COVID-19: Staging environment

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Flu vaccination and flu vaccination clinics during COVID-19: 2021-2022 update New

Original content for this section was developed with input from and support by Ontario College of Family Physicians (OCFP), Ontario Medical Association (OMA), Association of Family Health Teams of Ontario (AFHTO), Ontario Medical Association (OMA) SGFP, Nurse Practitioners’ Association of Ontario (NPAO) and Registered Nurses’ Association of Ontario (RNAO).

It was reviewed and endorsed in 2020 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.

Subsequent updates are developed by CEP.

Primary care has a critical role to play in the effort for a successful flu campaign. Aside from physically administering the vaccine, communication by trusted health professionals about the importance of the vaccine is directly linked to its uptake: 69% of survey respondents reported that the opinion of their family doctor, general practitioner or nurse practitioner was an important factor in their decision to get the flu vaccine. (PHAC, 2019).

Key health professional groups should consider engaging in or supporting public education campaigns related to the importance of receiving the flu vaccination, the variety of options available, the safety precautions in place and the need to plan in advance.

Frequently asked questions for 2021-2022 flu season

  • No. During the COVID-19 pandemic, individuals with any symptoms of acute respiratory infection, including minor symptoms such as sore throat or runny nose, should defer influenza vaccination until they have recovered, as they can pose an unnecessary risk to others and healthcare providers if they have COVID-19 (PHAC)
  • No. Individuals with suspected, probable, or confirmed COVID-19 and those who are close contacts of a case should defer influenza vaccination during their period of quarantine or isolation. Vaccination should be deferred until the individual is no longer required to isolate according to criteria indicated by public health authorities in their province or territory. (PHAC)
  • Yes. NACI now recommends that COVID-19 vaccines may be given at the same time as, or any time before or after, other vaccines, including live, non-live, adjuvanted or unadjuvanted vaccines. (NACI, Sept 28, 2021)
  • The province is monitoring COVID-19 testing wait times, and the Chief Medical Officer of Health has stated that more assessment centres will open this fall if necessary.
To support widespread flu vaccination during the COVID-19 pandemic, it is recommended that healthcare providers:
  • Receive influenza vaccine themselves to help prevent transmission of influenza to their patients.
  • Recommend patients receive the vaccine. Communication by trusted health professionals about the importance of the vaccine is directly linked to its uptake.
  • Use every opportunity to vaccinate people at risk, even after influenza activity has been documented in the community.
  • Discuss the risks and benefits of the vaccine with patients, as well as the risks of not being vaccinated.
  • Remind patients about influenza prevention practices.
  • Consider engaging in or supporting public education campaigns related to the importance of receiving the flu vaccination, the variety of options available, the safety precautions in place and the need to plan in advance.

What’s new for 2021-2022 flu vaccination

Simultaneous vaccination
  • New NACI guidance states it is safe for patients to receive the flu and COVID vaccines at the same time or within days of each other. Same day administration is preferred, and vaccines administered during the same visit should be administered at different injection sites. (NACI, Sept 28, 2021)
Mammalian cell-based influenza vaccine
  • Flucelvax® Quad (Seqirus) standard dose mammalian cell culture-based quadrivalent inactivated influenza vaccine is now authorized by Health Canada for use in persons ≥2 years of age.
Screening
  • Patients cannot be denied access to a flu vaccination clinic based on their COVID-19 vaccination status.
Early flu vaccination
  • Early influenza vaccination is only for those at high risk of flu-related complications and health care workers. Flu vaccine for the public can be given starting in November.  Providers wishing to conduct large-scale community flu vaccination clinics should wait until November to ensure that an adequate supply of flu vaccine can be ordered based on the available provincial supply
Reduced observation period post-vaccination
  • Evidence shows that many anaphylactic reactions occur between 0 to 15 minutes post-vaccination. Some but not all anaphylactic reactions will be captured in the first 5 minutes; syncope occurred very quickly, and seizures often occurred after 15 minutes.
  • The risk of COVID-19 transmission in a given immunization setting will vary; a risk assessment should be used based on local COVID-19 prevalence to weigh the risks of not identifying serious adverse events vs. the benefits of less interaction between people.
  • Cell-based vaccine recipients should not be considered for reduced post-vaccination observation time.

A shorter observation period should be considered only if the recipient:

  • has a past history of receipt of influenza vaccine;
  • has no known history of severe allergic reactions to any component of the influenza vaccine being considered for administration;
  • no history of other immediate post-vaccination reactions (e.g., syncope with or without seizure) after receipt of vaccines;
  • will not be operating a motorized vehicle or self-propelled or motorized wheeled transportation (e.g., bicycle, skateboard, rollerblades, scooter), or machinery for a minimum of 15 minutes after vaccination; and
  • is accompanied by a responsible adult/parent, who is not getting vaccinated at the same time, who will act as a chaperone to monitor the vaccine recipient for a minimum of 15 minutes post-vaccination. This is a requirement for children and adults. Chaperones can also receive the vaccine as long as each adult agrees to observe the other. The vaccine recipient and chaperone must be aware of when and how to seek post-vaccination advice and given instructions on what to do if assistance and medical services are required; and agree to remain in the post-vaccination waiting area for the post-vaccination observation period (5 minutes) and to notify staff if the recipient feels or looks at all unwell before leaving which would necessitate a longer observation period.

Vaccination in primary care

Though COVID-19 has created a complex environment for vaccination delivery, family physicians, nurse practitioners and registered nurses should maximize all opportunities to administer the flu vaccine. Practices will need to consider alternate means of delivery for the 2020-2021 season and develop outreach strategies. In some regions, Ontario Health Teams, in partnership with local long-term care facilities and home-care agencies, hope to work with community-based practices to administer the vaccine to vulnerable or housebound persons and to those living in congregate settings.

Putting it into practice

Opportunistic immunization

  • Provide immunization to patients and their accompanying persons when they are seen for other reasons.
  • Provide immunization during home care visits and, when feasible, in partnership with accompanying home care agencies.

All Ontarians over 6 months of age should be vaccinated. During the pandemic, concerted efforts should be made to vaccinate:

  • Anyone who is at high risk of severe COVID-19 related illness:
    • Older adults, especially over 65
    • Those with chronic medical conditions (lung disease, heart disease, diabetes, hypertension, etc.)
    • Those who are immunocompromised, with an underlying medical condition or taking medications that lower the immune system
    • People living with obesity (BMI of 40 or higher)
  • Anyone who is capable of transmitting influenza to those at high risk of severe and critical illness related to COVID-19, such as those with high-risk family members, or caregivers of high-risk individuals
  • Essential workers: health care workers, teachers, bus drivers, retail workers, grocery store clerks, etc.

Leverage your EMR to identify patients

When running reports in your EMR to identify patients consider the following:

  • Structured information (birthdate, sex) is typically the most easily queried.
  • You can use your EMR to search for specific health condition, immunization history, last visit date and other information about your practice. You can generate a report to pull the data from the EMR.
  • Consider creating searches using the patient’s CPP (e.g. Problems/Diagnosis list).
  • Reports particularly useful at this time would include:
    • Specific chronic conditions
    • A combination of last date seen OR last note made OR last date billed within your chosen date range (last 6 months, last 9 months, etc)
    • Preventative Care Queries/Preventative Care Summary Reports for active patients in need of cancer screening

If you are unsure of how to use your EMR to support proactive panel management, there are free Ontario MD resources to help you:

  • i4C Advisory Service: Free service providing hands-on support from OMD Practice Advisors and Peer Leaders to create an enhancement plan reflecting individual practice priorities.
  • Peer Leaders: Peer Leaders work one-on-one to help providers get more value from their certified EMR.

EMR Progress Assessment Tool: Free, evidence-based, online self-assessment for providers to assess their EMR use and make improvements to enhance patient care. The EPA investigates key functional areas: Practice management, information management, and diagnosis/treatment support.

Operating a flu vaccination clinic

If your clinic doesn’t have the resources to run a vaccination clinic:
  • Consider forming a cooperative clinic with other local medical practices, NP clinics, or home care providers.
  • Consider dedicating time each week to home vaccination visits for seniors, patients with mobility issues, and children 6 months to 6 years who are not eligible for vaccination at a pharmacy.
  • Consider partnering with home care agencies or sending primary care physicians/nurses to patient’s homes.
  • Direct patients to flu vaccination sites in your region. See Ontario flu vaccination clinics by region (CEP, TheHealthLine, 2020).

Selecting a type of clinic

General considerations during the COVID-19 pandemic:
  • Clinic locations and processes that were successful in previous years might not be appropriate due to COVID-era safety precautions. Even if the same space is used, it will likely need to be set up and function differently.
  • Outdoor clinics and smaller indoor clinics may provide the best option for staff and patient safety, weather permitting.
Consider populations to be served, environmental conditions, and individual site capability when selecting the type of clinic. Options include:
  • Office-based clinics
  • Offsite indoor clinics: held in indoor locations such as a school, church, auditorium, theatre, pharmacy, or inside a medical facility in a hallway, classroom, or cafeteria.
  • Walk-through clinics: held in an outdoor tent outside a medical facility.
  • Curbside or drive-through clinics: larger-scale operations held at fixed or rotating locations, including community buildings with a marquee, car washes, warehouses, insurance inspection stations, arena parking lots or drive-through tents erected for the occasion.
  • Mobile clinics: held out of vans or buses

Clinic implementation checklists

Click below on the implementation checklists for information and actionable advice on:

  • setting up your clinic: selecting a location, clinic layout, patient flow, accessibility, signage, supplies and utility considerations
  • operating your clinic: scheduling and booking appointments, staffing, cleaning, screening and vaccine administration
  • cold chain management: setup, storage, daily checklist and anticipating power outages

Additional resources

Primary care assessment and testing for COVID-19

Jump to:

Screening

If a patient thinks they have symptoms, or is worried they have been exposed to COVID-19, they should complete the provincial COVID-19 Self-Assessment which gives guidance tailored to self-reported symptoms and exposure. If responses indicate possible COVID-19, patients will be directed to contact you as their family physician/primary care nurse practitioner, or Telehealth Ontario.

Putting it into practice

Patients with possible COVID-19 should be screened by video or phone, not in person. If an in-person visit is necessary and feasible, patients should be advised to wear their own mask (cloth or other) to the office/clinic, if available, and the primary care setting should undertake the following active and passive screening.

Passive screening
  • Post information on clinic website or send an email to all patients on screening requirements and advise them to call prior to coming to the office/clinic. Consider mailing by post for those patients without email and/or internet.
  • Where possible, post signage outside the office/clinic asking patients to call before entry for appropriate screening and direction.
  • Post signage at the office/clinic entrance and at reception reminding patients that, regardless of symptoms, they are expected to wear a mask for the entirety of their visit and perform hand hygiene before reporting to reception. If office/clinic is in a shared building, post signage at building entrance.
Active screening
If a patient presents with symptoms and/or exposure to COVID-19:

Patients with severe symptoms should be directed to the emergency department. Otherwise, patients should be instructed to self-isolate until further discussion with their primary care provider.

Patients should be offered an assessment by video or phone, ideally on the same day. This discussion should include a thorough history-taking and assessment of symptoms and managing them, even if COVID-19 testing is being considered as part of the diagnostic plan.

Patients should be provided with a surgical/procedure mask and be advised to perform hand hygiene. Ensure patients do not leave their masks in waiting areas.

Patients should be immediately placed in an exam room alone with the door closed to avoid contact with other patients the office/clinic. If the is not possible, instruct patients to return outside (e.g. vehicle or parking lot, if available and appropriate) and inform them they will be texted or called when a room becomes available.

Patients should be provided with hand sanitizer (if available), access to tissue and a hands-free waste receptacle for their used tissues and used masks.

Instruct patients to cover their nose and mouth with a tissue when coughing and sneezing, dispose of the tissue in the receptacle and to use the hand sanitizer right afterwards. Patients may also be instructed to take their surgical/procedure mask home with them with instructions for doffing masks.

Assessment

Patients with possible COVID-19 should be assessed by video or phone, not in person. If patients screen positive in-person, you may offer clinical assessment and examination only if you can follow Droplet and Contact precautions and know how to properly don and doff PPE, including gloves, gown, a surgical/procedure mask, and eye protection (goggles, face shield). See Primary Care Operations in the COVID-19 Context > Personal protective equipment (PPE) for details.

Any persons experiencing one of the following should be told to self-isolate and tested as soon as possible. When assessing for the symptoms below, focus on evaluating if they are new, worsening, or different from an individual’s baseline health status. Symptoms should not be chronic or related to other known causes or conditions:

  • Fever (temperature of 37.8°C or greater)
  • Cough, including croup (barking cough, making a whistling noise when breathing)
  • Shortness of breath (dyspnea, out of breath, unable to breathe deeply, wheeze)
  • Sore throat (painful or difficulty swallowing)
  • Rhinorrhea (runny nose)
  • Nasal congestion (stuffy nose)
  • New olfactory or taste disorder (decrease or loss of smell or taste)
  • Nausea and/or vomiting, diarrhea, persistent/ongoing abdominal pain
  • Chills
  • Headaches (new and persistent, unusual, unexplained, or long-lasting)
  • Conjunctivitis (pink eye)
  • Fatigue, lethargy, or malaise (general feeling of being unwell, lack of energy, extreme tiredness)
  • Myalgias (muscle aches and pain)
  • Decreased or lack of appetite (for young children); difficulty feeding in infants
  • New or unusual exacerbation of chronic conditions
  • Tachycardia (fast heart rate; including age specific tachycardia for children)
  • Low blood pressure for age
  • Hypoxia (i.e. oxygen saturation less than 92%)
  • Delirium (acutely altered mental status and inattention)
  • Increased number of falls in older persons
  • Acute functional decline
  • Contact with a confirmed case in the last 14 days without proper PPE

See COVID-19 Reference Document for Symptoms (MOH, September 21, 2020) for a full list of signs and symptoms and examples of when symptoms may be related to other causes or conditions.

Keep in mind

A systematic review of 131 studies found that fever and cough were the most common symptoms, followed by nasal congestion, fatigue and sore throat, while approximately 19% of children were asymptomatic (EClinicalMedicine, June 26, 2020).

In addition to the symptoms most commonly associated with COVID-19, other atypical symptoms/signs should be considered in children (MOH, September 21, 2020). These symptoms/signs include:

For suggested criteria for assessing the severity of COVID-19 disease in children, see The acute management of paediatric coronavirus disease 2019 (CPS, April 20, 2020).

It’s important to monitor atypical symptoms because COVID-19 presents itself differently among older adults. For example, an older patient may not experience a fever or may experience unexplained or an increased number of falls (RGP, April 2, 2020; MOH, September 21, 2020).

Refer to the Atypical COVID-19 Presentations in Frail Older Adults (RGP, April 2, 2020) for a summary of what to look for such as:

  • Milder symptoms
  • Delirium or acute functional decline
  • Little or no temperature elevation
  • Mild hypoxia (O2S <90%) without respiratory symptoms
  • Unexplained or increased number of falls

When assessing patients by telephone or video, use the COVID-19 remote consultations infographic (BMJ, March 25, 2020) for guidance on setting up, connecting, taking a history and examination.

Although there are no evidence-based methods for assessing shortness of breath (dyspnea) by telephone or video, experts have recommended asking patients 7 key questions (Centre for Evidence-Based Medicine, March 23, 2020).

For information on differentiating between COVID-19 and heart failure exacerbation symptoms in patients with known heart failure, see Is it COVID-19 or Is It Heart Failure? (Canadian Cardiovascular Society, April 1, 2020).

Next steps based on symptoms and exposure:
  • Send patient to emergency department. Phone ahead and arrange safe transfer of patient to minimize contact/spread.
  • Tell patient to self-isolate immediately.

Testing

Frequently asked questions (FAQs)

Testing is available for the following populations:

  1. All people with at least one symptom of COVID-19.
  2. Asymptomatic people who have received a positive antigen point-of-care test result.
  3. Asymptomatic people who have been exposed to COVID-19, including people who are contacts of or may have been exposed to a confirmed case.
  4. Asymptomatic people who are at risk of exposure to COVID-19, including workers, residents and visitors of high-risk settings (e.g., long-term care homes, homeless shelters and other congregate settings). This includes residents and workers at specific outbreak sites.
  5. Asymptomatic people from certain populations but without known high-risk exposure may be considered for testing. This includes any individual identifies as part of a targeted testing campaign. For a list of groups, see COVID-19 Provincial Testing Guidance Update (May 26, 2021).

 

Adapted from COVID-19 Provincial Testing Guidance Update (MOH, May 26, 2021) and Additional Direction on Testing Strategy (MOH, May 24, 2020).

Testing in the primary care office/clinic can only be performed if the primary care provider is able to:

  • follow Droplet and Contact precautions outlined by the Ministry of Health (November 9, 2020);
  • has the appropriate tools and knowledge of how to test; and
  • can ensure coordination of sample delivery to the Public Health Ontario Laboratory or an alternative laboratory providing COVID-19 testing.

A single upper respiratory tract specimen will be accepted for COVID-19 testing, including nasopharyngeal swab (NPS), deep nasal swab, anterior nasal swab or viral throat swab. NPS is the preferred specimen when swabs are available, followed by deep nasal swab. Due to global shortages, Public Health Ontario (April 30, 2021) has provided information on alternative collection kits that are acceptable for COVID-19 testing (see Specimen Collection and Handling).

Nasopharyngeal swab collection is not considered an aerosol generating procedure and can be performed in the office/clinic with appropriate contact/droplet precautions of gloves, gown, surgical/procedure mask, and eye protection (e.g., goggles, face shield). This is important as many people will cough or sneeze when the nasal swab is done. Links to resources on properly conducting NP swabs are available under ‘COVID-19 Care’ on OCFP’s Clinical Care- Office Readiness page.

If testing is conducted in the office/clinic, it is important to conduct the nasopharyngeal swab properly to minimize the risk of a false negative sample:

  • Pre-label the swab so, once obtained, it can be placed in the bag without further handling.
  • Place the specimen in the bag, and place the completed requisition in the attached pouch.

Diagnosing COVID-19 is done by laboratory testing (NAAT result by PCR or nucleic acid sequencing) on at least one specific genome target.

Symptomatic patients

  • A single positive result is sufficient to confirm COVID-19.
  • A single negative result is sufficient to exclude COVID-19.

Asymptomatic patients

  • A positive result might represent one of the following scenarios:
    • current COVID-19 infection that is asymptomatic or pre-symptomatic, OR
    • prior COVID-19 infection (+/- symptoms) as testing can remain positive for several weeks after infection, OR
    • false positive result.
  • If a patient has a medium/high pre-test probability of infection, a single positive result is sufficient to confirm current or prior infection.
  • If a patient has a low pre-test probability of infection, a positive result should be immediately retested and may be cleared with a single negative retest (MOH, May 6, 2021). The patient must be managed as if they have current COVID-19 infection (i.e., immediate self-isolation) until cleared.
  • A single negative result is sufficient to exclude COVID-19.

In a patient who tested positive for COVID-19 AND was cleared, retesting should generally not be done due to persistent shedding (viral detection has been identified in some cases well beyond 4 weeks (>70 days) in some cases).

If the patient is within their 14-day self-isolation due to known exposure, the patient should remain in self-isolation for the rest of the 14-day period, regardless of the negative result.

See COVID-19 Quick Reference Public Health Guidance on Testing and Clearance (MOH, May 21, 2021) for more detailed information.

A recent study retroactively compared the results from 353 patients who received both OP and NP simultaneously, and found that 73.1% of NP-positive cases were negative in OP swab. The authors concluded that while use of both swabs slightly increased the positive rate over using NP swab only, NP swabs “may be more suitable” than oropharyngeal swab (Int. J. Infect. Dis., April 22, 2020).

Testing for COVID-19 involves sending a respiratory tract specimen – nasopharyngeal swab (NPS) or viral throat swab; NPS is preferred– to a PHO laboratory or other suitable laboratory with capacity for RT-PCR testing. RT-PCR is a type of nucleic acid amplification testing (NAAT), the gold standard used in Canada and abroad for the diagnosis of active COVID-19 infection, that tests for the presence of viral RNA during active infection (Health Canada, May 26, 2021). At this time, serology testing and antigen testing should not be used for diagnosis of acute COVID-19 infection (MOH, May 26, 2021).

Click here for a list of testing devices authorized by Health Canada.

The turnaround time for COVID-19 testing at a PHO Laboratory is for 60% of results to be completed within 24 hours and 80% to be completed within 48, but will vary depending on what laboratory performs the testing (PHO, April 30, 2021).

As of September 10, 2020, PHO Laboratory implemented a validated pooling approach to testing, which will allow an increase in testing throughput without greatly compromising sensitivity (PHO, March 30, 2021) . For pooled testing, a portion of three individual specimens are combined into a single pool and run on the SARS-CoV-2 PCR assay as a single test.

  • If the pool result is NOT DETECTED, all three specimens are individually reported as NOT DETECTED.
  • If the pool result is DETECTED, INDETERMINATE or INVALD, each individual specimen is tested individually and reported based on individual result obtained. ­­­­

Health Canada is prioritizing the review of point-of-care tests intended to diagnose COVID-19, including both nucleic acid-based tests and antigen-based tests, and have authorized several tests (Health Canada, May 26, 2021).

Click here for a list of testing devices authorized by Health Canada.

At this time, a positive result on a rapid test is considered a preliminary positive and should have a parallel sample taken for a confirmatory laboratory-PCR test (MOH, May 26, 2021).

Serology testing is only available for clinical use under specific clinical indications listed below. Serology testing should not be used for screening and diagnosis of acute COVID-19 infection, and a positive serology test does not mean a patient is immune to COVID-19 (MOH, May 26, 2021).

Clinical indications:

  • Patients presenting with symptoms compatible with Multisystem Inflammatory Syndrome in Children (MIS-C) who do not have laboratory confirmation of COVID-19 by PCR.
  • Patients with severe illness who have tested negative for COVID-19 by PCR and where serology testing would help inform clinical management and/or public health action. Serology testing for these patients requires consultation and approval by the testing laboratory.
  • A study retrospectively analyzed the results of tests administered to more than 15,000 individuals in order to identify the prevalence of false negative results. Of those results studied, 2,699 individuals who tested negative initially were subsequently tested again, and 60 (2.2%) of these individuals were determined to have false negative results in their initial test. The study led the researchers to recommend repeat testing for suspected COVID-19 patients, particularly those with symptoms and other clinical factors consistent with COVID-19 and during periods of high COVID-19 incidence (Open Forum Infect Dis, Nov 24, 2020; Johns Hopkins Center for Health Security, December 4, 2020).
  • The findings in a recently published systematic review (PLoS One, December 10, 2020) further reinforces the need for repeated testing in patients with suspicion of COVID-19 infection given that up to 54% of COVID-19 patients may have an initial false-negative RT-PCR. This is based on very low certainty of evidence.
  • A cohort study has found that even rigorous RT-PCR testing protocols might miss a substantial proportion of SARS-CoV-2 infections, perhaps in part due to difficulties in determining the timing of testing in asymptomatic individuals for optimal sensitivity (Lancet, January 19, 2021).
  • A recent study has determined that most false negative results were found to be due to low amounts of SARS-CoV-2 virus concentrations in patients with multiple specimens collected during different stages of infection. Post-test clinical evaluation of each patient is advised to ensure that rtRT-PCR results are not the only factor in excluding COVID-19 (Virol J, January 9, 2021).
  • A recent retrospective observational cohort study identified clinical characteristics associated with false negative SARS-CoV-2 testing. The study found that negative test results were associated with anosmia/ageusia, having a COVID-19 positive contact, and having an elevated lactate dehydrogenase level. Demographics, symptom duration, other laboratory values, and abnormal chest imaging were not significantly associated with false negative test results in multivariable analysis (Infect Control Hosp Epidemiol, April 19, 2021).

For patients experiencing respiratory tract infection (RTI) symptoms who have tested negative for COVID-19, a viral RTI is the most likely diagnosis. These patients can usually be treated virtually with supportive management. For information on when an in-person visit might be indicated, see The Cold Standard 2nd Edition (Choosing Wisely Canada, October 15, 2020).

The following are being implemented as part on Ontario’s six-point variant action plan (Government of Ontario, January 29, 2021):

  • Mandatory testing of travelers: On-arrival testing for international travellers at Toronto Pearson International Airport will be mandated starting February 1. Additional testing measures at Pearson International Airport and land border crossings will be explored in the coming weeks.
  • Enhanced screening and sequencing: Led by Public Health Ontario (PHO), the provincial diagnostic lab network will screen all positive COVID-19 tests in Ontario for known variants within 2 to 3 days of initial processing starting February 3. By February 17, PHO will be sequencing up to 10% of all positive tests in an effort to identify new and emerging variants.

For more information on the COVID-19 variants, see COVID-19 Variants and vaccines

Top resources

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).

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).

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.

Scroll (left-right) for details

  • 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.

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):

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 glovesFrequent 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.

Putting it into practice

Donning
Doffing
Donning and doffing tips
Click for details

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.

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).
Scroll (left-right) for details
  • 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.
    Click for Crisis capacity guidance
  • 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).
    Click for Crisis capacity guidance
  • 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.
    Click for Crisis capacity guidance
  • 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 (WHOPHOCPSBC).

  • N95 mask

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

    Click for Crisis capacity guidance

Top resources

Delivering patient care in person

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
Jump to:

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.

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

Elimination

Can you physically remove the hazard?

Examples: reducing person-to-person transmission

  • Restrict patients from coming in person to the clinic. (See Step 3, balancing remote and in-person care)
  • Have staff self-monitor and not come to work if they develop symptoms. Consider using the provincial COVID-19 Self-Assessment.
  • Ensure there is space to isolate healthcare staff who develop symptoms.
  • Restrict extra visitors such as multiple family members, non-urgent services or deliveries, forms and paperwork pick up.

Is this strategy feasible?

  • No: Continue to next control type.
  • Yes: Implement. Add to the new clinic protocols, train staff, and inform patients.
Substitution

Can you replace the hazard?

Examples: reducing person-to-person transmission

  • Offer remote (virtual/telephone) visits. (See Step 3, balancing remote and in-person care).
  • Have people wait outside instead of in the waiting room, and text/call when ready.

Is this strategy feasible?

  • No: Continue to next control type.
  • Yes: Implement. Add to the new clinic protocols, train staff, and inform patients.
Engineering controls

Can you isolate people from the hazard?

Examples: reducing person-to-person transmission

  • Set certain days/times to see patients with acute respiratory/infectious illness. Send these patients directly to the exam room.
  • See populations at higher risk of COVID-19 complications at separate times (i.e. first thing in the morning).
  • Incorporate physical (plexiglass) barriers and spacing in the waiting area.
  • Screen all visitors for COVID-19 before entry into clinic and use signage to instruct patients about protocols.
  • Set specific times (when no patients are present) for non-clinical visitors (maintenance, repair, cleaning) to come to clinic.

Is this strategy feasible?

  • No: Continue to next control type.
  • Yes: Implement. Add to the new clinic protocols, train staff, and inform patients.
Administrative controls

Can you change the way people work/move through the clinic?

Examples: reducing person-to-person transmission

  • Set certain days/times to see patients with acute respiratory/infectious illness. Send these patients directly to the exam room.
  • Have only certain staff see patients with acute respiratory/infectious illness, maintaining physical distancing where possible.
  • Perform POC Risk Assessment before each patient encounter.
  • Have all patients/visitors practice hand hygiene and wear masks for source control.
  • Space chairs to ensure physical distancing and mark out spaces for lineups on the floor.
  • If staff have recently traveled or been exposed to COVID-19, contact your local health unit for directive.

Is this strategy feasible?

  • No: Continue to next control type.
  • Yes: Implement. Add to the new clinic protocols, train staff, and inform patients.
PPE

Can you protect people with protective equipment?

Examples: reducing person-to-person transmission

Is this strategy feasible?

  • No: Refer patient to a setting equipped with required PPE.
  • Yes: Implement. Add to the new clinic protocols, train staff, and inform patients.

Step 3: Find a balance between remote and in-person care

Efforts should be undertaken to reduce in-person visits, particularly when local disease burden is high. This does not require an “either/or” approach, but a thoughtful analysis of what aspects of patient care can be performed remotely in order reduce patient time in-clinic. It is recommended that remote visits be conducted first, followed by a curtailed in-person visit only as necessary. For detailed information on condition-specific information, see CEP’s COVID-19 Resource Centre.

Consider:
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.

Operational requirements for in-person care

Screening and testing

  • 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.)

Risk assessment and mitigation

  • 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.

Resources for implementation

These supporting materials and resources are hosted by external organizations. The accuracy and accessibility of their links are not guaranteed. CEP will make every effort to keep these links up to date.

Functional overview

Text with Icon block

We use the “text with icon” field to quickly orient the user with the type of information/content to expect in the inline copy by using common and easy to understand visual cues/icons.

Used when providing guidance/best practice/recommendations re delivering care/permission to do something. 

For example:

Used when providing external links to recommendations/further information. 

For example:

Used when conveying REALLY important information that applies to the whole population, high risks, red flags, gov’t requirements, etc.  The point of use is to make the user STOP and read.  So we tended to use it sparingly otherwise the impact of the icon will be diluted.

For example:

  • Any persons experiencing one of the following should be told to self-isolate and tested as soon as possible:
    • Fever (temperature of 37.8°C or greater)
    • New/worsening cough
    • Shortness of breath (dyspnea)
    • Sore throat
    • Difficulty swallowing
    • New olfactory or taste disorder(s)
    • Nausea/vomiting, diarrhea, abdominal pain
    • Runny nose, or nasal congestion (in absence of underlying reason for these symptoms such as seasonal allergies, post nasal drip, etc.)
  • There is only low-quality evidence available on COVID-19, as it is an emerging virus. Many studies being released have not been peer-reviewed. Among those that have been peer-reviewed, many are small, retrospective observational studies and thus have serious limitations and risks of bias. While the findings of emerging COVID-19 studies can be useful in helping to broaden our understanding about how the virus might operate, the results of COVID-19 studies should not be considered validated.
  • As reports of children experiencing a multi-system inflammatory syndrome multiply, the Canadian Paediatric Surveillance Program issued a Public Health Alert (CPSP, May 12, 2020) encouraging those providing paediatric care to familiarize themselves with the presentations of this emerging syndrome. It has now been included in the case definition and is reportable to public health.

Generally used when conveying information that applies to the part of the population, things that are “strongly recommended” but maybe not yet mandated, cautions, etc. Similar criteria as the (!) icon, but with a content that isn’t quite as MUST READ. The point of use is to make the user PAUSE and read.  Used more frequently.

For example:

  • OCFP and CFPC suggest strongly considering PPE use for all patient encounters that involve less than 6 feet of separation due to the possibility of asymptomatic and pre-symptomatic transmission. For more information on PPE, see Infection prevention and control: PPE, HCW infection control, cleaning.
  • While rare, clinicians should be aware of this potential syndrome and maintain a high index of suspicion to identify cases. Some patients have deteriorated quickly and have required intensive care unit admission for vasopressors and mechanical ventilation.
  • Caution should be taken when using NSAIDs in the context of acute respiratory infections (ARI) and patients with the following conditions.

Commonly used and understood icon that conveys “geolocate”. Used when linking out to regional/local resources.  

For example:

Used for when we provide talking tips.

For example:

  • Responding to questions about unproven therapies for COVID-19: “Though research is underway, there are currently no medications recommended for preventing or treating COVID-19 because there is not enough evidence to make any conclusions yet” (CMAJ, 2020).
  • “This is your home and we will make every effort to make you comfortable in your new room with all of your belongings.”
  • “In-room dining is important for you and other residents so that we can protect everyone, including yourself.”
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Lorem ipsum dolor sit amet, consectetur adipiscing elit. Donec non maximus tellus, at tristique velit. Aliquam interdum arcu orci, id congue lacus elementum ac. Phasellus congue aliquam lectus sed porta. Morbi turpis tellus, pharetra fermentum consectetur sollicitudin, viverra pretium ex. Quisque consectetur faucibus felis et varius. Nulla mattis maximus dolor, in consequat est pulvinar ac. Pellentesque eleifend eu tortor et cursus. Integer iaculis quis sapien congue commodo. Proin ullamcorper posuere eros, nec ultrices odio elementum aliquam. Aliquam erat volutpat.

Lorem ipsum dolor sit amet, consectetur adipiscing elit. Donec non maximus tellus, at tristique velit. Aliquam interdum arcu orci, id congue lacus elementum ac. Phasellus congue aliquam lectus sed porta. Morbi turpis tellus, pharetra fermentum consectetur sollicitudin, viverra pretium ex. Quisque consectetur faucibus felis et varius. Nulla mattis maximus dolor, in consequat est pulvinar ac. Pellentesque eleifend eu tortor et cursus. Integer iaculis quis sapien congue commodo. Proin ullamcorper posuere eros, nec ultrices odio elementum aliquam. Aliquam erat volutpat.

  • Mostly commonly used “table”. “cleanest” in look and feel.  Allows for a maximum of 3 columns, infinite rows.
  • For example, used consistently throughout the tool in a section’s “Top resources”.
  • Inner border can be grey or blue.
Table with Icon

Lorem ipsum dolor sit amet, consectetur adipiscing elit. Donec non maximus tellus, at tristique velit. Aliquam interdum arcu orci, id congue lacus elementum ac. Phasellus congue aliquam lectus sed porta. Morbi turpis tellus, pharetra fermentum consectetur sollicitudin, viverra pretium ex. Quisque consectetur faucibus felis et varius. Nulla mattis maximus dolor, in consequat est pulvinar ac. Pellentesque eleifend eu tortor et cursus. Integer iaculis quis sapien congue commodo. Proin ullamcorper posuere eros, nec ultrices odio elementum aliquam. Aliquam erat volutpat.

Lorem ipsum dolor sit amet, consectetur adipiscing elit. Donec non maximus tellus, at tristique velit. Aliquam interdum arcu orci, id congue lacus elementum ac. Phasellus congue aliquam lectus sed porta. Morbi turpis tellus, pharetra fermentum consectetur sollicitudin, viverra pretium ex. Quisque consectetur faucibus felis et varius. Nulla mattis maximus dolor, in consequat est pulvinar ac. Pellentesque eleifend eu tortor et cursus. Integer iaculis quis sapien congue commodo. Proin ullamcorper posuere eros, nec ultrices odio elementum aliquam. Aliquam erat volutpat.

Lorem ipsum dolor sit amet, consectetur adipiscing elit. Donec non maximus tellus, at tristique velit. Aliquam interdum arcu orci, id congue lacus elementum ac. Phasellus congue aliquam lectus sed porta. Morbi turpis tellus, pharetra fermentum consectetur sollicitudin, viverra pretium ex. Quisque consectetur faucibus felis et varius. Nulla mattis maximus dolor, in consequat est pulvinar ac. Pellentesque eleifend eu tortor et cursus. Integer iaculis quis sapien congue commodo. Proin ullamcorper posuere eros, nec ultrices odio elementum aliquam. Aliquam erat volutpat.

FAQ/info block

Answer 1

Answer 2

Answer 3

Another “click to reveal” block. commonly used for FAQs, chronic diseasae mgmt, special pops, etc. For example:

Please note the content contained within the answer is NOT searchable using the search function.

Stack of papers. Multiple Choice
Option 1
can have multiple rows within section

Lorem ipsum dolor sit amet, consectetur adipiscing elit. Donec non maximus tellus, at tristique velit. Aliquam interdum arcu orci, id congue lacus elementum ac. Phasellus congue aliquam lectus sed porta. Morbi turpis tellus, pharetra fermentum consectetur sollicitudin, viverra pretium ex. Quisque consectetur faucibus felis et varius. Nulla mattis maximus dolor, in consequat est pulvinar ac. Pellentesque eleifend eu tortor et cursus. Integer iaculis quis sapien congue commodo. Proin ullamcorper posuere eros, nec ultrices odio elementum aliquam. Aliquam erat volutpat.

can have multiple rows within section

Lorem ipsum dolor sit amet, consectetur adipiscing elit. Donec non maximus tellus, at tristique velit. Aliquam interdum arcu orci, id congue lacus elementum ac. Phasellus congue aliquam lectus sed porta. Morbi turpis tellus, pharetra fermentum consectetur sollicitudin, viverra pretium ex. Quisque consectetur faucibus felis et varius. Nulla mattis maximus dolor, in consequat est pulvinar ac. Pellentesque eleifend eu tortor et cursus. Integer iaculis quis sapien congue commodo. Proin ullamcorper posuere eros, nec ultrices odio elementum aliquam. Aliquam erat volutpat.

can have multiple rows within section

Lorem ipsum dolor sit amet, consectetur adipiscing elit. Donec non maximus tellus, at tristique velit. Aliquam interdum arcu orci, id congue lacus elementum ac. Phasellus congue aliquam lectus sed porta. Morbi turpis tellus, pharetra fermentum consectetur sollicitudin, viverra pretium ex. Quisque consectetur faucibus felis et varius. Nulla mattis maximus dolor, in consequat est pulvinar ac. Pellentesque eleifend eu tortor et cursus. Integer iaculis quis sapien congue commodo. Proin ullamcorper posuere eros, nec ultrices odio elementum aliquam. Aliquam erat volutpat.

Option 2
can have multiple rows within section

Lorem ipsum dolor sit amet, consectetur adipiscing elit. Donec non maximus tellus, at tristique velit. Aliquam interdum arcu orci, id congue lacus elementum ac. Phasellus congue aliquam lectus sed porta. Morbi turpis tellus, pharetra fermentum consectetur sollicitudin, viverra pretium ex. Quisque consectetur faucibus felis et varius. Nulla mattis maximus dolor, in consequat est pulvinar ac. Pellentesque eleifend eu tortor et cursus. Integer iaculis quis sapien congue commodo. Proin ullamcorper posuere eros, nec ultrices odio elementum aliquam. Aliquam erat volutpat.

can have multiple rows within section

Lorem ipsum dolor sit amet, consectetur adipiscing elit. Donec non maximus tellus, at tristique velit. Aliquam interdum arcu orci, id congue lacus elementum ac. Phasellus congue aliquam lectus sed porta. Morbi turpis tellus, pharetra fermentum consectetur sollicitudin, viverra pretium ex. Quisque consectetur faucibus felis et varius. Nulla mattis maximus dolor, in consequat est pulvinar ac. Pellentesque eleifend eu tortor et cursus. Integer iaculis quis sapien congue commodo. Proin ullamcorper posuere eros, nec ultrices odio elementum aliquam. Aliquam erat volutpat.

Takes up a lot of page “real estate”. We tend to NOT use unless there are multiple Y/N questions/use of block consistently. For example, see: COVID-19: Social Care Guidance. Please note the content contained within the answer is NOT searchable using the search function.

Card block

We use this block when displaying similar information that has consistent headings/categories. It was originally developed to contain rx info. Allows us to use horizontal real estate and not overload the vertical/infinite scroll issue. Also gives provides opportunity to add additional information with each card that pops out for more details. Mobile friendly. Searchable in search function. For example:

Pop-out block

Designed for talking tips, etc. Generally used to contain information that is not necessarily immediately relevant for all users. But, for those that are interested, they can click to “opt-in” to view the content. Content is NOT searchable using the search function. For example:

Image block

Used for images of diagrams, static flow charts, evidence tables that go beyond three columns, etc. Please note, if we can we try NOT to use images for evidence tables are they do not render well in mobile. Where possible, consider how the content can be summarized differently/more succiently before going down the image route. For example:

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Managing COVID-19 in Long-term care homes

Jump to:

Universal masking in long-term care homes

Universal masking measures have been put in place for all staff and essential visitors of long-term care homes (LTCHs) regardless of whether the home is in outbreak or not (MOH, April 7, 2021).

Surgical masks or procedural masks (“masks” in this section) can function either as source control (worn to protect others) or part of personal protective equipment (to protect the wearer) (PHO, February 1, 2021).

With every patient/resident:

Infection control: healthcare worker and resident cohorting

Long-term care homes must use staff and resident cohorting to prevent the spread of COVID-19 (MOH, April 7, 2021).

In smaller long-term care homes, or homes where it’s not possible to maintain physical distancing of staff or residents, all residents and staff should be managed as if they are potentially infected, and staff should use droplet and contact precautions when in an area affected by COVID-19.

Putting it into practice

Healthcare worker cohorting can include:
  • Designating providers to care for either ill residents or well residents.
  • Limit the number of healthcare facilities and locations each healthcare worker accesses.
Resident cohorting can include:
  • Alternative accommodation in the home to maintain physical distancing.
  • Cohorting of the well and unwell.
  • Utilizing respite, palliative care, and other beds and rooms, as appropriate.

Navigating difficult conversations

When implementing resident cohorting strategies, recognize the emotional impact of moving and/or isolating residents. Use the talking tips below to help address resident stress and anxiety.

  • “This is your home and we will make every effort to make you comfortable in your new room with all of your belongings.”
  • “In-room dining is important for you and other residents so that we can protect everyone, including yourself.”

For more help managing difficult patient conversations in the context of COVID-19, see:

Screening for COVID-19

Putting it into practice

Passive screening
  • Signage should remind all persons in the LTCH to perform hand hygiene (PHO, March 16, 2020) and follow respiratory etiquette.
  • Signage should also indicate signs and symptoms of COVID-19 and steps (MOH, April 15, 2020) that must be taken if COVID-19 is suspected or confirmed in a staff member or a resident.
Active screening for all staff and visitors
  • LTCHs must implement active screening of all staff, visitors and anyone else entering the LTCH for COVID-19 with the exception of first responders, who should, in emergency situations, be permitted entry without screening.
Active screening for all residents
  • LTCHs must conduct active screening and assessment of all residents, including temperature checks, at least twice daily (at the beginning and end of the day) to identify if any resident has fever, cough or other symptoms of COVID-19 (MOH, June 4, 2021).

For a LTCH specific screening tool, see COVID-19 Screening Tool for Long-Term Care Homes and Retirement Homes (MOH, May 6, 2020).

Testing for COVID-19

Putting it into practice

LTCH not under outbreak
LTCH under outbreak
  • In the event an outbreak of COVID-19 is declared in the home, all staff in the entire home AND all residents in the home should be tested including on symptomatic and asymptomatic residents and staff members who have been in contact with cases.
  • Asymptomatic contacts of a confirmed case include:
    • All residents living in adjacent room.
    • All staff working on the unit/carehub.
    • All essential visitors that attended at the unit/carehub.
    • Any other contacts deemed appropriate for testing based on a risk assessment by local public health unit.
Keep in mind

Outbreak management

A suspect outbreak in a home is defined as one lab-confirmed COVID-19 case in a resident.

A confirmed outbreak in a home is defined as two or more lab-confirmed COVID-19 cases in residents and/or staff (or other visitors) in a home with an epidemiological link, within a 14-day period, where at least one case could have reasonably acquired their infection in the home. Examples of reasonably having acquired infection in a home include:

  • No obvious source of infection outside of the LTCH setting; OR
  • Known exposure in the LTCH setting.
  • The local public health unit is responsible for managing the outbreak response. Local public health units have the authority and discretion as set out in the HPPA to coordinate outbreak investigation, declare an outbreak based on their investigation, and direct outbreak control measures (MOH, June 4, 2021).

For guidance on admissions and transfers of residents back to their LTCH, see Directive #3 “Admissions and Transfers” (MOH, June 4, 2021).

Types of absences in LTCHs

As per Directive #3 for Long-Term Care Homes under the Long-Term Care Homes Act, 2007 (MOH, June 4, 2021), short term absences are defined as leaving the LTCH’s property for social or other reasons that does not include an overnight stay.

  • A request must be submitted and approved by the LTCH.
  • Upon return to the LTCH, residents must be actively screened (refer to Active Screening of All Residents above) but are not required to be tested or self-isolate.
  • Residents must be provided with a medical mask to be worn when outside of the LTCH (if tolerated) and reminded about the importance of public health measures including maintaining a safe distance of at least 2 metres from others and hand hygiene.

As per Directive #3 for Long-Term Care Homes under the Long-Term Care Homes Act, 2007 (MOH, June 4, 2021), temporary absences are defined as leaving the LTCH’s property for social or other reasons that includes one or more nights.

  • A request must be submitted and approved by the LTC.
  • Upon return to the LTCH, residents must be actively screened (refer to Active Screening above) and self-isolate for 14 days.
  • Residents must be provided with a medical mask to be worn when outside of the LTCH (if tolerated) and reminded about the importance of public health measures including maintaining a safe distance of at least 2 metres from others and hand hygiene.

As per Directive #3 for Long-Term Care Homes under the Long-Term Care Homes Act, 2007 (MOH, June 4, 2021), medical absences defined as leaving the LTCH’s property for medical reasons (i.e., outpatient visits, single night emergency room visit).

  • LTCHs cannot deny a resident’s request to leave the LTCH for medical visits.
  • Upon return to the LTCH, residents must be actively screened (refer to Active Screening above) but are not required to be tested or self-isolate.
  • Emergency room visits that take place over a single night (e.g., assessment and discharge from the emergency department spans one overnight period) are considered equivalent to an outpatient medical visit.
  • Residents must be provided with a medical mask to be worn when outside of the LTCH (if tolerated) and reminded about the importance of public health measures including maintaining a safe distance of at least 2 metres from others and hand hygiene.

*The requirements in this Directive (MOH, December 7, 2020) related to absences are not meant to apply to retirement homes. The requirements related to resident absences for retirement homes should continue to be guided by applicable Retirement Home Regulatory Authority and Ministry for Seniors and Accessibility requirements and policies, as amended from time to time.

Family physicians/primary care nurse practitioners providing care in LTCHs

The information below provides clinical guidance and logistical support to redeployed or volunteer primary care providers to LTCHs when providing in-person individual health assessments and hands-on care. It is not limited to COVID-19 specific care.

Please note: All non-essential visits are to be conducted virtually. Primary care providers can use the VirtualCare App (ThinkResearch, 2020) to remotely connect with nursing staff and residents. Providers can also visit LTC+ Virtual Care Support for Long-term Care Homes in Ontario (WCH, 2020) for a virtual care program that connects providers working in LTCHs with 24/7 virtual consultations with medical specialists and services. See Primary Care Operations in the COVID-19 Context > Delivering patient care remotely for more general information on remote/virtual visits.

If you are able to and are interested in being matched to work at long-term care facilities, see the following matching tools for healthcare workers:

For questions about medical-legal protection while working in a different clinical setting, see:

  • CMPA Physician Advisors are available to provide support throughout the pandemic and can be reached at 1-800-267-6522 Monday to Friday from 8:30 a.m. to 4:30 p.m. ET or through the CMPA member portal.
  • CNPS beneficiaries with questions about nursing during a pandemic are encouraged to contact CNPS for advice at 1-800-267-3390.

Practical tips and clinical guidance to keep in mind when working in LTCHs

  • Introduce yourself to the administrator and participate in the screening process. If you fail the screening, immediately leave the site, proceed to self-isolate (PHO, April 10, 2020) and conduct virtual visits only.
  • Have a discussion with the care staff to establish understanding of specific protocols and procedures within the LTCH.
    • Ensure you know how to summon assistance for a fire, cardiac arrest, and other emergencies. The colour codes used are the same for all of Ontario. If you do not know the colour code when you hear one, please ask.
  • Determine which HCWs and staff are available to assist with any assessments or hands-on care, if necessary. Can communicate with staff or refer to a schedule, if available.
  • Perform hand hygiene (PHO, March 16, 2020) before and after every resident/patient interaction.
  • Conduct a personal risk assessment (AHS, 2018) and don appropriate PPE before engaging with patients/residents.
  • Review patient’s history and what medications they are currently on.
  • If the patient has dementia and/or other cognitive disorders that impair decision-making ask LTCH staff to engage with Substitute Decision-Maker (SDM) via virtual means or telephone.
  • Ensure the proper storage of the resident’s records according to the protocols of the facility.
  • If more than one site will be visited in a single day, repeat the self-assessment process prior to arrival at the next site.
  • Self-monitor (PHO, May 17, 2020) for 14 days following your last on-site visit.

Top resources

These supporting materials and resources are hosted by external organizations. The accuracy and accessibility of their links are not guaranteed. CEP will make every effort to keep these links up to date.

Infection monitoring and protocols for healthcare workers

Self-monitoring and self-assessment

Recommended risk assessments

Point of Care Risk Assessment for healthcare workers

A Point of Care Risk Assessment (PCRA) assesses the task, the patient, and the environment. A PCRA should be completed by the HCP before every patient interaction to determine whether there is a risk to the provider or other individuals of being exposed to an infection, including COVID-19. A PCRA is the first step in routine practices, which are to be used with all patients, for all care and all interactions.

See Point of Care Risk Assessment (PCRA) (AHS, 2020).

Organizational Risk Assessment for health care entities

Each health care entity should conduct an organizational risk assessment (ORA) as a precondition to restarting services. An ORA is a systematic approach to assessing the efficacy of control measures that are in place to mitigate the transmission of infections in a health care setting.

Organizations that employ healthcare workers have a responsibility to provide education and training to healthcare workers regarding the organization’s ORA.

Pregnant healthcare workers

Pregnant women working in essential services, including healthcare workers, can continue to work during the pandemic (SOGC, May 15, 2020).

Pregnant healthcare workers should follow the same PPE recommendations as other healthcare workers. A pregnant healthcare worker who is required to wear an N95 respirator, and who has experienced significant weight changes during pregnancy, must ensure that their N95 respirator fit-test is up to date (SOGC, May 15, 2020).

If healthcare worker develops symptoms (including atypical):

They should immediately self-isolate and notify their local public health authority or family physician promptly so that they can coordinate testing.

They should be tested as soon as is feasible, if they develop any symptom compatible with COVID-19, including atypical symptoms (Ministry of Health, September 21, 2020).

COVID-19 resolution and return to work

Due to the evolving evidence surrounding the duration of symptoms, asymptomatic transmission, and duration of infectiousness of COVID-19, criteria for healthcare worker return-to-work is rapidly changing and may vary depending on individual circumstances and different healthcare facilities’ protocols. Please use the provincial guidance to adapt to your practice and local healthcare facilities.

Resolution of a case is defined as an individual having undergone isolation for the duration specified provided the individual is afebrile, and symptoms are improving. Absence of cough is not required for those known to have chronic cough or who are experiencing reactive airways post-infection. If an individual has tested positive but has never had symptoms, isolation recommendations should be based on date of test.

Healthcare workers should follow isolation and clearance with a non-test based approach (waiting 14 days from symptom onset (or 14 days from when swab was taken if persistently asymptomatic), unless they have required hospitalization during the course of their illness, in which case a test based approach is preferred. See detailed information on clearing cases at COVID-19 Quick Reference Public Health Guidance on Testing and Clearance (MOH, June 9, 2021).

In circumstances where additional staff is critically required, earlier return-to-work of a COVID-19 positive healthcare worker may be considered following work self-isolation guidance (see below) and recognizing that the individual may still be infectious.

Ministry of Health guidance (June 9, 2021) has the following criteria for essential healthcare workers returning to work:

Positive test result

Work self-isolation could start after a minimum of 72 hours after illness resolving, defined as resolution of fever (without the use of fever-reducing medications) and improvement in respiratory and other symptoms.

Negative test result

May return to work 24 hours after symptom resolution. If the healthcare worker was self-isolating due to an exposure at the time of testing, return to work should be under work self-isolation (see below) until 14 days from last exposure.

Positive test result

If there has been a recent potential exposure (e.g. tested as part of an outbreak investigation or other close contact to a case), work self-isolation (i.e. return to work) could start after a minimum of 72 hours from the positive specimen collection date to ensure symptoms have not developed in that time, as the positive result may represent early identification of virus in the pre-symptomatic period.

If there is a low pre-test probability (e.g. there has been no known recent potential exposures such as tested as part of surveillance and no other cases detected in the facility or on the unit/floor, depending on the facility size), see Management of Cases and Contacts of COVID-19 in Ontario (MOH, May 6, 2021) for repeat testing guidance. If follow-up testing is negative, the HCW is cleared and can return to work as per usual.

Practicing work self-isolation

Outside of work: practicing self-isolation measures outside of work for 14 days from symptom onset OR positive specimen collection date if asymptomatic, to avoid transmitting to household members or other community contacts.

At work: The healthcare worker should adhere to best practices listed in How to self-isolate while working (PHO, March 25, 2020).

International Travel

HCWs who are not fully vaccinated and returning from international travel are strongly recommended to quarantine for 10 days, whenever possible

Unvaccinated Staff

HCWs or office staff who are not fully vaccinated (i.e., More than 14 days since the final dose in a vaccine series) and have had a confirmed, high-risk exposure to a person with COVID-19 should self-isolate (MOH, Sept 14, 2021).

Vaccinated Staff

HCWs or office staff who are fully vaccinated and have had a high-risk exposure may not have to isolate as per Ministry of Health guidance and should follow the local public health guidelines (MOH. Oct 12, 2021).

Planning for flu season

Original content for this section was developed with input from and support by Ontario College of Family Physicians (OCFP), Association of Family Health Teams of Ontario (AFHTO), Ontario Medical Association (OMA) SGFP, Nurse Practitioners’ Association of Ontario (NPAO) and Registered Nurses’ Association of Ontario (RNAO).

It was reviewed and endorsed in 2020 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.

Subsequent updates are developed by CEP

September – October: before the start of flu season

Obtain and optimize PPE supply

  • PPE supply: Community-based family physicians and nurse practitioners can receive PPE at no cost through the province’s pandemic supply. Use Ontario Health’s Critical PPE: Intake Form or the Ontario Workplace PPE Supplier Directory.  This provincial stockpile is available on a transitional basis.
  • PPE optimization: Current Ontario Health guidance requests that where feasible, health care organizations:
    • implement the use of reusable instead of disposable PPE
    • re-use surgical masks, ensuring safe storage between use and hand hygiene after handling

Proactive outreach to all patients

Primary care providers in Ontario are facing diverse challenges across practice settings. Whether your practice has already expanded services and taken steps to address your backlog, or you’re still getting started, here are some resources to support this complex work.

Numerous resources have identified high-risk populations such as the frail elderly for visit prioritization – however, patients not included in these groups are at risk of ‘falling through the cracks’ – which may have the effect of patients presenting later in the fall, and in poorer health.  The compounding issues of concerns about COVID-19 transmission during visits, as well as patient delay or avoidance in seeking care, primary care providers are in a position where more proactive outreach on their part is needed to ensure patients receive the care they need – both routine and urgent care, virtually or in person.

Consider proactively contacting the following patients to schedule in-person or virtual visits (as appropriate):

  • Those at risk for developing or worsening mental health or addiction.
  • Those at risk of overdose. See CEP’s Opioid Overdose Risk and Prevention resource.
  • Those who are not up to date for immunizations (children and adults). See Ontario’s Immunization schedule.
  • Those with mobility issues.
  • Those with poorly-controlled chronic conditions.
  • Those with a scheduled procedure, test, or surgery that was postponed due to COVID-19.
  • Those who have missed or are due for a cancer screening. See Cancer Care Ontario for tip sheets and COVID-19 Cancer Screening Tip Sheet for Primary Care Providers (OH) for detailed guidance; however, note that LifeLabs is not yet accepting routine colorectal cancer screening requisitions. Primary care providers should only send new fecal immunochemical test (FIT) requisitions to LifeLabs for the following higher-risk patient groups:
    • Average risk people over age 60 who have never been screened for colorectal cancer
    • Average risk people with previous unsatisfactory FIT results
    • Eligible average risk people awaiting organ transplant

Consider a mass mail or email reach-out to remind all patients to seek care if needed. Encourage patients it is safe to seek care when they need it, and describe new processes, virtual care options and safety protocols for in-person visits.

Putting it into practice
Determine appropriateness of virtual vs. in-person care

For information about determining appropriateness of virtual vs. in-person care, see:

Leverage your EMR to identify patients

When running reports in your EMR to identify patients consider the following:

  • Structured information (birthdate, sex) is typically the most easily queried.
  • • You can use your EMR to search for specific health condition, immunization history, last visit date and other information about your practice. You can generate a report to pull the data from the EMR.
  • Consider creating searches using the patient’s CPP (e.g. Problems/Diagnosis list).
  • Reports particularly useful at this time would include:
    • Specific chronic conditions
    • A combination of last date seen OR last note made OR last date billed within your chosen date range (last 6 months, last 9 months, etc)
    • Preventative Care Queries/Preventative Care Summary Reports for active patients in need of cancer screening

If you are unsure of how to use your EMR to support proactive panel management, there are free Ontario MD resources to help you:

  • i4C Advisory Service: Free service providing hands-on support from OMD Practice Advisors and Peer Leaders to create an enhancement plan reflecting individual practice priorities.
  • Peer Leaders: Peer Leaders work one-on-one to help providers get more value from their certified EMR.
  • EMR Progress Assessment Tool: Free, evidence-based, online self-assessment for providers to assess their EMR use and make improvements to enhance patient care. The EPA investigates key functional areas: Practice management, information management, and diagnosis/treatment support.

practice

Updated Pretend title

Health Canada has approved the Pfizer vaccine for use in children aged 5 and over and the Moderna vaccine for use in children aged 12 and over. The Pfizer vaccine will be administered at a lower dose (10 mcg of mRNA) in children ages 5-11, compared to the 30 mcg dose for ages 12 and over. The recommended interval between doses of the pediatric Pfizer vaccine is 8 weeks (56 days). In light of the Omicron variant both NACI and the Ontario Immunization Advisory Committee continue to recommend this interval in order to optimize for a strong and robust immune response in children. It is recommended as a precaution that children ages 5-11 do not receive the Pfizer COVID-19 vaccines within 14 days of other vaccinations. (MOH, November 22, 2021, Health Canada, November 19, 2021, Public Health Ontario, December 23, 2021)

covid title

Primary care has a critical role to play in the effort for a successful flu campaign. Aside from physically administering the vaccine, communication by trusted health professionals about the importance of the vaccine is directly linked to its uptake: 69% of survey respondents reported that the opinion of their family doctor, general practitioner or nurse practitioner was an important factor in their decision to get the flu vaccine

Sample title