September 18 2020 COVID-19 report
Dear Colleagues: Welcome to our Friday, September 18 report – now in the seventh month of COVID-19 in Ontario. Visit the COVID-19 Portal for the many resources RNAO offers on COVID-19. Find earlier update reports here, including thematic pieces in my blog. RNAO media hits and releases on the pandemic can be found here. Daily Situational Reports from Ontario's MOH EOC can be found here. As always, feel free to share this report and links with anyone interested.
Such a profound loss with the passing of Ruth Bader Ginsburg, a trailblazer who changed with her intellects and with her advocacy the lives of many, especially as she fought incessantly for women’s justice and equality. A great loss and an inspiring icon! #RIP (peace and power), RBG
Is Your Hospital Using Blood Wisely?
RNAO is a member of Choosing Wisely Canada and together we partner in both advancing RNAO’s best practice guidelines and helping reduce unnecessary tests and treatments in health care through Choosing Wisely initiatives. We appreciate their contribution of the following article with important recommendations for making our blood supply and hospital services more efficient and accessible.
Every day, countless Canadians roll up their sleeves to donate blood. The generosity of donors from across the country has created a robust national blood supply that is essential for everyday medical procedures.
Yet, as seen at the height of the COVID-19 pandemic, hospitals across the country faced increasing pressures to avoid blood shortages. The postponement of elective surgeries and subsequent resumption in June caused additional concerns about the availability of blood products. While Ontario hospitals were able to avoid critical shortages, the challenges of managing the demand and supply of blood, especially in a crisis, reinforced the importance of using finite health care resources wisely.
Choosing Wisely Canada is the national voice for reducing unnecessary tests and treatments in health care—things that do not add value for patients, potentially expose them to harm, and consume precious time and resources. Since 2014, Choosing Wisely Canada has worked with professional societies and associations, including those representing nursing, to publish over 380 specific practices that should be stopped, with patient groups to increase awareness about the risks and benefits of tests and procedures, and with provider organizations to re-engineer their internal processes to be more evidence-based.
A number of Choosing Wisely Canada’s recommendations zero in on how we use blood. For example: “Don’t transfuse more than one red cell unit at a time when transfusion is required in stable, non-bleeding patients.” Current science says that in a stable, non-bleeding patient, often a single unit of blood is adequate to relieve patient symptoms or to raise the hemoglobin to an acceptable level. Transfusing two units at a time is common practice in many hospitals, but should no longer be the default. Yet, a recent province-wide audit of Ontario hospitals showed a 10-fold difference in red blood cell transfusion rates between the highest and lowest users. Another audit of 10 hospitals in Ontario found 1 in 5 red cell transfusions may be unnecessary.
This September, Choosing Wisely Canada and Canadian Blood Services is launching Using Blood Wisely, a national campaign to decrease inappropriate red blood cell transfusion practices in Canada. The campaign challenges hospitals across Canada to conduct a spot audit of recent red blood cell transfusions to see how they compare to national appropriateness benchmarks. These benchmarks are:
- At least 65% of red blood cell transfusion episodes are single unit transfusions
- At least 80% of inpatient red blood cell transfusions have a pre-transfusion Hb 80 g/L or less
Hospitals that meet these benchmarks will get designated as a “Using Blood Wisely Hospital” and be recognized nationally. Those that do not can enrol in a quality improvement program proven to reduce inappropriate transfusions and qualify for designation upon meeting the benchmarks.
Nursing plays a critical role in ensuring that evidence-based transfusion practices are followed. Nurses are an important part of the transfusion team that includes the ordering clinicians (including NPs) and the medical laboratory technologists in the blood bank. Often, the nurse may be the individual who follows up on abnormal hemoglobin results and is also aware of whether the patient is symptomatic or bleeding. The nurse will also be the first point of contact for the medical laboratory technologists calling the floor to inquire about the patient’s status, and the first to notice most of the acute adverse events related to transfusion.
The Registered Nurses’ Association of Ontario (RNAO) is an active member of the Choosing Wisely Ontario steering committee. The steering committee has made improving transfusion appropriateness a major priority and will be working with a variety of health sector partners to encourage hospital participation in the Using Blood Wisely campaign. You can learn about how to get involved by visiting: UsingBloodWisely.ca
This week, Choosing Wisely Canada also released a report called “Not Necessary: Policy Ideas for Limiting Low-value Care in Canada.” In addition to ways health system decision-makers can reduce inappropriate use of blood components and products, the report offers four other big ideas to thoughtfully affect the state of low-value care across Canada during the pandemic and beyond. The ideas are:
Idea 1: Streamline the perioperative pathway for scheduled surgeries and procedures to reduce wasteful practices and manage increasing demands for surgery. This includes reducing unnecessary pre-operative testing, redesigning surgical queues, and investing in virtual care to improve efficiency and minimize physical contact across the perioperative journey.
Idea 2: Reduce low-value laboratory testing that lead to additional downstream testing and tie up resources that could otherwise be used to provide high-value services. This includes retooling lab requisition processes at the provincial and organizational levels with built in appropriateness considerations, as well as investing in audit and feedback strategies.
Idea 3: Reduce low-value imaging that increases wait times and can expose patients to unnecessary harm. This includes investing in interprofessional programs to assess and manage imaging- intensive conditions such as back pain and implementing appropriateness criteria for common imaging requisitions.
Idea 4: Reduce overly aggressive life-sustaining measures at the end of life. This includes a concerted and adequately resourced approach to advance care planning, as well as improved palliative care capacity in the community.
Idea 5: Sustain the national supply of blood components and products. This includes establishing national appropriateness benchmarks and directing hospitals to measure their performance against benchmarks, as well as exploring whether alternative funding models that could strengthen incentives for hospital blood conservation efforts.
You can read the report at https://choosingwiselycanada.org/perspective/not-necessary/.
RNAO calls on Premier Ford and Minister Elliott to Delay Action on CNO Council Decision to Expand RPN Scope
Close to 6,000 have already signed RNAO’s Action Alert to its members and the public, issued on September 17 regarding the following:
The College of Nurses of Ontario (CNO) made a shocking and stunning decision approving a regulation change for the Registered Practical Nurse (RPN) scope of practice at its CNO Council meeting today, September 17, 2020 that will seriously jeopardize the safety of the public and render the Registered Nurse (RN) and Registered Practical Nurse (RPN) scope of practice virtually identical.
RNAO and ONA value the significant contributions of RPNs to Ontario’s health system. Scope of practice limitations guided by entry level education are a critical component of self-regulation that exists to protect the public. This is why this entry level major regulatory change is dangerous for Ontarians. RNs, RPNs and NPs all have a critical role to fill in advancing a strengthened health system that meets the needs of all Ontarians. Within this context, we are strongly opposed to this regulation change to the RPN scope due to its potentially damaging shortfalls in relation to:
- Protection of patient safety
- Knowledge and judgment required for “initiating” a procedure as different from “performing” a procedure with an order that are not part of the RPN skill set
- Adherence to the CNO’s three factor framework of client complexity, predictability and risk of negative outcomes
- The CNO’s mandate to regulate two major categories of nurse- RNs and RPNs- with distinct bodies of knowledge, abilities and skill sets that define and differentiate scope of practice.
RNAO and ONA call Premier Ford and Minister Elliott to delay any action on the September 17, 2020 CNO Council decision to expand RPN scope of during this time, given the pandemic has profoundly impacted the nursing profession.
To our alarm, the approval of the expansion of RPN scope of practice allows RPNs to independently initiate four controlled acts that are currently reserved for the registered nurse (RN) scope of practice.
Reiterating the strong opposition to this regulatory change expressed by each of our organizations individually, RNAO and ONA are jointly taking a stand against any further action by the Ontario government to move forward with the proposed RPN regulation change. The rationale for our action is clearly laid out in our respective letters to CNO. Both were included in the June 2020 Council Briefing Package, and in our joint letter. This change made without due process because of COVID-19, lack of full disclosure of ONA and RNAO’s joint position, and misinformation related to the evidence regarding patient need and patient safety is unconscionable. In summary, this decision that allows RPNs to perform the above intrusive procedures without an order from an appropriate provider: disregards the differences in educational preparation for RNs and RPNs; undervalues the four-year baccalaureate degree required of RNs to meet their standard entry-to-practice requirements; will contribute to further role blurring between RNs and RPNs; and was made in the absence of evidence regarding the safety of and the need for this scope of practice change, thus jeopardizing the safety of Ontarians receiving nursing and health care.
We urge you to sign the Action Alert below and tell Premier Ford, and Minister Christine Elliott that you want government to delay action on the CNO September 17, 2020 Council to expand the RPN scope of practice until post COVID-19.
You can sign the Action Alert here.
RNAO in the media
RNAO has had an enormous presence in the provincial and national media on matters related to the pandemic. You can find links to over 500 media items in the RNAO Covid-19 press room.
RNAO has continued to raise its concerns in the media, website and my blog about the incomplete and insufficient preparation in Ontario as we face a second wave of COVID-19. Readers may recall that RNAO has been calling on a preparedness plan from the Ontario government and we listed key areas of action in our July 24 article. Government has not heeded our call for more investment and smaller class sizes in schools (see also here and here). In LTC, we praise the advances made regarding family reunification, but are gravely concerned that no improvements in staffing have been made. To remind readers, RNAO has urged government to adopt the LTC Basic Care Guarantee. LTC remains woefully unprepared for this second wave and that may result in a second preventable tragedy. I suggest you follow the thread of Dr. Nathan Stall’s advise, and RT his tweet. Here is also an excellent article that summarizes what needs to be done for the second wave that appeared in a number of newspapers.
Update on RNAO webinars
Let’s Talk about Anti-Black Racism and Discrimination in Nursing
This is a monthly webinar series designed for members of the public interested in receiving updates on RNAO’s Black Nurses Task Force and to engage in meaningful conversations that will inform the work of the Task Force. The Black Nurses Task Force has a mandate to tackle anti-Black racism and discrimination within the nursing profession.
The upcoming webinar is this coming Monday, Sept. 21, 6:45-8:15 pm, and the topic is Exploring the impact of systemic racism and discrimination in health care on career development for Black nurses.
Part 1: Check the pulse on RNAO’s Black Nurses Task Force
Part 2: Explore the impact of systemic racism and discrimination in health care on career development for Black nurses:
- Increase participants’ awareness about the lack of Black nurses in executive and academic positions, regardless of their educational preparation and experiences.
- Identify barriers to career development for Black nurses, in order to further equal access to opportunities for executive and academic positions in health care and academic settings.
- Explore options for mentorship initiatives for Black nurses using a trauma-informed approach.
- Discuss the impacts of systemic racism and discrimination on Black nurses’ self-esteem and overall mental health with respect to career development.
- Dionne Sinclair MScN, MSHM, RN, CHE
Director, Medicine Programs, Southlake Regional Hospital
- Dania Versailles, RN, BScN, MScN (Mental health/Psychiatry), CPMHN(C)
Director, Clinical Services, Canadian Mental Health Association, Ottawa Branch
Its open to all, please register here.
On Monday, October 5, 6:45-8:00 pm we will be holding the next webinar for health providers that includes updates on COVID-19 and our health systems. Details will be posted as they become available here and you can register here.
Info on recent webinars:
- On September 15 RNAO presented a webinar on Approaches to Mental Health and Substance use for Health-Care Providers Supporting Indigenous People and Communities During COVID-19. This webinar was in partnership with Siouz Lookout First Nations Health Authority (SLFNHA), Chiefs of Ontario (COO), Nishnawbe Aski Nation (NAN) and Indigenous Services Canada (ISC). The presenters were Mae Katt, NP, Thunder Bay; Dr. Sharon Cirone, Sioux Lookout First Nations Health Authority; and Dr. Lindsay Hancock, Sioux Lookout First Nations Health Authority.
- On September 14 the topic was Health System Transformation and COVID-19: What kind of mindset and action is needed now? Community-anchored care is one reason why some regions of the world have fared better that others in their COVID-19 response. Come hear about successes from places like Cuba and the Balearic Islands (Spain) and discuss how these lessons apply to Ontario Health System transformation. You can watch the video and see the presentations slides here.
- On August 10 we focused on nurses’ mental health and wellbeing. The global pandemic has exacerbated health and mental health concerns amongst nurses. Shortages of PPE, fear of infecting family members, isolation from family members, increased emotional and physical exhaustion, and inability to take time off – all exacerbated mental health concerns among nurses which predated the pandemic. We heard about the Healthy Professional Worker Partnership that aims to identify interventions to better support nurses’ mental health and facilitate healthy return to work. An article presenting the issues is here. The guest speakers were Abby Ayoub (University of Ottawa), Melanie Lavoie-Tremblay (McGill University) and Ivy Bourgeault (University of Ottawa). You can watch the video and see the presentations slides here.
- On July 6 we focused on Reuniting families and residents in LTC: What will it take? We heard from a panel as they discussed this critical and timely topic and heard about related updates from RNAO, including ECCO 3.0, Bill 175 and the Nursing Home Basic Care Guarantee. You can watch the video and see the presentations slides here.
- On July 1, we hosted Dr. Jennifer Kwan, a family physician and one of the organizers of #Masks4Canada. She spoke about what we need to do to have a successful re-opening of the economy, and the role that COVID-19 surveillance, good data and masking have in achieving that. You can watch it here.
- On June 22 we discussed the Impacts of COVID-19 on Indigenous Communities with three guest speakers: Ontario Regional Chief RoseAnne Archibald; Mae Katt, Nurse Practitioner with Temagami First Nation; and Marilee A. Nowgesic, CEO of the Canadian Indigenous Nurses Association. You can watch it here.
Today is day #183 of RNAO’s #TogetherWeCanDoIt campaign. RNAO began this campaign on March 19 to cheer up health care workers and others in essential services. A central pillar of our campaign is #Maskathon to help spread the message and the actions of masks-for-all!
The number of new cases in Ontario today is 401 and our RO is at 1.4 – so, as we demand urgent government action, let’s also demand from ourselves, friends, family members, colleagues, neighbors and just about anyone you see to follow public health directives.
To inspire us, here is a set of beautiful masks and colleagues who do what is right – here and here and here and here – and so many more inspiring statements and pics from our @BpsoPhilippines showing their #maskathon campaign!
Visit our website for #Maskathon message alongside RNAO’s Maskathon Portal where you can borrow graphics for your own social media play! And, join us on the #Maskathon challenge by wearing your mask correctly, as together we educate and encourage everyone – to wear a mask including children!
Post your pics using #Maskathon because #TogetherWeCanDoIt.
MOH EOC Situational Report
We are posting each day the Daily Situational Reports from Ontario's MOH EOC at RNAO’s website. That way, you can access the Ministry’s guidance at any time.
For a more detailed Ontario epidemiological summary from Public Health Ontario, you can always go here.
Here is a segment from the latest Situation Report #237 for 18 September:
Case count as of 8:00 am September 18, 2020 / Nombre de cas à 8h00 le 18 septembre 2020
Area / Région
Case count / Nombre de cas
Change from yesterday / Changement par rapport à hier
Deaths / Décès
Change from yesterday / Changement par rapport à hier
Worldwide total /
30 383 093
Staying in touch
Please continue to keep in touch and share questions, comments and challenges. Send these to me at firstname.lastname@example.org and copy my executive assistant, Peta-Gay (PG) Batten <email@example.com>. RNAO’s Board of Directors and our entire staff want you to know: WE ARE HERE FOR YOU!
Thank you deeply to each and all of you for being there for our communities – everywhere and in all roles! Together, in solidarity, we are stronger and more resilient. These continue to be tough times for many colleagues – especially those working in the front lines in the US, India, Brazil, Russia, Peru, Colombia, Mexico, South Africa, Spain, Argentina, Chile, Iran, and other places that are still hit hard by evil COVID-19!
Remember, during stressful and exhausting times, the only silver lining is -- coming together and working as one people – for the good of all!
As case numbers are now consistently increasing in Canada – in particular in Ontario and Quebec – we must redouble our efforts to tackle COVID-19 with the best tools at hand: full, accurate and transparent information, calm, determination and public health swift actions.
Doris Grinspun, RN,MSN, PhD, LLD(hon), Dr(hc), FAAN, O.ONT
Chief Executive Officer, RNAO
PAST BLOG ITEMS:
11 Sept - International Overdose Awareness Day: Statement from RNAO – go here.
11 Sept - RNAO joins global movement: A Just Recovery for All – go here.
28 August - RNAO letter to Prime Minister Justin Trudeau regarding Speech from the Throne – go here.
21 August - Black August and an update on RNAO’s Anti-Black Nursing Task Force – go here.
21 August - Winter Surge Planning: How one Ontario Health Team is Preparing – go here.
14 August - Insights from Cuba: Primary care as the focus of COVID-19 prevention – go here.
7 August - School reopening: Ontario government can still do the right thing on class sizes – go here.
31 July - Preparing for the second wave of COVID-19: Discussion – go here.
31 July - Important announcement regarding the VIANurse program – go here.
31 July - Government must immediately mandate hiring to avert second tragedy in LTC – go here.
24 July - Preparing for the second wave of COVID-19: What is the plan? – go here.
17 July - RNAO launches new social media campaign #Maskathon – go here.
17 July - RNAO calls on government to reunite families in LTC homes in Ontario – go here.
10 July - Nurses’ mental health, leave of absence and return to work experiences – go here.
10 July - RNAO continues to pursue family reunification in LTC – go here.
10 July - Support Zimbabwean nurses arrested and fired for protesting deteriorating pay and working conditions during pandemic – go here.
3 July - RNAO launches task force to tackle anti-Black racism within the nursing profession – go here.
3 July - Rather than praise, let’s protect our nurses – go here.
3 July - Nurses celebrated diversity during Pride month – go here.
26 June - Nursing Home Basic Care Guarantee – go here.
26 June - Masks for all – the policy imperative in Canada – go here.
18 June - Annual General Meeting – an exhilarating week! – go here.
12 June - Petition on masks for Canada – go here.
12 June - LTC: RNAO releases list of 35 reports and recommendations dating back 20 years – go here.
6 June - Statement – RNAO stands together with our Black sisters and brothers – go here.
3 June - Adapting harm reduction during a pandemic – go here.
29 May - Foot care nurses – go here.
29 May - Update on pandemic pay; pandemic pay in consumption and treatment sites – go here.
28 May - RNAO Calls for Immediate Action in Response to the Canadian Armed Forces’ LTC report – go here.
26 May - Update on VIANurse – go here.
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.
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.
You can find up-to-date global numbers in Coronavirus COVID-19 Global Cases by Johns Hopkins CSSE.