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pocket card for physicians re COVID-19

March 31, 2020 - Dr. Archer's Update on COVID-19 response from the DOM and Medicine Program

There are 45 patients with COVID-19 in our region. To put this in perspective we had 8 cases ~ 1 week ago, so cases are increasing, as is true for Canada as a whole (see on-line graphic below). There are 5 admitted COVID-19 patients at KHSC with 19 patients with query COVID-19. Our positive test rate, based on 900 tests performed, remains at ~ 5%. Thus we are inching closer to the threshold where the community point prevalence would suggest community spread; but outside of nursing homes this is not yet the case. There have been several health care workers infected by COVID-19 and case tracking suggest the infection was acquired outside the hospital and indicates that no patients were infected. 

COVID-19 Canadian outbreak tracker

Update on Personal Protective Equipment (PPE): Our approach to the use of PPE continues to evolve; but the 3 principles upon which our policies are based remains unchanged. Throughout this epidemic we have always looked to:

  1. Ensure the safety of patients, staff and faculty.
  2. Guide policies based on the regional epidemiology of COVID-19 in the SELHIN. 
  3. Closely monitor our internal stores of PPE versus our supply (since the PPE supply chain globally is a choke point, with much more demand than supply)..

While we are guided by safety for our staff we have to balance our utilization with available supply of PPE. We estimate this supply will last 1 week at the current rates of use; however, the supply could be consumed in 1-2 days if unregulated use were to occur. This would leave us poorly prepared as we enter into this next, more intense, phase of the epidemic.

The Ontario nursing and hospital associations (ONA and OHA) have issued a joint statement last evening re: the use of PPE. Their communication relates to:

  • Precautions for interactions with suspected, presumed or confirmed COVID-19 patients, including relying on the clinical education and training that nurses receive to use their professional and clinical judgement;
  • Point-of-care risk assessments for every patient interaction to assess appropriate health and safety measures; and
  • Training on safe use of all personal protective equipment (PPE).

Our interpretation of their statement, which like our own policies, is meant to keep healthcare workers safe, is that while a practitioner can make a personal assessment of the PPE they prefer, the determination of the specific PPE provided still has to reflect local hospital policy and be based on the risk of the patient interaction and the reality of that hospital’s PPE supplies. That said, we are revising our PPE policies (in the general direction of more PPE in more locations as COVID-19 becomes more prevalent). We are also awaiting ministry clarification related to this very recent statement. We will still need to work together to conserve PPE and intend to do so by eliminating elective procedures, increasing our PPE reuse (through a re-sterilization program) and by cohorting of “query COVID-19” patients, to reduce the need for PPE to certain areas of the institution). Surgical masks have started to arrive but N-95 supply remains slow.

Good News: KHSC retains a pandemic supply of N-95 masks which would last 2-4 weeks. The deployment of this resource will be timed to deal with an anticipated surge in case numbers, which has not yet occurred.

For some staff and faculty the availability of the N-95 mask has become a defining factor in their personal feeling of being supported at work. This is a hearts and minds issue and is highly emotional for some. We are aware of this and are continuing to evolve our policies. As leaders in these fluid time there is no shame in changing policy as the disease and the supply of PPE change. Indeed, change will be our reality between now and the resolution of this epidemic. We have a moving enemy in this virus and we are all obligated to adapt to its course.

Bottom line regarding PPE policy: Our policies are changing and adapting both in response to the ONA/OHA statement but more importantly in response to the changing epidemic, balanced against a harsh reality (Ontario has a limited, but increasing, supply of PPE).

REACTS Video visits: Doctors in the Department of Medicine received activation e-mails today to create their REACTS accounts. This KHSC and SEAMO supported platform, which runs on Google Chrome, allows us to perform home video visits with patients on their personal devices. These visits are documented by dictations in the electronic health record and can be billed to OHIP. We will be piloting this tool to triage some new patients but will primarily utilize it to perform follow-up care for elective patients who cannot be seen during the epidemic. I am using REACTS tomorrow to see 2 cardiology patients and will let you know how it goes!

KHSC capacity: We continue to have sufficient capacity to accommodate increased admissions to our COVID-19 ward, Connell 3. Dr Smith and Michelle Matthews have detailed plans for additional cohorted space when/if this capacity is occupied. I want to thank my colleagues in the DOM who have volunteered as back up physicians, who will staff these additional units should they become necessary. This is a great example of the professionalism I see from our faculty members every day. To reassure those concerned by the possibility of “worst case scenarios”. The Incident Command Committee is considering all options that could be required, including off site care expansion.

A CME tool for MDs who may attend on COVID-19 services: In the case that we need to upstaff new medical units with faculty who have not done inaptient work or critical care work in some time, we will offer peer to peer support. In addition, this is an interesting on-line reference tool for practicing physicians, developed at the University of Toronto and shared with our organization by Dr Suzan Schneeweiss (click the link below).

Quick pocket guide to the ICU

It is an online resource for non-intensive care clinicians -- doctors, nurses, RTs, and others -- who may find themselves working in critical care during the pandemic. www.QuickICUTraining.com can serve as a study guide and quick reference resource for those up-skilling, renewing, or reviewing their critical care capabilities in response to COVID-19. It is meant to supplement simulation- and/or on-the-job learning and more formal training programs that your local region may be using. Thanks Dr. Schneeweiss MD, MEd, FRCPC Professor, Department of PaediatricsAssociate Dean, Continuing Professional Development Post MD Education Faculty of Medicine, University of Toronto.

Thought for the day: “One ought never to turn one’s back on a threatened danger and try to run away from it. If you do that, you will double the danger. But if you meet it promptly and without flinching, you will reduce the danger by half.” 

photo of Winston Churchill

 

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