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CMOH COVID-19 Directive #5 – Revised

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COVID-19 Directive #5 for Hospitals within the meaning of the Public Hospitals Act and Long-Term Care Homes within the meaning of the Long-Term Care Homes Act, 2007

Issued under Section 77.7 of the Health Protection and Promotion Act (HPPA), R.S.O. 1990, c. H.7

THIS DIRECTIVE REPLACES THE DIRECTIVE #5 ISSUED ON MARCH 31, 2020. THE DIRECTIVE #5 ISSUED ON MARCH 31, 2020 IS REVOKED AND THE FOLLOWING SUBSTITUTED:

WHEREAS under section 77.7(1) of the HPPA, if the Chief Medical Officer of Health (CMOH) is of the opinion that there exists or there may exist an immediate risk to the health of persons anywhere in Ontario, he or she may issue a directive to any health care provider or health care entity respecting precautions and procedures to be followed to protect the health of persons anywhere in Ontario;

AND WHEREAS pursuant to O. Reg 68/20 made under the Retirement Homes Act, as part of the prescribed infection prevention and control program, all reasonable steps are required to be taken in a retirement home, to follow any directive pertaining to COVID-19 that is issued to long-term care homes under section 77.7 of the HPPA;

AND WHEREAS, under section 77.7(2) of the HPPA, for the purposes of section 77.7(1), the CMOH must consider the precautionary principle where in the opinion of the CMOH there exists or there may exist an outbreak of an infectious or communicable disease and the proposed directive relates to worker health and safety in the use of any protective clothing, equipment or device;

AND HAVING REGARD TO the emerging evidence about the ways this virus transmits between people as well as the potential severity of illness it causes in addition to the declaration by the World Health Organization (WHO) on March 11, 2020 that COVID-19 is a pandemic virus and the spread of COVID-19 in Ontario, and the technical guidance provided by Public Health Ontario on scientific recommendations by the WHO regarding infection prevention and control measures for COVID-19 which is required to be followed by health care providers and health care entities, including hospitals and long-term care homes, in Directive #1, dated March 12, 2020 and revised on March 30, 2020;

AND HAVING REGARD TO the precautionary principle, which in my opinion has been met, in that this directive will protect health care workers’ health and safety in the use of any protective clothing, equipment and device in public hospitals and long-term care homes and the failure to adhere to this directive may put worker health and safety at risk;

I AM THEREFORE OF THE OPINION that there exists or may exist an immediate risk to the health of persons anywhere in Ontario from COVID-19;
AND DIRECT pursuant to the provisions of section 77.7 of the HPPA that:

Directive #5 for Public Hospitals within the meaning of the Public Hospitals Act and Long-Term Care Homes within the meaning of the Long-Term Care Homes Act, 2007
Date of Issuance: April 10, 2020
Effective Date of Implementation: April 10, 2020
Issued To: Public hospitals within the meaning of the Public Hospitals Act and long-term care homes within the meaning of the Long-Term Care Homes Act, 2007 referenced in section 77.7(6), paragraphs 4 and 10 of the Health Protection and Promotion Act.

Introduction:

Coronaviruses (CoV) are a large family of viruses that cause illness ranging from the common cold to more severe diseases such as Middle East Respiratory Syndrome (MERS-CoV), Severe Acute Respiratory Syndrome (SARS-CoV), and COVID-19. A novel coronavirus is a new strain that has not been previously identified in humans.

On December 31, 2019, the World Health Organization (WHO) was informed of cases of pneumonia of unknown etiology in Wuhan City, Hubei Province in China. A novel coronavirus (COVID-19) was identified as the causative agent by Chinese authorities on January 7, 2020.

On March 11, 2020 the WHO announced that COVID-19 is classified as a pandemic virus. This is the first pandemic caused by a coronavirus.

Related Directive

On March 12, 2020 I issued a Directive on Personal Protective Equipment (PPE) (Directive #1) which directed the use of droplet and contact precautions for the routine care of patients or residents with suspected or confirmed COVID-19, and airborne precautions when aerosol generating medical procedures (AGMPs) are planned or anticipated on patients or residents with suspected or confirmed COVID-19. That Directive was revoked and replaced with Directive #1 dated March 30, 2020.
To the extent that anything in this Directive conflicts with Directive #1, this Directive prevails.

On March 17, 2020 the Premier and Cabinet declared an emergency in Ontario under the Emergency Management and Civil Protection Act due to the outbreak of COVID-19 in Ontario and Cabinet made emergency orders to implement my recommendations of March 16, 2020. On March 30th 2020, the emergency declaration was extended.

Symptoms of COVID-19

For signs and symptoms of COVID-19 please refer to the update on guidance for testing issued on April 8, 2020.

Complications from COVID-19 can include serious conditions, like pneumonia or kidney failure, and in some cases, death. Complications from COVID-19 can include serious conditions, like pneumonia or kidney failure, and in some cases, death.

Required Precautions and Procedures

All public hospitals and long-term care homes must immediately implement the following precautions and procedures, as applicable to regulated health professionals as defined under the Regulated Health Professions Act, 1991 (“health care worker”) employed by or in public hospitals and long-term care homes and, where specified, other employees employed by or in public hospitals and long-term care homes (“other employees”) dealing with suspected, presumed, or confirmed COVID-19 patients or residents:

  • Public hospitals and long-term care homes, health care workers and other employees must engage on the conservation and stewardship of personal protective equipment (PPE). Public hospitals and long-term care homes must provide all health care workers and other employees with information on the safe utilization of all PPE and all health care workers and other employees must be appropriately trained to safely don and doff all PPE.
  • Hospitals and long-term care homes must assess the available supply of PPE on an ongoing basis. Public hospitals and long-term care homes must explore all available avenues to obtain and maintain a sufficient supply of PPE.
  • In the event that the supply of PPE reaches a point where utilization rates indicate that a shortage will occur, the government and employers, as appropriate, will be responsible for developing contingency plans, in consultation with affected labour unions, to ensure the safety of health care workers and other employees.
  • The public hospital’s or long-term care home’s Organizational Risk Assessment must be continuously updated to ensure that it assesses the appropriate health and safety control measures to mitigate the transmission of infections, including engineering, administrative and PPE measures. This must be communicated to the Joint Health and Safety Committee including the review of the hospital or long-term care environment when a material change occurs.
  • A point-of-care risk assessment (PCRA) must be performed by every health care worker before every patient or resident interaction in a public hospital or long-term care home.
  • If a health care worker determines, based on the PCRA, and based on their professional and clinical judgement, that health and safety measures may be required in the delivery of care to the patient or resident, then the public hospital or long-term care home must provide that health care worker with access to the appropriate health and safety control measures, including an N95 respirator. The public hospital or long-term care home will not unreasonably deny access to the appropriate PPE.
  • At a minimum, for health care workers and other employees in a hospital or a long-term care home, contact and droplet precautions must be used by health care workers and other employees for all interactions with suspected, presumed or confirmed COVID-19 patients or residents. Contact and droplet precautions includes gloves, face shields or goggles, gowns, and surgical/procedure masks.
  • For long term care homes only, all staff and essential visitors must wear surgical/procedure masks at all times for the duration of full shifts or visits in the long-term care home. For further clarity this is required regardless of whether the home is in outbreak or not. During breaks, staff may remove their surgical/procedure mask but must remain two metres away from other staff to prevent staff to staff transmission of COVID-19. This is to be implemented in conjunction with all other requirements contained in Directive #3 dated April 8th 2020 or as amended.
  • All health care workers or other employees who are within two metres of suspected, presumed or confirmed COVID-19 patients or residents shall have access to appropriate PPE. This will include access to: surgical/procedure masks, fit tested NIOSH-approved N-95 respirators or approved equivalent or better protection, gloves, face shields with side protection (or goggles) and appropriate isolation gowns.
  • The PCRA by the health care worker should include the frequency and probability of routine or emergent Aerosol Generating Medical Procedures (AGMPs) being required. N95 respirators, or approved equivalent or better protection, must be used by all health care workers in the room where AGMPs are being performed, are frequent or probable.

AGMPs include but are not limited to; Intubation and related procedures (e.g. manual ventilation, open endotracheal suctioning), cardio pulmonary resuscitation during airway management, bronchoscopy, sputum induction, non-invasive ventilation (i.e. BiPAP), open respiratory/airway suctioning, high frequency oscillatory ventilation, tracheostomy care, nebulized therapy/aerosolized medication administration, high flow heated oxygen therapy devices (e.g. ARVO, optiflow) and autopsy. Any change to this list is to be based on the Technical Brief “Updated IPAC Recommendations for Use of Personal Protective Equipment for Care of Individuals with Suspect or Confirmed COVID-19” dated March 25, 2020 as amended from time to time which has been prepared by Public Health Ontario

In accordance with O. Reg 68/20 made under the Retirement Homes Act, retirement homes must take all reasonable steps to follow the required precautions and procedures outlined in this Directive.

Note: As this outbreak evolves, there will be continual review of emerging evidence to understand the most appropriate measures to take. This will continue to be done in collaboration with health system partners and technical experts from Public Health Ontario and with the health system.

Questions

Hospitals, Long-term care homes and HCWs may contact the ministry’s Health Care Provider Hotline at 1-866-212-2272 or by email at emergencymanagement.moh@ontario.ca with questions or concerns about this Directive.
Hospitals, long-term care homesand HCWs are also required to comply with applicable provisions of the Occupational Health and Safety Act and its Regulations.

David C. Williams,
MD, MHSc, FRCPC Chief Medical Officer of Health