Here it is, your daily report for Friday, March 27, the third month of the COVID-19 outbreak in Canada – a global pandemic of historic proportions. To see previous reports visit RNAO updates and resources on COVID-19 for members and other health professionals, where you will also find other useful materials such as great educational graphics and supports. Feel free to share these updates with other health professionals at home or abroad. RNAO media hits and releases on the pandemic can be found here. I will be hosting a weekly COVID-19 webinar for health providers, every Monday 6:45-7:30 pm – free registration here.

Another intense day of preparations for the war on COVID-19. This was also another day receiving endless requests for assistance with lack of PPEs, which I have passed on to ministry officials. Most of them come from nursing homes. Is the lack of PPEs a factor in the multiplying clusters in nursing homes? Can something as simple as PPEs slow down the spread of the COVID-19 in nursing homes? These are questions that keep me up at night – not just in relation to nursing homes but more generally, with community care. The reality of nursing homes and community care practices is, in normal times, challenging. How are they supposed to tackle this pandemic without surgical masks, gloves and hand sanitizers? If you have these items to donate, please contact Heather McConnell hmcconnell@rnao.ca.  

Meanwhile, RNAO continues to urge the federal and provincial governments to move aggressively to take all the necessary measures so as to avail of the required Personal Protective Equipment (PPE) to protect our colleagues and their patients.

On the issue of masks, I tip my hat to the ingenuity of Dr. Jeff Powis, Medical Director at Michael Garron Hospital. With colleagues, they have issued a challenge to all sewists in East York to collectively make 1,000 fabric masks a week. They want east enders (not healthcare providers) wearing a fabric mask when they are within six feet of other people, especially vulnerable populations and the elderly. Help me congratulate Jeff, President & CEO Sarah Downey, and Chief Nurse Executive Irene Andress for their inspired leadership preparing for COVID-19. Here is my congrats tweet for you to RT.

Today was day #9 of the #TogetherWeCanDoIt campaign and the noise is becoming louder and louder in streets, workplaces and social media to #cheer4healthworkers. Join-in this community building moment every evening at 7:30pm local time - until we defeat COVID-19! and post tweets from your communities and workplaces with your cheers, songs or pots and pans (my preferred choice)! Because: #TogetherWeCanDoIt.

MOH EOC Situational Report #62 here  for Friday, March 27  – EOC reports that the total number of confirmed cases in Canada today is 4,173 cases (594 new) and 39 deaths. EOC reports 130 new cases in Ontario which brings our province to a total of 993 cases (this includes eight resolved cases and 18 deaths). EOC reports that in Ontario, at this time, we have 10,074 persons under investigation with lab results pending. EOC reports the following actions taken:

• The Ontario Pharmacists Association, Ontario Medical Association, and the Registered Nurses’ Association of Ontario have sent out a joint letter to Ontario’s doctors, nurse practitioners and pharmacists regarding inappropriate prescribing of unproven therapies. It can be accessed here.
• The Quick Reference document on Testing and Clearance has been updated and is available on the ministry website. This updated version includes additional detail around clearing health care workers to return to work.
• A new Guidance document with information on the use of N95 filtering face respirators beyond the manufacturer-designated shelf life has been created (see here). 
• The Command Table met today, and a letter with a summary of the discussion (see here).

Coronavirus COVID-19 Global Cases by Johns Hopkins -- CSSE reports a total of 994 cases in Ontario and 4,758 total cases in Canada as of March 27 at midnight. 

Kudos for the government’s new assessment tool: enhanced and interactive self-assessment tool. Please make sure you promote its use in your communities to help people determine if they are negative or it will provide them with guidance on where to seek care based on their needs. It’s extensive use will also 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. Please, do become a champion of sharing with as many people as you can about the tool.  

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 (including places of worship and funerals).

Situation Report 67 from WHO updates that worldwide there are 509, 164 confirmed cases (46,484 new) and 23,335 deaths (2,501 new). There are 80,539 confirmed cases (6,153 new) in Italy, 68,334 cases in the United States (4,764 new), 56,188 confirmed cases in Spain (8,578 new) and 29,406 confirmed cases (2,389 new) in Iran. Other countries to note are Germany (with 42,288) and France (with 28,786). China has 82,078 cases (with only 117 new), and 9,332 in South Korea (91 new), both countries clearly managing, at this point, to “flatten the curve”. The number of confirmed cases worldwide is 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 68,334 cases in the United States, CSSE reports 104,661, topping China as the country with the largest number of cases globally. Worldwide, WHO reports 509, 164 while CSSE reports 597,304 cases.

RNAO Policy Corner

The most worrisome news in Ontario today is about COVID-19 sweeping through nursing homes. At least 16 nursing homes have confirmed cases among residents or staff. The death toll shot up on Friday amid questions about fatalities that may not be counted as resulting from the pandemic. Two residents of a nursing home in Bobcaygeon, Ont., who had symptoms of the flu-like illness have died but neither was tested for the coronavirus. In fact, the Pinecrest Nursing Home said only three others were tested and confirmed positive, while 35 residents have coronavirus symptoms. We need to remember the context: RNAO and others have warned for over a decade that chronic understaffing, precarious working conditions, and poor workplace safety at nursing homes put Ontario’s vulnerable elders and the workers who care for them at risk. Ontario has the lowest RN to population in Canada, and the second lowest overall staffing in nursing homes. Now the COVID-19 pandemic is exploiting those flaws. If this is not an explosive mix, what is?

The results of an investigation into factors contributing to a COVID-19 cluster in a long-term facility in Washington State are telling. Factors listed likely to have contributed to the vulnerability of these facilities included: staff who had worked while symptomatic; delayed recognition of cases because of a low index of suspicion; limited availability of testing; staff who worked in more than one facility; infection control practices; and a number of aspects regarding PPE adherence to recommendations, training, as well as inadequate supplies.

RNAO’s ACTIONS

RNAO surveys on virtual clinical care and non-clinical services

As we continue our strong advocacy on the need to expand the capacity of Ontario’s health system to meet emerging health needs in tackling COVID-19, we need your help. The knowledge and skills of RNs, NPs and nursing students are needed to meet a range of health-care needs. For those of you who have already responded to our surveys asking for help, we thank you for your enthusiastic and generous response. Working in collaboration with the Ministry of Health, we are reaching out to RNAO’s network of RNs, NPs and nursing students asking for your willingness and availability. Our surveys/registry remain open for:

Critical Care

Virtual and Clinical Care

Nurse Practitioners

Nursing Students

If you are available to help, please complete the appropriate survey listed on our COVID-19 webpage.

Critical Care survey

We asked for your help, and got it!  In my update yesterday, I announced that we were releasing a survey yesterday (Thursday, March 26) to establish a registry of the available health human resources in the critical care areas of Emergency Rooms, Recovery Rooms, Intensive Care Units, Step Down Units or other relevant clinical area.  Your response was immediate, and strong.  We received responses from 573 nurses with experience and continued competency in the provision of critical care health services in these specialty areas.  This response, while not unexpected, is truly heartwarming in these difficult times!   As we receive requests from hospitals in your area, we will make connections so you can start the necessary HR hiring processes.  Many, many thanks for your enthusiastic and generous response. To others: The survey remains open. We have already connected all the respondents with an indigenous health authority in Northern Ontario who was very appreciative of RNAO’s timely assistance.  

NP survey

The knowledge and skills of nurse practitioners are needed to increase Ontario’s capacity during the COVID-19 pandemic. NPs with experience, current competency and specialty certificates in primary care, adult care and paediatrics and who are able to return to work if retired or increase their hours of work, are asked in a survey RNAO launched today to share their availability in providing health-care services during this unprecedented emergency.

Virtual and Clinical Care survey

RNAO’s survey on virtual clinical care and non-clinical services: As of today, 5,198 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!  

UNS/PSW

We created a web page listing the homes that have reached out to RNAO looking to hire PSWs since the initiative was launched on Monday. We sent an email to the nursing students we have on file and provided a link for them to apply to the homes they want to work for. The listing, with 187 senior’s residential care organizations, can be searched by city and organization. Students can apply from the page and the DOC or HR person of the home will receive the student’s application and take it from there. A number of organizations have reached out to us to say that they have hired the staffing they needed using the service provided by RNAO. Organizations that are not on the list can fill out a web form here and will be added within 24 hours. 

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, contact tracing, etc. - 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.

URGENT STEPS FOR GOVERNMENT TO TAKE: RNAO’s VOICE

1. Prepare for a New York City scenario. Today, Canada had a glimpse of good news with BC’s MOH Dr. Bonnie Henry stating in CBC that “the curve might be flattening, but is too early to tell.” She said that people should take hope that tough social distancing measures may be paying dividend. At the same time, B.C. health officials continue to prepare for 'worst-case' scenarios such as in Italy. This is the right approach. The delays in obtaining test results means data reflects the reality of a week ago, so that we do not have a good grasp of where we are in the curve today. 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. We do hope that social distancing will flatten the curve, but for the moment, we are seeing large increases in the number of new daily cases. 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. Nursing Homes a TOP priority for close attention: RNAO will continue to insist in the strongest possible terms, that nursing homes be a TOP priority for surgical masks, gloves and hand sanitizers to prevent the increasing number of outbreaks amongst this high risk population. This is especially urgent given the discussions taking place at the Critical Care Table regarding access to ventilators.  
3. Testing, contact tracing and self isolation: We applaud Ontario for continuing to increase our 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 still has 4,500 RNs awaiting to be utilized – hundreds could hire for contact tracing. 
4. Shut down of all non-essential movement in the streets. RNAO urges that construction be taken out of the list of essential services as their work and working conditions do not allow for 1) social distance and 2) proper sanitation, disinfected facilities and frequent hand washing. Construction projects across Ontario, except a few that are critical, should be stopped immediately. Construction workers are very worried about bringing COVID-19 to their families.  
5. Masks. Given the extensive community spread as well as the solid 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.
6. PPEs. RNAO continues to urge the federal and provincial governments 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 huge increase in the demand for PPE as we move towards the peak of the 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. 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.
7. 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 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. For RNAO, no one’s life should be lost because the proper equipment was not available. This week we issued a public statement on ventilators and PPEs and we also discussed these matters in the media (here and here).  
8. 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 those living in crowded shelters, 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 Ontario economic statement can be found here.
9. 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
10. 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 DEEPLY colleagues in the front lines, in administrative roles, and in governments 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   

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