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April 16, 2020 - Dr. Archer's Update on COVID-19 response from the DOM and Medicine Program

COVID-19 Update: The COVID-19 incidence and prevalence remain stable in Kingston and KFL&A. There are no new cases locally today. There remains only 1 COVID-19 patient in KGH and they are in ICU. Of 263 tests done recently there have been 5 new positives; but again these are from people in and around Peterborough and Lindsay and Perth-Smith Falls. There have only been 2 new cases in the KFL&A area in the past 7 days. Thus we have a much lower rate of positive tests in our region than is seen provincially or nationally. Nationally almost half a million tests have been done and ~ 6% of tests have been positive (below).

Graph Showing Daily Testing Rates in Canada

Daily testing rates for COVID-19 in Canada

I wrote yesterday about the SPARTAN point of care test for COVID-19. I want to reinforce that at test like this still awaits real-world validation. Assuming this validation goes well, this assay is mostly of benefit for areas lacking the state of the art PCR test that we have at KHSC (e.g. in more remote areas). It’s likely that point of care test distribution will be government controlled. On a local note our lab is gearing up to do 500 tests/day by month’s end and the turnaround times continue to accelerate with test results now available within 4 hours (at most times of day). This rapidity allows us to avoid lengthy isolation of people awaiting tests results. KUDOS KHSC Lab team!

Long term care facilities and a new single employer rule: All will be aware that nursing homes and long term care facilities have been hot spots for COVID-19 outbreaks. Health care workers at KHSC are being reminded of a new government policy. Effective next Wednesday health care workers must choose to work only for a single employer (i.e. one can’t work at KHSC and a long term care home). Effective next Wednesday those staff that currently work both in the hospital and a long term care facility will need to make a choice of where they will work until the epidemic is over. There is no restriction against working across the several KHSC sites (Providence Care Hospital, Hotel Dieu Hospital and KGH). Ontario Health has raised questions about redeploying staff to help in long term care facilities. Fortunately there are no outbreaks of COVID-19 in our KFL&A long term care facilities, which are carefully surveyed by our excellent public health colleagues, led by Dr. Kieran Moore. Thus there is no local shortage that needs to be filled. Moreover, we want to ensure we have staff at KGH to deal with the inevitable need to increase care for the 99 % of our patients who have diseases other than COVID-19. We don’t want to redeploy staff only to have to pull them back in short order to provide surgical, medical, diagnostic imaging and other form of care here.

Picture of a broken chain link

Disruption of the global supply chain (it’s not just PPE): We have a 2 week PPE supply at current level of activity. We are not yet introducing our re-sterilized, recycled masks and PPE into clinical practice. However, we have begun deploying recycled P-100 masks for use in dealing with chemical exposures. We can confidently assure staff and faculty that we will provide them with the PPE they need when and where they need it. However, there is still not sufficient PPE to resume elective procedures, which is a critical concern, shared by the entire organization (see my comments on the 99% below). Just as important as disruptions in the supply of PPE, there are supply chain disruptions for other key materials that we will need as we plan our eventual return to normal levels of health care provision. There is disrupted supply (and increased demand) for anesthetic agents that limits our ability to do many elective procedures. There are also supply limitations for nuclear medicine isotopes and other diagnostic imaging supplies. So while our low incidence and prevalence of COVID-19 in the KFL&A region led to a good discussion on the feasibility of loosening restraints on elective/semi-elective procedures (during the leadership call today) we realize we must have to have a stable supply chain in place to safely do this…and this is not just a limitation related to PPE supply.

Canadian COVID-19 epidemiology: early flattening of the Ontario curve?

There are currently 28,893 cases and 1048 deaths related to COVID-19 in Canada. (click link for daily update). Here are the trends in Ontario. It is becoming apparent that while the epidemic continues the curve is flattening. This can be attributed to adherence to physical distancing, rules, and closing of schools and non-essential services. While this is extremely hopeful, it is too early to declare victory or radically change policy.

graph showing early flattening of the curve slowing in Ontario

Early flattening of the curve-slowing of Ontario’s rate of rise in active cases (orange)

KHSC Town Hall Next Week: There will be a comprehensive town hall for the entire KHSC organization on Thursday April 23rd from noon-1pm. You can join on line or in person. Please stay tuned for details!

We care for the 99% (meaning patients who don’t have COVID-19): COVID-19 justifiably has grabbed our attention and we have had to radically reform our entire health care system in 2-3 months to deal with the pandemic that is at hand. That said, the usual diseases that harm or kill Canadians have not taken a vacation. We need to resume normal levels of care for these “other” conditions as early as we safely can. This graphic from Dr. Robyn Houlden, Chair of Endocrinology. (which I believe it originates from Diabetes Canada) is a graphic reminder of the consequences of delayed care, precipitated by the epidemic.

Health Footprint of Pandemic

Because access to health care for the “99%” is currently limited, one would assume that outcomes will be worse until regular care access can be resumed. (Mea culpa-I stole a phrase from Bernie Sanders that normally refers to all those who are not the most wealthy 1%).

Recently epidemiologists have begun counting certain in home or community deaths as being COVID-19 related deaths. This is certainly valid. However, it is also likely that much of the excess mortality, particularly as COVID-19 cases decline, will be the result of delayed care (waves 2 and 3 in the cartoon above). An article in The Economistrecently stated, “The best way to measure the full damage caused by such a medical crisis is to look at “excess mortality”: the gap between the total number of people who died from any cause during a given period, and the historical average for the same place and time of year.”  As you can see in the mortality data from Spain below, there is a huge increase in all-cause mortality since the epidemic struck that country. In orange one can see the major rise in COVID-19 attributable death, rising above the expected rate of death in the country (the dotted black line). However there is also a rise in mortality not due to COVID-19 (the beige section on the right above the dotted line but below the orange swath. I believe that while some of the beige peak may be undiagnosed COVID-19 disease, much of it reflects the consequence of delays in care for cancer, stroke, ischemic heart disease, diabetes and other conditions. The article is worth reading (click link).

Graph showing Deaths in Spain due to COVID-19

From: The Economist 2020: Tracking covid-19 excess deaths across countries

For our many patients, who comprise the 99%: Rest assured we have our eye on the ball and are using triage to select people with non-deferrable care needs for timely in-person care (in clinics and in hospital). Indeed, having done my face-face clinic at Hotel Dieu yesterday I can reassure you that we continue to do outpatient care of nonelective patients. People are safely receiving care for urgent conditions in all of KHSC’s units, from operating rooms and diagnostic imaging to cardiology and obstetrics and gynecology. We will be increasing the breadth of care back towards normal as the epidemiology permits and as the supply chain allows.

For those of you who need care now, a reminder that the hospital is safe! If you have an unstable of life threatening illness you should not fear coming to hospital. Indeed, you are more likely to contract COVID-19 in the community than in our hospital. For all the rest of our patients we are using triage tools including video visits, e-visits, telephone visits etc. to work with you and your family doctor and make sure your care can safely be deferred. If you dream of the days when we return to business as usual, they will come (and as the photo below shows-you are not the only dreamer)! Rest assured the staff and faculty at KHSC are anxious to resume work for the 99% as soon as possible.

photo of a crowd of people holding signs

Capacity in Kingston and beyond: KGH continues to have good surge capacity, as seen on today’s graphic indicator (below). Note that we have 55 available ventilators and 120 available beds.

graph showing KGH bed capacity

Capacity building at Providence Care hospital (PCH)

Our partners at PCH are busily preparing capacity should it be needed. Here is a photo of Founder’s Hall, courtesy of Allison Philpot, which they are in the process of outfitting with beds in preparation for a potential surge of patients due to COVID-19. They have also prepared several other smaller rooms in the hospital that look quite similar. PCH staff and administration have also assisted KGH greatly by accepting the transfer of many of our ALC patients. To our colleagues at PCH-a heartfelt thank-you!

Photo of a large make shift hospital room with many beds

Stay well!

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