This tip sheet is for employers, workers, and volunteers of medical emergency rooms (e.g., hospitals, urgent care centres, walk-in-clinics) including doctors, nurses, physicians, porters, medical technicians, cleaning staff, clerks, administrators, etc. It provides an overview of potential hazards and risks due to COVID-19 and guidance regarding control measures. Paramedic (and other first aid) specific tips can be found in the First Responder tip sheet.
COVID-19 is a contagious disease caused by the SARS-CoV-2 coronavirus. Infected individuals can spread the virus through respiratory particles when they cough, sneeze, breathe, etc. People can become infected when they inhale particles that contain the virus or by touching contaminated surfaces and then touching their face with unwashed hands.
Communicate to all workers and visitors that people who are sick (or may be sick) with COVID-19 should not enter the workplace or report to work (e.g., in-person meetings, performing medical procedures, delivering supplies, accompanying patients, etc.).
Monitor COVID-19 case numbers and trends in the facility and local community. Restrict access to visitors if necessary.
Notify visitors and the public that protective measures are necessary for the safety of everyone.
Consider installing barriers where physical distancing cannot be maintained (e.g., at reception, service counters, triage stations, inside vehicles, etc.).
Continually assess medical workers’ COVID-19 exposure risk levels, which are increased when:
In close contact or providing direct medical treatment to an individual who has COVID-19.
Performing aerosol-generating medical procedures.
In close contact with another person who has COVID-19 (e.g., co-worker, Emergency Medical Services (EMS) worker, or person accompanying the patient during intake).
Community transmission creates greater emergency room demand and crowding.
As the workers’ exposure risk increases, adjust control measures as appropriate. Consider modifying procedures and protective equipment requirements (e.g., replacing medical masks with respirators, performing additional cleaning and disinfecting).
Require all visitors and patients to wear a mask while in the facility, if possible.
Consider having a worker at the entrance to the emergency department to explain the current COVID-19 protocols to visitors and patients. Protocols could include providing a mandatory medical mask and requiring hand sanitization, followed by a COVID-19 screening and verifying proof of vaccination (if required by vaccination policy). Post large signs in multiple locally used languages outlining this process.
Require EMS workers to notify the emergency rooms before they arrive with any patients confirmed (or suspected) to have COVID-19.
Implement measures that promote physical distancing and reduce indoor crowds:
Remind workers to maximize the distance between themselves and others during any interaction with people they do not live with (e.g., training, department meetings, performing procedures, etc.).
Reduce the number of people (e.g., administrators, support staff, planners, etc.) that work in the facility by offering remote work options, where possible.
Stagger shift start and end times.
Control access to the facility (e.g., allow only one visitor per patient).
Conduct training virtually, outdoors, or in well-ventilated indoor spaces with participants spaced out, whenever possible.
Consider implementing a rapid testing program for workers to help prevent COVID-19 workplace outbreaks. Tailor the program according to local COVID-19 conditions.
Install sanitizer dispensers in high-traffic areas (e.g., main entrance, break rooms, administration offices, washrooms, inside vehicles, etc.).
If contact with illicit drugs is possible, train workers TO NOT USE hand sanitizer. Some hand sanitizers contain alcohol, which may increase the absorption of fentanyl and other hazardous substances through the skin. Have workers use appropriate gloves and other protective equipment when handling drugs and wash their hands after with soap and water.
Consider limiting the use of equipment (e.g., computers, tools, medical equipment, etc.) to one worker, especially when it is difficult to clean and disinfect. If equipment must be shared, instruct users to clean and disinfect the equipment before and after changing users.
Reduce the amount of paper documentation or other items being exchanged between workers and patients. Consider exchanging documents electronically. If this exchange cannot be avoided, wash or sanitize hands after handling items.
Require workers report to work in a clean uniform daily. Recommend they change into street clothes after their shift, transporting their worn uniform in a sealed container before washing them. Instruct them to keep street clothes and uniforms separate unless they are both clean.
Implement processes and procedures to minimize the transmission of COVID-19 in emergency rooms:
Staff doing pre-screening and registration should wear PPE (e.g., medical mask and eye protection).
Isolate confirmed or suspected cases of COVID-19 in their own examination room when they arrive. If that is not possible, attempt to maintain separate waiting areas, with their own washrooms, for patients known to have COVID-19.
Keep anyone who screened positive for COVID-19 away from those who have screened negative, whenever possible.
Have people known (or suspected) to have COVID-19 wear respirators instead of medical masks, if possible.
Create teams of health care workers (cohorts) who will work on the same shifts, if possible.
Position seats in waiting areas to keep at least 2 metres between patients, if possible.
Encourage any patient with signs and symptoms of an acute respiratory infection to cough in their elbow.
Provide tissues, alcohol-based hand sanitizer, and plastic lined waste containers in waiting areas.
Considerations when providing medical care:
Before any patient interactions, conduct a point of care risk assessment to determine the likelihood of exposing yourself or others to COVID-19. The assessment also identifies the required personal protective equipment (PPE) for the task.
Dedicate reusable equipment and supplies (e.g., blood pressure cuff) to one patient for the duration of their stay. If the equipment must be used for other patients, clean and disinfect (or sterilize) it between patients.
Continue to follow standard medical infection control protocols, including handling and disposal of contaminated waste materials.
Train workers to follow the World Health Organization’s “My 5 moments for hand hygiene” approach to hand cleaning:
(1) before touching a patient
(2) before any clean or aseptic procedure is performed
(3) after exposure to body fluid
(4) after touching a patient
(5) after touching a patient’s surrounding
Require workers to seal soiled linens within a container before transporting them and avoid shaking them out before putting them into the washing machine. Machine wash using the warmest water setting (preferably hot water) and laundry detergent. After washing, dry them thoroughly and keep them separate from soiled linens.
Medical personal protective equipment (PPE) considerations:
Make sure that workers are protected from COVID-19 while providing medical treatments. Update PPE requirements if necessary. Follow any specific PPE requirements of your jurisdiction (if applicable).
Train workers on the proper use of PPE including the fit, storage, care, inspection, cleaning and disinfection, and donning and doffing procedures.
Make sure that workers understand the limitations of the PPE they use.
Require workers to wear the appropriate PPE when a procedure requires droplet and contact precautions (includes gloves, a long-sleeved gown, a medical mask, and eye protection).
Fit test each worker before they are required to wear a respirator (e.g., N95). Fit testing verifies that there is an effective seal between the respirator and the worker's face.
Remind workers who wear (or may need to wear) tight-fitting respirators that facial hair can cause respirators to leak around the face seal. Require them to come to work clean shaven or provide them PPE that is designed to provide protection using other methods (e.g., hood-style supplied air).
Verify that appropriate supplies of PPE are available.
Ensure there is a designated area for workers to remove, dispose of, and decontaminate their PPE. All possibly contaminated waste including single-use PPE should be disposed of in a lined waste container. Contaminated waste should be sealed before it is transported.
Consider the Risks
The risk of COVID-19 transmission is increased when individuals are exposed to several risks at once, such as:
When person-to-person interactions are longer and more frequent.
In crowded spaces, especially when people cough, sneeze, or exhale forcefully.
In poorly ventilated spaces with other people.
When people have inadequate hand hygiene, respiratory etiquette, or do not have access to cleaning facilities and products.
When shared surfaces and objects are touched frequently.
When community COVID-19 hospitalizations or cases are high or increasing.
When sick individuals are allowed to stay in the workplace.
When individuals are exposed to several risks at once.
When other risks are high and workplace health measures are relaxed (e.g., dropping indoor mask wearing requirements, requiring all workers to return to the workplace, etc.).
Consider all possible COVID-19 exposure scenarios in your setting and perform COVID-19 risk assessments. Develop or use an existing risk assessment form to document and evaluate all work setting characteristics, activities, and job roles. It is good practice to review your assessment on a regular basis to make sure your control methods are effective.
Sample questions to ask during a COVID-19 risk assessment:
Are indoor spaces properly ventilated?
Where do individuals gather?
What activities require interactions, communication, or touching shared objects?
How long, frequent, and physically close are interactions between people?
Are people able to maintain adequate physical distance from each other?
Which workers are at higher risk?
What are the high-touch surfaces and shared objects?
Do individuals normally participate in activities that create respiratory droplets (e.g., singing, shouting, etc.).
Are people expected to stay in an enclosed space for an extended duration?
Meet your legal occupational health and safety obligations by doing everything reasonably possible in the circumstances to protect the workers and ensure the health and safety the workplace.
To provide the highest level of protection to workers, use multiple public health measures and workplace controls in a layered approach. No single measure is completely effective alone. Be careful not to create new hazards or negatively impact existing safety controls. Review and adjust measures as necessary in consultation with the health and safety committee or representative.
Create and implement a written workplace COVID-19 safety plan supported by the risk assessment. A written plan may be legally required by the jurisdiction in which you operate. Refer to local authorities for details on what must be included in the plan, if it needs to be posted, etc.
Implement policies and programs to accommodate workers, particularly those who are at high risk of severe disease or outcomes (i.e., immunocompromised, have chronic medical conditions, or are older) from a COVID-19 infection.
Communication and Training
Communicate new and updated workplace controls and applicable public health measures to all workers in languages they understand. Specific training requirements and recommendations may vary depending on your jurisdiction. Allow workers the opportunity to ask questions and share concerns. Respond to questions and provide feedback within a reasonable time.
Train workers on COVID-19 specific topics such as:
Screening: keeping individuals who may be infected with COVID-19 out of the workplace.
Contact tracing: identifying and notifying people exposed to the virus and offering advice.
Screen individuals who enter the workplace, if required by your local jurisdiction. Consider having a screening program even when it is not required as an additional measure to protect your workers.
Determine which type of screening your worksite requires: passive or active.
Passive screening requires individuals to self-monitor and self-report possible illness or exposure to COVID-19.
Active screening requires individuals to respond to questions about signs or symptoms of infection, recent possible
COVID-19 exposures, or recent travel outside of Canada.
Allow individuals that pass the screening to access the workplace. Deny access to anyone who does not pass the screening.
Have workers who do not pass the screening contact their supervisor. The supervisor should instruct them to return (or stay) home and follow local public health guidance which may include isolation, testing for COVID-19, or contacting their healthcare provider or public health authority.
Determine if you are required to implement contact tracing. If so, maintain a list of all individuals (for which contact tracing applies) entering the workplace, including their names, contact information, and time spent in the workplace. This information should be provided to the local public health authority if requested for the purpose of contact tracing. All information must be safely stored and destroyed as required by privacy legislation.
For additional information on screening and contact tracing, refer to:
Ventilate indoor spaces appropriately according to the number of occupants and types of activities.
Open windows and doors to the outside, if possible.
Maintain ventilation systems and seek advice from a ventilation specialist on possible improvements (e.g., increasing air exchanges per hour, reducing or eliminating recirculated air, or upgrading to air filtration and disinfection).
If possible, run ventilation systems continuously or for two hours before and after buildings are occupied.
Run local exhaust fans that vent to the outside to help remove contaminated air.
Make sure that air circulation or cooling fans do not direct air flow from person to person.
If ventilation cannot be improved, consider using portable air filtration units with high-efficiency particulate (HEPA) filters.
Keep indoor humidity between 30% and 50%.
For additional information on indoor ventilation, refer to:
PPE includes such items as respirators, medical masks, eye protection, gloves, and safety footwear.
Eye protection (safety glasses, goggles, or face shields) may be worn in addition to a mask when in close physical contact with others. Note: face shields do not provide respiratory protection and cannot replace masks.
COVID-19 PPE policies must not interfere when a higher level of protection is needed for a task.
Workers may need PPE for COVID-19 protection if they are:
Performing tasks that require them to be less than 2 metres from another person.
Using cleaning and disinfecting products (refer to the manufacturers’ safe handling instructions).
Follow the mask wearing requirements of your local jurisdiction. If not required, mask wearing should be encouraged as an additional measure when there is a high risk for COVID-19 spread, or when physical distancing is not possible.
Masks should be comfortable, well-constructed and well-fitting, covering the nose, mouth, and chin.
Consider using masks with a transparent window when communicating with people who are deaf or hard of hearing.
Masks should not be worn by anyone who is unable to remove it without assistance (e.g., due to their age, ability, or developmental status).
Allow workers to wear masks, even if not required, based on their discretion (e.g., being at risk of more severe disease, working in crowded setting, etc.).
Immediately have them wear a mask (preferably a respirator or medical mask, or if neither is available, a well-constructed and well-fitting non-medical mask). A respirator used in this way (i.e., as source control) may not need to be fit tested.
Have them leave as soon as possible.
If they cannot immediately leave, have them isolate in a designated area, away from others, until they can leave.
Call 911 for medical assistance if symptoms are life threatening. If it is a worker, notify their emergency contact.
Complete an incident report and begin an investigation.
Refer to guidance from your local public health authority to determine when the worker can return to work.
Consider updating your sick leave policy to provide support to workers who are or may be sick. Support may include paid or unpaid sick leave, long-term disability, and information on government programs, if available.
Note that this guidance is just some of the adjustments organizations can make during a pandemic. Adapt this list by adding your own good practices and policies to meet your organization’s specific needs.
Disclaimer: As public and occupational health and safety information is changing rapidly, local public health authorities should be consulted for specific, regional guidance. This information is not intended to replace medical advice or legislated health and safety obligations. Although every effort is made to ensure the accuracy, currency and completeness of the information, CCOHS does not guarantee, warrant, represent or undertake that the information provided is correct, accurate or current. CCOHS is not liable for any loss, claim, or demand arising directly or indirectly from any use or reliance upon the information.