COVID-19: Information for students and learners

Sunnybrook will follow the guidance of the student’s academic institution/program with respect to which patients they may see, and whether they can be involved in the care of patients with confirmed diagnoses of COVID-19. Students and trainees will not be assigned to provide care to confirmed COVID-19 positive patients unless their academic institutions/programs support this. Any exceptions must be approved by the Vice President of Education and the Academic Institution.

Aerosol-generating medical procedures (AGMP) are procedures carried out on a patient that can induce the production of aerosols of various sizes in high concentrations. These procedures present a risk for opportunistic airborne transmission of pathogens not otherwise spread by the airborne route (e.g., COVID-19). The following procedures conducted on any patient, regardless of if they are on Additional Precautions, are considered AGMPs:

• All Code Blues where AGMP is required (e.g. cardiopulmonary arrest). Compressions alone is not considered an AGMP
• Non-invasive ventilation for duration of therapy (e.g., CPAP, BiPAP, AIRVO, Optiflow)
• The act of intubation
• High frequency oscillation ventilation/jet ventilation
• Dental work with high-speed drilling
• Bronchoscopy
• Induced sputum (e.g. inhalation of nebulized saline solution to liquify and produce airway secretions, not natural coughing to bring up sputum)
• Extubation
• Open suctioning (e.g. “deep” insertion for naso-pharyngeal or tracheal suctioning, not inclusive of oral suction)
• Tracheotomy/tracheostomy procedures (insertion/removal/decannulation, not routine trach care with inner cannula change)
• Use of mechanical cough-assist device
• Chest tube insertion for trauma (where air leak is likely)
• Large volume nebulizers for humidity (e.g., trach mask with cool humidity)
• Manual ventilation (when unable to maintain full seal)
• Autopsy
• Nasopharyngoscopy, laryngoscopy
• Oral, pharyngeal, transphenoidal and airway surgeries, including thoracic surgery and tracheostomy insertion

Due to the COVID-19 pandemic, Sunnybrook has implemented detailed protocols that must be followed when these AGMPs are required. Students and trainees will therefore not participate in AGMPs for safety reasons. There are some exceptions (as approved by the Vice President of Education and the academic institution) for students in professions where developing competency in these procedures is mandatory in order to complete their placement objectives. These types of care will be done under the direct observation of a preceptor or supervisor and require the use of an N95 respirator, in addition to the PPE required by the patient’s Additional Precautions status and/or the risk assessment of the clinician.

Please note that rooms with ongoing AGMPs, where an N95 is required upon entry, are marked with a yellow and black ‘N95’ sign (see appendix). Students should not enter these rooms unless approved by the Vice President of Education and the academic institution.

As always, it is important to follow the policies and procedures that Sunnybrook has established and that you have learned in school to prevent the spread of infection:

• Follow routine practices
  • Perform hand hygiene as per the 4 moments of hand hygiene and as required as a component of personal care (e.g., after going to the washroom, before eating, etc.)
  • Perform a risk assessment before any patient interaction to determine what, if any, risk exists, for exposure to blood or body fluids. Select and don/doff personal protective equipment (PPE) as appropriate (e.g., gloves, gown, etc.)
    
    
• Use additional precautions when a communicable disease and/or organism of epidemiological significance is identified or suspected (e.g., contact, droplet & contact or airborne precautions). Any member of the health-care team (including students) should place a patient on additional precautions when there are concerns about transmission of infection, however additional precautions may only be discontinued after consultation with Infection Prevention and Control (IPAC).

During the COVID-19 pandemic, a mask and eye protection is required whenever you are within 2 metres (6 feet) of any patient, even if not on precautions. Keep your hands away from your face and perform hand hygiene before and after touching your mask when donning and doffing.

Just as you do in the community, please be sure to maintain physical distancing while at Sunnybrook. Masks are mandatory in all clinical and common areas. In locations where safe distancing (2 metres) can be assured, you are permitted to remove your mask (e.g., when alone in an office).

As always, do not attend placement if you have any infectious symptoms – no matter how mild – in order to prevent transmission to your patients and colleagues.

Flu shots are strongly recommended for students on placement during fall and winter terms. If a student chooses not to have a flu shot and there is an outbreak, they are not allowed to work on site, which could jeopardize their placement completion. If you were vaccinated by a provider other than Sunnybrook’s OH&S department, you must provide evidence to OH&S in order to be issued the sticker required on your photo ID badge. Evidence may include:

• ‘Influenza Vaccine Received Form’ signed by an authorized health-care practitioner. Please request a copy of this form from the appropriate member of the Education team if required.
• Documentation of immunization from an authorized health-care practitioner, including the Toronto Academic Health Sciences Network Flu Fighter card.
• Sticker issued at other hospitals within the Toronto Academic Health Sciences Network.

Vaccination is our best defence against COVID-19. While it is not mandatory, it is a good idea to get vaccinated to protect yourself, your patients, your colleagues, and friends and families. Registered students are being offered the opportunity to obtain vaccination for COVID-19 along with staff and in accordance with our organizational priority framework and vaccine availability from the province.

Eligible students include:

• All students in clinical/patient-facing placements
• All students whose placements are regularly on site at any Sunnybrook campus
• Students who have already started a placement or have a placement start date within the next two weeks

Ineligible students:

• Students whose placements are virtual/remote or involve only occasional time on site
• Second dose bookings for students who received their first dose elsewhere
• Students whose placement start date is more than two weeks away

While virtual platforms are encouraged, in-person classroom learning is sometimes required. In these cases you will be given additional information about infection prevention and control guidelines specific to the session. Sunnybrook room capacities have been adjusted to support physical distancing and many have designated seats indicated with orange tape; please use only these seats and do not move the chairs.

We are committed to providing students with a safe, healthy, secure and respectful environment while at Sunnybrook. If students have a concern during placement, the steps below are in place so we can act as effectively as possible. If you are uncomfortable speaking to the individuals suggested at any point during the escalation process, please feel free to contact a member of the Education team. 

Step 1

Speak with your preceptor or supervisor If you are comfortable, we encourage you to address the concern with the person you are working with on a daily basis.

Step 2

Speak with your area leadership or professional lead If the concern is not addressed at Step 1, please feel free to speak with your area or professional lead. This may include your site director, patient care manager, professional and education leader, advanced practice nurse or clinical coordinator.

Step 3

Speak with a member of the Student Centre leadership team If your concern has not been addressed to your satisfaction in Step 1 and/or Step 2, speak with a member of our Student Centre leadership team, such as the director of Interprofessional & Academic Education, director of the Peters-Boyd Academy, manager of Post-Graduate Medical Education and Education Observers, or the education lead for nursing.

Step 4

Speak with the vice-president of education If you feel the need to address your concern at the senior-leadership level, please feel free to connect with the Vice-President of Education, Dr. Ari Zaretsky.

Please note: Depending on the nature of your concern, your academic institution or other hospital-based leaders may become involved in your case.

Physical distancing remains one of the most important ways to prevent the transmission of COVID-19 between those who work at Sunnybrook. It is important to maintain a 2-metre distance as much as possible, especially in situations where you may not be wearing a mask, such as during breaks when you are eating or drinking.

Please do not use the staff lounge on your unit for breaks if the maximum number of people allowed in the room are already present. You may take your breaks off the unit in each campus’ cafeterias* or outside at a picnic table (weather and season permitting). M6 atrium and Grasett Hall (as available) has also been designated as a larger break space on the Bayview and St. John’s Rehab campuses, respectively. Make sure you speak with your preceptor/supervisor or professional leader/clinical coordinator as some professions have additional spaces allocated away from clinical areas which may be used for breaks or documentation. You may also wish to consider taking breaks at off peak times or staggering with other colleagues/students to optimize the use of available spaces. Please ensure you observe proper physical distancing and mask wearing in all of these locations. There should be no food or drink shared amongst persons.

*Please note that Sunny’s cafeteria in Veterans Centre should not be accessed by learners except those with a placement in Veterans Centre.

In most situations, you may continue to attend placement in the event a COVID-19 outbreak is declared on your unit as long as you have no symptoms of COVID-19 and your school approves. If an outbreak is declared on your unit of placement:

• You may be asked to be tested for the virus along with all other staff on the unit. The purpose of this is to help identify the source of the case due to pre-symptomatic/asymptomatic transmission from health-care worker to patient.
• You may not attend placement on another unit unless your placement requires you to regularly rotate across many units. In this case, you should see patients on the outbreak unit at the end of your shift, where possible.
• If your placement on the unit is ending and you are moving to a different unit or hospital, consult Occupational Health & Safety on testing and returning to placement.
• If you are deemed by OHS to have had a significant exposure to COVID-19, you may be required to self-isolate for 14 days. Please remember to wear a mask and eye protection for every patient encounter to minimize your risk of exposure. If you ever have any concerns about a breach in PPE, contact OHS at ext. 4175 as soon as possible.

Student placements on outbreak units may be reassessed by the education department, IPAC, Occupational Health & Safety (OHS) or your school depending on the circumstances.

Symptoms of COVID-19 include:

• Fever (temperature of 37.8C or greater)
• New or worsening cough
• Shortness of breath/hypoxia
• Sore throat
• Difficulty swallowing
• Decrease or loss of sense of taste or smell
• Vomiting
• Diarrhea
• Runny nose or nasal congestion
• Unexplained malaise, muscle aches or lethargy
• Conjunctivitis

As always, students, trainees, clinical instructors and faculty must follow the Healthy Workplace Policy (full policy is available on Sunnynet or through your preceptor/supervisor) and not attend placement if they have any infectious symptoms.

• Notify your preceptor/supervisor, your school and OHS that you are sick.
• If you develop any symptoms while on site at Sunnybrook, notify your preceptor/supervisor and leave the clinical area as soon as it is safe to do so.

If you have any one of the above symptoms (even if mild) you should also be tested for COVID-19.

You should get tested for COVID-19 whenever you develop any of the symptoms listed above (even if mild). Remember that a negative result only represents a moment in time. If you develop new symptoms at a later time after testing negative, you should get tested again.

Please email OHS at ohssurveillance@sunnybrook.ca to let them know you are being tested. Please call OHS at 416-480-6100 ext. 4175 only if you have no e-mail access. If you are symptomatic, you may not return to placement until cleared by OHS.

Students who have placements in the Veterans Centre should be tested before starting a placement and should not start until a negative result has been received. Students who have placements in the Veterans Centre should be tested weekly (even if asymptomatic) for the duration of their placement in accordance with the Ministry of Health directive.

The OHS clinic (room HG46 at Bayview campus) is the preferred location for testing during OHS business hours, Monday to Friday, 7 a.m. – 5 p.m. Walk-in testing is available for staff and students who are symptomatic.

Testing for COVID-19 in the OHS clinic can be booked online for those who have access to Sunnynet or have a Sunnybrook email address (preceptors may assist), or by calling Occupational Health and Safety at 416-480-6100 ext. 4175.

You can also be tested at the COVID-19 Assessment Centre at Sunnybrook outside of OHS business hours. When being tested at the Assessment Centre, please let them know that you are a student or trainee at Sunnybrook, and bring your ID badge, health card and cell phone to keep the registration process moving quickly.

Email OHS at ohssurveillance@sunnybrook.ca to let them know you are being tested. Please call OHS only if you have no e-mail access at 416-480-6100 ext. 4175. If you are symptomatic, you may not return to placement until cleared by OHS.

Students in the Veterans Centre who are completing weekly testing may have the opportunity to be tested on site at the Veterans Centre. Please check with your preceptor, clinical instructor or the area manager regarding the testing schedule for the unit you are placed on.

* We encourage you to get tested for COVID-19 at Sunnybrook. If you are getting tested elsewhere, it may result in a longer time before returning to placement.

If you test positive for COVID-19 and your testing was done at Sunnybrook, a member of the OHS team will contact you to follow-up. If you were tested outside Sunnybrook, e-mail OHS to notify them of your testing and result. They will provide guidance on self-isolation. You will also be contacted by your local Public Health unit. If your symptoms feel worse than a standard cold, call your health-care practitioner. You will be required to self-isolate for a minimum of 10 days from your symptom onset date or date of positive test (if asymptomatic).

If you think you have had an unprotected exposure (i.e., without appropriate PPE) to a patient/staff member/learner with COVID-19, please e-mail OHS to assess your risk. You will be provided with guidance on next steps to take and whether self-isolation is necessary.

Getting tested is strongly encouraged if you are concerned about any exposure to an individual with COVID-19. If this has occurred, the best time to be tested would be:

1) between day 4 and 8 following the presumed exposure if you are still asymptomatic, or

2) at the onset of symptoms where yield of testing is the highest.

• If you have a household member that is sick undiagnosed (i.e., has tested negative for COVID-19 or is not going to be tested): You may attend placement and self-monitor for symptoms
• If you have a household member that is awaiting a COVID-19 test because they are sick or were exposed: You may attend placement. Notify OHS to be placed on work isolation pending test results.
• If you have a household member is COVID-19 positive: Do not attend placement and notify OHS. 

• Information on how to self-monitor can be found here: How to Self-Monitor.
• Information on how to self-isolate can be found here: How to Self-Isolate.

During recent months some of your Occupational Health & Safety or other placement requirements may have lapsed, or you may not have been able to acquire the appropriate documentation.

TB testing

A grace period of 3 months is being granted with respect to TB tests, however you are welcome to contact Occupational Health & Safety for support with getting testing done.

Fit testing for N95 respirators

Current fit testing (or re-testing if you have been tested on a respirator that is not currently in stock at Sunnybrook) is only required for the small number of students/trainees who will be involved in AGMPs (see above) as part of their placements. For those meeting the requirement you may contact Occupational Health & Safety to book an appointment. If your mask fit testing certificate is expired (or Sunnybrook does not have model of mask you were tested on), you may not provide care to patients on Airborne precautions.

CPR (re)certification

For students/trainees who require CPR (re)certification you may complete the online module available through Heart and Stroke. In person training can be done at a later date when classes resume.

Criminal record checks

A grace period of 3 months is being granted with respect to criminal record checks.

Other placement requirements

Please get in touch with the appropriate member of the education team to clarify if you have other placement requirements which have lapsed or which you have not been able to complete due to COVID-19.

There are no restrictions on working in non-health-care related jobs while attending placement. If you are employed elsewhere and an outbreak is declared please do not attend placement. You are asked to follow any guidance provided to you by Toronto Public Health. Please contact the appropriate member of the Education Team for further discussion.

If you work in a long-term care (LTC) home or retirement home (RH), you may not be able to continue working in those settings while attending placement in order to comply with Ontario Regulations 146/20 (LTC) and 158/20 (RH), which limit employees/students/trainees of these settings from working with other health service providers. Please contact the appropriate member of the education team if this applies to you.

Students who are fully immunized (i.e. it has been at least 14 days since receiving the final dose required of the vaccine approved by Health Canada) are now permitted to work in more than one LTC home, health-care setting or retirement home.

If you are working for another health service provider when an outbreak is declared on either the unit at Sunnybrook or other health service provider, you may not attend placement at either location for a designated time period, depending on the type of outbreak, or until the outbreak is declared over, whichever is earliest. Please contact the appropriate member of the education team if this applies to you.

As always, do not go to work or attend placement if you have any infectious symptoms – no matter how mild.

The Canadian government is advising against all non-essential travel outside of Canada until further notice.

If you return from an essential trip outside of Canada within 14 days of starting your placement, or during your placement, you must complete a 14-day quarantine (self-isolation) period before attending placement as per the Emergency Order under the Quarantine Act put in place by the Government of Canada.

Veterans Centre is only accepting local (no out of province) students and students should not have traveled outside Ontario in the last 14 days.

Students are provided with the same access to PPE as preceptors/supervisors including masks, face shields, gowns and gloves. Details regarding required items as appropriate to the profession will be reviewed with students by the lead for each profession (or preceptor where applicable).

Medical-grade masks must be worn by all students in all work/clinical areas, as well as common areas (e.g., hallways, elevators, etc.), and whenever physical distancing of 2 metres (6 feet) from others cannot be assured. In non-clinical locations where safe distancing can be assured, you are permitted to remove your mask (e.g., when alone in an office). Eye protection must be worn when within 2 metres (6 feet) of any patient when no Plexiglas barrier is in place. Students should reuse their masks where appropriate, discarding only if it becomes soiled, damaged or hard to breathe through (see ‘how do I safely reuse a mask’ section below for more information).

Students must pick up their masks at the locations below. You must show your ID badge and clean your hands in order to receive a mask. Follow proper instructions for donning, doffing and storing your masks during meals and at other times. You may consider bringing a new medical-grade mask home with you at the end of your shift so you can wear it on entry to the building for your next shift. If you do not have a medical-grade mask on entry to the building, please wear a mask you bring from home and change into a medical-grade mask provided by the hospital as soon as it is safe to do so.

Bayview Campus:

• M-ground– 6:30 a.m. - 11 p.m.
• M1 screening station: 11 p.m. - 6:30 a.m.
• T-Wing north entrance: 6:30 a.m. - 4:00 p.m. at volunteer info desk
• L-Wing Veterans Centre info desk (for L-Wing and K-Wing only): 6:30 a.m. - 5 p.m. *Night nurses in Veterans Centre and Palliative Care will pick up their masks on their units.
• J-Wing, D-Wing and H-Wing screening stations: 6:30 a.m. to 6:30 p.m.

Weekend and holidays:

• M1 screening station: Fridays, 11 p.m. - Mondays 6:30 a.m.
• L-Wing Veterans Centre info desk (for L-Wing and K-Wing only): 6:30 a.m. - 5 p.m. *Night nurses in Veterans Centre and Palliative Care will pick up their masks on their units.

St. John’s Rehab / Holland Centre / RCC

• Main entrances

Before beginning placements/rotations at Sunnybrook students are required to complete a number of online training requirements/eLearning modules. These include: hand hygiene, routine practices and additional precautions, donning & doffing personal protective equipment (PPE) and PPE conservation.

Details regarding required items as appropriate to the profession will be reviewed with students by the lead for each profession (or preceptor where applicable). At the start of placement (and before providing care to patients) students must complete a return demonstration of PPE technique. Depending upon the profession of the student this may include: a simulation session, a small group training session, or an individual training session/ completion of our Return Demonstration Checklist.

Sunnybrook has implemented mask conservation strategies which will involve wearing masks/eye protection between patients and for more prolonged periods of time. View the videos assigned to you via our student registration system.

As always, gowns and gloves must be changed between each patient and hand hygiene must be performed according to the 4 moments of hand hygiene, as well as before donning and after doffing gloves.

This guidance is for use of masks and eye protection by a single person. These items must never be shared!

What are basic tips in caring for my mask?

• While wearing the mask, refrain from touching it with your hands and ensure that both nose and mouth are completely covered at all times
• The mask can be worn for several hours until soiled, damaged, or hard to breathe through
• Do not hang the mask around your neck or from your ear, or rest it on your head
• Perform hand hygiene before and after donning and doffing the mask

• The mask should be worn continuously until it is soiled, damaged, or hard to breathe through. The same mask can be kept on while providing clinical care to multiple patients and when working in common areas
• Wear the mask in the correct position: wire on bridge of nose, and white side towards face.
• The mask may only be removed outside of a patient care area, when physical distancing from others can be maintained, and only after performing hand hygiene

• Perform hand hygiene
• Clean the surface where you plan to place the mask
• Remove the mask using the ear loops (the front of the mask may be contaminated, so do not touch it); remove mask slowly and carefully
• After removing mask, visually inspect for contamination or damage; if contaminated or damaged, the mask should be discarded
• Store mask with inside facing upward on clean surface
• The mask may be put back on again after hands have been cleaned

Eye protection is mandatory for every patient encounter, regardless of if the patient requires additional precautions or not.

Masks are mandatory in all clinical and common areas. In locations where safe distancing (2 metres/6 feet) can be assured, you are permitted to remove your mask.

No, the Centre for Disease Control (CDC) guidelines on double-masking are intended for people in the community who do not have access to medical-grade personal protective equipment. Sunnybrook provides students with medica-grade masks to wear during placements. Wearing two disposable, medical-grade masks at the same time may increase your risk of self-contamination by adding additional complexity and increasing discomfort and perspiration, making it more likely that you bring your hands up to your face to adjust your PPE.

Instead, use these tips from our Infection Prevention & Control team to ensure your mask fits properly:

• Clean your hands prior to donning/doffing, and after doffing
• Fit the wire securely over your nose
• If your mask is feeling loose, use an ear saver to create a better seal
• Only make adjustments to your mask while donning it. Once it’s on, avoid bringing your hands up to your face to make further adjustments.

• Keeping the skin healthy starts with simple steps like maintaining hydration throughout the day, and ensuring a healthy diet and sleep routine.
• When performing hand hygiene, ensure hands are dry before applying gloves and use the unscented, water-based lotion available on the units frequently throughout the day.
• Attempt to remove your face mask every 2 hours for at least 15 minutes. Ensure that you are maintaining safe physical distancing and clean your hands before/after touching your mask.
• If you experience skin break down, irritation, rashes, or discomfort please contact OHS for further assessment and support.

We have also implemented conservation strategies for N95 masks. Part of these conservation strategies involve only fit-testing individuals who are required to interact with patients under airborne precautions or participate in AGMPs.

Current fit testing (or re-testing if you have been tested on a respirator that is not currently in stock at Sunnybrook) is only required for the small number of students/trainees who will be involved in AGMPs (see above) as part of their placements. For those meeting the requirement you may contact Occupational Health & Safety to book an appointment. If your mask fit testing certificate is expired (or Sunnybrook does not have the model of mask you were tested on), you may not provide care to patients on airborne precautions