Dear readers: To assist in your reading, I have used italic fonts for material repeated from a day earlier and I have also indicated NEW on totally new sections. If you read every day, you can jump directly to the new material, which appears in regular font.
We at RNAO hope that at least some of you are having some peace and rest during the weekend. For those doing their shifts or hectically busy and/or losing sleep on COVID-19 preparations, we are with you!
NEW: During times like this, we need to take care of the most vulnerable. We have repeatedly spoken about the need for universal masking in nursing home – before and not after an outbreak (more on this below). Today, Saturday, April 4, I touch on the tremendous concern of domestic violence at a time when most people are staying at home. I also elaborate on the action to protect persons experiencing homelessness, and the action required by the province and the city of Toronto to implement the plans to support them. I start by repeating our analysis and expression of grave concern regarding the insufficient plans for deployment of critical care services to address the COVID-19 emergency. As always, I also elaborate on the nightmare of PPE shortages and the action to resolve them.
Ringing the alarm on critical care planning
Yesterday, 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?
Supporting and protecting older people is everyone’s business: although all age groups are at risk of contracting COVID-19, older people face significant risk of developing severe illness. Read the statement by Dr Hans Henri P. Kluge, WHO Regional Director for Europe here.
On 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.
Sending Love and Comfort: RNAO sends love and deep condolences to the families and staff who have lost residents to the ravages of COVID-19. We embrace in comfort all of you, and especially Pinecrest Nursing Home in Bobcaygeon residents and families for your unimaginable suffering and to the staff for your courageous caring at this time of great distress. May the lives lost rest in peace.
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 with health officials and 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. Please do 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
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 professionalsFeel 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:
Together we can do it
NEW: Today was day #16 of the #TogetherWeCanDoIt campaign. 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 (my pick for today!), donations, or pots and pansBecause: #TogetherWeCanDoIt.
NEW: MOH EOC Situational Report #70 here for Saturday, April 4
EOC report #70 informs of the following actions taken:
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 3,630 cases in Ontario and 14,011 total cases in Canada. There are 312,076 cases in the United States, and worldwide, there are 1,202,827 cases.
NEW: RNAO policy corner: COVID-19, stay at home and domestic violence
WHO Director-General addressed the reports from some countries of an increase in domestic violence since the COVID-19 outbreak began.
As people are asked to stay at home, the risk of intimate partner violence is likely to increase. Women in abusive relationships are more likely to be exposed to violence, as are their children, as family members spend more time in close contact, and families cope with additional stress and potential economic or job losses. Women may have less contact with family and friends who may provide support and protection from violence.
WHO calls on countries to include services for addressing domestic violence as an essential service that must continue during the COVID-19 response.
If you are experiencing or at risk of domestic violence, speak to supportive family and friends, seek support from a hotline, or seek out local services for survivors. Make a plan to protect yourself and your children any way you can. This could include having a neighbour, friend, relative, or shelter identified to go to should you need to leave the house immediately.
There is never any excuse for violence. We abhor all violence of all forms, at all times.
In Canada, Prime Minister Justin Trudeau responded recently by allocating $50 million for women’s shelters and sexual assault centres in Canada. In Ontario, the Attorney General has announced a special $4 million fund that will aid support services for victims of domestic abuse and violent crime. Part of the fund goes to helping the courts transition to remote operations — so the wheels of justice can keep turning.
NEW: RNAO policy corner – COVID-19 and people experiencing homelessness
Thanks to Matt Kellway, RNAO Director of Policy, currently seconded to Inner City Health Associates (ICHA) to assist with protecting Toronto homeless persons from COVID-19, for writing this report.
In our collective response to this pandemic, it is the vulnerable that need to go to the top of our list for care and safe keeping. And, in that, we are failing the homeless because they have been relegated to the bottom.
This needs to change - urgently. Governments – all three orders – need to move with lightning speed to provide housing and care for people experiencing homelessness. The epicenter of this pandemic in this province – and in particular in the City of Toronto – threatens to be in homeless shelters where, still, residents are jammed in, face-to-face with each other and the deadly threat of this virus.
The response to this pandemic has ignored the vulnerabilities of this population. It is said that this virus doesn’t discriminate. But it most certainly does. It finds the cracks in our society – the ones so many people have fallen through – and it attacks there. It is said that this virus attacks the elderly. But this virus doesn’t know chronology – doesn’t know old from young. It only knows vulnerability.
A recent report out of the US estimates that homeless individuals will be twice as likely to be hospitalized, two to four times as likely to require critical care and two to three times likely to die from this virus. These estimates recognize that homeless individuals have age-related impairments typical of housed individuals 20 years older in addition to a susceptibility to this virus enhanced by challenges maintaining hygiene, respiratory distress and a mental weathering resulting from exposures to multiple challenges.
The COVID-19 crisis has created an untenable situation. The public is urged to implement social distancing and yet we have a shelter system that forces thousands each night to be in breach of those measures. The government has issued COVID guidelines for shelters that recommend social distance when that, as well as effective measures for infection prevention and control, are impossible to achieve.
As a solution, the province has funded Inner City Health Associates to roll out a nurse-led program to care for people experiencing homelessness in Toronto, where half of the provinces homeless reside. The plan is to convert city owned and/or leased properties into COVID persons-under-investigation (PUI) isolation centres and a COVID+ isolation centre. ICHA has relied on RNAO’s ViaNurse program for its RN/NP nursing complement. We are proud of the RNAO members who have stepped forward to help us all through this pandemic.
From RNAO’s standpoint, before these facilities become operational, the fullest measures must be taken and the highest standards must be in place to protect all healthcare workers. To achieve this, the province and the city must move urgently to provide the requisite health protections for clinical staff including PPE supply, and Infection Prevention and Control (IPaC) policies, protocols, training, and direction.
The request was placed a number of days ago and we are eagerly waiting to move forward. As I advised Minister Elliott and Mayor Tory, the population becomes more at risk with every passing day. One of the most vulnerable populations in Toronto keeps waiting for immediate and urgent action from the province and the city.
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 Information Resources
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.
Health Human Resource Capacity – RNAO’s COVID-19 ViaNurse Program
RNAO continues its strong advocacy on the need to expand the capacity of Ontario’s health system to meet emerging health needs in tackling COVID-19. RNAO was the first out the door addressing growing nursing human resource shortages, as many RNs, NPs and PSWs are being quarantined and/or falling sick, and staffing needs escalate together with the acuity of the pandemic.
RNAO launched its COVID-19 ViaNurse program on March 13 and it has already registered 159 nurse practitioners (NPs), 878 critical care RNs (who have experience and continued competency in the provision of critical care) as well as 5,939 RNs for virtual/clinical care.
RNAO is actively staffing nursing homes requiring RN and PSWs; so far, 332 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).
Seeking RNs, NPs and nursing students: Yes, 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 – we will be in touch. 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 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 878 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.
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 159 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, 5,939 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 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 332 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.
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 . 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 and your organization will appear in a 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.
Since March 13 when RNAO launched its VIANurse program, 65 organizations have been served to augment their human resources.
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
NEW: Dr. Jennifer Kwan, a family physician in Ontario, has written an excellent summary of what it will take to go back to somewhat normal life (until vaccines and/or therapies are developed) through three simple measures: 1) distancing, 2) easy testing and 3) masks for all. RNAO agrees 100%!
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 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
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