Step 1: Assess risk in workplace

The virus that causes COVID-19 spreads in several ways. It can spread in droplets when a person coughs or sneezes. It can also spread if you touch a contaminated surface and then touch your face. The risk of person-to-person transmission increases the closer you come to other people, the more time you spend near them, and the more people you come near. The risk of surface transmission increases when many people contact the same surface and when those contacts happen over short periods of time.

• We have involved frontline workers (Physicians and staff)
• We have identified areas where people gather, such as lunch rooms, exam rooms, waiting rooms.
• We have identified job tasks and processes where individuals are close to one another and/or members of the public.
• We have identified the office, medical and other equipment that staff and team members share while working.
• We have identified surfaces that people touch often, such as doorknobs, elevator buttons, and light switches.

Step 2: Implement Protocols to Reduce Risk

Documents used to create this plan include:

• The Provincial Health Officer’s order from May 15th.
• the College’s Guidance on providing in-person care during COVID-19
• the BCCDC’s COVID-19: Infection Prevention and Control Guidance for Community-Based Physicians, Nursing Professionals and Midwives in Clinic Settings
• WorkSafeBC’s Health Professionals: protocols for returning to operation

WorkSafeBCs diagram regarding levels of protection provides the framework for our plan

First level protection (elimination)

• We have established and posted an occupancy limit for our premises*. We have established and posted occupancy limits for common areas such as lunch rooms, examination rooms, waiting rooms, washrooms.

Capacity:

Waiting room = 3 people.

Lunch room = 3 people.

Washroom = 1 person

*Public Health has developed guidance for the retail food and grocery store sector that requires at least 5 sq. m unencumbered floor space per person.

• In order to reduce the number of people at the office, we have considered work-from-home arrangements, virtual care, rescheduling work tasks, and limiting the number of staff and patients in the workplace.
• We have implemented measures to keep staff and others at least 2m apart, wherever possible.

In developing our safety plan, we considered the following and documented the measures we are using to maintain physical distance in our practice:

• We have a total of 2 MOAs.  Each day, one MOA is assigned to the task of running (putting patients in rooms, taking vital signs from patients and cleaning rooms)  the other does desk duties and does not interact with patients.
• Where possible, staff will maintain physical distancing (e.g. avoid eating meals together (breaks are staggered), the space between desks/workstations is >2m.
• Patient who are seen in person are informed to enter the office no earlier than 5 minutes before their appointment, they are put directly in an exam room if the waiting room is at occupancy.  If the exam rooms and waiting rooms are full, patients will be asked to wait in their vehicle.  This is reinforced by a message on our website and telephone system. We have emailed our patients to let them know all the changes taking place in our office and what to expect.
• We have allocated a limited number of in person appointments per day to allow for physical distancing in common areas.
• We have placed occupancy limits on our waiting room and posted signs about these limits.  We have ensured chairs are at least 2 meters apart OR we have eliminated patients waiting in our waiting room entirely—they will immediately be taken back to an examination room.
• We no-longer accept “walk-in” appointments. Patients can access a same day virtual appointment through our virtual drop in clinic M-Th 10am-12pm. All patients seen virtually will be offered an in person appointment if it is needed.  There is a sign on the door informing patients that no walk-ins are being accepted and redirecting them to our website or to a phone number. This message is also on our website and phone system.
• All patient appointments will take place via phone or video. If required and appropriate, a scheduled in-person appointment will be offered.
• We have informed patients that they must not bring anyone to their appointment with them. We will make exceptions for pediatric patients or caregivers if necessary (ie. elderly or frail patients, patients with dementia or cognitive difficulties).
• We have limited surfaces that allow for physical contact:

• We have removed magazines, toys and books from the waiting room
• We have removed pillows, magazines, tissue boxes from exam rooms;
• We have installed contactless doors and garbage bins
• We have removed extra chairs from examination rooms.

• We have developed pick-up and drop-off protocols that eliminate people coming into the office:

• When possible, pick-up and drop-off of mail occurs outside the clinic main door in the vestibule.
• We have reduced the materials available for pick-up and drop-off to minimize non-vital in-person contacts.  Forms are faxed directly to those requesting or emailed to patients for distribution. Prescriptions and lab requisitions are faxed directly to pharmacies and laboratories.

Second level protection (engineering)

In developing our safety plan, we considered the following and documented the measures we are using to engineer physical distance in our practice:

• We have installed plexi-glass barriers where workers can’t keep physically distant from patients at the front desk.
• We have included barrier cleaning in our cleaning protocols.
• We have installed the barriers so they don’t introduce other risks to workers
• We have indicated increments of 2 meters in front of the front desk with stickers applied to the floor.
• We have implemented a video and telephone booking system and are implementing an online appointment booking system.  Patients who are seen by video, check in online.
• We have set up a dedicated examination room (Exam Room #3) with nearby PPE for patients with respiratory symptoms (for the rare instance that these patients are seen in the office).
• We have inspected and repaired all infrastructure systems (i.e. HVAC, water system, electrical system).
• We have increased the rate of air exchange/ventilation if possible; especially to fresh air if possible, avoiding recirculated air.

Third level protection (administrative)

In developing our safety plan, we considered the following and documented the rules and guidance we are using in our practice. We have identified rules and guidelines for how staff and team members should conduct themselves.  We have clearly communicated these rules and guidelines to staff and team members through a combination of training and signage.

• We have scheduled staff so that only one MOA is interacting with patients on any given day.  In addition, we have scheduled physicians so that one out of the four physicians sees patients in person each week.  This way if one team member becomes infected, risk to other staff on the team is minimized.
• If sick, physicians and staff must remain at home. They may continue to provide patient care via telephone or video if they are well enough to do so.
• If sick, physicians and staff will notify Dr. Key who will keep track of sick days.  It will be recommended that all Physicians and staff who are sick will have COVID-19 testing performed at the Prince George Testing Site.  Physicians and staff must not return to work until they have a negative COVID swab AND they are well enough to work.
• Staff will wear clothes dedicated for work, these clothes stay at work and are laundered in the office. Recommendations have been provided (see Appendix 1).
• All staff and physicians will perform hand hygiene when entering the office, when leaving the office and before and after every patient encounter. The BCCDC Hand Hygiene poster is being used to educate physicians, staff and patients on appropriate hand washing.
• All physicians and staff must don appropriate PPE when they cannot be 2m apart from a coworker or patient.
• Appropriate PPE for providing direct care to asymptomatic patients includes: safety glasses, gloves and a mask.
• Appropriate PPE for providing direct care to symptomatic patients includes: safety glasses, gloves, mask and a gown.
• All staff will clean their hands frequently—as this is the best thing anyone can do to decrease the transmission of COVID-19.
• We have prepared to cross-cover staff or team members who are ill or quarantined:
• We have put up laminated signage in washrooms outlining appropriate hand washing protocols,
• We have put up laminated signage at the entry to alert high-risk patients (i.e. respiratory symptoms, recent travelers) to notify staff immediately, don a mask and wash their hands.

• If paper signage is used, we will date when it should be discarded (monthly).
• If laminated signage is used we will wipe it down regularly.

Fourth level protection (PPE)

In developing our safety plan, we considered the following and documented the rules and guidance we are using in our practice:

• We have reviewed the information on selecting and using PPE. We understand the limitations of masks and other PPE. We understand that PPE should only be used in combination with other control measures.
• We understand that if PPE is not available, staff and physicians are NOT expected to risk their own health by providing in-person care.
• We have trained staff and physicians to use PPE properly, following manufacturers’ instructions for use and disposal.   Signage with instructions on how to don and doff PPE is displayed for staff and physicians.
• We are following the PPE guidelines for asymptomatic and symptomatic patients in community, as recommended by the BCCDC and our Regional Health Authority (Northern Health).
• We will provide masks for symptomatic patients (if seen in-office) and instructions on how to wear them OR through signage on our door and messaging on our website and phone system  We will encourage patients to wear their own masks.
• We will keep our mask on at all times, and keep our hands away from our face. If we touch it or remove it, or it becomes soiled or wet, we will change it.

Reduce the risk of surface transmission through effective cleaning and hygiene practices

The COVID-19 virus can survive on some surfaces for many days, therefore cleaning and disinfecting measures should be heightened to minimize risk of transmission. As defined by the BC Centre for Disease Control (2020), cleaning is the removal of soiling while disinfection is the killing of viruses and bacteria, and is never used on the human body. When the term “disinfection” is used in this document, it is assumed that cleaning will occur prior to disinfection.

• We have reviewed the information on cleaning and disinfecting surfaces.
• Our office has enough handwashing facilities on site for all our staff and patients.
• Handwashing locations are visible and easily accessed.
• We have policies that specify when staff and team members must wash their hands and we have communicated good hygiene practices to staff and team members. Frequent handwashing and good hygiene practices are essential to reduce the spread of the virus.
• We have implemented cleaning protocols for all common areas and surfaces — e.g., washrooms, tools, equipment, shared tables, desks, light switches, and door handles. Cleaning occurs at least three times per day – before and after clinic, after lunch, after use.  Examination rooms, medical equipment, computer keyboards, door knobs are cleaned after each patient encounter.
• Staff and team members who are cleaning have adequate training and materials.
• We have removed unnecessary tools and equipment to simplify the cleaning process.
• We have removed unnecessary items or items that are hard to disinfect from exam rooms and will only bring them into the room as necessary (e.g. tissue boxes, soft office furniture, any equipment not regularly used).
• We have placed the patient chair as far away as possible from the physician chair/stool in the exam room.
• In order to minimize exposure to patients, staff will provide verbal instructions—such as instructing patients in how to use a scale, baby weigh-station or wall-mounted measuring tape—instead of doing it for them.
• We have assigned each staff member to a dedicated work area and discouraged the sharing of phones, desks, offices, exam rooms and other medical and writing equipment.
• We have made hand hygiene supplies readily available for patients, staff and physicians. Our hand sanitizers are approved by Health Canada.
• We have increased disinfection of frequently touched surfaces in common areas (i.e. computer keyboards, door handles, phones, armrests, washrooms, etc.), even if not visibly soiled.
• Between patients, we will disinfect everything that comes into contact with the patient (i.e. pens, clipboards, medical instruments, stethoscopes).
• To reduce the risk of community spread and cross-contamination, we have created a bin of communal stethoscopes that can be used by any physician during clinic and a separate bin in which to place used stethoscopes that will be disinfected at the end of the day.
• We have set up a sanitizing station near the entrance for all patients entering the office.
• As we are seeing symptomatic patients, we have dedicated a room for symptomatic patients with nearby PPE.

Step 3: Policies Developed

1.Policy regarding staff or physician illness with symptoms of COVID-19 or at risk for COVID-19.

Staff and Physicians must stay home if:

• They have had symptoms of COVID-19 in the last 10 days. Symptoms include fever, chills, new or worsening cough, shortness of breath, sore throat, and new muscle aches or headache.
• They have a positive COVID-19 test
• They have been directed by Public Health to self-isolate.
• They have arrived from outside of Canada or have had contact with a confirmed COVID-19 case until they have isolated for 14 days to monitor for symptoms.

Staff and team members who start to feel ill at work.

• Staff and Physicians should report symptoms even if mild.
• Sick staff and physicians should wash or sanitize their hands, be provided with a mask, and isolate. The staff or physician must go straight home.
• Sick staff and physicians will inform Dr. Key who will keep track of sick days.
• It is recommended that all Physicians and staff who are sick will have COVID-19 testing performed at the Prince George Testing Site.
• Physicians and staff must not return to work until they have a negative COVID swab AND they are well enough to work.
• If the staff or physician is severely ill (e.g., difficulty breathing, chest pain), call 911. Clean and disinfect any surfaces that the ill staff or team member has come into contact with.

2. Policy regarding workflow for Physicians

The following information is sourced from Rosh and Mehta (2020).

• All individuals seeing patients are to perform hand hygiene and put on a mask as soon as they arrive in the clinic prior to doing anything else. This mask stays on until it is removed for lunch. After lunch, put on a NEW mask.
• Prior to opening of the clinic, staff are to review booked patients to see if you need any equipment for prep (baby scale, prenatal basket, O2 sat monitor, etc.) and ask staff to have these items either in the room before the patient arrives or close to the room.
• When you are ready to see your first patient:

• Don PPE (mask should already be on)—head covering, gloves and eye protection.
• Assess your patient: take history from as far away as possible and then move to examination (try to spend as little time as possible in close contact).
• When administering vaccines/medications, please do the following: Cross check the vaccine/medication vial(s) against provided checklist (this is a safety measure to reduce risk of medical error) Draw up the vaccine/medication and inject the patient yourself.
• When assessment completed  If patient is to leave right away Gloves remain on Ask the patient to use hand sanitizer as they leave Complete all charting in the room Still in the room: discard gloves, leave stethoscope and other equipment used in the room Keep head covering, eye protection and mask on unless soiled Perform Hand Hygiene If patient must remain in room Leave stethoscope and other equipment used in the room Open the door for yourself and before leaving the room, discard gloves Perform hand hygiene Chart at a dedicated workstation or leave charting until the end of day.
• Between patients:

• Staff will wipe down the bed, chairs, counters and any equipment that was used.
• Perform hand hygiene
• Put on gloves before next patient and repeat process above until all patients seen

• Once last patient seen (at end of day or at lunch), complete all steps below: Discard gloves in the room Remove stethoscope and eye protection and leave in the room for cleaning. Perform hand hygiene. Leave exam room. Perform hand hygiene. Remove mask and discard. Perform hand hygiene.
• Let staff know the last patient has left

Step 4: Develop communication plans and training

You must ensure that everyone entering the workplace, knows how to keep themselves safe while at your workplace.

• We have a monthly office meeting and address the COVID-19 Safety Plan regularly to ensure all staff and physicians are up to date on workplace policies and procedures.
• All staff and team members have received the policies for staying home when sick.
• We have posted signage at the office, including occupancy limits and effective hygiene practices.

Step 5: Monitor your workplace and update your plans as necessary

Things may change as our business operates. If we identify a new area of concern, or if it seems like something isn’t working, we will take steps to update our policies and procedures. We will involve workers in this process.

• At monthly staff meetings the COVID-19 Safety Plan will be reviewed. At office huddles (2x per week) any risk will be discussed.  We will make changes to our policies and procedures as necessary.
• Staff can approach any of the physician owners with health and safety concerns.