of facemasks by ONE HCP for multiple encounters with different patients – removing the mask after each encounter.

Selecting items for reuse: Facemasks with elastic ear hooks may be more suitable for reuse.

Use beyond shelf life

Intact masks with no visible signs of damage can be used beyond their shelf life. There is no specific timeframe beyond the expiry dates for masks at which they would no longer be considered suitable for use. Health Canada (4/17/2020)

Do not use masks if they are damaged, soiled, discoloured, or if any of the materials are degraded.

Removal and storage for reuse

As it is unknown what the potential contribution of contact transmission is for SARS-CoV-2, care should be taken to ensure that healthcare workers do not touch outer surfaces of the mask during care, and that mask removal and replacement be done in a careful and deliberate manner.

Face masks should be carefully folded so that the outer surface of the mask folds inward against itself, in order to prevent the outer surface of the mask from contacting other surfaces (including the storage bag/container).

The folded mask can be stored between uses in a clean sealable paper bag or breathable container. Consider adding a user identifier to the strap of the mask.

Storage containers should be labelled with the user’s name and disposed of or cleaned after each use.

When to discard/discontinue use

When the mask is wet, damaged, difficult to breathe through or soiled.

Place unsoiled, undamaged masks in a clearly labelled, dated receptacle for possible reprocessing after use. Use the bin only for surgical procedure masks.

Reprocessing

Currently there is no clear evidence supporting a validated method for sterilizing and disinfecting surgical/procedure masks

When no masks available

HCP might use homemade masks for care of patients with COVID-19, only as a last resort. This is not considered PPE.

Adapted from:
Optimizing Supply of Disposable Face Masks and Respirators (OMA).
Strategies to Optimize the Supply of PPE and Equipment (CDC, July 17, 2020).
Eye protection

The reuse of eye protection without appropriate reprocessing is strongly discouraged. See WHO Rational Use of PPE During COVID-19.

Contingency capacity
- Shift supply from disposable to reusable devices (i.e. goggles and reusable face shields).
- Ensure appropriate cleaning and disinfection between users.
- Extend use of disposable and reusable eye protection for repeated close encounters with several different patients without removing in between.
- While the use of both disposable and reusable eye protection can be extended, only reusable eye protection should be sterilized and used again according to usual practice. At the end of a shift, disposable eye protection should be discarded.
- When to remove: If it becomes visibly soiled or difficult to see through or if damaged (e.g. face shield can no longer fasten securely to the provider, if visibility is obscured and cleaning does not restore visibility).
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Crisis capacity

Consider using safety glasses (i.e. trauma glasses) that have extensions to cover the sides of eyes (CDC).

Cleaning guidance: Use manufacturer instructions.

When manufacturer instructions for cleaning and disinfection are unavailable, such as for single use disposable face shields, consider:

While wearing gloves, carefully wipe the inside, followed by the outside of the face shield or goggles using a clean cloth saturated with neutral detergent solution or cleaner wipe.

Carefully wipe the outside of the face shield or goggles using a wipe or clean cloth saturated with EPA-registered hospital disinfectant solution.

Wipe the outside of face shield or goggles with clean water or alcohol to remove residue.

Fully dry (air dry or use clean absorbent towels).

Remove gloves and perform hand hygiene.
Isolation gown (disposable or cloth)

The reuse of gowns without appropriate reprocessing is strongly discouraged. See: WHO Rational Use of PPE During COVID-19.

Contingency capacity
- Disposable gowns should be discarded, and cloth gowns laundered, after each patient encounter or after caring for multiple patients using contact and droplet precautions. Reusable (i.e. washable) gowns are typically made of polyester or polyester-cotton fabrics. Gowns made of these fabrics can be safely laundered according to routine procedures.
- Consider the use of coveralls.
- When to remove: Disposable gown should be discarded after each patient encounter. Cloth gowns should be laundered after each patient encounter. Do not take PPE home to launder.
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Crisis capacity

Extend use across multiple patients with the same infectious agent in the same location. This can be considered only if there are no additional co-infectious diagnoses transmitted by contact (such as C. difficile) among patients.

Reuse the same CLOTH gown after doffing without washing in between. Disposable gowns should NOT be reused as ties are likely to break during doffing process. Care should be taken to ensure that healthcare worker do not touch outer surfaces of the gown during care.

When to remove: If the gown becomes visibly soiled or after providing care to a patient (or cohort of patients) infected with the same infectious agent.

When no gowns available: Use labcoats, patient gowns, etc.

Adapted from: Strategies for Optimizing the Supply of Isolation Gowns (CDC).
Latex or nitrile gloves

Existing guidance advises against glove washing or reprocessing due to concerns over effectiveness of these practices due to potential loss of glove integrity (WHO, PHO, CPSBC).
N95 mask

All PPE used for aerosol-generating medical procedures (AGMPs), including N95 masks, should not be used for multiple patients.
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Crisis capacity

Use beyond shelf-life

Intact masks with no visible signs of damage can be used beyond their shelf-life. There is no specific timeframe beyond the expiry dates for masks at which they would no longer be considered suitable for use.

Do not use masks if they are damaged, soiled, discoloured, or if any of the materials are degraded.

Reprocessing

In settings where decontamination can be safely implemented, reprocess N95 respirators using validated sterilization and disinfection methods (OH, December 21, 2020).

Alternative respirators

If medical grade N95 masks are not available, consider using non-medical grade respirators, including N95, N99, N100, R95, R99, R100, P95, P99 or P100 masks. Do not use 3D-printed masks as an alternative.

Adapted from:
Optimizing the Supply of Personal Protective Equipment During the COVID-19 Pandemic (OH, February 25, 2021).
Strategies to Optimize the Supply of PPE and Equipment (Centers for Disease Control, July 17, 2020).

Top resources

Delivering patient care in person New

The following section has been reviewed and endorsed by the Provincial Primary Care Advisory Table established by the Ministry of Health. For more information, including organizations and members involved, see the Acknowledgement and legal section.

Last reviewed: January 26, 2021

Last updated: October 6, 2020

Step 1: Lay out a plan for mitigating COVID-19 transmission for in-person visits
Step 2: Assess possible mitigation strategies to determine feasibility for your practice setting
Step 3: Find a balance between remote and in-person care
Operational requirements for in-person care
Resources for implementation

Readiness assessment for delivering in-person care

The full spectrum of primary care services can be provided if safety protocols are implemented and capacity exists within the practice and local healthcare community. The CEP has developed this section to support primary care providers and their staff as they gradually increase the provision of in-person services during the COVID-19 pandemic. Adapted from the Ministry of Health’s COVID-19 Operational Requirements: Health Sector Restart (June 15, 2020), this section applies to all primary care settings.

While remote services should form the cornerstone of practice during the pandemic, clinics offering in-person visits should complete a risk assessment as per the Ministry of Health’s Directive #2. This section provides clear guidance on how to perform and implement a risk assessment in primary care. It represents the first step of an iterative process that will evolve in response to feedback and as COVID-19 evidence and best practices evolve.

Step 1: Lay out a plan for mitigating COVID-19 transmission for in-person visits

COVID-19 hazards are:

Person-to-person transmission (patients, staff, and visitors)
Surface transmission

Identify

Under what circumstances can transmission happen?

Consider all aspects of the work conducted in a clinical setting – people, places, equipment, and supplies. Include non-routine activities such as deliveries, maintenance and repairs.

Anticipate

What are factors contributing to high-risk scenarios?

Consider:

Patients at particular risk for worse outcomes (patients with comorbidities, older adults).
Patients at risk for transmitting disease (children, essential workers).
Foreseeable risks (cleaning products running out, patient tests positive after visiting office).
Training, skill, and experience of healthcare workers.

Prioritize

How likely are the possible consequences to occur?

Consider:

Probability: the likelihood of the hazard or risk occurring.
Frequency: how many people will be exposed and how often.
Severity: the potential for the hazard to cause serious harm.

Assess controls

Is the risk controlled effectively, or is further action required?

If further action is required, see Step 2 to assess mitigation strategies.

Adapted from the Canadian Centre for Occupational Health and Safety.

Step 2: Assess possible mitigation strategies to determine feasibility for your practice setting

Clinics should assess strategies methodologically to determine what measures are feasible for each unique setting. Remember that where feasible, strategies should be adopted based on effectiveness and not ease of implementation.

Control strategies

Listed in order of effectiveness for risk reduction from most effective to least effective