March 23, 2020 COVID-19 report

Colleagues, here we are on Monday, March 23 - month three of the COVID-19 outbreak in Canada – a global pandemic of major proportions. To see previous reports visit 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 or abroad.

I want to start by thanking you for reaching out to us with your experiences, your concerns and also your thanks. After reviewing and responding to most of today’s issues, PEE availability is undoubtedly today’s top concern. These is a concern for the protection of nurses, physicians, paramedics, midwives, lab technicians, other health workers and patients – with added urgency in long term care, primary care and home care.  

Given the extensive community spread of COVID-19, and the evidence that persons, including health workers, became contagious before symptoms appear, one cannot assume that asymptomatic health workers are not spreading the virus. Thus, RNAO is recommending to health officials that all health workers, at this point, should be using surgical masks while at work. Given the limited stocks of masks, this should start in our view in nursing homes and other setting where patient populations are most vulnerable, and, as stocks of surgical masks increase, all health workers in all settings should be using them.

RNAO continues to urge government – in the strongest possible terms – to move aggressively to secure a supply chain for these products. International procurement is not a likely option at this time, as every country in the world is desperate to procure. Thus, government needs to obtain required health care supplies by immediately taking control of the domestic supply chain. Place a prohibition on the commercial sale either by internet or in stores, of a list of healthcare supplies. All privately-held stocks of defined list of supplies (i.e., drugstore chains) should immediately be handed to government through legal order. Most importantly, the federal and provincial governments should be moving at breakneck speed to mobilize technical know-how and production capacity in the private sector to procure the key items required. There is absolutely no time to lose and we should be hearing from both levels of government how they are implementing this. It is an evidence-based statement to say: Lives are on the line. At the end of this nightmare, it will be shocking to see the correlation between the availability of the required PPEs and equipment, such as ventilators, and the death rate. On Saturday, we issued a joint press release of RNAO and OMA RT. 

We are working on many fronts. RNAO and OMA met today with the Coalition of Ontario Regulated Health Professions’ Associations (CORHPA) to share our intent to collect any available PPE stock. Indeed, for anyone ready this report – and residing in Ontario – if you have personal protective equipment (PPE*) that you are able to spare, please follow these instructions:

1. For Large Quantities and Access to Suppliers

The Ontario government has set up a website where you can disclose the resources you have available.

2. For Smaller Quantities

Please contact christine.poopalapillai@oma.org with the following information: a) Name of organization (college, university, etc); b)Location (please include postal code); c) Phone; d) Email; c) Supplies Available and Quantity.

PPE* includes the following: surgical/procedure masks, N95 masks, gloves, gowns, eye protection).

Today was the fifth day of the #TogetherWeCanDoIt campaign and the noise was even lauder to #cheer4healthworkers. My neighbours and I participated again from our own porches, thus keeping social distance and yet feeling a deep sense of togetherness. Please take a few minutes every day at 7:30pm local time, continuing every evening until we defeat COVID-19! This collective energy will continue to be necessary as we work together to get through this very tough pandemic. So, 7:30 pm local time, each evening, step out onto your porch, balcony or open a window and make some noise in honour of the heroes working on our behalf. You can bang some pots and pans, you can sing a song, you can applaud, ring your bike’s bell, and yes – you can honk. And then, of course, share in social media.

WHO and Global Citizen launched #TogetherAtHome, a virtual, no-contact concert series to promote physical distancing and action for global health. Chris Martin, lead singer of Coldplay, kicked it off earlier this week with a performance from his home. More Solidarity Sessions are planned to promote health, show support for people who are staying at home to protect themselves and others from COVID-19, and encourage donations to the COVID-19 Solidarity Response Fund.

As COVID-19 cases continue to increase, many countries are requesting individuals to stay at home in self-quarantine. WHO EURO has released a guide on how to stay physically active during self-quarantine. Information can be found here.

MOH EOC Situational Report #58 here  for Monday, March 23  – EOC reports that the number of confirmed cases in Canada today is 1,508 cases, and 21 deaths including six persons in Ontario. EOC reports 78 new cases that bring our province to a total of 503 cases (of which 8 are resolved cases and 6 deaths). EOC reports that in Ontario, at this time, we have 8,417 persons under investigation with lab results pending. Additional Information from EOC includes:

• Guidance for Consumption and Treatment Services here
• Mandatory closure of all non-essential workplaces effective as of Tuesday, March 24th at 11:59 p.m - for 14 days with the possibility of extending this order as the situation evolves. A full list of businesses that are permitted to stay open will be released tomorrow.
• Health Canada has released an FAQ document regarding Subsection 56(1) Class Exemption for Patients, Practitioners and Pharmacists Prescribing and Providing Controlled Substances in Canada during the Coronavirus Pandemic here
• Clarification around the Hospital Redeployment order (Regulation 74/20 under the Emergency Management and Civil Protection Act) here.
• A summary of today’s Command Table meeting here

Coronavirus COVID-19 Global Cases by Johns Hopkins -- CSSE reports a total of 503 cases in Ontario and 2,088 total cases in Canada as of March 22, at 11:50pm.   

Public Health Ontario maintains an excellent resource site on materials on COVID-19. This is an essential resource for Ontario health providers; I encourage you to visit it.  Make sure to check the Public Health Ontario technical brief on the Updated IPAC Recommendations for Use of Personal Protective Equipment for Care of Individuals with Suspect or Confirmed COVID-19 (in English and French).

Health Canada's website provides the best information capturing all of Canada. It contains an outbreak update, Canada's response to the virus, travel advice, symptoms and treatment, and resources for health professionals. This is, again, a vital resource for those following the COVID-19 outbreak in Canada.

The Public Health Agency of Canada has developed two new guidance documents for health system partners. The first, regarding community-based measures to mitigate the spread in Canada, and the second on informed decision-making related to mass gatherings.

Situation Report 63 from WHO updates that worldwide there are 332,930 confirmed cases (40,788 new) and 14,510 deaths (1,727 new). There are 59,138 confirmed cases (5,560 new) in Italy, 21,638 confirmed cases (1,028 new) in Iran, and 28,572 confirmed cases in Spain (3,646 new). Other countries to note are Germany (with 24,774) and France (with 15,821). China has 81,601 cases (with only 103 new), and 8,961 confirmed cases in South Korea (64 new), both countries clearly managing, at this point, to “flatten the curve”. The number of confirmed cases worldwide has reached one third of a million. The virus is now starting to spread in the South Asian and African regions, including many countries with very weak health systems, which is extremely worrisome.   Joint Statement of Pharmacist, Nurses and Doctors on  untested & potentially dangerous drugs for COVID-19

You can also find up-to-date global numbers in Coronavirus COVID-19 Global Cases by Johns Hopkins CSSE. These numbers appear to be more updated than those of WHO. For example, while WHO indicates there are 31,573 cases in the United States, CSSE reports 43,901.

Diagnostic testing for COVID-19 is critical to tracking the virus, understanding epidemiology, informing case management, and to suppressing transmission. WHO has updated the Laboratory Testing Strategy document according to the 4Cs transmission scenarios. All technical guidance can be found here.

Today we issued a Joint Statement of Pharmacist, Nurse Practitioner and Doctors on untested & potentially dangerous drugs for COVID-19. Specifically, the statement addresses the use of inappropriate use Hydroxychloroquine and Azithromycin for COVID-19 prophylaxis. Please RT.

WHO Regional Office for Europe has published interim guidance on how to deal with COVID-19 in prisons and other places of detention, available here.

RNAO’s ACTIONS:

As of today, 4,560 RNs and NPs responded to the RNAO survey with availability to provide virtual clinical care or non-clinical services. We have already deployed 59 to Ottawa Public Health and a good number to other places. RNAO is in the process of working with various other areas of need and will connect with you depending on the locations required. We also understand that Telehealth will necessitate additional staff. We know that you are ready and eager to help and thank you hugely for it!   

Note to employers in Public Health Units and other call centres: If you are experiencing a staff shortage to answer phone calls following protocols or contact tracing - please let us know. Write to Daniel Lau dlau@rnao.ca and we will connect you within hours with RNs and NPs in your locality.

Note to employers in Long Term Care Homes: Today, Monday, RNAO launched its partnership to supports LTC homes by facilitating the hiring of nursing students. Our leading team member for this is Daniel Lau, Director of Membership & Services at RNAO – he and his team connected already nursing students with 19 homes and tomorrow the work will be even more intense. I am inspired by seeing this awesome partnership with AdvantAge Ontario – Kudos to CEO Lisa Levin who reached out to us for support. Now, RNAO’s 5,000-strong nursing student members who completed year one of the BScN program are speedily beginning to move to fill-in spots as Personal Support Workers (PSWs) to increase the homes’ capacity to meet HR needs. We are here to support Nursing Homes that need help! Simply contact Daniel Lau  dlau@rnao.ca  and he will connect with nursing students in their 2nd, 3rd and 4th year, that live in the vicinity. For the nursing students, this is an opportunity to put into action their knowledge and skills, gain valuable experience as well as an income, as these will be paid positions. This is another just-in-time service RNAO and AdvantAge provide to the people of Ontario and their members, a win-win-win for all parties.  

URGENT STEPS FOR GOVERNMENT TO TAKE: RNAO’s VOICE

1. Prepare for large scale community spread. The COVID-19 data we hear every day from public health is simply the tip of a large pyramid of actual cases. The virus has likely been transmitting in the community for weeks now. In our estimate, and given our limited testing, the actual number of cases could be as high as 10 times or more the reported number we receive. There might be today thousands of persons in the community spreading COVID-19, the majority in early stages, asymptomatic or with mild symptoms. RNAO’s analysis is that we will see the impact very soon. Remember that in South Korea, one individual spread to hundreds of others. The practical lesson is that we should assume the virus is now everywhere in Canada, and spreading fast. That’s why the dramatic action is justified; otherwise the curve will shoot up even more.
2. Canada must continue ramping up testing, rigorous contact tracing and case isolation. We are pleased that in Ontario we are increasing significantly our testing capacity. We must continue to do so, at the same time as we enhance our capacity for contact tracing and self-isolation. One sometimes hears the view that when we are experiencing community spread and calling for social distancing, there is no purpose in continuing to test widely and trace the contacts to isolate them. This view is not evidence-based. Even when we manage to flatten the curve, as China, South Korea, Singapore and other countries have so far done, the virus will remain out there and ready to raise its head again. Only a rigorous, comprehensive system of testing, tracing and isolation, which is the case in those countries, will allow us to go back to some normalcy, until such time as new therapies or vaccines are ready to be used. Since contact tracing and isolation is a laborious process, if we need health personnel to strengthen public health units, RNAO still has 4,000 RNs awaiting to be utilized – hundreds could hired for contact tracing. 
3. Shut down of all non-essential movement in the streets. On Saturday, we urged Premier Ford and Minister Elliott to institute an immediate, full scale shut down of all non-essential movement in the streets, similar to the actions in Quebec, New Brunswick and elsewhere. This is a last resort measure to avoid a situation of an intensely overwhelmed healthcare system and many, many deaths. We were relieved when the government today announced the mandatory closure of all non-essential workplaces effective as of end of day Tuesday, March 24th. This closure will be in effect for 14 days with the possibility of extending this order as the situation evolves. A full list of businesses that are permitted to stay open will be released tomorrow. It is crucially important that we support the shutdown in our words and actions. We can go out for a walk around the block, keeping social distancing of two meters, or one person in the household going to buy groceries, but other than that, nobody should be in the streets. We should participate in making sure people stay at home or walk outside keeping social distancing. This is the best way we can support all those who cannot stay at home, be that a nurse, physician, personal support worker, paramedics, midwives, lab technician, grocery or warehouse worker, truck driver, police, fire, food bank, or another of the many other essential services that will allow us to sustain this period. The more stringent the physical distancing actually happens, the shorter this critical period of shutdown will be. 
4. ICU beds and ventilators. The evidence elsewhere shows that around 5% of the confirmed cases will require ventilation in an ICU or similar bed. If the equipment and specialized personnel are not available, the person likely dies. That has been the horrifying reality in Italy, which has had one of the highest death rates from COVID-19. In Hubei, China that was not the case after the first period since they managed to build massive makeshift hospitals in a few days, which requires an enormous capacity that is likely non-existing in the rest of the world. We know hospitals are on the thick of planning for space and staff deployment. We are less certain of where we are with the necessary gear for the staff and the ventitaros that will be required to save lives. We know that there are companies ready to engage production of critical equipment; are they being engaged? Let us repeat: These are matters of life and death.  
5. Support for vulnerable populations and workers. Governments should implement urgent measures to alleviate the enormous burden placed by fighting the virus. COVID-19, and the measures required to address the emergency, have profound social equity impacts. For example, protecting Ontarians experiencing homelessness and those living in crowded shelters are issues we are actively pursuing with government officials, and we are pressing for an urgent plan. We also know that government is meeting with Indigenous leaders to discuss their preparations for COVID-19, and we are eager to hear the outcome of those discussions. While we were pleased with the initial measures announced last week  by Ontario’s Premier Doug Ford to protect workers from losing their jobs as businesses suspend operations or they have to stay home to take care of children, RNAO was also urging for much more to be done to assist low-wage earners and those in precarious employment, who may transmit disease simply because they have no option. Thus, we are pleased with the announcements made last week by the federal government, but much more needs to be done. Workers and businesses hurt by the COVID-19 pandemic may be eligible for part of the $82 billion aid package announced by Prime Minister Justin Trudeau, which includes $27 billion in direct support for those struggling to find work or care for family members. The package, now before Parliament, stands to adjust the rules on who qualifies for employment insurance (EI), and includes two emergency benefits for those who don't.
6. Massive public education and enrollment. Please become a champion for #StayAtHome and #SocialDistance, by educating your families, friends, colleagues and members of your community. RNAO and our members are heavily engaged in mainstream and social media to keep the public fully informed, engaged and enrolled into #socialdistance action. We ask that you follow us at @RNAO and @DorisGrinspun and retweet + facebook as much as you possibly can. Send your friends and members of the public to the government website and here
7. Solidarity during a difficult time. It is very important to call on citizens to organize informal networks of support, largely virtual, for people who live alone, who may be elderly, or vulnerable, or who do not have the money to buy essentials, or who are struggling through this period in so many ways. With mental health and other conditions exacerbated by isolation, call on the public to display solidarity and humanity like never before – message: #togetherwecandoit.

Please continue to keep in touch and share questions and/or challenges of any kind, and especially shortages of PPE. Send these to me at dgrinspun@rnao.ca. We are responding daily and are continuously solving your challenges. WE ARE HERE FOR YOU! You can also use the health provider hotline and website regarding questions about the outbreak, protocols, preparedness, and more. The toll free number is 1-866-212-2272, and the health provider website, updated regularly with useful resources, can be accessed here. An important reminder that the health provider website and the toll free number are for you – as a health professional – and not for members of the general public.

Ontario’s ministry’s public website on the COVID-19 exists to inform the general public – encourage your family and friends to access this public website. The WHO has provided an excellent link for you to share with members of the public here. RNAO has updated its information page for the public. Please share it widely.

Let’s thank our colleagues in the front lines in Ontario, Canada and in other countries – especially Italy, Spain and Iran – now hit the hardest. We are here with you in solidarity. These are stressful and exhausting times; the only silver lining is coming together and working as one people – for the good of all!

Together, we are and will continue to tackle COVID-19 with the best tools at hand: accurate information, calmness, determination and swift actions! 

Doris Grinspun, RN,MSN, PhD, LLD(hon), Dr(hc), FAAN, O.ONT
Chief Executive Officer, RNAO