# A. Introduction
This document provides a practical guide for primary care practitioners, community-based physicians, nurse practitioners, nurses and midwives as well as related staff in clinics and urgent and primary care centres to support appropriate office-based infection prevention and control (IPC) practices to mitigate the impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the causative agent of COVID-19. This guidance outlines the IPC measures to provide care safely in these settings, including patients with confirmed COVID-19 and suspected COVID-19 cases (e.g., having symptoms of COVID-19 or required to self-isolate following close contact with a confirmed case or travel outside of Canada).
This guidance is based on the latest best practice and scientific evidence. The guidance may change as new information becomes available. Please see appendix A for a COVID-19 community clinic care preparedness checklist to assist with implementing this guidance.
All practitioners and related staff in clinics must follow all orders from the provincial health officer (PHO) and their local medical health officer (MHO).

# COVID-19 Immunization
Approved COVID-19 vaccines in Canada are safe and effective against COVID-19. We are continuing to learn about the impact that immunization has on SARS-CoV-2 transmission, and the effectiveness of vaccines against certain variants of concern. As the evidence evolves, public health and IPC guidance for individuals who have received their COVID-19 immunizations will be updated as needed.
For COVID-19 variants of concern, recommendations for IPC measures remain the same and should be strictly followed and reinforced. See guidance on SARS-CoV-2 variants of concern for more information. Some of the side effects from COVID-19 vaccines are similar to the common symptoms of COVID-19. Individuals experiencing any symptoms of COVID-19 after receiving their immunizations are to continue to use the BC COVID-19 self-assessment tool to determine if testing for COVID-19 is required.
In health-care facilities, regardless of whether an individual (e.g., patient, health-care worker, visitor) has received a COVID-19 vaccine and when they received it, they must continue to follow local processes for COVID-19 screening and managing COVID-19 like symptoms. When providing care to symptomatic patients, health-care workers (HCWs) must continue to conduct point-of-care risk assessments (PCRAs) and implement additional precautions as needed to prevent the transmission of SARS-CoV-2. 

# B. Infection Prevention and Control Measures
Implementation of IPC measures help create a safe environment for health-care providers, staff and patients. A hierarchy of infection prevention and exposure control measures for communicable disease describes the measures that can be taken to reduce the transmission of COVID-19. Control measures at the top are more effective and protective than those at the bottom. By implementing a combination of measures at each level, the risk of COVID-19 is substantially reduced.
Public health measures are society-wide actions to limit the spread of the SARS-CoV-2 virus and reduce the impact of COVID-19. The provincial health officer has implemented public health orders, including capacity limits for indoor and outdoor events, effective testing, case finding and contact tracing, and emphasizing the need for people to stay home when they are sick. Please see the Office of the Provincial Health Officer's website for more information related to COVID-19 orders and notices.
Environmental measures are physical changes in a setting that reduce the risk of exposure by isolation or ventilation. Examples include being in outdoor spaces, having suitable ventilation and air exchange, and frequent cleaning and disinfection of work and living spaces.
Administrative measures are the implementation of policies, procedures, training and education. Examples of these include implementing facility or organizational infection prevention and control policies and procedures (e.g., screening for symptoms and risk factors, use of appropriate signage), as well as HCW training.
Personal measures are actions individuals can take to both protect themselves, as well as to prevent the spread to others. Examples include respecting personal space, washing hands frequently, coughing into an elbow, staying home from work when sick and ensuring immunizations are up-to-date.

# Personal protective equipment (PPE)
is the last and least effective of the infection prevention and exposure control measures. It is not effective as a stand-alone preventive measure and should only be considered after implementing all other measures. PPE must be suited to the task and must be worn and disposed of properly.
Clinics can implement a combination of measures from the different levels described above to protect against COVID-19 as detailed below.

# C. Public Health Measures 2. Case Finding, Contact Tracing and Outbreak Management
When a COVID-19 positive person is identified by public health staff, significant efforts are undertaken to determine if that person is part of a cluster of cases or a local outbreak. Specific public health measures are implemented in facilities where an outbreak occurs to prevent further transmission of COVID-19 and keep others safe in the workplace.
Operators should maintain an updated list of staff and patients' first and last names, their phone numbers or emails, and the dates of clinic attendance, to support public health staff in potential contact tracing efforts.

# Self-Isolation
HCWs and staff with common cold, influenza or symptoms of COVID-19 should stay home, get assessed by their health-care provider and get tested for COVID-19 if their symptoms warrant, in accordance with provincial COVID-19 testing criteria.
When someone has symptoms of COVID-19, they should self-isolate and follow directions provided by their health-care provider. Self-isolation may be advised for those who are considered a close-contact of a confirmed case. Follow public health direction on contact management.

# D. Environmental Measures 4. Cleaning and Disinfection
Regular cleaning and disinfection are essential for preventing the transmission of COVID-19 from contaminated objects and surfaces. Clinic spaces should be cleaned and disinfected in accordance with BCCDC's environmental cleaning and disinfectants for clinic settings document.

# This includes the following:
 Minimize equipment brought into the exam room.  Clean and disinfect shared reusable equipment between patients.
- This includes stethoscopes, blood pressure cuffs, otoscopes, baby scales, tables and examination beds.  Clean and disinfect frequently touched surfaces at least twice a day.
- These include medical equipment, doorknobs, light switches, telephones, keyboards, mice, toys and all hard surfaces in bathrooms (e.g., sinks, faucets, handles).  Establish clear roles and responsibilities for those responsible for cleaning and disinfecting each piece of medical or non-medical equipment, and environmental surfaces.  Clean and disinfect the procedure and examination rooms at least once a day.  Clean and disinfect all surfaces that are visibly dirty.  Use a hospital grade disinfectant with a drug identification number, in accordance with manufacturer's instructions, and contact (wet) time requirements to ensure pathogens have been killed.  Limit items that are not easily cleaned (e.g., fabric or soft items).  Follow routine procedures for waste disposal and laundry management.  Empty garbage containers daily.  Wear disposable gloves when cleaning blood or body fluids (e.g., runny nose, vomit, stool, urine).  Perform hand hygiene before wearing and after removing gloves.
The risk of transmission of COVID-19 via paper or other paper-based products is low. 1,2 As such, there is no need to limit the distribution of paper resources, such as leaflets, to patients because of COVID-19.

# Physical Changes to the Clinic
Facilities may not be able to adopt all of the following measures; however, consideration should be given to incorporating as many measures as possible:
- Consider having a process and designated space for triage, waiting areas and examination rooms, for the management of patients presenting with communicable respiratory illnesses, including suspected or confirmed COVID-19.
- For clinics seeing patients on a walk-in basis, consider setting up communicable respiratory illness and COVID-19 screening stations for all individuals entering the facility at each designated entry point. - Maintain existing physical barrier(s) installed during COVID-19 pandemic if they do not impede normal operations. - Physical distancing or maintaining a distance of two metres between two or more people is no longer required. - Capacity limits for higher occupancy waiting rooms/areas are no longer required.
- Exam rooms:
- The exam room(s) closest to the entrance should be designated for patients with respiratory symptoms in order to allow rapid isolation pending formal assessment. o Exam rooms should be emptied of all but the bare minimum equipment (e.g., exam 

# Patient and Visitor Screening
Before each appointment, every patient must be screened for symptoms and risk factors associated with COVID-19 and communicable respiratory illness using the COVID-19 patient screening tool for direct care interactions.
For clinics seeing patients on a walk-in basis, screen patients for COVID-19 and communicable respiratory illness symptoms and risk factors upon entry to the clinic using the COVID-19 entrance screening tool for health-care facilities.
All visitors/support-persons accompanying patients must be actively screened for symptoms and risk factors associated with COVID-19 and communicable respiratory illness on every visit. See COVID-19 entrance screening tool for health-care facilities for more information.

# Patient Management
Plan for patient scheduling, patient flow and triage. Consideration should be given to the management of patients presenting with communicable respiratory illnesses including suspected or confirmed COVID-19 cases in the clinic. Options include having dedicated areas for COVID-19 and communicable respiratory illness patients and/or scheduling appointments for these patients later in the day; as well as seeing high-risk patients (e.g., elderly and those with chronic illnesses) as the first appointments of the day.

# Pre-Visit Messaging
Office telephone message/voice mail and the health-care practice website(s) should clearly instruct patients where to seek up-to-date instructions on assessment for COVID-19. For assessment, patients can be directed to the BC COVID-19 self-assessment tool and BCCDC's website for information on lab testing.

# Pre-Appointment Triage
A comprehensive triage process starts prior to a patient arriving at the clinic. When booking a patient's appointment:
Ask the COVID-19 screening questions (see BCCDC's website for a sample COVID-19 patient screening tool for direct care interactions), including whether the patient has symptoms of COVID-19 or has been confirmed to have COVID-19. Advise patients to self-monitor for COVID-19 symptoms and notify staff of any change in their health prior to coming into the clinic.
Ensure the patient is informed of the recommended precautions and requirements such as wearing a medical mask, practicing hand hygiene and respiratory etiquette.

# F. Personal Measures 9. Staff Safety
HCWs and staff are encouraged to become fully immunized against COVID-19 to protect themselves, patients, and others.
All HCWs and staff must stay home and self-isolate:
- if experiencing symptoms of COVID-19 OR - if required by public health following close contact exposure.
To determine the need for testing and whether to self-isolate, direct staff to the BC COVID-19 selfassessment tool.
If concerned, staff can be advised to contact 8-1-1, their health-care provider or the local public health unit to seek further advice.
See the BCCDC's exposures and return to work for health-care workers guidance on HCWs exposed to COVID-19 while at work, what to do if a staff member becomes ill, how long to self-isolate and criteria for return to work for those with symptoms. Please see the sample COVID-19 health-care worker selfcheck and safety checklist for more information.

# Routine Practices
Routine practices should be in place at all times in all health-care settings. This includes performing diligent hand hygiene, adhering to respiratory hygiene, conducting a point of care risk assessment (PCRA) before every patient care interaction and appropriate use of PPE.

# Hand Hygiene
Rigorous hand hygiene with plain soap and water or ABHR is the most effective way to reduce the spread of illness.
- Wash hands with plain soap and water for at least 20 seconds. Antibacterial soap is not needed for COVID-19. If sinks are not available, use ABHR containing at least 70% alcohol. - If hands are visibly soiled, ABHR may not be effective at eliminating respiratory viruses. Soap and water are preferred when hands are visibly dirty.
- To learn about how to perform hand hygiene, please refer to BCCDC's website for a hand hygiene poster.
Strategies to support and promote diligent hand hygiene:
- Hand hygiene stations should be set up at the clinic entrance, so everyone can perform hand hygiene when they enter; - Hand hygiene sinks, plain soap dispensers, paper towel holders, hand sanitizer dispensers, and related supplies, should be readily available throughout the facility; - Post signs or posters to promote regular hand hygiene; and - Paper towels should be disposed of in non-touch waste baskets lined with a garbage bag.
For patients, visitors, HCWs and staff, hand hygiene must be performed:
- On entering the clinic;
- On entering the examination room;
- On leaving the examination room;
- After using the washroom;
- After using a tissue for their face; and - After coughing or sneezing.
For HCWs and staff, hand hygiene must also be performed:
- Before and after contact with patient or the patient care environment;
- Before and after breaks;
- Before clean or sterile procedures;
- After risk of body fluid exposure;
- Before putting on/donning PPE; and - In between each step when taking off/doffing PPE.

# Respiratory Etiquette
Respiratory etiquette is also known as respiratory and cough hygiene.
Patients, HCWs and staff must cough or sneeze into their elbow sleeve or a tissue; throw away used tissues and immediately perform hand hygiene; refrain from touching their eyes, nose or mouth with unwashed hands. They must not share any food, drinks, unwashed utensils, cigarettes or vaping devices.

# Point-of-Care Risk Assessment
Prior to any patient interaction, all HCWs must assess the infectious risks posed to themselves, other HCWs, patients and visitors, the situation or the procedure.
The PCRA is based on professional judgment about the clinical situation, as well as up-to-date information on how the specific health-care facility has designed and implemented appropriate physical (engineering) and administrative controls, and the use and availability of PPE.
To conduct a PCRA, evaluate the likelihood of exposure to COVID-19:
- From a specific interaction (e.g., performing or assisting with aerosol generating medical procedures (AGMPs), non-clinical interactions, direct face-to-face interactions with patients); - With a specific patient (e.g., infants or young children, patients not able to practice hand hygiene or respiratory etiquette, frequent coughing or sneezing); - In a specific environment (e.g., patient is in a shared room).
See the BCCDC's website for a sample COVID-19 PCRA tool.

# G. Guidance for Personal Protective Equipment

# Key PPE Recommendations
HCWs and non-clinical staff must follow provincial guidance for Mask Use in Health-Care Facilities During the COVID-19 Pandemic in all health-care settings.
Use appropriate eye protection based on a PCRA and per additional precautions, where indicated.
For direct care of patients with suspected COVID-19 illness (e.g., patients with risk factors and/or symptoms of COVID-19) or a diagnosis of COVID-19, follow droplet and contact precautions. This includes wearing a medical mask, eye protection, gloves and gown.
Extend the use of PPE wherever possible. This includes:
- In the same patient cohort,0 F a keep PPE on between patient encounters unless damaged or visibly soiled. The exception is gloves, which must be changed between each patient. - Change PPE if moving from patients with confirmed COVID-19 to patients with suspected COVID-19. - Change PPE if moving between patients on additional precautions for non-COVID-19 reasons (e.g., airborne, droplet and contact). - Properly doff and dispose/clean and disinfect PPE when leaving the patient care area (e.g., at end of shift, during breaks or mealtimes).
Access to additional PPE, such as respirators, will be provided in circumstances where a HCW determines there is elevated risk of COVID-19 transmission through patient interaction.
a Patient cohort refers to a group of patients with the same diagnosis or suspected diagnosis. In the case of COVID-19, patients with a confirmed COVID-19 diagnosis, patients suspected to have COVID-19 (diagnosis not yet confirmed), and patients without symptoms suggestive of COVID-19, can each be a respective patient cohort. Decisions regarding cohorting should be made in consultation between facility director/administrator, medical health officer or designate and client care leader.
When Wearing PPE - Avoid touching your mask or eye protection. If you must touch or adjust your mask or eye protection, perform hand hygiene immediately before and after adjusting. - Leave the patient care area if you need to remove your mask (e.g., at end of shift or during a break) and ensure two metres distance from patient or exit exam room; do not re-use a doffed mask.
- Change PPE if it becomes damaged or visibly soiled.
- Use extreme care when taking off/doffing PPE and always perform hand hygiene after removing each individual piece of PPE and before putting on/donning new PPE. - In the context of COVID-19, use of an N95 respirator or equivalent is required when performing AGMPs on a person with suspected or confirmed COVID-19.
- Use an N95 respirator or equivalent and eye protection (e.g., goggles or face shield), gloves and gown for AGMPs for patients with suspected or confirmed COVID-19. o In addition, adhere to routine institutional IPC and workplace safety guidelines and practices. - Eye protection must be a well-fitting device that covers the front and sides of the face.
- Regular eyeglasses are not sufficient to protect from all splashes or droplet spray and are not considered adequate protection. o Eye protection, such as goggles, safety glasses or combination medical mask with attached visor, need to cover from the eyebrow to the cheekbone, and across from the nose to the boney area on the outside of the face and eyes. Eye protection should be fitted so that gaps between the edges of the eye protection and the face are kept to a minimum. o Full face shields should extend below the chin to cover the face, to the ears at both sides of the head, and there should be no exposed gap between the forehead and the shield's headpiece. o For tasks with significant risk of splash, like AGMPs, a full-face shield or goggles must be used. o When reusable eye protection is used for multiple patient encounters, it should be cleaned and disinfected as per the guidance found on BCCDC's webpage. o Properly doff, clean and disinfect your eye protection when visibly soiled and when leaving the patient care area (e.g., at end of shift or during a break).
Putting On (Donning) and Taking Off (Doffing) PPE For up-to-date information on PPE including putting on and taking off, as well as posters and signage, please refer to the BCCDC's personal protective equipment webpage.

# Discontinuation of Droplet and Contact Precautions
For patients in the community, discontinuation of droplet and contact precautions should be aligned with the requirements for self-isolation as per public health guidance for management of cases and contacts associated with COVID-19 in the community. This guidance supports a preference for a nontest-based strategy.
For management of patients in acute care settings, the strategies for discontinuation of additional precautions for patients may be different due to a risk assessment of their patient population. For these recommendations follow provincial guidance for discontinuing additional precautions related to COVID-19 for admitted patients in acute care and decision tree.

# PPE Guidance for Patients and Visitors
Please refer to Mask Use in Health Care Facilities During the COVID-19 Pandemic for guidance on mask use for patients and visitors in all health-care settings.
Visitors accompanying patients with symptoms of, or a diagnosis of, COVID-19 should follow droplet and contact precautions.
Patients and visitors must also follow routine practices and any additional precautions that are in place for non-COVID-19 reasons. Develop or update a clinic response strategy to ensure that all staff roles are clearly defined, and that information and decision-making pathways are identified. Designate one qualified office member as the lead for coordinating COVID-19 response at the practice level, including staff responsibilities, information gathering and dissemination, and developing a preparedness plan for the clinic.
Please see a sample COVID-19 community clinic care preparedness checklist in appendix A of this document to aid planning.

# Staff Education and Communication
Develop or update a communication strategy to ensure HCWs and staff have the most up-to-date information. Please see the key resources section for links to the latest information on COVID-19.
Ensure staff have clear, up-to-date information for communicating with patients. Provide appropriate education and training on the following topics, monitor for compliance, and take immediate corrective action when needed:
- Hand hygiene.
- Environmental cleaning and disinfection.
- How to conduct a PCRA prior to each patient interaction.
- Appropriate handling of HCW work clothing/uniforms. Work clothes must be laundered after each shift. - Respiratory protection, proper selection and use of PPE, and putting on (donning) and taking off (doffing) of PPE.
Ensure there is a process for reporting health and safety concerns.
 Prior to any patient interaction, perform a PCRA to assess the likelihood of exposure to infectious agents.  Implement medical mask use for HCWs (clinical and non-clinical), patients and visitors entering the facility in accordance with the B.C. Ministry of Health Policy Communique: Mask Use in Health Care Facilities During the COVID-19 Pandemic  Eye protection use is recommended based on a PCRA and per additional precautions.  Wear recommended PPE for droplet and contact precautions (medical mask, eye protection, gown and gloves) for any direct contact with patients with suspected or confirmed COVID-19.  Use an N95 respirator or equivalent and eye protection (e.g., goggles or face shield), gloves and gown for aerosol generating medical procedures (AGMPs) on patients with suspected or confirmed COVID-19.  Properly doff and dispose of PPE when leaving patient care area (e.g., at end of shift or during a break) or when PPE is visibly soiled or damaged.  Plan for the disposition of all patients following their office visit. Options for disposition include:
 Arrange testing per current guidelines (if suspected COVID-19)  Sending home with self-care guide  Referral to alternate-care site  Admission to acute care When referring patients with suspected or confirmed COVID-19, notify receiving facility in advance.  Monitor staff illness and ensure staff with COVID-19 infection follow appropriate guidance.

# Cleaning and Disinfection
 Inform all staff regarding current cleaning and disinfection guidelines, including approved cleaning products.  Clean and disinfect shared reusable medical equipment (e.g., stethoscopes, blood pressure cuffs, etc.) in between patients and at the end of each shift.  Clean and disinfect exam rooms at least once a day (e.g., chairs, tables, floors).  Clean and disinfect frequently touched surfaces at least twice a day (e.g., workstations, cell phones, doorknobs).  Maintain a minimum two-week supply of plain soap, paper towels, hand sanitizer, cleaning supplies and medical masks, if possible.

# Psychosocial Support
BCCDC offers guidance for psychosocial planning for HCWs during the COVID-19 pandemic. Please see the key resources section of this document for further information.

# Staff Scheduling and Reassignments
Develop a contingency plan for staff illnesses and shortages, with consideration given to staff scheduling:
- Consider adjusting clinic hours to accommodate patient and staffing needs, while supporting IPC measures. - Assess employee availability when greater staffing needs and employee absences for family or self-care are expected.

# Sick Leave Policy
Have open and frank dialogue with all HCWs and staff about sick leave policy prior to any staff illness or time away from work due to self-isolation or quarantine.
Clearly communicate that HCWs and staff who have suspected or confirmed COVID-19 must self-isolate at home, as well as those who have had a test and are waiting for their results.
Some staff might be only mildly ill or already recovering and/or caring for others and still able to perform some of their duties remotely by Internet or telephone, depending on how a clinic is set up.

# I. Key Resources
Information is Available on the Following Topics Relating to COVID-19:   Educate yourself and all staff about current information on the recognition, treatment and prevention of transmission of communicable respiratory illnesses including COVID-19.  Develop a contingency plan for staff illnesses and shortages.  Assign a staff member to coordinate pandemic planning and monitor public health advisories.  Make copies of pandemic educational materials and self-care guides available to patients (provided by public health).  Place appropriate COVID-19 posters and signage at entrance doors, in reception areas and in exam rooms.  Post signage and create voicemail message advising patients to check in by phone before coming to in-person appointments.  Ensure alcohol-based hand sanitizer (with at least 70% alcohol) is available at multiple locations: office entrance, reception counter, waiting room, at point of care and by every exam room for use before entering and upon exit.  Remove difficult to clean items (e.g., plush toys) from the waiting area.  Replace cloth-covered furnishings with easy-to-clean furniture where possible.  Provide disposable tissues and no-touch waste receptacles in waiting area and exam rooms.  Provide plain soap and paper towels in patient washrooms and at staff sinks with clear instructions on hand hygiene.  Display personal protective equipment (PPE) donning (putting on) and doffing (taking off) instructions in locations available to all health-care staff.  Empty exam rooms of all but bare minimum of equipment (e.g., exam table, chair, blood pressure cuff, lights).  Provide paper sheeting for exam tables and change between patients.

# Patient and Staff Management
 Where possible and appropriate, triage all patients over the phone.  In group practices, consider having one care provider or one team see all patients with communicable respiratory illnesses, including suspected or confirmed COVID-19.  If possible, schedule patients with symptoms associated with communicable respiratory illnesses, including COVID-19, during designated time slots.  Advise patients and accompanying visitors to practice diligent hand hygiene and respiratory etiquette.  If possible, designate one exam room for all patients with symptoms associated with communicable respiratory illnesses, including COVID-19, as close to the entrance as possible to minimize patient travel.  Minimize the number of tasks that have to be done in the exam room (e.g., chart completion).  Perform hand hygiene before and after each patient contact.