COVID-19: providing care

All health-care settings should continue to screen for COVID-19, according to the Ministry of Health’s patient screening guidance. Active screening of patients is also recommended by Public Health Ontario’s Interim Infection Prevention and Control Measures based on COVID-19 Transmission Risks in Health Care Settings. For community-based settings, patients should be screened virtually and at the point of entry to your clinic. If your clinic is located inside a shared building, consider placing signage both at the entry to the building and at the point of entry to your clinic.

Access a checklist for screening for COVID-19 symptoms and exposures (OCFP).

A screening for COVID-19 is clinically relevant (negative or positive) and therefore should be documented in the patient’s chart, according to the College of Physicians and Surgeon’s Medical Records Documentation policy.

Assess patients for COVID-19 symptoms and risk factors, either virtually or in person. The CPSO states that in-person care can be provided safely by taking appropriate precautions, including screening patients and using necessary PPE. Furthermore, it states that assessment and treatment of issues with symptoms that overlap with COVID-19 should not be delayed.

Clinical assessment centres

COVID-19 Clinical Assessment Centres (CACs) offer assessment, diagnosis and disposition planning for people whose symptoms cannot be safely self-monitored at home, but do not require emergency care. These centres are not intended to replace services offered by primary care.

Find a clinical assessment centre.

If you are a community-based physician, you may choose to provide lab-based PCR tests in your practice, but this is not required. The OMA has developed a guide to offering PCR testing in your practice, if you would like to learn more about providing this service. If you cannot test in your office and the patient is eligible for testing, refer the patient to a local testing site or clinical assessment centre. Patients with severe symptoms should be referred to the emergency department.

Rapid Antigen Testing

Rapid antigen testing can be used for routine screen testing, for people with COVID-19 symptoms who are not included in molecular testing priority groups, for test-to-work purposes and non-routing asymptomatic testing. Rapid antigen testing can be used for both individuals who are fully vaccinated and those who are not fully vaccinated.

All rapid tests have been deregulated, meaning that specimen collection can be performed by a wider group of individuals, including both health-care professionals and trained individuals, in accordance with instructions from the manufacturer.

Self-swabbing is permitted for rapid antigen tests. Performing a nasopharyngeal swab remains a controlled act that can only be performed by regulated health-care professionals.

Rapid testing kits are available free of charge

The MOH provides access to free rapid testing kits and swabs through the Provincial Antigen Screening Program. Health-care organizations, including community-based physician practices, can order rapid tests for the office to screen patients and staff. Screening is voluntary, and a patient’s decision to decline screening should not impact the provision of care.

The Ministry of Public and Business Service Delivery, on behalf of the Ministry of Health, has transitioned to a new online portal for ordering personal protective equipment, swab kits and rapid antigen tests from the Ontario government stockpile. Community-based physicians are encouraged to email the Ministry of Public and Business Service Delivery at sco.supplies@ontario.ca to get set up with an account. If you have an existing account, sign in to PPE supply portal to order PPE, swab kits and rapid antigen tests from the provincial stockpile. The ordering process via the eHealth Ontario portal has ended.

Any tests ordered through this provincial program cannot be sold and individuals tested cannot be charged a fee. Rapid molecular tests are also available, however, there are additional implementation and use case considerations. Practices interested in these can email covid19testing@ontariohealth.ca.

Resources:

• Point-of-care testing: provincial changes FAQs
• Provincial antigen screening program training sessions and modules (OH)

Testing for SARS-CoV-2 variants

There is currently no routine targeted screening for variants of the SARS-CoV-2 virus. However, whole genome sequencing is performed for surveillance purposes on a representative sample of positive PCR tests across Ontario, as well as on specimens from international travellers. Any patients who have recently travelled outside of Canada (including to the U.S.) should have that marked on the test requisition.

COVID-19 is a designated disease of public health significance reportable under the Health Protection and Promotion Act. Contact your local public health unit to report any probable and confirmed cases of COVID-19 based on the latest case definition.

The Ministry of Health provides the following general guidelines.

Those eligible for molecular testing (PCR or rapid molecular) include symptomatic people who are:

• Aged 60+
• Aged 18+ who have one or more comorbidity that puts them at higher risk of severe COVID-19 disease
• Aged 18+ who are unvaccinated or have not completed their primary series
• Aged 18+ whose last dose of COVID-19 vaccine was more than six months ago and have not had a SARS-CoV-2 infection in the past six months
• Immunocompromised
• Pregnant
• Patients seeking emergency medical care
• Outpatients being considered for COVID-19 treatment
• Patient-facing health-care workers
• Staff, volunteers, residents/inpatients, essential care providers and visitors in highest-risk settings (e.g. hospitals and congregate living settings)
• Household members of workers in highest-risk settings and patient-facing health-care workers
• Home and community care workers
• International agricultural workers in congregate living settings
• Underhoused or experiencing homelessness
• First responders, including fire, police and paramedics

Select asymptomatic populations are also eligible for molecular testing including patients who have a scheduled surgical procedure requiring a general anesthetic, treatment for cancer or hemodialysis. They are eligible for testing 24-48 hours prior to the surgery or treatment.

Asymptomatic staff of the highest-risk settings who, within the past ten days, have had close contact with an individual with COVID-19 symptoms/positive test, are eligible for molecular testing for the purposes of facilitating a return to work.

Additional populations are eligible for testing. Refer to the Provincial Testing Guidance for a complete list of individuals eligible for PCR or rapid molecular testing.

Yes. Serological testing is available in Ontario in three circumstances:

1. Patients with symptoms compatible with Multisystem Inflammatory Syndrome in Children (MIS-C) who do not have laboratory confirmation of COVID-19 by PCR testing.
2. Patients with severe illness who have tested negative for COVID-19 by PCR testing and where serology would help inform clinical management and/or public health action. (Serology for these patients requires consultation and approval by the testing laboratory).
3. To inform treatment decisions for monoclonal antibody treatment for certain patients who are critically ill (in the ICU due to COVID-19) or moderately ill (in hospital due to COVID-19 and requiring low-flow oxygen).

Serology should NOT be used for screening and diagnosis of acute COVID-19 infection. A positive serology test does not mean a patient is immune to COVID-19. Diagnostic testing for acute COVID-19 infection should be done by validated PCR testing.

No, a time-based approach to clearance can be used for all patients in the general population.

Individuals with any COVID-19 symptoms are recommended to isolate as follows, regardless of COVID-19 test result.

• General population (including health-care workers outside of highest-risk settings): Isolate until fever has resolved and until symptoms have been improving for 24 hours (48 hours for gastrointestinal symptoms)
• Those who are immunocompromised, live in a high-risk setting or were hospitalized for COVID-19: Isolate for 10 days
• Those who required ICU care: Isolate for 20 days, unless otherwise directed by hospital infection control

All groups listed above should wear a mask in public and avoid non-essential visits to high-risk settings such as hospitals and long-term care homes for 10 days from symptom onset.

• Do not need to self-isolate unless symptoms develop
• Should wear a mask in public and avoid non-essential visits to high-risk individuals and settings for 10 days from their positive test date

Household and non-household close contacts should do the following for 10 days from their last exposure:

• Self-monitor for symptoms and isolate if any symptoms develop
• Wear a mask in all public settings
• Avoid non-essential visits to anyone who is immunocompromised or at higher risk of illness (i.e. seniors)
• Avoid non-essential visits to any highest-risk setting, such as hospitals or long-term care homes

Health-care workers who work in a highest-risk setting (e.g. acute care hospital, complex continuing care hospital, congregate living setting or Indigenous community) should speak with their employer and follow their workplace guidance for return to work.

Those who are symptomatic or test positive:

• Should avoid work for 10 days after symptom onset or specimen collection date (whichever is earlier)
• Following the 10 days, they can return to work provided their fever has resolved and symptoms have been improving for 24 hours (48 hours for gastrointestinal symptoms)
• There are exceptions in critical staffing shortage situations

Those who are exposed to COVID-19 (including household and non-household close contacts):

• Should self-monitor for symptoms for 10 days from last exposure and can continue to attend work
• Additional measures, such as PCR or rapid molecular testing, may be required by the employer

The OMA has compiled a list of resources (member-only content) for finding a lawyer in your area to assist in drafting a will or dealing with other personal legal matters during the pandemic.

For general information on virtual care, visit OntarioMD virtual care. Note that if express verbal consent is collected, it should be documented in the chart.

Please also note the Information Privacy Commissioner has indicated that in a public health crisis, it is also understandable that health professionals,may need to send or receive information by phone, text, email or other messaging services.

During the pandemic, you are not required to inform the CMPA of a change in Type of Work (TOW) or Province of Work (POW) prior to commencing your efforts, but the CMPA would appreciate hearing from you when it is feasible or if you have any questions.

As well, under the Emergency Management and Civil Protection Act, the government can pass an order “authorizing, but not requiring, any person, or any person of a class of persons, to render services of a type that that person, or a person of that class, is reasonably qualified to provide.”

If the government invokes this power and orders redeployment of the health work force, you may be able to practice outside your practice area without incurring liability. This has not happened yet, but we are monitoring the situation closely.

In the absence of a formal order, the CPSO states that during public health emergencies, it may be necessary for physicians to temporarily practice outside their scope, but physicians must do so only if:

• The medical care needed is urgent
• A more skilled physician is not available
• Not providing medical care may result in greater risk or harm to the patient or public than providing it

You are not required to provide information about your travel plans, but at that point they may ask you to voluntarily not come in, or they may decide you cannot work there temporarily by invoking a temporary suspension provision in their by-laws.

Yes, it is possible that hospitals could restrict physicians from working based on their by-laws.

Hospitals are considered government actors for the purposes of the Canadian Charter of Rights and Freedoms. Your right to personal privacy under the charter in an urgent public health situation may be trumped by Section 1, which permits the override of rights for purposes justifiable in a free and democratic society.

During a pandemic, hospitals are likely to be given broad leeway to make difficult choices. Under the Professional Staff By-laws, the hospital can temporarily suspend privileges if there is a “reasonable” risk to patient safety or workplace safety. What is reasonable is fluid depending on the situation and the legal obligations of the hospital.