Information About Personal Protective Equipment (PPE)

Note that some sectors, like long-term care and retirement homes, have been issued specific guidance regarding the use of masks and other PPE by staff and patients.

The use of PPE should be based on the assessment of risk. Specific PPE recommendations have been issued for interacting with suspected or confirmed COVID-19 patients, and for performing aerosol-generating medical procedures (AGMP).

Based on guidance from a Ministry of Health update on June 8, 2020, health care organizations and providers should use this approach to obtain PPE supplies once a need has been determined:

• Work with their regular supplier to determine when they will receive their shipment of PPE
• Work with other local health care providers to determine if any in the local area have supplies they can provide
• Submit a request via the appropriate Personal Protective Equipment Intake Form. A Regional Table Lead will work to see if they can address the request within the region.  If the need cannot be addressed regionally, the Regional Table Lead will escalate the request to the Ministry Emergency Operations Centre.

The Ontario government now has a Workplace PPE Supplier Directory to help businesses secure PPE and other supplies.

Safe Resumption of In-person Care

• While virtual care can be a helpful tool to support access to care, the pressures that existed early in the pandemic that required virtual care to replace in-person services have diminished (e.g., lack of personal protective equipment) and, in most instances, in-person care can now be provided safely and appropriately.
  
  
• Physiotherapists must make decisions that are in their patient’s best interest and work together to find a solution that satisfies the need for patient access, safety, and quality care.
  
  
• Virtual care might still be a preferable option for some patients who wish to limit their physical contact. For example, if a person screens positive for exposure to the virus or is at risk of complications should they contract COVID-19. 

Hand Hygiene

• Physiotherapists must promote and have sufficient means for frequent and proper hand hygiene for staff and patients. This can be done by washing your hands with soap and water or using an alcohol-based hand sanitizer (between 70% and 90% alcohol content). Hand washing with soap and water must be performed if your hands are visibly dirty.

• At a minimum, physiotherapists should wash their hands before and after each patient contact, before putting on PPE, after taking off PPE, and after contact with potentially contaminated surfaces.

• Physiotherapists should consider:
  
  • Setting up handwashing and sanitization stations. 
  • Providing signage instructing on proper hand washing techniques. The Ministry of Health has provided signage to be posted on entrances, and a poster for within your setting. 
  • Requiring everyone, including staff, patients and visitors, to wash their hands upon arrival.

• Gloves alone are not a substitute to hand hygiene. Hands must be cleaned after removing gloves.

See a Helpful List of Infection Control Resources

Cleaning and Disinfecting

• Cleaning refers to the removal of visible dirt. Cleaning does not kill germs but is highly effective at removing them from a surface. Disinfecting refers to using a chemical to kill germs on a surface. Disinfecting is only effective after surfaces have been cleaned.
  
  
• Use a “wipe-twice” method to clean and disinfect. Wipe surfaces with a cleaning agent to clean off dirt and wipe again with a disinfectant. Or use a one-step process using a combined cleaner-disinfectant product.
  
  
• Regular household cleaning and disinfecting products are effective against COVID-19 when used according to the directions on the label.
  
  
• Use a disinfectant that has a Drug Identification Number (DIN) and a virucidal claim (efficacy against viruses). 
  
  
• Alternately, use a bleach solution in a well-ventilated area and never mix with other chemical products. To prepare diluted bleach for a solution to disinfect high-touch hard surfaces, do so according to instructions on the label or in a ratio* of:
  
  250 mL (1 cup) of water per 5 mL (1 teaspoon) bleach, or
  1 litre of water (4 cups) per 20 mL (4 teaspoons) bleach
  
  * assuming bleach is 5 % sodium hypochlorite, to give a 0.1 % sodium hypochlorite solution
  
  
• Health Canada has approved several hard-surface disinfectants and hand sanitizers for use against COVID-19. Use these lists to look up the DIN number of the product you are using or to find an approved product. Make sure to follow instructions on the product label to disinfect effectively.
  
  
• In addition to routine cleaning, surfaces that come into contact frequently with hands should be cleaned and disinfected twice per day and when visibly dirty. Special attention should be paid to commonly touched surfaces such as doorknobs, light switches, toilet handles, counters, handrails, touch screen surfaces, and shared materials, equipment, workstations, keypads, etc. All equipment used in patient contact should be cleaned and disinfected after each use.
  

   

• Cleaning of examination rooms and patient-contact surfaces should be performed based on patient screen status.   

  • For patients who screen positive, patient-contact surfaces (i.e., areas within 2 metres of the patient) should be disinfected as soon as possible. Treatment areas, including all horizontal surfaces, and any equipment used on the screen positive patient (e.g., exam table, thermometer, BP 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 processes can be used.
    
    

• Clothing and fabric items should be laundered and dried on the highest temperature setting possible. Ensure items are thoroughly dried.
  
  
• Develop and implement procedures for increasing the frequency of cleaning and disinfecting of high traffic areas, common areas, public washrooms and showering facilities.
  
  
• Document procedures around cleaning (e.g. frequency and by whom).
  
  

Review: 

IPAC Checklist for Clinical Office Practice

Booking Appointments 

• Physiotherapists should post information on their clinic website or email all patients advising them to call prior to coming to the office/clinic where applicable.

• Patients should be screened over the phone, or suitable online screening tool such as the Self-Assessment Tool, for symptoms of COVID-19 when scheduling appointments.
  
  
• All patients (and those accompanying them, if applicable) should be screened again by the staff at the point of entry to the office/clinic to assess for symptoms and exposure history on the day of their scheduled appointment.
  
  

  If a patient screens positive for COVID-19, physiotherapists should:

  • Advise the patient not to come to the office/clinic; offer to provide virtual care where appropriate
  • If you are providing care in the patient’s home, delay care if possible and only provide essential care
  • Advise the patient to self-isolate AND to complete the online self-assessment tool before calling their doctor or Telehealth Ontario

  When the patient arrives at the clinic, staff should then conduct active screening of the patient on site. If the patient screens positive, the appointment should be deferred if possible and the patient should be referred for testing. 

• All patients and visitors arriving at the office/clinic should be screened upon entry, even when they were screened previously. Ideally there should be a plexiglass barrier at the reception or administrative area where staff will conduct screening of patients and visitors in the office/clinic. If that is not possible, then staff working on those areas should use appropriate PPE e.g. masks, eye protections, gloves and gowns.
  
  If a visitor screens positive upon entry, they should not be allowed to accompany the patient.
  
  A patient who screens positive upon entry to the office/clinic should be encouraged to defer their visit. If they proceed with the visit, then they should be:

• Given a surgical/procedure mask,
• Advised to perform hand and cough hygiene,
• Provided with hand sanitizer (if available), access to tissue and a hands-free waste receptacle for their used tissues and used masks; ensure patients do not leave their masks in waiting areas,
• Placed in a room with the door closed where possible
• If it is not possible to move a patient from the waiting room to an available exam room, the patient can be instructed to return to their vehicle (if available) and informed that they will be texted or called when a room becomes available

• For more information on screening, review the following documents:

• Active and passive screening in primary care settings
• Patient screening guidance document
• Reference document for COVID-19 symptoms

• Pending the outcome of active screening, the decision to provide service should be based on risk, both to the patient and to you as the practitioner. Public Health Ontario has a document that walks you through recommended risk assessments. If you must provide service to a patient with symptoms or who has COVID-19, personal protective equipment (PPE) must be used. See “The Appointment” section below for more information.

• Inform patients over the phone or via email of any public health measures you have implemented. 

• Book appointments to allow time between patients to help maintain physical distancing and allow for surface and equipment cleaning after each appointment. 
  
  When possible, schedule symptomatic patients at the end of the day.

• Have policies in place for managing visitors to reduce the risk of transmission. Unless the patient requires assistance from another person, encourage them to come alone to their appointment. Exceptions include:
  • A parent/guardian accompanying a patient who is a child/youth
  • Those accompanying patients who require physical assistance
  • Individuals providing essential support to a patient

Preparing Your Place of Employment

•  You should have documentation in place around the following:
  
  • Start of day tasks
  • Process for booking appointments and conversations with patients
  • Cleaning schedule (who is responsible for cleaning what and how often, etc.)
  • End of day tasks (e.g. checking supplies for the next day)
  • Have a plan in place for what to do if a staff person becomes sick or if a patient who visited the office/clinic later tests positive for COVID-19
  • Have written measures and procedures for staff safety including for infection prevention and control
• Place clear, visible signage at all entrances and within the workplace, reminding patients about the signs and symptoms of COVID-19, what to do if they feel unwell and how to protect themselves (e.g., hand hygiene). The Ontario Government has provided signage in English for both patients and visitors that can be posted on entrances, and a poster for within your setting. Several public health units also have similar resources. 
  
  
• Minimize the number of people in the office/clinic at one time. Alternative solutions to waiting in the setting should be considered, such as asking people to wait in vehicles and texting or calling when appointments are ready.
  
  
• Set up the waiting area to allow for physical distance of two metres between individuals, such as rearranging furniture and using visual cues such as tape on the floor. Household contacts are not required to separate.
  
  
• Reduce the number of examination or treatment rooms being used.
  
  
• Minimize staff in the office/clinic. Consider what tasks can be done from home or outside of regular hours to minimize staff interactions with each other and patients, and stagger start times, breaks and lunches. 

• Have a designated space to isolate staff who develop symptoms and send them home if possible.

• Given the evidence that transmission of COVID-19 may occur from those who have few or no symptoms, masking (surgical/procedure masks) for the full duration of shifts is recommended for:
  
  • Healthcare workers working in direct patient care areas, and
  • Healthcare workers working outside of direct patient care areas when interacting with other healthcare workers and physical distancing cannot be maintained.

• If 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.

• Non-essential items should be removed from waiting areas, including magazines, water dispensers, toys and remote controls.
  
   

The Appointment

• Before each appointment, physiotherapists must:

• Conduct a point-of-care risk assessment to determine the level of precautions required,
• Wash your hands or use an alcohol-based sanitizer. 

• If you encounter a patient who has gone through the screening process and enters the setting yet exhibits signs and symptoms consistent with COVID-19, you must:
  
  
  • Separate the patient from others so that they are at least 2 metres apart.
  • Have the patient complete hand hygiene.
  • Provide a surgical/procedural mask for the patient to wear.
  • Provide access to tissue and a hands-free waste receptacle for their used tissues and used masks. Ensure patients do not leave used masks in the waiting area.
  • Care can continue only if the physiotherapist is able to wear the appropriate PPE, which includes s a fit-tested, seal-checked N95 respirator (or approved equivalent), eye protection (goggles or face shield).
  • Alternately, explain the concern to the patient that they are symptomatic, discontinue treatment and reschedule the appointment.
  • Advise the patient that they should self-isolate, complete the online self-assessment tool before calling their doctor or Telehealth Ontario.
  • Clean and disinfect the practice area immediately.
  • Wash your hands or use alcohol-based hand sanitizer after contact with the patient and patient environment, and after the removal of PPE.
  • Regulated health professionals should contact their local public health unit to report any probable and confirmed cases of COVID-19 based on the latest case definition posted on the Ministry of Health COVID-19 website.
    
    
• Encourage patients to wash their hands or to use an alcohol-based sanitizer before and after the appointment.
  
  
• Even when you are not interacting with a suspected or confirmed COVID-19 patient or someone with symptoms, if you are not able to maintain physical distancing with others, then:
  
  • You must wear a surgical/procedure mask.
  • If 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.

  • You should also advise patients to wear their own mask (cloth or other) to the office/clinic if they have one. Provide a mask to patients if they are not wearing their own. Ensure that patients do not leave their masks in waiting areas. Wash your hands or use alcohol-based hand sanitizer after contact with the patient and patient environment, and after the removal of PPE.

• If you are providing care in the patient’s home, you should wear a surgical/procedure mask at all times during the entirety of the home visit.
  
  
• If the appointment involves direct contact with patients who have a confirmed COVID-19 infection, appropriate PPE must be used.
  
  • This includes a fit-tested, seal-checked N95 respirator (or approved equivalent), eye protection (goggles or face shield), gown and gloves.

• Ensure that you understand the safe use, care and limitations of PPE, including putting on and taking off PPE as well as proper disposal.
  
  • Ensure that gloves have no pinholes or tears and fit securely around their hands.
  • Gloves should be removed first, and hand hygiene should be performed immediately after removing gloves. The mask should then be removed, and hand hygiene performed again.

   

After the Appointment

• After each appointment, wash your hands or use an alcohol-based sanitizer.
• Ensure that you clean the treatment area and surfaces, and anything used during the appointment by you and the patient.

Self-monitoring

• All healthcare providers should monitor themselves for signs of illness.
• If you are sick, stay home.
• If you start experiencing symptoms while you are at work, immediately put on a medical/procedure mask and leave work.
• If you have symptoms, think you were exposed to COVID-19, or travelled outside of Canada within the last 14 days, notify your supervisor immediately, complete the self-assessment and follow the instructions provided.
• With the emergence of the Omicron variant and rising case numbers, the Ministry has released interim guidance for all health care providers who have been in contact with an individual who is COVID-19 positive. If you have been notified of a high risk contact with a COVID case within any healthcare setting, you must self-isolate regardless of vaccination status and get tested as soon as possible. Contact your local public health unit for further information.