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South West IPAC Hub Monthly E-Newsletter

February 2022

Infection Prevention and Control Self-Assessment Tool
The self-assessment audit tool is designed for facilities to assess their current infection prevention and control practices.   Facilities should complete this tool for ongoing implementation of best practices and to facilitate quality improvement activities when gaps are identified.  This will help to decrease the spread of infectious diseases between visitors, residents, and staff.  Recognizing existing strengths and achievements can also build confidence within the facility.
For Long Term Care and Retirement Homes:
According to directive 3, the IPAC self-audits should be completed, at minimum every two weeks when the home is not in an outbreak and at minimum once a week when the home is in an outbreak. Homes must follow current Ministry of Health’s COVID-19 Guidance: Long-Term Care Homes and Retirement Homes for Public Health Units for detailed requirements and information regarding IPAC audits.
For Other Congregate Living Organizations:
This self-audit tool provides a point-in-time assessment. It is recommended that facilities complete regular evaluation of their infection control practices based on organization's policy and needs.  The score achieved from the assessment will determine audit frequency.  Facilities should consider using the self-audit tool when there are changes to staffing or after an outbreak.
  1. Public Health Ontario- Heating, Ventilation and Air Conditioning (HVAC) Systems in Buildings and COVID-19
  2. Public Health Ontario- Use of Portable Air Cleaners and Transmission of COVID-19
  3. Government of Canada- At home: Using ventilation and filtration to reduce the risk of aerosol transmission of COVID-19
  4. Government of Canada-Using Ventilation and filtration to reduce aerosol transmission of COVID-19 in long-term care homes
  5. Ontario Health West- Infection Prevention and Control (IPAC) Hub Congregate Living Organizations Webinar: The Importance of Ventilation and Filtration As an IPAC Measure
  6. Peterborough Public Health- At Home Ventilation, Air Filtration, and COVID-19
  7. Toronto Public Health- Long Term Care Home and Retirement Home COVID-19 Question and Answer (Q&A)
What, How and When

PPE assists in the prevention and control of COVID-19 infections. Remember: PPE is most effective when it is worn consistently and correctly.

A Personal Risk Assessment should always be conducted prior to choosing PPE and before interacting with a resident or client and/or their environment. A Personal Risk Assessment is a thought process conducted by health care providers to determine which interventions are required to help prevent the transmission of disease. Ask Yourself: What is the nature, type, and duration of the task I will be doing?

Appropriate PPE for staff is based on the task you will be doing. Below is a brief summary of PPE use as outlined in the COVID-19 Guidance: Congregate Living for Vulnerable Populations. Always check and follow your organization’s PPE policy and procedures.

  • Staff should always practice universal masking while indoors and outdoors – Surgical/medical masks are strongly recommended.
  • Surgical/medical mask required when providing direct care to and/or when coming within 2m distance of a person that is unmasked. A well-fitted surgical/medical mask is also required when providing direct care to and/or when coming within 2m distance of a person who is on droplet and contact precautions.
  • Masks may be removed when staff are eating (while maintaining 2m distance) or when working in a private room/office.
  • Required when providing direct care to and/or when coming within 2m distance of a person that is unmasked. Eye protection is not required if person is separated by a barrier from the unmasked person.
  • Eye protection is also required when providing direct care to and/or when coming within 2m distance of a person who is on droplet and contact precautions.
  • Required when providing direct care to and/or when coming within 2m distance of a person who is on droplet and contact precautions.
  • Required when preforming any aerosol-generating medical procedures (AGMP).
*Direct Care may include but is not limited to: helping with feeding, bathing, washing, turning, changing clothing, toileting and wound care.
  • Visitors must wear a mask at all times while indoors (with limited exceptions).
  • Strongly encourage visitors to wear a mask while outdoors if interacting with residents, especially if resident is immunocompromised and/or at high risk of severe disease from COVID-19, the COVID-19 vaccination status of the individuals present are unknown, or known to be unvaccinated or partially vaccinated.
  • Surgical/Procedural mask is preferred.
  • Residents/clients must wear a three-layer mask in any common area if physical distancing cannot be maintained. If residents are considered to be equivalent to a household, they are not required to wear a mask in common areas.
  • Residents/clients on droplet and contact precautions should wear a surgical/procedural mask during direct care (if tolerated).
  • Residents/clients should be encouraged to wear a three layer mask when in public settings, if tolerated.
  • Masks should NOT be worn by anyone who cannot take the mask off without help, who have trouble breathing, or children under 2 years of age
Choosing the Right Eye Protection for Staff
Rating Type of Eye Protection Considerations

Goggles with a snug fit around the eyes that cover the front and sides provide the most reliable eye protection from splashes, sprays, and respiratory droplets. There must also be a barrier at the top that extends towards the face, leaving no gaps between the goggles and the face.

Face Shield
Face shields must cover the front and sides of the face to reduce the possibility of splashes, sprays, and respiratory droplets from going around the face shield. The face shield should have a foam barrier on the top between your face and the shield.
Safety Glasses that cover the top and around the edges, eliminating all gaps

Only safety glasses that have a cover over the top and around the edges, eliminating all gaps, are considered appropriate for infection control purposes. Safety glasses without covers on the top and around the edges will NOT reduce the risk of exposure to respiratory droplets. Regular safety glasses allow gaps around your eyes between the glasses and your face. These are NOT appropriate for infection control. These are NOT recommended for close contact, especially if the client is unmasked.
Not Acceptable Prescription glasses/ sunglasses Prescription glass/ sunglasses are NOT an accepted form of eye protection as they may not fully cover the eye area and do not provide coverage from the side and/or top.
If you wear prescription glasses, wear a face shield or goggles that fit snuggly over the prescription glasses.


Additional guidance on eye protection:
• Eye protection may not be one brand fits all. What protects one person, might not fit the same for others. Ensure your eyes are fully protected when choosing your eye protection.
• Make sure that the eye protection fits properly and does not interfere with the proper fit of the worker’s mask.
• Eye protection should be replaced when soiled or damaged.
•Reusable eye protection must be cleaned and disinfected between uses.
How to Order Emergency and Critical PPE Supplies and Equipment
The CDC has a helpful tool called the
PPE Burn Rate Calculator. This tool can be used to help estimate the amount of PPE your facility might need to order.   

Ontario Health West has two options available for congregate living settings (Exception: MCCSS-funded and licensed settings have an independent PPE distribution process) looking to order PPE for their facility. Choose the option that best describes your situation, click on the form, complete the form with the applicable information and submit. Please be advised that the turn around time for the request may take up to 14 days. Below is an overview of the available options:

Option 1:
Emergency Allocations: All Health Care System Providers can receive up to 5 days of select PPE products, pending availability when faced with an emergency shortage (i.e. providers with 14 days or less of product on hand).  If in outbreak, may receive up to 14 days of selected product. This supply should only be used when there is an unexpected shortage of products and where the normal supply chain cannot accommodate.

Option 2:
Pandemic PPE Transitional Support (PPTS): For in-scope providers, the province has temporarily removed the requirement that certain providers source their own PPE first on the commercial market, before accessing the provincial pandemic stockpile. Providers in the applicable sectors can access PPE directly from the provincial pandemic stockpile, at no-cost through Ontario Health West. 

Reminder: It is imperative for health care partners to accurately and timely report into the Critical Supplies and Equipment (CSE) virtual inventory, as directed by the Minister’s Order for the health sector. This information is used by the province to inform and support its pandemic response, and is required for providers to access PPE from the provincial pandemic stockpile. 

PPE is ordered through the Ontario Association of Children’s Aid Societies (OACAS) Shared Services 
Details for ordering from this ministry can be found here.
Below is an overview of the PPE offered and how to secure your supply.
Core PPE (surgical/procedural masks, face shields, hand sanitizer, gloves, disinfectant wipes, and isolation gowns) use is tracked via the Critical Supplies and Equipment (CSE) survey portal. This transparency allows MCCSS to see when PPE supply is low (less than 14 day supply) and will trigger an automatic 14 day top-up shipment within 1 week of reporting.

Niche PPE (eye goggles, larger-sized gowns, thermometers) are also ordered through the OACAS Shared Services portal. Use of Core PPE over Niche PPE is advised when possible. 

N95 Respirators: If need is determined, inventory and consumption of N95 respirators should be reported through the CSE portal.
Note: orders for N95 Respirators must be placed through the MCCSS web portal link
  1. COVID-19 Guidance: Congregate Living for Vulnerable Populations
  2. Public Health Ontario - IPAC Personal Risk Assessment
  3.  Southwestern Public Health – Eye Protection Guidance
  4. Healthcare Materials Management Services – PPE Order Forms
  5. Covid-19 Guidance for MCCSS-funded and Licensed Congregate Living Settings | Ministry of Children, Community and Social Services (

Contact your Core IPAC Hub 


Or contact your local satellite IPAC hub at:

Middlesex London Health Unit:

Southwestern Public Health:

Huron Perth and Area Ontario Health Team:

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