A cardiac surgeon in Connecticut talks about nurses. “She rises at 5:15 a.m., arrives in the Covid-19 unit by 7:15. Receives the handoff information from the night shift. She washes down, dons the yellow gown, shoe covers, hair cover, the N95 mask, gloves and the eye shield and enters the negative pressure room. Her distraught patient is coughing uncontrollably. She administers a breathing treatment along with some Tylenol and fluids, checks her oxygen saturation, delivers a message from her family and reassures her that she will get better. She leaves and repeats the process with her next patient. She does this for 12 hours. She goes home and disinfects before she greets her family, has some dinner and goes to bed. Rises at 5:15 and repeats the process, trying not to be discouraged by the patients who go on ventilators or don’t survive. The nurses never say no, they are always there, eight, 12, sometimes 15 hours a day, and then they do it again the next day and the next. They are the front line.”

This quote is part of an article about heroic health care workers, and certainly nurses are at the front line. But heroes do not battle empty handed; even Batman, an imaginary hero, has his cap. Real life heroes need the tools and the equipment to fight this horrible COVID-19 fight for their patients – PPEs, ventilators, staffing levels, respect for their professionalism – these are the tools before, during and after COVID-19. In these pages we have strived to raise the concerns of nurses and other health care workers. Unfortunately in some places, such as New York, they have not been heard – Ontario’s provincial and the federal government still have time to act!  

RNAO has been at the forefront, pleading to governments to procure PPE and ventilators to protect workers and save lives. So far the reaction has been slow to match the need. Employers, in hospitals and in home care, are not waiting for answers. They are doing their best to find PPE and arm their workers to carry-on the fight.

RNAO has been also led in addressing critical shortages of staffing levels during the COVID-19 emergency. Health providers are going into quarantine, falling sick, and staffing needs are growing. RNAO launched its COVID-19 ViaNurse on March 13 and it has already registered 141 nurse practitioners, 650 nurses with experience and continued competency in the provision of critical care health services, 5,475 nurses for virtual/clinical care, and has registered 245 organizations seeking PSWs. We urge chief nurse executives and managers to access this talent now, so you are not scrambling later on (see details below).

Every day we welcome readers to this daily report: thank you deeply for the work you do during this health crisis, and also for keeping us well informed. You can see 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. RNAO media hits and releases on the pandemic can be found here.

Again, today, most of the emails received asked for assistance with Personal Protective Equipment (PPE) shortages, and most came from nursing homes. Clearly, there is a link between lack of proper protection and mounting infection clusters in nursing homes. RNAO has been sounding the alarm bell on this fear for several weeks. The time is NOW, to ensure all nursing homes are provided with sufficient quantities of surgical masks and other essential PPE, so that all staff wear one at all times – to prevent outbreaks and NOT after an outbreak as it currently is happening, RNAO has said it over and over and over. Also community health organizations – home care and primary care – are suffering from dire shortages of PPEs.  

While RNAO continues to call on federal and provincial governments to aggressively take measures to procure the required PPE, you can also donate PPE items. Please contact Heather McConnell .  

Today was day #12 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 #65 here  for Monday, March 30. Reporting has changed, and Ontario case counts are recorded in the province’s integrated Public Health Information System (iPHIS) and data is pulled at 4:00 p.m. the previous day. Updates to the website will now be provided once a day at 10:30 a.m. EOC reports that the total number of confirmed cases in Canada today is  6,258 cases (422 new) and 65 deaths. EOC reports 351 new cases in Ontario which brings our province to a total of 1,706 cases (this includes 431 resolved cases and 23 deaths). In Ontario, a total of 48,461 people have been tested. EOC reports the following actions taken:

• Issued a statement recommending that individuals over 70 years of age self-isolate, and urging all Ontarians to continue adhering to physical distancing and to remain at home.
• Changes to the case definition: clarifying swabbing requirements, simplifying laboratory confirmation, and eliminating repeat testing to clear cases managed at home. (See here)
• Guidance documents for Talking to Children About the Pandemic, Funeral and Bereavement Services, as well as resources for Ontarians Experiencing Mental Health and Addictions.
• A new link to the PPE survey was shared today. Acute care hospitals should continue to report PPE requirements through the Daily Bed Census only.
• There was a joint statement between government and the Ontario Nurses’ Association issued on health and safety measures in hospitals.
• The Chief Medical Officer of Health issued Directive 5 for public hospitals (see here). 
• Several directives have been updated today that are attached to today’s Situation Report (see here and here and here).
• The Command Table met today, and a letter with a summary of the discussion is here.

Coronavirus COVID-19 Global Cases by Johns Hopkins -- CSSE reports a total of 1,706 cases in Ontario and 7,448 total cases in Canada. 

Situation Report 70 from WHO updates that worldwide there are 693,224 confirmed cases (58,411 new) and 33,106 deaths ((3,215 new). There are 122,653 cases in the United States (19,332 new), 97,689 confirmed cases (5,217 new) in Italy, 78,797 confirmed cases in Spain (6,549 new), and 38,309 confirmed cases (2,901 new) in Iran. Other countries to note are Germany (with 57,298) and France (with 39,642). China has 82,447 cases (with only 106 new), and 9,661 in South Korea (78 new), both countries clearly managing, at this point, to “flatten the curve”. The number of confirmed cases worldwide is reaching three quarters of 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 122,653 cases in the United States, CSSE reports 161,807 topping China as the country with the largest number of cases globally. Worldwide, WHO reports 693,224 while CSSE reports 782,365 cases.

On 27 March, WHO European Region published an article on mental health and psychological resilience during the COVID-19 pandemic; highlighting the potential mental health impacts on children and the elderly. For more information, see here.

Other Information Resources

Public Health Ontario maintains an excellent resource site on materials on COVID-19. This is an essential resource for Ontario health providers. 

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.

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.

RNAO policy corner – Lessons for a pandemic, from those who’ve experienced one

Nurses and doctors in Médecins Sans Frontières have long experience fighting epidemics around the world. They are now sharing advice for Canadians preparing for one. There is no room for wishful thinking, they say. One must prepare for the worst-case scenario, while doing everything we can to avoid it. We must be mentally and organizationally prepared to deal with the conditions that are rocking Italy and Spain:

1. 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.

2. Our health-care workers are our best and last line of defense 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. 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.

3. 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.

RNAO’s ACTIONS

Health Human Resource Capacity – RNAO’s COVID-19 ViaNurse Program

RNAO started its Via Nurse program to recruit RNs, NPs and nursing students on March 13.

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 650 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. We are already addressing the needs from hospitals approaching RNAO for HHR augmentation. Here is the inspiring feedback from one of our partners, Michael Garron Hospital in Toronto who is hiring ViaNurse RNs in various roles: “The interest and number of applicants so far has been incredible. We're very grateful”.

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 forty one (141) 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, 5,475 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 245 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. 

Note to employers seeking RNs and NPs

Thanks to the vigorous response from RNs and NPs to RNAO’s surveys, we launched the web form for employers to request RNs/NPs to augment their nursing human resource’s needs during the COVID-19 pandemic. Any organizations needing support, we are here to help you here.

COVID-19 and persons experiencing homelessness

RNAO's Director of Policy, Matthew Kellway, has been seconded to serve as Director, Public Affairs for Inner City Health Associates (ICHA). Matt will be working closely with Dr. Andrew Bond, ICHA's Medical Director, Dr Leigh Chapman, ICHA's Director of Nursing and former RNAO Communications Director, Sine MacKinnon. ICHA, who provides health care to many of Toronto's shelters and drop-in centres, has been funded by the province to urgently bring to life an innovative, nurse-led program, to provide care to Toronto's homeless population through this Covid-19 pandemic. Absent urgent intervention, Toronto's shelter system threatens to be the epicentre of this pandemic in the city given the vulnerability of the population and the impossibility of social distancing in existing shelter facilities. I am so proud that ICHA is staffing it's program with RNAO members using RNAO's VIANurse program and I have the utmost confidence in ICHA's commitment to keep its nursing staff as safe as possible as it fulfills its critical mission.

ACTIONS FROM OTHERS

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.

URGENT STEPS FOR GOVERNMENT TO TAKE: RNAO’s VOICE

1. Prepare for a New York City scenario. A few 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 incubation periods and obtaining test results means data reflects the reality of a couple of weeks 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 government’s 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: 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 still has 4,500 RNs awaiting to be utilized – hundreds could hire for contact tracing. 
4. Shutting down of all non-essential movement in the streets. Government took yesterday 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. The government responded with some improvement measures but not delisting from the list of essential services. RNAO asks the government to reconsider. 
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 two weeks, actively recommending to health officials that all health workers should be using surgical masks while facing patients/clients/residents.
6. Massive 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. 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, it means 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 week and a half. In the view of RNAO, Ontario is still not well prepared for what likely is coming ahead, a pandemic that will last for several weeks, if not months. We call for URGENT and massively increased, procurement of PPE. 
7. Massive 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. 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 urge the government to substantively 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 (see RNAO and ICHA action above) 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 recent 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 New York, Italy, Spain, France, Iran and Germany – 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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