Primary Care Operations in the COVID-19 Context

Last Updated: February 15, 2023

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This resource 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.

Primary care is integral to an effective healthcare system and it is essential that care is delivered in the manner most appropriate for patients during the COVID-19 pandemic. This resource outlines recommendations and strategies to support you in providing optimal care during the COVID-19 pandemic while balancing your patient’s best interests.

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Testing and isolation requirements for healthcare workers New

The MOH provides separate isolation guidance for individuals who live, work, volunteer or are admitted in the highest risk settings, including (MOH, August 31, 2022):

  • Hospitals (including complex continuing care facilities)
  • Home and community care workers and congregate living settings with medically and socially vulnerable individuals, including, but not limited to, Long-Term Care, retirement homes, First Nation elder care lodges, group homes, shelters, hospices, correctional institutions, and hospital schools
  • Employer-provided living settings of International Agricultural Workers.

Isolation requirements for primary care providers

Primary care providers who do not work or volunteer in such high risk settings should follow the same isolation guidelines as other community members (described in detail in Testing and isolation requirements). Having immunocompromised patients in one’s primary care practice does not constitute a highest risk setting, however it is recommended that primary care providers wait an additional 5 days after returning from a 5 day isolation before seeing immunocompromised patients.

Testing and isolation requirements for highest-risk settings

Step 1

Presume any household members with COVID-19 symptoms have COVID-19.

All household members should isolate (stay home) UNLESS any of the following apply**:

  • They tested positive for COVID-19 within the prior 90 days
  • Are 18+ and boosted
  • Are under 18 years old and are fully vaccinated.

Healthcare workers should follow any work self-isolation policies.

Step 2

Obtain COVID-19 testing for the symptomatic person:

  • Serial rapid antigen test (RAT): 2 tests, taken 24 – 28 hours apart; OR
  • Polymerase chain reaction (PCR) test (household members of HCWs working in highest-risk settings are eligible for PCR testing as of Jan 13/22)
Step 3

If COVID-19 testing is NEGATIVE, the HCW can discontinue isolation.

If COVID-19 testing is POSITIVE, asymptomatic HCWs who have not had a positive COVID-19 test in the last 90 days should:

  • Obtain PCR testing per local Public Health guidance
  • Isolate (stay home) while the symptomatic person is isolating. If the HCW is immunocompromised, they will need to isolate for 10 days (20 days if they are severely immunocompromised
  • Not work for 10 days from their last exposure to the symptomatic person during their infectious period (from 48 hours prior to symptom onset until the end of their isolation period) unless they can complete RAT tests (see below).
  • Follow guidance for COVID-19 cases if symptoms develop or they test positive for COVID-19

Healthcare workers who are following workplace self-isolation should:

  • Stay home for the isolation period and only leave home for essential work;
  • Wear recommended personal protective equipment including a fit-tested N95 mask while at work
  • Stay 2 meters away from others at work except to provide direct patient care;
  • Take breaks alone and wash their hands often
  • Ideally, work at one facility only;
  • Follow testing requirements.


Under routine operations asymptomatic close contacts that work in highest-risk settings may return to work:

  1. Following a negative molecular test (e.g., PCR, rapid molecular) collected on/after day 5 from last exposure
    OR
  2. Following a negative molecular test (e.g., PCR or rapid molecular) collected before day 5 after last exposure AND performing daily rapid antigen tests for 10 days after last exposure or until a second negative molecular test is collected on/after day 5 after last exposure
    • Asymptomatic close contacts who are returning after a negative molecular test collected before day 5 after last exposure are recommended to follow the Workplace Measures below for reducing risk of exposure.

Please see Management of Cases and Contacts of COVID-19 in Ontario (November 30, 2022) for guidance during critical staff shortage


* highest risk settings include: hospitals including complex continuing care facilities and paramedic services; and congregate living settings, including long-term care homes, retirement homes, First Nation elder care lodges, group homes, shelters, hospices, and correctional facilities.
**Wear a well-fitted mask in public, physical distance and maintain other public health measures for 10 days following last exposure if leaving home. HCW should NOT visit or attend work in any highest risk settings and not visit individuals who may be at higher risk of illness (i.e., seniors or immunocompromised) for 10 days after your last exposure.

Healthcare workers (HCWs) with a positive COVID-19 rapid antigen test (RAT) or polymerase chain reaction (PCR) test must isolate (stay home).

  • HCWs who have had at least 2 COVID-19 vaccine doses must isolate for 5 days from the day of the positive test (day of positive test is Day 0).
  • HCWs who have NOT had at least 2 COVID-19 vaccine doses AND healthcare workers who are immunocompromised must isolate for 10 days from symptom onset (day of symptom onset is Day 0).
  • If symptoms develop, follow isolation guidance for symptomatic HCWs
  • HCWs can exit isolation once their isolation period is complete EVEN IF other household members are still isolating.

Healthcare workers who are close contacts who have previously tested positive for COVID-19 in the last 90 days (based on positive rapid antigen test or molecular test results) can attend work in the highest-risk setting, as long as they are currently asymptomatic. These individuals are advised to self-monitor for symptoms for 10 days after last exposure.

For early RTW:
Under routine operations, asymptomatic close contacts that work in highestrisk settings may participate in testing for early return to work:

  • Following a negative molecular test (e.g., PCR, rapid molecular) collected on/after day 5 after last exposure
    OR
  • Following a negative molecular test (e.g., PCR or rapid molecular) prior to first shift (if collected before day 5) AND perform daily rapid antigen testing for 10 days after last exposure or until a second negative molecular test is collected on/after day 5 from last
    exposure

Please see Management of Cases and Contacts of COVID-19 in Ontario (November 30, 2022) for guidance during critical staff shortage

 

** highest risk settings include: hospitals including complex continuing care facilities and paramedic services; and congregate living settings, including long-term care homes, retirement homes, First Nation elder care lodges, group homes, shelters, hospices, correctional facilities and home and community care settings.

Step 1

Healthcare workers (HCWs) with COVID-19 symptoms should presume they have COVID-19 and isolate (stay home) while awaiting test results.

Step 2

Where possible, the HCW should obtain COVID-19 testing:

  • Serial rapid antigen test (RAT): 2 tests, taken 24 – 28 hours apart; OR
  • Polymerase chain reaction (PCR) test
Step 3

If COVID-19 testing is NEGATIVE, the HCW can discontinue isolation when they have been fever-free for 24 hours AND symptoms have been improving for at least 24 hours (48 hours for gastrointestinal symptoms).

If COVID-19 testing is NOT AVAILABLE or POSITIVE, the HCW must isolate (stay home):

  • HCWs who have had at least 2 COVID-19 vaccine doses OR who have had a COVID-19 infection within 90 days must isolate for at least 5 days from symptom onset (day of symptom onset is Day 0).
    Isolation can end after 5 days IF they have not had a fever in 24 hours AND symptoms have been improving for at least 24 hours (48 hours for gastrointestinal symptoms).
  • HCWs who have NOT had at least 2 COVID-19 vaccine doses AND healthcare workers with immunocompromise must isolate for at least 10 days from symptom onset (day of symptom onset is Day 0). HCWs with severe immunocompromise must isolate for at least 20 days from symptom onset (day of symptom onset is Day 0).
    Isolation can end after Day 10 (or Day 20) IF they have not had a fever in 24 hours AND symptoms have been improving for at least 24 hours (48 hours for gastrointestinal symptoms).
  • HCWs can exit isolation once their isolation period is complete EVEN IF other household members are still isolating.

HCWs in highest risk settings* should follow workplace guidance to return-to-work (RTW). In general, HCWs who are not immunocompromised can RTW:

For routine operations, COVID-19 positive cases that work in highest-risk settings may return to work:

  1. 10 days after symptom onset or date of specimen collection (whichever is earlier)
    AND
  2. Provided they have no fever and other symptoms have been improving for 24 hours (or 48 hours if vomiting/diarrhea). 

Note: Testing for clearance is generally not recommended.

Please see Management of Cases and Contacts of COVID-19 in Ontario November 30, 2022) for guidance during critical staff shortage

 

* highest risk settings include: hospitals including complex continuing care facilities and paramedic services; and congregate living settings, including long-term care homes, retirement homes, First Nation elder care lodges, group homes, shelters, hospices, correctional facilities and home and community care settings.

Determining when to schedule in-person vs remote visits

Consider patient needs along with the presenting condition. Whether delivering care virtually or in person, the fundamental principle is that the quality of care is not compromised, and the standard of care is met (OCFP, 2022).

While virtual care is a helpful tool to access care during the pandemic, the pressures that existed earlier on have now diminished (e.g., unavailability of COVID-19 vaccines, lack of personal protective equipment). In most cases, in-person care can now be provided safely and appropriately and can resume based on clinical need and patient preference.

It is important to consider the patient’s best interests when balancing the type of visit. Take into consideration the patient’s preferences and clinical condition.

Frequently Asked Questions (FAQs)

No (CPSO, 2021). Even in the absence of a negative test result or vaccination, in-person care can be provided safely by taking appropriate precautions (screening patients and using necessary PPE). While you can encourage eligible patients to get vaccinated, patients cannot be denied access to necessary in-person care based solely on their vaccination status.

The right balance between providing in-person and virtual will vary by physician practice. Every practice is unique, and the decision about the care provided will require judgment on the part of the physician to determine how best to serve their patients’ needs. The pressures that existed at a different stage in the pandemic (e.g., lack of PPE, high number of cases) have now diminished. When taking appropriate precautions, in-person visits can now be provided safely and appropriately, and may be in your patient’s best interest in some instances.

Your patient’s best interests will include taking into consideration the type of visit they would prefer. In this situation an in-person visit should be offered as long as you are able. To ensure that the appropriate safety precautions are in place, see the PPE section for more information.

Clinical scenarios

Examples of when in-person care is recommended (OCFP, 2022):

  • Medical issues: such as undifferentiated acute problems, unstable mental health conditions or chronic diseases, joint injections, incision and drainage, and IUD insertions.
  • Physical examinations as normally would be required before making referrals or ordering tests.
  • Cancer screening: Ontario Health recommends gradually resuming routine breast and cervical screening. Primary care providers can also begin sending new fecal immunochemical test (FIT) requisitions to LifeLabs for all eligible people at average risk for colorectal cancer. For full guidance see Ontario Health’s COVID-19 Cancer Screening Tip Sheets (2021).
  • Confidential assessments for patients who cannot speak privately at home, on issues such as intimate partner violence, etc. 
  • When virtual care is too challenging or not possible, such as for individuals with hearing loss, or who have technology, language, or cognitive barriers.
  • Palliative and end-of-life care to ensure appropriate management of pain and other symptoms.

Putting it into practice

Consider the following principles as a guide for determining whether in-person care is appropriate (OCFP, 2022): 

See patients in person for conditions where:

  • Physical contact is necessary to provide care (e.g., newborn care, prenatal care). 
  • Physical assessments are necessary to make an appropriate diagnosis or treatment decision (e.g., undifferentiated conditions, physical examinations that cannot be done virtually, language barriers). 
  • You can provide high-impact prevention strategies, such as cancer screening and immunization that prioritize those at higher risk. 

Consider patient needs: 

  • Even if it is appropriate to provide care virtually, your patient’s best interests may be served by providing care in person. 
  • Patient age, language and communication barriers may all mean in-person care is preferable. 

Personal protective equipment (PPE)

The fundamental method of protecting workers is through the application of the hierarchy of hazard controls (NIOSH, January 13, 2015). Although PPE is the most visible of the hierarchy of controls, it is the last tier and should not be relied on as a standalone primary prevention program. The PPE tier refers to the availability, support and appropriate use of physical barriers between healthcare workers and an infectious agent/infected source to minimize exposure and prevent transmission (PHO, March 2022).

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, March 2022).

As of June 11th, 2022, all mask mandates have been lifted for indoor settings in Ontario, with the exception of long-term care and retirement homes (CPSO, November 18, 2022).

  • However, the Chief Medical Officer of Health continues to recommend that clinicians, staff, and visitors wear masks in all healthcare settings.
  • Primary care practices may continue to implement masking policies that ask all staff, patients, and other visitors to wear a mask.

Masking of patients in primary care settings

Despite mask mandates being lifted, primary care practices may continue to implement masking policies that ask all staff, patients, and other visitors to wear a mask (CPSO, November 18, 2022).

If a patient who does not need an accommodation/exemption refuses to wear a mask, explain the expectation in your practice is that a mask be worn. If the patient still refuses, consider that in most cases, the following strategies will limit your risk (CPSO, November 18, 2022):

  • Ensuring that you safely don appropriate PPE (see What to wear, when)
  • Isolating patients
  • Providing care to patients with suspected/confirmed COVID-19 during set times of the day
  • A virtual appointment, if appropriate

Physicians have a duty of care where care is urgently needed, and redirecting patients to other parts of the system may exacerbate existing and significant resource challenges (CPSO, November 18, 2022).

What to wear, when

Public Health Ontario recommends PPE when providing direct care for patients with suspect or confirmed COVID-19 including a fit-tested, seal-checked N95 respirator (or equivalent or greater protection), eye protection, gown, and gloves. Other appropriate PPE includes a well-fitted surgical/procedure (medical) mask, or non-fit tested respirator, eye protection, gown and gloves for direct care of patients with suspect or confirmed COVID-19 (PHO, June 2022).

Before every patient interaction, conduct a point-of-care risk assessment to determine the PPE required. See PHO’s advice on performing a risk assessment. Examples of risk factors to consider in your risk assessment that may increase transmission risk include:

  • HCW: Vaccination status
  • Patient: Unable to mask for source control, unvaccinated
  • Interaction: prolonged, close contact (i.e.,< 1 m for > 15 minutes), performing a high-risk procedure
For patients who screen negative for COVID-19

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

For patients who screen positive for COVID-19 (suspected or confirmed COVID-19 infection or contact)

HCWs should wear the following PPE:

  • Fit-tested, seal-checked N95 mask (if unavailable, a well-fitted surgical/procedural mask, KN95 mask, or non-fit tested N95 mask may be used)
  • Isolation gown
  • Gloves
  • Eye protection (goggles or face shield)
Performing aerosol generating procedures (AGMPs)

Fit tested N95 respirators (or equivalent or greater protection) should be used when aerosol-generating medical procedures (AGMPs) are performed or anticipated to be performed on patients with suspect or confirmed COVID 19 (PHO, June 2022).

Choosing a surgical/procedure mask, N95 mask or KN95 mask

The use of a fit-tested, seal-checked N95 mask is recommended for healthcare providers who are caring for patients with suspect or confirmed COVID-19, and must be worn when performing AGMPs. In instances where a fit-tested N95 mask is unavailable, or not required (e.g., when caring for patients who screen negative for COVID-19), healthcare providers should wear a well-fitted surgical/procedural mask, KN95 mask, or (non-fit tested) N95 mask (PHO, March 2022).

KN95 masks are similar to N95 masks, with the main difference being that they are not tested to North American standards (they are tested to Chinese standards) (Health Canada, November 29, 2021). This can lead to more variability among KN95 masks; some may be equivalent to N95 masks and some not. Overall, when deciding between a surgical/procedure mask, KN95 mask, and non-fit tested N95 mask, the better the mask fits in terms of minimizing air gaps, the more protection it will likely provide. In many instances, KN95 masks will minimize air gaps better than a surgical/procedure mask, but this must be determined by the individual wearing the mask. Healthcare providers should consider mask fit, mask availability, and their organizational and personal risk assessments when choosing a mask (PHO, March 2022).

When to discard PPE

Surgical/procedure mask, KN95 mask and N95 mask

If caring for patients who screen negative for COVID-19:

  • 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.

If caring for patients who screen positive for COVID-19 (suspected or confirmed COVID-19 infection or contact):

  • Discard after each encounter with patients with suspected or confirmed COVID-19.
  • Discard after performing an AGMP on a patient who has suspected or confirmed COVID-19 (Reminder that N95 mask must be used when performing an AGMP).
  • Discard if wet, damaged, soiled, or removed (e.g., to eat or drink), or you exit the patient care area.
Isolation gown (disposable or cloth)
  • Discard after each patient encounter. Do not extend use of disposable isolation gowns between multiple patients with confirmed COVID-19 infection unless gown supplies are limited.
  • Launder cloth gowns according to routine practices (CDC). Do not take PPE home to launder.
Latex or nitrile gloves
  • 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.
Eye protection (goggles or face shield)
  • 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.

PPE inventory and quality control

Accessing PPE

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

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

  • Step 1: Implement conservation and stewardship strategies to reduce the need for resupplying PPE.
  • Step 2: Use existing supply chain processes and collaboration with local partners to obtain supplies.
  • Step 3: Explore alternate inventories to obtain supplies.
  • Step 4:
    • For Providers in Toronto, Central, North and East Regions: Use Ontario Health’s Critical PPE Intake Form to escalate to your Regional Lead. Multiple PPE requests may be addressed in one form submission; however, please ensure all fields are accurately filled out to avoid shipment delays or lack of fulfillment. Orders continue to be processed Monday to Friday during regular business hours with a minimum 2-business day delivery time (MOH, August 24, 2022).  
    • For Providers in West Region: Use the Urgent Pandemic Supply Request form to escalate to your Area Hubs, who may in turn escalate to your Regional Lead.

Inventory management

The Ministry of Health manages an emergency stockpile containing PPE. The new guidance focuses on how to access the pandemic stockpile, who is eligible, and product availability (MOH, August 24, 2022).

Stockpiling guidance
  • Health care entities keep a four-week stockpile of PPE based on high transmissibility & low clinical severity scenarios.  
  • Health care entities should have supplies of both N95 respirators and medical (surgical/procedure) masks for health care workers, so they are prepared to implement routine practices and additional precautions and any added pandemic measures. 
Routine Stockpiling Operations

The MoH recommends that all health care entities incorporate modern inventory management and control practices into their routine stockpiling operations, including (MOH, August 24, 2022):

  • Monitoring and tracking inventory quantities;
  • Monitoring and tracking expiration dates; 
  • Monitoring and tracking lot codes;
  • Performing regular turn-over and replacement of aged inventory prior to expiration;
  • Disposing of expired stock in an ethical and environmentally friendly way.   

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

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

Ethical Allocation Framework

The Ethical Allocation Framework highlights criteria to guide prioritization of PPE in instances of limited supply. One of the prominent criteria is the urgency of need determined by current PPE supply, number of confirmed cases, consumption or “burn” rate of PPE, and projected need of a facility. Despite the Framework’s COVID-19 purpose, it can be a helpful guide for related pandemic pathogen cases beyond COVID-19 (MOH, August 24, 2022).  

Donning and doffing PPE

How to don PPE
Donning tips

Eye protection

Isolation gown (disposable or cloth)

  • Have a colleague tie your gown for you.

Latex or nitrile gloves

  • Choose the correct glove size.
  • Keep nails trimmed and polish free.
  • Avoid wearing jewelry on hands on arms.

Headbands, caps and other garments

  • Should only be worn if they do not interfere with proper fitting of PPE. Must be incorporated into the donning process and treated as another PPE item.
How to doff PPE

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

Common doffing errors:

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

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

Doffing tips

Mask

  • The practice of removing only one side of the mask to eat, talk, or perform other activities introduces a high risk of self-contamination and contamination of the mask.
  • Always fully remove and discard (or appropriately store in the case of re-use) the mask, then perform hand hygiene.

Order of removal

  • After exposure to a patient who is positive for COVID-19, remove gloves and gown while in the patient care area, then exit room and perform hand hygiene (Use of PPE, CDC, 2020).

Headbands, caps and other garments

  • Must be incorporated into the doffing process.
  • Non-medical equipment worn in patient care settings must be subjected to the same washing/sterilization protocols as PPE.

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.

Top resources

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