March 25, 2020 COVID-19 report

Wednesday, March 25. A beautiful spring day outside, being robbed from our lives by COVID-19. I was speaking with nurses and doctors in Spain, last night, as they were preparing to vacate non-COVID-19 patients from Vall d'Hebron University Hospital in Barcelona, since most of the hospital becomes COVID-19. One of my colleagues said: “We must keep in mind this is not a bottomless pit, but a tunnel… there is light at the end of it, and we will come out.” We will, my Ontario colleagues. While a good number of you are already in the frontlines of delivering care, and others are at the planning and execution tables, it is most remarkable how we have come together, as a people, like never before.

Yet, not all is ready, especially the essentials to carry this battle with the highest degree of success to sustain lives: ventilators as life-saving equipment, and personal protective equipment (PPE) to keep our health professionals and others facing patients safe. Today, RNAO issued a public statement that I want you to read.

Thanks again for reaching out to us with your experiences and your concerns. Thanks also for your thanks and generosity – it inspires us all! After reviewing and responding to most of today’s issues, PEE availability continues to be the top concern. This is a concern for the protection of nurses, physicians, paramedics, respiratory therapists, midwives, medical laboratory technologists and assistant/technicians, and other health workers, patients, clients and residents. This concern is especially urgent in long-term care, home care, and primary care sites. We address PPE availability towards the bottom of this report.  

Today was the seventh day of the #TogetherWeCanDoIt campaign and the noise was loud in various streets, workplaces and social media to #cheer4healthworkers. Please remember this community building moment every evening at 7:30pm local time - until we defeat COVID-19! 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 and enjoy a moment watching the fun pics and videos at #TogetherWeCanDoIt.

MOH EOC Situational Report #60 here  for Wednesday, March 25  – EOC reports that the total number of confirmed cases in Canada today is 2,892 cases and 28 deaths. EOC reports 100 new cases that bring our province to a total of 688 cases (this includes eight resolved cases and 13 deaths). EOC reports that in Ontario, at this time, we have 10,489 persons under investigation with lab results pending. EOC reports the following actions taken:

• Today announced an Emergency Order that requires any person entering Canada by air, sea or land to self-isolate for 14 days.
• Health Canada published guidance on optimizing the use of masks and respirators during the COVID-19 outbreak. This includes guidance on the use of expired N95 respirators and masks; and guidance on the use of commercial-grade respirators for medical purposes.
• The Order in Council to close non-essential businesses is attached (here).
• Statement from College of Physicians and Surgeons of Ontario and Ontario College of Pharmacists regarding drug prescribing and in particular hydroxyCQ prescribing here.
• The Public Health Management Guidance document has been updated and a new Quick Reference document on Testing and Clearance has been created. See (here) and (here).
• Several websites have been created for COVID-19 that act as a portal for trusted and legitimate information and resources and have been shared below.
  • COVID-19 Information Portal
  • COVID-19 EBSCO Resource Page
  • COVID-19 (Novel Coronavirus)
• The Command Table met today, a summary has been attached (here).
• The Ontario Chief Medical Officer of Health has issued directive for Ambulance Services and Paramedics under the Ambulance Act (here).

Coronavirus COVID-19 Global Cases by Johns Hopkins -- CSSE reports a total of 688 cases in Ontario and 3,404 total cases in Canada as of March 26 at 2:00 am.   

Kudos for the new assessment tool: With the increasing severity of the COVID-19 outbreak, Ontario has now launched an enhanced and interactive self-assessment tool. This new easy-to-use tool takes the public through a series of questions to inform those who are concerned they may have contracted COVID-19. In a matter of seconds, this tool will help people determine if they are negative or it will provide them with guidance on where to seek care based on their needs. Critically, the enhanced tool provides the province with real-time data on the number and geography of users who are told to seek care, self-isolate or to monitor for symptoms. This data will help inform Ontario's ongoing response in order to keep individuals and families safe.

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 64 from WHO updates that worldwide there are 414,179 confirmed cases (40,712 new) and 18,440 deaths (2,202 new). There are 69,176 confirmed cases (5,249 new) in Italy, 51,914 cases in the United States (9,750 new), 24,811 confirmed cases (1,762 new) in Iran, and 39,673 confirmed cases in Spain (6,584 new). Other countries to note are Germany (with 31,554) and France (with 22,025). China has 81,848 cases (with only 101 new), and 9,137 confirmed cases in South Korea (100 new), both countries clearly managing, at this point, to “flatten the curve”. The number of confirmed cases worldwide is close to half 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. There are enormous concerns regarding the impact of the pandemic in refugee camps, conflict zones, slums in large cities, and other populations at extremely high risk around the globe. 

You can also find up-to-date global numbers in Coronavirus COVID-19 Global Cases by Johns Hopkins CSSE. These numbers are more updated than those of WHO. While WHO indicates there are 51,914 cases in the United States, CSSE reports 66,132. Worldwide, WHO reports 414,179 while CSSE reports 468,523.

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.

This week 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. This statement has been extremely well received by the healthcare community and the media. Sadly, a patient in the USA self-prescribed himself with Hydroxychloroquine and died. 

RNAO Policy Corner:

RNAO welcomed today the economic measures announced today by the Ontario government while cautioning they represent the first essential steps needed to fully confront the outbreak facing the province and its people. This pandemic has exposed gaps in our health system. We applaud the government for responding quickly to help fill the gaps we know exist. However, we are only in the early days and more help is needed, in particular to ensure adequate supplies of personal protective equipment and ventilators. Such health measures include:

• $75 million for personal protective equipment and other essential medical supplies for frontline staff dealing with COVID-19
• A $160 million funding increase for public health specifically for monitoring, surveillance as well as lab and home testing for COVID-19, while also investing in virtual care and Telehealth Ontario
• $935 million for hospitals to help deal with capacity issues, $341 million for 1,000 acute care beds and 500 critical care beds, and assessment centres
• $243 million in funding to address surge capacity in long-term care, as well as funding for around-the-clock screening, more staffing for infection control, and supplies and equipment
• A dedicated $1 billion COVID-19 contingency fund for emerging needs related to the outbreak

RNAO’s ACTIONS:

RNAO survey on virtual clinical care and non-clinical services. 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 continue to deploy colleagues as requested. We know that you are ready and eager to help and thank you hugely for it!   

RNAO survey on critical care services. We need your help. The need for the provision of critical care services is anticipated to likely exceed our current capacity, based on the trajectory other countries have encountered with COVID-19.  RNAO is seeking RNs and NPs who are experienced and have continued competency in the provision of critical care health services in Emergency Rooms, Recovery Rooms, Intensive Care Units, Step Down Units or other relevant clinical areas, who are not currently working in these settings, or who are able to increase their hours of work, to share your availability in providing health care services during this unprecedented emergency. RNAO is releasing a survey tomorrow Thursday to establish a registry of the available health human resources in these specialty areas. Please stay tuned for a survey in your email.  

The College of Nurses of Ontario (CNO) is working quickly to help support Ontario’s health care system during this unprecedented and rapidly changing situation. To enhance Ontario’s nursing resources, it is expediting registration for non-practicing nurses, including those who have retired or have an expired registration implementing an emergency class for nurses who work or have worked in other jurisdictions in Canada or the U.S. For more details see here.

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: On Monday, RNAO launched its partnership to support LTC homes by facilitating the hiring of nursing students. Our leading team member is Daniel Lau, Director of Membership & Services at RNAO. Soon after RNAO and AdvantAge announced and launched the initiative to connect 2nd, 3rd and 4th year nursing students to work as PSWs in senior's residential care facilities, RNAO has connected 3,706 students with 21 facilities (some students connected to multiple homes which are in close proximity to each other).  Within two days, over 135 homes have contacted RNAO looking to augment their human resource capacity to tackle the pandemic. Requests continue to pour in. RNAO is modifying the way students are connected to the facilities to expedite the process in order to provide more timely connection for the high demand. Stay-tuned for an email to you.

The Ontario government informed that it is implementing enhanced measures to protect the safety of residents in long-term care homes. See here for details.

URGENT STEPS FOR GOVERNMENT TO TAKE: RNAO’s VOICE

1. Prepare for a New York City scenario. The crisis in New York leaves me speechless. The COVID-19 data we receive every day from public health is in RNAO’s view – and based on the scientific research available - 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 mild symptoms but untested. It is our view that we should assume the virus is now everywhere in Canada, and spreading fast. Scientists are developing various scenarios as to how the pandemic will evolve in Ontario and Canada, some worse than others. It is RNAO’s view that policymakers and governments should plan according to the worst-case scenarios. We are seeing this scenario unfold in the United States, right across the border, while President Trump spreads dangerous misinformation and absurd predictions that everything will be over in 3 weeks. At the same time as we hope that the social distancing measures of governments in Canada will flatten the curve, for the moment we are seeing large increases in the number of new daily cases. The only prudent approach at this time is to assume that Canada is going basically in the same direction, just a little behind. Of course we hope to avert worst-case scenarios, but we cannot afford at this point not to plan for such a case. If we were not to plan for such contingency, and it occurred, we might risk the tragic death of thousands of people.
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, Japan 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 hire for contact tracing. 
3. Shut down of all non-essential movement in the streets. On Saturday, RNAO 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 announced the mandatory closure of all non-essential workplaces effective today. This closure will be in effect for 14 days with the possibility of extending the order as the situation evolves. A full list of businesses that are permitted to stay open was released. RNAO shares its concern that the list of essential businesses that remain open is overly long. Industries such as construction, in large part, are not an essential business. The concern is that if the shutdown is incomplete, we are prolonging the suffering. Less social distancing and more people living a regular life means the pandemic curve continues to go up, and everyone is locked down for a longer period. It is crucially important that we support the shutdown in our words and actions, and make it as full as possible. Governments must enforce it. We can go out for a walk around the block, keeping social distancing of two meters, or one person in the household can go out 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, respiratory therapist, midwives, medical laboratory technologists, 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. Masks. There is extensive community spread as well as growing evidence about asymptomatic transmission of COVID-19. RNAO has been, for the past week, actively recommending to health officials that all health workers, at this point, should be using surgical masks while facing patients/clients/residents. Given the limited stocks of masks, we recommend that this start 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. We applaud Ontario’s teaching hospitals for moving in this direction, starting today.
5. PPEs. RNAO continues to urge the federal and provincial governments -- in the strongest possible terms -- to move aggressively to secure a supply chain for all the required Personal Protective Equipment (PPE) to protect our colleagues and their patients. Health organizations – across all sectors -- are reporting shortages of PPE. This situation is unacceptable and governments must address it urgently, including preparing for a massive increase in the demand for PPE as we move towards the peak of the COVID-19 pandemic. Moreover, in planning stocks, planners should assume worst-case scenarios (such as Spain is experiencing, or closer to home, New York city). We very much hope not to face that situation, but it is imperative we plan for it, particularly when such a tragedy is already a reality south of the border. It is an evidence-based statement to say: Lives are on the line if proper stocks of PPEs are not planned for. On Saturday, we issued an RNAO and OMA joint press release, on this matter RT.
6. ICU beds and ventilators. The evidence so far in Canada shows that around 6% of the cases have been hospitalized, 4% admitted to hospital but did not require ICU admission, and 2% have been admitted to ICU. That percentage could grow, as it did in other countries. The available ventilators required to save lives during this pandemic – including the 300 additional ones the province has ordered – vastly underestimate, in RNAO’s view, the real need under worst-case scenarios, by a factor of a least 10. For comparison, the governor of New York State is asking for 30,000 ventilators, as the worst-case scenarios become a reality across the United States. 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 – about 5% --from COVID-19. Thus, we must ensure that health organizations caring for patients necessitating ventilators have the necessary quantities -- assuming worst-case scenarios for the pandemic --, so no one’s life is lost because the proper equipment was not available. If Canada succeeds -- as we hope we do -- to avoid the worst scenarios, other jurisdictions will gladly purchase the equipment. We know that there are companies ready to engage production of critical equipment; we are relieved to hear the federal government is harnessing industry for this purpose. Let us repeat: we must move speedily - these are matters of life and death.  
7. 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 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 is 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 also federally. 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. We are also pleased with a new announcement of the Ontario government that it is providing $200 million in social services relief funding to help protect the health and safety of the province's most vulnerable people in response to the outbreak of COVID-19. In addition, the Government of Ontario is providing immediate electricity rate relief for families, small businesses and farms. See above our response to the economic measures announced today.
8. 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
9. 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, we call on all of us and the public at-large 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. RNAO’s Board of Directors and our entire staff want you to know: 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.

Our arsenal of tools to beat COVID-19 includes information – factual, current information. This, is the intent of this report.  For those of you that would like to read 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 or abroad.

THANK YOU colleagues in the front lines in Ontario, Canada and in other regions – especially Italy, Spain, Iran and in New York – 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