Urgent steps for government to take: RNAO's policy recommendations

1. Continue to prepare for a New York City scenario. Yes, our approach must be to continue to prepare for 'worst-case' scenarios such as in Italy or New York. Good for Premier Doug Ford to acknowledge today that “The hard truth is, right now, today, there is very little separating what we will face here in Ontario from the devastation we’ve seen in Italy and Spain.” We look forward to the presentation of Ontario’s modeling data tomorrow. Incubation periods and the delays in obtaining test results means today’s data reflects the reality of a couple of weeks ago. This means we do not have a good grasp of where we are in the curve. We are only testing a relatively small number of symptomatic individuals and likely missing a much larger number of persons without or with mild symptoms – thus test data is likely quite incomplete. This means there is lots of uncertainty as to the actual shape of the curve. It is RNAO’s view that policymakers and governments MUST continue to plan according to the worst-case scenarios. Unfortunately, we are seeing this scenario unfold in the United States. In Ontario and Canada, we do hope that social distancing will flatten the curve, but for the moment, we are seeing large numbers of new daily cases, and there are sectors in society not keeping social distancing. We hope to avert worst-case scenarios, but we cannot afford not to plan for such a case, that might risk the tragic death of thousands of people.
2. Communication: We are entering a very challenging period for all. During this period, it is crucial that governments at all levels engage in honest and transparent communication with the public. Don't try to gloss over issues, don't minimize them, be transparent when decisions are driven by lack of resources (such as shortages of PPE), acknowledge we may be entering into more difficult scenarios, with many deaths and, very likely, an overwhelmed health system. During this period we need to acknowledge the challenge and that we all, each one in our own way, are trying to do the best we can - and that we are all in this together. Not only governments and those filling essential services have a role – also the public has a crucial role in bringing down the curve, through "staying at home" and keeping "physical distance."
3. Nursing homes: RNAO has been expressing to government and to the media -- for several weeks -- our extreme concern about nursing homes and their vulnerability to outbreaks, given the vulnerability of their residents and the staff. We were pleased with important steps in government’s recent announcement. The Ministry is currently focusing on providing central supplies to Long-Term Care Homes that already have outbreaks. However, this is the wrong approach. A government directive MUST go out that all the staff should wear PPE – RNAO suggests providing at least one each day, upon entrance to the building, until there is more availability. The purpose ought to be to prevent outbreaks, not come to fix them after they have happened, residents died, and staff got ill. Staffing shortages should be addressed, taking advantage of available resources. On this point, RNAO has launched ViaNurse -- free of charge, including 5,000 BScN students ready to serve as PSWs. Finally, it is important that when one finds a single case of COVID-19 in a nursing home, then every person in the facility, both residents and staff, should be tested. Medical directors and attending NPs in nursing homes should ask for a test immediately that they see a symptomatic resident or staff.   
4. Home Care: Many of the home care agencies have only a few days of PPE supplies left. Staff are quitting as they demand PPE and clients don't let them go into their homes without PPE. Patients that require home care are persons with cancer, wounds, and more - they need home care. This situation must be fixed.
5. Expand testing, contact tracing and self isolation: Now is not the time to slow down on testing. Ontario MUST continue to increase its testing capacity and maintain rigorous contact tracing and self-isolation. Even when we manage to flatten the curve, as China, South Korea and 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 after the peak of the epidemic, 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 can assist through the ViaNurse program. 
6. Shutting down of all non-essential movement in the streets.  Let’s educate that the more stringent the shutdown, the shorter the period we will live through it. The more gradual, less effective, and less enforced are the physical distancing measures, the longer the shutdown will prolong and more people will die. We need to double down on making the shutdown effective. Government took a few days ago an important step by prohibiting gatherings of more than 5 people. The loopholes to the shutdown, allowing non-essential businesses to pass as essential (example, condo building), and the lack of enforcement of quarantine – all these have a price in shutdown time and lives. Clearly, there is still a sector of the public that believes they are invincible or does not understand the situation. Google has launched their Google Community Report for public health officials to understand responses to physical distancing guidance. The report on Canada can be found here. There are substantial reductions in mobility for Retail and Recreation (a drop of 60%), moderate for Grocery and Pharmacy (-35%) but not enough on Parks (-16%). For action: There must be enforcement of the distancing in parks, beaches, and other recreational spaces – it is just not happening enough and too many people feel it is business as usual. Governments must strengthen both education and enforcement of the measures. 
7. Telehealth: Virtual care plays a central role in physical distancing and helping fight the pandemic. Telehealth can help keep people in their homes and avoid them going to clinics and ERs. RNAO has reiterated the call to strengthen Telehealth to better fulfill that role at this crucial time. About a week ago we were receiving reports of wait times of 10 hours or more. Let us know if you have more recent experience using the service. In RNAO’s view, the Ministry should monitor wait times and assign resources so that they are within acceptable parameters.
8. With thanks to Médecins Sans Frontières -- Take care of healthcare workers: Our health-care workers are our best and last line of defence in a pandemic. For their sake and ours, we need to protect their physical and mental health. We need to make sure that our medical staff will always have the right PPE available at all times (see next two items). There should be guidelines prepared to guide health providers with the complex and harrowing decision-making they will face, should it become necessary to do so. We also need to help health-care workers protect and take care of their families. Should medical staff stay away from their loved ones? If medical staff are infected by COVID-19, where should they be hospitalized? Can health-care workers and their families count on being fully supported if they fall gravely ill? The mental pressure and anguish faced by health-care workers in a pandemic is unimaginably high. They must have access to psychological counselling and support.
9. Extensive use of surgical masks. Given the wide community spread as well as the solid evidence about asymptomatic transmission of COVID-19, RNAO has been, for the past two weeks, actively recommending to health officials that all health workers should be using surgical masks while facing patients/clients/residents.
10. Procurement of all Personal Protective Equipment (PPE). RNAO has been vocally urging the federal and provincial governments – and will continue to do so - to aggressively secure a supply chain for all the required 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 huge increase in the demand for PPE as we move towards the peak of the pandemic. We call for URGENT and massively increased, procurement of PPE. We were pleased to hear the federal government is investing $2 billion to support diagnostic testing and to purchase ventilators and PPE. We were similarly pleased with the Ontario government announcement of a $50 million fund to help businesses manufacture essential medical supplies and equipment, including gowns, coveralls, masks, face shields and testing equipment. We desperately need to know from both levels of government what are the timelines for delivery. Health care workers and patients lives are on the line.
11. Hospitals: Hospitals are working to ramp up their ability to receive an avalanche of COVID-19 patients, while trying to serve the needs of non-COVID patients. Government should provide the regulatory and financial resources so they can do so. Several are already building makeshift structures, redeploying personnel, and taking the measures to expand capacity. In New York State they have added tens of thousands of beds, including through a military hospital ship. Are we ready for to scale up capacity in this way? Let's plan for the very worse so we are ready to execute, and celebrate if we don't.
12. With thanks to Médecins Sans Frontières -- Separate COVID-19 patients: As much as possible, set up medical facilities dedicated only to COVID-19 patients: either stand-alone structures or a separate hospital within a hospital. It is tempting to try to manage COVID-19 cases within existing structures. This might work where case numbers are low. But when the numbers become overwhelming, chaos will take over and foster cross-contamination. There needs to be a dedicated COVID-19 area and a non-COVID-19 area with no interchange of staff or patients between the two. By separating patients, and by having separate staff, one can significantly decrease the risk of medical facilities becoming centres of amplification. Dedicated staff may also reduce the volume of personal protection equipment (PPE) required as staff will not go from one COVID-19-positive patient to a non-COVID-19 patient. Indeed, lack of this separation is one of the lessons why the death rate has been so high in Italy.
13. Expansion of ICU beds and ventilators. The information provided that the government has been successful in entering into contracts for up to 10,000 ventilators is great news. However, there is no specification about delivery dates, and how reliable those dates are, as Ontario Health has earlier reported that “it will take months” for orders to start coming in. We have, perhaps, a couple of weeks until hospitals start to become overwhelmed. In a different jurisdiction, 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, people needlessly die. That has been the horrifying reality in Italy, which has had one of the highest death rates – about 5% --from COVID-19. For RNAO, no one’s life should be lost because the proper equipment was not available. This past week RNAO issued a public statement on ventilators and PPEs and we also discussed these matters extensively in the media (here). We urge the government to substantively increase the procurement of ventilators. We heard yesterday good news that the federal government is investing $2 billion to support diagnostic testing and to purchase ventilators and PPE. Similar good news from the Ontario government announcing it has placed an order with O-Two Medical Technologies who, with the support of Ontario's manufacturing sector, will produce 10,000 ventilator units. We did not hear from either government about timelines for delivery
14.  With thanks to Médecins Sans Frontières -- Attend to critical care of non-COVID-19 patients: We must ensure that critical care to non-COVID-19 patients is maintained. During the height of the crisis, COVID-19 could get all the attention and monopolize all available resources. We have to make absolutely sure that highly treatable and preventable medical conditions do not become lethal. We should not create a second-rate status for non-COVID-19 patients with acute needs.
15. 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, especially on vulnerable and disadvantaged populations. This includes Ontarians experiencing homelessness and shelters and testing positive for COVID-19 (please RT urgently) and others living in crowded shelters (please RT urgently), as well as Indigenous communities and northern and isolated communities. Both the federal and provincial governments have announced important measures 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. RNAO’s response to the recent Ontario economic statement can be found here.
16. 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
17. 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.

Dr. Jennifer Kwan, a family physician in Ontario, has written an excellent summary of what it will take to go back to somewhat normal life (until vaccines and/or therapies are developed) through three simple measures: 1) distancing, 2) easy testing and 3) masks for all. RNAO agrees 100%!