COVID-19: Staging environment

• 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.

• Patients and visitors should be screened over the phone before coming to the clinic.
• Where patients present in-person without phone screening, patients and visitors should be screened upon arrival at the clinic.
• If they screen positive, appointment should be deferred if possible and the individual referred for testing. If the appointment is urgent, refer the patient to the emergency room.
• If a patient screens negative, appointment can be made. Remind the patient that if they develop symptoms between the time of the phone screening and the appointment, they should call the clinic for further instructions instead of coming in person.
• Patients and visitors should be screened on-site before entering the clinic.
• Patients and visitors should wear their own face covering. If they do not have one, provide one prior to entrance.
• In-person screening must include staff protection as follows:
  • Best option: staff should be behind a plexiglass barrier.
  • Second option: If a barrier is not available, a 2-metre distance should be kept between screening staff and individuals being screened.
  • Last resort: if a barrier is not available and 2-metre distance is not possible, screening staff should wear PPE according to Droplet and Contact precautions.
• If an individual screens positive, appointment should be deferred if it will not compromise patient safety, and the individual referred for testing.
• Visitors who screen positive should not be permitted to accompany or visit the patient, pending test results. If the patient cannot attend the visit without the visitor, reschedule the visit for when an alternative visitor can accompany the patient.

• Information about screening should be included on outgoing voicemail and email signatures, appointment confirmations, and clinic website, with links to the provincial online self-assessment tool where applicable.
• Signage must be posted at the entrance to the clinic and in the reception area, requiring all patients and visitors to wear face coverings (if available and tolerated), perform hand hygiene, and report to reception to self-identify.
• Signage should be accessible to all patients and visitors, reflecting the cultural context of the region and patient community. Download signage on MOH site, or see CMA’s resources in English, French, Arabic, Cantonese, Mandarin, Punjabi, and Spanish.

• Before every patient interaction, healthcare workers must conduct a point-of-care risk assessment to determine the level of precautions required.
• Healthcare providers may provide care to patients who screen positive for COVID-19 only if they have the PPE required to follow Droplet and Contact precautions ((Surgical/procedural mask, isolation gown, gloves, eye protection -goggles or face shield)and the sufficient knowledge to follow proper donning and doffing procedures. Practice donning and doffing with a buddy if staff are still being trained on procedures.
• If your setting does not meet these requirements, divert the care of the patient:
  • to the emergency department if the medical reason for the appointment is urgent
  • to assessment centre for assessment and testing if the medical reason for the appointment is not urgent. In the instance where the assessment centre is only able to provide a swab, and not manage the clinical presentation, a follow up appt should be booked when swab result is negative to finish assessment and management
• Patients who screen positive should be given a surgical mask and perform hand hygiene.
• The patient should be isolated.
• If an exam room is available, place the patient in the room with the door closed, avoiding contact with other patients if possible.
• If an exam room is not available, instruct the patient to wait outside the clinic and call/text them when a room is available.
• In the exam room, the patient should have access to tissues, hand sanitizer, and a touch-free/foot pedal-operated wastebasket.
• Instruct patient to take their mask home with them (do not leave in waiting room) and provide information on doffing procedures.

• Mask required and eye protection recommended for interactions with and within 2 meters of patients who screen negative.
• No gown or gloves unless consistent with Routine Practices for specific patient symptoms.
• Request all patients and visitors keep masks on.

• All patients with at least one symptom should be tested.
  • Asymptomatic patients who are concerned they have been exposed to COVID-19 should be tested.
  • Asymptomatic patients who are at risk of exposure through their work (essential workers) should be tested.
• If your setting is equipped, testing can happen on-site. All testing requires full droplet and contact PPE, even if the patient is asymptomatic.
• If not equipped to offer testing, cases should be referred elsewhere (an assessment centre, Telehealth, etc.)

• Use the Readiness assessment for primary care settings to develop strategies to mitigate risk of COVID-19 transmission.

• Have written measures for staff safety, including infection monitoring and control.
• Ensure stable supply of essential supplies (drugs, PPE, hand hygiene and cleaning supplies).
• Source and provide PPE through the regular supply chain, including regional leads or the provincial PPE Supplier Directory.
• Ensure adequate staffing for services. Use information from Readiness assessment for primary care settings to ensure staffing needs are aligned with PPE availability. Consider preserving staff capacity where possible in preparation for future outbreaks.
• Ensure service offerings align with related services such as laboratory diagnostics, rehabilitation, etc.
• Work collaboratively with local region and other primary care providers where possible to ensure coordinated service offerings.

• Ensure there is sufficient space to maintain 2-metre social distancing between people.
• Redesign physical settings and interactions to minimize contact.
• Provide face coverings where physical distancing is not possible.
• Request all patients and visitors wear face coverings if they have them.
• Provide tissues and lined garbage bins for patients and staff.
• Ensure sufficient supplies for proper hand hygiene: hand washing stations and 70% alcohol hand sanitizer.
• Post signage about symptom screening, hand hygiene, proper mask use, and respiratory etiquette. CMA has signage on high-level protections and symptoms available in English, French, Arabic, Cantonese, Mandarin, Punjabi, and Spanish.

• Employers and healthcare workers should determine which visitors are essential, and restrict all other visitors from entering the clinic.
• Where possible, schedule symptomatic patients for end-of-day visits.
• Minimize the time patients spend in the waiting room. If possible for patient, have them wait outside or in the car – otherwise, stagger appointments so that social distancing can be maintained.
• Minimize staff in the healthcare setting. Consider which roles can be performed remotely, or develop shifts to meet the necessary number of on-site staff while ensuring social distancing.
• Ensure healthcare workers, staff, and patients use proper PPE across clinic settings and have adequate observed training in donning and doffing.
• Healthcare providers should preserve the use of PPE by applying other mitigation strategies identified through the Readiness assessment for primary care settings.
• If a patient comes into the setting and later tests positive, contact local health unit for advice and guidance about the risk of possible exposure for healthcare workers.

• Staff should self-monitor for symptoms and not come to work if they develop symptoms. Consider using a daily screening form, log or app for staff as a prompt for this.
• Ensure there is space to isolate healthcare staff who develop symptoms.
• If a healthcare worker develops symptoms at work, they should put on a mask if not already wearing one, isolate, and they should be sent home as soon as possible.
• If they are critical to operations, healthcare workers who have returned from travel within the last 14 days (outside of Canada or from a COVID infected area within Canada) or had a confirmed exposure to a COVID-19-positive patient must self-monitor for symptoms but may continue to work with specific precautions.

• After every patient visit (symptomatic or asymptomatic), sanitize treatment areas, horizontal surfaces and equipment before another patient is brought in. Remember to include administrative equipment – mouse, keyboard, printer, etc.
• All common areas should be regularly cleaned, at least twice daily.
• Plexiglass barriers should be integrated into cleaning schedule and cleaned daily.
• Non-essential items should be removed from patient care areas to avoid contamination.

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