Dear Colleagues:  Welcome to my Thursday, April 16, COVID-19 report. We are now entering the fourth month of COVID-19 in Ontario – a long tunnel that is beginning to show signs of light at its end. To get a feel for RNAO’s analysis and recommendations throughout the crisis, you can refer to earlier reports here, including thematic pieces in my blog. Feel free to share this report or these links with anyone interested – they are public. A huge thanks to the many of you who continue to send questions, concerns and solutions. Rest assured – our team is responding to each of you individually.

As the light at the end of the tunnel begins to shine, so too does the sun as we welcome the warmer weather, and with it, the desire to live a fuller life. At this time, we must diligently and wisely examine what it is we want to take with us to our “new normal,” and what we want to leave behind. These reflections, in my view, ought to happen for each of us individually, as it relates to our personal lives, and collectively, as a society and a health system. Keeping true to the intent of my blog posts, which I write as Doris the individual and Doris the CEO, I will begin to share some of my own reflections on what I think we need to “leave behind” and “take forward.” These reflections are threads in my life’s quilt, as well as RNAO’s thinking for how the system ought to be shaped and reshaped given everything we’ve learned from COVID-19. 

A crucial question we face as we start thinking beyond the pandemic is what systemic factors have contributed to worsening its impacts, and which ones have mitigated them. I have expressed earlier RNAO’s concerns that an excessive hospital orientation within the health system in Ontario, and the neglect of community-based approaches, is most likely a factor that has aggravated the impacts in our province. Today I am profiling the way that the Balearic Islands, a province of Spain, has tackled COVID-19 with an innovative primary care and home-based approach. For the summary below, I thank my colleague and friend Consejera de Salud  (Minister of Health for the past five years) of Islas Baleares, Patricia Gomez - an RN with primary care experience and the leader of the Balearic Islands province-wide RNAO BPSO, and the Deputy Director of the Health Service, Carlos Villafáfila.  

A home based model to confront COVID-19 – the case of the Balearic Islands

The Balearic Islands, an archipelago in the western Mediterranean Sea, near the eastern coast of the Iberian Peninsula, is an autonomous community (a province) of Spain. COVID has hit hard on Spain, but there have been diverse experiences among different provinces within the country. The Balearic Islands has been successful, early on, in flattening its curve. It has brought down the curve to a relatively small number of new daily cases – around 20 new cases for a population of about 1.1 million during the last three days. The maximum number of daily cases hit 107 toward the end of March, and the curve went drastically down since then.

The Balearic Islands opted for a primary care (PC) approach to contain the COVID-19 pandemic. The restructuring of the entire PC in record time focused on the design of two differentiated work circuits within the province’s 45 community health centres – one specific for patients with respiratory symptoms, and the other for patients without those symptoms. In addition, a telephone triage system was put in place to distribute health care services through face-to-face, telephone and/or home visits, following the proper case definitions. Likewise, a virtual health consultation portal, #APMallorca, was launched in social media, with health professionals consulting online through Twitter, Facebook and Instagram. The community health centres played a central role – this is a network of primary care centres, each one serving, on average, about 20,000 people. They engaged proactively in telephone connection with advanced chronic patients or those with vulnerable pathologies to ensure their well-being, offer information and recommendations to family members and/or caregivers, and identify possible risk situations.

Parallel to the laser-speed reorganization of care through the community health centers, the government created mobile coronavirus care units (UVAC) served by an RN/family physician dyad and established a COVID-19 coordination centre led by primary care professionals. The UVAC did face-to-face home visits, obtained test samples at home, and followed-up with daily telephone monitoring of positive cases. The UVAC also refer these patients to hospitals in case of a worsening clinical situation. A team of nurses and doctors was placed in charge of the care and health education of family members and cohabitants of COVID+ patients, to minimize the spread.

A central role of the coordination center is the oversight on and control of nursing homes, where they carry out daily interventions, collect massive test samples of both vulnerable patients and healthcare workers in these homes, and also refer, when required, patients to hospitals.

For workplaces that continue active during the lockdown, five express (mobile) COVID units were launched to collect samples and carry out tests from essential workers, each unit carrying out about 200 tests each day.

This early primary care intervention has helped contain the outbreak in the home sector, thus protecting hospitals from collapse and allowing them to focus their efforts on the people severely affected by the disease. The organizing values for primary care as a gateway to the health system were defined as: accessibility, proximity, efficiency and resolution. This kind of primary care approach allowed hospitals to adopt the necessary structural and organizational measures to adequately care for patients affected with COVID-19, as well as maintain oncological and urgent activity not linked to COVID-19.

All this has been accompanied by an extraordinary increase in home and telephone care (in primary care and in hospitals), allowing the decongestion of the two healthcare areas.

From RNAO’s perspective, this is an insightful example of an approach that emphasizes keeping the health system whole for all. It limited the spread of COVID-19 by, early on, keeping people at home, including for purposes of getting tested. It promoted people’s active support by ongoing telephone connection and extensive homecare visits. The use of social media for virtual consultation with professionals is not something we have tried in Canada, nor is the intensive daily monitoring of COVID+ persons with extensive, quick, contact tracing and isolation. A coordination centre for COVID response led by primary care professionals is, again, a crucial element for us to consider in the go forward. The same holds for a reorganized health system of community care anchored in primary care and augmented robustly by home care, with responsibility for the totality of the population.

Many will remember these are concepts RNAO has advanced since the first release of Enhancing Community Care for Ontarians (ECCO) in 2012, revised and re-issued in 2014. This model has been discussed further, and a new revised version is forthcoming on May 12, 2020 – in celebration of Florence Nightingale’s 200th birthday. In RNAO’s view, these are important concepts to consider as we visualize Ontario’s future health system and the evolution of Ontario’s Health Teams (OHTs).   

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 and other organizations both 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! Today I focus on two issues:

Support for long-term care, testing, case and contact tracing, and self-isolation: Albeit late in coming, RNAO welcomes greatly the new directions from government regarding reliable provision of PPE to long-term care facilities, universal masking, employment of staff in one facility, and strong support for facilities undergoing an outbreak. We hope the plans for increased testing, contact tracing and isolation will materialize across the province as the record so far on contact tracing, even when testing has occurred, has been uneven. Many lives have been lost among our elders, and in the go forward many lives can and must be saved. RNAO raised the need for universal masking on March 22. In the days that followed, we continued to present recommendations and calls for action in the long-term care sector (see my daily reports here – go to the bottom of the page). We are glad government is addressing a number of RNAO’s recommendations (see here and here and here and here).

Plans for gradual re-opening of the economy: RNAO wants to stress the critical importance of engaging those plans in a responsible and cautious way. If we move to open the economy too fast we risk a second surge that would overwhelm the health care system. In such a case, not only we would lose many lives that can be saved, but also the economy would get a double hit by having to go back to a full lockdown. THANKS deeply to the consistent communications from both Premier Ford (go to paragraph 12) and Prime Minister Trudeau (go to min. 46), both rejecting the call for a quick opening and resisting the pressures to ease the restrictions too early. RNAO urges Ontario’s Command Table and Public Health Ontario (PHO) to share their plans and engage consultation before any restrictions are eased. Here is a remarkable, model-focused risk communication from German Prime Minister Angela Merkel, which lays out that concern in a crystal-clear fashion: https://twitter.com/BenjAlvarez1/status/1250563198081740800   

You can read earlier responses here.   

MOH EOC Situational Report #81 here for Wednesday, April 15

 Situation:

• 494 new cases were reported today in Ontario, bringing the cumulative total to 8,447 (this includes 3,902 resolved cases and 385 deaths).
• In Ontario, a total of 119,092 people have been tested, with tests performed at Public Health Ontario Laboratories and non-Public Health Laboratories. There are currently 4,429 tests under investigation.
• 795 patients are currently hospitalized with COVID-19; 254 are in ICU; and 188 are in ICU on a ventilator.

EOC report #81 for April 15 informs of the following actions taken: 

• The Government announced the COVID-19 Action Plan for Protecting Long-Term Care Homes to keep residents in long-term care homes safe. See also here.
• The government passed emergency orders that will come into effect on April 22, 2020 restricting long-term care staff from working in more than one long-term care home, retirement home or health care setting – see here.
• A Memo was issued regarding additional support for Long Term Care Homes (LTCHs) and Retirement Homes (RH) – see here and  here.
• A Memo was issued to temporarily stop all transfers from hospitals to LTCHs and RHs – see here.
• The CMOH Directive 3 has been updated to reflect the new limitation on working in only one location and to provide additional information on outbreak management and response – see here.
• A new guidance document for LTCHs and RHs on mask use – see here.
• The guidance documents for long-term care homes, long-term care outbreaks have all been updated to align with the new Action Plan and emergency order – see here and here.
• The ministry’s Public Health Management of Cases and Contacts of COVID-19 guidance for public health units is updated – see here.
• All memos up to and including April 10, 2020 are available in French and English on the ministry’s website.
• New signage has been created for health care settings and is available for download from the ministry’s website in French and English.
• The provincial Testing Guidance document was updated to reflect the next phase of the testing strategy – see here.
• The Command Table met today; a summary of the meeting – see 5) here.

RNAO’s ViaNurse Program

RNAO launched its COVID-19 ViaNurse program on March 13 and it has already registered 278 nurse practitioners (NPs), 1,004 critical care RNs (who have experience and continued competency in the provision of critical care) as well as 7,196 RNs for virtual/clinical care.

RNAO is actively staffing nursing homes and retirement homes requiring NPs, RN and PSWs; so far, 409 organizations have registered. We have also staffed many hospitals and indigenous communities. We urge CNEs, CNOs, and managers – in all sectors and regions of Ontario - to access this talent now to build HR surge capacity. 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  

RECENT RNAO POLICY CORNER ITEMS:

15 April - COVID-19 and the Challenges in Homecare – go here.

14 April - Reprocessing Of N95 – An Update – go here.

14 April - A New COVID-19 Facility For Persons Experiencing Homelessness In Toronto – go here.  

13 April - Practical Tips for Safe Use of Masks – go here.

10 April - Ontario’s Tragedy in Long Term Care Homes and Retirement Homes – go here.

10 April - RNAO Action – Supporting Long-Term Care – go here.

10 April - Update For Nursing Students – NCLEX Exam – go here.

9 April - Celebrating Passover, Good Friday, Holy Saturday, Easter Sunday and the start of Ramadan during a pandemic – go here.

9 April - Guidance on use of N95 mask – go here.

7 April - Sentinel surveillance and on-site testing in the homeless service sector – go here.

7 April - Reprocessing of n95 – safe? – go here.

5 April - We must change the way we do testing and case definition – go here.

5 April - Ringing the alarm bells on critical care beds – go here.

4 April - COVID-19, stay at home and domestic violence – go here.

We have posted earlier ones in my blog here. Please go and take a look.

Information Resources

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

Ontario’s health provider website is updated regularly with useful resources here.

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.

The World Health Organization plays a central role in addressing the COVID-19 pandemic. See here and here.

You can find up-to-date global numbers in Coronavirus COVID-19 Global Cases by Johns Hopkins CSSE.

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