Safety Is Not Negotiable: Pandemic Preparedness for the Coronavirus 2019 (COVID-19)

Publish date: Friday, February 28, 2020

CFNU

COVID-19

Health and safety

MNU members

Nursing profession

Union news

Workplace issues/practices

Please note that CFNU updated their Position Statement on COVID-19 on March 23, 2020. Please refer to this latest statement.

CFNU POSITION STATEMENT

It is the position of the Canadian Federation of Nurses Unions that in the event of an outbreak of any new virus, all nurses and frontline health care workers at risk (based on an organizational infectious disease risk assessment) with the potential for exposure, and/or who are caring for a suspected or confirmed 2019 novel coronavirus patient, be protected using a fit-tested NIOSH-approved N-95 respirator at a minimum. The N-95 respirator is designed to protect against 95% of airborne particulates free of oil when tested against a 0.3-micron particle.

Furthermore, the CFNU recommends that any worker who will be exposed to aerosol-generating medical procedures must be protected and trained on use, and donning and doffing, of a powered air-purifying respirator (PAPR) and provided with full body protection.

This standard should apply for all viruses which are known or unknown, or suspected to be airborne, or can be aerosolized, or any virus where there is uncertainty about the transmission route or clinical severity.

It is our position that a pan-Canadian approach to emergency preparedness must incorporate the precautionary principle so that all nurses and health care workers across Canada have the same access to health and safety in their workplaces, including the same standard for personal protective equipment (PPE) and pandemic planning. If the precautionary principle is not instituted throughout the health care system, nurses and other health care workers could readily become vectors spreading the disease to each other and their patients. Further, it is crucial for effective infection control and health and safety strategies that a hierarchy of controls (engineering, administrative and at the worker level) be developed and implemented throughout the organization, in conjunction with Joint Health & Safety Committees that include direct care providers (including nurses) and their unions.

This is a position that aligns with the U.S. Centers for Disease Control and Prevention Interim Infection Prevention and Control Recommendations for Patients with Confirmed 2019 Novel Coronavirus (2019-nCoV) or Persons Under Investigation for 2019-nCoV in Healthcare Settings, and similar guidance issued in the EU and the U.K. for health care professionals, as well as in Ontario. However, to-date, the Public Health Agency of Canada has not adopted this position.

A NOTE ON SCIENTIFIC UNCERTAINTY

As noted on the Public Health Agency of Canada (PHAC) website with respect to information on the 2019 novel coronavirus: “Significant additional information is required to fully understand the cause of the outbreak, the virus’ transmission dynamics, and the severity of illness in humans.”1

Advice by experts, including Dr. Mark Nicas and Dr. Rachael Jones, call for a rejection of the impractical distinction between “contact,” “airborne” or “aerosol”. Dr. Nicas and Dr. Jones have argued that a better way of looking at the problem of transmission is to assume that all infectious agents can theoretically be transmitted along all pathways, and that the job of researchers is to quantify what proportion of the transmission follows each path. The authors conclude that in the early stages of an outbreak, when there remains significant uncertainty as to what proportion of transmission follows each path, the best protective assumption for governments and health care workers is to assume the possibility of all paths of transmission and act accordingly in terms of mandating the appropriate personal protective equipment for all health care workers at risk.2

As recently noted by Dr. Bruce Ribner, Medical Director of the Serious Communicable Diseases Unit at Emory University Hospital in the U.S., “We don't really know how the coronavirus is being transmitted from person to person. What we know is that multiple modes of transmission are likely at play, including large droplets, small droplets (or aerosols), and contaminated hands.”3

Similarly, a recent Lancet article on the coronavirus 2019 outbreak calls for “aggressive” measures (such as N-95 masks, goggles and protective gowns) to ensure the safety of healthcare workers.4

BACKGROUND

Nurses are expected to be prepared, 24 hours a day, to face any number of health emergencies. The ability to respond quickly and efficiently to emergencies is fundamental to the nursing profession. However, rapid response requires the support of many parts of the health care system. It requires emergency preparedness planning, proper administrative and engineering controls, the support of the administrators of the health system, as well as the government to ensure the necessary protocols, measures, procedures, training and protective equipment that take into consideration risk and the precautionary principle.

EMPLOYER’S CHECKLIST

  • Consult the Joint Occupational Health & Safety Committee on all measures, procedures and training with respect to COVID-19.
  • Review and update existing institutional pandemic plans, developed in conjunction with the joint OH&S committees, to ensure they include staffing, communication, education and training for staff with respect to pandemic preparedness plans and the health risks of the current emergency and/or pandemic situation.
  • Ensure that workers have ready access to PPE, are regularly trained and fit-tested for the N-95 respirator (biennially) and regularly drilled in any potential hazards, including the reason for and use of protective equipment such as the N-95 respirator and powered air-purifying respirator (PAPR), how to don and doff all equipment, and all safety protocols.
  • Ensure that health care providers are fully trained, tested and drilled in the care provisions/ protocols required during a pandemic, including conducting a point-of-care risk assessment before each interaction with a patient and/or the patient’s environment to evaluate the likelihood of exposure to contact, droplet and/or aerosols in care procedures, equipment and treatment settings to determine the appropriate safe work practices.
  • Conduct a comprehensive organizational risk assessment, including determining all points of potential entry (and how to restrict them using prominent signage and limiting access) and other points of potential exposure for workers (e.g., screening, triage, isolation rooms).
  • Implement changes in policies, procedures, equipment and the environment to eliminate or minimize identified risks in accordance with a hierarchy of controls approach to hazards.
  • Have in place relevant travel screening and worksite/unit exposure controls. Ensure that sufficient protective measures and equipment are in place for all screening locations at all entry points.
  • Have in place suitable structural barriers (e.g., ceiling-to-floor plexiglas barriers at triage and registration), disposable equipment, separate examination rooms and waiting area.
  • Update N-95 respirator fit testing as needed and provide training for all identified health care workers at risk as well as information about the specific health risks present during an emergency pandemic situation so that protective equipment is used properly at all times; require all health care workers to carry identification indicating the size of the fit-tested N-95 respirator needed.
  • Have an adequate supply of appropriate N-95 respirators, gloves, impermeable gowns, head protection, face shield and foot protection as well as PAPR (for aerosol-generating medical procedures, e.g. intubation) and full body protection on hand.
  • Have airborne infection isolation rooms (negative pressure rooms) available and prepared for immediate occupancy whenever possible.
  • When a suspect patient is identified, implement isolation measures in a negative pressure room for those with symptoms and move patient immediately to this room, separate from other patients, with access to a dedicated washroom or commode, and ensure that only trained, properly equipped personnel (with appropriate PPE) are assigned as care providers and enter these rooms.
  • Create dedicated teams of clinicians who are protected with and trained, tested and drilled in the use of proper personal protective equipment for COVID-19, including teams trained in the use of N-95 respirators and PAPR (for aerosol-generating procedures), donning and doffing protocols, who can care for both suspected and confirmed cases of COVID-19.
  • Ensure sufficient staffing is available to supplement nurses and other health workers who need to care for patients in isolation and schedule work in a manner that allows for multiple rest periods and recovery periods, and implement systems for monitoring fatigue.
  • Implement surge capacity protocols as needed.
  • Implement cleaning protocols requiring at a minimum fit-tested N95, face shield, gloves, gowns, head and foot protection, and waste disposal protocols. Use disposable equipment whenever possible; non-disposable equipment should be dedicated to the patient.


NURSE’S CHECKLIST

  • Comply with existing workplace infection control policies and procedures.
  • Stay home when you are ill.
  • Update your N-95 respirator fit testing and wear an N-95 respirator if there could be any risk of exposure to COVID-19.
  • Use required droplet, contact and additional airborne precautions such as (but not limited to): gloves, goggles, gowns, face shields, respirators, powered air-purifying respirators (PAPR) (for aerosol-generating medical procedures, e.g. intubation).
  • Conduct a point-of-care risk assessment before each interaction with an affected patient and/or the patient’s environment to evaluate the risk of exposure to contact and/or aerosols in care procedures, equipment and treatment settings; at any time during this risk assessment nurses may request an increase in PPE.
  • Avoid touching your eyes, nose and mouth with hands to prevent self-contamination; clean hands before contact with any part of the body.
  • Avoid contact between contaminated gloves/hands and equipment and the face, skin or clothing when removing PPE.
  • Familiarize yourself with your collective agreement and legislation with respect to pandemic preparedness, occupational health and safety (OH&S) and the right to refuse dangerous work.
  • STOP if you do not have the required personal protective equipment or properly fitted respiratory protection, and/or have not been trained, drilled and tested in its care, use and limitations, and speak with your manager or supervisor; document the situation and copy your union and Joint OH&S Committee representative.
  • REPORT any health and safety concerns, including gaps in adequate protocols and procedures and/or communications, access to PPE, fit-testing and/or training or other health and safety concerns to your manager or supervisor, copying your Joint OH&S Committee and your union.

CONCLUSION

Nurses are expected to be prepared to face any number of health emergencies in numerous health care settings. The ability to respond quickly and efficiently to emergencies is fundamental to nursing. However, society has a reciprocal responsibility to protect nurses when they do so. A safe, secure and effective response requires the support of many parts of the health care system. It requires emergency preparedness planning, proper administrative, communication and engineering controls, the support of the administrators of the health system, as well as the government to provide the necessary personal protective equipment and training that takes into consideration risk and the precautionary principle.

Questions or concerns? If you have any questions or concerns, please speak with your union or a member of your Joint Occupational Health & Safety Committee.

For further information about the 2019 novel coronavirus:


1 Public Health Agency of Canada. Infection prevention and control for novel coronavirus (2019-nCoV): Interim guidance for acute healthcare settings. Retrieved on February 19, 2020. Retrieved from https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/health-professionals/interim-guidance-acute-healthcare-settings.html

2 Nicas, M., Jones, R. (2009). Relative contributions of four exposure pathways to influenza infection risk. Risk Analysis. 2009 Sep;29(9):1292-303. doi: 10.1111/j.1539-6924.2009.01253.x. Epub 2009 Jun 24.

3 Soucheray, Stephanie. (2020, February 13). Unmasked: Experts explain necessary respiratory protection for COVID-19. Center for Infectious Disease Research and Policy (CIDRAP). Retrieved from http://www.cidrap.umn.edu/news-perspective/2020/02/unmasked-experts-explain-necessary-respiratory-protection-covid-19

4 Chang, D., et al. (2020, February 13). Protecting health care workers from subclinical coronavirus infection. The Lancet. Retrieved from https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(20)30066-7/fulltex


"The point is not who is right and who is wrong about airborne transmission. The point is not science but safety. Scientific knowledge changes constantly. Yesterday’s scientific dogma is today’s discarded fable. When it comes to worker safety in hospitals, we should not be driven by the scientific dogma of yesterday or even the scientific dogma of today. We should be driven by the precautionary principle that reasonable steps to reduce risk should not await scientific certainty. Until this precautionary principle is fully recognized, mandated and enforced in Ontario’s hospitals, workers will continue to be at risk."
Justice Campbell, Chair of the SARS Commission

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