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This material is for general information only; please follow the direction provided by your regulatory college, the Chief Medical Officer of Health and your local public health unit. This guidance was developed for the CMA in conjunction with the Centre for Effective Practice (CEP), one of the largest independent knowledge translation organizations for primary care in Canada. Last updated June 25, 2020.

Jump to:
Providing virtual visits
Determining which services to resume
Resuming in-person visits
Plans and guidance for re-opening
Being prepared to shut down if circumstances warrant
Patient communication
COVID-19 screening
Safety measures

Virtual Visits

To reduce the spread of COVID-19, physicians have been advised to see patients virtually – by video, phone or text message – whenever possible.

The following resources can help physicians adopt and implement virtual care in their practice:  

Information on billing codes, virtual care standards and regulations, by province/territory Opens in a new window (Royal College)
Step-by-step guide to implementing virtual care in your practice (CMA)

In addition, the CMA has created a guide that physicians can share with their patients to help them prepare for and feel comfortable with "virtual visits."
How to navigate a virtual care visit (CMA)

    Determining which services to resume

    As some provincial/territorial governments begin to re-open essential services, physicians and their patients have questions about when to schedule in-person appointments.

     In general, clinics should:

    • Follow advice and orders of the provincial chief medical officer
    • Determine whether the provision of a service is in the best interest of each individual patient
    • Assess clinic capacity for service delivery
    • Take into account the level of risk and local prevalence of the virus

    As a starting place, use resources based on expert opinion to prioritize services and meet urgent care needs. Developing a list of services by priority will also provide a roadmap for those services to delay if emergency measures are resumed. Use templates as a guide, but emphasize the unique needs of the community when prioritizing services.

    Weighing risks and benefits of in-person and remote care

    This framework from the CMAJ blog can help you weigh the competing issues involved in balancing in-person and virtual visits. As well, use the following questions to help determine whether to bring a patient into an office/community facility:

    • Is the patient visit urgent/crucial to the patient's health?
    • Could further delay in provision of the care result in a worse outcome for the patient?
    • Will offering care in a community setting lessen the burden on hospital facilities, or prevent the need to access acute care in the future?
    • Are there other services developed to address medical needs that patients can be referred to? (e.g., municipal or regional child immunization clinics, COVID care clinics)
    • Would a group of peers support the decision of the care being important? Would colleagues perceive these actions as being self-serving, rather than putting the needs of patients, staff and society first?
    • Can you mitigate any risk and keep you and your staff safe? (Do you have adequate PPE? Are there protective measures in place for the patients? Is there a sick-leave policy in place for staff?)

     

    Resuming in-person visits

    Plans and guidance for re-opening services

    Federal guidance

    Health care facilities should:

    • Support core personal practices (hand hygiene supplies, tissues)
    • Implement physical distancing measures (tele-medicine, no waiting in waiting room, call in from car)
    • Schedule to protect patients at higher risk of severe illness (certain days, beginning of day)
    • Enhanced environmental cleaning (increase frequency of cleaning/disinfecting high-touch surfaces, between patients)

    See Lifting of restrictive public health measures - Recommendations from the F/P/T Special Advisory Committee on COVID-19 (PHAC, April 2020)

    Guidance from public health authorities, regulatory colleges and professional associations

    Alberta

    Ontario

    Saskatchewan

    Re-opening plans by province

    British Columbia

    Restart Plan

    New Brunswick

    Recover Plan

    Newfoundland and Labrador

    A Foundation for Living with Covid-19

    Prince Edward Island

    Renew PEI Together

    Northwest Territories

    Emerging Wisely

    Nunavut

    Nunavut's Path

    Being prepared to shut down if circumstances warrant

    When preparing to re-open your office, monitor provincial re-opening plans in order to keep track of current and future phases/stages and alert levels. Staying up-to-date with re-opening plans will inform physicians if the provincial government decides to take a step back to a previous phase/stage/alert level in light of a surge of new COVID-19 cases. Physicians can anticipate and prepare for this by creating a flexible re-opening plan that can be scaled up or down accordingly to reflect possible resurgences of new COVID-19 cases within their local area.

    • Consider preserving Health Human Resources (HHR) capacity where possible as part of planning for future surges/outbreaks
    • Inventory your supply/stock of PPE, and identify sources for urgent services and potential future surges
    • Continue to provide virtual care to patients, which will make transitioning back to a predominantly virtual care model easier if circumstances warrant

    Sources

    Patient communication

    During the period of re-opening practices, many patients will be hesitant to return to an office space. They need to hear that their care providers are still available to care for them and provide support, whether via phone, video or in-person with safety precautions in place. Communicating with patients prior to expanding in-person care will help them feel informed, safe and will help them prepare for their in-office visits.

    Tips for contacting patients

    • Frame the messages in your own voice – be as 'familiar and friendly as possible' 
    • Identify yourself clearly by letting them know which clinic you are from by name
    • Communicate your weekly schedule clearly to patients

    Communicate the benefits of virtual care in addition to offering in-person appointments:

    Communication tools

    In communications, it takes repeated messaging (often up to seven times) before someone "mentally acknowledges" the message you are trying to communicate. Use the following tools to communicate to your patients effectively prior to their office visit.

    Communication tools

    Tips

    Website

    Add (or link to) appropriate and up-to-date COVID-19 resources, updated information about the safety policies being implemented at the office, information on modifications made to the location, new appointment visit procedures, options for virtual care, and a link to a virtual COVID-19 assessment tool.

    Email

    Use secure email platforms and identify how your practice will use emails (e.g. to request appointments, for medical advice, for medication renewals) and who will monitor these.

    Send an email to patients containing COVID-19 resources as well as measures you are taking to ensure their safety. Ask them to complete and send in the Canadian Medical Protective Association's consent form for electronic communications and document this in your EMR. Consider adding a link in your signature line directing recipients to COVID-19 information on your website.

    See Doctors of BC Appendix—Email to patients for a sample email.

    Phone outreach

    Contact patients without email to check-in, outline your expansion plans, and book any needed appointments. Leverage office assistants, Residents or other team members and bill as appropriate.

    1. Consider using a digital phone number to mask your personal number and ensure that the name of your clinic shows up on call display. 
    2. Set up call forwarding to re-route clinic phone calls to the office assistant who is on shift/on call. 

    Voicemail message

    Create a clear voicemail advising patients that the clinic is still open and how they can book an in-person or virtual appointment.

    1. Outline your office's response to COVID and measures that patients should be taking (i.e. asking for patience due to high volume of calls, directing them to the appropriate contact for changing their appointment, etc.).
    2. Sample voicemail message: "'We are here to meet your health care needs, but due to COVID-19 there are changes in how you may access care. Please listen to this whole message to hear your options."

    Social media

    Echo the same key messages shared in email on social media platforms. Seek guidance from your provincial regulatory College for social media policies made for physicians. Ask patients to complete and send in the Canadian Medical Protective Association's consent form for electronic communications and document this in your EMR.

    Appointment reminders

    Modify messages to highlight COVID-19 and outline what patients should do if they have symptoms. Explain how a visit will be different from in the past.

    Sources

    COVID-19 Screening

    All physicians' offices/clinics should continue to screen patients for COVID-19.

    • Patients experiencing severe difficulty breathing, severe chest pain or losing consciousness should call 911 or head to the local emergency department.
    • Patients with COVID-19 symptoms should be directed to local COVID assessment centres or offered a virtual visit, to be assessed and to determine the need for further treatment/testing.

    Only those patients that pass the screen should come in for an in-person appointment.

    • Instruct patients (by email, or through the office/clinic website) to use a self-assessment tool before booking an appointment and again on the day of the appointment. You can use the federal self-assessment tool or a tool recommended by your local or provincial public health agency.
    • Instruct staff to screen patients by phone before booking an appointment, and again on the day of the appointment.

    Safety measures for in-person visits

    These protocols and procedures are based on IPAC Routine Practices (PHAC) and emerging COVID-19 guidance.

    Jump to:
    Administrative and operational controls
    Environmental cleaning
    Visits with symptomatic patients
    PPE and infection control measures
    How to get PPE

    Consolidated guidance: administrative and operational controls

    Scheduling visits

    • Consider providing some care virtually, and some in-person, to reduce the in-person time required.
    • Screen patients over the phone for symptoms of COVID-19 before coming for their visit.
    • Schedule appointments that limit the number of people in the office at one time.
    • Consider scheduling virtual appointments in between in-person appointments to avoid a buildup of patients in the waiting room.

    Patient and visitor protocols

    • Ask that whenever possible, patients come alone into the clinic. Make exceptions for children or caregivers as appropriate.
    • Limit non-patient or essential visitors. Clearly post your policy for individuals who are not patients, employees or essential visitors (including vendors, educators, service providers, etc.) outside the practice door and on your website.
    • Screen patients and essential visitors before physically entering the clinic. If possible, dedicate a room or space in the parking lot for this purpose. Anyone accompanying the patient (e.g. children or caregiver) should also be screened.
    • If visitors must come to the practice, designate a window of time outside normal office hours to minimize interactions with patients, clinicians or staff.
    • Advise patients and essential visitors to practice diligent hand hygiene, cough etiquette and physical distancing when inside the facility.
    • Request patients to wait outside or in their vehicle until the examination room is ready, and then text/phone them when it is time to enter.
    • Instruct patients to arrive no more than five minutes before their expected appointment.

    Health care personnel protocols

    Protocols for health care personnel management and infection control should be developed in alignment with local health authorities. Across jurisdictions, health care facilities should implement the following:

    • Point-of-care risk assessment before every patient interaction.
    • Comprehensive hand hygiene in accordance with Routine Practices (PHAC)
    • Practices should implement a staff infection monitoring protocol aligned with local health authority guidance. This should include:
      • Staff screening for symptoms before entering the clinic, and a notification protocol if they develop symptoms
      • On-shift exposure risk assessment
      • Quarantine and isolation
      • Resolution of symptoms and resuming work.

    For resources on health care personnel infection control, see:

    Setting up the clinic

    • Remove
      • Remove toys, magazines, brochures, remote controls and other shared items from waiting and exam rooms.
      • Empty exam rooms of all but the bare minimum of equipment (exam table, chair, BP cuff, lights).
    • Change
      • Replace cloth-covered furnishings with easy-to-clean furniture where possible.
      • Keep frequently used doors open to avoid recurrent door handle contamination.
      • Consider instituting contactless payment options such as tap.
      • Go paperless where possible to minimize the use of forms, clipboards, and pens with patients.
      • Limit the number of examination rooms being used.
      • Avoid the transfer of patients within and between facilities unless medically indicated.
      • Minimize staff in the office/clinic. Ask what tasks can be done from home or outside of regular hours to minimize staff interactions with each other and patients.
      • Wherever possible, discourage workers from sharing phones, desks, offices and other tools and equipment.
    • Provide
      • Place alcohol-based hand sanitizer (with at least 70% alcohol) at multiple locations: office entrance, reception counter, waiting room, and by every exam room for use before entering and upon exit.
      • Provide no-touch waste receptacles in waiting areas and exam rooms.

    Waiting area setup

    • Limit the number of patients in the waiting room.
    • Set up seating to maintain 2 metres of physical distancing between people. If maintaining physical distancing is difficult, install plexiglass separators where possible.
    • Provide designated spaces for lineups that are distanced from seated waiting areas. Use visual cues (directional arrows, waiting spots, tape on the floor) to maximize physical distancing.
    • Consider providing a protective barrier for reception area, such as glass or plexiglass, so that administrative staff won't require PPE.
    • Provide face coverings if possible, but ensure patients do not leave face masks in waiting areas.

    Signage

    Place COVID-19 posters and signage at entrance doors, reception area and exam rooms reminding patients about COVID-19 symptoms and hygiene practices to reduce the spread of the virus.

    The CMA has produced Stop the spread posters that can be displayed in clinics/offices to remind patients about the symptoms of COVID-19, and how to protect yourself from transmission.

    Available in English, French, Arabic, Cantonese, Mandarin, Punjabi and Spanish.

    Consolidated guidance: environmental cleaning

    • Post current cleaning policies and ensure office clinical and administrative staff are aware of cleaning policies
    • Consider designating a roving "sanitization technician" responsible for constant sanitization of areas of concern.
    • Ensure all cleaning products are included on Health Canada's list of products approved for disinfection of COVID-19.
    • Maintain a minimum 2-week supply of plain soap, paper towels, hand sanitizer, and cleaning supplies.
    • Provide paper sheeting for exam tables and change between patients.

    See Environmental Cleaning and Disinfectants for Clinic Settings (BCCDC, March 2020) for information on cleaning agents, concentrations, and uses.

    Cleaning schedule

      Equipment

      Frequency

      Time to complete

      Shared reusable medical equipment
      (stethoscopes, blood pressure cuffs, etc.)

      in between patients and at the end of each shift

      Time the cleaning protocol and build in this extra time for cleaning/sanitizing when scheduling patients.

      All necessary equipment for treatment

      in between patients and at the end of each shift

      Patient contact surfaces (whether symptomatic or not, after every patient visit, areas within 2 metres of the patient should be disinfected)

      in between patients and at the end of each shift

      Exam rooms
      (chairs, tables, floors)

      at least twice a day

      Frequently touched surfaces (workstations, cell phones, light switches, doorknobs, tables, chairs, door handles, clipboards, front office counter)

      at least twice a day

      Sources

       

      Cleaning guidance for specific materials

      Linens
      • Gowns made of polyester or polyester-cotton fabrics can be safely laundered according to routine procedures and reused.
        • Be careful to not touch the outer surfaces of the gown during care.
        • Laundry operations and personnel may need to be increased to facilitate additional washing loads and cycles.
        • Establish a system to routinely inspect, maintain/mend, and replace reusable gowns when they are worn out or ripped.
      • All linen used in the direct care of patients with suspected and confirmed COVID-19 should be managed as 'infectious' linen. Follow Routine Practices (PHAC) for detailed guidance on handling of infectious linen.

      Dishes and cutlery

      • Utensils, pots and pans, and other dishwasher-safe food preparation items can be cleaned and sanitized in the dishwasher with a hot rinse cycle or washed with hot soapy water.
      • No other special precautions are recommended. Routine practices should be used.

      Waste
      • At this time, there is no evidence to support the need of different waste management protocols for facilities caring for patients with COVID-19.

      Sources

      Visits with patients that have respiratory or other COVID-19 symptoms

      Patients with symptoms of an acute COVID-19 infection should be identified and asked that, if possible, they defer routine clinic visits until symptoms of the acute infection have subsided or they should be referred to a local COVID-19 assessment clinic.

      If patients cannot defer their clinic visit (i.e. those being assessed for COVID-19 or other symptoms/ conditions), follow the guidance above with the following additions:

      Source control

      • Request patients to wear a mask (homemade) when visiting the office/clinic, or if necessary, provide non-medical masks at the entrance.
      • Inform patient of required hand hygiene and/or respiratory hygiene recommendations

      Staffing & scheduling changes

      • Schedule appointments with symptomatic patients for a time when other patients are not present
      • Schedule patients with respiratory symptoms (acute or chronic) during designated time slots at the end of the day
      • Some group clinics are using a model where ALL patients with ANY respiratory symptoms are seen by one designated physician in the group, in a designated 'respiratory clinic' (one clinic block of rooms). This can help conserve PPE, if other clinicians are only doing phone and video assessments.
      • In group practices, consider having one care provider or one "team" of providers see all patients with suspected or confirmed COVID-19 OR refer to a centralized testing and assessment site, if available 
      • Personnel in the area to which the patient is to be transported should be aware of the patient's status, informed of precautions to follow and to see the patient efficiently to minimize time in waiting areas and reduce time spent outside of the patient room.

      Visit procedures

      • Patients who screen positive should be given a surgical/procedure mask and be advised to perform hand hygiene
      • Ensure patients do not leave their face masks in the waiting areas
      • Immediately place patient in a room with the door closed to avoid contact with other patients in common areas of the office/clinic
      • If possible, provide a separate entrance for patients with symptoms suggestive of COVID-19
      • Ask patients to show their health card so clinic staff do not have to handle/swipe the card

      If a patient is identified as COVID-19 positive after visiting the clinic:

      • Call the local public health unit for advice on potential exposure and implications for continuation of work.
      • Staff who were in close contact or may have been exposed without proper protection should self-isolate and monitor for 14 days.
      • If it has been more than 7 days since the person with confirmed COVID-19 visited or used the facility, additional cleaning and disinfection is not necessary.

      See Risk assessment and management of exposure of health care workers in the context of COVID-19 (WHO, March 19, 2020)

      Sources

       PPE and infection control measures

      • Follow droplet and contact precautions when seeing symptomatic or suspected COVID-19 patients. The Public Health Agency of Canada has provided infection prevention and control guidance for outpatient and ambulatory care settings which addresses these precautions.
      • Gloves, long-sleeved cuffed gown (covering front of body from neck to mid-thigh), mask and face or eye protection should be donned before entering the exam room.  PPE should be removed and discarded after exiting the exam room.
      • Here is an example from Public Health Ontario of the steps to take in donning and doffing PPE.
      • See below for information on how to source PPE by province.

      How to get PPE

      PPE supply and distribution

      Each province/territory has its own guidelines for requesting personal protective equipment. The following section will give you some background on who to contact to order PPE for your community practice.

        Newfoundland

        The Newfoundland and Labrador Medical Association (NLMA) is capturing PPE supply requirements from community physicians to help the provincial government provide those practices with a weekly supply. That weekly supply is based on the estimates physicians provided to the NLMA on May 14. This is a standing order you only need to submit once. Find more information here.

        The NLMA also maintains a contact list of local PPE suppliers.

        Nova Scotia

        The Department of Health and Wellness will be supplying community-based physicians and their staff with personal protective equipment (PPE) at no cost until September, 2020. Click here to submit a request for PPE. When your request is processed, your organization's primary contact will be notified by email of the approved supply that can be accessed and instructions to set up online ordering. For more information, email PPErequest@novascotia.ca

        Prince Edward Island

        The Medical Society of Prince Edward Island is asking physicians to submit their requests for PPE supplies to the Government of PEI. Requests for supplies will be assessed and distributed on a weekly business cycle.

        Find more information here.

          New Brunswick

          The New Brunswick Medical Society (NBMS) is partnering with the Department of Health and Service New Brunswick to facilitate the ordering and distribution of PPE. Physicians can order directly from the NBMS every two weeks. Staff will process the orders as they come in and arrange for delivery at the physician's chosen location.

          For more information: ppe@nbms.nb.ca

          Manitoba

          Doctors Manitoba is encouraging community-based physicians to order PPE through Shared Health, which is maintaining a central supply of PPE. In an effort to conserve PPE, Shared Health has enacted a "framework" to prioritize the delivery of supplies to care settings based on the level of risk to providers and patients. It is also recommending shifting as much patient care to virtual visits as possible.

          More information can be found here.

          Saskatchewan

          In an attempt to ensure stable access to PPE for private, community-based physicians, the Saskatchewan Medical Association, the Saskatchewan Health Authority and the Ministry of Health are working with a private provider, Schaan Healthcare Inc. N-95 masks are not included in the list of available supplies from Schaan. If you are already ordering from another supplier, you don't need to do anything.

          Read more here.

          Alberta

          Alberta Health Services (AHS) is coordinating the allocation of PPE during the COVID-19 pandemic and will distribute the supplies to zone-specific Primary Care Network (PCN) hubs. Member clinics can request supplies through their PCN point of contact who will place an order with AHS supply management. All non-PCN primary care providers that require PPE should contact their PCN hub. If you are unsure of your PCN contact or have questions about the distribution process, email: phc@ahs.ca.

          Read more information on using PPE in Alberta here.

          British Columbia

          Doctors of BC is working closely with the province's various health authorities around the supply and distribution of PPE. Physicians who have offices outside of hospitals are encouraged to contact their regional health authority here.

          Ontario

          Ontario Health is urging physicians to conserve existing PPE supplies, work with their regular suppliers to determine next shipments, and to reach out to other local health care providers to determine they have extra PPE. If these steps fail, there is an urgent PPE request process:  

          • Determine which of the five regions where your practice is located. Submit a request via the appropriate Personal Protective Equipment Intake Form. There are specific forms for OH East-Champlain and OH West; all other regions should use the main PPE intake form. Your Regional Table Lead will work to address your request within the region. They have been directed to address priority populations, with primary care as another sector that requires attention.   
          • If the need cannot be addressed regionally, the Regional Table Lead will escalate your request to the Ministry Emergency Operations Centre. 

          Didn't find your province/territory in this list?

          Contact your provincial medical regulator or provincial ministry of health for more information on requesting PPE.

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