Procedure

MNC-PRO-0131-20.docx 31/07/2020 1 of 15

Document ID: MNC-PRO-0131-20

Title: COVID-19 Staff & Visitor Screening Procedure

Site where document is utilised: MNC

Description: Procedure instructions for COVID-19 screening of all staff and visitors to any MNCLHD site or facility.

Keywords: COVID-19 Staff & Visitor Screening Procedure covid testing corona virus swabs

Directorate: Clinical Governance & Information Services

National Standard: NS3 - Infection Prevention

Replaces Existing Guideline: No

Registration Number of Superseded Document(s): [Superseded Document ID]

Related Legislation, NSW Health Policy or Circular, or other MNCLHD Documents:

Author: Lindy Ryan – District Infection Prevention and Control Lead

Phone: 02 6691 1984 Contact: Lindy.Ryan@health.nsw.gov.au

Aboriginal Health Impact Statement:

Date: Registration Number: [AHIS Registration Number]

MNCLHD Executive Director/Director Responsible for Communication, Implementation and Review:

Executive Director/Director Nursing Midwifery & Workforce

First Issued Date:

29/07/2020

Last Revision Date:

29/07/2020

Publish Date:

31/07/2020

Review Due Date:

29/07/2021

Approved for Electronic Distribution by the MNCLHD Senior Executive Team on 29/07/2020

MNCLHD COVID-19 Staff & Visitor Screening Procedure

July 2020

Page 3

MNCLHD COVID 19 Principles of screening in facilities

NSW Health COVID-19 Model Procedure for Visitors Local Health Districts and Specialty Networks sets out guideline and procedures that can be adopted by LHDs and SHNs to manage visiting, considering both the compassionate needs of patients and the need to minimise risk to other patients, health staff and the broader community. In some circumstances, this may mean excluding or refusing access.

CEC COVID-19 Infection Prevention and Control Guidance for Visiting Patients in Healthcare Facilities: During the COVID-19 pandemic NSW healthcare facilities should continue to enable their patients to receive visits from family and friends, carers and volunteers through additional screening, education and supervision of visitors using the correct personal protective equipment and using other infection prevention practices such as hand hygiene and physical distancing.

To promote safety and to reduce risks to patients and staff, there may be restrictions to the number of visitors allowed into a facility. There may be exemptions on compassionate grounds.

In circumstances where restricting visiting is necessary patients and their families and carers should be involved in discussions about the best ways to maintain connection.

Visitors who are a close contact of a confirmed COVID-19 case or who are in home isolation/quarantine will be unable to visit patients in a healthcare facility. Case by case exemptions are possible but will need prior approval with facility management. Any change or exemption must be notified to the delegated manager of the screening/concierge station to ensure increased congestion does not occur.

Healthcare facilities should consult patients and their families or carers’ regarding preferences about visiting and engage them in conversations about the risks of visiting and not visiting. Infection prevention and control measures that enable visitor access Healthcare facilities should have local infection prevention and control procedures that outline how they implement the required precautions to prevent the spread of COVID-19 and address visitor restrictions. Screening/Concierge activities

1. Active screening for COVID-19 risks and symptoms of anyone entering the facility, e.g. temperature checking, questioning about recent overseas travel, areas with confirmed community outbreaks, other questions recommended by NSW Health, contact with known or suspected cases and presence of symptoms.

2. Visitors should be encouraged to download the COVIDSafe app on their mobile devices.

3. Registering of visitor names, contact details, time of visit and whom they are visiting to enable contact tracing on the MNCLHD COVID-19 Visitor Register. Posting signs at all entrances and triage areas to prompt health workers, patients, volunteers and visitors not to visit the facility or to self-identify to a specific location or person if they experience COVID-19 symptoms, such as fever, cough, sore / scratchy throat, shortness of breath, loss of taste or smell. Atypical symptoms should be considered as well, especially in children, older persons and people with a disability.

4. Advising visitors to notify ward nursing staff before entering the patient’s room/area or providing a visitor information slip

Page 4

Requirements for Personnel/Concierge who conduct screening

1. Orientation to role a) Correct use of temperature measurement device b) Acceptable range of recorded temperature c) PPE requirements d) 1.5 distancing rules e) Handwashing equipment & location f) Correct directional flow of visitors g) Duress alarm functions & testing procedure h) COVID-19 Visitor register mandatory information required i) Script for visitor questions j) Explain

• Process to clarify purpose of visit eg inpatient name on list

• Process when visitors denied access 2. Ensure Mandatory Modules are complete

a) Local Induction to Personal Protective Equipment (F2F training)

b) Personal Protective Equipment for combined transmission-based precautions

c) Hand Hygiene

d) Infection prevention and Control Practices

Must wear appropriate PPE – Mask and Face Shield – No Gloves or gowns

Requirements for the screening station

1. Posters with information

2. Marking and signage to allow for social distancing and direct flow

3. Hand hygiene station - alcohol based hand rub (nearby facility for handwashing if alcohol-

based hand rub not suitable)

4. Surgical masks and face shields

5. Disinfectant wipes for personnel use only

6. Temperature monitoring device and spare batteries

7. MNCLHD COVID-19 Visitor Register, plastic clipboards and pens

8. Latest MNCLHD COVID-19 screening tool

9. Table/desk or counter for visitors to complete the visitor register. This may be in paper form

or electronic if a laptop is available (Electronic version is preferable) and a digital application

option will be explored)

10. Internal Phone communication to ask for assistance if escalation required

11. Garbage Bin

Page 5

Process

All staff assisting with this process are to wear PPE unless a 1.5m distance can be maintained

** If a visitor is not already wearing a face mask prior to passing screening questions and temperature check; the concierge must provide the visitor with a face mask upon entry to a MNCLHD facility.

Site requirements

1. Safety and security of staff is maintained through a local process e.g. duress alarms and a

process for testing of alarms

2. An escalation process for each concierge station must be provided

3. Sites must delegate a responsible person to collect completed MNCLHD COVID-19 Visitor

Register daily if in paper form, and upload electronically by the following naming convention:

RegisterCOVID-19VisitorFacility2020-mm-dd for ease of access for Public Health on request

4. Restrict Access points to ensure screening of all visitors occurs

5. Congestion is to be avoided and a strategy to manage peak times must be developed and

utilised by sites depending on their requirements

Visitors adhere to

1.5m social

distancing rules whilst

awaiting screening

Concierge conducts

temperature check & screens

visitor using MNCLHD COVID-19 screening

document*

Visitor passes screening

questions & temperature check. Visitor

to practice hand hygiene,

apply face mask** & proceed to

visitor registration

process

Visitor provides

name, contact details,

postcde, time of entry &

reason for visit to

MNCLHD site

Visitor provided

with a dated

clearance sticker or

dated screening clearance

slip

If visiting patient; patient location

verification conducted

& visitor directed to present to

correct ward

Visitor fails screening questions & / or temperature check - directed to go to

GP, COVID-19 Clinic or ED. Entry is denied to the facility

MNCLHD COVID 19 Screening Assessment

Daily Hot Spot Advice must be printed daily.

SCREENING QUESTIONS

The following questions must be asked by the concierge and responses do not need to be documented the Visitor Register.

All ‘no’ answers are required

Any ‘yes’ answer (except question1) will result in entry to the facility being denied and the concierge referring the visitor to their GP, a COVID-19 Testing Clinic or to the Emergency Department

1. Have you travelled outside of the Mid North Coast in the last two (2) weeks? If visitor

answers ‘no’ proceed to question 5

2. Have you returned from overseas travel (or a cruise ship) in the last 14 days?

3. Have you visited Victoria in the last 14 days?

4. Have you visited any hot spots in the last 14 days?

5. Have you had any close contact with a confirmed COVID-19 positive case in the last 14 days?

6. Do you have any symptoms including fever, cough, sore/scratchy throat, shortness of breath, loss of taste of smell?

TEMPERATURE

The temperature must be between 35°C and 37.4°C.

A reading of 35°C or lower requires the temperature check to be retaken until a reading above 35°C is recorded.

37.5°C and higher will result in entry to the facility being refused and the concierge must refer the visitor to their GP or a testing Clinic or to the Emergency Department.

ENTRY

Visitors who pass both temperature check and the screening assessment are required to apply a face mask if not already wearing one, observed performing hand hygiene and complete the MNCLHD Visitor Concierge register prior to entering the facility.

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Page 8

MNCLHD COVID 19 Staff Screening All staff entering a facility must complete a COVID-19 screening process every day they attend a MNCLHD site to ensure that they are not unwell or pose any risk to others.

Staff who feel unwell are not to attend work, they are to contact their manager who may refer them to COVID-19 Testing Clinic.

Staff travelling between sites and facilities who are not rostered on duty at a visited site or if a staff member is attending a site for any other reason except for work purposes, the staff member must present to the visitor screening station and complete screening and sign in using the visitor registration form - this is to enable contact tracing to occur if required.

For facilities that have restricted entry and staff enter through the same entry as visitors, staff must be screened by having their temperatures taken and answer all screening questions in the negative the same as all visitors. Staff are not required to complete visitor registration as they are able to be traced due to being rostered on duty in Healthroster.

For Facilities that have staff enter through access points that are not manned by a concierge and screening and temperature checks are conducted in the unit of work the following must be applied

• Hand hygiene must be practiced on entry to the facility

• The staff member must go directly to their place of work and attend screening

• Screening must occur prior to commencement of their duties

• Social distancing must be practiced until screening has been passed

• An up to date screening tool must be available

• Their temperature must range between 35°C and 37.4°C.

• If the reading is below 35°C the temperature must be retaken.

• If they answer yes to any screening question or have a temperature of 37.5°C or higher

they are to notify their manager immediately and will not be permitted to work

• ICP cleaning of the equipment and hand hygiene must occur after temperature has been

taken

• The manager of the area is responsible for ensuring all staff have attended screening and

are fit for work

• Paper records are not required to be kept, staff members rostered on and staff members

reported sick will be recorded in Health Roster. Managers may choose to record their staff

checks but it is not a requirement that temperatures and screening questions need to be

documented

• A dated sticker will indicate screening has been completed and passed

It must be understood by all staff that attending screening is a NSW Health Directive and they are in breach of the Code of Conduct if they fail to comply.

Date:___________________

MNCLHD visitor information

For the safety of our patients, staff and the community, we ask that you please observe our visitor arrangements during the COVID-19 pandemic.

Please report to nursing staff when you arrive at the ward prior to entering the patient’s room

We ask you to ensure visiting is restricted to only one visitor per patient per day.

Special circumstances will be considered on an individual basis.

Remember to maintain appropriate physical distancing - 1.5m, 2 arm lengths, 2 big steps and always practice good hand hygiene to help us keep our hospital safe.

Date:____________________

MNCLHD visitor information

For the safety of our patients, staff and the community, we ask that you please observe our visitor arrangements during the COVID-19 pandemic.

Please report to nursing staff when you arrive at the ward prior to entering the patient’s room

We ask you to ensure visiting is restricted to only one visitor per patient per day.

Special circumstances will be considered on an individual basis.

Remember to maintain appropriate physical distancing - 1.5m, 2 arm lengths, 2 big steps and always practice good hand hygiene to help us keep our hospital safe.

Date:____________________

MNCLHD visitor information

For the safety of our patients, staff and the community, we ask that you please observe our visitor arrangements during the COVID-19 pandemic.

Please report to nursing staff when you arrive at the ward prior to entering the patient’s room

We ask you to ensure visiting is restricted to only one visitor per patient per day.

Special circumstances will be considered on an individual basis.

Remember to maintain appropriate physical distancing - 1.5m, 2 arm lengths, 2 big steps and always practice good hand hygiene to help us keep our hospital safe.

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Page 11

Health Screening FAQs

Who needs to be screened?

Everyone who enters our hospitals and community health centres and offices needs to undergo health screening. This includes all staff, patients, visitors and contractors.

Is it compulsory?

Yes, it is compulsory. The Ministry of Health has advised that everyone who enters a MNCLHD site needs to undergo health screening, to protect our staff, patients and visitors.

Where are the health screening stations?

The health screening stations are located at the designated entrances to our facilities. These entrances are identified at a local level within each facility. Some of our usual facility entry points have been temporarily closed to enable effective screening, especially for our larger hospitals.

What does health screening involve?

As part of the health screening, you will be asked a series of questions. These will include whether you have been overseas or in Victoria in the past 14 days, whether you have been in close contact with someone with COVID-19 without wearing the required PPE, and whether you are experiencing any flu-like symptoms, such as fever, sore throat, cough, runny nose or shortness of breath. You will also have your temperature checked during screening.

Will I need to queue?

Where possible we will try to avoid congestion and long queues. If you are required to queue, you must comply with social distancing requirements - 1.5m, two armlengths or 2 big steps.

What happens if I have symptoms or don’t meet the entry requirements?

You will not be able to enter the facility and refer you to one of our COVID-19 clinics or your GP for assessment. If it is outside of clinic or GP opening hours, we will advise you to return home, self-isolate and present to a COVID-19 Testing Clinic or your GP the following morning. However, if you are in respiratory distress or have other significant illness or concerns, you will be advised to present immediately to the Emergency Department. If you are a staff member you will not be able to attend your shift. Notify your manager that you will not be able to return to work until the symptoms have resolved and you have a negative test result.

How will screening clearance be identified?

If you pass the screening requirements for entry, you will be issued with an authorised clearance slip or date specific sticker for the day. Staff must place the sticker on their ID card. Keep your staff photo identification card with you at all times.

What do I do if I lose my Slip or sticker?

If you lose your slip or sticker during the day, you will need to present to a health screening station for re-screening and a replacement slip or sticker.

Can I use my slip or sticker the next day?

No, the slips and stickers are valid for a single day only. Each day you enter our facilities, you will need to undergo health screening and receive a new slip or sticker.

Do managers still need to screen their staff?

Yes, all managers ensure every staff member understand their responsibility to undertake screening at the start of each shift. If a staff member does not have a clearance sticker, they need to be directed to undertake screening immediately. Managers and colleagues are also required to check on the

wellbeing of staff during their shifts.

MNCLHD COVID-19 Visitor Register

Site_______________________ Date_______________________

All visitors including but not limited to patient’s visitors, contactors, staff from other sites must be registered on entry. This is to aid public health with contact tracking and tracing.

Excludes staff who are rostered on to the site/ward in Health Roster

First Name Last Name Post Code

Contact

Phone Number

Patient Being Visited /Area/ Reason for Visit

Time of Entry

This register needs to be scanned and uploaded electronically daily with the naming convention RegisterCOVID-19VisitorFacility2020-mm-dd for easy electronic access by the sites for Public Health as required

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Implementation Checklist • Needs to be available for review when requested

Detailed written plan available of current lockdown access points

For Staff Yes No

(action required)

For Visitors Yes No

(action required)

Action:

Have you met the principles which are in this document outlined in Principles of Screening?

Infection prevention and control measures that enable visitor access

Yes No (action required)

Screening/Concierge activities Yes No (action required)

Requirements for Personnel/Concierge who conduct screening

Yes No (action required)

Requirements for the Screening station Yes No (action required)

Process Yes No (action required)

Site requirements Yes No (action required)

Action:

Are you ensuring that the MNCLHD COVID-19 Screening tool is being used?

Hot spots are to be checked daily for updates via link in document

Yes No

(action required)

Screening questions are asked in accordance with the MNCLHD COVID-19 Screening tool

Yes No

(action required)

Temperatures are being checked Yes No

(action required)

Visitors are observed performing hand hygiene Yes No

(action required)

Visitors who pass both temperature check and the screening assessment are required to apply a face mask if not already wearing one

Yes No

(action required)

Action:

Visitor completes MNCLHD COVID-19 Visitor Register prior to entering the facility

MNCLHD COVID-19 Visitor Register is reviewed for completeness of information provided and legibility of visitor contact details

Yes No

(action required)

Uploading of document follows assigned naming convention and is stored an area which is accessible 24/7 by Executive team members/AHNM.

Yes No

(action required)

Does any electronic version have the same requirements as outlined in MNCLHD COVID-19 Visitor Register?

Yes No

(action required)

Action:

Site has process for validating visitor screening has occurred

Dated visitor slip Yes No

(action required)

Dated sticker Yes No

(action required)

Action:

Staff Screening when Rostered to Site

Locations have equipment for temperature checks to be performed Yes No

(action required)

Screening questions are up to date and asked in accordance with the MNCLHD COVID-19 Screening tool at the commencement of each shift

Yes No

(action required)

Screening is to occur prior to commencement of shift Yes No

(action required)

Action:

Staff Screening when Not Rostered to Site

Visiting staff not rostered to site are entering via visitor entrance and have registered with site

Yes No

(action required)

Action:

Staff Awareness

Are all staff aware of MNCLHD COVID-19 Staff and Visitor Screening Procedure in PDS?

Yes No

(action required)

Action:

Completed by:_________________________ Date:______________