Dear All,

Yesterday was World Health Day and RNAO’s board of directors had a three-hour meeting to celebrate, share and plan ahead. We comforted our president, Dr. Angela Cooper Braithwaite, who had just lost her niece to COVID-19 in New York. To Angela’s family, many of whom I know read this blog – we love you! To the thousands of families, friends and co-workers of COVID-19 victims all around the world, including loved ones across Canada and Ontario, know that our hearts are heavy and our resolve to save lives continues strong. May the comfort of past memories, of good times, of smiles and songs, bring you comfort. Know that you are not alone. To our colleagues -- nurses, doctors, respiratory therapists, paramedics, and those who help us clean – you inspire us beyond imagination with your knowledge, compassion and courage. To you we dedicate the World Health Organization video, and this tribute.

Many are thinking about the upcoming faith-related holidays. Some are thinking they will get together with their extended families and others yearning for it. Political leaders and public health officials ask us to stay at home. We ask the same. Please stay at home. Staying at home ought not to mean being alone, and this is why today’s blog, Wednesday, April 8, we explore how to have a real celebration, COVID-19 and all. For today’s blog, I also discuss the use of N95 respirators (masks) in hospitals, and who should be using them. We need to conserve PPE, and health providers must feel safe. This is the fine line we need to walk. I also address a number of issues you raised in your rich messages. Please keep them coming!

RNAO POLICY CORNER

Celebrating Passover, Good Friday, Holy Saturday, Easter Sunday and the start of Ramadan during a pandemic

This is a special and meaningful time of the year for families; friends and communities who in normal times get together to celebrate. This time it will be different; as in so many other aspects of our life, everything seems to be changed – hopefully for not too long. We urge each of us – everyone -- to stay put in our homes. But, staying-at-home, doesn’t mean being alone.  There are many ways to connect with friends and loved ones who are in a different place, thanks to technology. At these times, if we have not yet done so, we should all become familiar with WhatsApp, Facetime, Skype, Zoom or other similar apps. Let’s also help people who don’t have access to technology or don’t know how to use it. Make sure you call, connect, text, send a picture, keep in touch. My key message is: let’s become champions of staying at home and let’s be connectors of not being alone.   

There are many ideas of how one can celebrate despite the situation. Even though we can't physically be next to each other, we still can be with each other. We can still have all the same conversations and enjoy each other's company. Some people are organizing Easter egg hunts in their neighborhoods. It sounds counterintuitive to social distancing guidelines, but it works by families hanging pictures of Easter eggs on their front door or windows (for details, see here). If you're concerned about missing church on Easter Sunday, you can attend an online service or search for a drive-in service in your area. Maybe participate in a virtual egg decorating contest. A virtual Passover Seder is the way to go this year, but it requires organization since it is more than "just the communal family dinner." Even if one cannot have company, Passover doesn’t need to be lonely. Celebrations of Ramadan will continue through livestreaming and other digital forms. In the words of a Canadian Imam, "It's a community coming together. This is where we're scrambling and we don't know all the answers. At the end of the day, you want to stay healthy and stay alive."

Here are good articles for those celebrating and playing with children: here and here and here and here.

Guidance on use of N95 mask

We continue to receive messages from RNs who, in their judgment, require the use of N95 and are denied their use. The guidance, given the shortage of N95, is that they are specifically allocated for use in ICUs and mainly for aerosolized procedures. However, exceptions to this guidance should be recognized.

An RN reports working in a hemodialysis unit with chronic renal patients that often have difficulty breathing, with cough symptoms that could mask real Covid-19 symptoms. Nurses may provide oxygen to ease up breathing while preparing for the hemodialysis. This poses a real threat to the health and workload of the staff. Even with surgical mask and gown, the constant coughing of the patient, as well as the oxygen flow, could potentially be seen as aerosolized actions. Even for renal nurses doing the hemodialysis of COVID-19 patients in the ICU, the guidance in this particular hospital is still not to use N95. She reports that a number of staff in the hemodialysis unit have already tested Covid+. 

According to the Ontario Chief Medical Officer of Health’s directive,

• A point-of-care risk assessment (PCRA) must be performed by every health care worker (“worker”) before every patient interaction in a public hospital.
• If a worker determines, based on the PCRA, and based on their professional and clinical judgement, that health and safety measures may be required in the delivery of care to the patient, then the public hospital must provide that worker with access to the appropriate health and safety control measures, including an N95 respirator. The public hospital will not unreasonably deny access to the appropriate PPE.
• At a minimum, contact and droplet precautions must be used by workers for all interactions with suspected, presumed or confirmed COVID-19 patients. Contact and droplet precautions includes gloves, face shields or goggles, gowns, and surgical/procedure masks.
• All workers who are within two metres of suspected, presumed or confirmed COVID-19 patients shall have access to appropriate PPE. This will include access to: surgical/procedure masks, fit tested NIOSH-approved N-95 respirators or approved equivalent or better protection, gloves, face shields with side protection (or goggles), impermeable or, at least, fluid resistant gowns.
• The PCRA should include the frequency and probability of routine or emergent Aerosol Generating Medical Procedures (AGMPs) being required. N95 respirators, or approved equivalent or better protection, must be used by all health care workers in the room where AGMPs are being performed, are frequent or probable, or with any intubated patients. AGMPs include but are not limited to; Intubation and related procedures (e.g. manual ventilation, open endotracheal suctioning), cardio pulmonary resuscitation, bronchoscopy, sputum induction, non-invasive ventilation (i.e. BiPAP), open respiratory/airway suctioning, high frequency oscillatory ventilation, tracheostomy care, nebulized therapy/aerosolized medication administration, high flow heated oxygen therapy devices (e.g. ARVO, optiflow) and autopsy.

RNAO’s view is that the list of specific procedures in the last item should not be seen as exhaustive. The evidence-based judgment of the RN, when performing the point-of-care risk assessment (PCRA), must prevail.

We understand the enormous pressure on hospital administrators to conserve PPE when they do not have assured supplies coming in and the stocks are dwindling. This conservation, however, must be done responsibly, in consultation with the health providers themselves, using an evidence-based approach, and applying a precautionary principle – better safe than sorry. 

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 and 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 since yesterday:

• A reader shares she is concerned with the public using nitrile gloves to 'protect' themselves: cashiers, grocery clerks, the people serving drive-through, and people shopping. They have a false sense of security and don't understand cross-contamination. Posts on social media, mainly in a joke format, show people touching everything while wearing gloves. We need education. RNAO: Everything touched wearing the same gloves becomes contaminated.
• A member of the public writes: “I am watching an ICU nurse from NYC talk on television about watching people dying alone and the feeling of despair. This woman looks terrible and her body language is heartbreaking. We are going to have a whole generation of our finest and brightest suffer from PTSD from this traumatic experience and some will leave the professions as a result of this. As part of our “recovery” this province needs to officially recognize this issue NOW and move quickly, once the emergency is over, to assist health providers. We cannot allow them (health professionals) to be the walking casualties of this war.” RNAO: Yes, we saw this during SARS and COVID-19 is exponentially larger. 
• “I am a new graduate nurse who is unable to write the NCLEX and complete my CNO registration due to the delays in NCLEX exam administration. The exam has been pushed from its March original date to June. I am unable to apply for a temporary licence as I do not have a job offer and many others are in the same position. Can we advocate to get NCLEX testing reopened sooner? We feel defeated and powerless. We want to help and we want to work but are unable to.” RNAO: Yes, we are tackling this and other issues related to students.
• “With an exemption made for border crossings to make way for the arrival of migrant agricultural workers into Canada, and hundreds of workers already working on farms throughout the country, organizations that work with this population are very concerned about the spread of transmission and potential loss of life among this cohort. Housing, working conditions, access to health care, and employer-mediation to access services, benefits and compensation are among many of the factors that make this group uniquely vulnerable. They typically live in overcrowded bunkhouses, with dozens sharing access to one washroom, isolated from amenities and services. Many of these workers are also arriving in Canada with no knowledge of the virus. They are moving in large groups (because they depend on their employer to access groceries, etc.), and they have not been made aware of the severity of COVID-19. There are several organizations that have developed important recommendations and guidelines, but we need to make sure that public health authorities act on these steps and take this group into account as they implement comprehensive social distancing measures and treatments. Temporary migrant agricultural workers are being allowed entry into the country because they are deemed essential workers and crucial to our food system, I hope that you can support me in keeping them safe!” RNAO: Please see here Guidance for Employers of Temporary Foreign Workers Regarding COVID-19.
• “An estimated additional 180 - 195 deaths per day occurring at home in New York City due to COVID-19 are not being counted in the official figures. ‘Early on in this crisis we were able to swab people who died at home, and thus got a coronavirus reading. But those days are long gone. We simply don't have the testing capacity for the large numbers dying at home. Now only those few who had a test confirmation *before* dying are marked as victims of coronavirus on their death certificate. This almost certainly means we are undercounting the total number of victims of this pandemic,’ said Mark Levine, Chair of New York City Council health committee.” Are we planning to count all the COVID-19 deaths in Ontario? RNAO: You are right on. This is a question I ask daily from Dr. David Williams. In the view of RNAO Ontario is vastly undercounting COVID-19 related deaths – especially in nursing homes, homes, shelter, and even in ICU. What we count today is persons that had been tested as COVID-19 positive and who die. We are also urging to massively scale up testing, and are hopeful it will happen.
• “We should protect health care workers’ families by providing shelter for hospital workers so they do not need to go back to their homes. Since the government failed to protect us at the workplace, at least stop further spread to our families. This is a costly proposition, however, ICU beds are even more costly. This would significantly decrease health care providers stress as we are worried about bringing the illness home; it could reduce stress on us and our loved ones and increase staff morale. It would also be an incentive for more nursing staff to come back to critical care practice.” RNAO: Stay tune, we are working on it.

You can read earlier responses here. 

MOH EOC Situational Report #73 here for Tuesday, April 7

 Situation:

• 379 new cases were reported today in Ontario, bringing the cumulative total to 4,726 (this includes 1,802 resolved cases and 153 deaths).
• In Ontario, a total of 81,364 people have been tested, with tests performed at Public Health Ontario Laboratories and non-Public Health Laboratories. There are currently 691 tests under investigation.
• 614 patients are currently hospitalized with COVID-19; 233 are in ICU; and 187 are in ICU on a ventilator.

 EOC report #73 informs of the following actions taken: 

• The Government of Ontario has launched an online portal to match available health care workers with employers.
• The Government of Ontario announced a commitment of $37 million to support outbreak planning, prevention and mitigation to ensure the health and well-being of Indigenous people and communities.

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 4,726 cases in Ontario and 17,897 total cases in Canada. There are 399,929 cases in the United States, and worldwide, there are 1,432,577 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 256 nurse practitioners (NPs), 962 critical care RNs (who have experience and continued competency in the provision of critical care) as well as 6,966 RNs for virtual/clinical care.

RNAO is actively staffing nursing homes requiring RN and PSWs; so far, 373 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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