Preventing the transmission of COVID-19 and other coronaviruses in older adults aged 60 years and above living in long-term care: a rapid review

Background The objective of this review was to examine the current guidelines for infection prevention and control (IPAC) of coronavirus disease-19 (COVID-19) or other coronaviruses in adults 60 years or older living in long-term care facilities (LTCF). Methods EMBASE, MEDLINE, Cochrane library, pre-print servers, clinical trial registries, and relevant grey literature sources were searched until July 31, 2020, using database searching and an automated method called Continuous Active Learning® (CAL®). All search results were processed using CAL® to identify the most likely relevant citations that were then screened by a single human reviewer. Full-text screening, data abstraction, and quality appraisal were completed by a single reviewer and verified by a second. Results Nine clinical practice guidelines (CPGs) were included. The most common recommendation in the CPGs was establishing surveillance and monitoring systems followed by mandating the use of PPE; physically distancing or cohorting residents; environmental cleaning and disinfection; promoting hand and respiratory hygiene among residents, staff, and visitors; and providing sick leave compensation for staff. Conclusions Current evidence suggests robust surveillance and monitoring along with support for IPAC initiatives are key to preventing the spread of COVID-19 in LTCF. However, there are significant gaps in the current recommendations especially with regard to the movement of staff between LTCF and their role as possible transmission vectors. Systematic review registration PROSPERO CRD42020181993


INTRODUCTION Purpose and Research Questions
The Infection Prevention & Control of the World Health Organization (WHO) Health Emergency Programme presented a query on preventing and managing COVID-19 in older adults aged 60 years and above living in long-term care facilities including privately paid for and publicly paid for settings with a 5-business day timeline. According to the WHO, "long-term care covers those activities undertaken by others to ensure that people with, or at risk of, a significant ongoing loss of intrinsic capacity can maintain a level of functional ability consistent with their basic rights, fundamental freedoms and human dignity" (https://www.who.int/ageing/long-term-care/WHO-LTC-series-subsaharan-africa.pdf?ua=1). Examples of long-term care include nursing homes, charitable homes, municipal homes, long-term care hospitals, long-term care facilities, skilled nursing facilities, convalescent homes, and assisted living facilities (https://www.canada.ca/en/health-canada/services/home-continuing-care/long-term-facilitiesbased-care.html).
The overall objective of this rapid review of clinical practice guidelines was to identify infection protection and control measures for adults aged 60 years and older in long-term care settings. In order to focus the research question to increase feasibility, we proposed the following key research questions: 1. What are the infection prevention and control practices/measures for preventing or reducing respiratory viruses (including coronavirus and influenza) in older adults aged 60 years and above living in long-term care? 2. How do infection prevention and control practices differ for adults aged 60 years and above living in long-term care with respiratory illness and severe comorbidities or frailty differ than those without such severe comorbidities/frailty? 3. How do infection prevention and control practices differ for adults aged 60 years and above living in long-term care with respiratory illness from low-and middle-income economy countries (LMIC) differ than those living in high-income economy countries and do differences exist across different cultural contexts?

METHODS
The rapid review conduct was guided by the Cochrane Handbook for Systematic Reviews of Interventions 1 along with the Rapid Review Guide for Health Policy and Systems Research 2 . The team used an integrated knowledge translation approach, with consultation from the knowledge users from the WHO at the following stages: question development, interpretation of results, and draft report. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement 3 to guide the reporting of our rapid review results; a PRISMA extension for rapid reviews is currently under development. This rapid review of guidelines was completed in conjunction with a rapid overview of systematic reviews published in a separate report titled: Preventing respiratory illness in older adults aged 60 years and above living in long-term care: A rapid overview of reviews".

Protocol
We prepared a brief protocol for this query that is available in Appendix 1. If publication in a peer-reviewed journal is planned in the future, we will register this rapid review with the Open Science Framework (https://osf.io/).

Literature search
Comprehensive literature searches addressing all research questions were developed by an experienced librarian for MEDLINE, EMBASE, the Cochrane Library, as well as online guideline repositories (e.g., guidelines.ecri.org, joulecma.ca/cpg, www.guidelinecentral.com). The full MEDLINE search strategy can be found in Appendix 2 and the full list of CPG sites searched can be found in Appendix 3. Due to the rapid timelines for this review, a peer review of the literature search was not conducted.

Eligibility criteria
The Eligibility criteria followed the PICOST framework and consisted of: Population: Individuals aged 60 years and above residing in long-term care facilities. The age cut-off for an older adult might be 50 years and above in different LMIC and/or cultural settings. As such, we included these in level 1 screening of titles and abstracts and presented potentially relevant studies in an appendix.
Intervention: Any form of infection control and prevention, such as hand hygiene, respiratory hygiene/etiquette, personal protective equipment (for patients and health care providers), triage (on arrival), source control, isolation, daily monitoring/surveillance for signs and symptoms of respiratory illness (e.g.,  in residence, environmental cleaning, cleaning of linen and medical equipment used by patients, restrictions on resident movement and transportation, restrictions on visitors, restrictions on travel for health care providers and other long-term care facility staff, waste management, dead body management. Only those measures used to prevent and control respiratory illnesses, including influenza and coronavirus (e.g., COVID-19, MERS, SARS) were included. Interventions focused on preventing bacterial respiratory outbreaks (e.g., strep, pneumonia, klebsiella) or aspiration pneumonia were excluded. Interventions specifically focused on vaccination were excluded, as a vaccine for the coronavirus currently does not exist.
Study designs: We limited inclusion to clinical practice guidelines using the Institute of Medicines definition of a guideline (http://www.iom.edu/Reports/2011/Clinical-Practice-Guidelines-We-Can-Trust.aspx).
Time periods: All periods of time and duration of follow-up were eligible.
Other: No other restrictions were imposed.

Study selection
For both level 1 (title/abstract) and level 2 (full-text) screening, a screening form was prepared based on the eligibility criteria and pilot-tested by the review team using 25 citations prior to level 1 screening and 5 full text articles prior to level 2 screening. Agreement between reviewers was sufficiently high (>75%) in both cases so no further pilot-testing was required. Full screening was completed by a single reviewer for both level 1 and level 2 using Synthesi.SR, the team's proprietary online software (https://breakthroughkt.ca/login.php).

Data items and data abstraction
Items for data abstraction included guideline scope, target audience, guideline development methods, recommendations, and level of evidence for reach recommendation. A standardized data abstraction form was developed. Prior to data abstraction, a calibration exercise was completed by 2 team members independently. Following successful completion of the calibration exercise, included guidelines were abstracted by single reviewers.

Quality appraisal
Quality appraisal was carried out using the AGREE-2 tool (https://www.agreetrust.org/resourcecentre/agree-reporting-checklist/) for clinical practice guidelines. The AGREE-2 tool includes 23 items that are categorized according to the following six domains: scope and purpose, stakeholder involvement, rigour of development, clarity of presentation, applicability, and editorial independence.

Synthesis
Included guidelines were synthesized descriptively including summary and detailed tables of guideline characteristics and recommendations. Where available, information on relevant subgroups were highlighted.

Literature Search
The database search returned a total of 3,267 citations, while the grey literature searches returned 32 citations for level 1 screening. A total of 3,183 citations were excluded after level 1 screening. Of the 116 full-text articles screened at level 2, 17 clinical practice guidelines were included ( Figure 1).

Characteristics of included clinical practice guidelines
The 17 clinical practice guidelines were produced by organizations in the United States (n=8), Canada (n=6), Australia (n=2), and the United Kingdom (n=1). The topics covered by the guidelines included influenza (n=6), infection control in long-term care facilities in general (n=2), respiratory illness outbreaks (n=5), pneumonia (n=1), severe acute respiratory syndrome (n=1), and COVID-19 (n=2). Detailed characteristics of the included guidelines can be found in Appendix 4.

Quality Appraisal Results
The 17 clinical practice guidelines were of very low quality (Table 1)
Managing respiratory illness in long-term care facilities: Ten clinical practice guidelines recommended the use of antivirals for prophylaxis of staff and/or residents and one recommended early mobilization of residents ( Table 2, Appendix 6).

DISCUSSION
The WHO commissioned a rapid review to address the urgent question of the infection prevention and control practices/measures for respiratory viruses in long-term care facilities that could be applied to COVID-19. A comprehensive literature search of both electronic databases and grey literature sources resulted 17 included clinical practice guidelines. None of the clinical practice guidelines specifically focused on issues related to residents with respiratory illness and severe comorbidities or frailty. Furthermore, none focused on issues in LMIC or different cultural contexts.
The most commonly recommended prevention strategies across the clinical practice guidelines were hand hygiene, wearing personal protective equipment, social distancing/isolation, disinfecting surfaces, droplet precautions, surveillance and evaluation, conducting diagnostic testing to confirm suspected respiratory illness, policies and procedures for visitors, policies and procedures for staff, and respiratory hygiene/cough etiquette. For managing respiratory illness in long-term care facilities, the majority of the clinical practice guidelines recommended antivirals for prophylaxis of staff and/or residents. However, most of the clinical practice guidelines failed to address multiple AGREE-II items, suggesting that they are most likely based on expert opinion.
There are several limitations to the review methods employed here, single screening and abstraction for example, however they were selected to thoughtfully tailor our methods according to our knowledge user needs and the urgent nature of the request to provide timely results. There is also a chance that our literature search missed guidance documents from various state and provincial authorities. However, we were unable to perform an exhaustive grey literature search of websites, due to the timelines imposed on this review.

CONCLUSIONS
The recommendations from current guidelines overall seem to support environmental measures for infection prevention and antiviral chemoprophylaxis for infection management as the most appropriate first-line response to viral respiratory illness in long-term care. However, these recommendations should be viewed with caution as it is unclear how many of these guidelines are based on the best available evidence due to their poor overall quality. Objective and research questions:

APPENDIX 1 -PROTOCOL
The Infection Prevention & Control of the WHO WHE Programme has presented a query on the transmission of COVID-19 in older adults aged 60 years and above living in long-term care including privately paid for and publicly paid for settings with a 5business day timeline. According to the World Health Organization, "long-term care covers those activities undertaken by others to ensure that people with, or at risk of, a significant ongoing loss of intrinsic capacity can maintain a level of functional ability consistent with their basic rights, fundamental freedoms and human dignity" (https://www.who.int/ageing/long-term-care/WHO-LTC-series-subsaharanafrica.pdf?ua=1) Examples of long-term care will include nursing homes, charitable homes, municipal homes, long-term care hospitals, long-term care facilities, skilled nursing facilities, convalescent homes, and assisted living facilities (https://www.canada.ca/en/health-canada/services/home-continuing-care/long-termfacilities-based-care.html).
The proposed research questions are: 1. What are the infection prevention and control practices/measures for preventing or reducing respiratory viruses (including coronavirus and influenza) in older adults aged 60 years and above living in long-term care? 2. How do infection prevention and control practices differ for adults aged 60 years and above living in long-term care with respiratory illness and severe comorbidities or frailty differ than those without such severe comorbidities/frailty? 3. How do infection prevention and control practices differ for adults aged 60 years and above living in long-term care with respiratory illness from low-and middle-income economy countries (LMIC) differ than those living in high-income economy countries and do differences exist across different cultural contexts?

Research approach:
The research question will be addressed through a rapid review informed by the methods proposed by the WHO Guide to rapid reviews (https://www.who.int/alliancehpsr/resources/publications/rapid-review-guide/en/).

Protocol
Due to the urgent nature of the request and limited time frame to complete the work, this document will serve as the protocol for this query. If publication in a peer-reviewed journal is planned in the future, we will register this rapid review with the Open Science Framework (https://osf.io/).

Literature search
Comprehensive literature searches will be developed by an experienced librarian for MEDLINE, EMBASE, the Cochrane Library, biorxiv.org/medrxiv.org, and GIDEON (Global Infectious Diseases and Epidemiology Network). Grey (i.e., difficult to locate or unpublished) literature will be searched via clinicaltrials.gov. Due to the rapid timelines for this review a peer review of the literature search will not be conducted.

Eligibility criteria
The Eligibility criteria will follow the PICOST framework and will consist of: Population: Individuals aged 60 years and above residing in long-term care facilities. The age cut-off for an older adult might be 50 years and above in some LMIC and/or cultural settings. As such, we will include these in level 1 screening of titles and abstracts and include anything deemed relevant at level 2 screening of full-text articles in an appendix.
Interventions: Any form of infection control and prevention, such as hand hygiene, respiratory hygiene/etiquette, personal protective equipment (for patients and health care providers), triage (on arrival), source control, isolation, daily monitoring/surveillance for signs and symptoms of respiratory illness (e.g., COVID-19) in residence, environmental cleaning, cleaning of linen and medical equipment used by patients, restrictions on resident movement and transportation, restrictions on visitors, restrictions on travel for health care providers and other long-term care facility staff, waste management, dead body management. Only those measures used to prevent and control respiratory illnesses, including influenza and coronavirus (e.g., COVID-19, MERS, SARS) will be included. Interventions focused on preventing bacterial respiratory outbreaks (e.g., strep, pneumonia, klebsiella) will be excluded.
Comparator: One of the interventions listed above or no intervention Outcomes: Lab-confirmed respiratory illness due to the virus (e.g., SARS, MERS, COVID-19, influenza) [primary outcome], secondary bacterial infection, symptoms, secondary transmission (e.g., other patients, healthcare workers, visitors), goal concordant care, hospitalization, intensive-care unit (ICU) admission, mortality Study designs: Due to the rapid nature of this request, we will limit inclusion to clinical practice guidelines and systematic reviews, using the Cochrane definition of a systematic review. If there is scant evidence from these study designs, we will expand inclusion to include the following study designs: o Randomized controlled trials (RCTs) o NRCTs (e.g., such as quasi-RCTs, non-randomized trials, interrupted time series, controlled before after), o Observational studies (e.g., cohort, case control, cross-sectional) o Case studies, case reports, and case series, including outbreak reports Time periods: All periods of time and duration of follow-up will be included.
Other limitations: No other limitations will be imposed. If possible, we will translate studies written in languages other than English (e.g., Mandarin, Cantonese) that are deemed relevant.

Study selection process
In order to meet the requested timeline of 5 working days a streamlined approach to study selection will be employed. A screening form based on the eligibility criteria will be prepared and a brief calibration exercise will be conducted prior to citation and full-text screening. Screening will be completed by single reviewers using Synthesi.SR, the team's proprietary online software (https://breakthroughkt.ca/login.php).

Data items and data abstraction process
Items for data abstraction will include study characteristics (e.g., duration of follow-up, study design, country of conduct, multi-center vs. single site, long-term care setting characteristics, such as availability of medical support, characteristics of care staff, family/community engagement, accommodation characteristics, collective practices), patient characteristics (e.g., mean age, age range, co-morbidities), intervention details (e.g., type of intervention, duration and frequency of intervention, timing of intervention), comparator details (e.g., comparator intervention, duration and frequency of intervention, timing of intervention), and outcome results (e.g., lab-confirmed viral respiratory infection, symptoms, secondary transmission, hospitalization, ICU admission, mortality) at the longest duration of follow-up. For the clinical practice guidelines, we will abstract the recommendations and level of evidence for reach recommendation.
Prior to data abstraction, we will complete a calibration exercise of the form amongst all reviewers using a random sample of 2 included articles. Following calibration, included studies will be abstracted by single reviewers.

Synthesis
The synthesis will involve providing a descriptive summary of included studies with summary tables and detailed tables of study results. Tables of study results will be organized according to interventions of interest and reported outcomes and where available, information on relevant subgroups will be presented separately.

Preliminary knowledge translation plan:
The summary of results will be sent to the WHO and other relevant policy-makers as a brief summary report (1-5 pages) and 1-page policy brief (see http://www.cihrirsc.gc.ca/e/documents/dsen-abstract-en.pdf for an example). We will work with the WHO team to consider submitting this paper to an open-access, peer-reviewed journal for publication (e.g. British Medical Journal).

Timeline (from the point of official approval):
Five business days (March 16, 2020)

Updates provided to the WHO:
Daily emails will be sent to the WHO

Funding:
Funding will be obtained from the WHO

APPENDIX 2 -MEDLINE SEARCH STRATEGY
1 respiratory tract infections/ or exp bronchitis/ or exp common cold/ or exp influenza, human/ or laryngitis/ or exp pharyngitis/ or exp pleurisy/ or exp pneumonia/ or exp rhinitis/ or exp rhinoscleroma/ or exp severe acute respiratory syndrome/ or exp sinusitis/ or exp supraglottitis/ or exp tracheitis/ or exp whooping cough/ 2 coronaviridae infections/ or coronavirus infections/ or SARS Virus/ 3 (coronavirus* or "corona virus*" or mers or "middle east respiratory syndrome*" or "Severe Acute Respiratory Syndrome*" or SARS or CoV or SARS-CoV or MERS-CoV or 2019-nCoV or COVID-19 or "2019 novel coronavirus disease" or "2019 ncov disease" or "2019 ncov infection" or "coronavirus disease 19" or "severe acute respiratory syndrome coronavirus 2" or "severe acute respiratory syndrome coronavirus 2" or "wuhan" or "sars cov 2").tw,kf. 4 (flu or influenza or "respiratory tract infection*" or "respiratory infection*" or bronchitis or "common cold" or laryngitis or pharyngitis or pneumonia or rhinitis or rhinoscleroma or sinusitis or supraglottitis or tracheitis or "whooping cough").tw,kf. 5 or/1-4 6 pc.fs. 7 exp Infection Control/ or secondary prevention/ 8 exp hand hygiene/ or hygiene/ 9 (prevent* or "respiratory hygiene" or "respiratory etiquette " or "cough etiquette" or "Hand Hygiene" or "hand wash*" or "handwash*" or "patient isolation" or "quarant*" or "infection control" or "blood safety" or steril* or disinfect* or "contract tracing" or "disease notification" or fumigat* or "personal protective equipment" or triage or "source control" or isolation or "daily monitoring" or surveillance or "waste management" or cadaver or body or corpse or "face mask*" or facemask* or "social distanc*" or housekeeping).tw,kw. 10 (clean* adj3 (linen or equipment or environment)).tw,kf. 11 (restrict* adj3 (resident* or patient* or visit* or family or travel* or staff or provider* or employee*)).tw,kf. 12 personal protective equipment/ 13 Housekeeping, Hospital/ 14 Waste Management/ 15 patient isolation/ 16 triage/ 17 Cadaver/ 18 or/6-17 19 5 and 18 20 Long-Term Care/ or exp Nursing Homes/ or Homes for the Aged/ or Assisted Living Facilities/ 21 ("long-term care" or "long term care" or "senior* home*" or "senior* residence*" or "nursing home*" or "old age home*" or "old age residence*" or "home* for the aged" Although not regulatory in scope, these guidelines support infection prevention and control (IP&C) professionals, health care organizations and health care providers in developing, implementing and evaluating IP&C policies, procedures and programs to improve the quality and safety of health care and patient outcomes. They may also assist in standardizing IP&C practices throughout the province. Regional health authorities (RHAs) and provincial health services organizations (PHSOs) are expected to develop regional policies and procedures based on these guidelines. ☒Recommendations in a summarized box, typed in bold, underlined, or presented as flow charts or algorithms ☐Specific recommendations grouped together in one section

FACILITATORS AND BARRIERS TO APPLICATION
Describe the facilitators and barriers to the guideline's application.
☐Types of facilitators and barriers that were considered ☐Methods by which information regarding the facilitators and barriers to implementing recommendations were sought (e.g., feedback from key stakeholders, pilot testing of guidelines before widespread implementation) ☐Information/description of the types of facilitators and barriers that emerged from the inquiry (e.g., practitioners have the skills to deliver the recommended care, sufficient equipment is not available to ensure all eligible members of the population receive mammography) ☐How the information influenced the guideline development process and/or formation of the recommendations 19. IMPLEMENTATION ADVICE/TOOLS Provide advice and/or tools on how the recommendations can be applied in practice.
☐Additional materials to support the implementation of the guideline in practice.
For example: • Guideline summary documents ☐Types of cost information that were considered (e.g., economic evaluations, drug acquisition costs) ☐Methods by which the cost information was sought (e.g., a health economist was part of the guideline development panel, use of health technology assessments for specific drugs, etc.) ☐Information/description of the cost information that emerged from the inquiry (e.g., specific drug acquisition costs per treatment course)

CONSIDERATION OF BENEFITS AND HARMS
Report the health benefits, side effects, and risks that were considered when formulating the recommendations.
☐Supporting data and report of benefits ☐Supporting data and report of harms/side effects/risks ☐Reporting of the balance/trade-off between benefits and harms/side effects/risks ☐Recommendations reflect considerations of both benefits and harms/side effects/risks

LINK BETWEEN RECOMMENDATIONS AND EVIDENCE
Describe the explicit link between the recommendations and the evidence on which they are based.
☐How the guideline development group linked and used the evidence to inform recommendations ☐Link between each recommendation and key evidence (text description and/or reference list) ☐Link between recommendations and evidence summaries and/or evidence tables in the results section of the guideline 13. EXTERNAL REVIEW Report the methodology used to conduct the external review.
☐Purpose and intent of the external review (e.g., to improve quality, gather feedback on draft recommendations, assess applicability and feasibility, disseminate evidence) ☐Methods taken to undertake the external review (e.g., rating scale, open-ended questions) ☐Description of the external reviewers (e.g., number, type of reviewers, affiliations) ☐Outcomes/information gathered from the external review (e.g., summary of key findings) ☐How the information gathered was used to inform the guideline development process and/or formation of the recommendations (e.g., guideline panel considered results of review in forming final recommendations)

UPDATING PROCEDURE
Describe the procedure for updating the guideline.
☐A statement that the guideline will be updated ☐Explicit time interval or explicit criteria to guide decisions about when an update will occur ☐Methodology for the updating procedure ☐Types of facilitators and barriers that were considered ☐Methods by which information regarding the facilitators and barriers to implementing recommendations were sought (e.g., feedback from key stakeholders, pilot testing of guidelines before widespread implementation) ☐Information/description of the types of facilitators and barriers that emerged from the inquiry (e.g., practitioners have the skills to deliver the recommended care, sufficient equipment is not available to ensure all eligible members of the population receive mammography) ☐Types of cost information that were considered (e.g., economic evaluations, drug acquisition costs) ☐Methods by which the cost information was sought (e.g., a health economist was part of the guideline development panel, use of health technology assessments for specific drugs, etc.) ☐Information/description of the cost information that emerged from the inquiry (e.g., specific drug acquisition costs per treatment course) ☐How the information gathered was used to inform the guideline development process and/or formation of the recommendations 52 21. MONITORING/ AUDITING CRITERIA Provide monitoring and/or auditing criteria to measure the application of guideline recommendations.
☐Criteria to assess guideline implementation or adherence to recommendations ☐Criteria for assessing impact of implementing the recommendations ☐Advice on the frequency and interval of measurement ☐Operational definitions of how the criteria should be measured

CONSIDERATION OF BENEFITS AND HARMS
Report the health benefits, side effects, and risks that ☐Supporting data and report of benefits 57 were considered when formulating the recommendations.
☐Supporting data and report of harms/side effects/risks ☐Reporting of the balance/trade-off between benefits and harms/side effects/risks ☐Recommendations reflect considerations of both benefits and harms/side effects/risks

LINK BETWEEN RECOMMENDATIONS AND EVIDENCE
Describe the explicit link between the recommendations and the evidence on which they are based.
☐How the guideline development group linked and used the evidence to inform recommendations ☐Link between each recommendation and key evidence (text description and/or reference list) ☐Link between recommendations and evidence summaries and/or evidence tables in the results section of the guideline 13. EXTERNAL REVIEW Report the methodology used to conduct the external review.
☐Purpose and intent of the external review (e.g., to improve quality, gather feedback on draft recommendations, assess applicability and feasibility, disseminate evidence) ☐Methods taken to undertake the external review (e.g., rating scale, open-ended questions) ☐Description of the external reviewers (e.g., number, type of reviewers, affiliations) ☐Outcomes/information gathered from the external review (e.g., summary of key findings) ☐How the information gathered was used to inform the guideline development process and/or formation of the recommendations (e.g., guideline panel considered results of review in forming final recommendations)

UPDATING PROCEDURE
Describe the procedure for updating the guideline.
☐A statement that the guideline will be updated ☐Explicit time interval or explicit criteria to guide decisions about when an update will occur ☐Methodology for the updating procedure

FACILITATORS AND BARRIERS TO APPLICATION
Describe the facilitators and barriers to the guideline's application.
☐Types of facilitators and barriers that were considered ☐Methods by which information regarding the facilitators and barriers to implementing recommendations were sought (e.g., feedback from key stakeholders, pilot testing of guidelines before widespread implementation) ☐Information/description of the types of facilitators and barriers that emerged from the inquiry (e.g., practitioners have the skills to deliver the recommended care, sufficient equipment is not available to ensure all eligible members of the population receive mammography) ☐How the information influenced the guideline development process and/or formation of the recommendations

IMPLEMENTATION ADVICE/TOOLS
Provide advice and/or tools on how the recommendations can be applied in practice.
☒Additional materials to support the implementation of the guideline in practice. ☐Types of cost information that were considered (e.g., economic evaluations, drug acquisition costs) ☐Methods by which the cost information was sought (e.g., a health economist was part of the guideline development panel, use of health technology assessments for specific drugs, etc.) ☐Information/description of the cost information that emerged from the inquiry (e.g., specific drug acquisition costs per treatment course) ☐How the information gathered was used to inform the guideline development process and/or formation of the recommendations 21. MONITORING/ AUDITING CRITERIA ☐Criteria to assess guideline implementation or adherence to Appendices Provide monitoring and/or auditing criteria to measure the application of guideline recommendations.
recommendations ☒Criteria for assessing impact of implementing the recommendations ☒Advice on the frequency and interval of measurement ☐Operational definitions of how the criteria should be measured ☐Supporting data and report of harms/side effects/risks ☐Reporting of the balance/trade-off between benefits and harms/side effects/risks ☐Recommendations reflect considerations of both benefits and harms/side effects/risks

LINK BETWEEN RECOMMENDATIONS AND EVIDENCE
Describe the explicit link between the recommendations and the evidence on which they are based.
☐How the guideline development group linked and used the evidence to inform recommendations ☐Link between each recommendation and key evidence (text description and/or reference list) ☐Link between recommendations and evidence summaries and/or evidence tables in the results section of the guideline 13. EXTERNAL REVIEW Report the methodology used to conduct the external review.
☐Purpose and intent of the external review (e.g., to improve quality, gather feedback on draft recommendations, assess applicability and feasibility, disseminate evidence) ☐Methods taken to undertake the external review (e.g., rating scale, open-ended questions) ☐Description of the external reviewers (e.g., number, type of reviewers, affiliations) ☐Outcomes/information gathered from the external review (e.g., summary of key findings) ☐How the information gathered was used to inform the guideline development process and/or formation of the recommendations (e.g., guideline panel considered results of review in forming final recommendations)

UPDATING PROCEDURE
Describe the procedure for updating the guideline.
☐A statement that the guideline will be updated ☐Explicit time interval or explicit criteria to guide decisions about when an update will occur ☐Methodology for the updating procedure

SPECIFIC AND UNAMBIGUOUS RECOMMENDATIONS
Describe which options are appropriate in which situations and in which population groups, as informed by the body of evidence.
☒A statement of the recommended action Intent or purpose of the recommended action (e.g., to improve quality of life, to decrease side effects) ☐Relevant population (e.g., patients, public) ☐Caveats or qualifying statements, if relevant (e.g., patients or conditions for whom the recommendations would not apply) ☐If there is uncertainty about the best care option(s), the uncertainty should be stated in the guideline ☒Recommendations in a summarized box, typed in bold, underlined, or presented as flow charts or algorithms ☐Specific recommendations grouped together in one section

FACILITATORS AND BARRIERS TO APPLICATION
Describe the facilitators and barriers to the guideline's application.
☐Types of facilitators and barriers that were considered ☐Methods by which information regarding the facilitators and barriers to implementing recommendations were sought (e.g., feedback from key stakeholders, pilot testing of guidelines before widespread implementation) ☐Information/description of the types of facilitators and barriers that emerged from the inquiry (e.g., practitioners have the skills to deliver the recommended care, sufficient equipment is not available to ensure all eligible members of the population receive mammography) ☐How the information influenced the guideline development process and/or formation of the recommendations

IMPLEMENTATION ADVICE/TOOLS
Provide advice and/or tools on how the recommendations can be applied in practice.
☒Additional materials to support the implementation of the guideline in practice. ☐Types of cost information that were considered (e.g., economic evaluations, drug acquisition costs) ☐Methods by which the cost information was sought (e.g., a health economist was part of the guideline development panel, use of health technology assessments for specific drugs, etc.) ☐Information/description of the cost information that emerged from the inquiry (e.g., specific drug acquisition costs per treatment course) ☐How the information gathered was used to inform the guideline development process and/or formation of the recommendations 21. MONITORING/ AUDITING CRITERIA ☐Criteria to assess guideline implementation or adherence to Provide monitoring and/or auditing criteria to measure the application of guideline recommendations.
recommendations ☐Criteria for assessing impact of implementing the recommendations ☐Advice on the frequency and interval of measurement ☐Operational definitions of how the criteria should be measured ☐Outcomes of the recommendation development process (e.g., extent to which consensus was reached using modified Delphi technique, outcome of voting procedures) ☐How the process influenced the recommendations (e.g., results of Delphi technique influence final recommendation, alignment with recommendations and the final vote)

CONSIDERATION OF BENEFITS AND HARMS
Report the health benefits, side effects, and risks that ☐Supporting data and report of benefits 75 were considered when formulating the recommendations.
☐Supporting data and report of harms/side effects/risks ☐Reporting of the balance/trade-off between benefits and harms/side effects/risks ☐Recommendations reflect considerations of both benefits and harms/side effects/risks

LINK BETWEEN RECOMMENDATIONS AND EVIDENCE
Describe the explicit link between the recommendations and the evidence on which they are based.
☐How the guideline development group linked and used the evidence to inform recommendations ☐Link between each recommendation and key evidence (text description and/or reference list) ☐Link between recommendations and evidence summaries and/or evidence tables in the results section of the guideline 13. EXTERNAL REVIEW Report the methodology used to conduct the external review.
☐Purpose and intent of the external review (e.g., to improve quality, gather feedback on draft recommendations, assess applicability and feasibility, disseminate evidence) ☐Methods taken to undertake the external review (e.g., rating scale, open-ended questions) ☐Description of the external reviewers (e.g., number, type of reviewers, affiliations) ☐Outcomes/information gathered from the external review (e.g., summary of key findings) ☐How the information gathered was used to inform the guideline development process and/or formation of the recommendations (e.g., guideline panel considered results of review in forming final recommendations)

UPDATING PROCEDURE
Describe the procedure for updating the guideline.
☐A statement that the guideline will be updated ☐Explicit time interval or explicit criteria to guide decisions about when an update will occur ☐Methodology for the updating procedure ☒Recommendations in a summarized box, typed in bold, underlined, or presented as flow charts or algorithms ☐Specific recommendations grouped together in one section

FACILITATORS AND BARRIERS TO APPLICATION
Describe the facilitators and barriers to the guideline's application.
☐Types of facilitators and barriers that were considered ☐Methods by which information regarding the facilitators and barriers to implementing recommendations were sought (e.g., feedback from key stakeholders, pilot testing of guidelines before widespread implementation) ☐Information/description of the types of facilitators and barriers that emerged from the inquiry (e.g., practitioners have the skills to deliver the recommended care, sufficient equipment is not available to ensure all eligible members of the population receive mammography) ☐How the information influenced the guideline development process and/or formation of the recommendations

IMPLEMENTATION ADVICE/TOOLS
Provide advice and/or tools on how the recommendations can be applied in practice.
☐Additional materials to support the implementation of the guideline in practice. ☐Types of cost information that were considered (e.g., economic evaluations, drug acquisition costs) ☐Methods by which the cost information was sought (e.g., a health economist was part of the guideline development panel, use of health technology assessments for specific drugs, etc.) ☐Information/description of the cost information that emerged from the inquiry (e.g., specific drug acquisition costs per treatment course) ☐How the information gathered was used to inform the guideline development process and/or formation of the recommendations 21. MONITORING/ AUDITING CRITERIA ☐Criteria to assess guideline implementation or adherence to Provide monitoring and/or auditing criteria to measure the application of guideline recommendations.
recommendations ☐Criteria for assessing impact of implementing the recommendations ☐Advice on the frequency and interval of measurement ☐Operational definitions of how the criteria should be measured ☐Outcomes of the recommendation development process (e.g., extent to which consensus was reached using modified Delphi technique, outcome of voting procedures) ☐How the process influenced the recommendations (e.g., results of Delphi technique influence final recommendation, alignment with recommendations and the final vote)

CONSIDERATION OF BENEFITS AND HARMS
Report the health benefits, side effects, and risks that ☐Supporting data and report of benefits 84 were considered when formulating the recommendations.
☐Supporting data and report of harms/side effects/risks ☐Reporting of the balance/trade-off between benefits and harms/side effects/risks ☐Recommendations reflect considerations of both benefits and harms/side effects/risks

LINK BETWEEN RECOMMENDATIONS AND EVIDENCE
Describe the explicit link between the recommendations and the evidence on which they are based.
☐How the guideline development group linked and used the evidence to inform recommendations ☐Link between each recommendation and key evidence (text description and/or reference list) ☐Link between recommendations and evidence summaries and/or evidence tables in the results section of the guideline 13. EXTERNAL REVIEW Report the methodology used to conduct the external review.
☐Purpose and intent of the external review (e.g., to improve quality, gather feedback on draft recommendations, assess applicability and feasibility, disseminate evidence) ☐Methods taken to undertake the external review (e.g., rating scale, open-ended questions) ☐Description of the external reviewers (e.g., number, type of reviewers, affiliations) ☐Outcomes/information gathered from the external review (e.g., summary of key findings) ☐How the information gathered was used to inform the guideline development process and/or formation of the recommendations (e.g., guideline panel considered results of review in forming final recommendations)

UPDATING PROCEDURE
Describe the procedure for updating the guideline.
☐A statement that the guideline will be updated ☐Explicit time interval or explicit criteria to guide decisions about when an update will occur ☐Methodology for the updating procedure ☒Recommendations in a summarized box, typed in bold, underlined, or presented as flow charts or algorithms ☐Specific recommendations grouped together in one section

FACILITATORS AND BARRIERS TO APPLICATION
Describe the facilitators and barriers to the guideline's application.
☐Types of facilitators and barriers that were considered ☐Methods by which information regarding the facilitators and barriers to implementing recommendations were sought (e.g., feedback from key stakeholders, pilot testing of guidelines before widespread implementation) ☐Information/description of the types of facilitators and barriers that emerged from the inquiry (e.g., practitioners have the skills to deliver the recommended care, sufficient equipment is not available to ensure all eligible members of the population receive mammography) ☐How the information influenced the guideline development process and/or formation of the recommendations

IMPLEMENTATION ADVICE/TOOLS
Provide advice and/or tools on how the recommendations can be applied in practice.
☐Additional materials to support the implementation of the guideline in practice. ☐Types of cost information that were considered (e.g., economic evaluations, drug acquisition costs) ☐Methods by which the cost information was sought (e.g., a health economist was part of the guideline development panel, use of health technology assessments for specific drugs, etc.) ☐Information/description of the cost information that emerged from the inquiry (e.g., specific drug acquisition costs per treatment course) ☐How the information gathered was used to inform the guideline development process and/or formation of the recommendations 21. MONITORING/ AUDITING CRITERIA ☐Criteria to assess guideline implementation or adherence to Provide monitoring and/or auditing criteria to measure the application of guideline recommendations.

CONSIDERATION OF BENEFITS AND HARMS
Report the health benefits, side effects, and risks that ☐Supporting data and report of benefits 93 were considered when formulating the recommendations.
☐Supporting data and report of harms/side effects/risks ☐Reporting of the balance/trade-off between benefits and harms/side effects/risks ☒Recommendations reflect considerations of both benefits and harms/side effects/risks

LINK BETWEEN RECOMMENDATIONS AND EVIDENCE
Describe the explicit link between the recommendations and the evidence on which they are based.
☐How the guideline development group linked and used the evidence to inform recommendations ☐Link between each recommendation and key evidence (text description and/or reference list) ☐Link between recommendations and evidence summaries and/or evidence tables in the results section of the guideline 13. EXTERNAL REVIEW Report the methodology used to conduct the external review.
☐Purpose and intent of the external review (e.g., to improve quality, gather feedback on draft recommendations, assess applicability and feasibility, disseminate evidence) ☐Methods taken to undertake the external review (e.g., rating scale, open-ended questions) ☐Description of the external reviewers (e.g., number, type of reviewers, affiliations) ☐Outcomes/information gathered from the external review (e.g., summary of key findings) ☐How the information gathered was used to inform the guideline development process and/or formation of the recommendations (e.g., guideline panel considered results of review in forming final recommendations)

UPDATING PROCEDURE
Describe the procedure for updating the guideline.
☐A statement that the guideline will be updated ☐Explicit time interval or explicit criteria to guide decisions about when an update will occur ☐Methodology for the updating procedure

FACILITATORS AND BARRIERS TO APPLICATION
Describe the facilitators and barriers to the guideline's application.
☐Types of facilitators and barriers that were considered ☐Methods by which information regarding the facilitators and barriers to implementing recommendations were sought (e.g., feedback from key stakeholders, pilot testing of guidelines before widespread implementation) ☐Information/description of the types of facilitators and barriers that emerged from the inquiry (e.g., practitioners have the skills to deliver the recommended care, sufficient equipment is not available to ensure all eligible members of the population receive mammography) ☐How the information influenced the guideline development process and/or formation of the recommendations

IMPLEMENTATION ADVICE/TOOLS
Provide advice and/or tools on how the recommendations can be applied in practice.
☒Additional materials to support the implementation of the guideline in practice. ☐Types of cost information that were considered (e.g., economic evaluations, drug acquisition costs) ☐Methods by which the cost information was sought (e.g., a health economist was part of the guideline development panel, use of health technology assessments for specific drugs, etc.) ☐Information/description of the cost information that emerged from the inquiry (e.g., specific drug acquisition costs per treatment course) ☐How the information gathered was used to inform the guideline development process and/or formation of the recommendations 21. MONITORING/ AUDITING CRITERIA ☐Criteria to assess guideline implementation or adherence to Provide monitoring and/or auditing criteria to measure the application of guideline recommendations.
recommendations ☐Criteria for assessing impact of implementing the recommendations ☐Advice on the frequency and interval of measurement ☐Operational definitions of how the criteria should be measured

CONSIDERATION OF BENEFITS AND HARMS
Report the health benefits, side effects, and risks that ☐Supporting data and report of benefits 102 were considered when formulating the recommendations.
☐Supporting data and report of harms/side effects/risks ☐Reporting of the balance/trade-off between benefits and harms/side effects/risks ☐Recommendations reflect considerations of both benefits and harms/side effects/risks

LINK BETWEEN RECOMMENDATIONS AND EVIDENCE
Describe the explicit link between the recommendations and the evidence on which they are based.
☐How the guideline development group linked and used the evidence to inform recommendations ☒Link between each recommendation and key evidence (text description and/or reference list) ☐Link between recommendations and evidence summaries and/or evidence tables in the results section of the guideline Section 1

EXTERNAL REVIEW
Report the methodology used to conduct the external review.
☐Purpose and intent of the external review (e.g., to improve quality, gather feedback on draft recommendations, assess applicability and feasibility, disseminate evidence) ☐Methods taken to undertake the external review (e.g., rating scale, open-ended questions) ☐Description of the external reviewers (e.g., number, type of reviewers, affiliations) ☐Outcomes/information gathered from the external review (e.g., summary of key findings) ☐How the information gathered was used to inform the guideline development process and/or formation of the recommendations (e.g., guideline panel considered results of review in forming final recommendations)

UPDATING PROCEDURE
Describe the procedure for updating the guideline.
☐A statement that the guideline will be updated ☐Explicit time interval or explicit criteria to guide decisions about when an update will occur ☐Methodology for the updating procedure

FACILITATORS AND BARRIERS TO APPLICATION
Describe the facilitators and barriers to the guideline's application.
☐Types of facilitators and barriers that were considered ☐Methods by which information regarding the facilitators and barriers to implementing recommendations were sought (e.g., feedback from key stakeholders, pilot testing of guidelines before widespread implementation) ☐Information/description of the types of facilitators and barriers that emerged from the inquiry (e.g., practitioners have the skills to deliver the recommended care, sufficient equipment is not available to ensure all eligible members of the population receive mammography) ☐How the information influenced the guideline development process and/or formation of the recommendations

IMPLEMENTATION ADVICE/TOOLS
Provide advice and/or tools on how the recommendations can be applied in practice.
☐Additional materials to support the implementation of the guideline in practice. ☐Types of cost information that were considered (e.g., economic evaluations, drug acquisition costs) ☐Methods by which the cost information was sought (e.g., a health economist was part of the guideline development panel, use of health technology assessments for specific drugs, etc.) ☐Information/description of the cost information that emerged from the inquiry (e.g., specific drug acquisition costs per treatment course) ☐How the information gathered was used to inform the guideline development process and/or formation of the recommendations 21. MONITORING/ AUDITING CRITERIA ☐Criteria to assess guideline implementation or adherence to Provide monitoring and/or auditing criteria to measure the application of guideline recommendations.
recommendations ☐Criteria for assessing impact of implementing the recommendations ☐Advice on the frequency and interval of measurement ☐Operational definitions of how the criteria should be measured ☐A statement that the guideline will be updated ☐Explicit time interval or explicit criteria to guide decisions about when an update will occur ☐Methodology for the updating procedure ☐Types of facilitators and barriers that were considered ☐Methods by which information regarding the facilitators and barriers to implementing recommendations were sought (e.g., feedback from key stakeholders, pilot testing of guidelines before widespread implementation) ☐Information/description of the types of facilitators and barriers that emerged from the inquiry (e.g., practitioners have the skills to deliver the recommended care, sufficient equipment is not available to ensure all eligible members of the population receive mammography) ☐How the information influenced the guideline development process and/or formation of the recommendations

IMPLEMENTATION ADVICE/TOOLS
Provide advice and/or tools on how the recommendations can be applied in practice.
☐Additional materials to support the implementation of the guideline in practice.
For example: • Guideline summary documents ☐Types of cost information that were considered (e.g., economic evaluations, drug acquisition costs) ☐Methods by which the cost information was sought (e.g., a health economist was part of the guideline development panel, use of health technology assessments for specific drugs, etc.) ☐Information/description of the cost information that emerged from the inquiry (e.g., specific drug acquisition costs per treatment course) ☐How the information gathered was used to inform the guideline development process and/or formation of the recommendations 21. MONITORING/ AUDITING CRITERIA Provide monitoring and/or auditing criteria to measure the application of guideline recommendations.  ☐A statement that the guideline will be updated ☐Explicit time interval or explicit criteria to guide decisions about when an update will occur ☐Methodology for the updating procedure ☒Additional materials to support the implementation of the guideline in practice.
For example: • Guideline summary documents ☐Types of cost information that were considered (e.g., economic evaluations, drug acquisition costs) ☐Methods by which the cost information was sought (e.g., a health economist was part of the guideline development panel, use of health technology assessments for specific drugs, etc.) ☐Information/description of the cost information that emerged from the inquiry (e.g., specific drug acquisition costs per treatment course) ☐How the information gathered was used to inform the guideline development process and/or formation of the recommendations 21. MONITORING/ AUDITING CRITERIA Provide monitoring and/or auditing criteria to measure the application of guideline recommendations.  ☒A statement that the guideline will be updated ☒Explicit time interval or explicit criteria to guide decisions about when an update will occur ☐Methodology for the updating procedure ☒Additional materials to support the implementation of the guideline in practice.
For example: • Guideline summary documents • Links to check lists, algorithms Table 10 132 • Links to how-to manuals ☐Types of cost information that were considered (e.g., economic evaluations, drug acquisition costs) ☐Methods by which the cost information was sought (e.g., a health economist was part of the guideline development panel, use of health technology assessments for specific drugs, etc.) ☐Information/description of the cost information that emerged from the inquiry (e.g., specific drug acquisition costs per treatment course) ☐How the information gathered was used to inform the guideline development process and/or formation of the recommendations ☐A statement that the guideline will be updated ☐Explicit time interval or explicit criteria to guide decisions about when an update will occur ☐Methodology for the updating procedure ☐Types of facilitators and barriers that were considered ☐Methods by which information regarding the facilitators and barriers to implementing recommendations were sought (e.g., feedback from key stakeholders, pilot testing of guidelines before widespread implementation) ☐Information/description of the types of facilitators and barriers that emerged from the inquiry (e.g., practitioners have the skills to deliver the recommended care, sufficient equipment is not available to ensure all eligible members of the population receive mammography) ☐How the information influenced the guideline development process and/or formation of the recommendations

IMPLEMENTATION ADVICE/TOOLS
Provide advice and/or tools on how the recommendations can be applied in practice.
☒Additional materials to support the implementation of the guideline in practice.
For example: • Guideline summary documents ☐Types of cost information that were considered (e.g., economic evaluations, drug acquisition costs) ☐Methods by which the cost information was sought (e.g., a health economist was part of the guideline development panel, use of health technology assessments for specific drugs, etc.) ☐Information/description of the cost information that emerged from the inquiry (e.g., specific drug acquisition costs per treatment course) ☐How the information gathered was used to inform the guideline development process and/or formation of the recommendations 21. MONITORING/ AUDITING CRITERIA Provide monitoring and/or auditing criteria to measure the application of guideline recommendations.  ☐Purpose and intent of the external review (e.g., to improve quality, gather feedback on draft recommendations, assess applicability and feasibility, disseminate evidence) ☐Methods taken to undertake the external review (e.g., rating scale, open-ended questions) ☐Description of the external reviewers (e.g., number, type of reviewers, affiliations) ☐Outcomes/information gathered from the external review (e.g., summary of key findings) ☐How the information gathered was used to inform the guideline development process and/or formation of the recommendations (e.g., guideline panel considered results of review in forming final recommendations)

UPDATING PROCEDURE
Describe the procedure for updating the guideline.
☐A statement that the guideline will be updated ☐Explicit time interval or explicit criteria to guide decisions about when an update will occur ☐Methodology for the updating procedure ☐Types of facilitators and barriers that were considered ☐Methods by which information regarding the facilitators and barriers to implementing recommendations were sought (e.g., feedback from key stakeholders, pilot testing of guidelines before widespread implementation) ☐Information/description of the types of facilitators and barriers that emerged from the inquiry (e.g., practitioners have the skills to deliver the recommended care, sufficient equipment is not available to ensure all eligible members of the population receive mammography) ☐How the information influenced the guideline development process and/or formation of the recommendations

IMPLEMENTATION ADVICE/TOOLS
Provide advice and/or tools on how the recommendations can be applied in practice.
☐Additional materials to support the implementation of the guideline in practice.
For example: • Guideline summary documents ☐Types of cost information that were considered (e.g., economic evaluations, drug acquisition costs) ☐Methods by which the cost information was sought (e.g., a health economist was part of the guideline development panel, use of health technology assessments for specific drugs, etc.) ☐Information/description of the cost information that emerged from the inquiry (e.g., specific drug acquisition costs per treatment course) ☐How the information gathered was used to inform the guideline development process and/or formation of the recommendations 21. MONITORING/ AUDITING CRITERIA Provide monitoring and/or auditing criteria to measure the application of guideline recommendations.  ☐Outcomes of the recommendation development process (e.g., extent to which consensus was reached using modified Delphi technique, outcome of voting procedures) ☐How the process influenced the recommendations (e.g., results of Delphi technique influence final recommendation, alignment with recommendations and the final vote) NR

CONSIDERATION OF BENEFITS AND HARMS
Report the health benefits, side effects, and risks that were considered when formulating the recommendations.
☐Supporting data and report of benefits ☐Supporting data and report of harms/side effects/risks ☐Reporting of the balance/trade-off between benefits and harms/side effects/risks NR 156 ☐Recommendations reflect considerations of both benefits and harms/side effects/risks 12. LINK BETWEEN RECOMMENDATIONS AND EVIDENCE Describe the explicit link between the recommendations and the evidence on which they are based.
☐How the guideline development group linked and used the evidence to inform recommendations ☐Link between each recommendation and key evidence (text description and/or reference list) ☐Link between recommendations and evidence summaries and/or evidence tables in the results section of the guideline NR 13. EXTERNAL REVIEW Report the methodology used to conduct the external review.
☐Purpose and intent of the external review (e.g., to improve quality, gather feedback on draft recommendations, assess applicability and feasibility, disseminate evidence) ☐Methods taken to undertake the external review (e.g., rating scale, open-ended questions) ☐Description of the external reviewers (e.g., number, type of reviewers, affiliations) ☐Outcomes/information gathered from the external review (e.g., summary of key findings) ☐How the information gathered was used to inform the guideline development process and/or formation of the recommendations (e.g., guideline panel considered results of review in forming final recommendations) NR

UPDATING PROCEDURE
☐A statement that the guideline will be updated NR Describe the procedure for updating the guideline. ☐Explicit time interval or explicit criteria to guide decisions about when an update will occur ☐Methodology for the updating procedure ☐Methods by which information regarding the facilitators and barriers to implementing recommendations were sought (e.g., feedback from key stakeholders, pilot testing of guidelines before widespread implementation) ☐Information/description of the types of facilitators and barriers that emerged from the inquiry (e.g., practitioners have the skills to deliver the recommended care, sufficient equipment is not available to ensure all eligible members of the population receive mammography) ☐How the information influenced the guideline development process and/or formation of the recommendations 19. IMPLEMENTATION ADVICE/TOOLS Provide advice and/or tools on how the recommendations can be applied in practice.
☒Additional materials to support the implementation of the guideline in practice. ☐Types of cost information that were considered (e.g., economic evaluations, drug acquisition costs) ☐Methods by which the cost information was sought (e.g., a NR health economist was part of the guideline development panel, use of health technology assessments for specific drugs, etc.) ☐Information/description of the cost information that emerged from the inquiry (e.g., specific drug acquisition costs per treatment course)

CONSIDERATION OF BENEFITS AND HARMS
Report the health benefits, side effects, and risks that were considered when formulating the recommendations.
☐Supporting data and report of benefits ☐Supporting data and report of harms/side effects/risks ☐Reporting of the balance/trade-off between benefits and harms/side effects/risks NR 165 ☒Recommendations reflect considerations of both benefits and harms/side effects/risks

LINK BETWEEN RECOMMENDATIONS AND EVIDENCE
Describe the explicit link between the recommendations and the evidence on which they are based.
☐How the guideline development group linked and used the evidence to inform recommendations ☐Link between each recommendation and key evidence (text description and/or reference list) ☐Link between recommendations and evidence summaries and/or evidence tables in the results section of the guideline NR 13. EXTERNAL REVIEW Report the methodology used to conduct the external review.
☐Purpose and intent of the external review (e.g., to improve quality, gather feedback on draft recommendations, assess applicability and feasibility, disseminate evidence) ☐Methods taken to undertake the external review (e.g., rating scale, open-ended questions) ☐Description of the external reviewers (e.g., number, type of reviewers, affiliations) ☐Outcomes/information gathered from the external review (e.g., summary of key findings) ☐How the information gathered was used to inform the guideline development process and/or formation of the recommendations (e.g., guideline panel considered results of ☐Types of facilitators and barriers that were considered ☐Methods by which information regarding the facilitators and barriers to implementing recommendations were sought (e.g., feedback from key stakeholders, pilot testing of guidelines before widespread implementation) ☐Information/description of the types of facilitators and barriers that emerged from the inquiry (e.g., practitioners have the skills to deliver the recommended care, sufficient equipment is not available to ensure all eligible members of the population receive mammography) ☐How the information influenced the guideline development process and/or formation of the recommendations NR 19. IMPLEMENTATION ADVICE/TOOLS Provide advice and/or tools on how the recommendations can be applied in practice.
☒Additional materials to support the implementation of the guideline in practice. ☐Types of cost information that were considered (e.g., economic evaluations, drug acquisition costs) ☐Methods by which the cost information was sought (e.g., a health economist was part of the guideline development panel, use of health technology assessments for specific drugs, etc.) ☐Information/description of the cost information that emerged from the inquiry (e.g., specific drug acquisition costs per treatment course) ☐How the information gathered was used to inform the guideline development process and/or formation of the recommendations  ☒Recommendations in a summarized box, typed in bold, underlined, or presented as flow charts or algorithms ☐Specific recommendations grouped together in one section DOMAIN 5: APPLICABILITY

FACILITATORS AND BARRIERS TO APPLICATION
Describe the facilitators and barriers to the guideline's application.
☐Types of facilitators and barriers that were considered ☐Methods by which information regarding the facilitators and barriers to implementing recommendations were sought (e.g., feedback from key stakeholders, pilot testing of guidelines before widespread implementation) NR ☐Information/description of the types of facilitators and barriers that emerged from the inquiry (e.g., practitioners have the skills to deliver the recommended care, sufficient equipment is not available to ensure all eligible members of the population receive mammography) ☐Types of cost information that were considered (e.g., economic evaluations, drug acquisition costs) ☐Methods by which the cost information was sought (e.g., a health economist was part of the guideline development panel, use of health technology assessments for specific drugs, etc.) NR ☐Information/description of the cost information that emerged from the inquiry (e.g., specific drug acquisition costs per treatment course) ☐How the information gathered was used to inform the guideline development process and/or formation of the recommendations 21. MONITORING/ AUDITING CRITERIA Provide monitoring and/or auditing criteria to measure the application of guideline recommendations. • Treatment for NHAP should take into account the individual's personal directives • There is a lack of well-designed studies in this patient population • Chest radiography is not widely available or practical in many locations • Microbiologic diagnosis of NHAP has significant limitations and as such, treatment of NHAP is usually empiric • Delay in administration of antibiotics for the empiric treatment of NHAP may lead to increased patient morbidity and mortality • Inappropriate use of antibiotics may adversely affect patient outcomes and may increase antimicrobial resistance Prevention • Limit the spread of infections (e.g., hand washing and attention to outbreak management guidelines) • Influenza and pneumococcal vaccines are recommended (see Appendix 2) • Smoking cessation and avoidance of environmental tobacco smoke Diagnosis • Although a new infiltrate seen on chest X-ray with compatible clinical signs is the gold standard for the diagnosis of NHAP, in nursing home settings the diagnosis must often be made on clinical grounds alone. • The physical examination must include blood pressure, heart rate, respiratory rate and auscultation of the respiratory system • Ideally the diagnosis of pneumonia should be supported with chest X-ray, oxygen saturation, complete blood count and differential, blood cultures, and sputum cultures. • As these tests are frequently unavailable in the nursing home setting, refer to management below.
• Note: There is still value in performing these tests even after treatment has been initiated.

Management/Assessment
• Determine the degree of medical treatment desired by the patient or legal decision maker such as a guardian or agent named in an enacted personal directive.

• Review vital signs
• Consider transfer to hospital if impending respiratory failure or hemodynamic compromise • Oxygenation • Oxygen therapy is indicated for hypoxemia (e.g., O2 <90%) • If oxymetry is not available consider oxygen at 2 litres/minute • Note: COPD baseline oxygenation may be lower and therefore must be individually assessed • Hydration • Ensure adequate hydration (1 litre in a 24 hour period is required to replace insensible losses under most circumstances).
• Note: Consider hypodermoclysis • Note: Fluid requirement for older persons without cardiac or renal failure is 30ml/kg/day in addition to estimated fluid deficit. General Management • Analgesics/antipyretics for pain and fever • Cough suppressants are not routinely recommended CONTINUING MANAGEMENT In the nursing home setting, the care team needs to be involved in daily assessments to alert the physician to significant changes in patient status: • Mobility • Hydration: 1 litre/day • Nutrition: weight loss of >5-10% is related to increased morbidity (Significant weight loss in the nursing home >5% in 30 days or >10% in 6 months) • Review medication profile and consider holding or adjusting dosage where appropriate: psychoactive drugs, including hypnotic sedative drugs, cardiovascular drugs • Review antibiotic treatments at 48 to 72 hours for evidence of response to therapy: • temperature stabilization or lower respiratory rate • If failure of therapy occurs, consider change in antibiotics or transfer to hospital if: • Hemodynamic compromise • Clinical deterioration after 72 hours of antibiotic therapy • No improvement after completion of antibiotic therapy • Consider: • Host-related factors: non-infectious pulmonary pathology, immunosuppression • Pathogen-related factors antibiotic resistance, Non-bacterial etiology, viruses, Mycobacterium spp, fungi • Drug-related factors -Adherence, malabsorption, drug-drug interactions, drug fever Aoki, 2015; Country: Canada, Sponsor: Association of Medical Microbiology and Infectious Disease (AMMI) Canada Scope: Long-term care facility outbreak control NI drugs, oseltamivir (Tamiflu®, Hoffmann-La Roche Ltd, Canada) and zanamivir (Relenza®, GlaxoSmithKline Inc, Canada), are the antiviral medications to be prescribed for both treatment and prevention of influenza, including H3N2 viruses. Amantadine is not to be 191 prescribed due to resistance of the H3N2 virus to its inhibitory action.
In view of vaccine mismatch for H3N2 viruses in 2014-2015 and anticipated reduced VE for that component, it is recommended that antiviral chemoprophylaxis be considered for all staff working at the site of a declared influenza A(H3N2) LTCF outbreak regardless of whether they have received this year's 2014-2015 influenza vaccine. Controlling outbreaks of influenza in LTCF requires a multifaceted approach including: 1. Surveillance for influenza-like illness (ILI) 2. Laboratory testing to identify the cause of ILI 3. Promotion of, and adherence to, infection control guidelines and practices including respiratory etiquette and routine practices, and the use of personal protective equipment 4. Timely communication 5. Influenza immunization for residents and staff 6. Exclusion of ill staff, visitor exclusion and new admission deferral 7. Antiviral drug therapy for ill residents and staff 8. Antiviral drug prophylaxis of non-ill residents and staff 1. Antiviral drug therapy i. Residents: a. Oseltamivir or zanamivir treatment should be administered as soon as the clinical diagnosis of influenza has been made because residents of LTCF are, by definition, at increased risk of complications (6). b. Nasal/nasopharyngeal secretions should be tested to confirm the diagnosis but treatment initiation should not wait for the test result. c. Antiviral therapy works best when initiated within the first 48 h after symptom onset. However, these medications can still help even if begun more than 48 h after illness onset. d. The dosage regimens for adults are oseltamivir 75 mg PO BID or zanamivir two inhalations BID. e. The recommended duration of therapy is five days. f. There is no need to reduce doses in patients with mild to moderate reduced renal function and drug-drug interactions are also not generally a concern (6). ii. Staff: a. Staff with ILI during an outbreak should be offered antiviral treatment and sent home until their symptoms have resolved. b. Dose is per E1id, above.
2. Antiviral drug prophylaxis i. Residents: a. Upon diagnosis of an influenza outbreak, all residents becoming ill should be treated (vide supra) while all non-ill residents regardless of whether they have received the current seasonal vaccine should be started on chemoprophylaxis with either oseltamivir or zanamivir b. Generally, it is preferable to wait to initiate chemoprophylaxis until laboratory confirmation has been received. c. The prophylactic doses are oseltamivir 75 mg PO once daily or zanamivir two inhalations once daily for adults. d. Prophylaxis should be continued for 14 days minimum or until the outbreak has been declared over (see section D above). ii. Staff: a. In the context of significant antigenic drift and/or vaccine mismatch for which suboptimal VE may reasonably be anticipated, and in particular in relation to H3N2 viruses this season, it is recommended that staff who provide resident care or conduct activities where they may have the potential to acquire or transmit influenza (21) should also take prophylactic antiviral medication during the outbreak, regardless of whether they have received the current season's influenza vaccine. This is because, despite some vaccine protection anticipated, a substantial proportion of vaccinated individuals, including healthy working-age adults, are anticipated to remain susceptible to drifted H3N2 viruses. b. Antiviral prophylaxis recommendations should be reinstituted whenever an outbreak is declared even for the same subtype and within the same setting and season. The maximum duration of continuous prophylaxis should be eight weeks, but outbreaks managed with antivirals should generally be terminated well within this period. In the unusual event that the outbreak is more prolonged, control measures should be reassessed in consultation with the local Medical Officer of Health and other experts. c. Doses and durations should be as in section E2ic above.
3. Continued surveillance for ILI during an outbreak: a. Residents or staff developing ILI while on prophylactic doses of an antiviral agent need to be considered for treatment doses if influenza is diagnosed or considered likely. b. Residents or staff receiving chemoprophylaxis who develop ILI should be assessed and tested to determine the cause of their illness, which may be due to the current virus, another viral agent or an oseltamivir-(or zanamavir)-resistant influenza virus. Expert consultation is suggested to address: the cause, organize testing for NI resistance, and to assess the possible need to possibly switch to another NI.
Buynder, 2017; Country: Australia, Sponsor: Not reported Scope: The purpose of this document is to provide national best practice guidelines for, preparing for, preventing, identifying and managing outbreaks of influenza in residential care facilities (RCFs) in Australia. 5.1 Infection control measures to prevent spread of influenza: Standard precautions are a group of infection prevention practices always used in healthcare settings, and in RCFs with a suspected or confirmed influenza outbreak. Standard precautions include performing hand hygiene before and after every episode of resident contact, the use of PPE including gloves, gown, mask and eye protection, depending on the anticipated exposure, good respiratory hygiene/cough etiquette and regular cleaning of the environment and equipment.
Transmission-based precautions are work practices used in addition to standard precautions to reduce transmission opportunities due to the specific route of transmission of a pathogen. These practices are implemented depending on the type of spread. For example, respiratory infections are commonly spread by droplet and airborne routes. For influenza, droplet precautions are required.
Key elements of droplet precautions are to use PPE, maintain a 1 metre distance between the infected resident and others, encourage good cough etiquette, use resident-dedicated equipment where possible; and allocate ill residents to single rooms or cohort (put in a shared room) those with confirmed influenza. Additionally, enhanced cleaning and disinfection of the ill resident's environment and minimising transfer of residents within and between facilities may help reduce spread. Detailed advice on these precautions is presented later in this chapter. All staff in a residential care facility should receive general education on policies, including the principles of infection prevention and control. This would include a review of hand hygiene and infection control precautions, along with refresher training, as required. The use of antivirals should be stated in the RCF's influenza outbreak management policy. During outbreaks, information and education should be provided for residents and their families, and should include their specific condition, and practices necessary to reduce the risk of infection. Practical infection control information, tips, diagrams and signs are in Appendix 1.

Hand hygiene
As influenza viruses can be spread by hands, frequent hand cleansing is important. Alcohol based hand rubs are the gold standard for hand hygiene practice in healthcare settings. However, if hands are visibly soiled or had direct contact with body fluids they should be washed with liquid soap and running water then dried thoroughly with disposable paper towel (refer to Appendices 1.1-1.4, and Hand Hygiene Australia (HHA) (http://www.hha.org.au/home/)). Influenza viruses can persist on hard surfaces and remain viable for up to 24 hours on hard, non-porous surfaces. Infectious influenza virus can be transferred to hands from these surfaces for at least 2 -8 hours after contamination of the surface. Virus transfer from porous materials to hands is less efficient due to rapid drying of the virus.23 Increased environmental cleaning can help interrupt virus transmission. Hands should be cleaned with an alcohol-based hand rub or water and liquid soap solution before and after caring for a resident. • All staff must perform hand hygiene after every contact with an ill resident. • Even when hands are visibly clean. • After being in contact with contaminated surfaces. • Whether or not gloves are worn.
When visibly soiled with body fluids and/or substances, use water and liquid soap for hand washing. Alcohol-based hand rub 194 solutions can be used when performing procedures whenever hands are not visibly soiled.2 Refer to Hand Hygiene Australia 5 moments (http://www.hha.org.au/home/5-moments-for-hand-hygiene.aspx).

Respiratory hygiene and cough etiquette
The importance of respiratory hygiene and cough etiquette for respiratory illnesses should be explained to residents as part of droplet precautions (refer to Appendices 1.4, 1.5). Encourage residents with respiratory symptoms to cover their nose and mouth when they cough or sneeze, use tissues, and dispose of them into a rubbish bin /receptacle. Bin contents can be disposed of as general waste.

Personal protective equipment (PPE)
Appropriate PPE is important for all staff caring for infected residents requiring standard and droplet precautions (refer to Appendix 1.6). Staff must change their PPE and perform hand hygiene after every contact with an ill resident, when moving from one room to another, or from one resident care area to another.

Surgical face masks
Any RCF staff member providing direct care to a resident with an ILI or influenza should wear a surgical mask. Surgical face masks must meet Australian Standards 18 and be fluid resistant, protecting the wearer from droplet contamination of the nasal or oral mucosa (refer to Appendix 1). All staff and visitors entering the room of a person with a respiratory illness should wear a single-use surgical face mask for close contact (less than (<)1 metre). Note. Single-use surgical face masks protect the user against droplets. However, P2 respirators (known as N95 respirators or facemasks (USA equivalent rating)) protect the user against aerosols as well as droplets. Insufficient evidence exists to support the use of P2 respirators to further reduce the risk of infections transmitted by the droplet route.
Aerosol generating procedures should be avoided, or if necessary, performed in a single room that is properly cleaned before further use.25 This advice extends to nebulisers, which should not be used; use individual patient spacers instead. Single-use surgical face masks should be worn by RCF staff when exposure to respiratory droplets is likely, that is, when within 1m of an affected resident: • The mask should be put on when entering the room. • Remove the mask after leaving the room, handling only by the tapes, and place in a clinical (yellow) waste bin. Perform hand hygiene after disposing of the mask.
• Never re-use masks.
When undertaking activities that require an infected resident to leave their room, the resident should wear a mask if tolerated.2 For example, during transfer within or between facilities. RCF staff members and well residents may be required to wear a mask while these activities are undertaken, based on likely exposure.

Gloves and gown
Gloves and gowns should be used as described in standard precautions. After use, they should be removed in a manner which prevents contamination of the hands or surfaces or the workers clothing, then placed in the appropriate waste bin. Hand hygiene should be performed after removing PPE. Refer to Appendix 1 5.1.6 Eye protection Eye protection includes the use of safety glasses, goggles or face shields but does not include personal eye glasses. Goggles or other protective eyewear must be disposed of, or where approved for re-use, cleaned after use.2 Eyes should be protected where there is potential for splattering or spraying of blood, body fluids, secretions or excretions, including coughing; or when undertaking aerosol-generating procedures such as nasopharyngeal aspiration.

Environmental measures
Regular, scheduled cleaning of all resident care areas is essential. Frequently touched surfaces are those closest to the resident, and should be cleaned more often (for example -bedrails, bedside tables, commodes, doorknobs, sinks, surfaces and equipment close to the resident).
During a suspected or confirmed influenza outbreak, an increase in the frequency of cleaning with a neutral detergent is recommended, especially for frequently touched surfaces. Ensure appropriate availability, quantity and placement of disposal units for tissues, used PPE, etc., as well as appropriate cleaning for reusable items.
Suggested minimum cleaning frequencies for many items are specified in the Minimum Cleaning Frequency table in the Australian Guidelines for the Prevention and Control of Infection in Healthcare (p.159, B 5.1).2 As a guide, the risk profiles of most RCFs during an influenza outbreak would be similar to general hospital wards. Refer to Appendix 2 for further information on cleaning.
Ideally, any care equipment should be dedicated for the use of an individual resident. If resident care equipment must be shared, the items must be cleaned and disinfected between each resident use.
Linen should be laundered using hot water and detergent. Linen should be dried on a hot setting in a dryer. There is no need to separate the linen of ill residents from that of other residents. Appropriate PPE should be used when handling soiled linen.
Crockery and cutlery should be washed in a dishwasher or if not available, by hand using hot water and detergent, rinsed in hot water and dried. Separation of cutlery and crockery from ill residents is not required.

Exclusion of staff
RCF staff members with ILI should be excluded from work while they are infectious, that is, at least 5 days after onset of acute illness, or until they are symptom free, whichever is longer. As unvaccinated staff are at higher risk of acquiring influenza, during a confirmed influenza outbreak, unvaccinated staff are recommended to work only if asymptomatic and wearing a mask, or asymptomatic and taking appropriate antiviral prophylaxis, in keeping with the RCF's influenza outbreak management policy. Any antiviral use by staff should be documented. If issues arise regarding compliance with work exclusions, options should be reviewed by the Outbreak Management Team (refer to Section 6). 5.3.1 Rationale for allowing staff on antivirals to return to work Antiviral prophylaxis for staff members works to protect residents from infection, firstly, by reducing the acquisition of infection by staff (and ability to further transmit the virus) and secondly, by reducing viral shedding from asymptomatic infected staff (refer to Appendix 16: Antiviral Prophylaxis in residential care facilities decision tool).

Isolation and cohorting 5.4.1 Resident placement
Any residents with a respiratory illness should be cared for in a single room, where practicable. Isolating sick residents in single rooms reduces the risk of resident-to-resident transmission. The importance of respiratory hygiene and cough etiquette should be explained to all residents.
If single rooms are not available, the following principles can guide decision-making on resident placement: • As a priority, place residents with excessive cough and sputum production in single rooms. • Place together in the same room (cohort) residents infected with the same pathogen and who are assessed by the RCF as suitable roommates.
• Importantly, ensure that residents sharing a room are physically separated (more than (>1 metre apart) from each other. Draw the privacy curtain between beds to minimise the risk of droplet transmission.
Note: Clinical ILI may be caused by influenza A virus or influenza B virus. Only laboratory tests distinguish between these causes. Separation of ill residents is important unless it is clear their infection is caused by the same viral pathogen.

Staff
Once resident isolation measures are in place, to further reduce the risk of transmission, it is preferable to allocate specific (vaccinated) RCF staff to the care of residents isolated in rooms. These staff members should not move between their section and other areas of the facility, or care for other residents. Staff members should self-monitor for signs and symptoms of respiratory illness and self-exclude from work if unwell. When ILI is apparent in an RCF, influenza can be spread within the facility by unvaccinated staff, who should work only if well and wearing a mask, or taking antiviral prophylaxis. Preferentially, only staff vaccinated against influenza should care for residents with confirmed influenza or suspected ILI. Unvaccinated staff who have been working in an outbreak-affected area should not be moved to other parts of the RCF, as they may be incubating influenza.

Droplet precaution sign
Place droplet precaution signs (refer to Appendix 3) outside ill residents' rooms to remind staff and visitors about the requirement for transmission-based infection control work practices.

Resident movement during an outbreak
There is some evidence for the benefits of restricting internal movement of residents and visitors during an outbreak.26 RCF outbreak response plans should consider restricting resident mingling in communal living/dining areas, and prepare a guide for restrictions based on the RCF layout and usual practices. To minimize the direct interaction of residents within the facility during an outbreak, it is important for RCFs to also consider suspending group social activities for residents.

New admissions
Admissions of new residents into the facility should be restricted. Depending upon the extent of the outbreak and the physical layout of the building, the restriction on admissions might be applied to one floor, one wing or the entire facility. The 21 RCF_Guidelines rationale for restriction on admissions is related to both the risk of infection for the newly admitted resident and potential to prolong the outbreak by adding new, potentially susceptible residents. Though normally not recommended, if important for resident wellbeing, admissions may be reconsidered once outbreak controls are having effect. To clarify the extent to which restrictions may be relaxed, consult with your PHU.

Re-admission of residents who have had influenza
The re-admission of residents who had influenza and were transferred to hospital or another facility, requires the provision of appropriate accommodation, care and infection control.

Re-admission of residents without influenza
The re-admission of residents who have not had suspected or confirmed influenza in the outbreak (i.e. who are not known cases) is generally not recommended during an outbreak. If required, admissions may be considered once the outbreak is under control. To clarify relaxation of admission restrictions, consult your public health unit. Factors to consider if re-admission of non-cases is being sought, include: • The availability of appropriate accommodation for the returning resident.
• Vaccination status of the person for re-admission.
• The ability to protect the readmitted resident from infection. • Infection control measures currently in place.
• Provision of antiviral prophylactic medications. • Availability of adequate staff at the RCF to care for the re-admitted resident.

Non-infected residents
In some circumstances, it may be feasible to transfer residents who definitely do not have ILI to other settings for care (e.g. family care). In these circumstances, the family should be aware that the resident may have been exposed to influenza and is at risk of developing disease. NB: In residential Aged Care settings, security of tenure provisions of the Aged Care Act 1997 will need to be considered.

Transfers
If transfer to hospital is required, notify the ambulance service and receiving hospital of the outbreak and the suspected or confirmed diagnosis. A template for resident transfer advice is available at Appendix 4.

Visitor restriction and signage
During an outbreak, preferably, minimize the movement of visitors into and within the facility. If recommended by the outbreak management team, RCFs should: • Suspend group social activities that involve visitors such as musicians.
• Postpone visits from non-essential external providers, if possible. • Inform regular visitors and families of residents and of the outbreak of influenza and request they only undertake essential visits; discourage unnecessary visitors. • Ask those who do visit an ill resident, to: o Visit only one person. o Enter and leave directly without spending time in communal areas. o Use an alcohol-based hand rub or wash their hands before and after visiting. o If giving direct care, use PPE as directed by RCF staff. • Initiate passive screening for respiratory symptoms using "Attention Visitors" signage (refer to Appendix 3), and reminding visitors: o Not to visit if unwell. o To limit visiting to one resident. o To follow signs for the use of PPE, as indicated. o To practice hand hygiene and respiratory hygiene/cough etiquette.
• Post "Attention Visitors" signs at the entrance(s) and other strategic locations in the facility (refer to Appendix 3). • Initiate active screening (incoming visitors report to the desk) as required.

Education and training
The RCF should provide ongoing education to staff, residents and volunteers, and opportunistic education to regular visitors (e.g. residents' families) about outbreak prevention, infection control and related policies. Topics for staff (some apply to residents) include: • Personal hygiene, particularly hand hygiene, sneeze and cough etiquette. 6.1 Preparing for influenza outbreaks Seasonal influenza typically peaks over winter and early spring, although sporadic cases occur year-round. Outbreaks of influenza are not uncommon in RCFs. To protect the health of staff and residents and to ensure the RCF is well prepared to manage an outbreak of influenza, it is important to consider the following actions: • Plan for a possible outbreak: 200 a. Develop easily accessible internal policies and procedures on infection control and an outbreak management plan. A copy of these guidelines and the Influ-Info Kit produced by the Department of Social Services should be used as references.27 b. Include a medical practitioner (or equivalent) in the development of the outbreak management plan; this is essential for consideration of use of antiviral medications. c. Acquire adequate stocks of materials such as personal protective equipment (PPE) and cleaning materials (refer to Appendices 1 and 2). Consider having an outbreak kit / box specifically for use in an outbreak. d. Ensure RCF staff know the symptoms and signs of influenza, and are trained in infection control procedures for use of PPE (Appendix 1). e. Policies supporting use of antiviral drugs for prophylaxis should reflect the reduced effectiveness of antivirals with either delays in implementation or low levels of compliance, and a response option for poor compliance. f. If there is an intention to use influenza antivirals for prophylaxis in the management of outbreaks, RCFs may develop processes with attending GPs for antiviral prescriptions/ standing orders prior to the influenza season (see 6.2.9), as to be effective antiviral medication must be used in a widespread fashion at the same time. g. For residents with renal failure, GP assessment of the renal function is needed before or soon after prophylaxis commences (Appendix 16). Note. Legislation relating to the use of standing drug orders may differ between jurisdictions. • Develop a systematic method for detecting and recording residents in the facility who develop symptoms of ILI, such as fever or cough. An ILI detection system may include increased frequency of temperature observation during winter and methods to alert the responsible clinician of symptomatic residents. • Maintain a functional system for the timely detection of potential influenza outbreaks (3 residents/staff with ILI within 3 days) in the RCF. This may be a daily summary of all ILI records. Ensure daily hand-over time for ILI monitoring and outbreak detection for those assigned to this important task. • Early in the year, plan to ensure at least 95% of staff and residents are vaccinated (refer to Section 3: Vaccination). Encourage staff, family members and regular visitors such as hairdressers etc., volunteers, allied health and support workers to be vaccinated. This helps keep them healthy and reduces the likelihood of influenza being brought into the facility. • Keep vaccination records for staff and residents up-to-date, and ensure they are easily accessible when needed for an outbreak response.
Preparation and training in outbreak management and infection control for RCFs is relevant to outbreaks caused by any pathogen. A checklist of outbreak preparedness actions for RCFs can be found in Appendix 9.
6.2 RCF response to an outbreak of ILI Actions in response to an outbreak: NBsome are simultaneous: 6.2.1 Notify -ALL staff, residents, PHU, GPs, visitors (and others). 6 Outbreak preparedness & management checklists are in Appendices 9, 10, 11.

Notifications
It is important to notify the local public health authority early! PHU can assist with advice on investigation and management of potential outbreaks. Contact details for regional public health authorities are available in Appendix 15 The RCF response to an outbreak will depend on the nature of the institution and the setting of the outbreak. Larger institutions with dedicated infection control practitioners (ICP) may require little assistance, whilst others may look to PHU for advice. The public health unit (PHU) will require some essential information from RCFs including: • The name, contact number and email address of a designated person or position at the RCF who will be the point of contact for the PHU. These include details for after hours and weekends, and the name and contact number of the primary ICP or delegate at the RCF.
• The number of residents in the RCF, as well as the number with ILI, their symptoms, date of onset of symptoms, whether reviewed by a GP or medical officer, likely diagnosis, and investigations requested. • The total number of staff, and number of staff who are ill with ILI. • The name of the testing laboratory and results of any tests completed or pending.
• The initial infection control measures that have been implemented. • A floorplan, clearly showing the layout of different areas in the RCF.
• Current influenza vaccination rates and numbers for both residents and staff, i.e. those currently vaccinated.
To assess an outbreak, the RCF (and PHU) needs to determine the population at risk. This requires: • The total number of residents in the RCF, and the total number of staff employed at the facility, including casual workers, and nonresident-care staff.
• If the outbreak is restricted to one area/unit, the number of residents and staff associated with that area/unit. Refer to Appendix 14 for a generic PHU initial notification form.
Note. PHU: If requested, the PHU can provide advice regarding infection control, and assist the RCF to consider when to declare an outbreak. Refer to Section 4 for definitions of ILI, influenza and an outbreak of influenza. The PHU can supply the RCF with additional information on testing for influenza, including advice on collecting and storing specimens, and laboratory submission of samples (see Section 6.2.3). PHU personnel may discuss results already reported, as well as request a line list of those with ILI (refer to Section 6.2.4 and Appendix 13). It will be important for the RCF to promptly notify the following of the outbreak: • All staff (everyone employed in the RCF) and residents. • Visiting medical officers/GPs of residents, and arrange clinical review for ILI. • The laboratory where specimens will be sent for testing, if needed.
To increase awareness and encourage cooperation: • Warn visitors of the influenza risk including -scheduled allied health and service providers, and regular visitors such as family and friends.
• Place appropriate signage at the facility entrance and other strategic points.
• If transfer to hospital is required for any resident, notify the ambulance service and receiving hospital of the suspected/confirmed outbreak in the RCF, and clinical diagnosis status of the resident (well, ILI, or confirmed influenza).

Implement preliminary infection control measures
The initial outbreak response actions in an RCF are to investigate and confirm whether the outbreak is due to influenza, and concurrently initiate appropriate management of the outbreak (regardless of the respiratory pathogen involved).
Ideally, standard precautions are in routine use. However, as soon as an influenza outbreak is suspected, transmission-based control measures (such as isolation, droplet precautions and respiratory hygiene) should be implemented as well. Refer to Section 5 for detailed advice on PPE and Infection Control, and Appendix 7 for an initial response flow chart.

Testing of residents with ILI
Testing some residents with ILI for influenza is essential to establish a diagnosis. In an outbreak, several people meeting the ILI case definition should be tested (usually 4 to 6, but up to 10). Nose or throat swabs are collected for an influenza NAT/PCR test. Once three or more cases of ILI occur within 3 days, and at least one has a positive laboratory test for influenza, the outbreak is confirmed. Further cases of ILI are assumed to be due to influenza and should be treated as such. No clinical or public health benefit is derived from continuing to test those with ILI in a confirmed RCF influenza outbreak, unless requested by the treating clinician or the PHU.

Collate information onto a line list 203
A line list is a simple and useful record of both staff and residents who meet the ILI case definition, or are confirmed influenza cases.
The line list provides important information for the RCF outbreak control team about the number of affected residents, their symptoms and vaccination status, and can be used to summarise information each day. Additionally, the PHU may use a copy of the line list to track progress and inform advice provided to the RCF on management of the outbreak. An outbreak line list is cumulative; that is, it retains past information and is updated daily. It should include individual information such as: • Demographic details of cases (name, age/date of birth, sex, RCF area, etc.). • Symptomsonset date, type, and duration. • Results of any laboratory tests.
• Both vaccination and clinical status, including antiviral treatment.
Note. PHU: The local PHU may have a preferred line list format which they supply to an affected RCF. Example templates for line lists for residents and staff are available in Appendix 13. For large RCFs, ensure each area/unit is included in the line list or keep a separate line listing for each area affected by the outbreak. A separate line listing should be completed for staff with ILI. When completing a line list, it is important to understand that it is a cumulative document. All previous cases listed remain on the list, and each day new cases are added to the bottom of the list. An RCF will need to update the information recorded for previous cases, for example, with new test results, hospitalisation and deaths.
The use of a line-list continues throughout the outbreak response, but is particularly important in the initial phase to allow proper characterisation of the outbreak. Note. PHU: From the line-list, as appropriate: • Develop an epidemic curve, tracking the magnitude of the outbreak. • Review symptoms and duration of illness; these indicate 'what to look for'. • Follow up and review all laboratory tests results.
• Summarise information such as characteristics of cases, attack rate, severity of illness (morbidity), and deaths (mortality). • Track the vaccination status of those who are ill with confirmed influenza. 6.2.5 Confirm and declare an influenza outbreak Outbreaks can be caused by various infectious respiratory pathogens. If one or more respiratory samples from ILI cases in a suspected outbreak returns a positive laboratory result for influenza, then an influenza outbreak is confirmed. Confirming influenza as the pathogen is an important step that will guide decisions regarding control measures such as vaccination, and use of antiviral medications. 204 6.2.6 Forming an outbreak management team When a team is formed, it is important to meet regularly, usually daily at the height of the outbreak, to monitor the outbreak, initiate changes to response measures and to discuss outbreak management roles and responsibilities. Even a relatively small respiratory outbreak in an RCF is disruptive because of the risks of complications in vulnerable residents and transmission to staff, with resulting absenteeism. Early recognition of suspected outbreaks and swift management actions are essential for effective response to control spread.
Ideally, a full outbreak management team (OMT) should be formed by the RCF to coordinate the response. The OMT directs and oversees the management of all aspects of an outbreak, meeting at least daily during the peak of the outbreak. It considers the progress of the response, undertakes ongoing monitoring, deals with unexpected issues, and initiates changes, as required.
Several functions are critical within the OMT, and some roles may be performed by the same person. In reality, a small number of people often perform multiple roles and undertake many tasks. For further details, refer to Appendices 9 -12. The outbreak management team should initially meet daily to: • Direct and oversee the management of the outbreak. • Monitor the outbreak progress and initiate changes in response, as required.
• Liaise with GPs and PHU, as arranged.
• The Outbreak Management Team may include the following people: Chairperson (Facility Director, Manager, or Nursing Manager) The chairperson is responsible for co-ordinating outbreak control meetings, setting meeting times, agenda and delegating tasks. Secretary The secretary organises OMT meetings, notifies committee members of any changes, and records and distributes minutes of meetings. Outbreak Coordinator (Nurse / Infection Control Practitioner or delegate) The coordinator ensures that all infection control decisions of the OMT are carried out, and coordinates activities required to contain and investigate the outbreak. This role is often given to an Infection Control Practitioner(ICP) or delegate. Media spokesperson/s (Facility Director, or Manager, or delegate) Significant media interest in outbreaks in RCFs is common, especially if there are adverse outcomes. A media spokesperson from the OMT should be designated as the only individual with responsibility to provide information to the media. This media spokesperson is usually a representative from the RCF, but occasionally, can be from the PHU, if involved. In rare situations, there may be joint spokespeople, one from each organisation. Visiting General Practitioners 205 Some GPs may be available to participate in the OMT and their role should be identified during the planning process. It is valuable to identify a clinical lead amongst those GPs who attend a facility. In the management of an outbreak, the role of this person is important in facilitating assessment and management of ill residents, and in working with the RCF and PHU to implement control strategies. Public health authority staff An understanding of what assistance can be provided by the public health authority and role/responsibility clarification should be confirmed at the initial OMT meeting, although it is usually not necessary for PHU staff to be part of the OMT. Refer to Appendix 9 for an outbreak Plan checklist, Appendix 10 for details of OMT tasks and Appendix 11 for an OMT task checklist.

Infection control during an outbreak
During an influenza outbreak it is essential that infection control measures are put in place expeditiously to minimise the spread of disease in the facility. These procedures are detailed in Section 5. A checklist of infection control procedures to be considered in an outbreak can be found at Appendix 12.

Vaccination during an outbreak
During influenza outbreaks, the influenza vaccination records of all residents and staff should be reviewed as a priority. Influenza vaccination clinics may be arranged for unvaccinated residents and staff, and recommended for unvaccinated visitors. Alternatively, the RCF may recommend directing the person to consult their primary health provider for vaccination; remembering it takes around two weeks to develop a protective immune response following vaccination. 6.2.9 Antiviral medication during an outbreak Residents' GPs are responsible for prescribing antiviral medications. Antiviral use for case management -treatment • Early initiation of antiviral treatment (within 48 hours of symptom onset) in adults with confirmed influenza reduces the risk of secondary complications requiring antibiotic therapy, and hospitalisation. Provision of medication after this time to cases will decrease shedding time and reduce transmission but not affect the course of illness.
• To facilitate early case treatment in the context of an identified influenza outbreak, treatment on syndromic grounds may be warranted,29 particularly for individuals with underlying chronic conditions that place them at increased risk of a severe clinical course with influenza, and for whom observational studies suggest the greatest clinical benefit.

Antiviral use for prophylaxis
The widespread use of antivirals in institutions that house residents at high risk of severe disease and death from influenza is supported by observational cohort studies and one randomised controlled trial. During an outbreak, other facility residents will have been, or may become, exposed to infectious residents. The provision of antivirals works as early treatment for those incubating disease and reduces shedding in those infected. Data are available to support the premise that this treatment/shedding reduction process prevents continued spread in the facility. (Appendix 16) Antiviral prophylaxis should only be used in addition to other outbreak control measures. The decision to administer antivirals as prophylaxis should be made by the OMT in collaboration with local public health authorities and residents' GPs, depending on local arrangements. If recommended, to optimise the chances of reducing transmission and bring the outbreak under control, antiviral prophylaxis should be given to ALL asymptomatic residents (regardless of vaccination status) and ALL unvaccinated staff.
Prompt administration of medication and estimated levels of compliance should be considered in the decision to use antivirals for prophylaxis. Hence, outbreak plans should incorporate the expediency of acquiring and administrating medication (for residents), an acceptable compliance level and a response option for poor compliance.
If antivirals are used for influenza prophylaxis in an RCF: • Ideally, antivirals should be commenced by all targeted residents and staff within 24 hours, AND • Medication safety issues, including renal function/renal insufficiency, must be appropriately considered during the prescribing phase.
• RCF staff need to be aware of the most common side effects, e.g. for oseltamivir, nausea and vomiting.
Further information is available in the appendices including: Appendix 16.  The OMT should review all control measures and consider seeking further advice from PHU if: • The outbreak comprises more than 10 cases. • The rate of new cases is not decreasing. • Three (3) or more residents are hospitalised related to influenza, OR • An influenza-related death has occurred: telephone to notify the PHU of this.
Specialised advice is available from the following sources: • A local state, territory or regional PHU. • Infection control practitioners may be available for advice in local hospitals, state and territory health departments, or as private consultants.
• Geriatricians or Infectious Disease physicians may be approached for specialist management of complex infections.
6.4 Concluding the outbreak 6.4.1 Declaring the outbreak over The OMT, with approval from the local public health authority, has responsibility for declaring the outbreak is over. The time from the onset of symptoms of the last case until the outbreak is declared over can vary, and depends on whether the last case was a resident or staff member. Generally, an influenza outbreak can be declared over if no new cases occur within 8 days following the onset of symptoms in the last resident case (8 days is the sum of the usual infectious period [5 days] plus maximum incubation period [3days]). A decision to declare the outbreak over should be made by the OMT, in consultation with the PHU. The OMT may take decisions about ongoing RCF surveillance after declaring the outbreak over, considering the following needs: • To maintain general infection control measures. • To monitor the status of ill residents, communicating with the public health authority if their status changes.
• To notify any late, influenza-related deaths to the PHU. • To alert the PHU to any new cases, signaling either re-introduction of infection or previously undetected ongoing transmission. • To advise relevant state/territory/national agencies of the outbreak, including the Commonwealth Department of Health and Ageing state/territory office for outbreaks in Aged Care facilities, if applicable.

Communication
Once the outbreak has been declared over, the OMT should notify all individuals and agencies involved in the investigation of the declaration. The Outbreak Management Team is responsible for notifying the following people: • All staff and residents. • Visiting GPs of residents. • Visiting service providers, families of residents and other regular visitors.
• The ambulance service and any relevant receiving hospitals or other RCFs. 6.4.3 Organising a debrief after the outbreak Following a declaration that an outbreak is over, it is important for all parties to reflect on what worked well during the outbreak and which policies, practices or procedures need to be modified to improve responses for future outbreaks. Although a debrief may seem unnecessary for outbreaks of short duration involving a small number of cases, the OMT in collaboration with the local PHU should consider a debrief for any outbreak with many cases, a prolonged outbreak, or one with unusual features in relation to outbreak management. Outbreak investigation is a core function of PHUs, and after respiratory outbreaks in RCFs, a debrief whether formal or informal, is recommended in partnership with the RCF outbreak management team.
Audits are commonly used in clinical medical and nursing practice as part of continuous quality improvement, and may be an appropriate method by which to conduct a debrief. Australian public health practitioners and researchers have proposed a guide for an outbreak audit process, with a framework for deciding which outbreak investigations to audit, an approach for conducting a successful audit, and a template for trigger questions. This tool enables agencies such as RCFs to assess their outbreak response against best practice. If a formal debrief or an audit is undertaken, the OMT should arrange a meeting between key RCF staff, PHU staff, and other relevant agencies, to review the course and management of the outbreak. The purpose of this meeting is to identify what worked well, and what could be improved for future outbreaks. For preference, this meeting should occur within two weeks of the outbreak being declared over. A debrief provides the opportunity to identify strengths and weaknesses in outbreak response and investigation processes, and provide information to help improve the management of similar outbreaks in the future. It should involve all members of the OMT and 209 any others who participated in the response to the outbreak.
Preparation, training and experience for RCF personnel in outbreak management, response, and infection control for influenza is directly applicable to outbreaks in RCFs caused by any respiratory pathogen; much applies to gastrointestinal illness.
California 7. Respiratory hygiene/cough etiquette is necessary for all individuals year-long. Influenza virus is transmissible to others for 24 hours before an individual has typical signs and symptoms of influenza. Additionally, older individuals and those who are immunocompromised may not present with classical signs of influenza (2,4,5). Containing all respiratory secretions (source containment) at all times is therefore necessary.
8. When an influenza outbreak in a SNF is suspected (2,13), prompt and simultaneous implementation of interventions (https://academic.oup.com/cid/article/68/6/e1/5251935) can minimize the size and scope of the outbreak and adverse impact on resident health. Outbreak management requires a collaborative effort among all HCP with specific task assignments and tracking their completion. a. Prompt administration of antiviral agents for treatment and prophylaxis will shorten an outbreak (6, 7). b. Communicating with residents, HCP, and families, during an outbreak provides needed reassurance. c. Communicating with the local health department will facilitate additional guidance during an outbreak. Educate and train HCP. Reinforce sick leave policies. Remind HCP not to report to work when ill. Reinforce adherence to infection prevention and control measures, including hand hygiene and selection and use of personal protective equipment (PPE). Have HCP demonstrate competency with putting on and removing PPE. Educate both facility-based and consultant personnel (e.g., wound care, podiatry, barber) and volunteers. Including consultants is important because they often provide care in multiple facilities and can be exposed to or serve as a source of pathogen transmission.
Educate residents and families including: information about COVID-19 actions the facility is taking to protect them and their loved ones, including visitor restrictions actions residents and families can take to protect themselves in the facility Provide Supplies for Recommended Infection Prevention and Control Practices Hand hygiene supplies: Put alcohol-based hand sanitizer with 60-95% alcohol in every resident room (ideally both inside and outside of the room) and other resident care and common areas (e.g., outside dining hall, in therapy gym). Make sure that sinks are well-stocked with soap and paper towels for handwashing.
Respiratory hygiene and cough etiquette: Make tissues and facemasks available for coughing people. Consider designating staff to steward those supplies and encourage appropriate use by residents, visitors, and staff.
Make necessary Personal Protective Equipment (PPE) available in areas where resident care is provided. Put a trash can near the exit inside the resident room to make it easy for staff to discard PPE prior to exiting the room, or before providing care for another resident in the same room.
Facilities should have supplies of: facemasks respirators (if available and the facility has a respiratory protection program with trained, medically cleared, and fit-tested HCP) gowns gloves eye protection (i.e., face shield or goggles).
Environmental cleaning and disinfection: Make sure that EPA-registered, hospital-grade disinfectants are available to allow for frequent cleaning of high-touch surfaces and shared resident care equipment. Refer to List Nexternal icon on the EPA website for EPA-registered disinfectants that have qualified under EPA's emerging viral pathogens program for use against SARS-CoV-2.
Evaluate and Manage HCP with Symptoms of Respiratory Illness Implement sick leave policies that are non-punitive, flexible, and consistent with public health policies that allow ill HCP to stay home. As part of routine practice, ask HCP (including consultant personnel) to regularly monitor themselves for fever and symptoms of respiratory infection. Remind HCP to stay home when they are ill. If HCP develop fever or symptoms of respiratory infection while at work, they should immediately put on a facemask, inform their supervisor, and leave the workplace. Consult occupational health on decisions about further evaluation and return to work. When transmission in the community is identified, nursing homes and assisted living facilities may face staffing shortages. Facilities should develop (or review existing) plans to mitigate staffing shortages.

Consider New Policies and Procedures for Visitors
Because of the ease of spread in a long-term care setting and the severity of illness that occurs in residents with COVID-19, facilities should discourage visitation and begin screening visitors even before COVID-19 is identified in their community. Facilities should: Send letters or emails to families advising them to consider postponing or using alternative methods for visitation (e.g., video conferencing) during the next several months. Post signs at the entrances to the facility instructing visitors to not enter if they have fever or symptoms of a respiratory infection.

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Consider having visitors sign visitor logs in case contact tracing becomes necessary. Ask all visitors about fever or symptoms of respiratory infection. Restrict anyone with: Fever or symptoms of respiratory infection (e.g., cough, sore throat, or shortness of breath). International travel within the last 14 days to affected countries. Information on high-risk countries is available on CDC's COVID-19 travel website. Contact with an individual with COVID-19. When allowed, visitors should be encouraged to frequently perform hand hygiene and limit their movement and interactions with others in the facility (e.g., confine themselves to the resident's room).
When visitor restrictions are implemented, the facility should facilitate remote communication between the resident and visitors (e.g., video-call applications on cell phones or tablets), and have policies addressing when and how visitors might still be allowed to enter the facility (e.g., end of life situations). Evaluate and Manage Residents with Symptoms of Respiratory Infection Ask residents to report if they feel feverish or have symptoms of respiratory infection. Promptly assess residents for fever and symptoms and signs of respiratory infection upon admission and throughout their stay in the facility. Implement appropriate infection prevention practices for symptomatic residents: If a resident has severe respiratory infection, or a cluster (e.g., ≥ 3 residents or HCP with new-onset respiratory symptoms over 72 hours) of residents has symptoms of respiratory infection, or there is an increase in cases reported in the community, begin active monitoring of all residents and HCP in the facility for signs and symptoms.
Notify the health department about residents with severe respiratory infection and clusters of respiratory infection. See State-Based Prevention Activities for contact information for the healthcare-associated infections program in each state health department. CDC has resources for performing respiratory infection surveillance in long-term care facilities during an outbreak. In general, when caring for residents with undiagnosed respiratory infection use Standard, Contact, and Droplet Precautions with eye protection unless the suspected diagnosis requires Airborne Precautions (e.g., tuberculosis). This includes restricting residents with respiratory infection to their rooms. If they leave the room, residents should wear a facemask (if tolerated) or use tissues to cover their mouth and nose. Continue to assess the need for Transmission-Based Precautions as more information about the resident's suspected diagnosis becomes available If COVID-19 is suspected, based on evaluation of the resident or prevalence of COVID-19 in the community, Residents with known or suspected COVID-19 do not need to be placed into an airborne infection isolation room (AIIR) but should ideally be placed in a private room with their own bathroom. Room sharing might be necessary if there are multiple residents with known or suspected COVID-19 in the facility. As roommates of symptomatic residents might already be exposed, it is generally not recommended to separate them in this scenario. Public health authorities can assist with decisions about resident placement. Facilities should notify the health department immediately and follow the Interim Infection Prevention and Control Recommendations for Patients with COVID-19 or Persons Under Investigation for COVID-19 in Healthcare Settings, which includes detailed information regarding recommended PPE. If a resident requires a higher level of care or the facility cannot fully implement all recommended precautions, the resident should be transferred to another facility that is capable of implementation. Transport personnel and the receiving facility should be notified about the suspected diagnosis prior to transfer. While awaiting transfer, symptomatic residents should wear a facemask (if tolerated) and be separated from others (e.g., kept in their room with the door closed). Appropriate PPE should be used by healthcare personnel when coming in contact with the resident.

Additional Measures
Minimize group activities inside the facility or field trips outside of the facility. Develop criteria for halting group activities and communal dining, closing units or the entire facility to new admissions, and restricting visitation. Create a plan for cohorting residents with symptoms of respiratory infection, including dedicating HCP to work only on affected units. In addition to the actions described above, these are things facilities should do when there are cases in their community but none in their facility.

Policies and Procedures for Visitors
Visitation should be limited further to only those who are essential for the resident's emotional well-being and care. The facility should send communications to families advising the COVID-19 has been identified in the community and re-emphasizing the importance of postponing visitation. Ideally, visits should be scheduled in advance during a limited number of hours. Any visitors (that are permitted after screening) should wear a facemask while in the building and restrict their visit to the resident's room.

Healthcare Personnel Monitoring and Restrictions
Restrict non-essential personnel including volunteers and non-essential consultant personnel (e.g., barbers) from entering the building. Screen all HCP at the beginning of their shift for fever and respiratory symptoms. Actively take their temperature and document absence of shortness of breath, new or change in cough, and sore throat. If they are ill, have them put on a facemask and self-isolate at home. HCP who work in multiple locations may pose higher risk and should be asked about exposure to facilities with recognized COVID-19 cases. Consider implementing universal use of facemasks for HCP while in the facility.

Resident Monitoring and Restrictions
Actively monitor all residents (at least daily) for fever and respiratory symptoms (shortness of breath, new or change in cough, and sore throat). If positive for fever or symptoms, implement recommended IPC practices Cancel group field trips and activities and consider cancelling communal dining. In addition to the actions described above, these are things facilities should do when there are cases in their facility or sustained transmission in the community.

Policies and Procedures for Visitors:
Restrict all visitors to the facility. Exceptions might be considered in limited circumstances (e.g., end of life situations). In those circumstances the visitor should wear a facemask and restrict their visit to the resident's room.
Healthcare Personnel Monitoring and Restrictions: Implement universal use of facemask for HCP while in the facility. Consider having HCP wear all recommended PPE (gown, gloves, eye protection, N95 respirator (or facemask if not available)) for the care of all residents, regardless of presence of symptoms. Implement protocols for extended use of eye protection and facemasks.

Resident Monitoring and Restrictions:
Encourage residents to remain in their room. If there are cases in the facility, restrict residents (to the extent possible) to their rooms except for medically necessary purposes. If they leave their room, residents should wear a facemask, perform hand hygiene, limit their movement in the facility, and perform social distancing (stay at least 6 feet away from others). In addition to cancelling group field trips and activities, cancel communal dining. Implement protocols for cohorting ill residents with dedicated HCP ECRI, 2020; Country: USA, Sponsor: ECRI Scope: 2003 outbreak of severe acute respiratory syndrome ECRI has established the following levels of concern related to the risks of infection associated with the circumstances described: No infection concern. There is no concern about infection from external surfaces that have been cleaned and disinfected.
Minimal infection concern. If the interior of a device is exposed to SARS-CoV from room air-most likely air drawn into the device by a cooling fan-there may be some concern about contamination. Until more is known about the transmission of SARS, we suggest that hospitals err on the side of caution and use simple protective measures for even such minimal-risk situations. These measures are readily implemented (see Specific Protective Steps, below). Note, however, that the warm air that is generally circulating inside a device with a cooling fan promotes drying and dilution of contaminants, which may reduce the viability of some viruses.
Higher infection concern. Surfaces that have been in contact with the patient's oral secretions or other excretions and cannot be readily disinfected pose a bigger concern. This is because, although the infection risk is still likely to be extremely low on these surfaces, there is a greater probability that the virus has remained viable. Such surfaces include the following: Breathing circuits (including ventilator accessories and any portions of the breathing circuit inside ventilators), suction devices and systems, or any other devices that are exposed to the patient's oral secretions (including contaminated condensate), urine, feces, and other excretions HEPA filtration systems, which are installed systems or portable systems (i.e., mobile high-efficiency-filter air cleaners [MHEFACs]) used to control room air contamination levels and ensure negative pressure in isolation rooms Any handheld items or other items that can be found in beds, including nurse call buttons, remote controls for televisions, pillow speakers, blood pressure cuffs, and telemetry transmitters Highest infection concern. The highest level of concern is posed by entering the room of a SARS patient without appropriate personal protective equipment (PPE). This is because of the close proximity to the patient, the potential risk of exposure to droplet secretions from coughs and sneezes, exposure to contaminated surfaces, and possible exposure associated with aerosol-generating procedures. Keep in mind that even the highest level of risk is not an insurmountable concern as long as servicing personnel take the protective steps listed in the next section.

Specific Protective Steps
The following practices should be implemented to protect personnel while they are maintaining and repairing equipment that has been used on-or that has been in the same room as-patients who have or who are suspected of having SARS. For the most part, these represent good infection control practices that should be followed when servicing any device, independent of SARS concerns.
1. Do not enter the room of a SARS patient Access to such rooms should be restricted to essential personnel only. This is to ensure the safety of personnel and to minimize disease transmission. However, if you must enter the room, follow relevant hospital procedures to minimize the exposure risks.
2. Minimize exposure of medical equipment to SARS Before a patient with SARS is brought into a room, remove any unessential equipment. Use breathing-circuit filters to protect exhalation valves and other ventilation components from contamination (for more on this topic, see the Guidance Article Mechanical Ventilation of SARS Patients: Lessons from the 2003 SARS Outbreak). Use disposable devices or accessories for SARS patients whenever possible.
3. Observe proper hand hygiene Frequent and thorough handwashing with soap and water is essential. Alcohol-based handrubs can be used when hands are not visibly soiled and handwashing facilities are not immediately available. Personnel should not rub their eyes or touch their mouth, nose, or other mucous membranes while working on exposed equipment. While wearing gloves, personnel should also avoid touching other surfaces in the room that are not involved in the equipment repair (e.g., doorknobs, telephones, test equipment, computer terminals, keyboards, manuals). In addition, personnel should not eat, drink, chew gum, smoke, or apply cosmetics until they have removed all protective wear and washed their hands. 4. Use proper decontamination and transport procedures Equipment should not be transported until it has been cleaned and disinfected and disposables have been removed by housekeeping, central processing, or other appropriate personnel. (Note that commonly used disinfectants are effective against the SARS virus.) If equipment from the room of a SARS patient must be removed before the exterior can be cleaned and disinfected, follow any hospital policies on transporting contaminated devices. 5. Choose an appropriate work area Equipment that poses particular infection concerns should be worked on in designated areas where servicing can be performed without the risk of infecting patients or other employees. These areas should not be near any patient care areas, food preparation or storage areas, medication areas, or other clean areas.
6. Wear protective equipment when appropriate For personnel working on minimal-risk surfaces, we recommend using the following PPE: Gloves Clean, nonsterile gown, apron, or laboratory coat Eye protection (e.g., goggles) A face shield is an alternative form of eye protection. Although a face shield should provide adequate protection against an occasional minor splatter that may occur during servicing, the U.S. Occupational Safety and Health Administration (OSHA) requires the use of goggles (or special protective eyeglasses) when eye protection is used. CDC, on the other hand, recommends goggles or a face shield for protection against a splash or spray of body fluids.

Respiratory protection
Update: As of February 3, 2020, CDC recommends, in the case of the COVID-19 outbreak, that staff "use respiratory protection (i.e., a respirator) that is at least as protective as a fit-tested NIOSH-certified disposable N95 filtering facepiece respirator before entry into the patient room or care area." That recommendation matches the guidance ECRI Institute initially issued (in June 2003) in the case of the 2003 SARS outbreak.
Note, however, that respiratory protection recommendations can evolve over time. For example, as new information about airborne transmission of SARS became available and as concern lessened, we updated our recommendations for that circumstance: In February 2004, we specified that it would be prudent for personnel working with the equipment to wear a surgical mask, but that there was no significant benefit to using an N95 respirator for that application, particularly in light of the considerable time and effort that respirator use entails. 7. Before starting work . . . If there is any question about whether the exterior surfaces of the equipment were adequately disinfected, including the bottom and back, disinfect those surfaces immediately. Also, if disposable components have not already been discarded, do that right away as well. If the equipment is not needed immediately, ECRI suggests allowing time-several hours to overnight-for viruses to die before servicing is carried out. (Note, however, that this waiting period should not be seen as a substitute for other infection control procedures.) 8. If the interior of the equipment is dusty . . . Use a vacuum cleaner with a HEPA filter to remove dust as soon as adequate access is gained during disassembly and before working on the interior. Never blow on the equipment or use compressed air to remove dust or other particulates. 9. Clean up when done. Clean and disinfect the work area after servicing is complete. 10. If an exposure occurs . . . If you believe you have been exposed to SARS-CoV while unprotected, consult with the hospital's infection control practitioner, epidemiologist, or employee health staff for the procedures to follow.
Manitoba Health Seniors and Active Living, 2019; Country: Canada, Sponsor: Not reported Scope: these guidelines support infection prevention and control (IP&C) professionals, health care organizations and health care providers in developing, implementing and evaluating IP&C policies, procedures and programs to improve the quality and safety of health care and patient outcomes Active surveillance for additional cases should be implemented as soon as possible when one healthcare-associated laboratoryconfirmed influenza case is identified in a hospital or one case of laboratory-confirmed influenza is identified in a long-term care facility (A-III).
49. Outbreak control measures should be implemented as soon as possible, including antiviral chemoprophylaxis of residents/ patients, and active surveillance for new cases, when 2 cases of healthcare-associated laboratory-confirmed influenza are identified within 72 hours of each other in residents or patients of the same ward or unit (A-III). 50. Implementation of outbreak control measures can be considered as soon as possible if one or more residents or patients has suspected healthcare-associated influenza and results of influenza molecular testing are not available on the day of specimen collection (B-III).
Which Residents/Patients Should Be Considered to Have Influenza and Be Treated With Antivirals During an Influenza Outbreak in a Long-term Care Facility or Hospital? Recommendations 51. When an influenza outbreak has been identified in a longterm care facility or hospital, influenza testing should be done for any resident/patient with one or more acute respiratory symptoms, with or without fever, or any of the following without respiratory symptoms: temperature elevation or reduction, or behavioral change (A-III). 52. Empiric antiviral treatment should be administered as soon as possible to any resident or patient with suspected influenza during an influenza outbreak without waiting for the results of influenza diagnostic testing (A-III).
To Control an Influenza Outbreak in a Long-term Care Facility or Hospital, Should Antiviral Chemoprophylaxis Be Administered to Exposed Residents/Patients? Recommendation 53. Antiviral chemoprophylaxis should be administered as soon as possible to all exposed residents or patients who do not have suspected or laboratory-confirmed influenza regardless of influenza vaccination history, in addition to implementation of all other recommended influenza outbreak control measures, when an influenza outbreak has been identified in a long-term care facility or hospital (A-III).
During an Influenza Outbreak at a Long-term Care Facility, Should Antiviral Chemoprophylaxis Be Administered to Residents Only on Affected Units or to All Residents in the Facility? Recommendation 54. Antiviral chemoprophylaxis should be administered to residents on outbreak-affected units, in addition to implementing active daily surveillance for new influenza cases throughout the facility (A-II).
Which Healthcare Personnel Should Receive Antiviral Chemoprophylaxis During an Institutional Outbreak? Recommendations 55. Clinicians can consider antiviral chemoprophylaxis for unvaccinated staff, including those for whom chemoprophylaxis may be indicated based upon underlying conditions of the staff or their household members (see recommendations 40-44) for the duration of the outbreak (C-III). 56. Clinicians can consider antiviral chemoprophylaxis for staff who receive inactivated influenza vaccine during an institutional influenza outbreak for 14 days postvaccination (C-III). 57. Clinicians can consider antiviral chemoprophylaxis for staff regardless of influenza vaccination status to reduce the risk of short staffing in facilities and wards where clinical staff are limited and to reduce staff reluctance to care for patients with suspected influenza (C-III).
How Long Should Antiviral Chemoprophylaxis Be Given to Residents During an Influenza Outbreak in a Long-term Care Facility? Recommendation 58. Clinicians should administer antiviral chemoprophylaxis for 14 days and continue for at least 7 days after the onset of symptoms in the last case identified during an institutional influenza outbreak (A-III).

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Victoria State Government, 2018; Country: Australia, Sponsor: Victoria State Government Scope: guidelines apply to all residential care facilities (RCFs) in Victoria. This refers to any public or private aged care, disability services or other congruent accommodation setting in Victoria where residents are provided with personal care or health care by facility staff. Prevention and preparedness Facilities must ensure they are prepared for respiratory outbreaks prior to the start of the influenza season (March / April).

Antiviral medication
There is good evidence that the timely administration of antiviral medication, as treatment and/or prophylaxis (prevention), can reduce the duration of an influenza outbreak and the number of residents who are affected. As per the Communicable Disease Network Australia (CDNA) Guidelines for the Prevention, Control and Public Health Management of Influenza Outbreaks in Residential Care Facilities in Australia (2017) <http://www.health.gov.au/internet/main/publishing.nsf/Content/cdna-fluguidelines.htm>, the department recommends the use of antiviral medications in symptomatic residents during laboratory confirmed influenza outbreaks, and the consideration of prophylaxis for asymptomatic residents (regardless of vaccination status) and unvaccinated staff3. The department recommends that facilities have clear internal policies in place regarding the use of antiviral medication as prophylaxis and/or treatment of influenza during outbreaks. It is strongly recommended that clinical staff liaise with residents' families and GPs / clinicians regarding this aspect of the outbreak management plan prior to an outbreak occurring. Where possible, a decision should be made prior to the influenza season regarding the intention to use antiviral medication in an outbreak setting for each resident which should be documented in the resident's file and/or the facility's outbreak management plan.
Identifying respiratory outbreaks 4.1 Identifying an outbreak This section includes how to identify and whom to report outbreaks to 5 Outbreak management 5.1 Establishing an outbreak management team It is the facility's responsibility to self-manage the outbreak. If possible, an internal outbreak management team (OMT) should be established to direct, monitor and oversee the outbreak, confirm roles and responsibilities and liaise with CDPC.

Implementing infection prevention and control measures 5.2.1 Standard precautions
Standard precautions refer to the work practices required to achieve a basic level of infection prevention and control. They apply to all residents, regardless of suspected or confirmed infection status, in all health care and long-term residential care settings. and assessed as being suitable roommates.
• When a single room is not available, and cohorting of ill residents is not possible, a resident with a respiratory illness may be cared for in a room with a roommate(s) who does not have a respiratory illness. This is the least favourable option. In this case -residents' beds should be separated by at least one metre -the curtain should be kept drawn between residents' beds the roommate must be vaccinated against influenza with the current season's vaccine prior to that year's season starting or at least two weeks prior to being in the same room as the ill resident. • In shared rooms (both cohorted with like illness and residents with and without illness), staff must ensure they change their PPE and perform hand hygiene when moving between residents.

Resident movement
• Where possible, residents in droplet precautions should be restricted to their room for five days after symptom onset. Residents may attend necessary medical or procedural appointments. • Residents with a respiratory illness who must leave their room should wear a mask if tolerated.
• Consider placing all residents at least one metre apart in communal areas such as dining, lounge and other areas, where possible, during a respiratory outbreak. • Communicate the respiratory illness status of the resident to other healthcare facilities and services before transfer so that appropriate infection prevention and control precautions can be implemented at the accepting facility.

Signage
A droplet precaution sign must be placed outside symptomatic residents' rooms to alert staff and visitors to the requirement for transmission-based precautions.

Personal protective equipment
All staff and visitors entering the room of a person with a respiratory illness should wear a single use face mask for close contact, generally within one metre. For further information regarding mask use see section 5.2.1.2.2 Single use face masks. Gowns, gloves and protective eyewear need only be worn as per standard precautions, that is, if contact or splash with blood or body fluids is anticipated.

Equipment and instruments/devices
Use disposable equipment where possible (for example, blood pressure cuffs) or dedicate use of non-disposable equipment to any residents with a respiratory illness. If equipment must be shared (for example, lifting machine) for multiple residents, ensure the equipment has been cleaned and disinfected before use on another resident. Consider cohorting equipment to use for patients in droplet precautions, or to a wing or unit under isolation. If equipment is cohorted, it must still be cleaned and disinfected between each patient use.

Linen and laundry items
Handle, transport, and process used linen or items requiring laundering (for example, clothing) in a manner that avoids contamination of air, surfaces and persons. If linen or resident clothing is laundered onsite compliance with the Australian Standard AS/NZS 4146:2000 Laundry Practice is required. No additional precautions are required for the management of linen for residents with influenza or other respiratory infections. Linen and clothing items from residents with a respiratory illness do not need to be segregated or laundered separately.

Eating utensils
Crockery and cutlery should be washed in a dishwasher or if not available by hand using hot water and detergent, rinsed in hot water and dried. The use of disposable cutlery or separation of cutlery and crockery during an outbreak is not required.

Waste management
Ensure waste is appropriately segregated into the different waste streams, for example, general, recyclable, or clinical and related waste. Storage and handling of all waste must meet the Environment Protection Authority (EPA) Victoria legislative requirements. For more information refer to EPA Victoria's Clinical and Related Waste -Operational Guidance <www.epa.vic.gov.au/business-andindustry/guidelines/waste-guidance/clinical-waste-guidance>. All gloves, masks, protective eyewear or gowns used whilst caring for a resident with influenza should be disposed of into clinical waste (yellow bin or bag).

Ceasing droplet precautions
Generally, people with influenza are considered infectious for five days. Droplet precautions should therefore continue for at least five days after symptom onset.

Environmental cleaning and disinfection
Influenza viruses are able to survive on environmental surfaces, particularly hard surfaces, for periods of one to two days. Infection can occur through contact with contaminated surfaces then infecting oneself or others by touching eyes, nose or mouth with contaminated hands. As such, regular cleaning and disinfection of surfaces should be undertaken during a suspected or confirmed outbreak to minimise the spread of influenza and other respiratory viruses.

Visitors and communal activities
During an outbreak, where possible, minimise the movement of visitors into and within the facility. Facilities should consider implementing the following strategies.
• Suspend all group activities, particularly those that involve visitors (for example, musicians). • Postpone visits from non-essential external providers (for example, hairdressers). • Inform regular visitors and families of residents of the respiratory outbreak and request that they only undertake essential visits. • Ask visitors who do visit an ill resident to visit only the ill resident wear PPE as directed by staff enter and leave the facility directly without spending time in communal areas -perform hand hygiene before entering and after leaving the resident's room.

Staff
For suspected or confirmed cases of respiratory illness in residents caused by influenza it is preferable that only staff who have been vaccinated for influenza provide care for these residents. During a confirmed influenza outbreak unvaccinated staff are recommended to attend work only if they are asymptomatic and wear a single use face mask, or are asymptomatic and taking appropriate antiviral prophylaxis. All staff members (vaccinated and unvaccinated) should self-monitor for signs and symptoms of respiratory illness and self-exclude if unwell. Staff with respiratory illnesses should be excluded from work for the period during which they are infectious (generally five days after the onset of the acute illness or until symptoms have ceased). During an outbreak, wherever possible, HCWs should not move between wings or units of the facility to provide care for other residents. This is particularly important if not all wings/units are affected by the outbreak. It is preferable to cohort staff to areas (in isolation or not in isolation) for the duration of the outbreak. Unvaccinated staff who have been working in the outbreak affected area should not be moved as they may be incubating infection. They should be offered immediate influenza vaccination. Please note that vaccination may not prevent illness if already incubating. A protective immune response takes approximately two weeks to develop.

Admissions and transfers
5.2.7.1 New admissions An ongoing outbreak does not mean the facility has to go into complete "lock down". It is preferable that admission of new residents to an affected unit during an outbreak does not take place. Where new admissions are unavoidable, new residents and their families must be informed about the current outbreak and adequate outbreak control measures must be in place for these new residents. Families may wish to make alternative arrangements until the outbreak is over.

Re-admission of cases
The re-admission of residents who met the case definition and have been hospitalised for their illness is permitted, provided of these viral and mixed infections. . In the case of seasonal influenza outbreaks or a pandemic situation, the national recommendations should be followed.
PHAC, 2010; Country: Canada Sponsor: Public Health Agency of Canada Scope: infection prevention and control guidance to healthcare workers in the management of patients with suspected or confirmed seasonal influenza Source Control, achieved through administrative and engineering measures, is the most effective way to prevent the transmission of infectious agents in all healthcare settings. The most effective way to prevent and control seasonal influenza is through immunization of both healthcare workers and patients.
In addition to Routine Practices, patients with suspected or confirmed seasonal influenza in acute care and LTC settings should be placed on Droplet and Contact Precautions.
hands are visibly soiled. Other types of waterless products may contain either no alcohol or alcohol in concentrations of less than 60%. There is no efficacy data on these products, and they should not be used for hand hygiene in healthcare settings.

Accommodation
Patients suspected or confirmed to have influenza should be cared for in single rooms if possible. Perform a risk assessment to determine patient placement and/or suitability for cohorting when single rooms are limited or if in a LTC setting. Patients who are known to have influenza should be cohorted with suitable roommates. If cohorting is not possible and a cubicle or designated bedspace is used in a shared room, privacy curtains should be drawn between beds. Infection control signage should be placed at the room entrance indicating Droplet and Contact Precautions required upon entry to the room. 8. Patient Flow/Activities Patients with ILI 5 should be restricted to their room until symptoms have resolved. Participation in group activities should be restricted while the patient is symptomatic. Movement/transport of patients with suspected or confirmed influenza should be restricted to essential diagnostic and therapeutic tests only. Transfer within facilities should be avoided unless medically indicated. If transport is necessary, transport services and personnel in the receiving area should be advised of the required precautions for the patient being transported. Patients with influenza who leave their room for medical reasons (i.e., essential diagnostic and therapeutic tests) should wear a mask and adhere to respiratory hygiene. 9. Personal Protective Equipment (PPE) a) PPE in addition to Routine Practices • Facial protection (masks and eye protection, face shields, mask with visor attachment) should be worn when within 2 metres of a patient with suspected or confirmed influenza. • In acute care settings, gloves should be worn when entering the room of a patient with suspected or confirmed influenza. • In LTC settings, gloves should be worn for direct personal care with the patient or if direct contact with frequently touched environmental surfaces is anticipated. • A long-sleeved gown should be worn if it is anticipated that clothing or forearms will be in direct contact with the patient or with environmental surfaces or objects in the patient care environment. • Remove all PPE just before leaving the patient's room and discard in a hands-free waste or linen receptacle within the room. • Hand hygiene should be performed after removing gloves and gown, before removing facial protection, and after leaving the room. Note: In a shared room/cohort setting, facial protection may be worn for the care of successive patients. b) Aerosol generating medical procedures (AGMPs) • AGMPs should only be performed on patients with confirmed or suspected influenza if medically necessary.
• The number of HCWs present should be limited to only those essential for patient care and support. • Wherever possible, the HCWs present during the procedure should be limited to those who have received influenza vaccine. g. Consider chemoprophylaxis for all unvaccinated HCWs, unless contraindications exist. h. Consider excluding unvaccinated HCWs who are not taking chemoprophylaxis from direct patient care. i. Consider influenza vaccination (unless contraindications exist) for unvaccinated HCWs who receive chemoprophylaxis; these individuals may continue to work without restrictions.
MOHLTC, 2018; Country: Canada Sponsor: Ontario Ministry of Health and Long-term Care Scope: assist long-term care facilities and public health units with prevention, detection and management of respiratory infection outbreaks 3.1 Outbreak Management Step 1 -Assess the Suspect or Confirmed Outbreak, Establish a Preliminary Outbreak Case Definition, and Begin a Line-list.
Step 3 -Declare an Outbreak in your LTCH and Notify the Local Medical Officer of Health or Designate at your PHU of the Suspect or Confirmed Outbreak.
Step 4 -Notify Appropriate Individuals Associated with the LTCH of the Outbreak and Establish OMT Membership.
Step 5 -Call an initial OMT Meeting.
Step 6 -Communicate the Results of Laboratory Tests Step 7 -Monitor the Outbreak on an Ongoing Basis.
Step 8 -Declare the Outbreak Over.

General IPAC Measures 4.1.2 Hand Hygiene
Four Moments for HH: 1.Before initial resident/resident environment contact. 2.Before invasive/aseptic procedures. 3.After body fluid exposure risk and contact with blood, body fluids, secretions and excretions. 4.After resident/ resident environment contact.

Personal Protective Equipment
PPE is used alone or in combination to prevent exposure, by placing a barrier between the infectious source and one's own mucous membranes, airways, skin and clothing.

Control of Respiratory Infection Outbreaks in Long-Term Care Homes
The selection of PPE is based on the nature of the interaction with the resident and/or the likely mode(s) of transmission of infectious agents. Selection of the appropriate PPE is based on the risk assessment (e.g., interaction, status of resident) that dictates what is worn to break the chain of transmission. The selection of controls should be based on a hierarchy of controls approach. PPE ranks lowest in the hierarchy of controls. PPE is a last line of defense for workers against hazards related to infectious agents that cannot otherwise be eliminated or controlled.
LTCHs must ensure that staff has sufficient supplies of, and quick, easy access to, the PPE required. As well, LTCHs should provide education in the proper selection and use of PPE to all health care providers and other staff who have the potential to be exposed to blood and body fluids. LTCHs should also consider the requirement of the HCRF Regulation 67/93 section 10 in this regard, which states that: 1)A worker who is required by his or her employer or by this Regulation to wear or use any protective clothing, equipment or device shall be instructed and trained in its care, use and limitations before wearing or using it for the first time and at regular intervals thereafter and the worker shall participate in such instruction and training.
2)Personal protective equipment that is to be provided, worn or used shall, a) be properly used and maintained; b) be a proper fit; c)be inspected for damage or deterioration; and d)be stored in a convenient, clean and sanitary location when not in use.

Gloves
When a resident is placed on Contact or Droplet-Contact precautions, gloves are used when direct care will be provided. In addition, gloves must be worn when it is anticipated that the hands will be in contact with mucous membranes, non-intact skin, tissue, blood, body fluids, secretions, excretions, or equipment and environmental surfaces contaminated with the above. Indiscriminate or improper glove use has been linked to transmission of microorganisms. Gloves are task specific and single use for the task Masks A mask is used by a health care provider (in addition to eye protection) to protect the mucous membranes of the nose and mouth when it is anticipated that procedure or care activity is likely to generate splashes or sprays of blood, body fluids, secretions or excretions, or when within two metres of a coughing resident Eye Protection Eye protection is used by health care providers (in addition to a mask) to protect the mucous membranes of the eyes when it is anticipated that a procedure or care activity is likely to generate splashes or sprays of blood, body fluids, secretions or excretions, or within two meters of a coughing resident Gowns A gown is recommended when it is anticipated that a procedure or care activity is likely to generate splashes or sprays of blood, body fluids, secretions, or excretions, or a resident is on contact or droplet/contact precautions and direct care will be provided. Long-sleeved gowns protect the forearms and clothing of the health care provider from splashing and soiling with body substances during procedures and resident care activities which are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions.

IPAC Measures for Residents
Generally, LTCHs and PHUs discuss with OMT members the respiratory infection outbreak IPAC measures and decide jointly on appropriate measures to implement. The extent to which outbreak IPAC measures can be implemented and what is considered reasonable throughout the course of each outbreak will vary. Examples of reasonable and appropriate measures during the course of an outbreak include: •limiting visiting hours; •limiting the number of residents with whom the visitor has contact; •requiring anyone (including visitors, other residents, etc.) providing direct care toa resident on Additional Precautions to wear the necessary PPE; •requiring visitors to not visit when they have an ARI; •requiring visitors to wear the required PPE when visiting a resident on Additional Precautions and to carefully remove and discard PPE and perform HH upon leaving the room; •requiring residents to wear a gown, masks or other PPE, if they have an ARI and are leaving their room or are within 2 metres of others who are not wearing PPE; •posting signs at entrances of LTCHs and/or affected unit/area, discouraging visitors during the outbreak period; and •notifying persons of the outbreak.
However, under outbreak conditions that present a greater risk to the resident population of the LTCH, more restrictive control measures may be required and occasionally there may be a conflict relating to PHU recommended outbreak IPAC measures. If the PHU assesses the risk of not complying with outbreak control recommendations to be high -that is, the probability of adverse health events to other residents, such as disease transmission, is high -the PHU may have to consider a written order from the Medical Officer of Health or designate under the HPPA to the licensee of the LTCH to ensure compliance with outbreak IPAC measures. Under these circumstances, it is reasonable and necessary for the Medical Officer of Health or designate, if he or she is satisfied that the statutory test in the HPPA is met, to issue a section 22 order under the HPPA to the licensee of the LTCH, to: •stop new admissions to the LTCH •restrict resident movement to and from the home, or