It is Saturday March 28th 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:
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.
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:
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.
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!
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 firstname.lastname@example.org and we will connect you within hours with RNs and NPs in your locality.
URGENT STEPS FOR GOVERNMENT TO TAKE: RNAO’s VOICE
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 email@example.com. 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
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