Note: This is a reproduction of the CFNU Position Statement on COVID-19, which was updated and published in PDF form on March 23, 2020.
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
New evidence and information on COVID-19 is emerging daily, and CFNU’s recommendations remain based on emerging science and Occupational Health and Safety principles, including the precautionary principle; in particular, as it applies to nurses using their professional clinical judgment1 when performing a point-of-care risk assessment2. As well, the occupational health and safety principle of the hierarchy of controls applies. It starts with eliminating the hazard when possible. When that cannot be accomplished, a combination of engineering and administrative controls, combined with personal protective equipment, must be applied. The system is called a hierarchy because you must apply each level in the order that they fall in the list; a systematic comprehensive approach must be taken to reducing hazards; a hierarchy of controls cannot be applied in a piecemeal fashion.
1 Professional judgement: knowledge, skills, reasoning and education.
2 Point-of-care risk assessment: a risk assessment undertaken by the HCW prior to any interaction with the patient to determine the risk based on, for example, the client symptoms, the specific task, or the environment and the related potential for exposure, in order to determine the appropriate personal protective equipment (PPE) to protect themselves and their patients, and prevent and control the spread of infectious viruses in acute care, long-term care and the community.
Examples of engineering controls:
plexiglas barriers; negative pressure rooms; private rooms with private toilet and patient sink; HEPA filters; an appropriate supply of and accessibility to PPE; designated hand washing sinks for HCW use.
Examples of administrative controls:
training on the employer’s pandemic plan; active screening protocols; respiratory protection program; enhanced environmental cleaning; application of precautions (droplet, contact, airborne); safe patient transportation policies; training, testing and drilling; education, surveillance and auditing practices; visitor restriction policies; policies on PPE; policies on supply of PPE.
As promised, our Network of Occupational Health & Safety (OH&S) experts have reviewed and revised CFNU’s position on COVID-19 as of March 23, 2020, in light of the declaration of a pandemic by the World Health Organization and the spread of the virus throughout Canada.
It is the position of the Canadian Federation of Nurses Unions (CFNU) that, in the event of an outbreak of any new respiratory virus, we acknowledge that the best respiratory protection for health care workers at risk is a fit-tested N95 or greater respirator (e.g., powered air-purifying respirator (PAPR), given emerging science and the precautionary principle.
Given the amount of uncertainty around COVID-19 and the current threat to health care workers across Canada, the Canadian Federation of Nurses Unions (CFNU) recognizes the critical importance of the point-of-care risk assessment (PCRA), an activity that is based on the individual nurses’ professional judgment (i.e., knowledge, skills, reasoning and education). Underlying the PCRA is the principle that individual health care workers are best positioned to determine the appropriate personal protective equipment (PPE) required based on the situation and their interactions with an individual patient. They do so by evaluating the likelihood of exposure to themselves or others based on a specific task, environment, conditions, interaction or patient. Among the factors that should be considered in the PCRA are: the potential for contamination of skin or clothing; exposure to blood, body fluids or respiratory secretions; the potential for inhaling contaminated air; the patient’s ability or willingness to comply with infection control practices (e.g., wearing a mask); whether care requires very close contact; what engineering and administration controls are in place; and whether the patient could require an aerosol-generating medical procedure at any point and/or is in an aerosol-generating hot spot” (e.g.: intensive care units, emergency rooms, operating rooms, post-anesthetic care units and trauma centres) that are managing COVID-19 patients. Personal protective equipment should be selected based on the potential for exposure in order to minimize the risk of exposure to HCWs, a specific patient or other patients in the environment.
For those workers involved in triage and screening and testing for COVID-19, ideally a floor‑to‑ceiling plexiglas barrier with speaker phone would eliminate worker exposure to the hazard if there was no further direct contact with a patient required. However, if the barrier is not in place and direct contact is required, other administrative and engineering controls such as disposable equipment, signage procedures, training, separate examination rooms and waiting area should be in place before direct contact with the patient, and workers must be equipped with the PPE described above, trained and drilled in its use. Patients should be provided with surgical masks as a source control to be donned before entering the health care environment. Further, it is evident that for the direct care/treatment of presumed and confirmed cases, engineering controls are insufficient to prevent exposure.
For those engaged in taking a nasopharyngeal swab for obtaining specimens for testing from patients with known or suspected cases of COVID-19: HCWs must perform a PCRA to determine the level of risk. Some factors to consider are the patient’s respiratory secretions, the frequency and severity of coughing, any breathing difficulties and whether there is a fever. If the PCRA indicates the need for respiratory protection, a fit-tested N95 respirator as a minimum must be worn.
A recent legal opinion posted by a leading Canadian law firm Osler, Hoskins & Harcourt LLP recommends employers “benchmark to current best practices” and follow “appropriate precautionary measures”:
“Where there is conflicting evidence as to whether a certain precautionary measure is required or not, hospitals should adopt the elevated precautionary measure(s). Hospitals should be cognizant that it will be the hospital that will be legally liable for any failures to protect patients and staff from harm, even if hospitals have relied on federal, provincial or municipal government directives in establishing its own plans, policies and procedures.”
This legal opinion makes it clear that health care employers must respect nurses’ professional judgement as expressed through the PCRA to determine when and where to use PPEs and to determine under what circumstances the level of PPE needs to be increased. The CFNU is clear that the clinical judgement of our members – as expressed through the PCRA – should prevail.
Employers’ responsibilities are clearly laid out in provincial OH&S law: employers must work with joint OH&S committees on their pandemic plans, protocols and measures; provide training, testing and drilling for all employees on health and safety measures; establish a respiratory protection plan and provide fit-testing for N95 respirators to all employees who may need them as based on their areas of work or potential work responsibilities; and employers are also responsible for making PPE readily accessible and available to health care teams so they can do their jobs safely.
Several jurisdictions in Canada have established surgical masks as part of the precautions to be used with suspected and actual COVID-19 patients, when not involved in AGMPs. The CFNU rejects the ‘blanket’ rules currently in place which treat the safety of health care workers as an afterthought and fail to respect their professional judgement in undertaking a PCRA.
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, which includes long-term care facilities, nurses and other health care workers could readily become vectors spreading the disease to each other and their patients and families. 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.
If AT ANY TIME you feel that your employer is not following the OH&S laws and principles as outlined above, please contact your union immediately.
The above position draws on international guidance on infection prevention and control in health care settings from the U.S. Centers for Disease Control and Prevention (CDC), the EU European Centre for Disease Prevention and Control (ECDC), and similar guidance in the UK and Australia. For more information, visit CFNU’s website for information on international infection control and prevention guidance, and the current science related to COVID-19, including how it spreads and the efficacy of personal protective equipment.
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.
For workers, we recognize the critical importance of the point-of-care risk assessment and that individual health care workers, using their knowledge, skills, judgement and education, are best positioned to determine the appropriate PPE required based on their interaction with an individual patient in a particular environment.
If you have any questions or concerns, please speak with your union or a member of your Joint Occupational Health & Safety committee.