It is Saturday March 28^th at 11pm. Saturdays are usually a time of rest, except for those working a shift. Today, however, it’s not the same. As a front-line nurse working in a hospital, you are either in a shift, coming back from one or planning your next one tomorrow. These are not normal shifts since COVID-19 has turned everything on its head. If you are a directors of infection control, manager or executive in a health organization, this in no normal weekend either, packed with preparations and ramping up execution. Other colleagues, in the front lines, are heroically serving persons experiencing homelessness and vigorously preparing for rates of infection four times higher in this vulnerable population. And so it goes – each one raising to the challenges according to our roles and our work places. COVID-19 is a terrible plague, with one brilliant silver lining – it is bringing out the best in people. This is something to celebrate and cherish in an otherwise most difficult time.

For readers new to this report, you and your feedback are always welcome! You can see previous reports at RNAO updates and resources on COVID-19 for members and other health professionals, where you will also find other resources such as great educational graphics and supports. RNAO has a page with all the Daily Situational Reports from Ontario's MOH EOC. 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.

Launching this coming week: I will be hosting a weekly COVID-19 webinar for health providers, every Monday 6:45-7:30 pm – free registration here.

Again, today, most of the emails received asked for assistance with Personal Protective Equipment (PPE) shortages, which I passed on to ministry officials. Same as yesterday, most came from nursing homes. Clearly, there is a link between the lack of proper protection and mounting infection clusters in nursing homes. This issue keeps me up at night – and I am constantly communicating it to health officials and the media. Other worrisome PPE shortages are in home care, primary care and other community settings. The reality of nursing homes and community care practices is, in normal times, challenging. How are health organizations and their health care workers supposed to tackle this pandemic without surgical masks, gloves and hand sanitizers?

As you know, RNAO has continually urged the federal and provincial governments to aggressively take all the necessary measures to procure the required PPE to protect our colleagues and their patients, as well as the ventilators to save lives. The Ontario government has taken important steps (see here and here), which I address in a section below. Meanwhile, if you have these items to donate, please contact Heather McConnell .  

Today was day #10 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, lights, claps, songs or pots and pans (my preferred choice)! Because: #TogetherWeCanDoIt.

MOH EOC Situational Report #63 here  for Saturday, March 28  – EOC reports that the total number of confirmed cases in Canada today is 4,757 cases (584 new) and 55 deaths. EOC reports 151 new cases in Ontario which brings our province to a total of 1,144 cases (this includes eight resolved cases and 18 deaths). EOC reports that in Ontario, at this time, we have 8,690 persons under investigation with lab results pending. EOC reports the following actions taken:

• A Minister’s Order was issued today directing health system providers to report PPE inventories on a daily basis to the ministry to optimize the availability of PPE and maintain a centralized repository of information on PPE supplies (see here). 
• The ministry also issued an update on the PPE stewardship, procurement and distribution.
• The Ontario government is proclaiming the Supply Chain Management Act to make sure critical supplies, equipment and services can be deployed to where they are needed most.
• The Ontario government announced new penalties to combat price gouging and hold offenders accountable.

Coronavirus COVID-19 Global Cases by Johns Hopkins -- CSSE reports a total of 1144 cases in Ontario and 5,655 total cases in Canada as of March 28 at midnight. 

Please be a champion of actively promoting the use of Ontario’s assessment tool: enhanced and interactive self-assessment tool, to self-assess and guide where to seek care, if necessary. It’s extensive use will also 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.   

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).

Ontario’s health provider website is updated regularly with useful resources here. An important reminder that the health provider website is for you – as a health professional – and not for members of the general public.

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.

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 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 571,678 confirmed cases (62,514 new) and 26,494 deaths (3,159 new). There are 86,498 confirmed cases (5,959 new) in Italy, 85,228 cases in the United States (16,894 new), 64,059 confirmed cases in Spain (7,871 new) and 32,332 confirmed cases (2,926 new) in Iran. Other countries to note are Germany (with 48,582) and France (with 32,542). China has 82,230 cases (with only 152 new), and 9,478 in South Korea (146 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 85,228 cases in the United States, CSSE reports 124,464 topping China as the country with the largest number of cases globally. Worldwide, WHO reports 571,678 while CSSE reports 664,695 cases.

RNAO policy corner – Thoughts on death rate predictors

There is much discussion about how to reduce the death rate of COVID-19. Worldwide, more than 4% of patients have died, with many more to come, and each death its own heartbreaking story. Yet even with similar populations of infected patients as, for example, France, Spain and the US, the German Covid-19 mortality rate is about 0.4%. Below are a few of RNAO’s observations to-date on factors influencing death rates:

Capacity to deliver large-scale testing, contact tracing and self isolation: A rigorous, comprehensive system of testing, contact tracing and directing self-isolation allow a health system to flatten the curve during a pandemic and gain back some normalcy after its peak, until such time as new therapies or vaccines are ready to be used. Since contact tracing and directing self-isolation is a laborious process the capacity to rapidly mobilize resources towards it is critical.  

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. Those percentages could change, and they have been larger, even double, in other countries. We don’t have data for Canada, but let’s assume half of the ICU beds will also require a ventilator, around 1% of the total cases. These are conservative numbers. If we assume that 30% of the population will become infected with COVID-19 (a very conservative assumption), the number of patients connected to a ventilator in Ontario would be about 44,000 over the course of this pandemic. Of course, one ventilator serves more than one patient, the number depending on how long each patient remains connected, and how much we can flatten the curve so that the use of the ventilators extends through a longer period. Having a clear estimate of the necessary ventilators for a worse-case scenario is central to saving lives. Procuring those in a timely manner delivers the targeted results. As it stands, the available ventilators planned to save lives in Ontario during this pandemic vastly underestimate, in RNAO’s view, the real need under worst-case scenarios, by a factor of at least 10. The issue of availability of ventilators is as much capacity to procure as is willingness to pay.  

Nursing Health Human Resources: A CNN commentator reports that among the nine countries with the highest number of Covid-19 cases, the country with the highest nurse per population ratio also has the lowest death rate from the disease. Germany has 13.2 nurses per 1,000 (echoing a trend for high nurse numbers throughout Northern Europe) far above the other heavily Covid-19 affected countries. Why this would make a difference, the author asks? Perhaps higher numbers of nurses may reflect one of two beneficial factors, or both, he says: first, nurses, the backbone of hospital (and especially ICU) care, are essential to patient management and, ultimately, survival. The second is that the sort of hospital or country that knows the value of nurses also is a hospital or country that understands how to deliver effective health care and has likely made countless other unmeasured adjustments to improve quality. (Incidentally, the number of RN/NPs in Ontario in 2018 was 6.9 per 1,000; if we include RPNs the number was 10.1 per 1,000) (source: CIHI).

Personal Protective Equipment (PPE): RNAO Personal Protective Equipment (PPE) is central to protecting our colleagues and their patients. In Ontario, as it stands, health organizations – across all sectors -- are reporting shortages of PPE. 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. Today, government took an important step by providing an update on PPE stewardship, procurement and distribution. We applaud this first step, but remain gravely concerned about the planning parameters of the Ministry. See more in the next section: RNAO Actions.

Prevention of Outbreaks in Long-Ter-Care Facilities: The most worrisome news in Ontario since yesterday is about COVID-19 sweeping through nursing homes. At least 16 nursing homes had 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; poor infection control practices; and a number of aspects regarding PPE adherence to recommendations, training, as well as inadequate supplies.

RNAO’s ACTIONS

Health Human Resource Capacity

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!  We released a survey on Thursday 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 have received responses so far from 603 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 on Friday, March 28 to share their availability in providing health-care services during this unprecedented emergency. One hundred and one (101) NPs have filled out the survey to indicate their willingness and availability to work during the pandemic.

Virtual and Clinical Care survey

RNAO’s survey on virtual clinical care and non-clinical services: As of today, 5,309 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 198 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. A couple of days ago 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 an updated 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 and URGENT priority for PPE: RNAO has been reporting for days our extreme concern about nursing homes and their vulnerability to outbreaks of COVID-19, given the vulnerability of their residents and the staff. We were pleased with important steps in today’s government announcement. The Ministry is currently focusing on providing central supplies to Long-Term Care Homes who already have outbreaks. However, if we want to prevent the outbreaks, then nursing homes should be a TOP priority for surgical masks, gloves and hand sanitizers before there are COVID-19 positive residents and staff. This is especially urgent given the discussions taking place at the Critical Care Table regarding access to ventilators. 
3. Expand 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. Shuting down of all non-essential movement in the streets. Government took today an important step by prohibiting gatherings of more than 5 people. 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 worried about bringing COVID-19 to their families.  
5. 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 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. Massive Procurement of all Personal Protective Equipment (PPE). RNAO has been vocally urging the federal and provincial governments to aggressively 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. Today, government took an important step by providing an update on PPE stewardship, procurement and distribution. While this is welcome first step, RNAO urges to change the planning parameters of the Ministry to assume worst-case scenarios (such as Spain, France or New York City). The planning document specifies additional procurement of 12 million surgical masks from suppliers and the federal government. In comparison, the government of France announced the purchase of 1 billion surgical masks, given that their weekly consumption is 40 million masks. If we translate those numbers to the population of Ontario, that would mean a purchase of 217 million masks for a weekly consumption (during a worst-case scenario such as France) of 9 million per week. These numbers suggest that the current procurement of the Ontario government will last, during a France-type situation, roughly for a bit more than a week. In the view of RNAO, Ontario is still not well prepared for what likely is coming ahead. Furthermore, the current COVID-19 pandemic will last for several weeks, if not months. Thus, we must fasten and massively increase the procurement of PPE.  
7. Massive Expansion of ICU beds and ventilators. The information today 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. Ventilators on a procurement contract that may be realized within a year are not going to help. We have, at best, only weeks available until hospitals are 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 week RNAO issued a public statement on ventilators and PPEs and we also discussed these matters in the media (here and here). We are urging the government to substantially increase the procurement of ventilators. 
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!

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 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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