Dear All,

Today is World Health Day. Long before the COVID-19 pandemic was in sight, the World Health Organization (WHO) was planning to use, April 7, to release a report on the state of the world’s nursing workforce. What WHO and its partners, the International Council of Nurses and Nursing Now, never fathomed was that the report (available here) would be issued without any big fanfare, and yet with the biggest of the biggest appreciation for the role health professionals -- and in particular nurses -- are playing all over the world during the pandemic. Take a moment to reflect. To all of you, on behalf of RNAO, we say: THANK YOU. You inspire us every day, now more than ever!  

A few tools for you to take pride: image to use under your signature here, World Health Organization video, RNAO press release and our own Paula Manuel tribute to nurses.

On today’s blog, I address concerns you have raised about the upcoming guidance on decontamination and repurposing of N95 respirators. It is a signal of how fragile our PPE situation is that this is a real option on the table. We provide an update and refer to CDC guidance so far. We also continue to focus on vulnerable populations – in particular the lack of testing among persons experiencing homelessness, and a proposed plan to remedy that serious gap. We hope you find this issue useful.

RNAO POLICY CORNER

1. Reprocessing of N95 – safe?

The shortage of N95 masks is driving the efforts to find ways to reprocess (sometimes referred to as decontaminate, sterilize, sanitize or disinfect) these filtering facepiece respirators (FFR). We continue to receive emails expressing concerns from health providers worried that ineffective reprocessing will leave them exposed to contamination or degraded respirators. This is an issue that is evolving, there is ongoing research, and we provide here an update.

Reprocessing is a crisis management tool. Before contemplating reprocessing, all recognized procedures to conserve supplies should be exhausted. The US Centers for Disease Prevention and Control (CDC) provides guidelines for extended use and limited reuse of N95. The guidelines recommend a combination of approaches to conserve supplies while safeguarding health care workers in such circumstances. Extended use refers to the practice of wearing the same N95 respirator for repeated close contact encounters with several patients, without removing the respirator between patient encounters. Reuse refers to the practice of using the same N95 respirator for multiple encounters with patients but removing it (‘doffing’) after each encounter. Both extended use and reuse have been widely used as an option for conserving respirators during previous respiratory pathogen outbreaks and pandemics.

If standard conservation methods are insufficient, reprocessing may become an option. 3M, a major producer of the N95 respirator, states that based on currently available data, 3M does not recommend or support attempts to sanitize, disinfect, or sterilize 3M FFRs. 3M is a private corporation and legally accountable only to its shareholders.

According to the CDC, FFRs are not approved for routine decontamination and reuse as standard of care. However, FFR decontamination and reuse may need to be considered as a crisis capacity strategy to ensure continued availability during the pandemic. Decontamination and subsequent reuse of FFRs should only be practiced as a crisis capacity strategy. Research is ongoing regarding three methods discussed by CDC in the document. To date, no current data exists supporting the effectiveness of these decontamination methods.

One Ontario hospital executive shares that Ontario Health sent guidance documents related to PPE use/conservation and instructed hospitals a few days ago to conserve PPE. Hospitals are expecting to hear more details from Ontario Health related to reprocessing and alternative / repurposing strategies for PPE. In anticipation of these guidelines, hospitals are developing internal processes for sterilization and collection of used PPE (such as N95 masks and face shields). The intention is to follow Ontario Health guidance to ensure the technology, process and standards that are put in place are based on the best available science and expert advice.

A backgrounder with more details about CDC’s approach to extended use, reuse, as well as decontamination and reuse of FFR, can be found here.

The Ontario Command Table informed on April 6 that it will engage targeted actions to ensure Ontario’s patients and workers have the critical supplies and equipment they need by focusing implementation efforts in four areas:

• Distribution of PPE to the settings and sectors that need it most;
• Identification of approaches to conserve PPE, working with providers on how best to implement these in workplaces;
• Harnessing expertise and capacity in other Ontario industries towards the production of clinical supplies and equipment, working with the Ministry of Economic Development, Job Creation and Trade; and
• Reprocessing of PPE in alignment with forthcoming guidance from the Public Health Agency of Canada.

Researchers from a number of universities scoured the scientific literature to create N95decon.org, a web portal that medical professionals can access for trustworthy information on how to decontaminate used N95 masks.

RNAO wants to stress – again and again – that while masks are very important, you MUST focus on hand hygiene and practice. Please ensure that you:

• Put your mask on when you arrive and don't take it off.
• Don't keep fiddling with your mask as every time you touch it you could contaminate yourself.
• Use a face shield to cover the mask so people don't touch it.
• Clean your hands before you come anywhere near your face.

2. Sentinel surveillance and on-site testing in the homeless service sector

The deepening crisis amongst persons experiencing homelessness is a major concern for RNAO and one we are actively urging all levels of government to immediately address.

We asked Dr. Aaron Orkin, Population Medicine Lead with Inner City Health Associates (ICHA), to share with RNAO his expert advice about sentinel surveillance and on-site testing for persons experiencing homelessness in Toronto, which of course is applicable to any other city and jurisdiction.   

The importance of sentinel surveillance is well captured by comparing shelters and the populations we serve in long-term care facilities. We know that long-term care facilities act like canaries in the coal-mine of a broad epidemic – now, with growing numbers of nursing homes outbreaks and growing numbers of related deaths. We have been seeing that happen across North America and in Ontario over the last two weeks.

Shelters are analogous, but in some ways more calamitous for population health. The population in shelters is vulnerable, but largely less frail, and much more mobile and distributed than long-term care residents. There is no capacity to implement lock-downs, restrictive cohorting, or contain outbreaks in shelters in the same manner as is effective in long-term care. There is also much more limited healthcare infrastructure in shelters than in long-term care because shelters do not operate under the health care administrative umbrella. As a result, outbreak management, testing, and treatment procedures are less robust in shelters.

All this conspires to make shelter outbreaks dangerous for the shelter residents, for their staff and for the population at large. In effect, preventing and managing shelter outbreaks is a key element in preventing and managing the outbreak across the entire urban landscape. This is similar to long-term care because the outbreaks will be early and calamitous, but different because the outbreaks are perhaps harder to identify, harder to control, and result in wider community spread.

The goal of a sentinel surveillance program would be to identify COVID-19 in shelters earlier than we could identify it otherwise. So far, there have been a handful of confirmed cases in the shelter system in Toronto, but this is likely a severe underestimation. A large number of patients and clients in shelters are unable or very unwilling to go to a COVID-19 Assessment Centre, and therefore do not receive testing for COVID-19. There is no infrastructure for on-site testing (swabs, PPE, personnel). 

Dr. Orkin says that with support from the provincial government, a nimble partnership between COVID-19 Assessment Centers, an organization working with the homeless population, and public health could launch a sentinel surveillance program within days. He stresses that together, they would assemble small teams of staff, with the right equipment and supports, and go on-site to shelters. RNAO knows this is possible, we have leadership in Street Health  that would eagerly join a collective effort to massively scale up testing, and offer on-site nasopharyngeal swabs to anyone who was symptomatic, in our shelters. A partnering lab (hospital or public health) would provide prompt results under the structure of a surveillance program. Dr. Orkin adds that we would then be able to implement appropriate interventions in shelter settings, catch COVID-19 earlier in these high-risk settings, and reduce spread community-wide. This program could operate for people who are sleeping outside as well. I can see nursing leaders like Cathy Crowe, Kathy Hardill and many others echoing with a yes, yes, yes!

With ongoing surveillance in the shelter setting, we would also be able to use emerging hotel space more rationally and for the greatest impact.

A robust sentinel surveillance program in shelters will also be critical for the subsequent phases of the epidemic, says Dr. Orkin, referring to the time when we will be trying to determine whether there is ongoing transmission and identify facilities that are COVID-19 free. Ongoing surveillance will be critical for that in the shelters, otherwise COVID-19 transmission will continue in these facilities long after the epidemic has subsided elsewhere in the community, and will be an ongoing source of health problems, worker problems, and stigma.

In RNAO’s view, a sentinel surveillance program such as that proposed by Dr. Orkin, is both essential and urgent. We urge all levels of government to listen and act now by funding ICHA to bring together various stakeholders to come to the table and launch a sentinel surveillance program STAT. Inaction on this front will have devastating impacts on the homeless population and on the community at large.  

Your messages: Voices and responses

Every day we welcome new readers to this daily report: thank you deeply for the work you do during this public 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. Many of the articles you see here are posted in my blog, where you can catch up with earlier issues.

Thank you for your messages! Here are several of the important issues you raised today:

• Physical distancing also at the hospital:  A member writes: “I see groups of staff in PPE posting pictures on Facebook with their arms around each other and big grins! They are motivated by a positive intention to boost team morale and solidarity, but the message they send does a disservice.”
• Cloth caps: We also heard that: “Staff are wearing cloth scrub caps and/or headbands, often with a button on each side over the ears to hold the elastic ear loops off the backs of their ears. I’m concerned about impact on fit if the masks are worn this way, and also concerned that some may not realize that caps and headbands must be washed after every shift, just like scrubs.”
• Not enough swabs: A reader reacts to our calls to escalate testing: “The province doesn’t have enough swabs, that’s why there is case definition for swabbing now opened to healthcare workers and nursing home residents. They are anticipating getting more swabs at which point more people will be swabbed. Right now the priority with the swabs we have is to test the most critical people.”
• Keeping cell phones clean: A reader writes “Can cell phones spread COVID-19 within our clinical spaces? Most patient/staff alike access their phones at work, on breaks, or when waiting to be seen by medical staff. Everyone should be asked to wipe their phones down (or leave them in cars) when they enter the hospital, then put it in a plastic bag, and leave it there within all clinical areas.” Good advice. For more info, read here.
• Making a will: “I'm an RN on the front line. Both my wife and I are nurses, and we have two teens. I don’t have a will and am afraid of leaving my kids without a will. The likelihood that one of us gets sick is very high. Is there a lawyer or software that is actually free to create our own will?  Obviously time is of the essence.” Although this is not my area of expertise. I found this article useful.
• Public using medical masks: “When I see the general public wearing medical masks I want to cry! Two thirds of the customers at the grocery store were wearing surgical masks and not one of them was a homemade mask. Those wearing a homemade mask in public are protecting everyone from COVID-19 and respecting frontline workers who deserve to have all of the medical/surgical masks available.”
• Telehealth: A reader writes: “I can’t believe that telehealth has not gotten their act together, I waited yesterday 15 hours and gave up.” RNAO shares on this disappointment. RNAO has repeatedly been calling for Telehealth to hire more nurses (which RNAO can deploy instantly) and start providing timely service. Minister Elliott was asked about people experiencing COVID-19 symptoms and having to wait two or three days before receiving a call back from a Telehealth nurse. The health minister said this was "not acceptable." She responded: "We really want to get that down to within 24 hours, so that’s something that we’re continuing to work on," Elliott said, encouraging people to call their family doctors for a "more timely way to deal with it." Minister, even 24 hours wait for Telehealth is unacceptable. We have the nurses – please hire them.
• Thank you: “I just want to take this opportunity to thank everyone! I want to thank all of our frontline workers (RNs, RPNs, PSWs, DOCs, ADOCs etc.). I also want to thank all other essential workers too that are not healthcare related (we are a huge team of people; not just healthcare workers who are fighting hard in this pandemic). Finally, I want to thank all of you at the RNAO – I read your email postings every day; thank you so much.” To you and the many others who thank us daily: We are honoured to be here for you!

You can read earlier responses here. 

MOH EOC Situational Report #72 here  for Monday, April 6

 Situation:

• 309 new cases were reported today in Ontario, bringing the cumulative total to 4,347 (this includes 1,624 resolved cases and 132 deaths).
• In Ontario, a total of 78,796 people have been tested, with tests performed at Public Health Ontario Laboratories and non-Public Health Laboratories. There are currently 329 tests under investigation.
• 589 patients are currently hospitalized with COVID-19; 216 are in ICU; and 160 are in ICU on a ventilator.

 EOC report #72 informs of the following actions taken: 

• The Government of Ontario announced today a one-time financial assistance during school and child care closures.
• Public Health Ontario issued a technical brief today: IPAC Recommendations for Use of Personal Protective Equipment for Care of Individuals with Suspect or Confirmed COVID-19.
• All previously issued directives have now been uploaded to the ministry’s website.
• Please see summary from today’s Command Table here.
• Please see memo from the Deputy Minister of Health to the Collaboration and Command Tables regarding personal protective equipment here and here.
• A memo was sent to CEOs of Ontario Public Hospitals today regarding the use of alternate health facilities and temporary structures such as field hospitals and conference centres.

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 4,347 cases in Ontario and 16,667 total cases in Canada. There are 368,376 cases in the United States, and worldwide, there are 1,348,184 cases.

RNAO policy corner: These are longer pieces and issues we follow. We have posted earlier ones in my blog here. Please go and take a look.

RNAO’S policy recommendations for addressing the COVID-19 crisis: We have 17 recommendations for government at this particular juncture. Read them here.

RNAO’s ViaNurse Program

RNAO launched its COVID-19 ViaNurse program on March 13 and it has already registered 246 nurse practitioners (NPs), 947 critical care RNs (who have experience and continued competency in the provision of critical care) as well as 6,886 RNs for virtual/clinical care.

RNAO is actively staffing nursing homes requiring RN and PSWs; so far, 364 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. For details and forms, please go here.

Staying in touch          

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  

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.

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