Dear Colleagues:  Welcome to my Tuesday, April 21, COVID-19 report -- now in the fourth month of COVID-19 in Ontario. I want to begin my report expressing our collective shock and mourning over the lives lost in the Nova Scotia rampage shooting. The pain is numbing and our love for the families and friends must be constant and vibrant. Only this collective demonstration of love can help the NS family, and the families and friends of each robbed life, carry on with their own. Please RT and add your commentary of love and strength to RNAO’s tweet. 

COVID-19 Portal: Please visit the portal which contains very important and useful information including VIANurse should you need to augment your nursing human resources. You can refer to earlier update reports here, including thematic pieces in my blog. Feel free to share this report or these links with anyone interested – they are public.

Issues of fullness and accessibility of data are central to the understanding of any pandemic and the design of effective policy responses. This is particularly the case with a novel virus such as COVID-19. Given the relatively limited testing in Ontario, RNAO has expressed concern about deficiencies in the available data. For example, we supported an expanded case definition that incorporated into the COVID data clinical identification for untested individuals. We also repeatedly called for counting deaths including suspected cases when the person was never tested, such as in nursing homes with outbreaks. We have also asked Dr. David Williams on numerous occasions that reporting on hospitalizations include both confirmed and probable COVID-19 cases.

We have asked Dr. Jennifer Kwan, a family physician in Burlington, Ontario, to expand on this key topic. What follows is her article. I encourage you to follow her on Twitter – her feed is an excellent source of useful data on COVID-19.

We require expanded and accessible COVID-19 data in Ontario

COVID-19 has caused a major shift in everyone’s routines, with personal sacrifices being made in different ways. Apart from health risks, people are also suffering financial and economic loss, having procedures, appointments, and surgeries postponed, and missing out on major life events such as weddings and graduations. It is also a lot to ask of people to remain indoors despite the approach of summer. The public deserves a clear picture of the COVID-19 situation in order to be informed and help understand the justification for social distancing measures. Public Health Ontario continues to make significant improvements on data reporting, including the announcement of a new data platform called the  Pandemic Threat Response (PANTHR). However, there remain many questions to address.

Comorbidity. Researchers studying the health effects of COVID-19 on populations require data on underlying comorbid conditions, and ask whether it is being gathered and analyzed. In the federal epidemiological summary there is only mention of four major groups of pre-existing conditions - respiratory disease, cardiac, diabetes, and other. Could this be broken down into more specific categories while ensuring patient anonymity?

Social determinants of health. Although COVID-19 can infect anyone, some groups face pre-existing barriers that impact on their access to health services, and/or face increased risk of infection and poorer health outcomes. Is data being gathered on the socioeconomic determinants of health, such as income, employment status, and race? Could this additional information be published, so that disparities can be addressed?

Excess deaths over normal trends. How does the number of overall deaths from all causes compare to the same timeframe in previous years? COVID-19 may cause deaths from unrelated diseases since people may delay or avoid seeking appropriate medical attention, such as for heart attacks or strokes. What about deaths specifically related to respiratory or flu-like illnesses?

Healthcare workers: As of Apr 19, 2020, there have been 1267 cases in healthcare workers. 644 were infected in long-term care and 90 in hospitals. What about the remaining 533? Were they infected at work, or was it suspected to be due to community transmission? If it occurred at work, were there any concerns about PPE shortages? What kind of work was it - high risk aerosolizing procedures, or routine patient care? Was the likely source of infection a patient or a staff member?

The report also mentions one death of LTC staff, and no hospital staff. However, media reports at least two healthcare worker deaths - Christine Mandegarian, a 31 year old PSW who worked at the Sienna Altamont Care Community (Scarborough) and passed away on April 15, as well as a 58 year old  environmental services employee at Brampton Civic Hospital who passed away on April 9.

Long-term care homes and other vulnerable populations: As of Apr 19, 2020 there have been 1317 LTC resident/patient cases and 249 reported deaths. Were the LTC residents offered transfer to hospital for treatment, intensive care, and/or ventilation? Did they pass away in the LTC home or at the hospital? Could there be a centralized list published of the 114 LTC outbreaks in Ontario? Why does the provincial modeling data released on April show 127 LTC outbreaks instead of 114?

Long-term care homes are only one of the many vulnerable populations that are disproportionately affected by COVID-19. What about outbreaks, cases, and deaths in retirement homes, homeless shelters, and correctional facilities? What about home care? Indigenous populations? What percentage of the total do they contribute to?

ICU and hospitalization: ICU and ventilation case numbers have been reassuringly stable over the past week. However, was it because patients improved clinically well enough to be discharged, or did they deteriorate and pass away? What is the average duration of hospitalization, ICU admission, and/or time on a ventilator?

Testing: With regards to testing, there have been gains made in the number of tests per day. However, the province previously reported the number of persons tested, then shifted to the number of total tests completed (including potentially multiple tests per person). If the data is already available, why not report both measures? What is the current lab capacity, and what is the average wait time for results? Is it significantly different between regions? How many tests are being done in the community, versus in LTC or in hospital settings? How many tests were initially negative, then positive on a repeat test, and vice versa?

Ontario continues to improve on its reporting on pertinent COVID-19 data, however there remain more questions than answers. Additional data must continue to be gathered, analyzed, and presented to guide in the understanding of the COVID-19 pandemic in Ontario. It will help Ontarians understand why everyone’s lives have drastically changed, hopefully to achieve better outcomes in the long-term.

RNAO: We thank Dr. Kwan and want to reinforce the urgent need for data transparency and access. Comprehensive data collection and data sharing are vital to measure pandemic curve performance, prevent outbreaks in vulnerable communities, plan an exit strategy from large-scale self-isolation, and prepare for future COVID-19 waves. Without comprehensive data collection we act blindly. If data is collected but not shared, that is unacceptable. Our Prime Minister and Premier say: We are all in this together. RNAO agrees, and access to comprehensive data is essential to leaving no one behind.

As Premier Ford said when the first pandemic projections were presented on April 3, history will judge us, adding that we can and must write a better final chapter. At RNAO we agree with the Premier, and part of making the final chapter better is to ensure there is comprehensive data collection and full transparency – in particular about COVID-related deaths. It is unthinkable that we are only counting “confirmed” persons, but those who die as “suspected” cases are not counted. We must know that those lives lost to COVID-19 – whether tested or suspected – are all lives that we should count and remember. We must allow families and communities to grieve collectively – because #togetherwecandoit. We must have a full account of the toll of COVID-19. 

Your messages: Voices and responses

Each 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. The COVID-19 Portal is here.

This week I want to acknowledge a group of essential health professionals who are not always front of news. April 20-24 is Medical Laboratory Professionals week. We want to thank all MedLab professionals for their hard work and dedication -- your work is essential to the battle against COVID-19 and we could not do it without you. Thank Med Lab professionals and learn more about them.

Together we can do it

MOH EOC Situational Report #86 here for Monday, April 20

Situation:

606 new cases were reported today in Ontario, bringing the cumulative total to 11,184 (this includes 5,515 resolved cases and 584 deaths).

In Ontario, a total of 164,840 tests have been completed, with tests performed at Public Health Ontario Laboratories and non-Public Health Laboratories. There are currently 3,799 tests under investigation.

802 patients are currently hospitalized with COVID-19; 247 are in ICU; and 193 are in ICU on a ventilator.

EOC report #86 for April 20 informs of the following actions taken: 

The Government of Ontario released new modelling projections today regarding the COVID-19 pandemic. More details can be found on the website.

The Ministry has developed guidance for community emergency evacuations during the COVID-19 pandemic. Please share this guidance with any partners who may be involved in the potential evacuations of First Nations communities due to Spring flooding this year. The guidance is available in English and French on our website.

RNAO’s ViaNurse Program

RNAO launched its COVID-19 ViaNurse program on March 13 and it has already registered 283 nurse practitioners (NPs), 1,013 critical care RNs (who have experience and continued competency in the provision of critical care) as well as 7,256 RNs for virtual/clinical care.

RNAO is actively staffing nursing homes and retirement homes requiring NPs, RN and PSWs; so far, 419 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 around the world. 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 must redouble our efforts 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:

20 April - Can Loss of Smell and Taste Help Screen for COVID-19? –  go here.

18 April - COVID, Trump and the World Health Organization – go here.

16 April - A Home Based Model To Confront COVID-19 – The Case Of The Balearic Islands – go here.

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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