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Infection Prevention and Control for Clinical Office Practice

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Approved by the Board: September 2024

Companion Resource: Advice to the Profession

Policies of the College of Physicians and Surgeons of Ontario (“CPSO”) set out expectations for the professional conduct of physicians practising in Ontario. Together with the Practice Guide and relevant legislation and case law, they will be used by CPSO and its Committees when considering physician practice or conduct.

Within policies, the terms ‘must’ and ‘advised’ are used to articulate CPSO’s expectations. When ‘advised’ is used, it indicates that physicians can use reasonable discretion when applying this expectation to practice.

Additional information, general advice, and/or best practices can be found in companion resources, such as Advice to the Profession documents.


Ensuring infection prevention and control (IPAC) practices are implemented safely and effectively is an important component of medical care. All physicians are responsible for complying with appropriate IPAC practices.

Policy1

  1. Physicians must undertake infection prevention and control practices, in line with the Provincial Infectious Diseases Advisory Committee’s (PIDAC’s) Infection Prevention and Control for Clinical Office Practice2,3.
  2. Physicians must undertake Routine Practices and Additional Precautions4, including:
    1. hand hygiene for patient and physician safety, in accordance with Appendix B: Ontario’s Just Clean Your Hands Program: Your 4 Moments for Hand Hygiene and Appendix C: Hand Hygiene Methods;
    2. wearing gloves if there is expected exposure to blood, body fluids, secretions, skin rash or non-intact skin;
    3. wearing a medical mask when required to prevent transmission of infectious agents in droplets and airborne particles, and during aseptic and invasive procedures; and
    4. wearing eye protection and a gown when required to protect eyes, skin, and clothing from blood, body fluids, secretions, or excretions.
  3. Physicians must ensure safe medication practices are undertaken, in accordance with Appendix H: Checklist for Safe Medication Practices, including:
    1. never reusing single dose vials;
    2. ensuring there are facilities for hand hygiene in the medication room/area;
    3. ensuring all needles and syringes are single patient use only;
    4. using single use vials wherever possible;
    5. when use of a multidose vial cannot be avoided:
      1. never reinserting a used needle or syringe into a vial;
      2. never leaving a needle in a vial to be attached to a new syringe;
      3. accessing vials aseptically on a clean surface and away from dirty, used or potentially contaminated equipment;
      4. the diaphragm of the vial is scrubbed using friction and 70% alcohol, and is allowed to dry before inserting a new needle and a new syringe;
      5. ensuring each vial is used for a single patient whenever possible and is marked with the patient’s name and date of entry;
      6. discarding the multidose vial within 28 days unless otherwise specified by the manufacturer’s instructions.
  4. Physicians must ensure a clean and safe health care environment is maintained with environmental cleaning5 and disinfection appropriate to the clinical setting performed on a routine and consistent basis.
  5. Physicians must ensure medical equipment is cleaned and disinfected in accordance with Appendix I: Recommended Minimum Cleaning and Disinfection Level and Frequency for Medical Equipment.
  6. Physicians must ensure medical equipment is reprocessed in accordance with Section 8: Reprocessing Medical Equipment, including:
    1. aligning the level of reprocessing with the type and use of the medical equipment; and
    2. ensuring devices and medical equipment that enter a sterile body site, including the vascular system, are cleaned and then sterilized with an effective sterilization process.6
  7. Physicians must ensure appropriate handling and disposal of sharps, equipment, and infectious materials is undertaken, including handling regulated waste in line with accepted standards7.
  8. Physicians in positions of leadership in their practice8 must ensure the following is in place to support appropriate IPAC practices9:
    1. well documented policies and procedures which are periodically reviewed by staff;
    2. all staff are properly trained and are provided with regular education and support to assist with consistent implementation of appropriate IPAC practices;
    3. responsibility for specific obligations are clearly defined in writing and understood by all staff; and
    4. mechanisms are in place for ensuring a healthy workplace, recommended staff immunizations10, and written protocols for exposure to infectious diseases.
  9. Physicians in positions of leadership in their practice must ensure that there is an ongoing process for monitoring IPAC practices and adjusting practices where necessary to improve safety and quality of care.

Endnotes

1This policy sets out infection prevention and control expectations for physicians in office-based practices. There are additional expectations for physicians working in out-of-hospital premises. For more information on out-of-hospital premises infection prevention and control expectations, please see the Out-of-Hospital Premises Standards.

2Ontario Agency for Health Protection and Promotion (Public Health Ontario), Provincial Infectious Diseases Advisory Committee. Infection Prevention and Control for Clinical Office Practice. 1st Revision. Toronto, ON: Queen’s Printer for Ontario; April 2015.

3A summary of mandatory practices and best practice recommendations for clinical office practice is set out on page 72 of Infection Prevention and Control for Clinical Office Practice.

4See the Advice to the Profession: Infection Prevention and Control for Clinical Office Practice document for more information on routine practices and additional precautions.

5See the Advice to the Profession: Infection Prevention and Control for Clinical Office Practice document for more information on environmental cleaning.

6See the Advice to the Profession: Infection Prevention and Control for Clinical Office Practice document for more information on reprocessing of medical equipment.

7“Regulated Waste” means: a) liquid or semi-liquid or other potential infectious material; b) contaminated items that would release blood or other potential infectious materials in a liquid or semi-liquid state are compressed; c) items that contain dried blood or other potential infectious materials and are capable of releasing these materials during handling; d) contaminated sharps; e) pathological and microbiological wastes containing blood or other potentially infectious materials.

8For example, physicians who are employers or supervisors under the Occupational Health and Safety Act R.S.O. 1990, c. O.1. More information on physician’s roles under the Act can be found in the Public Services Health and Safety Association’s document Physicians' Occupational Health & Safety Roles and Responsibilities.

9In line with PIDAC’s Infection Prevention and Control for Clinical Office Practice and the Occupational Health and Safety Act, R.S.O. 1990, c. O.1. For more information, refer to Appendix N: Immunization Schedule for Clinical Office Staff and Ontario’s Routine Immunization Schedule.

10For more information, refer to Appendix N: Immunization Schedule for Clinical Office Staff and Ontario’s Routine Immunization Schedule.