MEMO: COVID-19 Guidance for Providing Primary Care and In-person Visits, COVID-19 Vaccinations & Testing

TO: Health Care Professionals in the Niagara region

FROM: Environmental Health Division, Niagara Region Public Health

REFERENCE: COVID-19 Guidance for Providing Primary Care and In-person Visits, COVID-19 Vaccinations & Testing

DATE: August 9, 2021

As the province begins to re-open and continue towards a ‘new normal’, health care professionals will need to be cautious in resuming practice in a controlled and gradual manner while taking steps to protect yourself, your staff, the patient and the public. On July 28, 2021, the Ministry of Health has released a revised COVID-19 guidance document for primary care providers in community settings. The following is a compiled list of key public health measures and best practices, intended to act as a guide to assist you in resuming in-person care in your practice.

*** Please be advised that this list is not all inclusive***

Physical Distancing

Physical distancing of 2 metres remains an important measure in preventing the spread of COVID-19, and is required regardless of a person’s immunization status. Here are ways in which physical distancing can be achieved and encouraged in your office:

In the waiting area: maintaining capacity limits to ensure all patients and staff can safely maintain 2 metre distance from one another by
- Setting up your waiting area by removing and distancing furniture as necessary
- Posting capacity limit(s) in a conspicuous location
- Assigning in/out routes with signs and/or visual markings
- Installing barriers when physical distancing cannot be maintained (e.g. at your reception desk).
- Using booked appointments to limit the number of people in the facility, waiting outside and/or in their car prior to an appointment. You can also consider limiting the number of people who attend appointments with your patients.
In the break room: set and maintain capacity limits of break rooms, remove & distance furniture as necessary, encourage staggered breaks and remind staff of masking requirements when not eating or drinking.

Screening

As an employer, you must continue to practice appropriate screening of both patients and staff. The following should continue to be implemented:

All staff should be actively screened daily prior to work and continue passive monitoring for symptoms throughout the day.
Screen patients prior to entry (at entrance of facility or when possible, through video, telephone or using web-based/online technologies) and at the point of care.
Develop policies and procedures to manage patients and staff who fail screening.
- Primary care providers and all office/clinic staff must actively screen themselves daily before coming into the office/clinic.
- Refer to pages 6-7 in the guidance document for steps to take when a patient fails screening.
- If a patient or staff member was in the office/clinic and later tests positive for COVID-19, primary care providers and/or office/clinics, if aware, should call Niagara Region Public Health’s COVID-19 health care professional’s information line (905-688-8248, press 7, then 1) for advice on their potential exposure and implications for continuation of work.

Ventilation

As the science of COVID-19 transmission has progressed, aerosol transmission has been identified as playing a more important role than previously understood, particularly in poorly ventilated spaces. The following is recommended to improve your ventilation system;

Consult with a Professional to ensure your heating, ventilation and air conditioning (HVAC) system is maintained and operating properly.
Avoid using portable fans, ceiling fans, and single unit air conditioners if possible.
If you must use a fan or window air conditioning unit, aim the air stream away from patients and staff.
Open windows and doors to increase airflow and natural ventilation.
Consider the use of portable air cleaners (i.e. HEPA filtration units).

Improving ventilation of a space does not replace basic infection control measures, which reduce transmission in situations of close contact, but is meant to supplement these practices in a layered approach.

Cleaning and Disinfecting

Appropriate cleaning and disinfecting procedures play an important role in reducing the spread of COVID-19 and other infectious diseases and can be achieved by:
Daily cleaning and disinfecting high touch surfaces (e.g. door handles, light switches) at least twice daily or more frequently if necessary.
- Review approved disinfectants including appropriate application and contact time by following the Manufacturer’s Instructions For Use.
Removal of all items which cannot be properly cleaned and disinfected (e.g. magazines, toys).
Cleaning and disinfecting of examination rooms in-patient contact surfaces should be performed based on patient screen status.
- For patients who screen positive, patient contact surfaces (i.e. areas within 2m of the patient) should be cleaned and disinfected as soon as possible.
- Treatment areas, including all horizontal surfaces, and any equipment used on the screened positive patient (e.g. exam table, thermometer, blood pressure cuff) must be cleaned and disinfected before another patient is brought into the treatment area or used on another patient.
For patients who screen negative, standard cleaning and disinfection processes can be used. Please refer to PIDAC best practices documents for more information about environmental cleaning.

Personal Protective Equipment and Mask Use

The proper use of personal protective equipment (PPE) is critical to keeping both clinicians and patients safe.

Conduct a point of care risk assessment (view pages 10-11) to determine additional PPE requirements (i.e. aerosol generating procedures, client’s with mask exemptions).
Universal mask use is required for all patients (and those accompanying them, if applicable) and staff, at all times.
Store and dispense PPE in a manner to protect from potential contamination.
Post appropriate respiratory etiquette signage and mask use requirements in a conspicuous location. You can order this on our “order resources” webpage under Infection Prevention and Control.
Droplet and Contact Precautions (i.e. surgical/procedural mask, isolation gown, gloves and eye protection) for interactions with patients who screen positive for COVID-19 or as determined by a point of care risk assessment.
Train staff on proper donning and doffing of PPE, cleaning, disinfecting and storage of re-usable PPE (i.e. goggles, face shields).

COVID-19 Vaccinations

In the coming weeks and months it is critical that together we find ways to reach the remainder of our population that has yet to be fully vaccinated. As the first point of access to the health care system, primary care represents a key partner in this effort and can play a unique role in supporting patients in making the decision to receive two doses of the vaccine and address any hesitancy that may exist. Primary care, alongside pharmacy, will be key COVID-19 vaccine distribution channels as we look ahead to the fall and it is critical that we work together and continue to expand community-based access to vaccination and increase coverage levels.

If your practice is not yet participating in the COVID-19 vaccine program, please review the 5-step onboarding process, watch the general onboarding webinar on the page, and contact HCPengagement@niagararegion.ca to express interest in participating in the program locally.

COVID-19 Vaccine Interval Recommendations - Update

In follow-up to the Medical Advisory on COVID-19 Vaccines and Interval Recommendations issued on April 1, 2021, NACI indicates that the minimum waiting period between vaccines is precautionary and there may be circumstances in which simultaneous administration or a shortened interval may be warranted on an individual basis. For more information on what these circumstances may include, visit Recommendations on the use of COVID-19 vaccines - Canada.ca.

COVID-19 Testing

The revised guidance document also provides minor updates to the ‘Testing’ section and new information on point-of-care testing. A brief summary is included below.

Testing for COVID-19 should be offered to, or arranged for, all patients with new or worsening symptoms that are compatible with COVID-19 where possible and asymptomatic contacts of a confirmed case.
Reference the COVID-19 Provincial Testing Guidance Update for testing guidance and the COVID-19 Reference Document for Symptoms for the latest version of the COVID-19 symptom list, including exceptions related to underlying conditions.
Testing in the primary care office/clinic can be performed if the primary care provider is able to follow Droplet and Contact Precautions as outlined above, has the appropriate tools and knowledge of how to test, and can ensure coordination of sample delivery to a laboratory providing COVID-19 testing.
- Please view Nasopharyngeal Specimen Collection Instructions available on Public Health Ontario’s webpage.
Any symptomatic individual who has been referred for testing must be told to isolate until a negative result is received.
- If patients are referred to a hospital or a testing location, make efforts to ensure that the patient is aware of the need for safe arrangements for travel to the hospital or testing location that maintains isolation of the patient (i.e. patient should wear a surgical/procedure mask and should avoid public transit if possible).
Point-of-care testing (also known as ‘rapid testing’) can be used as an additional layer of screening within the primary care environment.
- Antigen point-of-care testing is not to be used for diagnosis of COVID-19.
- Individuals who test positive on a rapid antigen test must be referred for confirmatory PCR testing.

More Information

Ministry of Health – COVID-19 Guidance: Primary Care in Community Settings
CPSO - COVID-19 FAQs for Physicians
COVID-19: Guidance on indoor ventilation during the pandemic - Canada.ca
Niagara Region Public Health’s Frequently Asked Questions for Health Care Professionals – View Infection Prevention and Control section.