Originally issued May 27, 2020

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The College routinely reviews this document to ensure it remains relevant and current. In this recent version, the information on hand hygiene, gloves and masks has been updated to reflect the latest public health advice. The key revisions are listed below:

  • Occupational therapists must promote and have sufficient means for frequent and proper hand hygiene for all people present in the practice environment. This can be done by washing hands with soap and water or using an alcohol-based hand sanitizer (70-90% alcohol content is recommended).
  • Gloves alone are not a substitute to hand washing hygiene. Gloves are to be single use, following which they must be disposed of and changed.
  • OTs should change their masks in between clients, and always if a mask becomes wet or soiled.

Additional resource links have also been added.


On May 26, 2020, Directive #2 from Ontario's Chief Medical Officer of Health was revoked and replaced. The new Directive #2 authorizes the beginning of the gradual restart of deferred, non- essential and elective services. As always, public safety remains the priority. There are necessary preconditions to this Directive that all health professionals must meet, including compliance with operational requirements such as enhanced screening and use of personal protective equipment. 


The College of Occupational Therapists has developed the following guidance for occupational therapists to consider as Ontario begins re-opening businesses and resuming healthcare services. The College will continue to develop guidance and update the COVID-19 section of the website at www.coto.org as more information becomes available.

If you have specific questions after reading this guidance, please email practice@coto.org.

Introduction

  • Occupational therapists must follow all directions provided by Ontario’s Chief Medical Officer of Health (CMOH) and the Ontario Ministry of Health’s guidance for the health sector. Orders, directives and guidance from the Ministry of Health and CMOH overrule anything that may be in this document.
  • In addition to direction from the CMOH and Ministry of Health, occupational therapists should refer to the guidance prepared by their employers, each of whom is responsible for directing their employees on how to operationalize and implement the public health orders. Follow-up with your supervisor/manager or professional/clinical practice lead with any concerns or if clarification of your employer’s direction is required.
  • The intent of this document is to augment existing organizational guidance or provide assistance to occupational therapists who are self-employed or working in private practice clinics or facilities.
Guiding Principles

  • Services that can be safely and effectively provided remotely (online, by telephone or other virtual means) should be.
  • In-person services may only resume once the necessary preconditions in the Ministry of Health’s COVID-19 Operational Requirements: Health Sector Restart (the “Operational Requirements”) are met including carrying out the necessary Organizational and Point of Care Risk Assessments.
  • In-person services must only proceed when the anticipated benefits of the services outweigh the risks to the patient/client, the occupational therapist and where applicable, other organizational staff. The College assumes that each occupational therapist is best- suited, using their professional judgment and within the limits of the direction from the CMOH and Ministry of Health, to determine whether they will resume service delivery.
  • All decisions around the resumption of service delivery will be guided by the foundational principles of proportionality, minimizing harm to patients/clients, equity and reciprocity as set out in Directive #2. The type of occupational therapy services provided and the way in which they are delivered by occupational therapists, are very diverse. The College assumes that each occupational therapist is best-suited to determine how to implement this return to work guidance to their own unique practice, within their own existing policies and procedures, and in alignment with the College’s Standards of Practice and Code of Ethics.
Guidance for Occupational Therapists who are also Employers

Employers have a legal duty under Ontario’s Occupational Health and Safety Act to take every reasonable action to protect the health and safety of workers. This duty is particularly important in the context of COVID-19, where there is a need to protect workers and the public from contracting the virus. Employers should carefully review the government’s sector-specific guidance and be mindful that a precondition to the gradual resumption of deferred healthcare services is that employers of healthcare professionals carry out an Organizational Risk Assessment.

Keep in mind that guidance is likely to evolve as the pandemic evolves. It is important to frequently check the relevant Ministry website for updates:

Return to Practice Considerations

Before returning to practice, occupational therapists should review this College guidance as it relates to their practice. Please read each section carefully. The College recognizes that some of these measures apply only to certain settings and must be applied in conjunction with any other guidance provided by employers, the Ministry of Health and the CMOH. This guidance is organized into the following categories:

In-Home and Community Services

Occupational therapists who provide in-home services have unique challenges in establishing safe practices for both the patient/client/family and themselves. There is less control of variables within the home environment that can impact the potential risk of transmission. To help mitigate these risks the government has developed sector-specific guidance for providers of in-home services. When applying professional judgment about safety measures, occupational therapists must follow the government’s guidance on these types of settings, depending on their area of practice. See:

Occupational therapists working in this type of practice setting should also familiarize themselves with and follow the guidance provided by the Public Health Agency of Canada:

Hand Hygiene (Revised in Version 3)

  • Occupational therapists must promote and have sufficient means for frequent and proper hand hygiene for all people present in the practice environment. This can be done by washing hands with soap and water or using an alcohol-based hand sanitizer (70-90% alcohol content is recommended).  

    Occupational therapists should consider:
    • Setting up handwashing and/or sanitization stations.
    • Providing signage instructing on proper hand washing techniques.
    • Requiring everyone, including staff, patients/clients, and visitors, to wash their hands upon arrival or use an alcohol-based hand sanitizer.
  • Gloves alone are not a substitute to hand washing hygiene. Gloves are to be single use, following which they must be disposed of and changed. If gloves are used, be aware of the potential interaction with gloves and topical products. Hands must be cleaned after removing gloves. 
Cleaning and Disinfecting

  • Cleaning refers to the removal of visible soil. Cleaning does not kill germs but is highly effective at removing them from a surface. Disinfecting refers to using a chemical to kill germs on a surface. Disinfecting is only effective after surfaces have been cleaned.
  • Follow the Workplace Hazardous Materials Information System (WHIMS) guidelines.
  • Use a “wipe-twice” method to clean and disinfect. Wipe surfaces with a cleaning agent to clean off soil and wipe again with a disinfectant.
  • Regular household cleaning and disinfecting products are effective against COVID-19 when used according to the directions on the label.
  • Use a disinfectant that has a Drug Identification Number (DIN) and a viricidal claim (efficacy against viruses). Alternatively, use a bleach-water solution with 100 ml of bleach to 900 ml water.
  • Health Canada has approved several hard-surface disinfectants and hand sanitizers for use against COVID-19. Use these lists to look up the DIN number of the product you are using or to find an approved product. Make sure to follow instructions on the product label to disinfect effectively.
  • In addition to routine cleaning, all common areas should be cleaned and disinfected at a minimum of once per day and when visibly dirty. Special attention should be paid to commonly touched surfaces such as doorknobs, light switches, toilet handles, counters, handrails, touch screen surfaces, and shared materials, equipment, workstations, keypads, plexiglass barriers, etc. Occupational therapists should refer to Public Health Ontario’s guidance on cleaning and disinfection for public settings.
  • See “After the appointment” section below for information about required cleaning and disinfecting processes to occur after each patient/client interaction.
  • Clothing and fabric items should be laundered and dried on the highest temperature setting possible. Ensure items are thoroughly dried.
  • Develop and implement procedures for increasing the frequency of cleaning and disinfecting of high traffic areas, common areas, public washrooms, and showering facilities.
  • Document procedures around cleaning, for example, frequency and by whom.
Preparing your place of employment

  • Apply the hierarchy of hazard controls in the development of all processes, policies, measures, and procedures in response to the COVID-19 pandemic.
  • You should have written measures or procedures in place around the following:
    • Start of day tasks
    • Process for booking appointments and conversations with patients/clients, including documenting informed consent around the risks associated with presenting at the clinic/facility, for example, risk of infection on public transit and at the clinic/facility weighed against risk of not presenting
    • Systems for virtual and/or telephone consultations to determine if remote service delivery is appropriate or an in-person appointment is necessary
    • Cleaning schedule with initials (who is responsible for cleaning what and how often and a record of sanitization, etc.)
    • End of day task, for example, checking supplies for the next day
  • To reduce the risk of transmission of COVID-19, consideration should be given to how visitors to the practice setting are managed. Visitor policies developed should balance the need to mitigate the risk to the patient/client, staff, and visitors, with the mental, physical, and spiritual needs of patients/clients for their quality of life. Occupational therapists must refer to the “Managing Visitors” section of the Operational Requirements when developing visitor policies to ensure compliance with government requirements.
  • Place clear, visible signage at all entrances, and create an alert on voicemails and websites instructing patients/clients to schedule appointments in advance and prohibiting walk-ins and unscheduled visits.
  • Place clear, visible signage at all entrances and within the workplace, reminding patients/clients and visitors about the signs and symptoms of COVID-19, what to do if they feel unwell and how to protect themselves and others, for example, hand hygiene. The Ontario Government has provided signage for both patients and visitors that can be posted on entrances, and a poster for within your setting. Several public health units also have similar resources.
  • Place clear, visible signage at all entrances and in reception areas requiring patient/clients and visitors to wear a face covering/non-medical mask (if available and tolerated), and ensure they do not leave their used face coverings or masks in waiting or other common areas.
  • All signage placed around your place of employment should be accessible and accommodating to patients/clients and visitors.
  • A confidential register of all people entering the setting should be kept to help in contact tracing, if required. This would include people in the clinic aside from patients/clients, for example, couriers, guardians accompanying a patient/client, etc. The register should include name and telephone number. This is not an open sign-in book and should be kept and managed privately by the clinic. This registry should be kept until further notice. Explain to visitors that this information will be used for contact tracing only, should someone who visited the setting later be diagnosed with COVID-19, and that visitors can refuse to provide their name and telephone number.
  • If a patient/client who attended the health care setting later tests positive for COVID-19, if aware, occupational therapists or the appropriate person at their organization, are encouraged to contact their local public health unit for advice on their potential exposure and implications for continuation of work.
  • Alternative solutions to waiting in the setting should be considered, such as asking people to wait in vehicles and texting or calling when appointments are ready.
  • Seats in waiting areas should be spaced to maintain a minimum physical distance of two metres. Persons living in the same household are not required to separate.
  • If possible, install a plexiglass barrier at reception failing which, reception and other administrative staff should maintain a two-metre distance from the patient/client.
  • Products and devices for sale should be displayed behind a barrier or display case.
  • Non-essential items should be removed from waiting areas, including magazines, water dispenser, tea and coffee service, toys, remote controls, etc.
  • Provide a dedicated, covered and clearly marked receptacle(s) for disposal of masks, gloves, facial tissues, paper towels, etc. No touch receptacles, such as garbage cans with a foot pedal, are preferred.
  • Ensure there is a designated space to isolate staff who develop COVID-19 symptoms
  • Develop an outbreak procedure checklist in the event a patient/client becomes infected after being treated at the clinic or facility.
  • Ensure there is a stable supply of PPE and other essential supplies.
Booking appointments

  • Wherever possible, services that can be safely and effectively provided remotely should be.
  • When booking appointments, ask patients/clients and any visitors over the phone if they are experiencing any symptoms of COVID-19. You should develop a checklist for this purpose that you then include as part of the patient/client record.

    For more information, review the following documents:
    If patient/client screening reveals risk factors, signs, or symptoms of COVID-19, if possible, in- person services should be deferred, and the patient/client should be referred for testing. If an accompanying visitor screens positive, they should not be permitted to accompany or visit the patient/client pending test results.

  • Pending the outcome of active screening, the decision to provide in-person service should be based on risk, both to the patient/client and to you as the practitioner. Public Health Ontario has a document that provides more information on risk assessments. If you must provide service to a patient/client with symptoms or who has COVID-19, personal protective equipment (PPE) must be used. See “The appointment” section below for more information. In-person services cannot be provided to patients/clients who screen positive unless you can follow Droplet and Contact precautions and are knowledgeable on how to properly don and doff PPE. If a patient/client has suspected or confirmed COVID-19, consideration should be given to the time of booking, for example, end of day, to minimize the risk of transmission.
  • Inform patients/clients over the phone or via email of any public health measures you have implemented and address any concerns or expectations regarding the visit, for example, maintaining social distancing recommendations, and other infection prevention activities, etc.
  • Advise patients/clients to attend alone, if possible, or limit to one person accompanying them. Book appointments to allow time between patients/clients to help maintain physical distancing and allow for surface and equipment cleaning after each appointment.
  • To minimize waiting room transmission of disease, develop a system to have clients and accompanying visitors to wait outside or in their vehicle, if appropriate. Advise the patient/client of the system developed and ask them if they would like to receive a phone call or text message when they can enter the clinic or facility. If this is not possible, advise the patient/client and any accompanying visitors to arrive as close to the appointment time as possible.
  • Given the unique circumstances, patients/clients may request accommodations. Be flexible with these requests when possible and if safe to do so. Both the occupational therapist and the patient/client should feel comfortable during the appointment.
The appointment

  • Staff must screen the patient/client and any accompanying visitor to ensure their COVID-19 status has not changed from the pre-booking screening. If upon this second screening a patient/client exhibits signs and symptoms consistent with COVID-19, you must:
    • Establish and maintain a safe physical distance of two metres.
    • Have the patient/client complete hand hygiene.
    • Have the patient/client put on appropriate PPE, for example, surgical/procedural mask, if available and the patient/client can tolerate wearing one, and complete hand hygiene.
    • Isolate the patient/client in a room with the door closed, away from common areas and others in the clinic. If this is not possible, the patient/client can be instructed to return outside and advised that they will be texted or called when a room becomes available.
    • Explain the concern that they may be symptomatic, discontinue treatment and reschedule the appointment.
    • Advise the patient/client that they should self-isolate and call their primary care provider, Telehealth Ontario at 1-866-797-0000 or an Assessment Centre for further clinical assessment.
    • Clean and disinfect the practice area immediately, including all areas the patient/client may have touched.
    • Ensure a record is kept of all close contacts of the symptomatic patient/client and other visitors and staff in the clinic at the time of the visit. This information will be necessary for contact tracing if the patient/client later tests positive for COVID- 19.
    If a visitor screens positive, they should be referred for further assessment and testing (Assessment Centre, Telehealth Ontario at 1-866-797-0000, or their primary care provider, Self-Assessment Tool) and should not be permitted to accompany or visit the patient/client pending test results.

  • Before each appointment, wash your hands with soap and water or use an alcohol- based hand sanitizer.
  • Before every patient/client interaction, occupational therapists must carry out A Point of Care Risk Assessment to determine whether there is a risk to the provider or other individuals of being exposed to an infection, including COVID-19.
  • Require patients/clients to wash their hands or to use an alcohol-based sanitizer before and after the appointment.
Personal Protective Equipment (PPE) (Revised in Version 3)

  • Recommendations regarding use of PPE in the practice environment should follow the directives, recommendations and guidance provided by the Chief Medical Officer of Health, the Ministry of Health, and Public Health Ontario.
  • Occupational therapists providing healthcare services during the COVID-19 pandemic must familiarize themselves with the Recommendations from Ontario Health on the Use and Conservation of PPE. The government expects appropriate stewardship of PPE to reduce negative impacts on other parts of the health system, with the conservation of PPE occurring through the application of the hierarchy of controls.
  • During this pandemic, in the absence of a specific government PPE recommendation applying to the type of patient/client interaction or the occupational therapist’s practice setting or environment, occupational therapists must assess what the appropriate level of PPE is. At a minimum, occupational therapists must follow the required precautions respecting PPE as set out in the Operational Requirements and ideally will wear a surgical/procedural masks for the full duration of their working day, including throughout all patient/client interactions. OTs should change their masks in between clients, and always if a mask becomes wet or soiled. Occupational therapists should also require their patients/clients to wear a face covering/non-medical mask throughout the service delivery, where available and tolerated. 
  • Determining the appropriate level of PPE should be based on the assessment of risk. Public Health Ontario has a risk assessment tool to help you determine if you should and what type of PPE to use.
  • Occupational therapists must ensure that they and their patients/clients understand the safe use, care and limitations of PPE, including putting on and taking off PPE and proper disposal. Examples of factors to consider include:
    • Ensure that gloves have no pinholes or tears and fit securely around their hands.
    • Gloves should be removed first, and hand hygiene should be performed immediately after removing gloves. The mask should then be removed, and hand hygiene performed again.
  • Occupational therapists must familiarize themselves with Public Health Ontario’s specific PPE recommendations which have been issued for interacting with suspected or confirmed COVID-19 patients and for performing aerosol-generating medical procedures (AGMP).
  • If the appropriate PPE is not available, in-person patient services must be deferred.
  • Occupational Therapists should familiarize themselves with the guidance prepared by the Government of Canada to help organizations and healthcare professionals determine appropriate PPE for providing services to people with disabilities.
  • The Ministry of Health is recommending that healthcare professionals and their employers source PPE through their regular supply chain. PPE allocations from the provincial stockpile will continue. PPE can also be accessed, within the available supply, on an emergency basis through the established escalation process through the Ontario Health Regions. The Ontario government has also developed a Workplace PPE Supplier Directory to help businesses secure PPE and other supplies
After the appointment

  • After each appointment, wash your hands or use an alcohol-based sanitizer.
  • After every patient/client interaction, patient/client contact surfaces (i.e., areas within 2 metres of the patient/client) should be cleaned and disinfected as soon as possible, and before another patient/client is seen. In occupational therapy practice, this includes taking measures to ensure that equipment, including supplies and devices, used in the delivery of services are cleaned, disinfected, and maintained appropriately.
Self-Monitoring

  • All occupational therapists should monitor themselves for signs of illness.
  • If you are sick, stay home.
  • If you have symptoms, think you were exposed to COVID-19, or have returned from travel outside of Canada or from a COVID-19 affected area within or outside of Ontario within the last 14 days, do not go to work, notify your supervisor immediately, and contact Telehealth Ontario at 1-866-797-0000 or your primary care provider for further clinical assessment.
  • If you start experiencing symptoms while you are at work, if not already wearing one, immediately put on a surgical/procedural mask, self-isolate (remove yourself from providing care), and inform your supervisor or Occupational Health and Safety Department.
  • If you are deemed critical to your organization’s operations, you may continue to work if you self-monitor for symptoms and meet specific precautions even if you returned from travel outside of Canada or from a COVID-19 affected area within the last 14 days and/or have a confirmed unprotected exposure to a person with COVID-19. Refer to and follow Public Health Ontario’s How to Self-isolate while working fact sheet and the Ministry of Health’s Quick Reference Sheet Public Health Guidance on Testing and Clearance.
Additional resources