Dear RNAO members,  

Today is Sunday, what used to be a day of relaxation and fun for many that were not working – especially as spring begins. Instead, COVID-19 has turned our lives upside down, and today was another long day for you in the front-lines of care, for managers, for executives making critical decisions, for government officials, civil servants, us at RNAO and countless other – all doing intense work to fight the COVID-19 beast!

Here is your RNAO daily communication – for Sunday, March 22 – our third month of the COVID-19 outbreak in Canada – a global pandemic of major proportions. To see previous updates visit 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.

PPEs: A key area of concern is the availability of PPEs for the protection of nurses, physicians, other health workers and patients. Given the extensive community spread of COVID-19, and the evidence that persons, including health workers, became contagious before symptoms appear, one cannot assume that asymptomatic health workers are not spreading the virus. Thus, RNAO is recommending to health officials that all health workers, at this point, should be using surgical masks while at work. Given the limited stocks of masks, this should start in our view in nursing homes and other setting where patient populations are most vulnerable, and, as stocks of surgical masks increase, all health workers in all settings should be using them.

Availability of PPEs is becoming more acute each day. Many emails and phone calls I received today related to PPE issues, and in particular, dwindling stocks. One hospital administrator shared that the institution is using today 10 times the normal daily usage in non-COVID-19 times -- and we have not even entered the critical stage of the pandemic -- when the hospitals will be flooded with patients and will consume vast amounts of PPE per day. RNAO is urging government – in the strongest possible terms – to move aggressively to secure a supply chain for these products. International procurement is not a likely option at this time, as every country in the world is desperate to procure. Thus, government needs to obtain required health care supplies by immediately taking control of the domestic supply chain. Place a prohibition on the commercial sale either by internet or in stores, of a list of healthcare supplies. All privately-held stocks of defined list of supplies (i.e., drugstore chains) should immediately be handed to government through legal order. Simulation labs, dentist offices, and all other education and health organizations that have a stock of PPE should be re-purposed immediately by government. Most importantly, the federal and provincial governments should be moving at breakneck speed to mobilize technical know-how and production capacity in the private sector to procure the key items required. There is absolutely no time to lose and we should be hearing from both levels of government how they are implementing this. It is an evidence-based statement to say: Lives are on the line. At the end of this nightmare, it will be shocking to see the correlation between the availability of the required PPEs and equipment, such as ventilators, and the death rate. Bluntly put, the number of deaths will be correlated to the availability of PPE and critical equipment such as ventilators. We issued today a joint press release of RNAO and OMA, please read and RT. 

Today was the fourth day of the #TogetherWeCanDoIt campaign and the noise was even lauder to #cheer4healthworkers. My neighbours and I participated from our own porches, thus keeping social distance and yet feeling a deep sense of togetherness. Please take a few minutes every day at 7:30pm local time, continuing every evening until we defeat COVIC-19! Join in whichever way you can – our collective energy can cheer the millions of health providers, social service and other essential front-line workers in Ontario, Canada, and around the world tackling #COVID-19. At 7:30 pm local time, each evening, step out onto your porch, balcony or open a window and make some noise in honour of the heroes working on our behalf. You can bang some pots and pans, you can sing a song, you can applaud, ring your bike’s bell, and yes – you can honk. 

WHO and Global Citizen launched #TogetherAtHome, a virtual, no-contact concert series to promote physical distancing and action for global health. Chris Martin, lead singer of Coldplay, kicked it off earlier this week with a performance from his home. More Solidarity Sessions are planned to promote health, show support for people who are staying at home to protect themselves and others from COVID-19, and encourage donations to the COVID-19 Solidarity Response Fund.

As COVID-19 cases continue to increase, many countries are requesting individuals to stay at home in self-quarantine. WHO EURO has released a guide on how to stay physically active during self-quarantine. Information can be found here.

MOH EOC Situational Report #57 here for Sunday, March 22  – EOC reports that the number of confirmed cases in Canada today is 1,318 cases, and 19 deaths including five persons in Ontario. EOC reports 36 new cases that bring our province to a total of 412 cases (of which 8 are resolved cases and 5 deaths). EOC reports that in Ontario, at this time, we have 8,360 persons under investigation with lab results pending.   Ministry reminds organizations in the health system that:

• all employees who have travelled outside of Canada should self-isolate for a period of 14 days starting from their arrival in Ontario 
• health care workers should not attend work if they are sick
• if there are particular workers who are deemed critical, by all parties, to continued operations of an organization, these groups should undergo regular screening, use of appropriate PPE and active self-monitoring. 
• Ontario has issued a temporary order that would give hospitals the ability to cancel and postpone services to free-up space and valuable staff, identify staffing priorities, and develop, modify and implement redeployment plans.
• Ontario has launched a website to act as a central point for businesses and organizations who can supply emergency products and innovative solutions to support our response to Covid-19.

Coronavirus COVID-19 Global Cases by Johns Hopkins -- CSSE reports a total of 425 cases in Ontario and 1,470 total cases in Canada as of March 22, at 11:50pm.   

Public Health Ontario maintains an excellent resource site on materials on COVID-19. This is an essential resource for Ontario health providers; I encourage you to visit it.  Make sure to check the Public Health Ontario technical brief on the Updated IPAC Recommendations for Use of Personal Protective Equipment for Care of Individuals with Suspect or Confirmed COVID-19 (in English and French).

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. This is, again, a vital resource for those following the COVID-19 outbreak in Canada.

The Public Health Agency of Canada has developed two new guidance documents for health system partners. The first, regarding community-based measures to mitigate the spread in Canada, and the second on informed decision-making related to mass gatherings.

Situation Report 61 from WHO updates that worldwide there are 292,142 confirmed cases (26,069 new) and 12,784 deaths (1,600 new). There are 53,578 confirmed cases (6,557 new) in Italy, 20,610 confirmed cases (966 new) in Iran, and 24,926 confirmed cases in Spain (4,946 new). Other countries to note are Germany (with 21,463) and France (with 14,296). China has 81,498 cases (with only 82 new), and 8,897 confirmed cases in South Korea (98 new), both countries clearly managing, so far, to “flatten the curve”. The number of confirmed cases worldwide has reached almost 300,000. It took over three months to reach the first 100,000 confirmed cases, only 12 days to reach the next 100 000, and just 3 days for the third one.

You can also find up-to-date global numbers in Coronavirus COVID-19 Global Cases by Johns Hopkins CSSE. These numbers appear to be more updated than those of WHO. For example, while WHO indicates there are 15,219 cases in the United States, CSSE reports 33,760.

RNAO’s ACTIONS:

As of today, 4,560 RNs and NPs responded to the RNAO survey with availability to provide virtual clinical care or non-clinical services. We have already deployed 59 to Ottawa Public Health and a good number to other places. RNAO is in the process of working with various other areas of need and will connect with you depending on the locations required. We also understand that Telehealth will necessitate additional staff. We know that you are ready and eager to help and thank you hugely for it!   

Note to employers in Public Health Units and other call centres: If you are experiencing a staff shortage to answer phone calls following protocols or contact tracing - please let us know. Write to Daniel Lau dlau@rnao.ca and we will connect you within hours with RNs and NPs in your locality.

Note to employers in Long Term Care Homes: Starting this Monday, RNAO has responded to AdvantAge’s call to supports its 400 LTC homes by facilitating the hiring of nursing students. RNAO’s 5,000-strong nursing student members who completed year one of the BScN program can work as Personal Support Workers (PSWs) to increase the homes’ capacity to meet HR needs. If you are a Nursing Home that needs help, contact Daniel Lau dlau@rnao.ca and he will connect with nursing students in their 2nd, 3rd and 4th year, that live in the vicinity. For the nursing students, this is an opportunity to put into action their knowledge and skills, gain valuable experience as well as an income, as these will be paid positions. This is another just-in-time service RNAO and AdvantAge provide to the people of Ontario and their members, a win-win-win for all parties.  

URGENT STEPS FOR GOVERNMENT TO TAKE: RNAO’s VOICE

1. Prepare for large scale community spread. The COVID-19 data we hear every day from public health is simply the tip of a large pyramid of actual cases. The virus has likely been transmitting in the community for weeks now. In our estimate, and given our limited testing, the actual number of cases could be as high as 10 times or more the reported number we receive. There might be today thousands of persons in the community spreading COVID-19, the majority in early stages, asymptomatic or with mild symptoms. RNAO’s analysis is that we will see the impact in about two weeks. Remember that in South Korea, one individual spread to hundreds of others. The practical lesson is that we should assume the virus is now everywhere in Canada, and spreading fast.
2. Canada must continue ramping up testing, rigorous contact tracing and case isolation. We are pleased that in Ontario we are increasing significantly our testing capacity. We must continue to do so, at the same time as we enhance our capacity for contact tracing and self-isolation. RNAO still has 4,000 RNs awaiting to be utilized – hundreds could hired for contact tracing. 
3. Shut down of all non-essential movement in the streets. Today, we recommended to government to institute an immediate, full scale shut down of all non-essential movement in the streets, similar to the actions in Quebec, New Brunswick and elsewhere. This is a last resort measure to avoid a situation of overwhelmed healthcare services and many, many deaths. We should adopt the call to #StayAtHome that we hear about in many parts of the world. We can go out for a walk around the block, keeping social distancing of two meters, but other than that, nobody should be in the streets. The government, using its emergency powers, should mandate a shutdown of the province for a limited time period, defining the essential services that keep functioning. This must be enforced. Until the government makes its decision, we ask that you remain locked at home at least for the next 14 days, except for going to work if you are a nurse, physician, PSW, a grocery store worker, truck driver or another of the essential services.
4. ICU beds and ventilators. The evidence elsewhere shows that around 5% of the confirmed cases will require ventilation in an ICU or similar bed. If the equipment and specialized personnel are not available, the person likely dies. That has been the horrifying reality in Italy, which has had one of the highest death rates from COVID-19. In Hubei, China that was not the case after the first period since they managed to build massive makeshift hospitals in a few days, which requires an enormous capacity that is likely non-existing in the rest of the world. Where are we in the planning, procurement, and deployment of the units, beds, specialized personnel, and equipment required? We have heard calming messages from both levels of government, but no concrete information about the status of preparation and our capacity to sustain the enormous spike in numbers of critically-ill COVID-19 patients that will happen in the next few days. We know that there are companies ready to engage production of critical equipment; are they being engaged? Let us repeat: These are matters of life and death.  
5. Support for vulnerable populations and workers. Governments should implement urgent measures to alleviate the enormous burden placed by fighting the virus. COVID-19, and the measures required to address the emergency, have profound social equity impacts. For example, protecting Ontarians experiencing homelessness and those living in crowded shelters are issues we are actively pursuing with government officials, and we are pressing for an urgent plan. We also know that government is meeting with Indigenous leaders to discuss their preparations for COVID-19, and we are eager to hear the outcome of those discussions. While we were pleased with the initial measures announced last week  by Ontario’s Premier Doug Ford to protect workers from losing their jobs as businesses suspend operations or they have to stay home to take care of children, RNAO was also urging for much more to be done to assist low-wage earners and those in precarious employment, who may transmit disease simply because they have no option. Thus, we are pleased with the announcements made last week by the federal government, but much more needs to be done. Workers and businesses hurt by the COVID-19 pandemic may be eligible for part of the $82 billion aid package announced by Prime Minister Justin Trudeau, which includes $27 billion in direct support for those struggling to find work or care for family members. The package, now before Parliament, stands to adjust the rules on who qualifies for employment insurance (EI), and includes two emergency benefits for those who don't.
6. Massive public education and enrollment. Please become a champion for #StayAtHome and #SocialDistance, by educating your families, friends, colleagues and members of your community. RNAO and our members are heavily engaged in mainstream and social media to keep the public fully informed, engaged and enrolled into #socialdistance action. We ask that you follow us at @RNAO and @DorisGrinspun and retweet + facebook as much as you possibly can.
7. Solidarity during a difficult time. It is very important to call on citizens to organize informal networks of support, largely virtual, for people who live alone, who may be elderly, or vulnerable, or who do not have the money to buy essentials, or who are struggling through this period in so many ways. With mental health and other conditions exacerbated by isolation, call on the public to display solidarity and humanity like never before – message: #togetherwecandoit.

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. WE ARE HERE FOR YOU! You can also use the health provider hotline and website regarding questions about the outbreak, protocols, preparedness, and more. The toll free number is 1-866-212-2272, and the health provider website, updated regularly with useful resources, can be accessed here. An important reminder that the health provider website and the toll free number are for you – as a health professional – and not for members of the general public.

Ontario’s ministry’s public website on the COVID-19 exists 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. RNAO has updated its information page for the public. Please share it widely.

Let’s thank our colleagues in the front lines in Ontario, Canada and in other countries – especially Italy and Spain – 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  

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