COVID-19: Staging environment

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.

Patient access

• Does the patient have access to the technology necessary to participate in remote visits? Telephone, internet/computer access?
• Do they have the financial resources to use technology for a remote visit? (Some patients don’t have/can’t afford a data plan that would support a consultation.)
• Does the patient have sufficient technological literacy to participate in remote visits? Download attachments, follow links, watch videos, send photos/videos?
• Does the patient have access to a quiet and private place, where confidentiality can be maintained?
• Are there language or other communication barriers that would make remote care difficult?

Clinical concerns

• Is a physical exam necessary for diagnosis, treatment, or management?
• See Determining when to schedule in-person vs remote visits for a guide on the problems that can be safely addressed and treated remotely.
• Can a provider do a brief check in to monitor any deterioration in symptoms and can patients easily update providers on any changes?
• Are there necessary measurements, scans, samples that can only be taken in-clinic? How often do these need to be taken?
• Do remote consultation tools allow for appropriate level of assessment? Do photos/videos allow for high enough resolution? What are the targets for home measurements?
• What is a reasonable amount of time for the patient to spend on the waitlist without negatively affecting health outcomes?
• Are self-management tools and supports available to help the patient manage their condition at home? Apps, worksheets, videos, patient educators, helplines?

Community capacity

• Would it be feasible to form a local network to “share” patients, as a way of expanding beyond the capacity of your individual setting?
• Are community services available for coordinated care? (Assessment centres, community laboratories, pharmacies, specialists, rehabilitation)
• How will community partners be impacted by an increase in services?
• Are provincial services available to support care (ie. If patient is requesting a pap test, are these currently being processed provincially?)

Patient communications

• Ensure patients know the clinic is open for services, as well as how to contact the clinic. Use physical signage, as well as outgoing voicemail and email signatures, and clinic website. Use physical signage for screening, hand hygiene, proper mask use, and respiratory etiquette. Signage should be accessible to all patients and visitors, reflecting the cultural context of the region and patient community. CMA has signage on high-level protections and symptoms available in English, French, Arabic, Cantonese, Mandarin, Punjabi, and Spanish.
• Communications should be clear and timely for patients to ensure support across the full continuum of care. Set expectations about what to expect for in-person and remote (virtual and telephone) visits, how to provide information (consent documents, self-monitoring logs), how information will be shared (prescriptions, referrals, self-management resources), and the process for scheduling follow-ups.
• Accept feedback and proactively request input. Identify patients/caregiver suggestions, expectations, and areas of concern.

Active screening

• 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.

Passive screening

• 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.

Care for positive-screened patients

• 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.

Care for negative-screened patients

• 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.

Testing

• 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.)

Operational assessment

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

Employer responsibilities

• 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.

Physical areas

• 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.

Daily operations

• 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.

Healthcare worker infection control

• 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.

Cleaning

• 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.

Foundational/broad overview resources

• COVID-19 Operational Requirements: Health Sector Restart (MOH).
• Directive #2 (MOH).
• Guidance for Primary Care Providers in a Community Setting (MOH).
• Preparing to Resume In-Person Care: A COVID-19 checklist for community-based practices (OMA).
• COVID-19 resource centre (CEP).
• Maintaining Regular Primary Care Practice in the COVID-19 Context (CEP).
• Canadian Centre for Occupational Health and Safety.
• Ontario public health units.

COVID-19 screening, assessment, testing, signage

• How to self-monitor (PHO).
• Screening guidance (PHO).
• COVID-19 Assessment centres.
• COVID-19 Testing information (PHO).
• Reference document: COVID-19 symptoms (MOH).
• English and French passive screening signage (MOH).
• English, French, Arabic, Cantonese, Mandarin, Punjabi, and Spanish signage (CMA).
• Cover your cough signage (PAHO).
• COVID-19 hand hygiene (PHO).
• Safely use non-medical face covering (Health Canada).

Healthcare worker infection control

• POC Risk Assessment flowchart (PHO).
• HCW: Working while self-isolating (PHO).
• COVID-19 Quick Reference Public Health Guidance on Testing and Clearance (MOH).
• PPE for in-person visits (OCFP).
• Donning and doffing (PHO).
• PPE supplier validation checklist (OMA).
• Provincial PPE Supplier Directory.
• Ontario Regional Leads.
• Environmental and equipment cleaning (BCCDC).

Decision-making supports for service expansion

• COVID-19 Local surveillance data (PHO).
• Virtual Care Playbook (CMA).
• COVID-19: Local service availability (CEP and thehealthline.ca).

That can be safely assessed and treated remotely (Virtual Care Playbook, CMA, 2020):

• Mental health issues.
• Skin problems (have patient submit photos in advance as resolution is much better than a high-quality video camera).
• Urinary, sinus and minor skin infections (pharyngitis too if you can arrange throat swabs).
• Sexual health care, including screening and treatment for sexually transmitted infections, and hormonal/oral contraception.
• Travel medicine.
• Conditions monitored with home devices and/or lab tests (e.g., hypertension, lipid management, thyroid conditions and some diabetes care; in-person consultations will still be needed for some exam elements).
• Lab, imaging and specialist reports.
• Other assessments that do not require palpation or auscultation.

That may warrant an in-person visit (OCFP, March 26, 2020):

• Non-infectious complaints of an acute nature:
  • Neurological complaints
  • lacerations/incision and drainage
  • abdominal pain
  • gynaecological disorders
  • potential exacerbation of a chronic condition (like COPD or heart failure)
• Low-risk prenatal care (see Prenatal and postnatal care)
• Well child visits (see Prenatal and postnatal care)
• Allergy shots (for only those severely affected by deferring visit)
• Immunizations (see Interim guidance on continuity of immunization programs during the COVID-19 pandemic (Government of Canada, May 13, 2020))

When businesses and schools reopen

• Acute or subacute symptoms
• Potentially unstable chronic disease, such as post-myocardial infarction, post-stroke, congestive heart failure (CHF), uncontrolled diabetes, cancer
• Severe or unstable mental health diagnoses
• Pre-existing developmental concerns among infants / children
• Pregnancy and newborn care
• Mental Health visits, if concerned destabilization will result without in-person visit
• Other matters presenting risk, for example addiction, at-risk sexual practices
• IUD insertion/removal, endometrial biopsy
• Skin biopsies (for suspected melanoma)
• Injections (anti-psychotics, Depo-Provera, Prolia, methotrexate, etc)
• Adult vaccines (Prevnar/Pneumovax)
• Joint injections for chronic/acute pain
• Allergy shots (if office space allows)
• Suture removal
• Palliative care visits (office or home)
• MAID requests
• Driver’s Medicals/3rd party medicals for essential service workers

When pandemic epidemiology is stable

• Chronic symptoms
• Well infant / child visits
• Contraception
• Chronic diseases previously well controlled, requiring interval follow-up (diabetes, hypertension, renal insufficiency, stable CHF, mental health diagnoses)
• Adult immunizations (routine Shingrix, Tdap, etc)
• Driver’s Medicals/3rd party medicals for non-essential services
• Pap smears for follow-up of prior abnormal
• Mental Health (routine visits)
• ENT, cardiac, GU non-urgent issues requiring exam
• Deaf or vulnerable patients unable to have virtual visits (if non-urgent concern)
• Skin exams if photo/video insufficient
• Skin biopsies (for non-melanoma lesions)
• Liquid nitrogen treatments (warts, AKs)

When pandemic epidemiology is stable, physical distancing requirements are lifted, most activities have returned to normal

• Blood pressure checks for those without chronic disease
• Sexually transmitted infection screening in average risk individuals
• Cancer screening: cervix and colon, then breast
  • For cervical cancer screening in individuals without a history of abnormal lesions there is no rush to do a Pap test even if it has been a bit more than 3 years. Some countries do Pap tests every five years, with no difference in cervical cancer mortality (Milbank Quarterly, 2012).
  • For breast screening, considering low effect size of screening and CTFPHC recommendation for 2-3 year screening, this could wait until 3 years (CTFPHC, 2018).
• Meet and greets for new patients
• Routine PAP
• Periodic/Preventative Care Reviews
• B12 injections
• Diabetic checks
• Hypertension review
• Stable CHF/COPD visits
• Contraception review
• STI screening
• Smoking cessation

When capacity exists

• Patient-initiated health promotion