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photo of Pinecrest Nursing home

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

COVID-19 Update: There are no new cases of COVID-19 in our region today. The running total for the epidemic is thus 61 cases in the KFL&A region. The SARS-CoV2 test prevalence is 1.5% for our region (meaning 1.5% of local tests are positive). Thus, the prevalence and incidence of the disease remains low in KFL&A. There are no COVID-19 patients in KGH today. Locally we did 391 COVID-19 tests yesterday and 3 were positive, with 1 of these being from Perth-Smith falls and 2 from the Peterborough area. All tests from KFL&A were negative. Flattening of the COVID-19 curve is occurring nationally and in Ontario, although there are still many new cases occurring each day, just fewer than in past weeks.

Who is dying in Canada’s COVID-19 epidemic? A sad look at our long-term care facilities.

Pinecrest Nursing Home

The SARS-CoV-2 virus did not come to Canada via nursing homes or long term care (LTC) facilities and retirement homes; but that’s where it has been wreaking the most havoc. The SARS-CoV2 virus came to Canada from Asia, through many points of entry, via travellers from abroad. However, once infected people were in Canada they (or their contacts) visited people in LTCs and this delivered a highly infectious virus to LTC facilities which are structurally ideal for viral spread and which house some of Canada’s most vulnerable of our people.

Almost half of all Canada’s COVID-19 deaths are occurring in the elderly, particularly in Canada’s network of long term care homes (LTC). In Ontario where we have had ~ 16,608 COVID-19 cases to date, 2700 in LTC residents and another 1482 in LTC workers. Of 1,121 deaths in Ontario 861 were residents of LTC facilities. Likewise, in retirement homes there were 555 cases in tenants resulting in 123 tenant deaths. The retirement homes have also seen 324 cases in their staff. Thus 5061/16,608 cases (30%) and 984/1121 deaths (88%) and are related to residents and staff in LTCs and retirement homes. This is tragic but not surprising.

Why is this happening? First people in LTC and retirement homes are older and being older is a major risk factor for COVID-19 infection and for poor outcomes. In Ontario 22.6% of all cases are in people over 80 while 44.7% of all COVID-19 infections are in people over 60 years of age. In contrast, just 2.3% of COVID-19 cases are in people under the age of 19. However, beyond age there are issues with our LTC/retirement homes that make it an (unfortunately) ideal environment for this infection to spread. 

  1. LTC/retirement residents are often in communal rooms. Multiple residents allow spread of this droplet born disease because of close proximity.
  2. Most LTC facilities are understaffed, The work is hard, underpaid and not glamourous; however it is essential and honorable. The pandemic pay initiative, which I have previously discussed, goes some way to address this issue.
  3. These facilities have limited numbers of highly trained specialized staff to ensure the optimal public health and infection prevention measures are in place. Some well-run facilities have excellent standard procedures and protocols to deal with isolation of sick residents; however, many did not.
  4. Many residents need but do not have well-documented and up to date “goals of care”, leading to unnecessary trips to hospitals.
  5. Many of these facilities are run as for profit institutions and one may wonder whether the practices and policies pre-COVID-19 were shaped by profit motives, rather than safety/quality considerations. In fairness, we (society) have not come up with a robust publicly funded system of senior care, so I concede we should not criticize the development of a for profit system in this vacuum. Moreover, some for profit facilities focus on delivery of a high quality, safe experience for residents and may meet or exceed what a public system would offer.

So while the good news is that the COVID-curve has flattened in Ontario (see Figure below).

Ontario COIVD-19 cases curve

The bad news is that this not true in our LTC facilities, as summarized in this story (click link).

graph showing long term care deaths

When this pandemic is resolved Canada will need a complete revision and upgrade of its porous system of senior care system. This particularly involves the conduct of care and staffing of retirement homes and LTC facilities. The facts speak for themselves, we have let Canada’s senior citizens down. We can and should do better.

Care for the 99%: KHSC has a preparedness plan for the anticipated and necessary return to increased service for all patients, the 99% who do not have COVID-19 disease, under the leadership of Dr. Mike Fitzpatrick, Chief of Staff. The province is close to announcing when we can ramp up. Ontario Health will likely base the decision on when/how to ramp up the system on local/regional conditions, including: local epidemiology, the status of COVID-19 in local LTC facilities and a hospital’s local supply chain. Based on these three criteria, KHSC should be ready to begin a gradual ramp up as soon as we receive the green light from Ontario Health.

alarm clock with smiley face

A reminder for people in the community re COVID-19 testing and seeking health care in our hospitals: People in the community can self-refer for assessment and possible and testing. We are still focusing on testing symptomatic people(since the test for COVID-19 is likely not as specific in asymptomatic people) or people with confirmed COVID-19 contacts. In either circumstance please self-quarantine and seek out testing at Memorial Centre in Kingston, (see instructions below). Our hospitals and clinics are safe places to receive care (in part because everyone including staff is screened prior to entry and in part because the local incidence of COVID-19 remains low). You should not delay accessing care that you or your doctor deem to be urgent.

community instructions for testing

Canadian COVID-19 epidemiology-some good news: To date we have had 53,236 cases of COVID-19 and 3184 deaths. This is a modest increase in cases from yesterday of only 221 cases and 4 deaths. This reflects the fact the epidemic has peaked in Canada and is beginning to slowly recede. (click link for daily update). This aggregate data from ministries of health data does show the ongoing impact on the country with 2884 hospitalized people including 507 in intensive care units. So, while we are heading in the right direction… it’s not over yet!

COVID-19 Canadian outbreak tracker

The graph below offers a more granular view of the data from across the country. In the top left the orange line shows flattening of the rate of case accumulation. On the top right it is evident that the number of cases/day has declined from ~1900 to 1600 cases. Quebec remains the epicentre of the epidemic with half the cases and more than half the deaths (bottom left).

graph showing cases by province

To see where Canada stands amongst nations in the COVID-19 pandemic, click here. To date there have been over 3.3 million cases and over 235,121 deaths globally. There is continuing evidence that the global incidence of COVID-19 is flattening (blue and gold graphs at bottom of Figure).

numbers showing globally COVID-19 cases and deaths

Capacity in KGH: KGH continues to have good surge capacity (below). Note that we still have plenty of ventilators and beds available.

KGH Bed Capacity

What I am grateful for this Friday: Seen here is our amazing Infections Disease physician team practicing physical distancing. They have been instrumental, through service on IPAC, incident control and clinical services, in leading our response to COVID-19 at KHSC.

photo of doctors sitting around a table each 2m apart

From left to right: Drs Jorge Martinez-Cajas, Gerald Evans , Evan Wilson, Santiago Perez Patrigeon, and Kirk Leifso (Pediatrics)

TGIF!

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