Coronavirus: Ontario changes directive regarding PPE for long-term care homes, hospitals

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As Ontario continues into the second wave of the novel coronavirus pandemic, the province has updated its directive that governs rules related to personal protective equipment for both regulated and unregulated health care staff at hospitals, long-term care and retirement homes.

The updated Directive #5, which was released Monday, makes it easier for unregulated health professionals — like personal support workers, environmental service employees and porters — to access N95 masks, a protective device that seals the area around the nose and mouth.

Read more: Ontario wants to change PPE directive for long-term care workers, CUPE says

N95 respirators filter out at least 95 per cent of airborne particles, which is different from surgical masks. The latter does not protect the wearer from inhaling small, airborne particles and isn’t considered to be respiratory protection, according to the CDC.

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Previously, if a long-term care facility or hospital was experiencing a COVID-19 outbreak, unregulated workers in Ontario had no access to N95 masks. Now, those workers can access fit-tested N95s when in contact with a suspected, probable or confirmed coronavirus case, where a two-metre distance can’t be assured.

Previously, employers were also able to deny staff access to N95 respirators if they considered the request to be “unreasonable” during a coronavirus outbreak. Under the new directive, employers must provide N95s to unregulated health professionals if it’s deemed to be needed.

For regulated health professionals, employers can only deny requests for N95s if they’re not based on a point-of-care-risk-assessment (PCRA), which looks at the circumstances surrounding the patient, task and environment to determine what precautions are needed.

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“It basically gives the non-regulated staff much more ability to request upgraded PPE when they deem it necessary,” said Sharleen Stewart, president of SEIU Healthcare, one of the unions that represents front-line health-care workers.

Before the changes to Directive 5 earlier this week, Stewart said, only regulated health professionals could determine if N95s were needed for unregulated staff through a PCRA.

“Because of the crisis in staffing, particularly in long-term care, sometimes to find a regulated staff person, especially on night shifts, sometimes there isn’t even one on there,” Stewart said. “This definitely allows them to protect themselves when they can’t get a regulated staff person to deem it necessary to upgrade the personal protective equipment.”

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Stewart said the updated directive will save many health care workers’ lives by improving the protections they’re able to take, in addition to their access to PPE.

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“SEIU ourselves lost three personal support workers, who are non-regulated, to the virus early in the first wave,” the union head added.

“The numbers show that the health care workers were predominantly in the unregulated classification who were infected.”

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Alon Vaisman, an infection control and infectious disease physician at the University Health Network, said the new directive is more inclusive of all types of workers who are providing care in hospitals and long-term care facilities.

While he said it’s good the province is refining its language to make sure workers are aware of their rights when it comes to asking for and receiving PPE, he doesn’t think it will solve the issue of COVID-19 outbreaks in nursing homes.

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“The issue with LTCs (long-term care homes) isn’t so much that we didn’t know the science and when to use which PPE,” Vaisman said. “It was more that they simply either didn’t have enough PPE or they didn’t have any infection control expertise there, which is a huge problem for LTCs.”

According to Vaisman, it’s important long-term care homes have infection control expertise available — just wearing the right PPE isn’t enough.

“There needs to be a sustained model for LTCs where they can be either self-sufficient or have some kind of relationship with infection control experts that can be sustained over long periods of time,” he added.

“Before COVID, there was really such a huge gap in that.”

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In an email to Global News Tuesday, Ontario Ministry of Health spokespeople said the updates to Directive 5 have been based on an “ongoing assessment of risks” to patients, residents and workers. These include the “challenges” that came with implementing the previous directive, although government representatives didn’t specify what these challenges were.

Ministry spokespeople also said the updates to the directive are based on the increased transmission of COVID-19 in recent weeks, illness rates among health care workers, in addition to the need for a “stable workforce” during a second wave of the novel coronavirus in Ontario.

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“The changes to the directive help to clarify the role of the PCRA for outbreak and non-outbreak situations in hospitals and long-term care homes, as well as how health care workers (unregulated health workers) are supported by the PCRA process,” reads a Ministry of Health document on the updated Directive 5.

“In the context of coronaviruses, and in particular COVID-19, the epidemiology of the infection has been demonstrated not to be airborne.”

One challenge with the updated directive, Vaisman said, is with people who could potentially misinterpret it.

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“When you see a patient, you use droplet contact precautions, which means when it comes to face protection, a mask or procedure mask, surgical mask,” the infection control expert said.

“When certain procedures are done that are higher risk that lead to aerosol generation, then the recommendation is to use an N95, which is a resource that’s more scarce and it should be used only when indicated.”

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Vaisman said aerosol generating medical procedures are seldom used in long-term care homes and that non-regulated health care workers would rarely be involved in performing them.

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“I suppose it’s possible in some extreme scenarios,” Vaisman said. “It’s a matter of making sure they all have access to it, and that’s a very important thing — everyone, regulated and non-regulated, must be able to have access to the PPE.”

Stewart said the government must ensure companies are abiding by the updated Directive 5 moving forward.

“It’s going to be imperative that the companies stop cutting corners and locking up these PPEs and just making it very difficult for frontline workers to access it,” she said.

“It’s just imperative the government holds these companies accountable to adhere to these new standards.”

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