Today, Friday, April 3, was an important marker in tackling COVID-19 in Ontario as public health officials released modeling projections for the remainder of the month of April. The government’s presentation can be found here. It is good the premier and public health authorities are hearing the advice from RNAO and others to engage in honest and transparent communication with the public. In our Recommendation #2, below, we write: “Don't try to gloss over issues, don't minimize them, be transparent when decisions are driven by lack of resources (such as shortages of PPE), acknowledge we may be entering into more difficult scenarios.”

The numbers are sobering, as the government is expecting 1,600 deaths by end of April and between 3,000 and 15,000 over the 18 to 24 months course of the pandemic. RNAO’s concern is that this planning still happens under a “best-case scenario,” from the outset, RNAO has been calling not to make that assumption. The death toll numbers could be much higher if we are not prepared for a less beneficial scenario. If you look at the planning for Ontario ICU capacity in page 14 of the presentation (here), you will see that avoiding a shortage of ICU capacity is based on that “best-case” assumption. Under a “worst-case” assumption, by the end of April, there will be about 2,200 patients that required an ICU bed and were not able to obtain one – in other words, they will die. The current planning of 900 additional planned ICU beds for COVID-19 patients is insufficient for the needs in the month of April – much less for the needs beyond that date under certain scenarios. RNAO calls for an immediate reconsideration of the plan for only 900 additional ICU beds, which almost assuredly means that people who could live, will die.

Our concerns are aggravated by the lack of transparency on a central issue: planning for ventilators. The government’s presentation is silent on that crucial aspect, which contradicts the purpose of transparency and accountability on – literally – life and death decisions. Why is there no account of the actions, plans and projections on ventilators? Moreover, the government released internally on March 28, but did not disclose to the public, a document entitled Clinical Triage Protocol for Major Surge in COVID Pandemic. The document is “intended to outline criteria to be used for the allocation of critical care resources (especially mechanical ventilators) in a scenario where the need for ventilator support is greater than the existing resources,” adding that “The use of a triage protocol should be considered a last resort…” The problem of planning for an insufficient number of ICU beds and ventilators, as we are doing, is that the likelihood of having to make use of “clinical triage” becomes almost certain – not a last resort.

In short, the modeling projections presented by Ontario’s government officials today leave us gravely concerned about the current planning for critical care capacity expansion. RNAO has been speaking for months against applying assumptions of “low risk” or a “best case scenario.” South Korea is considered a best-case scenario, but we escalated our action relatively late compared with that comparator, and we have not engaged the actions they used to bring down the curve, such as early, extensive and rigorous testing, tracing contacts, and isolation. At this point we should expect a massive surge in critical care patients, and in particular those that require ventilation.

When you combine this reality with the application of “clinical triage” recommendations, it appears – shockingly -- that vulnerable populations will become the real casualties of the COVID-19 pandemic in Ontario. These are persons who would likely score low under the clinical criteria specified in the Clinical Triage Protocol document, but who in normal times would be treated in critical care beds. In a scenario of ICU shortage, likely they will not. Nurses, cannot and will not accept such a painful reality, unless government officials explains why, given the available evidence, it will not engage NOW and URGENTLY -- in further measures to increase critical care capacity beyond those currently planned, and address all other measures we have been urging for weeks.

The expansion of critical care in Ontario is small compared with what other jurisdictions are doing. So many seriously ill patients are anticipated that New York City is preparing to turn all its 20,000 permanent hospital beds into intensive care ones, while trying to add 65,000 temporary beds for other patients. London, UK, is just launching the largest critical care unit in the world with 4,000 beds, only one project among many others in that country. A group of Toronto researchers have been predicting a “critical shortage of ventilators” in Ontario since mid-March; their research can be found here. Researchers at the Imperial College London wrote in a devastating new analysis that even stringent mitigation measures of case isolation, home quarantine, and social distancing “would still result in an 8-fold higher peak demand on critical care beds over and above the available surge capacity.” Although the analysis relates to the UK and US, a similar logic applies in Ontario. We have had the luxury of being able to learn from the tragedy in Italy, which is now counting about 15,000 official deaths (unofficially, the real death toll is much higher), with lack of ICU beds, ventilators and nurses as key factors. Are we heeding the advice?  

Protecting seniors

Thursday, April 2, we achieved an important breakthrough in our effort to protect residents and staff in nursing homes, residential homes and other institutions for seniors. Ontario Health Toronto is recommending that long-term and continuing care homes in the Toronto Region follow a policy of Pandemic Universal Masking for healthcare workers providing routine resident care (see here). Two procedure masks per day will be provided for all healthcare workers that interact with residents, or entering resident areas for any reason, only if the home’s PPE supply allows. RNAO has been pushing for this measure for at least two weeks, with the intent of preventing outbreaks of COVID-19 in nursing homes. Unfortunately, at last count, today, RNAO is aware of 77 outbreaks in nursing homes and retirement homes, with at least 40 residents who have tragically died. RNAO hopes that this universal masking measure will be expanded immediately to other regions in Ontario, as each day that staff work unmasked is a day when the spread of the virus continues rampant.

More (and more) on PPE

As yesterday and the days before, essential supplies and equipment remain a central concern. Earlier this week we heard the federal government is mobilizing industry to fight COVID-19, increasing Canada’s ability to respond to the outbreak with necessary medical equipment and supplies, boosting capacity to manufacture items such as portable ventilators, surgical masks, and rapid testing kits. It is also investing $2 billion to support diagnostic testing and to purchase ventilators and PPE, including for bulk purchases with provinces and territories. Today the Ontario government announced a $50 million fund to help businesses manufacture essential medical supplies and equipment, including gowns, coveralls, masks, face shields, testing equipment and ventilators. The government has recently placed an order with O-Two Medical Technologies who, with the support of Ontario's manufacturing sector, will produce 10,000 ventilator units.  Our response to both the prime minister and the premier is: FANTASTIC!!!! Now, we need breakneck delivery timelines as -- without PPE and ventilators -- Canadians and healthcare workers’ lives are on the line. Months from now, no equipment or supplies will be of any help – there is not a single day to waste. The purchase of ventilators is not reflected in the critical care projections discussed by Ontario’s health officials today, why?  

RNAO has been at the forefront, pleading to governments to procure PPE and ventilators to protect workers and save lives. We are glad to now see a sense of urgency and we deeply hope that it is not too late. Employers and staff need timelines. For now, they are doing their best to find PPE and arm their workers to carry-on the fight. Yesterday, the Ontario Hospital Association added its voice to the plea for PPE with a statement regarding shortage of PPE. These calls for action – including those from RNAO and OMA and from RNAO, are now all more important given president Trump’s threats to prohibit 3M from exporting N95 masks to Canada.

Some family doctors in Ontario say their practices are under threat because of the ongoing shortage of masks and other protective equipment caused by the coronavirus pandemic. They don't have the PPE to keep things safe along the way, and staff are getting burned out, so they are practicing mostly telemedicine. Some are worried that more deaths could result from the sudden loss of primary care for patients than from the respiratory illness caused by the coronavirus.

Given how vocal RNAO has been in the media regarding shortages of PPE, we have started receiving calls from importers of PPE. Several of them say they have received either no answer or unhelpful answers from the Ontario government’s procurement arm. We have made a connection with a couple of desperate front line organizations that decided to purchase directly from an importer rather than continue to wait for supplies that do not arrive. We understand that the government normally prefers to deal with registered suppliers selling large stocks with certified products. But we are not in normal times. One supplier, who appeared to be honest and forthcoming, claimed they had sent a shipment of one million N95 respirators to the United States because they got no response to their offer. We are not advocating the use of uncertified and unregulated products, but we also do not advocate – in even stronger terms – not using PPE at all because the health provider has run out of it. If it is a matter of testing a product, such as a surgical mask, the government has access to testing facilities that can provide that service. One doctor reports printing their own face shield in a 3d printer. The message to the government is: we don’t care how you obtain the PPE, but it is unacceptable that health providers do not have what they need! This is not the time for normal procurement processes and timelines. Make it happen, somehow, now! 

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 . 

Nursing and health human resources

RNAO has been proactively addressing expected – and now real - nursing human resource shortages related to the COVID-19 emergency. Many RNs, NPs and PSWs are being quarantined and/or falling sick, and staffing needs are growing. RNAO launched its COVID-19 ViaNurse on March 13 and it has already registered 157 nurse practitioners (NPs), 710 critical care RNs (who have experience and continued competency in the provision of critical care) as well as 5,761 RNs for virtual/clinical care. RNAO is also actively staffing nursing homes requiring RN and PSWs; so far, 312 organizations have registered. We urge CNEs, CNOs, and managers – in all sectors and regions of Ontario - to access this talent now - so you are not scrambling later on (see details below).

Daily update

Every day we welcome new 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. Daily Situational Reports from Ontario's MOH EOC can be found here.

We continue to receive your emails. Here is a sample of topics:

• Many concerns address PPE shortages in different sectors. There are still hospitals not allowing front line workers to use PPE, while other hospitals have moved to supply two surgical masks per day. There are community health organizations – home care and primary care – suffering from dire shortages, and some have lost hope and tried to obtain their own PPE. RNAO’s urgent recommendation is that all front line health care workers facing patients – in all sectors and settings – must wear a surgical mask. Kudos to Pembroke Regional Hospital – a staff shared her pride that they are directing staff to mask for every encounter with a patient.
• There is a horrific crisis unfolding in nursing homes, and a direct link between lack of proper protection and mounting infection clusters reported by the media in at least 41 nursing homes and 77 by our account. RNAO has been sounding the alarm bell for well over a month. We will not stop saying it: 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 has happened. We must #flattenthecurve of nursing home outbreaks! 

• Fourth year BScN nursing students are expressing concern, as they are eager to graduate and begin working as RNs to protect and care for patients during this difficult time. They share with RNAO that they face barriers to complete their studies and registration with the CNO, as well as in their application for temporary licenses. Many want to be in clinical placement to help with this crisis and are not allowed in.
• Should the public wear a surgical mask in public spaces, as many do in south east Asian countries? Given the shortages of regulated PPE for health care workers, the public should not be purchasing those. There is a live discussion on whether to wear home-made and other unregulated types of masks. The general advice has been to keep two meters physical distancing and thus it is optional to wear a mask. However, if you have to shop groceries, take public transit, work as an essential worker, or other activities where you cannot keep physical distancing, a cloth-made mask is recommended. The CDC in the US has issued such a recommendation.
• We reported earlier about Michael Garron Hospital launching #MGH1000masks campaign. The hospital is challenging makers in the community to fabricate 1,000 masks a week, which will be worn by all approved visitors who enter the hospital, all discharged patients as they reintegrate into the community, and the broader east Toronto community to prevent the transmission of COVID-19.
• Violation of the measures for physical distancing, or other actions that create risk, are a concern we all share. Colleagues have written to report they’ve seen health workers, still wearing their scrubs and masks, doing grocery shopping or in other public spaces; that’s a serious risk to others. Others have heard colleagues sharing their plans to meet with extended families for Easter. I urge all of us to avoid these types of lapses in judgment and abide by physical distancing rules.

Together we can do it

Today was day #15 of the #TogetherWeCanDoIt campaign (following is our pics for the day!). The noise is becoming louder and louder in streets, workplaces and social media to #cheer4healthworkers – and it has gone even to the UK! Please remember to 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 donations, or pots and pans -- Because: #TogetherWeCanDoIt.

MOH EOC Situational Report #69 here  for Friday, April 3. 

 Situation:

• 462 new cases were reported today in Ontario, bringing the cumulative total to 3,255 (this includes 1,023 resolved cases and 67 deaths).
• In Ontario, a total of 66,753 people have been tested, with tests performed at Public Health Ontario Laboratories and non-Public Health Laboratories. There are currently 1,245 tests under investigation.
• 462 patients are currently hospitalized with COVID-19; 194 are in ICU; and 140 are in ICU on a ventilator.

EOC report #69 informs of the following actions taken:

• The Government of Ontario is increasing Public Health Units’ capacity to stop COVID-19, including:
  • Launching a new user-friendly online portal for the public to easily access their COVID-19 lab test results
  • A new emergency order to provide public health units the authority and flexibility they need to make staffing decisions.
  • Dr Peter Donnelly, President and CEO of Public Health Ontario, Matthew Anderson, President and CEO of Ontario Health and Adalsteinn Brown, Dean of the Dalla Lana School of Public Health gave a news conference today on modelling projections for COVID-19 in Ontario.
• The  Government of Ontario announced additional business closures to stop the spread of COVID-19
• The Registered Nurses’ Association of Ontario powers a free VIANurse website which helps health sector organisations secure RNs, NPs and PSWs.
• Summaries of Command and Collaborative Tables – see here and here.

EOC report #68 informs of the following actions taken:

• A new memo was issued to provide information regarding the use of alternate health spaces to assist in hospital COVID-19 strategies. These documents are attached, along with the previously released memo and ADM letter (see here and here and here and here).
• The guidance documents released yesterday for Homeless Shelters and Group Homes and Co-Living Settings are now available in English and French on the ministry’s website.
• Public Health Ontario published two new fact sheets on Physical Distancing and Taking Care of Yourself and Each Other on their website.   
• The Ontario government announced new emergency funding to expand online and virtual mental health supports for front-line workers during the COVID-19 outbreak.

You can 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. They report a total of 3,255 cases in Ontario and 12,545 total cases in Canada. There are 277,953 cases in the United States, topping China as the country with the largest number globally. Worldwide, there are 1,099,389 cases.

WHO report: The routes of transmission from COVID-19 patients

As the outbreak evolves, we are learning more about the virus. WHO summarizes what is known about transmission of the virus. For details, go here and scroll down to the section on Subject in Focus: The routes of transmission from COVID-19 patients.

Symptomatic transmission: Symptomatic transmission refers to transmission from a person while they are experiencing symptoms. The virus is primarily transmitted from symptomatic people to others who are in close contact through respiratory droplets, by direct contact with infected persons, or by contact with contaminated objects and surfaces. Shedding of the virus is highest in the upper respiratory tract (nose and throat) early in the course of the disease, within the first 3 days from onset of symptoms. Preliminary data suggests that people may be more contagious around the time of symptom onset as compared to later on in the disease.

Pre-symptomatic transmission: The incubation period, which is the time between exposure to the virus (becoming infected) and symptom onset, is on average 5-6 days, however can be up to 14 days. During this period, also known as the “pre-symptomatic” period, some infected persons can be contagious. Therefore, transmission from a pre-symptomatic case can occur before symptom onset. This is supported by data suggesting that some people can test positive from 1-3 days before they develop symptoms. Pre-symptomatic transmission still requires the virus to be spread via infectious droplets or through touching contaminated surfaces.

Asymptomatic transmission: An asymptomatic laboratory-confirmed case is a person infected with COVID-19 who does not develop symptoms. Asymptomatic transmission refers to transmission of the virus from a person who does not develop symptoms. There are few reports of laboratory-confirmed cases who are truly asymptomatic, and to date, there has been no documented asymptomatic transmission. This does not exclude the possibility that it may occur. Asymptomatic cases have been reported as part of contact tracing efforts in some countries.

There is controversy regarding some of WHO’s analysis, and we will address that debate in an upcoming report.

The practical conclusion from WHO’s summary is straightforward. Individuals without any symptoms, whether pre-symptomatic or asymptomatic, may be, unknowingly, shedding the virus. Thus, we must keep physical distance from any person, whether symptomatic or not.  

Other WHO reports

WHO has released a Medical Product Alert that warns consumers, healthcare professionals, and health authorities against a growing number of falsified medical products that claim to prevent, detect, treat or cure COVID-19. Find more here.

WHO has released a scientific brief on the off-label use of medicines for COVID-19. A number of medicines have been suggested as potential investigational therapies, many of which are now being or will soon be studied in clinical trials, including the SOLIDARITY trial co-sponsored by WHO and participating countries. More information can be found here.

WHO recognizes the importance of addressing the needs of refugees and migrants when preparing for or responding to the COVID-19 pandemic. WHO European Region has released a guidance document to assist healthcare working with refugees and migrants. More information can be found 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. 

Ontarios’ 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.

Worth repeating: RNAO policy corner – COVID-19 and the US health care system

The COVID-19 pandemic is hitting Canadians very hard. However, in one important regard, we have a privileged position compared to many other parts of the world: nobody in Canada has to worry about paying their test, medical bills and hospitalization if they become sick with the virus. That is not the case south of the border.

Before the COVID-19 pandemic, 27.5 million Americans had no health insurance, but now, many more are at risk of losing their current coverage plans as businesses lay off workers because of COVID-19 physical distancing. States, advocacy organizations and health care professionals are taking steps to ensure that the uninsured can still get testing and treatment, but that hasn’t dissipated the confusion. If there are people who are not getting the screening, testing and treatment because of fear of a bill, that not only endangers themselves but also spreads the virus. In addition to U.S. citizens who lack health insurance coverage, there are also millions of undocumented immigrants who are not eligible. Another 2 million people who live in the 14 states that did not expand Medicaid under the Affordable Care Act also fall into a coverage gap. They are not eligible for Medicaid, but are also ineligible for federal subsidies that make health insurance affordable through the national exchange. In the words of an expert, “A crisis like this, where everyone is at risk and everyone can be affected, highlights the gaps in our health care system in a way that we don’t often see.”

The cost of a test for an uninsured patient could be close to $500 at a doctor’s office, while one at a hospital would likely be at least $1,000. The cost of care if one were to test positive, varies depending on a person’s insurance and its various cost-sharing components. Most insurance plans have deductibles that could be around $1,500 to $2,000. Many plans also have coinsurance charges of roughly 15% to 20%. Individuals who don’t require hospitalization will likely incur relatively small out-of-pocket costs, but patients who do require hospitalization could expect a hefty bill. This could be between $75,000 and $100,000 for 10 days, including hospital stay, drugs and treatments. While insurance – for those who have it – would cover some of that, it almost certainly wouldn’t cover the full price tag.

An independent journalist without health insurance says: “I haven’t gone to the doctor since 2013… Like 27.5 million other Americans, I don’t have health insurance. It’s not for a lack of trying – I make too much to qualify for Medicaid, but not enough to buy a private health insurance plan on the Affordable Care Act exchanges. Since I can’t afford to see a doctor, my healthcare strategy as a 32-year-old uninsured American has been simply to sleep eight hours, eat vegetables, and get daily exercise… When you multiply my situation by 27.5 million, you end up with a country full of people who won’t see a doctor unless they’re extremely sick. And when you combine a for-profit healthcare system – in which only those wealthy enough to get care actually receive it – with a global pandemic, the only outcome will be unmitigated disaster.” 

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 a week ago 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 710 RNs with experience and continued competency in the provision of critical care. This response, while not unexpected, is truly heartwarming in these difficult times!  We are already addressing the needs from several hospitals approaching RNAO for HHR augmentation and connecting these with you so they can proceed with the hiring processes. We have also connected respondents with an indigenous health authority in Northern Ontario who was very appreciative of RNAO’s timely assistance. Many, many thanks for your enthusiastic and generous response. Please note: The survey remains open.

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. Until now 157 NPs have filled out the survey to indicate their willingness and availability to work during the pandemic. The survey remains open.

Virtual and Clinical Care survey

RNAO’s survey on virtual clinical care and non-clinical services: As of today, 5,761 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!  

PSW positions for nursing students

RNAO is helping to increase LTC Homes, Seniors’ Housing and Community Service Providers’ capacity to meet human resource needs to tackle the COVID-19 pandemic. The facilities listed in this registry are looking to fill personal support worker (PSW) positions. These are paid positions. They are looking for second, third or fourth year nursing students to fill these positions. The registry includes 312 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, including several undergoing an outbreak, have already been served by accessing RNAO’s ViaNurse. 

NOTE TO ORGANIZATIONS SEEKING TO EMPLOY RNS, NPS AND PSWS

RNAO can help organizations increase their nursing human resource capacity to tackle COVID-19. To request RNs and NPs for your organization, fill out this form.  RNs and NPs in the city where your organization is located will be connected with you.

To request nursing students in second, third or fourth year for personal support worker (PSW) positions, fill out this form and your organization will appear in a registry where students will select hiring organizations through this registry. (Your home will appear on the registry within 24 hours.) Nursing students will be able search the registry by city and name of the homes. 

COLLEGE OF NURSES

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. Continue to prepare for a New York City scenario. Yes, our approach must be to continue to prepare for 'worst-case' scenarios such as in Italy or New York. Good for Premier Doug Ford to acknowledge today that “The hard truth is, right now, today, there is very little separating what we will face here in Ontario from the devastation we’ve seen in Italy and Spain.” We look forward to the presentation of Ontario’s modeling data tomorrow. Incubation periods and the delays in obtaining test results means today’s data reflects the reality of a couple of weeks ago. This means we do not have a good grasp of where we are in the curve. We are only testing a relatively small number of symptomatic individuals and likely missing a much larger number of persons without or with mild symptoms – thus test data is likely quite incomplete. This means there is lots of uncertainty as to the actual shape of the curve. It is RNAO’s view that policymakers and governments MUST continue to plan according to the worst-case scenarios. Unfortunately, we are seeing this scenario unfold in the United States. In Ontario and Canada, we do hope that social distancing will flatten the curve, but for the moment, we are seeing large numbers of new daily cases, and there are sectors in society not keeping social distancing. We hope to avert worst-case scenarios, but we cannot afford not to plan for such a case, that might risk the tragic death of thousands of people.
2. Communication: We are entering a very challenging period for all. During this period, it is crucial that governments at all levels engage in honest and transparent communication with the public. Don't try to gloss over issues, don't minimize them, be transparent when decisions are driven by lack of resources (such as shortages of PPE), acknowledge we may be entering into more difficult scenarios, with many deaths and, very likely, an overwhelmed health system. During this period we need to acknowledge the challenge and that we all, each one in our own way, are trying to do the best we can - and that we are all in this together. Not only governments and those filling essential services have a role – also the public has a crucial role in bringing down the curve, through "staying at home" and keeping "physical distance."
3. Nursing homes: RNAO has been expressing to government and to the media -- for several weeks -- our extreme concern about nursing homes and their vulnerability to outbreaks, given the vulnerability of their residents and the staff. We were pleased with important steps in government’s recent announcement. The Ministry is currently focusing on providing central supplies to Long-Term Care Homes that already have outbreaks. However, this is the wrong approach. A government directive MUST go out that all the staff should wear PPE – RNAO suggests providing at least one each day, upon entrance to the building, until there is more availability. The purpose ought to be to prevent outbreaks, not come to fix them after they have happened, residents died, and staff got ill. Staffing shortages should be addressed, taking advantage of available resources. On this point, RNAO has launched ViaNurse -- free of charge, including 5,000 BScN students ready to serve as PSWs. Finally, it is important that when one finds a single case of COVID-19 in a nursing home, then every person in the facility, both residents and staff, should be tested. Medical directors and attending NPs in nursing homes should ask for a test immediately that they see a symptomatic resident or staff.   
4. Home Care: Many of the home care agencies have only a few days of PPE supplies left. Staff are quitting as they demand PPE and clients don't let them go into their homes without PPE. Patients that require home care are persons with cancer, wounds, and more - they need home care. This situation must be fixed.
5. Expand testing, contact tracing and self isolation: Now is not the time to slow down on testing. Ontario MUST continue to increase its testing capacity and maintain rigorous contact tracing and self-isolation. Even when we manage to flatten the curve, as China, South Korea and Singapore and other countries have so far done, the virus will remain out there and ready to raise its head again. Only a rigorous, comprehensive system of testing, tracing and isolation, which is the case in those countries, will allow us to go back to some normalcy after the peak of the epidemic, until such time as new therapies or vaccines are ready to be used. Since contact tracing and isolation is a laborious process, if we need health personnel to strengthen public health units, RNAO can assist through the ViaNurse program. 
6. Shutting down of all non-essential movement in the streets.  Let’s educate that the more stringent the shutdown, the shorter the period we will live through it. The more gradual, less effective, and less enforced are the physical distancing measures, the longer the shutdown will prolong and more people will die. We need to double down on making the shutdown effective. Government took a few days ago an important step by prohibiting gatherings of more than 5 people. The loopholes to the shutdown, allowing non-essential businesses to pass as essential (example, condo building), and the lack of enforcement of quarantine – all these have a price in shutdown time and lives. Clearly, there is still a sector of the public that believes they are invincible or does not understand the situation. Google has launched their Google Community Report for public health officials to understand responses to physical distancing guidance. The report on Canada can be found here. There are substantial reductions in mobility for Retail and Recreation (a drop of 60%), moderate for Grocery and Pharmacy (-35%) but not enough on Parks (-16%). For action: There must be enforcement of the distancing in parks, beaches, and other recreational spaces – it is just not happening enough and too many people feel it is business as usual. Governments must strengthen both education and enforcement of the measures. 
7. Telehealth: Virtual care plays a central role in physical distancing and helping fight the pandemic. Telehealth can help keep people in their homes and avoid them going to clinics and ERs. RNAO has reiterated the call to strengthen Telehealth to better fulfill that role at this crucial time. About a week ago we were receiving reports of wait times of 10 hours or more. Let us know if you have more recent experience using the service. In RNAO’s view, the Ministry should monitor wait times and assign resources so that they are within acceptable parameters.
8. NEW, with thanks to Médecins Sans Frontières -- Take care of healthcare workers: Our health-care workers are our best and last line of defence in a pandemic. For their sake and ours, we need to protect their physical and mental health. We need to make sure that our medical staff will always have the right PPE available at all times (see next two items). There should be guidelines prepared to guide health providers with the complex and harrowing decision-making they will face, should it become necessary to do so. We also need to help health-care workers protect and take care of their families. Should medical staff stay away from their loved ones? If medical staff are infected by COVID-19, where should they be hospitalized? Can health-care workers and their families count on being fully supported if they fall gravely ill? The mental pressure and anguish faced by health-care workers in a pandemic is unimaginably high. They must have access to psychological counselling and support.
9. Extensive use of surgical masks. Given the wide community spread as well as the solid evidence about asymptomatic transmission of COVID-19, RNAO has been, for the past two weeks, actively recommending to health officials that all health workers should be using surgical masks while facing patients/clients/residents.
10. Procurement of all Personal Protective Equipment (PPE). RNAO has been vocally urging the federal and provincial governments – and will continue to do so - to aggressively secure a supply chain for all the required PPE to protect our colleagues and their patients. Health organizations – across all sectors -- are reporting shortages of PPE. This situation is unacceptable and governments must address it urgently, including preparing for a huge increase in the demand for PPE as we move towards the peak of the pandemic. We call for URGENT and massively increased, procurement of PPE. We were pleased to hear the federal government is investing $2 billion to support diagnostic testing and to purchase ventilators and PPE. We were similarly pleased with the Ontario government announcement of a $50 million fund to help businesses manufacture essential medical supplies and equipment, including gowns, coveralls, masks, face shields and testing equipment. We desperately need to know from both levels of government what are the timelines for delivery. Health care workers and patients lives are on the line.
11. Hospitals: Hospitals are working to ramp up their ability to receive an avalanche of COVID-19 patients, while trying to serve the needs of non-COVID patients. Government should provide the regulatory and financial resources so they can do so. Several are already building makeshift structures, redeploying personnel, and taking the measures to expand capacity. In New York State they have added tens of thousands of beds, including through a military hospital ship. Are we ready for to scale up capacity in this way? Let's plan for the very worse so we are ready to execute, and celebrate if we don't.
12. NEW, with thanks to Médecins Sans Frontières -- Separate COVID-19 patients: As much as possible, set up medical facilities dedicated only to COVID-19 patients: either stand-alone structures or a separate hospital within a hospital. It is tempting to try to manage COVID-19 cases within existing structures. This might work where case numbers are low. But when the numbers become overwhelming, chaos will take over and foster cross-contamination. There needs to be a dedicated COVID-19 area and a non-COVID-19 area with no interchange of staff or patients between the two. By separating patients, and by having separate staff, one can significantly decrease the risk of medical facilities becoming centres of amplification. Dedicated staff may also reduce the volume of personal protection equipment (PPE) required as staff will not go from one COVID-19-positive patient to a non-COVID-19 patient. Indeed, lack of this separation is one of the lessons why the death rate has been so high in Italy.
13. Expansion of ICU beds and ventilators. The information provided that the government has been successful in entering into contracts for up to 10,000 ventilators is great news. However, there is no specification about delivery dates, and how reliable those dates are, as Ontario Health has earlier reported that “it will take months” for orders to start coming in. We have, perhaps, a couple of weeks until hospitals start to become overwhelmed. In a different jurisdiction, the governor of New York State is asking for 30,000 ventilators, as the worst-case scenarios become a reality across the United States. If the equipment and specialized personnel are not available, people needlessly die. That has been the horrifying reality in Italy, which has had one of the highest death rates – about 5% --from COVID-19. For RNAO, no one’s life should be lost because the proper equipment was not available. This past week RNAO issued a public statement on ventilators and PPEs and we also discussed these matters extensively in the media (here). We urge the government to substantively increase the procurement of ventilators. We heard yesterday good news that the federal government is investing $2 billion to support diagnostic testing and to purchase ventilators and PPE. Similar good news from the Ontario government announcing it has placed an order with O-Two Medical Technologies who, with the support of Ontario's manufacturing sector, will produce 10,000 ventilator units. We did not hear from either government about timelines for delivery
14.  NEW, with thanks to Médecins Sans Frontières -- Attend to critical care of non-COVID-19 patients: We must ensure that critical care to non-COVID-19 patients is maintained. During the height of the crisis, COVID-19 could get all the attention and monopolize all available resources. We have to make absolutely sure that highly treatable and preventable medical conditions do not become lethal. We should not create a second-rate status for non-COVID-19 patients with acute needs.
15. Support for vulnerable populations and workers. Governments should implement urgent measures to alleviate the enormous burden placed by fighting the virus. COVID-19, and the measures required to address the emergency, have profound social equity impacts, especially on vulnerable and disadvantaged populations. This includes Ontarians experiencing homelessness and shelters and testing positive for COVID-19 (please RT urgently) and others living in crowded shelters (please RT urgently), as well as Indigenous communities and northern and isolated communities. Both the federal and provincial governments have announced important measures to protect workers from losing their jobs as businesses suspend operations or they have to stay home to take care of children. RNAO is urging for much more to be done to assist low-wage earners and those in precarious employment, who may transmit disease simply because they have no option. RNAO’s response to the recent Ontario economic statement can be found here.
16. Massive public education and enrollment. Please become a champion for #StayAtHome and #SocialDistance, by educating your families, friends, colleagues and members of your community. RNAO and our members are heavily engaged in mainstream and social media to keep the public fully informed, engaged and enrolled into #socialdistance action. We ask that you follow us at @RNAO and @DorisGrinspun and retweet + Facebook as much as you possibly can. Send your friends and members of the public to the government website and here
17. Solidarity during a difficult time. It is very important to call on citizens to organize informal networks of support, largely virtual, for people who live alone, who may be elderly, or vulnerable, or who do not have the money to buy essentials, or who are struggling through this period in so many ways. With mental health and other conditions exacerbated by isolation, we call on all of us and the public at-large to display solidarity and humanity like never before – message: #togetherwecandoit.

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 and the rest of the United States, 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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