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article from public health showing diagnosis and management of COVID-19

April 1, 2020 - Dr. Archer's Update on COVID-19 response from the DOM and Medicine Program

Team Medicine: You continue to exceed all my expectations. I am proud of all that you do. This teamwork begins with housekeeping and extends through all support services, to our nurses, managers, admins, secretaries, trainees and faculty. KUDOS!

The great mother, necessity: Necessity is the mother of invention! It is great to see problems that would have been insoluble pre-pandemic are now being rapidly resolved and bureaucratic barriers to collaboration are being eased.

  1. Improved internet for video visits: To support our REACTS video visit patient care program, Queen’s and KHSC have partnered and within 1 day have improved the internet services in Etherington Hall. Thanks to Denis Bourguignon (FHS), Anita Ng (DOM administration) Dr. Sid Srivastava (GIM faculty) who identified the problem and facilitated great work by teams from Queen’s and KHSC!
  2. COVID-19 admission and discharge order set. Likewise thanks to Dr. Srivastava for creating a COVID-19 admission and discharge order set. Thanks to Dr. Chris Smith, Dr. Mike Fitzpatrick (Chief of Staff), the IPAC team, Pharmacy, and Mr. Chris Gillies (medical affairs), for expediting this important document. It should be approved and on Entry Point by next week.
  3. Palliative care for COVID-19 patients: We have developed and approved a palliative care pathway for patients with COVID-19 that enter a palliative care track. This has been shared with the medical staff by Dr. Chris Smith. Thanks for leadership in this initiative go to Dr. Danielle Kain, Dr. Leonie Herx and the entire palliative care team.
  4. Cleanliness is next to godliness: Purell is almost as precious as gold these days. We are fortunate to have procured a supply and are distributing hand sanitizer to all residents, administrative assistants and faculty in the DOM.
photo of hand sanitizer

Knowledge is power: Click this link for a pdf of a reliable 4-page summary of COVID-19 disease suitable for healthcare workers and most lay people. I recommend this brief summary of the cause, signs, symptoms, prognosis and treatment of covid-19 from the American Thoracic Society.

American Thoracic Society COVID-19 summary

 

Working on site policy: The Department’s policy, supported by both Queen’s FHS HR and KHSC HR is that our medical secretaries are essential employees and when healthy must work on site. The DOM policy for our physicians mirrors this. While we acknowledge faculty may on some days work remotely, the default position is that we will work on site, while practicing physical distancing. This policy reflects our need to be available to provide timely service and to show moral leadership. When a person is ill they should of course stay home. Likewise we acknowledge there can be extenuating family and childcare issues which may require exceptions from attending work on site. These should be cleared with your manager (for admins) or with your Division Chair/Department Head (for MDs).

Update on case load in the SELHIN: There are 46 patients with COVID-19 in our region. There are 5 admitted COVID-19 patients at KHSC, 4 of which are on our COVID-19 ward, Connell 3. In Canada most COVID-19 cases are in Quebec, Ontario and BC. The population prevalence of COVID-19 positive tests/total tests is now ~6% in our community. The epidemic has not reached the intensity in the SELHIN that is being seen in other parts of Ontario (so far). In Canada as a whole there have been ~9000 cases and 105 deaths that are attributed to COVID-19 (see on-line graphic below). COVID-19 testing has ramped up at KHSC. We are currently running tests twice a day with same day results and performing 300 tests/day. Results are returning within hours. KUDOS to our colleagues in the KHSC Lab.

COVID-19 Canadian outbreak tracker

Therapy: Therapy for patients with COVID-19 remains largely supportive (oxygen and mechanical ventilation as necessary), as described in the review article above. KHSC and our Critical Care Division, led by Dr Dan Howes, has done great work to build substantial ventilator capacity. There are drugs that have been used “off-label” in patients with COVID-19 disease, but they are unproven. Investigational agents include: hydroxychloroquine (blocks viral entry into the endosome; in vitro data suggests some utility but data from RCTs are lacking), remdesivir (anti-viral nucleotide analog) and Lopinavir/ritonavir (anti-viral protease inhibitors; recent negative RCT). At KHSC we are hoping to use these drugs primarily through clinical trials so we can actually learn whether they are beneficial, neutral, or harmful. These trials re being coordinated through our infectious diseases division and are part of larger national studies.

KSHC bed capacity: We have ~ 200 beds available with a ventilator capacity of ~ 50 people at KHSC. We have achieved this in part by relocation of many ALC people to Bayshore and Providence Care Hospital. Their help has been extremely important in making space in KGH for the anticipated influx of patients as the epidemic progresses. Thank you to these valued partner institutions.

PPE Update: Thank you to our staff for trusting us and IPAC and recognizing the balance between supply and demand and being judicious in their use of PPE. As previously indicated our PPE policies have been updated as case prevalence increases. As the next step in escalating availability of PPE, KHSC is now injecting our pandemic reserve of PPE supplies into the pool for current use. This will bridge us until the PPE shipment, which the province has shipped to us, arrives. This will allow increased PPE usage in various areas (in addition to the Emergency Department and Urgent Care Centre). Three new areas will be using PPE more broadly soon. 

PLEASE UNDERSTAND THAT THE CHANGES IN PPE USE IN THE AREAS BELOW WILL NOT BE IMPLEMENTED TODAY BUT WILL START BY END OF DAY FRIDAY

New areas for PPE use by end of day Friday:

  1. Connell 5-labour and delivery
  2. Dialysis unit
  3. Cancer clinic

FAQ:

Aerosol generating medical procedures (AGMPs) and other PPE concerns: We have clear guidelines that identify procedures are considered aerosol generating procedures (because they require a higher level of PPE protection). This list will be reinforced in the KHSC communication today. While fear and anxiety may make one worry about many other procedures generating aerosols, I can reassure you that KHSC’s list of procedures for which N-95 masks and visors are required is well defined and based on broad expert opinion. For more on PPE use see this brief myth-busting video (starring Dr. Gerald Evans from IPAC/ID…also known as a band member in the DOM’s own rock group, ODNT-Old Docs New Tricks): VIDEO: Use and allocation of PPE with Dr. Gerald Evans

Why have we not yet broadened the use of PPE for Cardiology emergency procedures, like angioplasty for acute heart attacks (PCI for STEMI): The reason we have not intensified PPE in these areas is that these patients have been screened for COVID-19 risk, prior to entering the angiography suite. The interventional Cardiology program is downstream from where the patient enters the system (either via paramedics or the Emergency room). Consequently, the arriving patients have already been screened for COVID-19. Dr. McLellan Chair of Cardiology and PMD for Cardiac Sciences has designated one of our angio labs as being reserved for COVID-19 and suspected COVID-19 patients. If patients are screened and are low risk they go to the standard lab with standard PPE rules. If they are known to be positive or are considered suspected cases they go to the other angio lab, and this assignment is accompanied by the appropriate intensified rules for PPE use.

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