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March 20, 2020 - Dr. Archer's Update on COVID-19 response from the DOM and Medicine Program

Hi all. Another day and another amazing demonstration of the great team with have at KHSC and Queen’s FHS. Here’s what’s happening…

Breaking News

I) As of 1645: Visitor restrictions and family support policy: In compliance with provincial policy we will be significantly restricting visitor access to KHSC to prevent the spread of COVID-19. We will be doing so in a way that is compassionate, nuanced and mindful of the challenges families face and the important role of family in patient recovery. Please await the policy, which will be issued later today, before acting.

News from the front line

II) Pay it Forward: There are many acts of kindness and mutual support afoot in KHSC. Not only are the nurses and interprofessional team conducting themselves with calm professionalism, they have also started a “pay it forward” initiative in which ward teams send each other edible gifts of encouragement and thanks for their mutual support.  If you have a story of staff we should celebrate send it my way!

III) Personal Protective Equipment (PPE):Protective measures for COVID-19 are the same as the droplet and contact precautions that we should already be practicing for any Influenza-like illness. An N95 mask is the required PPE only if an Aerosol Generating Medical Procedures (AGMP). PPE preparedness is a critical defense against COVID-19 transmission within the hospital. However, we need to follow guidelines for use and should not be using masks or other PPE inappropriately. If we exhaust our supplies for nonindicated applications (e.g. seeing patients who are not suspected of COVID-19 or to calm our own fears), we will compromise our capacity to handle COVID-19 cases when numbers increase. Ensure that you do not remove PPE from the hospital.  Dr. Barry Chan tells me that in Vancouver this is a problem and they are beginning to prosecute removal (theft) of PPE.

IV) Scripts for contacting patients to tell them their appointments are postponed,  proceeding as scheduled or being replaced by virtual visits: The cancer clinic has created a script to help their team reschedule patients. I have written one for my own use and shared it with Department members today. This script is for clinical administrative support workers and ensures all charts are risk stratified by the attending (me in this case). It divides patients into non-elective and elective care pathways based on my chart review. The script guides the administrative assistant in the explanation of how they will access care (in person or via a virtual clinic appointment). I am happy to share these and thank Ms Krista Knight for assistance in their creation. Dr. Appireddy’s and the KHSC team is working on the launch of Video Visits as a pilot program using the REACTS tool and will have a more robust e-visit approach for us soon!

V) Thoughts about the families of health care workers: I know many of you as health care workers are worried about bringing COVID-19 home to your family. I don’t have any science to offer you yet so my best advice is to focus on changing clothes when you return from work, careful hand hygiene and self-isolating within the home.  This will be a challenge that will last several months so moving out of your home is unlikely to be a sustainable strategy. I will refer you to this thoughtful letter in the NEJM written by a doctor who has a mother-in-law at home with chornic lung disease.

Am I part of the Cure or Part of the Disease.  https://www.nejm.org/doi/full/10.1056/NEJMp2004768.

Interesting practices from colleagues across Canada and abroad

University of Chicago has drive-through testing: I talked to my good friend Dr Will Sharp, an ER doc at University of Chicago, where I used to work. Things there are in rapid evolution, as they are here. Like South Korea, they are rapidly ramping up COVID-19 testing and evolving their practices to better protect staff. Medical students no longer on service, as of the last week (just like Queen’s). The have gone from not testing for the virus often (with most testing in the ER) to frequent testing (most of which is now outpatient). Testing rates are ~16% positive (for ED patients) and less often positive for outpatients (as would be expected). Like south Korea they have set up drive through testing to accelerate testing and minimize contact of symptomatic people with the hospital. They use an on-line tool where registered patients can sign up COVID-19 screening (if they are symptomatic). Once the online registration is approved they are scheduled for a drive through appointment and they are swabbed while in their vehicle (see Dr. Sharp’s tweet). With this program testing has increased in number and increasingly moved out the Emergency Department. Emergency doctors are wearing gowns, gloves and eye shields and N-95 masks are reserved for intubations. Urgent care is open but visitors are discouraged from attending with the patients.

drive up COVID-19 testing in Chicago

University of Minnesota: Per my colleague there, Dr. Thenappan, they have made duplicate teams for some critical services, for example they have created inpatient and an outpatient teams for management of pulmonary hypertension. They ensure these teams don’t overlap/interact.  This is intended to minimize the possibility that an entire critical team becomes simultaneously infected. I have done the same with my DOM administrative team, having half of them work from home and half work in the office, on a rotation. My understanding is the University of Minnesota has at least one patient on ECMO and they have seen severe disease in a least one previously healthy, young, adult. This will be something we will carefully watch for, because most severely ill COVID-19 patients are elderly and have co-morbidities, like hypertension and diabetes.

Clarification:  I modified this statement slightly (yellow highlight) with input from Dr. Evans. A letter in the NEJM has created some confusion re: how COVID-19 is transmitted COVID-19 is primarily spread from the upper respiratory track via large droplets. This means that spread requires proximity of ~3 feet to an infected person. This is different from infections that primarily effect the lower airway, which are spread by aerosol (small droplets suspended in air). Airborne transmission is much harder to control and requires more extensive personal protective equipment (PPE). In a recent NEJM letter van Doremalen artificially created a droplet preparation of the virus using a special rotating drum that removed the effect of gravity. Thus, we view that their finding that the virus can survive in aerosolized lab settings is not directly relevant to the patient or community setting. We continue to view COVID-19 as being a disease transferred by large droplets from infected people in close proximity. Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1 Neeltje van Doremalen et al This letter was published on March 17, 2020, at NEJM.org.

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