A new respiratory diseasecoronavirus disease 2019 (COVID-19)is spreading globally and there have been instances of COVID-19 spread in communities across the globe. The novel coronavirus COVID-19 may be introduced into an Adult Residential Facility (ARF) through individuals, such as residents, visitors and staff, with a link to International travel or to cases within the community. Staff members in ARFs have a critical role to play in identifying and managing potential cases of COVID-19. There are basic steps an ARF can take to help prevent the introduction or spread of viral infections like COVID-19. For information regarding COVID-19, visit the Canada.ca and WHO web site and the Government of New Brunswick (GNB) Coronavirus web site: www.gnb.ca/coronavirus- Fever (signs or history of fever) and/or - Cough (new or exacerbated chronic) Other symptoms may include:If a resident is experiencing symptoms of COVID-19, follow the ARF Clinical Care Pathways document and the control measures below. Residents that are symptomatic should be considered priority for testing for COVID-19.# 
- Control access o Need to buzz in, check in with operator or designate before entering o Post signs at the entrance of the building instructing visitors not to visit. o Empower staff to politely ask visitors to leave. - Stringent active screening of employees at entry of facility.
- Exclude staff who have symptoms of respiratory infection from work. o Exclude staff who have travelled outside of New Brunswick. They should be excluded for 14 days from when they arrived back in New Brunswick.
- Monitor residents for respiratory symptoms and/or fever.
- Support hand and respiratory hygiene, as well as cough etiquette by residents, visitors, and employees. - Restrict residents with fever or acute respiratory symptoms to their room (See Appendix A). - Residents should maintain social distancing of 2 meters from others at all time.

# Hand Hygiene
Hand washing is an effective way to reduce microbial contamination of hands and should be part of the daily routine of residents, staff and visitors. Soap and water should always be used if hands are visibly soiled and after personal toileting. Use of an alcohol-based hand rub between 60-90% ethyl alcohol (70% or greater is best against non-enveloped viruses such as norovirus) is also appropriate and is the method of choice for health care settings. Waterless products that contain either no alcohol or alcohol in concentrations of less than 70% should not be used for hand hygiene.
- Ensure access to handwashing facilities following toileting and before meals or food preparation.
- Educate residents on how and when to wash their hands - Assist residents with hand hygiene where required.
- Ensure alcohol-based hand rub is available and maintained at the point of care, ideally both inside and outside of residents' room. - Ensure alcohol-based hand rub is located and maintained at entrances to the facility. - Soap and water are required if hands are visibly soiled and after personal toileting.
- Make sure tissues are available and any sink is well-stocked with soap and paper towels for hand washing. - Post signage directing all persons entering the building to wash their hands.
- Educate staff on the 4 critical moments for hand hygiene and review on a regular basis. - See Appendix B for directions for staff and Appendix C for residents and visitors regarding hand hygiene.

# Respiratory Hygiene
- Respiratory hygiene should be encouraged for residents who have respiratory symptoms. - Contain respiratory secretions by using tissues to cover the mouth and nose during coughing/sneezing, with prompt disposal into a no touch waste receptacle. - Cover the mouth and nose during coughing/sneezing against a sleeve/shoulder if tissues are not available. - Turn the head away from others when coughing/sneezing. - Maintain a spatial separation of 2 meters between residents with respiratory symptoms.

# Personal Protective Equipment (PPE)
Any aerosol-generating medical procedures (AGMP) performed on patients with suspect or confirmed COVID-19 require additional precautions including use of N95 respirator. Any AGMP should be avoided in the home environment. If an AGMP is required, consideration should be given to transferring the case/PUI to hospital due to the need for Additional Precautions.
AGMPs include:
- non-invasive positive pressure ventilation (CPAP, BiPAP)
- nebulized therapy Oxygen therapy is not considered an AGMP.
Provide the right supplies to ensure easy and correct use of PPE. (see Appendix D)
- Use of personal protective equipment (PPE) for asymptomatic patient care is not indicated. - Staff should wear disposable gloves when in direct contact with the ill person, or when in direct contact with the ill person's environment as well as soiled materials and surfaces. Hand hygiene should be performed before putting gloves on and after removing them - Post signs on the door or wall outside of the resident room that clearly describe the type of precautions needed and required PPE. - Make PPE, including procedure facemasks, eye protection, gowns, and gloves, available immediately outside of the resident room if required. - Position a trash can near the exit inside any resident room to make it easy for employees to discard PPE. - Residents who are not sick are discouraged from using facemasks.

# Staff:
- Provide staff with training and reminders on hand hygiene, proper use of PPE and their responsibility to monitor respiratory symptoms and stay home when sick. - Ensure staff have access to information on COVID-19, infection prevention and control precautions and have a chance to practice putting on and taking off protective equipment PHAC Infection Prevention Control Measures - Should staff develop symptoms while at work they should immediately exclude themselves from the resident environment, don a medical / procedure mask, clean their hands, and notify their supervisor, and call 1-833-475-0724. - If a staff is in contact with a known person with COVID-19 they should self-isolate at home for 14 days and monitor their symptoms. - If a staff is a contact of someone who travelled outside New Brunswick, they should selfmonitor for 14 days and self-isolate if develop symptoms.
- Health Care workers and staff that are symptomatic (new onset/exacerbation of chronic cough or fever) and provide direct patient contact should be tested for COVID-19 regardless of travel history, and they should stay off work and self-isolate until test results are negative. - A dedicated telephone line has been set up for Health Care workers and staff to call should they develop symptoms compatible with COVID-19; (new onset/exacerbation of chronic cough or fever) at 1-833-475-0724. - Plan for fluctuating staffing levels by identifying essential functions and creating plans for continuity of operations. - Staff should avoid working in different facilities when possible.
- If there is an outbreak in one of the facilities, restrict staff from moving around to a different facility.
- Consider what your residential care facility would require to maintain critical operations.
- Cross-train personnel to perform essential functions so the workplace can operate even if key staff are absent.

# Communication:
- Prepare and practice calm, reassuring and accurate communication with residents, their families and other stakeholders. Acknowledge the seriousness of the situation and the feelings of fear and anxiety that might produce. Share only the facts from trusted sources: o www.gnb/coronavirus o 
- Keep residents and employees informed if a case of COVID-19 is identified in the ARF.
- Describe what actions the facility is taking to protect them, including answering their questions and explaining what they can do to protect themselves and their fellow staff and residents.
- Staff should monitor Public Health information to understand COVID-19 activity in their community to help inform their evaluation of individuals with unknown respiratory illness.
If there is transmission of COVID-19 in the community, in addition to implementing the precautions described above for residents with acute respiratory infection, facilities may also consult with public health authorities for additional guidance if required.

# Ill Residents:
Early epidemiologic evidence suggests that the majority of people who develop COVID-19 will have mild illness and may not require care in a hospital. It is important that people who do not require hospital-level care convalesce at home as long as effective self-isolation and appropriate monitoring (i.e. for worsening of illness) can be provided.
- Restrict residents with fever or acute respiratory symptoms to their room. If they must leave the room for medically necessary procedures, have them wear a medical / procedure facemask (if tolerated).

# April 4, 2020
Office of the Chief Medical Officer of Health
- In general, for care of residents with undiagnosed respiratory infection or COVID-19 use standard, contact, and droplet precautions with eye protection.

# Environment:
Environmental cleaning of the ill resident's room
- Clean and disinfect the room twice a day with special attention to all horizontal and frequently touched surfaces for the duration of illness. - Ensure all staff responsible for the environment adhere to required cleaning and disinfection practices. - Increased frequency of cleaning and disinfecting high-touch surfaces is significant in controlling the spread of microorganisms during a respiratory infection outbreak. Environmental cleaning products registered in Canada with a Drug Identification Number (DIN) and labelled as a broad-spectrum virucide are sufficient for use. All surfaces, especially those that are horizontal and frequently touched, should be cleaned and disinfected at least twice daily and when soiled.

# Resident care equipment
- Ensure all staff responsible for utilizing resident care equipment is adhering to required cleaning and disinfection practices. - All shared equipment is cleaned and disinfected before reuse by another resident.
- Appropriate cleaning techniques are used.
- Appropriate disinfection solutions are used.
- Ensure correct disinfectant concentration per manufacturer's directions.
- Ensure correct wet contact times.
- Electronic games, toys/games, personal effects are not to be shared.
- All care equipment (e.g., thermometers, blood pressure cuff, commodes, etc.) used with an ill resident should be dedicated to that resident. - Single person/resident devices are discarded after use with one resident (may be more than one use). - Single use devices are discarded in a waste receptacle after a single use on one resident.

# Laundry
- Contaminated laundry should be placed into a laundry bag or basket with a plastic liner and should not be shaken. - Gloves and a medical/procedure mask should be worn when in direct contact with contaminated laundry. - Clothing and linens belonging to the ill person can be washed together with other laundry, using regular laundry soap and hot water (60-90C). - Laundry should be thoroughly dried.
- Hand hygiene should be performed after handling contaminated laundry and after April 4, 2020
Office of the Chief Medical Officer of Health removing gloves. - If the laundry container comes in contact with contaminated laundry, it should be disinfected Cohorting:
- Consider identifying dedicated employees to care for COVID-19 patients - Residents suspected or confirmed to have COVID-19 should be cared for in single rooms if possible. - Perform a risk assessment to determine resident placement and/ or suitability for cohorting when single rooms are limited. - Consider cohorting residents and staff to the affected unit/wing to ensure there is no contact with the staff/residents in the unaffected units/wings. If possible, further cohort staff, so one group cares for the ill residents and a second cohort cares for the non-ill residents on the affected unit/wing. - If cohorting is not possible in a shared room, privacy curtains should be drawn between beds. When possible there should be a minimum of two meters between the beds. - Residents who have recovered from COVID-19 can be cohorted with either group.
- Post infection control signage at the room entrance indicating droplet and contact precautions are required upon entry of the room. - When cohorting each resident must be isolated separately. Hand hygiene and a change of gown and gloves is required between contact with each resident and/or a resident's environment.
Admissions, Readmissions, Transfers:
- Notify facilities and Ambulance NB prior to transferring a resident with an acute respiratory illness, including suspected or confirmed COVID-19, to a higher level of care and advise of the required precautions for the resident being transported. - Admission with a resident diagnosed with COVID-19 into a ARF is not recommended.
- Movement/ transport of residents with suspected or confirmed C O V I D -19should be restricted to essential medical reasons. - Residents with COVID-19 who must leave their room for essential medical reasons should adhere to respiratory and hand hygiene and wear a mask. - Should it be necessary to readmit residents who have not had COVID-19 into a facility where there is a case of COVID-19 consult with the MOH.

# Communal /Social Activities:
- Cancel or re-schedule some or all social/group activities as needed - Restrict all well residents to their rooms as much as possible.
- Minimize activities to essential activities only. Such essential activities should be defined in advance consider the full spectrum of resident care needs (physical, mental, psychological). - Serve in-room meals to residents - Avoid touching your eyes, nose and mouth.
- Cough/sneeze into the band of your arm, not your hand, or into a tissue. Dispose of tissues in a lined waste container. - Individuals providing care can wear disposable gloves when in direct contact with the person in isolation, or when in direct contact with soiled materials and surfaces.

# Avoid contaminating common items and surfaces
- Do not share personal items with others, such as toothbrushes, towels, bed linen, utensils or electronic devices. - At least once daily, clean and disinfect surfaces that you touch often, like toilets, bedside tables, doorknobs, phones and television remotes using a diluted bleach solution (1 part bleach and 9 parts water) or regular household disinfectants. Household disinfects should have a DIN number and state that they are effective against viruses. - Clothing and linens belonging to the person in isolation can be washed together with other laundry, using regular laundry soap and hot water (60-90C). Laundry should be thoroughly dried. Laundry containers can be disinfected as above.
- Place contaminated items that cannot be cleaned in a lined container, secure the contents and dispose of them with other household waste. - Put the lid of the toilet down before flushing.

# Monitor your symptoms daily
- Monitor your health and symptoms daily.
- Record your temperature daily. If you are taking medication to reduce fever (e.g. acetaminophen/ Tylenol or ibuprofen/Advil), record your temperature at least 4 hours after your last dose of fever-reducing medicine. - If you develop symptoms or your symptoms get worse immediately contact Tele-care 8-1-1 or Public Health. Describe your symptoms and history. They will provide advice on what you should do.

# Care for yourself
- Get some rest, eat a balanced diet and nutritious food, and stay hydrated with fluids like water. Over the counter medication can be used to reduce fever and aches. - Staying at home and not being able to do normal everyday activities outside of the home can be socially isolating. Stay in touch with family and friends by phone or computer. - Call your employer/school administration and share what Public Health has asked you to do so alternative work/study arrangements can be made where possible.
Appendix A Instructions for Self-isolating

# Self-Isolation
You have been asked to isolate yourself because you might have been diagnosed with COVID-19 or you might be at risk of developing COVID-19. Self-isolation means staying at home and avoiding contact with other people to help prevent the spread of disease to others in your home and your community.
For the next 14 days, it is expected that you take the following measures:

# Limit contact with others
- Do not leave home unless absolutely necessary, such as to seek medical care.
- Do not go to school, work, other public areas or use public transportation (e.g., buses, taxis). - Arrange to have groceries and supplies dropped off at your door to minimize contact.
- Stay in a separate room and use a separate bathroom from others in your home, if possible.
- If you have to be in contact with others, keep at least 2 metres between yourself and the other person. Keep interactions brief. - Avoid contact with individuals with chronic conditions, compromised immune systems and older adults. - Avoid contact with pets if you live with other people that may also be touching the pet.
- Limit the number of caregivers.

# Keep your hands clean
- Wash your hands often with soap and water for at least 20 seconds, and dry with disposable paper towels or dry reusable towel, replacing it when it becomes wet.
- Wet your hands and apply liquid soap or clean bar soap - Rub your hands vigorously together, scrubbing all skin surfaces - Pay special attention to the areas around your nails and between your fingers - Continue scrubbing for at least twenty seconds (as long as it takes to sing the happy birthday song twice) - Rinse your hands and dry them well - You can also remove dirt with a wet wipe and then use an alcohol-based hand sanitizer.
- Wash your hands
- Before and after preparing food;
- Before and after eating;
- After using the toilet;
- After you cough or sneeze,
- Before and after using a surgical/procedure mask - After disposing of waste or handling contaminated laundry;
- Whenever hands look dirty.

# Appendix B: Hand Hygiene for staff
Hand hygiene is the single most effective measure to prevent the transmission of Health Care Associated Infections (HCAI). It has been documented that HCAIs kill 8,000-12,000 Canadians every year. Good hand hygiene saves lives and reduces the strain on our healthcare system.
Hands must be cleaned at the point of care and it is crucial that hand hygiene is performed at these 4 critical times:
- Before initial resident/resident environment contact. Follow these simple instructions when using an alcohol-based hand rub:
- Apply a measured pump of the product (enough of the product to cover all surfaces of the hand) into your open palm. 2. Rub into hands covering all surfaces including front and back of hands, between fingers, around nails (especially cuticles), thumbs and wrists. 3. Rub until dry.
Hands must be fully dry before touching the resident or the environment/equipment for the alcohol-based hand rub to be effective and to eliminate the extremely rare risk of flammability in the presence of an oxygen-enriched environment.

# Appendix C: Hand Hygiene for Residents and Visitors
Hand washing is the single best way to prevent spread of infection. It is estimated that 80% of common infections such as the cold and flu are spread by unwashed hands. Good hand washing technique is easy to learn.
If there is visible soiling, hands should be washed with soap and water.

# Follow these simple instructions when washing your hands with plain soap and water:
- Wet hands with warm water. 2. Apply soap and rub for 15 -20 secondsall surfaces including front and back of hands, between fingers, around nails (especially cuticles), thumbs and wrists. 3. Rinse well. 4. Dry with a paper towel. 5. Turn off faucet without re contaminating hands, for example, use towel to turn off taps.
Follow these simple instructions when using an alcohol based hand rub:
- Apply a measured pump of the product (enough of the product to cover all surfaces of the hand) into your open palm. 2. Rub into hands covering all surfaces including front and back of hands, between fingers, around nails (especially cuticles), thumbs and wrists.  Eye protection is recommended to protect the mucous membranes of the eyes during care or activities likely to generate splashes or sprays of body fluids including respiratory secretions.
- Eye protection should be worn over prescription eye glasses. Prescription eye glasses alone are not adequate protection against respiratory droplets. - Protective eye wear should be put on after putting on a mask.
- After applying eye protection, gloves should be donned (see above).
- To remove eye protection, first remove gloves and perform hand hygiene. Then remove the eye protection by handling the arms of goggles or sides or back of face shield. The front of the goggles or face shield is considered contaminated. - Discard the eye protection into a plastic lined waste container. If the eye protection is not intended for single use, clean it with soap and water and then disinfect it with a bleach solution of one part bleach to 9 parts water, being mindful not to contaminate the environment with the eye protection. - Perform hand hygiene.

# Gloves
Disposable single use gloves should be worn when in direct contact with the ill person, cleaning contaminated surfaces, and handling items soiled with body fluids, including dishes, cutlery, clothing, laundry, and waste for disposal. Gloves are not a substitute for hand hygiene; caregivers must perform hand hygiene before and after putting on and taking off gloves.
- Gloves should be removed, hand hygiene performed, and new gloves applied when they become soiled during care. - To remove gloves safely, with one of your gloved hands pull off your glove for the opposite hand from the fingertips, as you are pulling, form your glove into a ball within the palm of your gloved hand. To remove your other glove, slide your ungloved hand in under the glove at the wrist and gently roll inside out, and away from your body. Avoid touching the outside of the gloves with your bare hands. - Gloves must be changed and hand hygiene performed when they are torn.
- Discard the gloves in a plastic-lined waste container.
- Perform hand hygiene.
- Double-gloving is not necessary.
Reusable utility gloves may be used; however, they must be cleaned with soap and water and decontaminated after each use with a bleach solution of one part bleach with nine parts water (to make a 0.5% sodium hypochlorite solution).