April 10, 2020 RNAO COVID-19 update

Dear readers:  Welcome to my COVID-19 report. Earlier reports are here and thematic pieces from earlier issues are in my new blog, here. You can always go back to the blog and catch up. Feel free to share this report or these links with anyone interested – it is public. To each of you, at home and all over the world: Thanks for your formidable work. Your expertise, compassion and courage in your day-to-day work and your leadership in your varied roles and sectors – inspires us all! You will be part of history books, and for us now – you are the reality that keeps us grounded and going. Thanks also for your many and important questions, concerns and solutions, as well as commentaries, all of which directly inform my writing. Please stay well and safe, Doris

 

Dear All,

Today, Good Friday, April 10, focuses on long term care. I chose this as my report’s focus as their residents are most affected by COVID-19 – in their isolation from loved ones and in the devastating fatalities we as a society have experienced. For the families and friends of residents in nursing homes and retirement homes and especially those who have lost loved ones: our hearts are with you at this difficult time. We told you to stop visiting your loved ones so we could keep them safe. And, so far, we have failed you. For this, as a nurse and a health system leader: I apologize.

To residents in nursing homes and retirement homes, to their families and friends, and to all staff working so very hard: Know that RNAO will continue to pressure – without any stopping --that all necessary measures to protect residents in nursing homes and retirement homes be fully and immediately implemented. As we protect them, we also need to protect the staff, as the safety of one is the safety of the other.

We know, that even when all measures will be put in place – and they must – we will still have lives lost – but many will be saved, and families who were once told to stay away will be once again be able to reunite and embrace.

This blog is testament to the profound sadness at what’s happening and RNAO’s unwavering efforts to push for urgent interventions to save lives, help with the existing outbreaks and prevent new ones. We call on governments at all levels and their health officials – in the strongest possible terms – to act immediately and comprehensively.

In today’s report, we also describe the direct actions that RNAO is taking and for which we have full control, to support families and staff in nursing homes and retirement homes.

RNAO policy corner – Ontario’s tragedy in long term care homes and retirement homes

A tragedy of major proportions has been unfolding in front of our eyes in nursing homes and residential care in Ontario; the response so far has been slow, partial and ineffective. How many deaths are required until we start taking this horrific situation with the urgency, rigour and resources it requires? Words and promises do not suffice, what is needed – immediately – is action.  

The outbreaks are spreading like fire in dry bush. We hear anecdotal evidence of terrible situations in some of the institutions. Many nursing homes are depleted of staff to start with, and now are facing dire lack of staff, many of which are sick or in isolation or unable to work, and we hear some reports of residents who are virtually abandoned in their rooms. Most nursing homes and retirement homes are doing heroic efforts to attend to their residents and provide dignified care under conditions they would have never imagined before and without the basic tools required, such as adequate staffing and PPE.

For the families, the situation is desperate. The homes and residences, rightly so, have limited visits so they are physically unable to visit their loved ones. They are also urged to have very difficult conversations given the clear message that treating the elderly and frail in hospitals may not be in their best interest. Are the LTC institutions set up to facilitate the passing away of so many residents, within the home, with dignity and the palliative care they deserve, and without the presence of family members? What will be the lasting trauma for families, staff and administrators who have to live through this nightmare?

The latest information we have is that there are over a 100 nursing homes in outbreaks and 40 or more retirement homes, across Ontario. Some of the information shows devastating scenarios, such as the Seven Oaks senior home in Toronto, with at least 16 deaths, 45 confirmed cases and 56 probable cases of COVID-19 among 249 residents. There were also 13 confirmed cases among staff members.

That the LTC sector is not prepared for this crisis is an understatement, and something all governments in Ontario have known for many years. The sector has been severely under-resourced, under-staffed and under-prioritized for decades. RNAO has repeatedly called for changing the provincial government formula for funding of nursing homes and for changing the staffing levels and mix. The changes so far, prior to the COVID-19 pandemic, have been minimal.

Indeed, these are the reasons why the sector was in a shambles during the 2003 SARS epidemic. RNAO was already saying then that the SARS outbreak was exacerbated by a “nursing workforce that battles with dangerously low staffing levels, high workloads, and an over-reliance on part-time, casual and agency staff.” Sadly, the only area where staffing has improved, in nursing, is that now we have a higher proportion of the workforce employed full-time. Nothing else has changed in any material way since 2003.

In RNAO’s report Mind the Safety Gap – released in 2016 and well known to past and current to past and current governments in Ontario – RNAO repeated its plea to increase the ratios of RNs, RPNs and NPs in nursing homes to the proper staffing skill mix. As recent as February 2019, RNAO recommended (see here and here) providing adequate staffing levels and an appropriate staffing skill mix in nursing homes. RNAO also recommended increasing the number of beds as well as changing the funding model to reward improvements in the wellness, quality of life and health outcomes of their residents. We repeated this plea, providing all the necessary evidence, in meetings and consultations with Minister of Health Christine Elliott and with Minister of Long-Term Care Minister Merrilee Fullerton, as late as March 11, the day that WHO called COVID-19 a pandemic.   

During the current pandemic RNAO has been ferociously voicing for weeks our concern in every ambit possible: at daily morning briefings with Ontario’s Medical Officer of Health, with the Ministry’s Collaborative Table of associations, through these COVID-19 reports, through the media and of course with nurses and others who write to us in desperation.

Post COVID-19, RNAO will issue a report calling for a complete overhaul of the long term care sector to make it a priority for humane, dignified and safe care. For now, we must tackle ways to mitigate the utter devastation we are all experiencing.

The latest set of government measures for long-term care was announced yesterday, representing a step in the right direction. However, government must intervene immediately, fully and vigorously. RNAO has advised for key policy measures, some of which have been adopted fully or partially by government:  

• Universal masking for all staff facing patients: This policy, which RNAO has been calling for, was adopted by government in their directive this week. However, we continue to receive multiple reports from nursing home operators, directors of nursing and staff that they do not have the necessary PPE to implement the policy.
• Pre-outbreak testing and surveillance: RNAO has been critical of the policy that has directed testing only of suspected cases among residents, in other words, only after an outbreak has started. It is urgently required that testing be used as a surveillance tool to prevent outbreaks in homes that do not yet have one. The testing guidance updated yesterday expands somewhat the span of testing but it still limited to persons demonstrating symptoms or upon admission to the LTC home. The government document directs that “Testing of asymptomatic patients, residents or staff is generally not recommended.” Thus, there is no surveillance at this time. RNAO urges once again to reconsider and establish an effective system of random testing for surveillance prior to outbreak.
• Robust case and contact tracing: RNAO has emphasized that when a COVID+ case is identified, there must be rigorous case and contact tracing, and isolation. Although this has been part of the policies in place, it is difficult to assess to what extent it has been implemented, due to lack of resources and reporting. We suspect that the resources have not been there and the action has been limited. RNAO has the human resources to support this time consuming endeavour through the VIANurse program here.   
• Self-isolation of suspect and confirmed cases: Every resident and staff suspect, and certainly confirmed COVID+, must be placed in self-isolation for 14 days. The latest directive is insufficient, since it says “Staff who have tested positive and symptomatic cannot attend work. Staff who have tested positive and have symptom resolution and are deemed critical may return to work under work isolation.” How many COVID+ workers will be considered “critical” and still be in “work isolation”?  
• Workers should work with one facility full-time rather than work with multiple employers. Again, the directive issued this week is insufficient since it states “Wherever possible, employers should work with employees to limit the number of work locations that employees are working at, to minimize risk to patients of exposure to COVID-19.” There is no requirement to act or compensation for the workers who will lose their income from not being able to work their normal assignments. British Columbia has been ahead of the curve implementing strong measures.

Late this evening, April 10, the government issued a new directive (see here), which appears to supersede the one issued earlier in the week. The new directive seems to limit the requirement of universal masking for all staff facing patients, since it states “In the event that the supply of PPE reaches a point where utilization rates indicate that a shortage will occur, the government and employers, as appropriate, will be responsible for developing contingency plans, in consultation with affected labour unions, to ensure the safety of health care workers and other employees.” We are waiting for further clarity from the Ministry and will provide updates as soon as they are available.

RNAO action – Supporting Long-Term Care

RNAO is listening, anticipating and responding to the needs of the long-term care sector during this unprecedented time. All of the resources described below are available to anyone requiring them in the fight against COVID-19. Our deepest gratitude to the directors of nursing, attending NPs, medical directors, CNSs, RNs, RPNs, PSWs, and other workers in nursing homes and retirement homes, as well as our RNAO staff who are diligently and proactively supporting them, always and especially during the pandemic.  

Addressing staffing needs

RNAO has been working since March 13, through its ViaNurse program here, to address human resource needs of nursing homes and retirement residences seeking RNs, NPs and PSWs. Nursing students in 2d, 3d and 4th year can legally work as PSWs. If you would like to register for work, or if you are an organization seeking help, please go here.

Nurse Practitioner Knowledge Exchange Webinars

We have already held several webinars with NPs working in LTC.  This knowledge exchange Zoom forum centres on a wide range of needs and the identification of practice issues requiring more direction and tools, which we have quickly developed to support our colleagues in the field. We know these needs will continue to expand over the coming days, weeks and months, and we are eager, able and ready to respond. The new resources, tools and supports are summarized below:

Protocols/Resource Identification:

Suggestions and Strategies for Isolating Residents in Long-Term Care

To our knowledge there is no current research evidence or best practice guidelines that directly address COVID-19 isolation measures in relation to the population and residents with dementia in long-term care. This document outlines suggestions and strategies for isolating residents in long-term care homes during the COVID-19 pandemic. RNAO has gathered this list of suggestions and strategies from a number of long-term homes, and has received endorsement from both AdvantAge Ontario and the Ontario Medical Association. For details, see here.

Palliative Care Delivery in Long-Term Care during the COVID-19 Pandemic

This summary of palliative care and end-of-life resources is for health care providers in Ontario long-term care homes to help them to quickly address the issues they are confronting during this COVID-19 pandemic. Recommendations for advanced care planning are based on the Ontario legal framework. For details, see here.

Mental Health and Well-being: Resources for Psychosocial Support during the COVID-19 Pandemic

Mental health and well-being is essential to our overall health. To maintain the safety of health care workers and their families during this pandemic, a list of recommended resources has been compiled to support you in getting the help you may need. We will continue to update this document as new resources are identified. For details, see here.

Facebook Supports

VIAFamily: RNAO LTC Support for Connecting Families

We recognize the profound impact social distancing is having on families and friends who have loved ones living in long-term care homes. Given the current visiting restrictions, RNAO established a Facebook Group the week of March 30th to provide a forum for families and friends of nursing homes and retirement homes residents to share stories and get support from others experiencing a similar situation. As of today, there are 150 members in the group. To join, go here.

Two emerging groups this week - we are responding to your needs – were launched yesterday!

Professional’s Peer-to-Peer Support During COVID-19
We know that as a health professional you are facing unprecedented stresses with the COVID-19 pandemic. You are working exhausting hours, making harrowing decisions and are anguished about the safety of your patients, yourselves and your own families. RNAO established a Facebook Group to provide a forum for health workers — nurses and other colleagues — to share stories with your peers and offer mutual support. To join, go here.

Sharing and Tackling Emerging Care Issues

This Group is for you, health workers - nurses and other colleagues - who are facing unprecedented challenges during the COVID-19 pandemic to raise concerns about practice issues affecting staff and/or the recipients of care and to offer mutual support that promotes safe, high quality care. You are encouraged to share your experiences and strategies to address practice concerns and cope with the challenges. To join, go here.

All three Facebook Groups will be moderated by RNAO staff, including registered nurses and policy experts. RNAO staff will direct participants to credible resources and identify unanswered questions, emerging issues and trends that require further action from us at RNAO and top officials in the province. You can join any of the groups through the links in RNAO’s Facebook page, here.

Update for nursing students – NCLEX Exam

In order to respond to student inquiries -- about the NCLEX Exam, access to a Temporary License, and completion of clinical placements -- we have contacted the College of Nurses of Ontario (CNO). They have advised that the NCLEX exam became available again on March 31st and more centres continue to become available as writing centres are able to open given current requirements for social distancing and cleaning. Students are registering to write the exam. Students with questions about the examination should access the CNO website at  http://www.cno.org/students As we understand it, candidates can schedule their exams for appointments starting May 1st and beyond, if conditions allow.

A further issue is that many students are attempting to obtain a temporary license to enable them to become a part of the nursing and care team, having met all the requirements except that of a job offer. RNAO is working with possible employers and the CNO to expedite this process to enable students to join the workforce.

We have heard from many 4th year students who are concerned that they have been unable to complete their programs because their clinical placements are no longer being honored in the service setting at this time. RNAO is working with various heads of Schools of Nursing to clarify and help resolve the issues involved in facilitating students to meet program requirements through completion of their clinical placements. Again, these students are keen and ready to join their nursing colleagues in the battle against COVID 19. 

Your messages: Voices and responses

Every day we welcome new readers to this daily report: thank you deeply for the work you do during this public health crisis, and also for keeping us well informed. You can see previous reports at RNAO updates and resources on COVID-19 for members and other health professionals. Feel free to share these updates with other health professionals at home and abroad. RNAO media hits and releases on the pandemic can be found here. Daily Situational Reports from Ontario's MOH EOC can be found here. Many of the articles you see here are posted in my blog, where you can catch up with earlier issues.

Thank you for your messages! Here are important items that respond to some of your questions and concerns in the past two days:

• conquercovid19.ca  is a grassroots incubator that is facilitating access to priority products that are in short supply but essential for the healthcare community during the COVID-19 pandemic. Collecting masks/respirators, tablets, diapers/formula for women’s shelters, etc. Seeking volunteers. For details, go here.
• A new website was created to inform public health with real-time insights on the COVID-19 pandemic. You contribute your health status daily – it takes two minutes – and help track the virus. I very strongly encourage you to participate. Go here.
• Several articles have raised the critical situation in LTC and universal PPE for all sectors. Please, take action and retweet: here, here, here and here.   
• This week I joined a panel in TVO’s The Agenda with Steve Paikin: “Health-care workers now comprise one in 10 known Ontario COVID-19 cases. Do they feel as protected as possible while executing their work? How can Canada ensure the safety of those fighting this disease on the frontlines? The Agenda discusses the immediate and future need to protect health-care workers with Dr. Sohail Gandhi, president of the Ontario Medical Association; and Doris Grinspun, CEO of the Registered Nurses' Association of Ontario.” You can watch here.

 

You can read earlier responses here. 

Together we can do it

Today was day #21 of RNAO’s #TogetherWeCanDoIt campaign. The noise is becoming louder and louder in streets, workplaces and social media to #cheer4healthworkers – and it has gone even to the UK see here! Please remember to join-in this community building moment every evening at 7:30pm local time - until we defeat COVID-19! and post tweets from your communities and workplaces with your messages here, cheers here, and other expressions of gratitude -- Because: #TogetherWeCanDoIt.

 

MOH EOC Situational Report #76 here  for Friday, April 10

 Situation:

 

Case count as of 8:00 a.m. April 10, 2020
Area	Case count	Change from yesterday	Deaths	Change from yesterday
Worldwide total	1,617,472	+86,157	96,929	+7,411
Europe	789,325	+33,872	66,927	+4,805
China	83,962	+75	3,336	+01
Middle East	136,487	+7,407