Dear Colleagues: Welcome to our Friday, August 14 report – now in the sixth month of COVID-19 in Ontario. Visit the COVID-19 Portal for the many resources RNAO offers on COVID-19. Find earlier updates here, including thematic pieces in my blog. RNAO media hits and releases on the pandemic can be found here. Daily Situational Reports from Ontario's MOH EOC can be found here. As always, feel free to share this report and links with anyone interested.

Reminder to take action regarding Nursing Homes before it’s too late! Add your name to over 8,000 who have written to Premier Ford demanding the Nursing Home Basic Care Guarantee and to begin hiring staff in August! So far all we hear is about layoffs in LTC and that is shocking!

Insights from Cuba: Primary care as the focus of COVID-19 prevention

Today our focus is on Cuba, a Caribbean island with about 11 million population and a very different economic and political regime. Canadians know Cuba well through their tourist visits – more than one million in 2019 – enjoying the beaches, food, music and friendly welcoming from the Cuban people. Today, we are interested in a different facet of Cuban society – the community focus of its health system and their success, so far, in controlling the COVID-19 pandemic. There are important insights for us in Ontario.

By Ontario standards, Cuba has done excellent, so far, in terms of flattening the COVID-19 wave, although it is now facing an upsurge in cases. As of yesterday’s count, it reached a total of 3,174 cases overall and 89 deaths. Ontario, in contrast, with a population of about 14 million, has had 40,459 cases and 2,788 deaths. We provide next an excerpt from an article on Cuba’s initial COVID response by UK Professors Emily Morris and Ilan Kelman and we then follow with our own commentary.

Coronavirus response: Why Cuba is such an interesting case (excerpt)

By Emily Morris and Ilan Kelman

…

Cuba has several advantages over many states [in handling the COVID-19 pandemic], including free universal healthcare, the world’s highest ratio of doctors to population, and positive health indicators, such as high life expectancy and low infant mortality. Many of its doctors have volunteered around the world, building up and supporting other countries’ health systems while gaining experience in emergencies. A highly educated population and advanced medical research industry, including three laboratories equipped and staffed to run virus tests, are further strengths.

Also, with a centrally planned, state-controlled economy, Cuba’s government can mobilise resources quickly. Its national emergency planning structure is connected with local organisations in every corner of the country. The disaster-preparedness system, with mandatory evacuations for vulnerable people such as the disabled and pregnant women, has previously resulted in a remarkably low loss of life from hurricanes.

However, COVID-19 presents differences. Cuba’s lack of resources, which hampers recovery from disasters, also contributes to a housing shortage that makes physical distancing difficult. And the island’s poor infrastructure creates logistical challenges.

Also, the pandemic comes at a particularly difficult time, as tightened US sanctions have sharply cut earnings from tourism and other services, deterred foreign investment, hampered trade (including medical equipment imports) and obstructed access to international finance – including emergency funds.

Given these strengths and weaknesses, Cuba provides an interesting case study in responding to the current pandemic.

Cuba’s reaction to the coronavirus threat was swift. A “prevention and control” plan, prepared in January 2020, included training medical staff, preparing medical and quarantine facilities, and informing the public (including tourism workers) about symptoms and precautions. So, when the first three reported cases were confirmed on March 11, arrangements were in place to trace and isolate contacts, mobilise medical students for nationwide door-to-door surveys to identify vulnerable people and check for symptoms, and roll out a testing programme. [Editor’s note: the term “medical” in this paragraph includes nurses and nursing students]

On March 20, with 21 confirmed cases reported, the government announced a ban on tourist arrivals, lockdown for vulnerable people, provision for home working, reassignment of workers to priority tasks, employment protection and social assistance.

As issues arose, the Cuban government adjusted its response. For example, when face-masks and physical distancing proved insufficient to keep public transport safe, services were suspended and state and private vehicles and drivers were hired to transport patients and essential workers. And to reduce crowding in shops, the distribution system was reorganised and online shopping introduced. Physical distancing enforcement has also been stepped up in response to instances of non-compliance.

…

(This article excerpt is republished from The Conversation under a Creative Commons license. Read the original article.)

Cuba’s approach to COVID-19 and RNAO’s insights for Ontario

Cuba promotes itself as recognizing health as a human right. Although it is not a rich country and has suffered the continuous impact of the US blockade for 60 years, it has an effective universal health system focused on primary care and localized services reaching people in their communities. Many years ago I had the opportunity to visit a family clinic in Habana (here is a more recent account). The clinic was situated inside a large apartment complex, and the clinic was a regular apartment in the building where a family doctor and a family nurse worked under spartan conditions doing very effective work. The nurse and the physician lived in the neighborhood and knew the community members closely. They served around 120 families (about 600-700 people of all ages). The most striking difference with our patterns of health-care provision was that the doctor and the nurse did not see their role as waiting for individuals from their catchment community to walk into the clinic. Instead, they acted on health promotion and active surveillance of health risks in their community. The dyad team worked extremely collaboratively and took much pride in the results, which at the time were recorded in hand-made charts.    

During COVID, since their first positive case, Cuba has tackled quickly and effectively case and contact tracing followed by the 14-days WHO recommended isolation. The doctor and/or nurse visit community members daily at their home and if any present the slightest symptoms they are transferred to the hospital to be tested. In addition, a national search plan was launched, going house by house, using doctors, nurses – and students in these professions – to find out if someone in the family has symptoms. A journalist recalls someone knocking in his door and asking “Is everyone okay, someone with a cough or fever?” Cuba’s Minister of Health stated that the strategy “is not to wait for the virus to appear, but to go out and look for it.” The New York Times calls Cuba “a rare success story in Latin America for its textbook handling and containment of its coronavirus outbreak through contact tracing and isolation of potential asymptomatic carriers of COVID-19,” and its network of local family clinics closely knit within their communities stands at the core of this success.

Since late July, Cuba has been confronting an upsurge in COVID-19 cases. With single digit number of new daily cases in June, numbers have jumped to an average of 57 new daily cases during the last week. Although from an Ontario perspective this is a very low case number, the Cuban government has responded assertively to put down the latest upsurge. In Havana, restaurants, bars and pools are once again closed, public transportation suspended and access to the beach has been banned. Several other measures have been implemented and the Habana area has been isolated from the rest of the country where with few exceptions no cases have been reported in more than two months.             

What can we learn in Ontario from Cuba’s experience? There are many factors that are intrinsically different. Cuba is an island and does not have thousands of kilometers of southern border with a country suffering from an inept federal government that has given rise to the largest COVID-19 crisis in the world. While there are aspects of Cuban society we would not want to emulate, such as the struggle to democratize political institutions, their approach to community-led health delivery and focus on health promotion and disease prevention is something we should learn from. In an earlier article, we spotlighted a primary-care/home-based model to confront COVID-19 in the Balearic Islands, in Spain – another excellent example of community-lead health services.

We have characterized our experience in Ontario with the first wave of COVID-19 as a tale of two pandemics. One is the management of the spread of the disease in the general population, and its containment though physical distancing, self-isolation and hospitalization, when necessary. During the first four months of the pandemic, Ontario’s response was slow in coming and was focused mainly on the role of hospitals, while other sectors remained an afterthought. Hospitals prepared very well and were given priority in access to PPE and other equipment; although they reached intensive levels of activity during the April-May peak, they were never overwhelmed (thankfully). In contrast, all other sectors and especially primary care and homecare were on the verge of collapse, and long-term care (LTC) did collapse. Local public health units were activated with delays to carry out the vital work of intense case and contact tracing.

RNAO released in May its Enhancing Community Care for Ontarians (ECCO) 3.0 report. It was intended as a call, in the context of Ontario’s health-system transformation, to both government and health-system partners to strengthen community care and anchor the health system in primary care to better meet the needs of all residents. ECCO 3.0 calls for an integrated health system that can always effectively serve Ontarians, even when confronted with a deadly pandemic. RNAO has argued for over a decade that Ontario must recalibrate its heavy reliance on hospital care with much-needed and strengthened community care – and that the health system must be anchored in primary care tightly linked to public health. This is a vision that focuses on health promotion and disease prevention and on improving people’s health at their homes – which is where most Ontarians wish to live.

As RNAO has strongly argued, “improving people’s health at their homes” includes LTC residents for whom nursing homes are their home, as well as strengthening homecare services – another sector that is underfunded, neglected, and in pressing need of reform. There are many advantages to supporting people remain in their community rather than rely on institutionalization, when that can be avoided – whether hospitals or nursing homes. Not only is it better for individuals to be well supported in our communities – a strong community care anchored in primary care delivers a high functioning and cost-effective health system. It also addresses concerns such as “hallway healthcare” in hospitals and the large number of alternate level of care (ALC) patients. In October 2018 there were 4,635 ALC patients waiting in an acute or post-acute hospital bed. How many could have been nursed to return and remain in their homes, if we had a robust homecare sector?    

Ontario’s health-system transformation, including the launch of Ontario Health and its now existing 29 Ontario Health Teams (OHT), was a step in the right direction. Our struggles with COVID-19 suggest we need an even more integrated system of care. However, government decisions during COVID-19 went the opposite direction. For example, aligning LTC homes struggling with COVID-19 with hospitals rather than with primary care or homecare was puzzling. Why did we not benefit from a homecare sector that saw sharp decreases in care volumes due to cancelled surgeries? It would have helped nursing homes with better suited health human resources and helped homecare agencies keep their staff employed.

More recently, the Ontario government announcement of its Accelerated Build Pilot Program to build LTC homes at hospital sites and under their oversight, is equally puzzling. Why, instead, not invest in smaller nursing homes geared to persons with Alzheimer’s who require personalized environments? Why not invest in homecare so persons in need can remain active members of our communities? Centralizing our health system through hospital-led models is wrong-headed and does not advance a comprehensive health system of care. Strong community care expertise exists in Ontario – it just needs to be utilized and given the priority it finally deserves.

Real reforms require resources, but experiences in middle-income Cuba or in Spain’s Balearic Islands shows it is not simply a matter of resources – it is also a matter of vision and mindset. We should put the spotlight on community-based care and emphasize decision-making from a wellness perspective. The focus should be on health promotion and disease prevention, education, nutrition, housing and other basic necessities of life – these are resources that help people live better and healthier lives in the midst of our communities, rather than segmented out.

It is not enough to have organizational change such as implementing OHTs. We require a change in mindset, which is not going to be achieved by placing hospitals – whose primary mission is to cure illnesses – in charge of community care organizations such as homecare, or of organizations that ought to be treated as community care, such as nursing homes.

RNAO was so hopeful when OHTs came to be. We were proud to inform the Request for Proposals, we were thrilled to read the embargoed draft, we joined many of the announcements and thought “Wow, this government is really serious about recalibrating the health system towards community care.” Today, after several announcements of hospitals taking over nursing homes and seeing no real investments to strengthen primary care, homecare and LTC services (i.e., improvements in staffing), I wonder if we are back to Ontario’s same old, same old. A quote attributed to Albert Einstein says: "The definition of insanity is doing the same thing over and over again, but expecting different results."

Update on webinars

Here is the info regarding this coming Monday’s webinar:

Understanding Anti-Black Racism in the Education System: From Preschool to Graduate School

Monday, August 17, 2020 6:45 - 8:15 pm

Although people of all races are entitled to legislated protection under the Canadian Charter of Rights and Freedoms, 1982 and the Canadian Human Rights Act, 1977, Black people are not guaranteed true protection from systemic racism in all sectors (health care, business, politics, etc.), academic institutions (universities, colleges) and organizations. Black nurses are subject to racism in all of the aforementioned sectors, institutions and organizations, as racism continues to be deeply embedded in the health system and structures within Ontario.  

On June 3, 2020, RNAO released a statement to address the devastating death of George Floyd and all who have experienced anti-Black racism and violence. We stated that “we must put a spotlight on injustice, and mobilize to enact real change.” Our COVID-19 webinar series focused on the topic of Let’s Talk about Racism on June 15, 2020, as a group of passionate nurses engaged in meaningful conversations about experiences of and solutions to tackle systemic racism in Ontario and within our health system.

This event is the third of a webinar series hosted by RNAO's Black Nurses Task Force.

Topic: Understanding Anti-Black Racism in the Education System: From Preschool to Graduate School.

When: Monday August 17, 2020 6:45 - 8:15 pm EDT

Webinar objectives

• Provide a brief overview of the historical context of anti-Black racism within Ontario and Canada’s education sector
• Discuss anti-Black racism and systemic inequities within Ontario's largest district school boards—with a focus on how new findings affect black people from preschool through to graduate education
• Describe some of the impacts of systemic anti-Black racism on enrollment in 'academic vs. applied' course streams and 'college vs. university' post-secondary pathways
• Describe systemic barriers that impede opportunities for Black students to succeed in the education system
• Highlight strategies and approaches to address anti-Black racism and discrimination in nursing educational programs
• Discuss opportunities for the supportive practice of mentoring in educational systems for Black nurses

Presenters:

Keisha Jefferies, RN, PhD(C), Dalhousie University

Jacqueline Spence, Superintendent of Equity, Anti-Racism, Anti-Oppression, & Early Years, Toronto District School Board

Register for this webinar here. 

Mark your calendar for upcoming webinars in this series and stay tuned for details:

Sept. 21, 2020

Oct. 19, 2020

Nov. 16, 2020

COVID-19 Webinars: Together We Can Do It!

RNAO held weekly COVID-19 webinars every Monday evening between March 30 and early July, with decreased frequency after that. Attendance is always anywhere between 200 and 350! The COVID-19 Webinars: Together We Can Do It! are free and open to all.

The next webinar will be on September 14, 6:45-8:00 PM – details to be announced.

Mark your calendar also for upcoming webinars:

Oct. 5, 2020

Nov. 9, 2020

Dec. 14, 2020

Info on recent webinars:

• The last webinar was on August 10, focusing on nurses’ mental health and wellbeing. The global pandemic has exacerbated health and mental health concerns amongst nurses. Shortages of PPE, fear of infecting family members, isolation from family members, increased emotional and physical exhaustion, and inability to take time off – all exacerbated mental health concerns among nurses which predated the pandemic. We heard about the Healthy Professional Worker Partnership that aims to identify interventions to better support nurses’ mental health and facilitate healthy return to work. An article presenting the issues is here. The guest speakers were Abby Ayoub (University of Ottawa), Melanie Lavoie-Tremblay (McGill University) and Ivy Bourgeault (University of Ottawa). You can watch the video and see the presentations slides here.

• On July 6 we focused on Reuniting families and residents in LTC: What will it take? We heard from a panel as they discussed this critical and timely topic and heard about related updates from RNAO, including ECCO 3.0, Bill 175 and the Nursing Home Basic Care Guarantee. You can watch the video and see the presentations slides here.
• On July 1, we hosted Dr. Jennifer Kwan, a family physician and one of the organizers of #Masks4Canada. She spoke about what we need to do to have a successful re-opening of the economy, and the role that COVID-19 surveillance, good data and masking have in achieving that. You can watch it here.
• On June 22 we discussed the Impacts of COVID-19 on Indigenous Communities with three guest speakers: Ontario Regional Chief RoseAnne Archibald; Mae Katt, Nurse Practitioner with Temagami First Nation; and Marilee A. Nowgesic, CEO of the Canadian Indigenous Nurses Association. You can watch it here.

#Togetherwecandoit

MOH EOC Situational Report

As announced above, we will be posting each day the Daily Situational Reports from Ontario's MOH EOC at RNAO’s website. That way, you will be able to access the Ministry’s guidance without having to wait for my COVID-19 report. Again, the link is here and you can check it every day.

Since this report will come out once weekly, that will provide a more timely access to Ministry guidance.

For a more detailed Ontario epidemiological summary from Public Health Ontario, you can always go here.

Here is a segment from the latest Situation Report #202 for 14 August: 

Actions taken:

• The COVID-19 Provincial Testing Guidance has been updated to clarify considerations for testing of asymptomatic individuals.  The document can be found here and here.
• The COVID 19 Guidance for Summer Day Camps has been updated.

 Staying in touch         

Please continue to keep in touch and share questions, comments and challenges. Send these to me at dgrinspun@rnao.ca and copy my executive assistant, Peta-Gay (PG) Batten <pgbatten@rnao.ca>. Due to the volume of comments and questions, we are responding as fast as we can. RNAO’s Board of Directors and our entire staff want you to know: WE ARE HERE FOR YOU!

Thank you deeply to each and all of you for being there for our communities – everywhere and in all roles! Together, in solidarity, we are stronger and more resilient. These continue to be tough times for many colleagues – especially those working in the front lines in India, Brazil, Peru, Chile, Colombia, Mexico, the US, Russia, South Africa, Iran, UK  and other places that are still hit hard by evil COVID-19!

Remember, during 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: full, accurate and transparent information, calmness, determination and swift actions. 

Doris Grinspun, RN,MSN, PhD, LLD(hon), Dr(hc), FAAN, O.ONT
Chief Executive Officer, RNAO

PAST BLOG ITEMS:

7 August - School reopening: Ontario government can still do the right thing on class sizes – go here.

31 July - Preparing for the second wave of COVID-19: Discussion – go here.

31 July - Important announcement regarding the VIANurse program – go here.

31 July - Government must immediately mandate hiring to avert second tragedy in LTC – go here.

24 July - Preparing for the second wave of COVID-19: What is the plan? – go here.

17 July - RNAO launches new social media campaign #Maskathon – go here.

17 July - RNAO calls on government to reunite families in LTC homes in Ontario – go here.

10 July - Nurses’ mental health, leave of absence and return to work experiences – go here.

10 July - RNAO continues to pursue family reunification in LTC – go here.

10 July - Support Zimbabwean nurses arrested and fired for protesting deteriorating pay and working conditions during pandemic – go here.

3 July -   RNAO launches task force to tackle anti-Black racism within the nursing profession – go here.

3 July -   Rather than praise, let’s protect our nurses – go here.

3 July -   Nurses celebrated diversity during Pride month – go here.

26 June - Nursing Home Basic Care Guarantee – go here.

26 June - Masks for all – the policy imperative in Canada – go here.

18 June - Annual General Meeting – an exhilarating week! – go here.

12 June - Petition on masks for Canada – go here.

12 June - LTC: RNAO releases list of 35 reports and recommendations dating back 20 years – go here.

6 June   - Statement – RNAO stands together with our Black sisters and brothers – go here.

3 June   - Adapting harm reduction during a pandemic – go here.

29 May - Foot care nurses – go here.

29 May - Update on pandemic pay; pandemic pay in consumption and treatment sites – go here.

28 May - RNAO Calls for Immediate Action in Response to the Canadian Armed Forces’ LTC report – go here.

26 May - Update on VIANurse – go here.

26 May - Ending homelessness: Will you join us to build a COVID-19 recovery for all? – go here.

24 May - Technology as a solution: Opportunities and pitfalls of COVID contact-tracing apps – go here.

21 May - Debunking PPE myths with Dr. Jeff Powis: Which masks should health care workers wear during COVID-19? – go here.

20 May - RNAO response to announcement of an independent commission into Ontario's long-term care system – go here.

19 May - With the pandemic curve flattening, VIANurse program will focus its effort on outbreaks – go here.

14 May - Nursing Week update – go here.

14 May - Pandemic puts health system to the test: Nurses have answers for shortfalls – go here.

14 May - Disappointment for not being included in pandemic pay – go here.

13 May - RNAO saddened by the loss RN Brian Beattie to COVID-19 – go here.

13 May - End racism and prejudice – go here.

12 May – Enhancing Community Care for Ontarians (ECCO 3.0) – go here

11 May - Nurses share their successes and challenges during National Nursing Week – go here.

10 May - A story of hope, ingenuity, support and genuine care for an LTC resident – go here.

7 May    - Counting the missing deaths: Tracking the toll of the coronavirus outbreak – go here.

5 May    - Life on the front lines of the pandemic: Profile of RNAO member NP Daria Gefrerer – go here.

5 May    - Addressing differential access to virtual care due to technology inequities – go here.

3 May    - Being person-and-family-centred during COVID-19 – go here.

1 May    - Migrant agricultural workers and the COVID-19 crisis – go here.

30 April - COVID-19 pandemic in provincial institutions and correctional centres – go here.

28 April - Supporting First Nation Communities during COVID-19 – go here.

27 April - Responses to COVID-19 for persons experiencing homelessness in Toronto: An update – go here.

25 April - Lessons learned through a COVID-19 nursing home outbreak – go here.

25 April - Letter from a retired RN to Premier Ford: The problems with LTC were evident long before COVID – go here.

23 April - Working with seniors in long-term care requires specialized knowledge – go here.

22 April - Shaking the stigma: We need a proactive COVID-19 response for mental health and addiction – go here.

21 April - We Require Expanded and Accessible COVID-19 Data in Ontario – go here.

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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