COVID-19: NLCHP

Newfoundland and Labrador Council of Health Professionals (NLCHP)

COVID-19 Guidelines and Resources for Health Professionals.

CONTENTS

Overview........................................................................................................................................... 3

COVID-19......................................................................................................................................... 3

Public Health Orders and Measures................................................................................................... 4

Preparing your workplace.................................................................................................................. 4

College Documents.......................................................................................................................... 6

Personal Protective Equipment (PPE)............................................................................................... 6

Aerosol Generating Medical Procedures (AGMPs)............................................................................ 7

Cleaning and Disintecting................................................................................................................. 8

Client Screening and Appointment Protocals................................................................................... 9

Process for Handling Exposures....................................................................................................... 10

Telepractice................................................................................................................................... 10

References and Resources.............................................................................................................. 11

References.................................................................................................................................. 11

General Resources...................................................................................................................... 11

Health Professional Specific Resources....................................................................................... 11

OVERVIEW

This document provides direction and resources for health professionals registered under the Health Professions Act in relation to re-opening services during the COVID-19 pandemic. The Government of Newfoundland and Labrador has outlined a 5-Level Alert System in terms of the public health restrictions in place due to COVID-19. It is anticipated that health care providers previously prevented from working will be allowed to resume practice in Alert-Level 3. We recognize that resuming practice does not mean a return to normal services, as they had operated in the past. In some cases, health professionals may decide to continue to provide emergency and/or urgent care only or to remain closed. In all cases, it is recommended that health professionals, if not self-employed, contact their employers to discuss a return-to-work plan.

The intent of this document is to outline requirements that health professionals will need to consider in resuming services and resources available to health professionals. Health professionals who work within Regional Health Authorities and/or the Provincial Government should refer to guidelines provided by their employers.

Please note this document is subject to change based on directives and guidelines issued by the Province of Newfoundland and Labrador and the Department of Health and Community Services. Please check regularly for updates to this document.

COVID-19

Coronaviruses are a large family of viruses found mostly in animals. In humans, they can cause diseases ranging from the common cold to more severe diseases, such as Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS). The disease caused by this new coronavirus, SARS-CoV-2, has been named COVID-19. While many of the characteristics of COVID-19 are still unknown, mild to severe illness has been reported for confirmed cases.

COVID-19 is most commonly transmitted through large droplets produced when a person infected with COVID-19 coughs or sneezes. The virus in these droplets can enter through the eyes, nose, or mouth of another person if they are in close contact with the person who coughed or sneezed. The virus can also enter a person’s body from touching something with the virus on it and then touching one’s eyes, mouth, or nose with unwashed hands.

PUBLIC HEALTH ORDERS AND MEASURES

The Government of NL has advised that all levels of the alert system the following measures will continue to be in place at every Alert Level:

Staying informed and being prepared to follow public health advice.
Practicing good hygiene (wash your hands, avoid touching your face, cough and sneeze into your sleeve or a tissue).
Maintaining a physical distance of at least 2 arm lengths. Use a non-medical or cloth mask when physical distancing cannot be maintained.
Frequent cleaning and disinfection of high-touch surfaces.
Staying at home and away from others when you are sick unless it is to get medical attention.
Wearing a non-medical or cloth mask if you have symptoms when going out to access health care services.
Working from home, where possible.
Continuing to shop online and using curbside pickup, where possible.
Limiting non-essential travel in and outside of the province.
Keeping a log of when you go out in public and your interactions with others.

Health professionals are responsible to stay informed of the public health measures as updates are provided daily on the government website: https://www.gov.nl.ca/covid-19/

PREPARING YOUR WORKPLACE

It is important to ensure your practice/workplace can operate within the guidelines recommended by the public health. Before returning to practice consideration must be given to the flow of people through the practice. It is important to create an office flow to ensure anyone present in the office can maintain physical distancing when not being treated.

Consideration should be given to using barriers (like screens) at the reception desk, if possible. Government of NL has released guidelines for workplaces including but not limited to:

< >Workplaces are exempt from the limitations on the number of people in gatherings; however, physical distancing of two-metres (or two arm’s lengths) between individuals

should be maintained as much as possible. Operations may need to be altered or postponed to maintain physical distancing.

Use of electronic payment devices are preferred when possible. However, if you must handle money, ensure that employees are practicing effective hand hygiene after each instance by washing their hands with soap and water or using an alcohol-based hand sanitizer that contains at least 60 per cent alcohol.
Limit the exchange of papers (e.g., signing contracts). If documents must be exchanged, leave them on a clean surface while maintaining a two-metre distance. Avoid sharing pens and office equipment. Disinfect after each use.
Operators must ensure they have all the necessary supplies such as hot/cold potable running water, liquid soap, paper towel, and garbage bins, for handwashing; or minimum 60 per cent alcohol-based hand sanitizer; toilet paper; cleaning and disinfecting supplies; and, personal protection equipment (non-medical masks and disposable gloves) if required.
Common areas should not accommodate employees or patrons to group together, even for eating meals/snacks/drinks. Physical distancing must be maintained at all times. The use of vending machines/shared appliances such as coffee pots should be avoided.
Where public washrooms are available, they must be equipped with hot and cold running water under pressure, liquid soap, paper towel, toilet paper, and garbage containers.
Handwashing signs must be posted. Handwashing stations should enable handwashing by providing clean water, soap, paper towel, and a disposal bin. In the absence of this, minimum 60 per cent alcohol-based hand sanitizer should be made available. Signage is available at: https://www.gov.nl.ca/covid-19/files/Covid19-Hand-Washing-Poster.pdf
All workers must self-monitor for symptoms and stay home if they are sick. Employers should have plans in place for increased worker absences due to illness or self-isolation requirements.
All businesses should have a workplace illness policy. If a policy does not currently exist or does not align with COVID-19 recommendations, the following should be included: o Sick employees must stay home or be sent home from work. Sick employees must use the self-assessment tool for COVID-19 and follow the subsequent directions; and, when employees go home sick, their work areas must be cleaned and disinfected.
Practice proper hygiene: Regular and thorough handwashing; Avoid touching face; and Cough or sneeze into your arm.

More information is available: : https://www.gov.nl.ca/covid-19/files/Guidance-for-Workplaces.pdf.

The Government of NL also provides the following guidelines in terms of mail and delivery services:

Workers who handle mail and deliveries do not require special protection; however, they should wash their hands frequently with soap and water after handling all materials.
Workers delivering products must minimize contact with people and surfaces at their delivery locations.
Contactless drop-off procedures should be implemented, where possible.

COLLEGE DOCUMENTS

The following guidance documents have been prepared by the Health Professional Colleges. Health professionals are required to review the guidelines from their respective Colleges prior to returning to work:

< >NLCDHCASLP-NLCTCMPANL

PERSONAL PROTECTIVE EQUIPMENT (PPE)

There is currently a global shortage that is impacting the ability to acquire the necessary. Careful consideration needs to be given to the use of PPE for staff and clients.

Currently the British Columbia Centre for Disease Control (BCCDC) is recommending that where there is low incidence and prevalence of COVID-19, additional PPE over and above that required for normal precautions is not required. (http://www.bccdc.ca/HealthProfessionalsSite/Documents/COVID19_IPCGuidelinesCommunityBasedAlliedHCPsCli nicSettings.pdf)

BCCDC recommends prior to any patient interaction, all health care providers have a responsibility to assess the infectious risks posed to themselves, other health care workers, other patients and visitors from a patient, situation, or procedure. The PCRA is based on the health care provider’s professional judgment about the clinical situation, as well as up-to-date information on how the specific health care facility has designed and implemented physical (engineering) and administrative controls, and the use and availability of PPE. Performing a PCRA to determine whether PPE is necessary is also important to avoid over-reliance on PPE,

misuse, or waste. Over-reliance on PPE may result in a false sense of security. Incorrect use and doffing of PPE can expose clinicians and staff to infectious agents and contaminate the environment. Key Points:

< >Always follow routine practices and conduct a PCRA prior to any patient interaction.

Health care providers and staff who have direct contact with symptoms suggestive of COVID-19 must follow droplet and contact precautions. This includes wearing a surgical/procedure mask, eye protection, gloves, and gown.
PPE is not required for HCWs who work more than 2 meters from patients at all times.

The Government of NL has guidelines available for employers regarding PPE available at:

https://www.gov.nl.ca/covid-19/files/Guidance-on-Personal-Protective-Equipment-PPE-for-Employers.pdf

The document outlines the PPE requirement for health care workers. There are extensive PPE requirements for employees in the health care system when providing care when COVID-19 is confirmed or suspected . The appropriate use of PPE to protect against the COVID-19 virus is based on established infection prevention and control measures. PPE requirements based on droplet and contact precautions include:

Gloves, a long-sleeved gown, procedure/surgical mask, and facial/eye protection when entering a patient room and in close contact with a COVID-19 patient. These items must be removed after leaving the room.
Gloves, long-sleeved gown, an N95 respirator, and facial/eye protection when in direct contact with a COVID-19 patient and an aerosol generating medical procedure is performed that could result in fluid from the patient's respiratory system becoming airborne (e.g., intubation, CPR).
Proper hand hygiene, including washing with soap and water or alcohol-based hand sanitizer that contains at least 60 per cent alcohol when hands are not visibly soiled
Masks and other disposable PPE can be discarded into a plastic-lined garbage container.

If appropriate PPE is not available, services should not be performed. N95 masks must be professionally fitted in accordance with Occupational Health and Safety Regulations, 2012 and CSA guidelines.

The Government of NL also provides resources regarding the donning and doffing of PPE. There resources are available at: https://www.health.gov.nl.ca/health/publichealth/cdc/PPE_Putting_It_On.pdf and https://www.health.gov.nl.ca/health/publichealth/cdc/PPE_Taking_It_Off.pdf. For further information on masks and respirators during COVID-19 please reference: https://www.canada.ca/en/health- canada/services/drugs-health-products/medical-devices/masks-respirators-covid19.html

AEROSOL GENERATING MEDICAL PROCEDURES (AGMPS)

AGMPs that generate small droplet nuclei in high concentration present a risk for airborne transmission of pathogens not otherwise able to spread by the airborne route (e.g. coronavirus, influenza). When performing AGMPs for a person under investigation (PUI) including for the purpose of specimen collection, BCCDC recommends observing the following:

Place patient in a negative pressure if possible, or in a single room that minimizes exposure to HCWs and other patients;
Limit the number of HCWs to only those required for the procedure;
Ensure HCWs performing or assisting with AGMP wear appropriate PPE: gown, gloves, a fit tested N95 respirator and eye protection (i.e. face shield/goggles);
Observe appropriate hand hygiene, donning and doffing procedures.

More information is available at: http://www.bccdc.ca/Health-Info-Site/Documents/Respiratory-protection- COVID19.pdf

CLEANING AND DISINTECTING

The COVID-19 virus can survive on different surfaces and objects for several days. Frequent cleaning and disinfection are important to prevent the spread of disease. The Government of NL provides general guidelines for cleaning and disinfecting in public settings (https://www.gov.nl.ca/covid-19/files/factsheet-covid-19-environmental-cleaning-NL.pdf).

In addition to routine cleaning, surfaces that have frequent contact with hands should be cleaned and disinfected twice per day and when visibly dirty. Examples include doorknobs, elevator buttons, light switches, toilet handles, counters, handrails, touch screen surfaces and keypads.

It also advises to use only disinfectants that have a Drug Identification Number (DIN). A DIN is an 8-digit number given by Health Canada that confirms it is approved for use in Canada. More information can be found: https://www.gov.nl.ca/covid-19/files/factsheet-covid-19-environmental-cleaning- NL.pdf

BCCDC has developed guidelines for Environmental Cleaning and Disinfectants for Clinic Settings (http://www.bccdc.ca/Health-Professionals-Site/Documents/COVID- 19_MOH_BCCDC_EnvironmentalCleaning.pdf) This includes:

< >Shared equipment should be cleaned in between patients/clients. This includes equipment, practice tools, tables, and examination beds.Frequently touched surfaces should be cleaned and disinfected at least twice a day. These include medical equipment, doorknobs, light switches, telephones, keyboards, mice, pens, charts, cell phones, toys, and all hard surfaces in bathrooms such as sinks, faucets, handles.General cleaning and disinfecting of procedure and examination rooms should occur at least twice a day.

Clean and disinfect any surface that is visibly dirty.
Use common, commercially available detergents and disinfectant products and closely follow the instructions on the label.
Limit items that are not easily cleaned such as fabric or soft items.
Empty garbage containers daily.
Wear disposable gloves when cleaning blood or body fluids, for example, runny nose, vomit, stool, urine.
Perform hand hygiene before wearing and after removing gloves.

CLIENT SCREENING AND APPOINTMENT PROTOCALS

Client bookings will need to be limited to maintain necessary public health measures and may need to be prioritized based on urgency.

Considerations need to be given the waiting areas and the ability for clients to maintain physical distancing while waiting for their appointment. Seating should be placed to maintain physical distancing. Handwashing stations or hand sanitizers should be available in these areas. Should physical distancing not be possible in waiting areas, clients should be advised to wait in their vehicles until they are called for their appointment.

All clients should be pre-screened for symptoms consistent with COVID-19. Prior to the appointment, the following questions should be asked before booking:

Do you have any COVID-19 symptoms (Fever >38 C, cough, sore throat, shortness of breath, running nose, other flu-like symptoms)?
Do you have any COVID-19 risk factors (close personal contact with a suspected or lab confirmed COVID-19 patient in the last two weeks, any travel outside Canada in the past two weeks)?

Health professionals may determine if appointments for symptomatic clients should be cancelled. If the client answers yes to these questions the clients should not be seen. If emergency or urgent care is required, an alternate plan should be developed within a health care facility.

Client charts should include answers to screening questions, the name of the health professional who provided treatment, date, and time of the appointment.

PROCESS FOR HANDLING EXPOSURES

Should you or an employee develop symptoms consistent with COVID-19, you should self- isolate immediately and contact the Public Health line at 811. Public Health officials will assist with the appropriate contract tracing and provide guidance on whether clients need to be contacted.

TELEPRACTICE

NLCHP recognize the desire to offer tele-practice services where available. NLCHP is currently developing guidelines for tele-practice. Health professionals using telepractice are expected to practice within their area of competence. It is the responsibility of the health professional to assess one’s own competence to ensure he or she has the skills, knowledge, and experience to provide quality services.

It is also the responsibility to ensure that the services offered through telepractice meet the needs and treatment plans of each client. Individual assessments should be completed on each client to determine if telepractice is appropriate for the individual.

NLCHP is unable to recommend an appropriate online platform for tele-practice at this time. When considering offering tele-practice service, health professionals must ensure that any platform used protects client confidentiality and compliant with the applicable privacy legislation such as ATIPPA, PHIA and PIPEDA regarding personal health information. Sessions should never be recorded.

All clients should sign a consent form prior to a tele-practice session. Health professionals should consult with their professional liability insurance provider to ensure they are covered for tele-practice.

Health professionals residing outside this province must be registered with the NLCHP to offer tele-practice services. Health Professionals offering tele-practice services in other provinces should check with regulators in those provinces regarding registration requirements.

REFERENCES AND RESOURCES

REFERENCES

Government of Newfoundland and Labrador COVID-19 Resources

https://www.gov.nl.ca/covid-19/

Health Canada: Optimizing the use of masks and respirators during the COVID-19 outbreak https://www.canada.ca/en/health-canada/services/drugs-health-products/medical-devices/masks-respirators- covid19.html

British Columbia Centre for Disease Control (BCCDC) http://www.bccdc.ca/HealthProfessionalsSite/Documents/COVID19_IPCGuidelinesCommunityB asedAlliedHCPsClinicSettings.pdf

http://www.bccdc.ca/Health-Info-Site/Documents/Respiratory-protection-COVID19.pdf

http://www.bccdc.ca/Health-Professionals-Site/Documents/COVID- 19_MOH_BCCDC_EnvironmentalCleaning.pdf

Occupational Health and Safety Regulations, 2012 https://www.assembly.nl.ca/Legislation/sr/Regulations/rc120005.htm#83_

GENERAL RESOURCES

Health Canada

https://www.canada.ca/en/public-health/services/diseases/coronavirus-disease-covid-19.html