Dear Colleagues:  Welcome to my Monday, April 27, COVID-19 report – now in the fourth month of COVID-19 in Ontario. For the many resources RNAO offers on COVID-19, visit the COVID-19 Portal. In particular, VIANurse is your go-to page if you need to augment your nursing and personal support worker 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.

Today, we continue our concern about vulnerable populations. I begin with residents of long term care, and return once again, to persons experiencing homelessness and living in shelters.

COVID-19: A tale of two stories

Public health officials – both provincial and City of Toronto – distinguished between two different COVID-19 disease processes, during their second modeling press conference on April 20^th – the spread through community and the spread of the virus through congregate settings. They claimed, cautiously, that COVID-19 spread in the community has peaked but that spread is growing in congregate settings. The evidence of the virus’ devastating effect on long-term care and retirement homes has been laid out in these reports. With yesterday’s news that 752 lives have been lost so far in long term care facilities, they account for 78% of all COVID-related deaths in Ontario. While the health and care of residents in long term care has been the focus, the situation in shelters for the homeless population remains uncertain. RNAO has ringed the alarm for several weeks fearing a similar tale than that of LTC. Our calls, including for open and transparent reporting of data, remain unanswered.

Here is what we know.

Responses to COVID-19 for persons experiencing homelessness in Toronto: An update

In previous reports, we have cited evidence of the particular vulnerability to COVID-19 of those experiencing homelessness. The evidence from the US suggests that people experiencing homelessness will be twice as likely to be hospitalized, two to four times as likely to require critical care and two to three times likely to die from this virus. And, evidence emerged just this week that points to, on average, a twenty-five percent COVID-positive rate amongst residents in a sample of shelters in a number of US cities.  Notably and of great concern, the 66% COVID-positive rate amongst residents at a San Francisco shelter suggests that the high infection rate at Willowdale Welcome Centre (see below) may not be an outlier.

Dr. Aaron Orkin, Population Medicine Lead with Inner City Health Associates, has noted in my April 7 report that shelters are “analogous” to long term care homes “but in some ways more calamitous for population health.” In spite of this, coordinated universal testing in the shelter system has yet to be triggered by public health authorities. (In fact, the Chief Medical Officer of Health of Toronto, home to about two-thirds of the province’s homeless population, makes a point – regularly - of citing provincial jurisdiction over testing.) Although Toronto has more than 60 city-funded and city-operated shelters, the city is reporting the results of COVID testing in only 14 shelters suggesting that testing across the system remains very limited and disorganized. Only as late as April 16, the province changed its guidelines to allow mass testing of homeless shelters. Provincial protocols previously did not allow for those in shelters to be tested en masse.

Unsurprisingly, a COVID-19 outbreak has surged among Toronto’s homeless in the last 10 days with at least 135 cases, the majority of which come from one shelter that houses refugees and other persons experiencing homelessness. Now there are 88 residents, out of 200, at the Willowdale Welcome Centre alone who have tested positive for the disease. Luckily, officials say the majority of the cases at the shelter are asymptomatic or have mild symptoms of the disease. The local councillor asked why the province didn’t allow for mass testing on the site at the time after the first positive case of COVID-19 came in two weeks ago, which would have avoided the spread.

The Willowdale experience suggests that now is not the time to overturn plans to provide health care capacity for people experiencing homelessness if tragedy is to be averted. These were plans for a 400-bed COVID-positive recovery site for people experiencing homelessness supported by Médecins Sans Frontières bringing their global expertise in dealing with pandemics. Yesterday’s news that the City of Toronto has overturned the plans are hugely worrisome. At its daily press conference, the General Manager of Toronto ‘s Shelter, Support & Housing Administration (SSHA) acknowledged that 130 beds at the city’s existing 175-bed COVID-positive recovery centre were full (the City says it has a 200 bed capacity). Clearly, another outbreak like Willowdale – even a mild outbreak in another sizeable shelter – will overwhelm the existing and committed resources to care for people experiencing homelessness. Instead of the cancelled plan for an “open-air congregate setting”, the City informs it is actively working with the provincial government and healthcare partners to open a second recovery site in a hotel. We are not aware of an explanation from the City why this is a preferred model over the cancelled one, nor when will it open.

A coalition of public-interest organizations filed legal proceedings on Friday against the City of Toronto over what they're calling "deplorable" conditions in the city's shelter system and respite sites amid the COVID-19 pandemic. The groups threatened to file proceedings earlier this week if the city didn't act swiftly to enhance its physical distancing measures and procure additional shelter space. "Beds or cots are still only two feet apart, people are in bunk beds, bathrooms aren't being cleaned more," said Greg Cook, an outreach worker with Sanctuary Ministries. Cook says he'd like the city to enact an order ensuring two metres of distancing within shelters. "People's lives are at risk, people's health is at risk and we're kind of using any tool we have to make sure the city moves faster," Cook said.

In an announcement, the City of Toronto informed of other actions details of actions it has taken with partners to rapidly tailor solutions for the city's most vulnerable. As of Friday, the City says it has opened 11 new facilities and secured more than 1,200 hotel rooms. Some 770 people have been moved to hotel rooms and another 492 people to community space. Earlier, the City had opened a 200-bed recovery facility for people experiencing homelessness who have tested positive for COVID-19. This first-of-its-kind facility in Canada was done in partnership with Inner City Health Associates and other community health providers. It is also utilizing its fleet to safely transport individuals awaiting COVID-19 test results and those who test positive to isolation and recovery facilities. The City is also working with the Provincial government to ensure scaled up proactive COVID-19 testing is being conducted in the shelter system.

RNAO’s ViaNurse Program               

RNAO’s VIANurse program, launched on March 13, has already registered 284 NPs, 1,020 critical care RNs (who have experience and continued competency in the provision of critical care) as well as 7,300 RNs for virtual and clinical care. RNAO is continuously responding to requests from health organizations. So far, we have served 255 organizations, of which over 190 are nursing homes and retirement. RNAO has also offered the government to identify NPs and RNs who can help manage LTC organizations that are in crisis, and assist with urgent interventions where severe outbreaks are ongoing. For any nursing HHR needs go to RNAO’s VIANurse program

** Seeking RNs, NPs and nursing graduates ready to work in nursing homes in active outbreak

RNAO launched on Friday, April 24^th a fourth survey for RNs, NPs and nursing graduates urging them to register for work in nursing homes that are on an active outbreak. This will fasten even more the matching of nursing staff to homes in dire need. Yesterday we responded, within hours, to the staffing needs of 11 additional organizations. Please retweet the following urgent tweet to have many more RN, NP and new graduates enrolled.  

For those of you ready to work in a nursing home with an outbreak – we need you – please CLICK HERE and complete our survey ASAP. We need your response as soon as possible given the rapidly evolving situation, and the urgent need in nursing homes across the province. The government has now improved the compensation, recognizing your critical role – see Ontario’s press release here.

So far we have got 148 responses: 19 NPs, 126 RNs – ready to go to nursing homes in an active outbreak - plus, 3 RNs who can do non-clinical work. These colleagues are being deployed as we speak, including over the weekend. 

Your messages: Voices and responses

Each day we welcome new readers to this daily report: thank you deeply for the work you do always and especially 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.

RN Timea Andersen, responds to the letter from Diana Sebera we published on Saturday:

I was very glad to read such a clear, informative letter from the LTC nurse which you included here. I have always had great appreciation for the calling of nurses working in both palliative and geriatric settings. Clearly, a tremendous amount of education of both other nurses and medical personnel as well as the general public is required about the stigmas and the value our elderly and vulnerable people have to our society as well our obligations to them, whether we know them or not.

RN Andersen continues by emphasising what can happen when governments refuse to help the facilities pay all their employees on the same scale across all sectors. To see the full letter, go here.

Together we can do it

MOH EOC Situational Report #92 here for Sunday, April 26

Situation:

• 437 new cases were reported today in Ontario, bringing the cumulative total to 14,432 (this includes 8,000 resolved cases and 835 deaths).
• In Ontario, a total of 229,638 tests have been completed, with tests performed at Public Health Ontario Laboratories and non-Public Health Laboratories. There are currently 7,417 tests under investigation.
• 938 patients are currently hospitalized with COVID-19; 252 are in ICU; and 195 are in ICU on a ventilator.

EOC report #92 for April 26 informs of the following actions taken:

• The Minister of Education announced today that all publicly-funded schools will remain closed until at least May 31, 2020, as part of an effort to keep students, staff and families safe from COVID-19.

EOC report #91 for April 25 informs of the following actions taken:

• Ontario announced today that it is supporting frontline staff on the COVID-19 outbreak with pandemic pay.
• The Government of Ontario issued new emergency orders and amended some existing emergency orders to better support Ontario's long-term care homes and the deafblind community. Further information regarding these orders can be found here.
• The Screening Tool for Long-Term Care Homes and Retirement Homes has been updated and is here (English) and here (French).
• The guidance document for Primary Care Providers in a Community Setting has also been updated and is 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: 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  

RECENT RNAO POLICY CORNER ITEMS:

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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