May 29, 2020 COVID-19 report

Dear Colleagues: Welcome to our Friday, May 29 report – now in the fifth month of COVID-19 in Ontario. Visit the COVID-19 Portal for the many resources RNAO offers on COVID-19. You can refer to earlier update reports here, including thematic pieces in my blog. Feel free to share this report or these links with anyone interested – they are public.

COVID-19 webinars

I am tremendously uplifted with our continuing series of weekly COVID-19 webinars for health providers, organized by our awesome RNAO staff.  What inspires me is our team’s unwavering and steadfast dedication, their energy to organize the webinars during the evening hours, and the topics they select, always in response to requests. We all get energized when we see the incredible attendance week after week after week!

We’ve had already close to 1,200 participants over the 8 sessions. Each webinar includes COVID-19 updates – the latest news and pressing issues –, guest speakers from the front lines, questions & answers, as well as a call to action. Health providers from Ontario, Canada, and anywhere in the world are welcome to join at no cost. The upcoming webinar is on Monday, June 1, 2020, 6:45 PM to 8:00 PM (Ontario time). You can register and also watch recorded earlier webinars and get more information here.

The most recent webinar took place on Monday, May 25 where the topic of discussion was re-opening the province and safe practices with guest speaker Dr. Jeff Powis, Chief of Infection Prevention and Control at Michael Garron Hospital. More than 200 participants attended the webinar and learned about determining when to ease public health measures and the trend for new daily cases and daily resolved cases. This archived session can be found here.

Canadian Armed Forces’ LTC report: The report from the Canadian Armed Forces on their work in five Ontario nursing homes has been prominent in the news. Such a horrific report should not have come as a surprise to anyone who has been following the situation in long-term care in Ontario in general and especially during COVID-19. Kudos to the CAF for their transparency as it forces a response. Tragically, this is not the first report of this nature; however, there is a promise from government to act in a serious way. RNAO is calling on the government to act on July 31, 2020. Likely, most readers will not know why this specific date, and to readers from Ontario, this means we forget quickly – please read on to understand. To learn more about “July 31, 2020” and RNAO’s response to the CAF report, see next our press release.

RNAO Calls for Immediate Action in Response to the Canadian Armed Forces’ LTC report with Minister Fullerton’s July 31 Report to Legislature

TORONTO, May 28, 2020 – The Registered Nurses’ Association of Ontario (RNAO) is calling on the government to take immediate and concrete action to address the long-standing shortfalls in long-term care (LTC) homes made blatantly evident in the Canadian Armed Forces’ (CAF) report, released on Tuesday. Although the province announced May 19 it would set up an independent commission to examine conditions residents are experiencing in LTC, first expected to begin its work in September and yesterday moved to July, RNAO says the litany of serious and egregious issues outlined by CAF cannot wait another day. Rather than only relying on a future commission, the immediate step is to start implementing the recommendations from past inquiries and commissions.

“Seniors are dying, LTC staff members are disheartened and exhausted, and families and communities are devastated that such a horrifying debacle can happen in our rich province,” says Dr. Angela Cooper Brathwaite, RNAO president. “The CAF report Operation Laser - Joint Task Force Central Observations in LTC Facilities in Ontario has validated critical shortfalls and is a clarion call for immediate action,” stresses Cooper Brathwaite.

RNAO is gratified that Premier Ford sees the health and safety of residents and staff in LTC as the number one priority, and is fully prepared to work with his government to “fix the long-term care system in Ontario.” RNAO says such action should begin right away since Minister of Long-Term Care Dr. Merrilee Fullerton is expected to deliver a report on the adequacy of regulated staffing in LTC to the legislature on July 31. This is a requirement in the recommendations of The Long-Term Care Homes Public Inquiry led by Justice Eileen Gillese, in 2019.

RNAO wants Minister Fullerton to recommend and immediately implement substantial measures and funding to address the current regulated staffing crisis that permeates all nursing homes. Such a move will show the public that Premier Ford’s government is ready to act with urgency. Acting on a past commission’s recommendations will demonstrate that Premier Ford is intent on implementing the recommendations of a future one.

“Although staffing is only one component of what needs strengthening in our long-term care system, it is a central one. Adequate overall levels of staffing, as well as strengthening the skill mix between regulated and unregulated staff alongside the funding to make it real will go a long way to start addressing the damage done to nursing home residents, their families and their staff,” says RNAO’s CEO Dr. Doris Grinspun. “RNAO is bringing a concrete evidence-based proposal for Minister Fullerton to adopt in her July 31 report to the legislature, and implement immediately thereafter. RNAO’s proposal is well-known to government since it took office in June 2018 and addresses the dangerous levels of staffing and skill mix currently found in LTC,” Grinspun adds.

RNAO is proposing a basic formula to address the crisis of staffing in LTC to include: (a) adequate numbers of staff, and (b) the proper skill mix of regulated and unregulated staff – including larger utilization of nurse practitioners (NP), registered nurses (RN) and registered practical nurses (RPN), allocated as follows: 

Basic staffing formula: 

• Each resident shall receive four (4) hours of direct nursing and personal care each day, as follows: 
  0.8 hour of RN care (regulated)
  1 hour of RPN care (regulated)
  2.2 hours of personal support worker (PSW care) (unregulated)
• In addition, there should be one (1) NP per 120 residents, and  
• One (1) infection prevention and control specialized nurse (preferably an RN), per home.

In 2017, the government committed to providing four (4) hours of direct care per day per resident. This target was based on a 2008 report by RN Shirley Sharkey. Shockingly, to this day, the four (4) hours of direct care per day per resident has not been implemented leaving residents short of staff to meet their needs. Equally worrisome, is that current legislation in Ontario does not specify ratios for RNs, RPNs and PSWs; it only assigns one RN on-site per shift, which is gravely inadequate, as the CAF report shows. Added to these deficiencies is the fact that only a small number of nursing homes have NPs and most must do without any. In short, the current standard fails on two counts: the overall number of hours of care is too low, and there is no requirement that a certain number of those hours of care be provided by an NP, RN and RPN (regulated staff).    

The proposed RNAO standard also recognizes the specialized nature of LTC and the need to have a nurse (preferably RN) dedicated to lead on-boarding, orientation, mentoring, and staff development, as well as infection prevention and control, as part of the mandatory staffing required.

The CAF report provides multiple examples to understand the profound impact of these numbers:

Inadequate overall levels of staffing: The indications are everywhere in the CAF report: “Morale and well-being of staff at risk. Many are overworked, seem burned out and have no time off (some have not seen their families for weeks).” The staffing is such that it is impossible to provide care at a pace that is appropriate to each resident or allow them any kind of independence.”

Inappropriate standards of care due to the absence of regulated nursing staff: For example, a resident requiring palliative care was not given hydromorphone injection since an RN was unavailable (page 4). The presence of regulated staff is essential since PSWs have short, hands-on oriented training with little to none (depending on the program) theoretical background. For example, CAF reports that “PSWs can be task focused and do not always report discovered abnormalities to registered staff” (page 5).

Negative implications of lack of RNs: The CAF Senior Nursing Officer (SNO) notes the lack of RNs and the impact on safety: “No (civilian) RN in the building other than SNO during weekends. SNO and Executive Director (also an RN) only RNs on site on numerous occasions during the week. Significant resultant safety concerns regarding patient ratios (1 RN for up to 200 patients)” (page 8).

RNAO says the issues identified in the five long-term care homes supported by the military represent many of the long-standing issues that have existed and have never been addressed in this sector, in particular issues related to inadequate levels of regulated staffing. “Report after report including the 2005 Coroner’s Inquest into the Casa Verde home in Toronto, have called for urgent action and nothing has happened,” insists Grinspun.

RNAO calls on the Ford government to:

1. Adopt the basic staffing formula presented above.
2. Release on July 31, 2020 a plan of action for implementation of the new staffing formula to be completed within 6 months – by the start of 2021.

RNAO has been raising staffing concerns for years and now is calling for immediate action to avoid adding harm to the damage already done. “Minister Fullerton has a golden opportunity to deliver on a first installment of building public trust. The shortfalls of staffing have been discussed and examined and the time to act is July 31, when the minister must table the results of her consultations in response to Justice Gillese recommendations in the long-term care public inquiry report, released on July 2019. One of her key recommendations ̶ #85 ̶ called on the government to increase the number of registered nursing staff in long-term homes by undertaking a study and tabling its results in the legislature by July 31, 2020.

The Canadian Armed Forces report reinforced once again that key staffing issues must be immediately addressed. There is no need to wait for a new commission and – once again – delay addressing staffing issues. “Premier Ford – here is your opportunity to fix the system, as you have promised, and we are eager to help you do so,” offers Grinspun.

Your messages: Voices and responses

Each day we receive numerous messages. Each day we also welcome new readers to this daily report: Thank you deeply for the work you do always and especially during this public health crisis, and also for keeping us well informed. You can see previous reports here. Feel free to share these updates with other health professionals and other organizations both 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. The COVID-19 Portal is here.

Update on pandemic pay: Today we received an update from government on their response to the concerns on pandemic pay raised by a number of groups. You can see the new guidelines for pandemic pay in a slide show here. There are important gains in consumption and treatment sites; mental health and addiction programs; community and home care; public health and emergency health services nurses; as well as nurses (RN, RPN, NP), PSWs and respiratory therapists, as well as some auxiliary staff, in all hospitals. Again, for details, go to the slide show here. There are also disappointments as, for example, we have not yet been able to persuade the government to extend pandemic pay to nursing managers in LTC, in correctional facilities and other settings where they serve, effectively, as front-line pandemic workers.

On this same topic, I received a letter a week ago from RNAO member Christina Hughes (included in this blog with permission):  

Pandemic pay in consumption and treatment sites

Dear Doris,

Thank you for all the work the RNAO is doing on behalf of nurses and our communities across the province.

I am writing to you to request advocacy on behalf of staff working at Consumption and Treatment Services (CTS) Sites, across the province.

For the purpose of this email, I will speak to the experiences we are having at our location in Guelph.

Currently, the prioritized roles for pandemic pay do not include CTS Sites.

Since the rationale for inclusion criteria indicates specifically roles wherein the primary function is caring for high risk individuals in congregate settings, it is my belief that CTS sites do qualify (and absolutely should). It is confounding that the pandemic pay criteria has not been interpreted this way.

I understand that extensive advocacy is underway to have CTS staff included as recipients of pandemic pay, including them as addiction and mental health workers in congregate settings. Our staff at the CTS in Guelph, operated out of the Guelph Community Health Centre, would like to be added to those who are fiercely advocating that our teams be considered for pandemic pay.

We here at our site continue to see vulnerable peoples, some of whom are positive for Covid19 and travel to us from a Supported Isolation Center (SIC) for the homeless or precariously housed (these folks are symptomatic and/or positive for COVID-19).

While we endeavour to maintain physical distance and are donning the appropriate PPE, proximal care is obviously required when responding to overdoses or other medical emergencies. We also continue to provide wound care and basic assessments as required and when possible.

I am sure I don’t need to tell you that the opioid crisis has not paused for the pandemic, and that now, more than ever, our vulnerable and marginalized communities face even greater barriers to accessing care and connection.

Our doors here are open daily, including weekends and holidays. We have nurses, peers, social work, harm reduction workers, indigenous workers, and cleaning staff. All of them continue to work relentlessly to deliver lifesaving services amidst this pandemic, and, as a result, are exposed daily to populations who are at high risk of COVID-19.

In communities where other sites have been forced to close their doors, we saw a marked increase in deaths due to overdose. Here we work with and support upwards of twenty to thirty folk each day, and have seen only a minimal increase in adverse events from substance use in our community.

We connect clients with food and shelter services, as needed medical care, and harm reduction education and supply distribution. Two of our nurses provide intake support to the SIC as needed.  Clients continue to access us daily and often speak of how isolated and disenfranchised they would be if our doors were not open to them.

Please help us to continue this essential work. Support our team by qualifying this work to be included in the pandemic pay. 

I stand with my team, and for the people I serve.

Thank you for your time and consideration of this advocacy request,

Sincerely,

Christina Hughes, RN

Guelph CHC, CTS Site

RNAO’s response: Christina, thanks so much for the awesome work that you and your colleagues do! I want to publicly acknowledge you for drafting this letter that triggered me to advocate for pandemic pay for health providers working in consumption and treatment sites. As you can see in the government’s new guidelines (item above), we have heard today that you and your colleagues will receive pandemic pay. This is so well-deserved!

You asked and RNAO delivers: Another webinar and resources for foot care nurses

Thank you to all those who were able to join our first Forum for Foot Care Nurses: Dialogue and Discussion webinar that took place on Thursday, May 28. Due to the overwhelming response and positive feedback we've received, we are hosting a second session to continue our dialogue. All webinars will be recorded and will be available to view via the link below. Two documents updated as of May 29, have been produced by RNAO staff regarding questions submitted and available resources – see here and here. Please take note that these resources were finalized May 29, and that the information provided may change over time as it relates to COVID and re-opening.

The next webinar of the Foot Care Nurse series will be taking place Wednesday, June 3, 3:30 - 4:30 pm. Registration is now open, please ensure that you've registered before the webinar. Once you have registered, you will receive a link to join the webinar. To register go here.  The webinar that took place May 28 has been archived here. If you have any questions on the above or want to send us questions ahead of the next webinar, please reach out to Melissa Aziz (maziz@rnao.ca) and Beverly Faubert (bfaubert@rnao.ca). 

Together we can do it

Today is day #72 of RNAO’s #TogetherWeCanDoIt campaign… RNAO began this campaign on March 19 to cheer up health care workers and others in essential services. The campaign keeps expanding far and wide and shows to the world that  #TogetherWeCanDoIT.

Today I want to thank HornonTheCob for being a “dependable cheerer” with beautiful music. As always my dear friend Dr. Irmajean Bajnok has posted another inspirational message. Another dependable cheerer is Valerie Gelinas and her children, who posts every evening upbeat messages.  If you know James Francoeur, tell him that RNAO thanks him and welcomes him as a new cheerer!  Also, thanks to Alex for helping us spread the campaign, and check this incredible tweet. Deirdre Boyle here, are my thanks to you!

Wendy Stephen and her children stole my heart and is a must watch and RT message that shows incredible dedication and work! Thanks Mitzie Hunter for your awesome dedication!

Please remember to join in this community building moment every evening at 7:30pm local time - until we defeat COVID-19! Make sure to post tweets using #TogetherWeCanDoIt.

MOH EOC Situational Report #125 here for Friday, May 29

Situation:

Case count as of 8:00 a.m. May 29, 2020
Area	Case count	Change from yesterday	Deaths	Change from yesterday
Worldwide total	5,932,171	+118,891	362,612	+4,718
Europe	1,979,615	+18,892	171,874	+987
China	82,995	0	4,634	0
Middle East	557,463	+11,879	13,880	+122
Asia & Oceania	436,517	+16,896	11,006	+381
Africa	132,254	+5,011	3,819	+95
Latin America and Caribbean	886,207	+42,523	47,178	+1,791
North America	1,857,120	+23,690	110,221	+1,342
United States	1,768,608	+22,697	103,344	+1,230
Canada	88,512	+993	6,877	+112

 

• 344 new cases were reported in Ontario today, bringing the cumulative case count to 27,210 (this includes 20,983 resolved cases and 2,230 deaths).
• In Ontario, a total of 680,687 tests have been completed, with tests performed at Public Health Ontario Laboratories and non-Public Health Laboratories. There are currently 13,351 tests under investigation.
• 826 patients are currently hospitalized with COVID-19; 129 are in ICU; and 100 are in ICU on a ventilator.

EOC report #122 for May 26 informs of the following actions taken:

• An updated Reference Document for Symptoms has been uploaded to the ministry’s website.
• The CMOH Directive #2 (issued March 19, 2020) has been amended to reflect the gradual restart of all deferred and non-essential and elective services carried out by health care providers. The revised Directive is here along with the accompanying document “COVID-19 Operational Requirements: Health Sector Restart” here. This document outlines measures that must be in place for the provision of in-person health services by health care providers. Health care providers must also adhere to guidance provided by their applicable health regulatory college. Both documents will be translated and posted on the website in the coming days. The sector is reminded of OH’s framework as per its May 7, 2020 document: A Measured Approach to Planning for Surgeries and Procedures During the COVID-19 Pandemic for hospitals to assess their readiness and begin planning for the gradual resumption of scheduled surgeries and procedures, while maintaining capacity to respond to COVID-19. 

EOC report #123 for May 27 informs of the following actions taken:

• Directive #2 has been uploaded to the ministry’s website. The Operational Requirements for Health Sector Restart was provided yesterday.
• The Ontario government continues to protect the health and safety of the public during the COVID-19 outbreak by extending all emergency orders in force under s.7.0.2 (4) of the Emergency Management and Civil Protection Act.

EOC report #124 for May 28 informs of the following actions taken:

• A new Congregate Living for Vulnerable Populations Guidance Document is here and will be available in English and French on the Ministry website shortly. This Guidance Document is intended to assist with minimizing COVID-19 transmissions from individuals working or residing in congregate living settings and to help prevent, detect and manage individual cases and outbreaks of COVID-19 within these settings. The new document is aligned with the government’s COVID-19 Action Plan for Vulnerable People, released on April 23, 2020, and replaces the former guidance documents for Group Homes and Co-Living Settings, Guidance for Homeless Shelters, and Guidance for Community-Based Mental Health and Addictions Service Providers in Residential Settings.
• To further protect seniors and staff in long-term care homes, the Ontario government announced today that it is extending the mandate of the Incident Management System Long-Term Care Table.

EOC report #125 for May 29 informs of the following actions taken:

• As the province carefully and gradually reopens the economy, the Ontario government announced the implementation of the next phase of the COVID-19 testing strategy to detect and quickly stop the spread of the virus. Testing will now be available to more people in more locations across the province. This phase of the testing plan is outlined in the document Protecting Ontarians Through Enhanced Testing.
• The Quick Reference Public Health Guidance on Testing and Clearance has been updated to support the new provincial testing plan. Key updates include: information on the testing and clearance process for asymptomatic patients, and updates approaches to clearing cases. This document is available on the Ministry website.
• The COVID-19 Provincial Testing Guidance document has also been updated to support the new provincial testing plan. Key updates include: guidance on asymptomatic testing, testing prior to surgical procedures, and contact-based testing in specific settings. This document is available on the Ministry website.
• The document entitled “COVID-19 Operational Requirements: Health Sector Restart” has been posted on the ministry’s website. 

Staying in touch        

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!

Thank you deeply colleagues in the front lines; in administrative roles; in all labour, professionals and sector associations, and in governments in Ontario, in Canada and around the world. 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 must redouble our efforts to tackle COVID-19 with the best tools at hand: full, accurate and transparent information, calmness, determination and swift actions. 

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

 

RECENT RNAO POLICY CORNER ITEMS:

26 May - Ending homelessness: Will you join us to build a COVID-19 recovery for all? – go here.

24 May - Technology as a solution: Opportunities and pitfalls of COVID contact-tracing apps – go here.

21 May - Debunking PPE myths with Dr. Jeff Powis: Which masks should health care workers wear during COVID-19? – go here.

20 May - RNAO response to announcement of an independent commission into Ontario's long-term care system – go here.

19 May - With the pandemic curve flattening, VIANurse program will focus its effort on outbreaks – go here.

14 May - Nursing Week update – go here.

14 May - Pandemic puts health system to the test: Nurses have answers for shortfalls – go here.

14 May - Disappointment for not being included in pandemic pay – go here.

13 May - RNAO saddened by the loss RN Brian Beattie to COVID-19 – go here.

13 May - End racism and prejudice – go here.

12 May – Enhancing Community Care for Ontarians (ECCO 3.0) – go here

11 May - Nurses share their successes and challenges during National Nursing Week – go here.

10 May - A story of hope, ingenuity, support and genuine care for an LTC resident – go here.

7 May    - Counting the missing deaths: Tracking the toll of the coronavirus outbreak – go here.

5 May    - Life on the front lines of the pandemic: Profile of RNAO member NP Daria Gefrerer – go here.

5 May    - Addressing differential access to virtual care due to technology inequities – go here.

3 May    - Being person-and-family-centred during COVID-19 – go here.

1 May    - Migrant agricultural workers and the COVID-19 crisis – go here.

30 April - COVID-19 pandemic in provincial institutions and correctional centres – go here.

28 April - Supporting First Nation Communities during COVID-19 – go here.

27 April - Responses to COVID-19 for persons experiencing homelessness in Toronto: An update – go here.

25 April - Lessons learned through a COVID-19 nursing home outbreak – go here.

25 April - Letter from a retired RN to Premier Ford: The problems with LTC were evident long before COVID – go here.

23 April - Working with seniors in long-term care requires specialized knowledge – go here.

22 April - Shaking the stigma: We need a proactive COVID-19 response for mental health and addiction – go here.

21 April - We Require Expanded and Accessible COVID-19 Data in Ontario – go here.

20 April - Can Loss of Smell and Taste Help Screen for COVID-19? – go here.

18 April - COVID, Trump and the World Health Organization – go here.

16 April - A Home Based Model To Confront COVID-19 – The Case Of The Balearic Islands – go here.

15 April - COVID-19 and the Challenges in Homecare – go here.

14 April - Reprocessing Of N95 – An Update – go here.

14 April - A New COVID-19 Facility For Persons Experiencing Homelessness In Toronto – go here. 

13 April - Practical Tips for Safe Use of Masks – go here.

10 April - Ontario’s Tragedy in Long Term Care Homes and Retirement Homes – go here.

10 April - RNAO Action – Supporting Long-Term Care – go here.

10 April - Update For Nursing Students – NCLEX Exam – go here.

9 April - Celebrating Passover, Good Friday, Holy Saturday, Easter Sunday and the start of Ramadan during a pandemic – go here.

9 April - Guidance on use of N95 mask – go here.

7 April - Sentinel surveillance and on-site testing in the homeless service sector – go here.

7 April - Reprocessing of n95 – safe? – go here.

5 April - We must change the way we do testing and case definition – go here.

5 April - Ringing the alarm bells on critical care beds – go here.

4 April - COVID-19, stay at home and domestic violence – go here.

We have posted earlier ones in my blog here. Please go and take a look.

RNAO’S policy recommendations for addressing the COVID-19 crisis: We presented 17 recommendations for government, last revised on April 2. Read them here.

 

Information Resources

Public Health Ontario maintains an excellent resource site on materials on COVID-19. This is an essential resource for Ontario health providers. 

Ontario’s health provider website is updated regularly with useful resources here.

Ontario’s public website on the COVID-19 is there 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.

Please promote the use of Ontario’s COVID-19 self-assessment tool: It also has a guide where to seek care, if necessary. Its use will provide 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. Data will inform Ontario's ongoing response to keep individuals and families safe.

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.

The World Health Organization plays a central role in addressing the COVID-19 pandemic. See here and here.

You can find up-to-date global numbers in Coronavirus COVID-19 Global Cases by Johns Hopkins CSSE.