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 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 (ie. 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 (ie. cardiopulmonary arrest). Compressions alone is not considered an AGMP
• Non-invasive ventilation for duration of therapy (ie. CPAP, BiPAP, AIRVO, Optiflow)
• The act of intubation
• High-frequency oscillation ventilation/jet ventilation
• Dental work with high-speed drilling
• Bronchoscopy
• Induced sputum (ie. inhalation of nebulized saline solution to liquify and produce airway secretions, not natural coughing to bring up sputum)
• Extubation
• Open suctioning (ie. “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 (ie. 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 (ie. 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 (ie. gloves, gown, etc.)
    
    
• Use additional precautions when a communicable disease and/or organism of epidemiological significance is identified or suspected (ie. contact, droplet and 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 two metres (six feet) of any patient, even if not on precautions (see appendices for additional information on the care and use of approved eye protection). 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 (two metres) can be assured, you are permitted to remove your mask (ie. 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 OHS department, you must provide evidence to OHS 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

Sunnybrook Health Sciences Centre requires all students commencing a placement at Sunnybrook to be fully vaccinated in order to be eligible for a placement. Medical exemptions or exemptions based on creed may be assessed by Sunnybrook to determine a plan on a case-by-case basis.

Students who have a confirmed placement at Sunnybrook and require vaccination in order to begin their placement are being offered the opportunity to obtain vaccination for COVID-19 along with staff, and in accordance with our organizational priority framework and the provincial approach. Please note that students must have received their final dose of the COVID-19 vaccine at least 14 days prior to the start of placement.

The COVID-19 Vaccine Clinic is located at 80 Armistice Drive on the Bayview campus of Sunnybrook Health Sciences Centre.

Please use the website – sunnybrook.ca/vaccine - to view hours available for walk in appointments or contact the appropriate member of the education team if you would like to book a first or second dose.

Please wear a mask and bring the following to your appointment:

• Consent form – if you can, please print it in advance and sign it
• Your Ontario health (OHIP) card
• Staff ID badge
• Reading glasses (if applicable)
• Loose fitting shirt or t-shirt (for easy access to upper arm)

Capacity limits on meeting rooms have been lifted, meaning educational sessions and business meetings that have been virtual can now move back to being in-person, as needed. Like everywhere else in the hospital, masking must remain in place at all times in these meetings. Simulations that require the doffing of a mask (ie. CPR training) must continue to adhere to physical distancing at all times. In other areas, including meeting rooms and common areas where universal masking remains in place, physical distancing should be considered as much as possible.

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 any of us (see contact list at the end of this document).

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 one, 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 one and/or step two, 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.

When taking off your mask to eat and drink in break spaces and cafeterias, physical distancing must continue to be observed.

With more visitors coming through the hospital and needing to use the public cafeteria space, we encourage staff and learners to take their food and eat it elsewhere, including outdoors at a picnic table when weather permits.

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.

At Bayview campus, M1 Food Emporium, the M6 Atrium and the Blythwood patio are available as dedicated staff break spaces, and more space is being created in the Harlequins cafeteria (E-wing, first floor). At St. John’s Rehab campus Grasett Hall (as available) has also been designated as a larger break space. 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 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.

*Sunny’s cafeteria in Veterans Centre should not be accessed by learners except those with a placement in Veterans Centre. Learners placed on the acute care units in the Veterans Centre (K3E and K3C) are also not permitted to use Sunny’s.

Students may work across multiple hospital units/areas as part of their placements with the exception of students placed on units that are on certain types of outbreaks. If the student is expected to be at the Veterans Centre and a unit on another campus on the same day, please ensure they work at the Veterans Centre first, then other units later in the day as a risk mitigation strategy. If you are assigned a student placement within Veterans Centre units but are also a staff member working in other areas of the hospital, please contact the education team so we can work through an individualized plan.

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 (OHS) 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. 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 or ohssurveillance@sunnybrook.ca 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 38 degrees celcius 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 and your school 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. Students should contact OHS surveillance if they test positive for COVID-19 or requesting clearance to return to work.

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.

Email COVID test results to OHS Surveillance (ohssurveillance@sunnybrook.ca) for return to work clearance. Please call OHS at 416-480-6100 ext. 4175 only if you have no email access. If you are symptomatic, you may not return to placement until cleared by OHS.

COVID testing is available at the Sunnybrook assessment centre. For booking information, please follow this website: COVID-19 Assessment Centre. 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.

Prior to continuing placement onsite, email your COVID test result to OHS Surveillance and receive a return to work clearance from OHS. Please call OHS only if you have no email access at 416-480-6100 ext. 4175. If you are symptomatic, you may not return to placement until cleared by OHS.

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 surveillance to notify OHS 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 surveillance 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 seven and 14 following the presumed exposure if you are still asymptomatic, or
2. At the onset of symptoms where yield of testing is the highest.

If students believe they may have been exposed to COVID-19 they are advised to contact Occupational Health & Safety (ohssurveillance@sunnybrook.ca). For example, students should contact OHS in situations such as:

• They live with or have had contact with someone who is a confirmed positive case for COVID-19.
• They live with someone who is experiencing COVID-related symptoms and is not able/chooses not to get tested.
• They live with someone who is identified as a high-risk exposure to a COVID positive case and is not able/chooses not to get tested.

• 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.

Most schools are supporting normal processes for Occupational Health and Safety or other placement requirements. If one of the requirements below has lapsed, or you were not able to acquire the appropriate documentation due to interruptions from COVID-19, please get in touch with your contact from the education team and we will determine next steps:

• TB testing
• Fit testing for N95 respirators
• CPR (re) certification
• Criminal record checks
• Other placement requirements

• Sunnybrook’s COVID-19 wellness resources are available to students and trainees.
• A student assistance page has also been created specifically for students/trainees.

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 (see contact information at the end of this document).

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.

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.

TRAVEL WITHIN CANADA
There are currently no requirements to quarantine after returning to Ontario from another Canadian province, regardless of your COVID-19 vaccination status.

INTERNATIONAL TRAVEL
All students are expected to be fully vaccinated (ie. you received your second dose of the COVID-19 vaccine at least 14 days ago):
The federal government has updated its quarantine policy for fully vaccinated travelers, in effect July 6, 2021. If you are fully vaccinated, you may be exempt from the required 14-day quarantine upon returning from international travel. However, all staff, physicians or learner, must still follow the process listed below:

• Before you leave Canada: Contact Occupational Health (ohssurveillance@sunnybrook.ca) and indicate your return date from international travel.
• Upon your return to Canada: You must receive clearance from OHS before returning to work. You will need to provide OHS Surveillance the following information for clearance:
  
  • Proof of a negative COVID PCR test (collected after return from travel). Antigen tests are accepted. Please note that it can take one to two days to receive a negative test result, so plan for the extra time needed to be away from work when making international travel arrangements.
  • Proof of completed series of COVID-19 vaccination
  • Confirmation indicating no known contact with a COVID positive case any time during or after travel

Confirmation that you are symptom-free of any COVID-related symptoms. Please note that OHS is not able to modify quarantine requirements provided by Canada’s Border Services (CBSA). Upon return from travel, it is highly recommended for all students to follow quarantine instructions as outlined by the CBSA.

In addition, Sunnybrook learners are reminded to not be in contact with others who have travelled outside of Canada during their subsequent 14-day quarantine period. If the employee is concerned about their ability to properly separate themselves from their quarantining family member or household contact, they must contact Occupational Health (ohssurveillance@sunnybrook.ca) for advice.

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).

It is important that students use hospital-provided and approved PPE. Masks, face shields and other individually acquired personal protective equipment should not be brought into the hospital.

Medical-grade masks must be worn by all students in all work/clinical areas, as well as common areas (ie. hallways, elevators, etc.), and whenever physical distancing of two metres (six 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 two metres (six feet) of any patient when no plexiglas barrier is in place.

• Students will obtain their medical mask from their unit or work area.
• Students will require a mask upon entry to any Sunnybrook buildings. This may include a non-medical mask until they arrive at their work area where a medical grade mask will be donned.
• Students arriving to work without any masks will need to enter through one of the patient and visitor entrances to pick up a mask from a screening station. There will not be separate staff/student lines at these entrances so students are encouraged to come with a mask to avoid delays.

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), donning and doffing masks with integrated visors, 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 and consult the PPE selection guide (see appendices) included in this package for information and tips on PPE conservation strategies.

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.

What are basic tips in caring for my mask (see appendices for more details)?

• 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.

How long can I wear the mask allocated to me by the hospital, and when should it be changed?

• 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.

Masks are mandatory in all clinical and common areas. In locations where safe distancing (two metres/six feet) can be assured, you are permitted to remove your mask (ie. when alone in an office).

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

Should I wear two masks or "double mask" while at Sunnybrook?

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 medical 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 two 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.