Table 1.

The McMaster Home Visit PPE Procedure for Patients With Respiratory Illnesses - Revised

Phase 1: PreparingPhase 2: Entering the HomePhase 3: Leaving the HomePhase 4: After the Visit and Reprocessing

  1. Pre-visit screening: All care professionals should self-monitor before the visit using current provincial and employer screening practices.

  2. Conduct a virtual visit or telephone call before going to the home. Do history taking and as much discussion as you can over the telephone or video, so that only a physical exam will take place in the home and whatever discussion is needed as a result of your clinical assessment. Request that a family member or caregiver be in the home to help you exit the home safely afterwards.

  3. Ask the family/caregivers to:

    • Place a garbage bin lined with a garbage bag just inside the entrance of the home/apartment

    • Ensure the patient is wearing a surgical mask when you arrive. The family/caregivers should also put on surgical or cloth masks when you arrive. (Remember to bring extra masks in case they do not have any)

    • If they have hand sanitizer, have the patient do hand hygiene when you arrive

    • Keep pets and children in a separate area, away from the front door where you will set up your workstation and ask them to request that other people not visit while you are there.

    • Try to limit the number of people in the home to the patient and 1 caregiver, if possible, during your visit. Advise them that you will need to maintain physical distancing as much as possible during your visit.

  4. Print 2 copies of the Doffing PPE Cue Sheet (https://fhs.mcmaster.ca/palliativecare/documents/HomeVisitPPEFullProcedurev.12.128July2020.pdf), one for outside the door and one for inside the door.

  5. Bring with you:

    • A container of alcohol-based hand rub (ABHR)a

    • A container of disinfectant wipes (or ziplock bag containing 2–3 disinfectant wipes)

    • A large plastic garbage bag

    • A small plastic bag (for carrying supplies into the home)

    • Two empty pails – one labeled “Clean” and one “Dirty” (a lid for the dirty pail would be ideal)

    • Extra ear-loop masks for patient and caregivers if they do not have any

    • Two copies of the Doffing PPE Cue Sheet.

    • Your PPEb

    • Two to 3 extra sets of gloves in a second ziplock bag

    • Diagnostic equipment you need (eg, stethoscope, oximeter)

  1. Call the house from the driveway and confirm that the family has a mask for the patient and any caregivers in the house. If they do have masks, you do not need to bring spare masks into the home. Ask everyone to don their masks.

  2. Place the empty pails outside the door with lid(s) off, with the “Clean” pail closest to the door so that it can be easily reached from the threshold. Put one of the clean cue sheets on the ground next to the pails, secured so it doesn’t blow away.

  3. Don PPE outside the home.

  4. Enter the home carrying the small plastic bag in which you have placed the disinfectant wipes, the spare gloves, the large plastic garbage bag, the ABHR, the spare mask (if needed) and your diagnostic equipment.

  5. Place the small plastic bag on the floor inside the doorway.

  6. Lay the unopened large garbage bag flat on the floor next to the patient’s garbage bin just inside of the front of the home. This will serve as a clean work surface. Remove from the small plastic bag the disinfectant wipes, the ABHR, the spare gloves, and the second copy of the Doffing PPE Cue Sheet and place these on the clean work surface.

  7. Bring the small plastic bag containing your diagnostic equipment and mask for patient (if needed) to the patient’s room. Ensure the patient is wearing a mask and does hand hygiene with their own ABHR if they have not already done so. Do not offer your own ABHR for this purpose.

  8. Perform physical exam then place the used equipment back in the small plastic bag.

  1. With full PPE still on, bring the small plastic bag with used equipment to the front door. Lay the plastic bag on the floor beside the clean large garbage bag work surface so as not to contaminate the work surface.

  2. Perform hand hygiene on your gloves with the ABHR (remember, you have now contaminated the ABHR container). Alternatively, gloves may be removed and discarded into the patient’s garbage bin, hand hygiene is performed with ABHR, then fresh gloves are donned. The spare sets of gloves may also be useful if a glove is torn in the process.

  3. With a disinfectant wipe, clean your diagnostic equipment and lay the clean equipment on the large garbage bag. If still wet, use the same disinfectant wipe to clean the container of ABHR, the ziplock bag containing the spare gloves, and the inner door handle to the home.

  4. After a minute, repeat step 3 with a fresh wipe.

  5. Touching only the clean door handle, open the door and drop the clean equipment and ABHR into the “clean” pail outside the door. Keep the ABHR accessible as you will need it again.

  6. Discard the small bag that had contained the equipment and the empty ziplock bag that had contained the disinfectant wipes into the patient’s garbage bin.

  7. Doff gown and gloves inside the front door and put in the patient’s garbage bin. Don’t push down.

  8. Exit the house touching only the cleaned door handle, leaving behind the Doffing PPE Cue Sheet on the large flat garbage bag.

  9. Outside of the door, perform hand hygiene with ABHR.

  10. If wearing goggles or face shield with separate mask, remove goggles or face shield by touching only the most posterior parts of the arms, and place in the “Dirty” pail.

  11. Remove mask touching only the back of the ear loops and put it in the “Dirty” pail with the eyewear. If you have a used N95 mask, it may be prudent to save your mask, as techniques for reprocessing N95 masks may be coming. If so, place it in the “Dirty” pail to bring with you for later reprocessing.

  12. Put the outdoor copy of the Doffing PPE Cue Sheet in the “Dirty” pail.

  13. Hand hygiene with ABHR.

  14. Put the lid on the “Dirty” pail. Don’t touch the goggles/face shield or mask.

  15. Pack your car.

  1. At your clinical base, don fresh gloves and eye protection. A face shield is ideal. Consider wearing a washable cloth gown also, in case of a splash.

  2. Remove already-cleaned equipment from the “Clean” pail then disinfectant wipe the pail.

  3. Prepare a solution of 0.1% sodium hypochlorite (1 part household bleach to 49 parts water, eg, 50 ml bleach added to 2,450 ml of water).

  4. With PPE still on, open the “Dirty” pail, remove any masks and cue sheets and place in garbage, making sure you don’t touch the outside of the garbage bin/box with the masks or gloves as these are considered contaminated. Consider placing N95 masks in a paper bag (such as a large leaf bag) for storage and potential future reprocessing.

  5. Put some dish soap and water carefully in the “Dirty” pail so as not to splash.

  6. Wash goggles, rinse with water, then place in 0.1% sodium hypochlorite solution to soak for 10 minutes.

  7. Wash out the pail thoroughly then disinfectant wipe it. Disinfectant wipe the dish soap bottle and your face shield.

  8. Remove gloves and dispose in garbage and remove gown if worn).

  9. Hand hygiene with ABHR.

  • ABHR = alcohol-based hand rub; AGMP = aerosol-generating medical procedures; BIPAP = bilevel positive airway pressure; CPAP = continuous positive airway pressure; DIN = drug identification number; LPM = liters per minute; PPE = personal protective equipment; N95 = respiratory protective device with very close facial fit and very efficient filtration of airborne particles.

  • ↵a ABHR sanitizer must be at least 60% ethanol

  • ↵b PPE in this instance will include an isolation gown, eye protection (goggles, face shield, or a mask with an integrated visor), gloves, and a mask. The previous version of this protocol suggested a medical mask unless AGMPs are being conducted. However, with the growing realization that aerosol transmission of COVID-19 is common, a point-of-care risk assessment must be done, and consideration given to wearing a fit-tested N95 respirator with any patient with a respiratory illness, regardless of vaccination status.

  • Note: We found varying opinions for cleaning of reusable eye protection (goggles and face shields). Some suggest using only disinfectant wipes while others suggest a diluted bleach soak. Health Canada recommends cleaning with soap and water then disinfecting using an approved hard surface disinfectant with a DIN number, or alternatively, a bleach soak. The theoretical advantage of the bleach soak is that it will penetrate the hinges and small parts of the eye protection, and that it conserves disinfectant wipes which may be in short supply. Health Canada states that eyewear may be disinfected (after appropriate cleaning with soap and water) using a 0.1% sodium hypochorite solution soak (20 ml household bleach to 980 ml of water or 1 part bleach added to 49 parts water), which is an approved low-level disinfectant, for 10 minutes. In a previous version of this protocol, we had suggested 0.5% sodium hypochorite (1 part bleach to 9 parts water) which remains an approved high-level disinfectant.