March 26, 2020 - Dr. Archer's Update on COVID-19 response from the DOM and Medicine Program
I remain so impressed with the staff and faculty at KHSC and in the DOM/Medicine program. In less than 2 weeks the hospital has been transformed with new COVI-19 PCR assays, a new COVID-19 Ward and a complete change in patient flow and the use of PPE. We were only able to adapt so quickly because of the calm, altruistic and collegial team work of everyone, from CEOs and Division Chairs, to frontline doctors, nurses, allied health professionals, support services and our trainees. KUDOS to all of you
Update on COVID-19 cases: One new patient with COVID-19 was admitted overnight, while or other inpatient prepares for discharge. This new individual had travelled to Europe and was exposed to COVID-19 and developed symptoms after return. They were handled appropriately with correct use of PPE by our medical team. There are now 15 cases in region. Our test positivity rate remains 1-2%. There is likely community transmission in Kingston but it has not been detected by our surveillance testing. The rate of increase in new cases in Ontario (think of it as the velocity of growth of the epidemic) is slowing slightly-suggesting that the public health policy of physical distancing is flattening the curve,
PPE directives FROM province: Although PPE is now used more liberally in our Emergency Dept (because it is our community interface with acutely ill people) we are still choosing wisely to conserve PPE (see examples below). We do this on Medicine by sending smaller consultative teams to the ED (fewer to protect) and prolonging the use of face shields and masks (provided they are no contaminated). Ontario hospitals are responding to the relative shortage of PPE with moves to use existing stores responsibly until replenished by manufacturers next week. While many in the community are making homemade cotton masks, and these which may be of some value for patients, they are not predictable in terms of pore size and do not substitute for medical grade PPE.
Different PPE for handling different types of care for a patient with known or suspected COVID-19: Below is an illustration of the escalating PPE used, depending on the care provided. Please note that, at this point, none of this PPE is required for managing patients who are not known or suspected cases of COVID-19 (except in designated areas like the Emergency Dept).
Physicians who fall ill with an acute respiratory infection are required to:
Please contact an Occupational Health Nurse in one of the KHSC’s Occupational Health & Safety (OHS) departments. Please do not present in person.
Occupational Health & Safety can be reached at:
KGH site x4389 (Monday through Friday 0600-1600) or
HDH site x2265 (Monday through Friday 0600-1600).
An Occupational Health Nurse is also on call on weekends/stats from 0700-2100 and can be reached through switchboard.
Indicate your name, phone number, and where you work, and an Occupational Health Nurse will return your call and review your symptoms and any other risk factors. Where COVID-19 testing is recommended, the physician will be provided with information on where and when they can present for testing at the health care worker only testing location.
If COVID-19 testing is not recommended, the physician will they will need to remain on self-isolation for a time period as per OHS advice.
Occupational Health testing of health care workers for COVID-19: If you are a health care worker and having symptoms and are offered testing, please accept it even if you have to spend some time waiting in the HDH screening centre. We need all hands on deck and want you back at work as soon as you are healthy. The PCR assay that we use has extremely good negative predictive values (if the test is negative you are extremely unlikely to have COVID-19). OHS will tell you when to come for testing. For those called to come for testing you will be instructed to enter the testing centre via Brock St entrance. Their hours for health care workers are 0900-1300 and tests are run in the 3pm lab cycle so we get test results by 6pm. Thanks to Joanna Noonan, Director of OHS and her team, who handled 200 calls yesterday alone!
KGH Capacity and our new COVID-9 ward: We have capacity on the Medicine service and ICU for an influx of COVID-19 patients when this occur. Connell 3, our new COVID-19 ward, is ready for a soft launch today, with patients moving there from Kidd 10. Going forward, Connell 3 will be reserved for patients with a primary diagnosis of COVID19 or for whom the primary clinical question is “query COVID-19”.
Noninvasive ventilation: COVID19 patients who have high oxygen demand will be intubated and managed by our ICU colleagues. Those who are stable but need oxygen (<50% oxygen concentration) are managed on Medicine (soon to be Connell 3). There are gray areas for people with underlying lung diseases (like COPD), who do not have known COVID-9 and who would normally require BiPAP. Guidelines are forthcoming soon for the location of care and ventilatory management of these patients.
Eye on the non-COVID-19 ball: We need to be mindful of the care of patients who don’t have COVID-19. For example in clinic yesterday I saw 2 new patients with critical aortic stenosis, including one with no family doctor and an aortic valve area of 0.4cm2. (normal is 3-4 cm2). The natural history of the many diseases we treat at KHSC has not changed because of COVID-19! We are working with Incident Control Committee to ensure service is maintained for urgent and semi-urgent cases across all disciplines. There is ongoing outstanding care/service in radiology, the clinical laboratory and our many interventional and minimally invasive units for stroke, STEMI, certain surgeries, labor and delivery and other non-elective conditions. However as the epidemic continues, and becomes better understood, we will likely have to increase service to manage people with semi-urgent conditions, such as the aortic stenosis patients I mentioned.
Other causes of acute respiratory infections in the community: Unfortunately there are many other viruses afoot in Kingston at the moment that cause cough and fever and thus can mimic COVID-9. These include Influenza A and Respiratory Syncytial Virus (RSV) and the common cold (rhinovirus).
While you should not self-diagnose, here are some general traits of these pretenders:
Rhinovirus: (the common head cold)-no or little fever, no cough, nasal predominant symptoms
RSV: Mostly prolonged cough and sometimes wheezing
Influenza A: Often very sudden onset. Patient often completely and suddenly (within 2 hours develops a high fever).
COVID-19: Travel history, COVID-19 contact, fever, persistent cough and shortness of breath
I offer this mostly to remind staff that they should not be alarmed when someone coughs, has a runny nose and is off work for several days. Although they should work through OHS if they are a health care worker, most of the time the final diagnosis will not be COVID-19.
What do I tell my patients with an acute respiratory illness in the community: In general I tell them that unless you are deteriorating, you should stay home until you begin to recover. If you are not improving and have a family doctor, please call them rather than just going in for a visit. Obviously if the patient is severely ill they are advised to come to the hospital.