COVID-19: Clinical and Practical Guidance for Primary Care Providers

Last Updated: May 27, 2020

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The COVID-19 Resource Centre is intended for family physicians and primary care nurse practitioners in Ontario. It is revised often and new content is added regularly to guarantee that the latest evidence and regulatory recommendations are included. The CEP is committed to ensuring this information is accurate and up to date.

Do things look different? We’ve reorganized our COVID-19 Resources so you can easily find what you’re looking for and use it in practice.

Maintaining Regular Primary Care Practice in the COVID-19 Context
Navigate through patient care in a world where COVID-19 is the “new normal.” Use this tool to provide day-to-day care in a familiar but different environment. From child mental health to opioid use disorder and other conditions, this interactive tool covers topics providers see with their patients every day while considering present-day obstacles due to COVID-19.

Ontario COVID-19 Assessment Centres
Access our up-to-date list of COVID-19 assessment centres across Ontario.

Use this tool to help provide the best possible COVID-19 care for your patients. It pulls together and tangibly interprets the latest recommendations surrounding COVID-19 including assessment and testing, management, provider mental health, infection prevention and more.

Check back daily for the latest updates.

Click on the sections below to get started:
Primary care assessment and testing for COVID-19
Last reviewed: May 26, 2020
Last updated: May 27, 2020
Screening

If a patient thinks they have symptoms, they should complete an online self-assessment tool. Some regions in Ontario have developed self-assessment tools that connect patients with a primary care provider and local resources in their area:

Patients outside these regions should complete the provincial COVID-19 Self-Assessment, which gives guidance tailored to self-reported symptoms. If symptoms are consistent with 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 and or send an email to all patients advising them to call prior to coming to the office/clinic. 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 requesting patients with symptoms put on a mask (if available and tolerated), perform hand hygiene, then self-identify to reception. If office/clinic is in a shared building, post signage at building entrance.

Active screening

  • Before scheduling appointments, patients should be screened over the phone using the COVID-19 Patient Screening Guidance Document (MOH, May 17, 2020).
  • If patients present in-person without phone screening, screen upon entry with the following precautions:
    • To protect from contact/spread, staff conduction screening should be behind a plexiglass barrier, if available, or maintain a 2-metre distance from the patient.
    • If a barrier or 2-metre distance is not possible, use contact/droplet precautions. This includes the following PPE: gloves, gown, a surgical/procedure mask, and eye protection (goggles, face shield).  See Infection prevention and control: PPE, HCW infection control, cleaning for details.
If a patient presents with symptoms of 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 Infection prevention and control: PPE, HCW infection control, cleaning for details.

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.)
Keep in mind

Symptoms in children are usually mild and mainly consist of fever (temperature over 38’C), dry cough and sore throat. Nausea, vomiting, abdominal pain and/or diarrhea at presentation is more common in children than adults (Government of Canada, April 2, 2020; CPS, April 29, 2020).

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).

In addition to the symptoms most commonly associated with COVID-19, other atypical symptoms/signs should be considered in children, including:

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, May 17, 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

See COVID-19 Reference Document for Symptoms (MOH, May 14, 2020) for a full list of common and atypical signs and symptoms.

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.

Tell patient to self-isolate and self-monitor for 14 days, and to call back for direction if they develop symptoms.

Provide reassurance and advise patient to practice physical distancing and hand hygiene.

For asymptomatic patients who suspect they may have been exposed:
Testing
Frequently asked questions (FAQs)

Any Ontarian presenting with at least one symptom or sign associated with COVID-19 should be considered for testing for COVID-19. Routine testing of asymptomatic patients is not recommended (PHO, May 20, 2020).

For help with deciding on testing of individuals suspected or confirmed to have COVID-19, see the COVID-19 Provincial Testing Guidance Update (MOH, May 14, 2020).

This information may be updated as the situation continues to evolve.

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 (May 22, 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 (May 20, 2020) 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 ‘In-Person 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.

In symptomatic and asymptomatic patients with or without exposure risk:

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

If symptoms develop, change or worsen, consider the need for re-testing. If the patient is within their 14-day self-isolation as a result of a known exposure, the individual should remain in self-isolation for the rest of their 14-day period.

See COVID-19 Quick Reference Public Health Guidance on Testing and Clearance (MOH, May 2, 2020) for more detailed information.

*By laboratory testing (NAAT result by PCR or nucleic acid sequencing) of a single NP swab.

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).

Reverse Transcription Polymerase Chain Reaction (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 in symptomatic patients. It tests respiratory tract specimens – nasopharyngeal swab (preferred) or viral throat swab – for the presence of viral RNA during active infection, but will not indicate if a person was infected and subsequently recovered (Johns Hopkins Center for Health Security, May 26, 2020).

Testing in patients suspected of having COVID-19 involves sending a respiratory tract specimen – nasopharyngeal swab (NPS) or viral throat swab; NPS is the preferred specimen – to a PHO laboratory for RT-PCR testing. The turnaround time for COVID-19 testing at a PHO Laboratory is up to four days, but will vary according to geographical location and proximity to a PHO Laboratory location (PHO, May 20, 2020).

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

The Spartan Cube COVID-19 System has been recalled due to concerns raised by National Microbiology Laboratory (NML) regarding the efficacy of the proprietary swab used in the test. No concerns were raised regarding the reagents and portable DNA analyzer device.

This POC test was previously approved by Health Canada, but is now authorized for research use only while these concerns are being investigated.

Serological tests detect the presence of antibodies produced in response to an infection. Due to the variability in time required to produce antibodies after an infection, serological tests are not appropriate for early diagnosis of COVID-19. However, Health Canada has begun authorizing the sale of serological testing devices in Canada for other purposes.

See Serological tests for use against COVID-19 (Health Canada, May 12, 2020) for important information to understand about results from serological testing.

False negative rates of RT-PCR vary between tests, testing platforms and protocols, specimen type, and time of collection (Ann of Intern Med, Apr 13, 2020). When measured in the lab, sensitivity rates as high as 95% (false negative rate of 5%) have been recorded (Euro Surveill., January 23, 2020). In practice, false negative results may be higher due to inadequate sample collection, testing those with asymptomatic or mild disease, or testing early in the course of the disease, when viral levels are below the limit of detection.

  • (Int. J. Infect. Dis., April 8, 2020) Sample size: 353 patients. Findings: 73.1% of patients testing positive with nasopharyngeal (NP) swabs were negative with oropharyngeal (OP) swabs.
  • (Radiology, Feb. 19, 2020) Sample size: 51 patients. Findings: Sensitivity of chest X-ray was 98% vs. 71% with PCR (45/51 patients had throat swabs and 6/51 patients had sputum samples).
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.

Emerging evidence: Asymptomatic shedding, paediatric symptoms and Rx research
Last reviewed: May 26, 2020
Last updated: May 26, 2020

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.

Asymptomatic shedding
Frequently asked questions (FAQs)

Data suggest that people can test positive for COVID-19 one to three days before developing symptoms. (MMWR, April 10, 2020). A review of evidence on asymptomatic transmission found that transmission in people who are currently asymptomatic occurs in approximately 6-13% of cases, although modelling suggests this might be higher (ACFP, April 14, 2020). Presymptomatic transmission occurs through droplets and contaminated surfaces. A study by He et al (April 15, 2020) estimates that 44% of secondary cases are infected during the primary case’s presymptomatic period.

According to the WHO (April 2, 2020), the time between virus exposure and symptoms (incubation period) is five to six days on average, and may be as long as 14 days. Asymptomatic shedding may occur during this time.

There is epidemiologic, virologic and modeling evidence that asymptomatic and presymptomatic transmission can occur (Emerg Inf Dis., May 4, 2020). According to the CDC (May 20, 2020), there have been a number of reports of presumed asymptomatic transmission and viable virus has been cultured in patients with asymptomatic infection. The exact amount of viral shedding required for transmission is not yet clear.

A literature search (CEBM, April 6, 2020) found that between 5% and 80% of people testing positive for SARS-CoV-2 may be asymptomatic. In reviewing 21 reports, authors noted:

  • Symptom-based screening will likely miss cases.
  • Some asymptomatic cases are known as ‘pre-symptomatic’ and will become symptomatic over the course of approximately a week.

 
Evidence reviewed by the ACFP (April 14, 2020) reported similar results. When testing all individuals in closed environments (e.g. cruise ship, long-term care home), approximately 50% of patients testing positive were asymptomatic at the time of testing. The CDC (May 20, 2020) estimates that 35% of infections are asymptomatic.

He et al (April 15, 2020) observed the highest viral load (by throat swab) at the time of symptom onset, suggesting that infectiousness peaks on or before symptom onset.

He et al (April 15, 2020) analysed the relative transmissibility of asymptomatic cases among close contacts and found that symptomatic cases were more likely to transmit COVID-19. The R for symptomatic groups was 0.78 vs. 0.20 for asymptomatic groups, for a risk ratio (RR) of infectivity of 3.9 for symptomatic vs. asymptomatic.

The exact duration is unknown. The CDC (May 12, 2020) reports that the virus may be detectable for several days to weeks after illness onset, but it is unknown how infectious it may be.

  • A study of 56 recovered COVID-19 patients who had mild-moderate disease (Xiao et al, April 19, 2020) found that virus was detectable by PCR in 100% at week one, 89.3% at week two, 66.1% at week three, 32.1% at week four, 5.4% at week five, and 0% at week six. Patients with prolonged viral shedding tended to be older and were more likely to have comorbidities such as diabetes and hypertension.
  • Another study in 41 recovered COVID-19 patients with severe disease (Zhou et al, April 17, 2020) found a median duration of viral shedding of 31 days from illness onset (shortest 18 days, longest 48 days).
  • A serial investigation by Yongchen et al (April 20, 2020) in 21 COVID-19 patients (11 non-severe, five severe and five asymptomatic carriers) found that the respiratory swab remained positive for a median of ten days (range two to 21) from symptom onset in non-severe patients, 14 days (range nine to 33) in severe patients, and 18 days (range five to 28) in asymptomatic cases. The differences between groups were not statistically significant. For current guidance on when to consider a patient recovering from COVID-19 non-infectious, see Managing COVID-19: Outpatient management and resolution.

According to the CDC (May 12, 2020), the immune response to COVID-19 is not yet known, including duration of immunity and if people can be reinfected.

An analysis of COVID-19 patients testing positive after recovery found that the positive test results were related to detection of non-viable virus rather than reinfection or reactivation (Korean CDC, May 19, 2020).

Multisystem Inflammatory Syndrome in Children (MIS-C)

Also called multisystem inflammatory vasculitis, hyperinflammatory syndrome, Kawasaki-like disease or toxic shock-like syndrome.

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.

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.

Clinical presentations include:

  • Persistent fever and features suggestive of Kawasaki disease (complete or incomplete).
  • Toxic shock-like syndrome.
  • Euvolemic shock states.
  • Severe gastrointestinal illness.
  • Severe myocardial dysfunction and multiple organ failure have also been reported.

If these symptoms present:

  • Take a comprehensive history to identify confirmed or potential COVID-19 contacts.
  • Order laboratory testing. Laboratory signs of systemic inflammation include:
    • raised C-reactive protein (CRP), serum ferritin, ESR, or procalcitonin levels
    • neutrophilia
    • lymphopenia
  • Consider antibody testing (including on convalescent serum) and stool polymerase chain reaction (PCR) testing. Recognizing that these tests are not easily available to all, paediatricians may want to contact their local laboratories to discuss storing serum for future testing.

 
Note: Serology may be positive or negative for SARS-CoV-2. While the WHO cites positive serology or possible contact as a criteria for the case definition, a recent study found that not all children with the syndrome had positive serology at time of testing (The Lancet, May 13, 2020).

New WHO Preliminary case definition:

  • Children and adolescents 0–19 years of age with fever > 3 days.
  • AND two of the following:
    • Rash or bilateral non-purulent conjunctivitis or muco-cutaneous inflammation signs (oral, hands or feet)
    • Hypotension or shock
    • Features of myocardial dysfunction, pericarditis, valvulitis, or coronary abnormalities (including ECHO findings or elevated Troponin/NT-proBNP)
    • Evidence of coagulopathy (by PT, PTT, elevated d-Dimers)
    • Acute gastrointestinal problems (diarrhoea, vomiting, or abdominal pain)
  • AND elevated markers of inflammation such as ESR, C-reactive protein, or procalcitonin.
  • AND no other obvious microbial cause of inflammation, including bacterial sepsis, staphylococcal or streptococcal shock syndromes.
  • AND evidence of COVID-19 (RT-PCR, antigen test or serology positive), or likely contact with patients with COVID-19 (Note: not all children with the syndrome will have positive serology).

 
See: Scientific Brief: Multisystem inflammatory syndrome in children and adolescents temporally related to COVID-19 (WHO, May 15, 2020)

A recent small observational cohort study from Italy The Lancet (May 13, 2020) compared a cohort of 10 children recently diagnosed with the syndrome to a cohort of children diagnosed before COVID-19, and found a 30-fold increase in incidence of “Kawasaki-like disease.” Those children diagnosed after the start of the epidemic were older, showed evidence of immune response to the virus, had a higher rate of cardiac involvement, and features of MAS.

Medication cautions
COVID-19 and Nonsteroidal anti-inflammatory drugs (NSAIDs)

The World Health Organization issued a scientific brief (April 19, 2020) stating that there is currently no evidence of severe adverse events, acute health care utilization, long-term survival, or quality of life in patients with COVID-19, as a result of the use of NSAIDs.

The NICE rapid guidelines (April 30, 2020) have advised patients to take paracetamol or ibuprofen if they have fever and other symptoms that antipyretics would help treat, and to continue only while the symptoms of fever and the other symptoms are present. If using an NSAID they should take the lowest effective dose for the shortest period needed to control symptoms.

Acute respiratory infections and NSAIDs

Caution should be taken when using NSAIDs in the context of acute respiratory infections (ARI) and patients with the following conditions.

Scroll (left-right) for details
  • Acute myocardial infarction (MI)

    NSAIDs increase the risk of acute MI, even with short term-use (odds ratio = 1.5) (BMJ, 2017).

    • Dose-response with increasing risk for acute MI with increasing dose.


    The risk of acute MI is increased in ARI and influenza (odds ratio = 2.7), and NSAIDs increase the risk of acute MI in ARI further (odds ratio = 3.4) (J. Infect. Dis, 2017Pharmacoepidemiol Drug Saf, 2017).

  • Stroke

    NSAIDs use during ARI episodes increases risk of stroke (ischemic odds ratio = 2.27; hemorrhagic odds ratio = 2.28) (Pharmacoepidemiol Drug Saf, 2018).

    Parenteral NSAIDs increase risk of stroke in patients with ARI (Pharmacoepidemiol Drug Saf, 2018).

  • Bacterial infection complication

    NSAIDs may worsen the course of a bacterial community-acquired pneumonia (pleuropulmonary complications odds ratio = 5.7 – 8.1; pleuroparenchymal complications odds ratio = 2.57).

    However, this may be due to symptom masking as studies show patients taking NSAIDs have a longer time to antibiotic initiation (Lung, 2017Chest, 2011Respir Med, 2017J Crit Care, 2014).

  • Hypertension

    NSAIDs can worsen hypertension (odds ratio = 1.4) (UpToDate, 2020Aging Dis, 2018).

  • Heart failure

    NSAIDs can worsen heart failure (odds ratio = 1.19) (UpToDate, 2020BMJ, 2016).

NSAIDs for symptom control

Fever: A recent literature review found that while health professionals viewed fever as deleterious, outcomes with use of antipyretics were mixed and included several studies finding increased mortality risk associated with their use. In administering antipyretics, physicians should consider individual patients’ comorbidities and symptoms of their underlying illness (Br J Nurs, 2019). The NICE rapid guidelines (April 30, 2020) recommend not using antipyretics with the sole aim of reducing body temperature.

Total symptoms and duration: NSAIDs do not significantly reduce total symptoms or duration of respiratory infections (BMJ, 2013).

Acetaminophen: Primary care studies show acetaminophen is just as effective for symptom relief in viral illness (BMJ, 2013).

Medication misconceptions
COVID-19 and ACE inhibitors or ARBs

There has been speculation that patients receiving these medications may be more susceptible to COVID-19 and are at increased risk for adverse outcomes:

• Angiotensin-converting enzyme 2 (ACE2) is a receptor for SARS-CoV-2.
• ACE inhibitors and ARBs may upregulate ACE2, which could facilitate virus entry into cells.

There is currently no clinical evidence to support that taking an ACE inhibitor or ARB will make a patient more susceptible to COVID-19 or worsen outcomes (UpToDate, May 16, 2020; Therapeutic Research Centre, April 2020; NEJM, May 1, 2020).

See the HFAM resource COVID and ACEi’s ARBs: Helpful or Harmful? (March 31, 2020) for more information.

Unproven therapies
Medications

Though research is underway, there are currently no medications recommended in the prophylaxis or treatment of COVID-19, because there is insufficient evidence (CMAJ, April 29, 2020).

As with any medication, these drugs are also associated with potentially serious harms.

Off-label prescriptions and the stockpiling of these drugs based on limited evidence to treat COVID-19 has led to drug shortages and compromised care for patients who need these medications for their intended use.

Professional organizations and institutes cautioning against the use of unproven medications for COVID-19 patients

Physician Resources – Treatment of COVID-19 with chloroquine or hydroxychloroquine (The College of Family Physicians of Canada): Statement in support of the Canadian Pharmacists Association’s advice to refrain from prescribing hydroxychloroquine or azithromycin at this moment.

Treatment of COVID-19 with chloroquine or hydroxychloroquine (Canadian Pharmacists Association): Statement on dispensing chloroquine or hydroxychloroquine outside of their usual clinical indications.

NIH COVID 19 Treatment Guidelines (April 21, 2020): NIH does not recommend the use of any agents for pre-exposure prophylaxis (PrEP) or post-exposure prophylaxis (PEP) of COVID-19. They state that “no drug has been proven to be safe and effective for treating COVID-19. There are insufficient data to recommend either for or against the use of any antiviral or immunomodulatory therapy in patients with COVID-19 who have mild, moderate, severe, or critical illness”.

The Infectious Diseases Society of America Guidelines on the Treatment and Management of Patients with COVID-19 (April 11, 2020) recommends that hydroxychloroquine/chloroquine +/- azithromycin, lopinavir-ritonavir, tocilizumab, and corticosteroids (for ARDS) only be used in hospitalized patients in the context of a clinical trial.

Current evidence

Azithromycin Prophylaxis: Azithromycin is not currently recommended in the prophylaxis of COVID-19, because there is insufficient evidence that it will prevent COVID-19 (CEBM, April 14, 2020).

A multinational registry analysis of 96,032 hospitalized COVID-19 patients found an increased risk of in-hospital mortality and new ventricular arrhythmias associated with hydroxychloroquine, hydroxychloroquine with a macrolide, chloroquine, and chloroquine with a macrolide compared to the control group, which did not receive any of these treatments. The study was unable to confirm a benefit for hydroxychloroquine or chloroquine, used alone or with a macrolide (Lancet, May 22, 2020).

Treatment: As with any viral pneumonia, COVID-19 itself is not an indication for antibiotics. If co-infection with a bacterial pathogen is suspected, antibiotics should be initiated based on institutional antibiograms and sensitivities (BC Centre for Disease Control, May 18, 2020).

Antiviral drugs are not currently recommended in the prophylaxis or treatment of COVID-19, because there is insufficient evidence that they will prevent or inhibit COVID-19 (CMAJ, April 29, 2020). The likelihood of death from COVID-19 in patients with mild to moderate disease is extremely low, therefore antiviral drugs will have little or no effect on mortality in such patients (CMAJ, April 29, 2020).

There is some evidence of appreciable harm with hydroxychloroquine, chloroquine, ribavirin and lopinavir-ritonavir and high uncertainty regarding adverse effects in other antivirals drugs (CMAJ, April 29, 2020).

Chloroquine and hydroxychloroquine: While initial results showing inhibitory effects of hydroxychloroquine and chloroquine against COVID-19 are encouraging further study, authors caution that the drugs should only be used in the context of research ethics-approved clinical trials (J Crit Care, March 10, 2020Int J Antimicrob Agents, April 3, 2020Int J Antimicrob Agents, March 20, 2020; Clin Infect Dis, March 9, 2020). Hydroxychloroquine may cause diarrhea and may increase headache, rash, nausea, vomiting and blurred vision, but the evidence is low-quality (CMAJ, April 29, 2020). Chloroquine and hydroxychloroquine may cause prolongation of the QTc interval (especially in patients with preexisting cardiac disease or if co-prescribed with azithromycin), hypoglycemia, neuropsychiatric effects, drug interactions and idiosyncratic hypersensitivity reactions, and they are highly toxic in overdose. They also cause numerous drug interactions including enhancing the response to direct-acting oral anticoagulants (DOACs), colchicine, cyclosporine, digoxin, and various chemotherapy agents; inhibiting the metabolism of metoprolol, carvedilol, and donepezil; and reducing the effectiveness of codeine and tramadol (CMAJ, April 29, 2020).

A multinational registry analysis of 96,032 hospitalized COVID-19 patients found an increased risk of in-hospital mortality and new ventricular arrhythmias associated with hydroxychloroquine, hydroxychloroquine with a macrolide, chloroquine, and chloroquine with a macrolide compared to the control group, which did not receive any of these treatments. The study was unable to confirm a benefit for hydroxychloroquine or chloroquine, used alone or with a macrolide (Lancet, May 22, 2020).

Favipiravir: In comparison with umifenovir and lopinavir-ritonavir, favipiravir may have a possible higher incidence of recovery and viral clearance respectively, but the evidence is only very low-quality (CMAJ, April 29, 2020). However, the BC Centre for Disease Control (May 18, 2020) recommends against favipiravir due to lack of data.

comparison with umifenovir and lopinavir-ritonavir, favipiravir may have a possible higher incidence of recovery and viral clearance respectively, but the evidence is only very low-quality (CMAJ, 2020).

Lopinavir-ritonavir and umifenovir: While initial results show that umifenovir and lopinavir-ritonavir may reduce cough, fever and progression to severe disease in patients with mild to moderate COVID-19, the initial evidence available is low-quality (CMAJ, April 29, 2020). Lopinavir-ritonavir may increase diarrhea, nausea and vomiting but the evidence is low-quality (CMAJ, April 29, 2020).

Oseltamivir: Not recommended for COVID-19 as neuraminidase inhibitors do not appear to have activity against the virus. Initial empiric therapy with oseltamivir might be reasonable during influenza season in critically ill patients if the patient is suspected to have influenza pneumonia; patients can have confirmatory NP swabs for influenza (BC Centre for Disease Control, May 18, 2020).

Remdesivir: There is currently limited evidence that remdesivir will prevent or inhibit COVID-19 (BC Centre for Disease Control, May 18, 2020). As a preliminary study has shown viral load reduction in vitro (Antivir. Res, April 3, 2020), there have been trials underway to study this drug with early data analyses demonstrating some improvements in clinical outcomes, such as a 31% faster time to recovery (median time to recovery was 11 days with remdesevir and 15 days with placebo, p<0.001) (NIH, April 29, 2020; NEJM, April 10, 2020) and a numerically shorter duration of mechanical ventilation (7 days vs. 15.5 days; not statistically significant); adverse events leading to medication discontinuation were 12% with remdesevir vs. 5% in placebo; number needed to harm = 15 (Lancet, April 29, 2020).

Ribavirin: The BC Centre for Disease Control (May 18, 2020) recommends strongly against ribavirin due to the risk of harm. Ribavirin may increase anemia and bradycardia but the evidence is low-quality (CMAJ, April 29, 2020).

Not recommended for treatment or prophylaxis outside of a randomized controlled trial due to insufficient evidence (BC Centre for Disease Control, May 18, 2020). Clinical trials are ongoing.

Convalescent plasma is not currently recommended in the treatment of COVID-19, because there is insufficient evidence that it will inhibit COVID-19 (CMAJ, April 29, 2020).

Initial low-quality evidence suggests that convalescent plasma may have little to no effect on mortality, may have a small benefit in hastening recovery, may reduce length of hospital stay and duration of mechanical ventilation and may result in little or no difference in rate of serious adverse events (CMAJ, April 29, 2020).

Some groups suggest that corticosteroids may be used in patients with severe COVID-19 and acute respiratory distress syndrome (ARDS), however the research community is currently divided on this recommendation (BC Centre for Disease Control, May 18, 2020; CMAJ, April 29, 2020). Corticosteroids are not recommended in patients with severe COVID-19 who do not have ARDS (CMAJ, April 29, 2020). However, steroids may be used if the patient has another compelling indication, such as an asthma exacerbation, refractory septic shock, or for fetal lung maturation in obstetric patients (BC Centre for Disease Control, May 18, 2020).

Anakinra: There are insufficient data to recommend either for or against use (NIH, May 12, 2020). Clinical trials are ongoing.

Interferon-α: With respect to interferon-α, there is very low-quality evidence that the addition of interferon-α to umifenovir therapy may not affect time to viral clearance or length of hospital stay relative to umifenovir alone (CMAJ, April 29, 2020). There is no evidence available on the harms.

Interferon-β: There is no published evidence regarding benefit or harm of interferon-β in patients with mild to moderate COVID-19 (CMAJ, April 29, 2020).

Tocilizumab: Not recommended outside of a randomized controlled trial due to insufficient evidence (BC Centre for Disease Control, May 18, 2020). If considered on an individual basis in patients with cytokine storm, it should only be done with expert consultation (Infectious Diseases and Hematology/Rheumatology). Clinical trials are ongoing.

Information is limited due to lack of data. Detailed assessment will be provided when credible scientific literature becomes available. (BC Centre for Disease Control, May 18, 2020). Clinical trials are ongoing.

Information on these therapies is limited due to lack of data. Detailed assessment on these therapies will be provided when credible scientific literature becomes available. (BC CDC, May 18, 2020). Clinical trials are ongoing.

COVID-19 Vaccine research

There is currently no approved vaccine for COVID-19, but researchers around the world are working to develop and test vaccine candidates. Health Canada is working to fast-track applications for vaccine development. The Canadian Center for Vaccinology at Dalhousie University in Halifax has been approved to begin trials of the vaccine candidate Ad5-nCoV.

Managing COVID-19: Outpatient management and resolution
Last reviewed: May 25, 2020
Last updated: May 26, 2020
Who can be managed at home?
  • Have mild to moderate, uncomplicated COVID-19.
  • Have an O2 saturation > 93% (if pulse oximeter is available).
  • Have a respiratory rate < 30.
  • Show no signs of respiratory distress.
  • Show no signs of confusion.
  • Are able to stay well hydrated.
  • Have the appropriate resources and social supports to manage any comorbidities at home, self-isolate and carry out regular activities of daily living.
Who should be hospitalized?

There is no reliable scoring system currently available for deciding which COVID-19 patients should be hospitalized (CEBM, April 20, 2020).

Patients should be instructed to seek an urgent follow-up assessment with their family physician or hospitalization if they experience any of the following red flag symptoms (PHAC, April 9, 2020; BMJ, March 25, 2020; WCH):

  • Severe shortness of breath at rest.
  • Difficulty breathing.
  • Increasing significant fatigue (reported in some patients as a marker for hypoxemia without dyspnea).
  • Reduced level of consciousness or new confusion.
  • Cold, clammy or pale and mottled skin.
  • Blue lips or face.
  • Little to no urine output.
  • Pain or pressure in the chest.
  • Neck stiffness.
  • Non-blanching rash.
  • Syncope.
  • Coughing up blood.
Managing patients at home

Counsel all patients about self-monitoring for red flag symptoms of worsening disease (see Who should be hospitalized?) and provide them with an on-call (or your) number. Encourage them to seek an urgent follow-up assessment with a family physician (by calling the on-call/your number) or hospitalization if they experience any of these symptoms (PHAC, April 9, 2020).

Assess patients for pre-existing conditions that may put them at a higher risk of deterioration (older age, asthma, COPD, cardiovascular disease and immunocompromising conditions are particularly relevant). Monitor these patients closely (CEBM, April 20, 2020BCCDC, April 14, 2020NICE, April 20, 2020UpToDate, May 11, 2020). See Symptom management and comorbid considerations

Determine an appropriate follow-up frequency based on patient’s symptom severity, comorbidities and social support (WCHBMJ, March 25, 2020; Dufferin/Caledon Community Based COVID Management, 2020).

Ask the patient to self-monitor if patient:

  • Is asymptomatic or has mild symptoms
  • Looks well
  • Has limited comorbidities

Contact patient once/day if patient:

  • Is on days 5-10 from date of symptom onset or positive swab
  • Has mild to moderate symptoms
  • Appears unwell
  • Has limited comorbidities

Contact patient twice/day if patient:*

  • Symptoms are changing rapidly
  • Has moderate symptoms
  • Appears unwell
  • Has comorbidities
  • Is ≥ 80 years of age

* This recommendation is based on the best available guidance at this time. If this frequency of follow-up is not feasible for you and your practice, please use your clinical judgment to determine a more feasible follow-up frequency and leverage community partners and supports (e.g. home care services).

If appropriate, discuss and establish goals-of-care (e.g. supportive care in the ED vs. palliative care in home). See Navigate difficult conversations with patients, families and caregivers and identify the patient’s goals of care for more information (WCH).

Instruct and support patients to self-isolate at home for 14 days (PHAC, April 9, 2020). Support patients to arrange delivery of prescriptions, over-the-counter supplies, household items and groceries where feasible (through delivery services, family members, caregivers, friends/neighbours, etc.) (ECDC, 2020). For pharmacy and grocery store delivery options, see thehealthline.ca. Send patients all required paperwork electronically if feasible (e.g. prescriptions, sick certificates) (BMJ, March 25, 2020).

Ask patient to take readings from instruments they have at home if available (e.g. thermometer, Fitbit, smartphone apps, pulse oximeter) while keeping in mind the unknown accuracy of some of these devices (BMJ, March 25, 2020). For medical equipment and supplies sales and rental options, see thehealthline.ca.

Establish a safety net. If patients live alone, support them to arrange for someone to check in on them regularly virtually or from a distance (BMJ, March 25, 2020).

If necessary, provide patients with information on symptomatic management, which is consistent with standard treatment for cold-like symptoms and influenza-like illnesses (BCCDC, April 14, 2020). See Symptom management and comorbid considerations.

Symptomatic management and comorbid considerations
Common symptom (MOH, May 14, 2020)

Potential management strategies (NICE, April 3, 2020)

Potential management strategies (NICE, April 3, 2020)

Potential management strategies (NICE, April 3, 2020)

Talking points
Comorbid considerations

It is probable that COVID-19 infection can trigger asthma exacerbation (Canadian Thoracic Society, 2020).

The Canadian Thoracic Society (April 7, 2020) recommends that:

  • Patients with asthma restart or continue to use their prescribed inhaled maintenance therapy, regardless of COVID-19 status.
  • Prednisone be used to treat severe asthma exacerbations, including those caused by COVID-19 infection.
  • Anti-IgE and anti-IL-5 monoclonal antibodies (biologics) be continued during the COVID-19 pandemic, regardless of COVID-19 status.
  • Patients who are already using nebulizers do so in a separate room from others and implement other infection control recommendations (CTS generally recommends that patients switch from nebulized therapy to metered dose inhalers with spacing devices or dry powder inhalers during the COVID-19 pandemic).

It is probable that cardiovascular disease may increase COVID-19 susceptibility and severity (CCSUpToDateUpToDate-CAD).

For patients with known heart failure, see the virtual assessment guide (CCS, April 1, 2020) to differentiate between COVID-19 and heart failure exacerbations.

The Canadian Cardiovascular Society (March 20, 2020) recommends that:

  • Patients with confirmed or suspected COVID-19 should not stop taking an ACEi/ARB/ARNi unless there is a compelling reason to do so, such as symptomatic hypotension or shock, acute kidney injury, or hyperkalemia.
  • Patients with confirmed or suspected COVID-19 should not stop low-dose acetylsalicylic acid.

It is probable that COVID-19 infection can trigger COPD exacerbation (Canadian Thoracic Society, 2020).

The Canadian Thoracic Society (April 8, 2020) recommends that:

  • Patients who are diagnosed with COVID-19 infection continue their inhaled maintenance therapies.
  • Oral prednisone (or other forms of systemic steroids if clinically warranted) be used to treat acute exacerbations of COPD, including those caused by COVID-19 infection.
  • Patients who are currently on oxygen continue their oxygen use as prescribed, regardless of COVID-19 status, while routinely cleaning their equipment using manufacturer’s instructions.
  • Patients who are already using nebulizers do so in a separate room from others and implement other infection control recommendations (CTS generally recommends that patients switch from nebulized therapy to metered dose inhalers with spacing devices, dry powder inhalers, or soft mist inhalers during the COVID-19 pandemic).

Patients with diabetes appear to be at increased risk of having a more severe COVID-19 infection and more likely to suffer poor outcomes (Canadian Healthcare Network, May 9, 2020 [login required]).

  • Controlling blood glucose may possibly impact the severity of COVID-19. Previous studies have shown that patients with chronically higher blood glucose levels are more likely to acquire bacterial or some viral infections.
  • Data is not yet available differentiating the impact of Type 1 from Type 2 diabetes in relation to COVID-19.
  • During acute illness, patients may be susceptible to adverse drug events due to comorbidities or medicine use. The following medications (SADMANS) may be of concern in some patients (Can J Diabetes, 2018):
    • Sulfonylureas
    • ACE Inhibitors and angiotensin receptor blockers (ARBs)
    • Diuretics
    • Metformin
    • NSAIDs
    • SGLT2 Inhibitors

Holding diabetes medications

It is probable that a weakened immune system may reduce a patient’s ability to fight infectious diseases  like COVID-19, which may cause immunocompromised patients to remain infectious for longer than other COVID-19 patients (CDC, 2020a).

It is recommended that:

  • If immunocompromised patients with COVID-19 are on immunosuppressant therapy, immunosuppressant therapy may have to be modified or stopped. Systemic corticosteroids should not be stopped abruptly(NICE, 2020aNICE, 2020bNICE, 2020cCEBM, 2020).
  • Apply more stringent requirements to criteria for discontinuation of self-isolation for immunocompromised patient with resolved COVID-19 (CDC, 2020b).

Condition specific guidance:

Keep in mind: Older adults ≥ 80 have the highest mortality rate due to COVID-19 in Ontario (Public Health Ontario, May 24, 2020).

Atypical COVID-19 presentations in frail older adults

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, 2020MOH, May 17, 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

In terms of adverse outcomes for pregnant women, data on outcomes are limited to case series in the latter half of pregnancy, where adverse outcomes were correlated with the degree of respiratory illness and near-term prematurity was the most common adverse outcome  (SOGC, April 2, 2020).

Pregnant women and newborns

Breastfeeding

Resolution

Patients with mild to moderate COVID-19 (diagnosed as a result of having symptoms compatible with COVID-19 or having tested positive for COVID-19) can be advised to discontinue isolation (MOH, May 2, 2020):

  • At 14 days after symptom onset IF the patient is afebrile and symptoms are improving* (MOH, May 2, 2020).

 
This guidance is applicable to healthcare workers and patients living in congregate settings (e.g. long-term care homes, shelters).

Patients with severe COVID-19 who were hospitalized, can be advised to discontinue isolation (MOH, May 2, 2020):

  • After two consecutive negative specimens are collected (at least 24 hours apart) AND the patient has become afebrile and symptoms are improving*. If swab remains positive, test again in approximately 3-4 days (once negative, conduct swab at least 24 hours later) (MOH, May 2, 2020).

 
This guidance is applicable to patients remaining in hospital after symptom improvement and those being discharged to congregate settings (e.g. long-term care homes, shelters) (MOH, May 2, 2020).

* Absence of cough is not required for those known to have chronic cough or those experiencing reactive airways post-infection (MOH, May 2, 2020).

Top resources
Managing COVID-19: Long-term care homes
Last reviewed: May 25, 2020
Last updated: May 27, 2020
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 10, 2020).

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, April 20, 2020).

With every patient/resident:
What to wear, when
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, May 23, 2020).

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.”

See Managing COVID-19: Palliative care for help with navigating conversations regarding goals of care or palliation.

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

  • LTCHs should instruct all staff to self-monitor (PHO, April 10, 2020) for COVID-19 at home.
  • Screening must occur twice daily (at the beginning and end of the day or shift) to identify symptoms (MOH, May 25, 2020), including temperature checks and atypical symptoms. This excludes emergency first responders who should, in emergency situations, be permitted entry without screening.
  • LTCHs should screen new admissions and re-admissions for symptoms and potential exposure to COVID-19. All new residents must be placed in isolation under contact and droplet precautions upon admission to the home and tested within 14 days of admission.
  • LTCHs must be closed to visitors, except for essential visitors. If an essential visitor is admitted to the home, precautions must be taken as outlined in Directive #3 (MOH, May 23, 2020).
  • For a LTCH specific screening tool, see COVID-19 Screening Tool for Long-Term Care Homes and Retirement Homes (MOH, May 6, 2020).
In the event of a positive screen:

Anyone showing symptoms of COVID-19 is not be allowed to enter the LTCH and must go home immediately to self-isolate.

Residents with symptoms of COVID-19 must be isolated according to droplets and contact precautions (PHO, March 17, 2020), and tested.

Testing for COVID-19
Putting it into practice

LTCH not under outbreak

  • Testing must be conducted on every symptomatic resident and staff member.

LTCH under outbreak

  • Testing must be conducted on symptomatic, 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.

Specimens from LTCHs and other residents of institutions will be prioritized if “Institution” is clearly marked on the PHO laboratory requisition (May 5, 2020).

See the MOH Provincial Testing Guidance Update (MOH, May 2, 2020) for a list of symptoms, including atypical signs and symptoms.

COVID-19 is likely to present atypically in older adults (nausea, diarrhea, decreased appetite and oral intake, weight loss and others), see Atypical COVID-19 presentation in frail older adults (RGP Toronto, April 7, 2020).

See Primary care assessment and testing for COVID-19 for the Testing Procedure FAQs.

Outbreak management

LTCHs must consider a single, laboratory confirmed case of COVID-19 in a resident or staff member as a confirmed COVID-19 outbreak.

If a resident who was admitted or re-admitted to the home is tested during the 14- day isolation period and the results are positive and the resident has been in isolation under contact and droplet precautions during the entirety of the 14-day period, declaring an outbreak may not be necessary.

When only asymptomatic residents and/or staff with positive results are found as part of the enhanced surveillance testing initiative for all residents and staff, it may not be necessary to declare an outbreak. This should only be assessed and done in consultation with the local public health unit.

Residents, staff or visitors who were in close contact with the infected resident, or those within that resident’s unit/hub of care, should be identified. See COVID-19 Outbreak Guidance for Long-Term Care Homes (MOH, April 15, 2020) for additional guidance.

Contact your local public health unit to report a staff member or resident suspected to have COVID-19 to ensure an outbreak number is provided.

Essential staff must follow self-isolation recommendations (PHO, March 25, 2020) inside and outside of the workplace. At minimum, a mask must be worn at all times in the workplace, including common areas. For healthcare worker symptom resolution and return-to-work guidance, see Infection monitoring and protocols for healthcare workers.

Readmission of residents to LTCHs

As per Ministry of Health guidance (May 2, 2020), Hospitals may discharge patients to LTCHs where:

  • It is a readmission to a long-term care home (the resident is returning to their home);
  • The receiving home is NOT in COVID-19 outbreak;
  • The resident has been tested for COVID-19 at point of discharge, has a negative result and is transferred to the home within 24 hours of receiving the result; and
  • The receiving home has a plan to ensure that the resident being readmitted can complete 14-days self-isolation.
Family physicians/primary care nurse practitioners providing care in LTCHs for the first time

Providing care in a long-term care home may be an unfamiliar experience for some. The information below provides clinical guidance and logistical support to the workflow of LTCHs when providing in-person individual health assessments and hands-on care. It is not limited to COVID-19 specific care.

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
  • Leave all non-essential belongings in the car/in a safe location.
  • 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.
As a front-line provider, the work you do is immensely valuable but it can also be challenging. Your mental health and wellness are important and there are supports available should you need them. Please see the Mental health and well-being supports for providers section for more information and resources.
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.

Managing COVID-19: Palliative care
Last reviewed: May 25, 2020
Last updated: May 19, 2020
The role of primary care
Navigate difficult conversations with patients, families and caregivers and identify the patient’s goals of care

Due to COVID-19’s increased strain on the healthcare system, primary care providers will need to engage in difficult conversations regarding restricted treatment options, rapid deterioration and end-of-life planning. Importantly, the provider will need to ensure the patient understands the nature and severity of their illness, and explore their goals of care to support decision-making and enable person-centred care.

Putting it into practice
  • Prepare yourself and explain the purpose of the meeting to the patient – or their family, power of attorney (POA), and/or substitute decision maker (SDM). Gather the information you need to know in order to have an informed goals of care discussion.
  • Explore your patient’s understanding of COVID-19 to determine what information your patient has and needs.
  • Discuss goals of care that are most aligned with the patient’s values and what is clinically appropriate/available.
  • Recommend and document a plan that summarizes the patient’s values and discuss what you will do first to help the patient before discussing treatments that will be stopped or not offered.
  • Reaffirm and support the patient.
Document decisions regarding do not resuscitate (DNR)
Putting it into practice

Prognostic considerations regarding DNR in the event of COVID-19:

Prognostic factors for complications and worse outcomes

  • In those over age 80, mortality increases to 15-20%.
  • Between five to 10 days after exposure, patients tend to stabilize or decompensate rapidly – e.g. Acute respiratory distress syndrome (ARDS).
  • Age > 65, diabetes, hypertension are all associated with ARDS.
  • Of those who develop ARDS, 52% may go on to a fatal outcome.
  • Anecdotal experience suggests that those who develop ARDS will likely die within eight to 12 hours if not intubated.

Lab markers associated with worse outcomes

  • Worsening lymphopenia
  • Elevated LDH
  • Elevated CRP, ferritin, IL-6
  • Elevated troponin
  • Other factors associated with outcome include their premorbid state and duration of illness
Manage symptoms, and address other palliative care needs for patients with COVID-19

Access to palliative care and hospice services for COVID-19 patients may become limited or unavailable. Family physicians and community palliative care nurse practitioners need to be prepared to address the palliative care needs of their COVID-19 patients.

Provide end-of-life care for COVID-19 patients

When patients with COVID-19 are in their final weeks and days of life, family physicians and community palliative care nurse practitioners need to be prepared to support and provide end-of-life care.

It is important to ensure rapid access to palliative medications that are often at higher doses than seen in standard practice (RCGP).

Dose ranges should be considered to allow for urgent decision-making regarding escalation of dose for distressing symptoms.

The most common terminal symptoms (fever, rigors, severe dyspnea, cough, delirium and agitation) can develop rapidly and be distressing.

Where possible, avoid use of the following as they may generate aerosolized COVID-19 virus particles and increase the risk of infecting healthcare providers, and family members:

  • Oscillatory devices (fans)
  • Oxygen Flow greater than 6L/min
  • High-flow nasal cannula oxygen
  • Continuous positive airway pressure (CPAP) or bilevelpositive airway pressure (BiPAP)
  • All nebulized treatments (bronchodilators, epinephrine, saline solutions, etc.)
  • Oral or airway suctioning (especially deep suctioning)
  • Bronchscopyand tracheostomy

For a small number of patients who have severe, refractory symptoms at the end of life, rapid titration or Continuous Palliative Sedation Therapy (CPST) may be needed. See Continuous Palliative Sedation Therapy Protocol For COVID-19 Pandemic (McMaster University, March 31, 2020).

For guidance on providing palliative care in a hospice setting see the Ministry of Health and Long-Term Care’s COVID-19 Guidance: Hospice Care resource (May 7, 2020).

Putting it into practice
Scroll (left-right) for details
  • Pain or dyspnea

    Hydromorphone

    • Dose: 0.25-0.5 mg; may start at lower dose (0.25 mg) if patient is opioid naive, frail or an older adult 
    • Route: Subcut
    • Frequency: q30min PRN; but low threshold to change to scheduled q4h dosing

    Morphine

    • Dose: 1-2.5 mg; may start at lower dose (0.25 mg) if patient is opioid naive, frail or an older adult
    • Route: Subcut
    • Frequency: q30min PRN; but low threshold to change to scheduled q4h dosing
    Click for treatment tips
  • Respiratory secretions / congestion

    Scopolamine (hyoscine HYDRObromide)

    • Dose: 0.4-0.6 mg
    • Route: Subcut
    • Frequency: q4h PRN

    Glycopyrrolate

    • Dose: 0.4 mg
    • Route: Subcut
    • Frequency: q2h-q4h PRN

    Atropine 1% ophthalmic drops

    • Dose: 3-6 drops
    • Route: SL
    • Frequency: q4h PRN

    Furosemide (if fluid overload)

    • Dose: 20 mg
    • Route: Subcut
    • Frequency: q2h PRN and monitor
    Click for treatment tips
  • Nausea or delirium

    Haloperidol

    • Dose: 0.5-1 mg (if patient is frail elderly, may start with 0.25 mg)
    • Route: Subcut
    • Frequency: q6h-q12h PRN
    Click for treatment tips
  • Sedation

    Midazolam

    • Dose: 1-2 mg (higher doses can be used for refractory dyspnea)
    • Route: Subcut
    • Frequency: q30 min PRN
    • Note: Higher doses can be used for refractory dyspnea

    Lorazepam

    • Dose: 0.5 mg (1-2 mg, if severe respiratory distress)
    • Route: SL (subcut, if more suitable for the patient)
    • Frequency: q1h PRN (q4h-q8h, if severe respiratory distress)
    Click for treatment tips
  • Fever and chills

    Acetaminophen 650 mg Suppositories

    • Dose: 650 mg
    • Route: PR
    • Frequency: q6h PRN
  • Agitation/restlessness

    Methotrimeprazine (if more sedation is desirable)

    • Dose: 2.5-12.5 mg
    • Route: PO / Subcut
    • Frequency: q2h PRN (up to three doses in 24 hours)*

    Haloperidol (if less sedation desirable)

    • Dose: 0.5 mg
    • Route: Subcut
    • Frequency: q1h PRN


    * If > 3 PRN in 24h, provider to review and consider scheduled q4h and q2h PRN dosing

    Click for treatment tips
  • Urinary retention

    Foley catheter 16 French

    • Insert catheter PRN
  • Dry mouth

    Mouth swabs

    • Mouth care q.i.d and PRN
Plan for an expected death in the home

In the final weeks and days of life, the focus of care moves towards managing the active dying process, which includes identifying that the patient is near death and ensuring that the patient, their substitute decision maker(s), their family and caregivers understand what to expect as death approaches. For many patients, the preference is to die at home. The processes for planning and managing expected deaths in the home are generally developed at the local or regional level.

Provide grief and bereavement support

For many people, the time following the death of a loved one can be filled with a range of emotions and physical reactions. It is important in the grief journey that people are able to openly talk about these experiences, reactions and feelings. Providers can recommend the following resources for those who have lost a loved one:

New fee codes

Focus practice physicians can bill as specialists using K083 (Ontario MD).

For regular palliative care codes, K081 and K082 could be used depending on the depth of the visit (Ontario MD).

Note: many palliative care physicians are family physicians and they are not immediately eligible for specialist codes unless they have a focused practice designation. If they do, they may bill with the K083 code (Ontario MD).

For more information on virtual care codes see Primary care operations in the COVID-19 context.

Top resources
Primary care operations in the COVID-19 context
Last reviewed: May 26, 2020
Last updated: May 26, 2020

Now more than ever it is important for your patients to look after their health and receive care from you as their healthcare provider. It’s essential that patients continue to seek out care that they need.

Consider letting your patients know that you are available by telephone or video to provide a variety of care, and if it’s needed you can provide certain in-person care provided the right precautions are taken. You can notify your patients of this through your outgoing office voicemail, on your website, or through email.

Delivering patient care virtually

In order to reduce community transmission during the COVID-19 pandemic and prevent the spread of the virus, family physicians and primary care nurse practitioners have been advised to practice virtually (MOH, March 13, 2020), when possible. To empower providers to do so, the national and provincial government have enacted temporary exemptions and have rolled out changes to the rules and regulations that govern the practice of medicine in Ontario.

The following virtual formats can be used to conduct your virtual patient encounter:
  • Telephone
  • Secure messaging (ONE Mail, DSG Secure, ProtonMail)
  • Provincial telemedicine platforms (e.g. Ontario Telemedicine Network)
  • EMR-integrated platforms (e.g. TELUS EMR Video Visits, VirtualClinic+ (Insig) – integrates to OSCAR, Medeo – integrated with Accuro EMR, Novari eVisit)
  • Standalone platforms created for medical care (e.g. VirtualCare, iTelemed, Adracare, Cloud DX, Doxy.me, InputHealth Collaborative Care Record, Livecare, MediSeen, OnCall Health, REACTS)
  • Other video calling platforms (e.g. Skype and Teams by Microsoft, Facetime by Apple, Zoom.us, Google Hangouts)
When deciding on the format of your virtual patient encounter, consider the following:
Frequently asked questions (FAQs)

You can safely use virtual care to:

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

The technology required to conduct a virtual patient encounter is widely available and cost effective.

Hardware

For telephone calls, you may consider using earphones/headphones for better sound quality and to ensure patient privacy. For video visits, reliant internet connection, a video camera and a microphone is needed. To ensure optimal connection speed, use hardwired internet.  You can use speedtest.net to test the speed. Hit “Go” and anything above 10 Mbps will be ideal for video calls. Consider using earphones/headphones/headset for better sound quality and to ensure patient privacy. Consider using a secure USB drive if you cannot save and edit third-party forms through your electronic medical record (EMR) and you still need secure electronic storage. Consider securing it with a strong password.

For more information and recommended hardware see: Virtual Care Hardware Considerations (Kaplan, 2020).

Software

For telephone calls, no software is required.  If you are using a Voice over Internet Protocol (VoIP) phone application (such as RingCentral, FanGo) ensure that you have received patient consent (verbal is sufficient) to use the application for your patient encounter. If you’re new to video visits, the key decision is whether to use general videoconferencing tools (e.g. Skype and Teams by Microsoft, Facetime by Apple, Zoom.us and/or Google Hangouts) or software platforms designed specifically for health care (e.g.EMR-integrated platforms, VirtualCare, iTelemed, Adracare, etc.). For more information, see OntarioMD’s comprehensive overview of the different virtual care options.

There are advantages to each:

  • General videoconferencing is widely available, there are versions for every computer and mobile device, and the platforms are supported by large companies that provide reliable service and can handle sudden surges in use (e.g., during pandemics).
  • Health care specific platforms are designed for virtual visits meaning that they can be more secure, have less configuration complexity and may integrate into your EMR.

Please note, if you opt to use a general videoconferencing platform you may need to configure the platform settings to protect the patient’s privacy:

  • Disable all meeting recording options.
  • Ensure that only one patient can enter a meeting at a time and/or that no patient can enter without specific permission from you.

Additionally, unless you are using virtual care technologies where consent is handled at sign-up, you must ask patients for their consent (verbal is sufficient).

An EMR is not required to conduct a virtual patient encounter. Any direct-to-patient telephone, telemedicine and video calling platforms can be used without an EMR.

Please note, Unless you are using virtual care technologies where consent is handled at sign-up, you must ask patients for their consent (verbal is sufficient). Once you’ve completed your virtual encounter, document, as before, in the patient’s medical record.

If necessary, you can save patient forms and documents onto a secure USB.

Much like providing care in-person, the provider and patient need to have an arrangement to meet at the same time, even if the patient has to first enter a “virtual waiting room”.

Depending on what platform you are using, the virtual waiting room can take the form of waiting in the “lobby” of a virtual platform until the host invites the patient in or entering the room first and giving the provider some time to join into the same link.

If you are using OTN, there is a “virtual waiting room” functionality built in.

Be prepared for longer visits, at first, as you and your patients become accustomed with the new visit format.  Consider spacing your scheduled appointments out to include “buffer”/”overflow” time.  Alternatively, give the patient a window of time for their appointment (e.g. “I will call you between 2pm and 4pm”).  This gives you some flexibility and manages expectations of the patient.

When confirming a virtual visit, ensure all of the necessary appointment information has been provided to the patient.  This includes:

When and where the visit takes place

  • Example: “You are scheduled for an appointment with Dr. [First Name] [Last Name] on [date] at [time]. Please use this link to connect [Virtual meeting link].”

How to cancel the appointment

  • Example: “If you need to cancel your appointment, please email or call the clinic at [clinic information] with at least ___ hours in advance notice to avoid missed appointment fees.”

How to address technical issues

  • Let the patient know of some alternatives if technical issues arise.
  • Example: if you are using a videoconferencing software, let them know that you can call them at their telephone number to continue the visit or re-book by phone if technical issues do not resolve after 5 minutes.

Healthcare offices provide many visible cues that assure patients that they are in a professional office to see a medical professional. Most of those cues are absent in virtual care.

Key recommendations:

  • Place your workstation in a location that protects the patient exchange from being seen, overheard or interrupted by others. That includes ensuring that there is no visibility of your screen(s) through a window.
  • Consider using earphones/headphones to improve sound quality and also to protect your patient’s privacy.
  • Use a professional/neutral backdrop and good lighting.
  • Consider wearing a white coat.  While many doctors resist wearing white coats, research shows that patients of all ages prefer their doctors to wear white coats and it reinforces for them that you are a health professional.
  • Make extra effort to engage with the patient at all times and assure them that they have your full attention. This includes eye contact, body language and attentiveness.  Make sure to look at the camera and not your computer screen.
  • Remind your patients of what you will be doing during the course of the visit (e.g. note-taking, looking at their chart, etc). That way your patient knows that even when you take your eyes off of them or the screen, you are still listening.
  • Collect/create patient education texts and links to share after the encounter to replace what you can show to patients when you are seated in the same room.

No, you are not required to use OTN for your virtual patient encounter.

Any direct-to-patient telephone, telemedicine and video calling platforms can now be used.  Please note, unless you are using virtual care technologies where consent is handled at sign-up, you must ask patients for their consent.

Allocate the appropriate amount of time based on patient’s indicated ailments and needs when they scheduled the appointment as you would when providing in-person care. The time will also depend on whether it is a routine visit or a follow-up visit.

Be prepared for longer visits, at first, as you and your patient become accustomed with the new technology.   For patients that may struggle with technology, try to arrange support and be prepared to troubleshoot tech issues.  But, don’t spend too much time trying to fix connection problems.  You can always switch to simpler solutions, such as the phone, when difficulties arise.

Virtual care is not exclusive to encounters handled over the internet.  You can always use the telephone to conduct your encounter.

Androids: To block an Androids number from being displayed, before entering the phone number, enter *67, and then the patient’s phone number.  Alternatively, open  voice app and go into Settings, under “Calls” turn “Anonymous Caller ID” on.

iPhone: To block an iPhone number from being displayed, before entering the phone number, enter #31#, and then the patient’s phone number. Alternatively, go into your iPhone Settings, scroll down to Phone, and tap “off” on “Show My Caller ID”.

Landlines: For landlines, before entering the phone number, enter *67, and then the patient’s phone number.

Yes. The ministry has made a policy change allowing physicians to accept scanned copies of completed and signed Patient Enrolment and Consent to Release Personal Health Information (E/C) forms from patients electronically via email or photo transmission by cell phone.

An original patient signature on the form is not required provided that the patient’s signature is legible on the scanned copy or picture of the E/C form. Physicians should ensure patients have their correct email address when transmitting the E/C form electronically as the completed E/C form contains the patient’s personal information including their birth date and health card number. If electronic submission is not possible, completed forms can also be returned by mail to the physicians’ offices.

During your virtual patient encounter

A virtual patient encounter is the same as an in-person one with a few additional key elements.

Be prepared, technology may fail you

Anticipate that technology may fail you and have a backup prepared (e.g. phone). 

To ensure optimal connection speed, use hardwired internet.  If video is not working well, switch to audio only as you/the patient may not have the necessary bandwidth to support both audio and video on the virtual platform.

Be prepared for longer visits, at first, as you and your patient become accustomed with the new technology.   For patients that may struggle with technology, try to arrange support and be prepared to troubleshoot tech issues.  But, don’t spend too much time trying to fix connection problems.  You can always switch to simpler solutions, such as the phone, when difficulties arise. 

Establish the patient’s identity and location

When initiating your virtual encounter, establish the patient’s identity (e.g. name and DOB) and location (in case of an emergency).

Ensure that the physical locations of both you and the patient offers adequate privacy, where the patient can comfortably share confidential information and where you can assess the patient and provide advice.

Gain patient’s consent

Unless you are using virtual care technologies where consent from the patient is handled from the onset, during your first virtual care patient encounter, you must ask the patient for their consent. Once received, record that verbally expressed consent was obtained in the patient’s medical record.

OntarioMD and the OMA Legal team have prepared short paragraph statements and information to provide to patients to initiate a virtual care patient encounter, which has also been vetted by the CMPA.

Tips to keep in mind during the virtual encounter

  • Mute the microphone when you are not speaking.
  • Take brief pauses between sentences to allow patient to have time to voice any questions or concerns.

Document your virtual encounter

Regardless of the virtual format, the services provided must be documented in the patient’s medical record or the service is not eligible for payment.

After completing your virtual encounter

Send the patient any information they may need (prescriptions, lab and imaging requisitions, patient education, weblinks, etc). Consider using Wellx, secure messaging such as NE Mail, DSG Secure, ProtonMail.

New fee codes

To support of the government’s efforts to limit the spread of COVID-19 in Ontario, the Minister of Health has made an Order under the authority of subsection 45(2.1) of the Health Insurance Act (March 13, 2020) to temporarily list, as insured services, the provision of assessments of, or counselling to, insured persons by telephone or video, or advice and information to patient representatives by telephone or video, as well as a temporary sessional fee code.

Additionally, as part of Ontario’s continued efforts to stop the spread of COVID-19, the Ministry of Health (May 5, 2020), established temporary payment mechanisms to facilitate hospital and physician payments for medically necessary services provided to patients who are not currently insured under OHIP or another provincial plan.

These new fee codes are not limited to COVID-19 screening or COVID-19 patients and came into effect March 14, 2020.

Effective May 1, 2020, physicians can now submit claims for services provided on or after March 14, 2020 using the new fee codes for insured patients.  

Effective May 5, 2020, physicians can submit claims for services provided on or after March 21, 2020 using the new fee codes for uninsured patients. 

New fee codes for insured and uninsured patients

Scroll (left-right) for details
  • For care of insured patients
    K080

    Service provider: Family physician

    Fee: $23.75

    Service description: Minor assessment of a patient by telephone or video, or advice or information by telephone or video to a patient’s representative regarding health maintenance, diagnosis, treatment and/or prognosis.

    View notes
  • For care of insured patients
    K081

    Service provider: Family physician

    Fee: $36.85

    Service description: Intermediate assessment of a patient by telephone or video, or advice or information by telephone or video to a patient’s representative regarding health maintenance, diagnosis, treatment and/or prognosis, if the service lasts a minimum of 10 minutes. Psychotherapy, psychiatric or primary mental health care, counselling or interview conducted by telephone or video, if the service lasts a minimum of 10 minutes.

    View notes
  • For care of insured patients
    K082

    Service provider: Family physician

    Fee: $67.75

    Service description: Psychotherapy, psychiatric or primary mental health care, counselling or interview conducted by telephone or video per unit (unit means half hour or major part thereof).

    View notes
  • For care of uninsured patients
    K087

    Service provider: Community-based physician (e.g. family physician)

    Fee: $23.75

    Service description: Minor assessment of an uninsured patient provided in-person or by telephone or video or advice or information provided in-person or by telephone or video to an uninsured patient’s representative regarding health maintenance, diagnosis, treatment and/or prognosis.

    View claim submission requirements
  • For care of uninsured patients
    K088

    Service provider: Community-based physician (e.g. family physician)

    Fee: $36.85

    Service description: Intermediate assessment of an uninsured patient provided in-person or by telephone or video, or advice or information provided in-person or by telephone or video to an uninsured patient’s representative regarding health maintenance, diagnosis, treatment and/or prognosis, if the service lasts a minimum of 10 minutes. Psychotherapy, psychiatric or primary mental health care, counselling or interview conducted by telephone or video, if the service lasts a minimum of 10 minutes.

    View claim submission requirements
  • For care of uninsured patients
    K089

    Service provider: Community-based physician (e.g. family physician)

    Fee: $67.75

    Service description: Psychotherapy, psychiatric or primary mental health care, counselling or interview conducted in-person or by telephone or video per unit (unit means half hour or major part thereof).

    View claim submission requirements
  • For care delivered in a COVID-19 assessment centre
    COVID-19 Sessional Fee

    Service provider(s): Family physicians and specialists

    H409 Fee: $170.00, per one-hour period, or major part thereof, Monday to Friday 7 a.m. to 5 p.m.

    H410 Fee: $220.00, per one-hour period, or major part thereof, Saturdays, Sundays, holidays, or Monday to Friday 5 p.m. to 7 a.m.

    View service description
  • For care of insured patients
    K083

    Service provider: Specialists

    Fee: $5.00

    Service description: Specialist consultation or visit by telephone or video payable in increments of $5.00.

    View notes
Putting it into practice

K080A-K083A require a diagnostic code to be submitted on the claim. If the claim is submitted without a diagnostic code the claim will be reject as “V21-Diagnostic Code Required”.

For current OTNInvite users (PEM physicians with rostered patients, GP focus practice designated physicians, and specialists): continue to bill as usual with the Ontario Virtual Care Program fee code(s) (see Virtual Care Billing Information Manual (MOH, 2020)) and any applicable automated premiums (e.g. age premiums, focus practice psychotherapy premium) will continue to be applied automatically to the payment.

For new OTNinvite (any physician) users: Bill the new temporary K codes.

If preferred, physicians eligible to bill under the Ontario Virtual Care Program (PEM physicians with rostered patients, GP focus practice designated physicians, and specialists)  must complete the OTN billing registration form to begin billing the virtual care program codes.

Frequently asked questions (FAQs)

No, virtual visits do not qualify for special visit premiums.

Yes, K080, K081 and K082 are included in-basket for capitated and salaried primary care enrolment models.

No, for those in a FHO/FHN, patients who obtain care outside the group will not count towards outside use. If the ministry is unable to complete the necessary computer programming, they will make any necessary access bonus adjustments retroactively.

No, for FHO/FHN provision of services to non-rostered patients, the application of the Hard Cap ceiling for these services will not be enforced.

Yes, A001 and A007 are the equivalent to K080 and K081.

For Alternate Payment Program contracts, K080, K081 and K082 will be shadow-billed and the appropriate flow-through and shadow-billing premiums (if applicable) applied based on the specific contract.

Yes, the virtual care K codes can be used for follow-ups. Use the code with the closest workflow and dollar value.

Yes K087 (minor assessment), K088 (intermediate assessment) and K089 (counselling) can be used for providing care to IFH/uninsured patients.  See above for details and claim submission requirements.

Claim submission requirements

  • Physicians can submit for these codes using their group billing number where the service was provided, or their solo billing number.
  • The codes cannot be billed using one of the COVID-19 Assessment Centre group billing numbers.
  • The codes cannot be billed with a Service Location Indicator of ‘OTN’.
  • Physicians will be paid Fee-For-Service.
  • No additional premiums or payment will be allowed with these codes.
  • For K087 and K088, the fee billed on the claim should equal the value of the service multiplied by the number of patients serviced. For example, if K087 is claimed for 3 patients seen during the same day, the fee billed should be $71.25 (3 x $23.75).
  • The number of services for K089 represent the total number of 30 minute intervals spent with all uninsured persons in a single day. For K089A, the current timekeeping rules for psychotherapy remain. See page GP54 of the Schedule for information time units and minimum time requirements.

Details for submitting your claim

  • The claim must be submitted with the Billing Number of the physician who provided the service.
  • The Health Number and Version Code fields on the claim must be left blank. If a physician submits these claims with a Health Number or Version Code, the claim will reject “VHB-No HN Required for FSC”.
  • The Birth Date field on the claim must be left blank. If a physician submits these claims with a value in the Birth Date, the claim will reject “VH1-Invalid Health Number”.
  • The Service Date on the claim will be the date the service was provided.

No, the new K codes only cover services rendered by telephone or videoconferencing.

Delivering patient care in person

While delivering patient care virtually can satisfy the majority of your patients’ needs, there are still times when a virtual consult is not adequate and an in-person visit cannot be deferred.

When determining if an in-person visit is necessary, balance the patient needs (e.g. encounter type, acuity/severity of complaint) and risk factors (e.g. patient’s age, comorbidities) against the risks of exposure (MOH, May 22, 2020).

Putting it into practice

Create a safer environment for you, patients and staff

  • Scan health cards or identification visually (i.e. “hands free”).
  • Post MOH signage in waiting and examination rooms.
  • Consider having the patient call from outside the clinic (e.g. in car, waiting at a distance) once arrived, and put in a room when available to avoid time spent in the waiting room.
  • Consider erecting a plexiglass barrier at reception.
  • Interact with your colleagues at a two-metre distance and wash hands frequently, keeping your hands to yourself.
  • Space chairs in waiting room two metres apart and remove extra objects in the room.
  • Space your appointments to try to avoid any need for a wait in the waiting room.
  • Minimize people entering with the patient.
  • Use minimal number of rooms and clear rooms of extraneous objects and/or cover what you can’t move, such as wall-mounted ophthalmoscopes.
  • Keep direct patient contact solely to the family physician/primary care nurse practitioner so all vitals are done by the provider, as necessary.
  • Lead patients directly to the exam table/beds.
  • Thoroughly clean surfaces after the patient leaves.

Ensure your safety

  • Keep distance until executing the exam, and use appropriate personal protective equipment (PPE).
  • Determining the type of PPE (e.g. gloves, surgical mask, eye protection) used should be guided by the exposure type.
  • See Infection prevention and control: PPE, HCW infection control, cleaning for details on:
    • What PPE to wear, when
    • Donning and doffing PPE
    • Extended and reuse guidance for PPE
    • Environmental cleaning
    • Equipment cleaning
New diagnostic code for COVID-19

Effective March 14, 2020, a new diagnostic code has been created for the COVID-19 outbreak:
Code: 080
Description: Coronavirus

The new diagnostic code should be used when treating patients with suspected or confirmed COVID-19 and/or when treating a patient by telephone/video for suspected or confirmed COVID-19. Use the appropriate diagnostic code when treating a patient for unrelated diagnoses by telephone/video due to COVID-19 related concerns.

Updates to prescribing rules and regulations
Specifically, and subject to the laws and regulations of the province or territory in which the pharmacist is entitled to practice, this exemption will:

Permit pharmacists to extend and renew prescriptions for controlled substances.

Permit pharmacists to transfer prescriptions for controlled substances to other pharmacists.

Permit practitioners to verbally prescribe prescriptions for controlled substances.

Allow an individual to deliver controlled substances to patients (at their homes or an alternate location).

Putting it into practice

As always, ensure your prescriptions are complete, specific to your patient, and include both you and your patient’s identifying information so pharmacists can validate the authenticity of the prescription.

Established channels

Where possible, it’s important to continue to use established channels such as phone, fax, your EMR or other e-prescribing systems when issuing a prescription. This helps to prevent fraud, avoid undue pressure on pharmacists to verify the authenticity of prescriptions, and to deliver safe and timely care to patients.

New channels

If necessary, CPSO, CNO, and OCP have made an exception to allow the use unencrypted email for the purpose of sending prescriptions to pharmacists during the declared emergency. If you wish to use unencrypted email to send prescriptions to a pharmacist, you must obtain the consent of the patient for this purpose and explain that unencrypted email may not be secure.

Prescribing opioids/narcotics

Given the extra care required for prescribing opioids/narcotics for chronic pain, or within the context of addictions treatment, you must continue to use traditional routes of communicating prescriptions for these drugs.  However, you can adapt the above new protocols that allow for verbal authorization (Health Canada, March 23, 2020).

Financial supports and programs
COVID-19 Advance Payment Program

The ministry has established the COVID-19 Advance Payment Program to address any cash flow issues that may arise during the COVID-19 outbreak and sustain physicians’ practices and ensure business continuity that will enable them to return to regular practice as soon as the outbreak begins to subside.

The COVID-19 Advance Payment Program provides monthly, interest-free, automated advance payments to eligible physicians in May, June and July 2020 that will be recovered from physicians’ billings in five equal monthly instalments starting in November 2020.

Physicians will automatically receive the advance if their monthly payment is below the 70% of average payments over the previous 12 months (April 1, 2019 to March 31, 2020). Physicians do not need to apply to the program. If eligible, the program will automatically top up eligible physicians’ payments to 70% of the historical monthly average for each month of the 3 months that the program is in place starting in May 2020.

Physicians may opt out of the program at any time by contacting the ministry. Physicians who want to opt out for the month of May can do so by returning their payment to the ministry by submitting a cheque to the Financial Management Branch, 49 Place d’Armes, 3rd Floor Kingston, Ontario K7L 5J3. The cheque is to be made payable to the Minister of Finance. Providers should also indicate this cheque is for the re-payment of the advance payment, including the specified month. For other options to return the payment, you can contact the Service Support Contact Centre at 1-800-262-6524. Physicians are still able to opt out for the second and third payments (June and July RA) by contacting the Service Support Contact Centre as well.

See the OMA’s COVID-19 Advanced Payment Program FAQs [login required] (OMA, May 22, 2020) for program eligibility, payment calculation, repayment terms and details for providers under specific payment models (fee for service, patient enrolment models and alternative funding agreements).

Supports
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.

Mental health and well-being supports for providers
Last reviewed: May 26, 2020
Last updated: May 26, 2020
Identifying stress, anxiety and burnout

Over time, the build up of stress can lead to feelings of extreme exhaustion and being overwhelmed.

Signs of burnout include (CMA, 2020):

  • Experiencing feelings of sadness, depression, failure, helplessness or apathy.
  • Becoming easily frustrated.
  • Blaming others or feeling generally irritable.
  • Feeling disassociated, indifferent or apathetic.
  • Isolating or disconnecting from other others.
  • Practicing poor self care.
  • Feeling tired, exhausted or overwhelmed.
  • Using negative coping strategies (i.e. alcohol or substance use, poor eating habits, excess caffeine).
Recognizing burnout
Start by assessing where your mood is on the self-assessment tool. Then use the resiliency tips below to help manage your stress.
Resiliency tips for providers
Stress can be managed by using the 5 Cs of Resilience Framework (CSPL, 2020):
Control

Given the uncertainty around COVID-19, it is important to recognize what we can control and let go of things we cannot control.

Things we can control

Being positive and kind, enjoying time at home, limiting time on social media, following up-to-date guidelines with trusted information.

Things we cannot control and should let go

Predicting how long long this will last and what is ahead of us.

Commitment

It can be valuable to reflect on why you do the work you do as a family physician/primary care nurse practitioner and how it aligns with your values.

Connection

Maintain connections at work and in your personal life.  Spend time together with friends and family over text, email, phone calls or video calls.

It may be helpful to have a buddy system at work and use the “HELP” acronym to check in (CMA, 2020):

H – Ask: “How are you doing?”

E – Be empathic and understanding.

LListen without judgement and state your concerns.

PPlan next steps: encourage them to seek formal support and/or ask what you can do to help.

Calming

A

Awareness

Notice your body, hands, legs and feet. Orient to self, place, date and time.

B

Breathe

Three long comfortable deep breaths with prolonged exhale.

C

Count

Three things you can see, hear, feel, smell and taste.

1

One Thing

What is the one next thing for you to do right now?

2

Two Strengths

What are two strengths you can draw on (internal or external)?

3

Three Thanks

What are three things you are grateful for?

Care for yourself

Exercise, sleep, laugh, be kind and learn to enjoy down time.

Supporting wellness of staff

Identifying and addressing the needs of staff is the first step to reducing the risk of burn-out. Organizations should express gratitude towards their health care professionals along with efforts to hear, protect, prepare, support and care for them especially during these unprecedented times.

Hear me: Arrange a variety of input and feedback channels and involve healthcare staff in decision making (e.g. listening groups, suggestion box).

Protect me: Reduce the risk of healthcare workers acquiring the infection by providing PPE, rapid access to COVID-19 testing if symptomatic, resources to reduce risk to family members, and workplace accommodations for providers at high risk due to age or medical conditions.

Prepare me: We are all in this together, therefore it is important healthcare workers are comfortable relying on others, and asking for help. Provide training to staff and access to experts in order to provide high quality of care to patients.

Support me: Support the physical needs, including access to healthy meals and hydration at work, lodging for providers who have rapid-cycle shifts, transportation assistance for sleep-deprived workers, assistance with other tasks and support for child-care. Support emotional and psychological needs, including general and individualized resources.

Care for me: Provide holistic support for healthcare workers and their families. This includes lodging for those living apart from family, support for tangible needs, check-ins, and paid time off if quarantine is necessary.

Home and family life

Discussing the COVID-19 pandemic with your family is difficult and these conversations can be more challenging if your work requires you to be exposed to the virus (CMA Joule Boldly, March 23, 2020). To help eliminate stress in your household (BCCDC, March 16, 2020):

Ensure that your family has accurate information about COVID-19 and how they can protect themselves.

Reinforce the importance of making time for one another and maintaining family routines.

Inform your family on how they can support one another in managing the stresses associated with having a loved one working as part of the COVID-19 response.

For more information on managing the mental wellbeing of your child during the pandemic see Maintaining Regular Primary Care Practice in the COVID-19 Context > Child mental health.

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 prevention and control: PPE, HCW infection control, cleaning
Last reviewed: May 25, 2020
Last updated: May 26, 2020

The hierarchy of controls 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 (Public Health Ontario).

PPE is the last in the hierarchy of controls and should not be relied on as a standalone primary prevention program. See Primary care operations in the COVID-19 context for information about virtual visits, and environmental precautions to take when seeing patients in person.

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 3, 2020).

Personal protective equipment (PPE)

What to wear, when

Due to community spread of COVID-19 within Ontario, and evidence for asymptomatic and pre-symptomatic transmission, it is recommended that surgical/procedural masks be worn for all patient encounters that involve less than 6 feet of separation (MOH, May 22, 2020; OCFP, April 16, 2020).

A point-of-care risk assessment (PCRA) identifying the Task, Patient and Environment should be conducted for all patient encounters in order to determine the PPE required (PHO, May 3, 2020).

COVID-19 is known to spread through contact and droplet transmission, therefore droplet and contact precautions should be used for patients with suspected or confirmed COVID-19, (PHO, May 3, 2020; OH, May 10, 2020). See PPE used for droplet and contact precautions (below) for details.

The possible role of airborne transmission is 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, May 10, 2020). 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. For a list of AGMPs that warrant airborne precautions, as well as those which should be avoided altogether during the pandemic, see Appendix C of Personal Protective Equipment (PPE) Use During the COVID-19 Pandemic (OH, May 10, 2020).

Putting it into practice

When caring for patients with suspected or confirmed COVID-19, use the following guidance to determine the level of PPE required (PHO, May 3, 2020):

* Public Health Ontario (2013) outlines Routine Practices for preventing the transmission of acute respiratory infections. Universal masking is not included as Routine Practice,  however OH and OCFP recommend that masks be worn for all patient encounters that involve less than 6 feet of separation (MOH, May 22, 2020; OCFP, April 16, 2020).

PPE used for droplet and contact precautions

PPE can be used for situations not listed below if determined during the point-of-care risk assessment (PCRA).

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

    • Extend use as long as possible if caring for multiple patients using contact and droplet precautions.
    • Discard after exiting examination room if not caring for multiple patients using contact and droplet precautions.
    • 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

    • 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.
PPE inventory and quality control
Accessing PPE
Inventory management initiatives

The MoH has issued an order for Mandatory Daily Reporting of PPE Inventory (in effect since March 27, 2020). 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. The ministry has provided detailed instructions about how to report.

OMA and MoH have asked for healthcare providers to save used, unsoiled masks and N95 respirators in case they may be able to be decontaminated in the future. Store surgical masks and N95 respirators separately in labelled and dated storage containers.

Quality control

PHAC warns about the sale of fraudulent N95 respirators that do not meet industry standards.

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.

Donning and doffing PPE

As of March 30, 2020, 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
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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, reprocessing, homemade masks
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). 
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 some PPE (e.g., surgical/procedural masks and N95 masks) is now recommended in Ontario. See Droplet and Contact Precautions (above).

  • Do not combine extended use and reuse practices.
  • Take care not to touch PPE. If you touch or adjust PPE, immediately perform hand hygiene with soap and water or sanitizer for 20 seconds.
  • Take extra care when removing PPE, as this is when self-contamination may occur. Removed PPE should be re-processed before it is used again.
  • Do not use anything in your home (ovens, microwaves) to disinfect contaminated equipment (Stanford Medicine COVID-19 evidence service).

These strategies should be combined with elimination and administrative controls. See Primary care operations in the COVID-19 context for information about virtual visits, and environmental precautions to take when seeing patients in person.

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  • Surgical mask

    Contingency capacity

    • Extend use of masks for repeated close encounters with several different patients without removing in between.
    • Restrict facemasks to use for HCP rather than for patients for source control.
    • When to discard: when the mask is wet, damaged, difficult to breathe through, soiled or removed.
    • Place unsoiled, undamaged masks in a clearly labelled, dated receptacle for possible reprocessing after use. Use the bin only for surgical procedure masks.
    Click for reuse and reprocessing 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 reuse and reprocessing 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

    • Shift gowns toward cloth isolation gowns. 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 reuse and reprocessing 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).

    While some studies testing the efficacy of glove washing and sanitizing exist, no authoritative Canadian source has communicated guidance on this practice in the context of COVID-19.

  • N95 mask

    Contingency capacity

    • Extend use of masks for repeated close encounters with several different patients without removing in between. Respirators can function within their design specifications for 8-12 hours of continuous use (CDC, 2020).
    • Consider using a cleanable face shield (preferred) over an N95 respirator and/or other steps (e.g. masking patients, use of engineering controls) when feasible, to reduce surface contamination of the respirator.
    • When to discard: When contaminated with blood, respiratory or nasal secretions, or other bodily fluids from patients, following use during aerosol-generating procedures, or following close contact with any patient coinfected with an infectious disease requiring contact precautions or inadvertent contamination of inside of respirator.
    • Place unsoiled, undamaged masks in a clearly labelled, dated receptacle for possible reprocessing after use. Use the bin only for N95 masks.
    Click for reuse and reprocessing guidance
Homemade masks
Most guidance available on the use of homemade cloth masks is intended for the public, not for healthcare workers.

However, some guidance can be applied to the healthcare setting.
Click for details
Top resources

Infection monitoring and protocols for healthcare workers

Self-monitoring and self-assessment
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 (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, May 2, 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, May 2, 2020).

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 (May 2, 2020) 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 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 has been no known recent potential exposures (e.g. tested as part of surveillance and no other cases detected in the facility or on the unit/floor, depending on the facility size), there is no minimum time off from the positive specimen collection date as it is unclear when in the course of illness the positive result represents (i.e. consistently asymptomatic HCWs can continue working in work self-isolation until 14 days from specimen collection date).

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).

Environmental and equipment cleaning

Environmental cleaning

COVID-19 environmental cleaning protocols are the same as for other common viruses. The cleaning products and disinfectants commonly used in healthcare settings are strong enough for COVID-19.

See Health Canada’s list of approved disinfectants to ensure your supplies are approved for disinfecting in a healthcare setting.

Equipment cleaning

Disinfectant wipes that meet healthcare standards may be used for cleaning small noncritical items between patients (stethoscopes, blood pressure cuffs, etc.) (Public Health Ontario).

Disinfectant wipes that meet healthcare standards may also be used for items that cannot be soaked. However, family physicians and primary care nurse practitioners should do this with caution, as it may be difficult to reach adequate disinfectant contact time (Public Health Ontario).

See COVID-19: Cleaning equipment and Family Physician Offices (BC Centre for Disease Control) resource on cleaning frequency by type of surface and list of disinfectants and cleaning agents known to be effective against coronaviruses.

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