May 5, 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 thus remains 61 cases in the KFL&A region and 57 people have already recovered. The SARS-CoV2 positive test prevalence is 1.3%. Thus, the prevalence and incidence of the disease remains low in KFL&A. There are no COVID-19 patients in KGH today. Because of the absence of inpatient COVID-19 patients locally we have temporarily repurposed Connell 3 and will re-designate Kidd 10 as our COVID-19 ward. As you recall this was our initial COVID-19 ward and worked very well (it just didn’t have the capacity of Connell 3). We did 314 COVID-19 tests from Friday to Sunday. There were 11 positive tests, with 7 of these being from Perth-Smith Falls, 3 from the Peterborough-Haliburton area and 1 from Belleville. All tests from KFL&A were negative.
The epidemic varies greatly by region. COVID-19 incidence remains high in Toronto and Ottawa (see note on Toronto Western outbreak-below). However, when COVID-19 rate of infection is expressed as cases/1000 population, the highest rate of disease in Ontario is nearby, in Leeds/Grenville/Lanark. In this region rates of disease are even higher than Toronto. Second to Leeds/Grenville /Lanark is Windsor, Ontario, likely because of its adjacency to Detroit.
PPE supply continues to improve but we are still committed to reprocess PPE to ensure a solid supply chain as we look to ramp up care volumes. We have continued to be successful with decanting ALC patients to partner facilities. This leaves KHSC with excellent surge capacity should it be needed for COVID-19 cases.
When will the second wave of COVID-19 come? We are all looking forward to ramping up the hospital and opening up Canadian society. However, we must be mindful of the possibility (certainty) of a second wave of COVID-19 disease. The viruses’ reproductive number (called Ro and defined as the number of new cases generated by one infected person) has dropped from 8 to 1 in Canada between March and now. This is not because the virus has changed, it’s because of our public health interventions which have slowed its spread. In Ontario the Ro for the virus is now down to 1. This means 1 infected person leads to infection of only 1 other person. At this reproductive number we should be able to control the epidemic. Interestingly the longer we maintain physical distancing and other nonpharmaceutical interventions (school and business closings) the longer the time to the second peak of COVID-19 will be. This delay comes at some cost as with good physical distancing in wave one, the severity of peak two may be greater…since there will remain more vulnerable people in the population who were not infected in the first wave. To truly return to normal new cases and hospitalizations need to return to near zero! We are nowhere near this. So as we reopen the hospital and broader society we need to remember that physical distancing and other interventions remain important. It is estimated that if we continue to practice impeccable behaviour a second peak may not occur for 153 days. In contrast, if we stop our public health interventions completely, a second peak would likely occur within 44 days. So the “new normal” will not be the old normal; but will be better than the current state.
Lessons from Toronto Western Hospital
From the Toronto Star today: “Toronto Western Hospital have identified 19 patients and 46 staff who tested positive for the coronavirus, triggering an “urgent” directive over the weekend that caused hospital disruptions and confusion for medical residents who failed to report for duty on Monday, the Star has learned.” Toronto Western Hospital has dealt with some of the highest number of COVID-19 positive patients in the city and healthcare workers are understandably concerned about risk in the workplace and availability of PPE, in light of this outbreak. Dr. Susy Hota, UHN’s medical director of infection prevention and control pointed out that the rate of infection in Toronto health care workers (~ 4%) is less than the general incidence of COVID-19 infection in Toronto (5-7%). This means the hospital is not a hotbed of infection. Nonetheless, the Toronto Western outbreak does raise some important points. First communication with staff and trainees should be frequent and done through respected chains of communication (i.e. Departmental Zoom meetings, daily briefing notes etc.). It also reinforces our approach of having a dedicated COVID-19 ward with specific staffing to minimize the movement of patients and staff throughout the hospital. Could this happen at KHSC? Certainly and thus, despite our low local incidence of COVID-19, we need to retain our vigilant screening program and testing program, and adhere to nonpharmacological interventions and evidence-based use of PPE.
Care for the 99%: KFL&A is better positioned than the rest of the province to ramp care back up once given permission by Ontario Health. This announcement is expected to come tomorrow and “re-opening” or ramping up will likely be geographically heterogenous, as is the epidemic itself. So expect a ramp up that is customized to our regions local epidemiology, the status of COVID-19 in local LTC facilities and a hospital’s local supply chain. Once given the green light KHSC will implement its preparedness plan for the anticipated and necessary return to increased service for all patients, the 99% who do not have COVID-19 disease.
A daily 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. There will soon be increased testing of certain vulnerable populations, stay tuned. If you are symptomatic with a new cough, fever, sore throat etc. 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.
How’s the epidemic going? It depends on where you are! The COVID-19 epidemic is beginning to relent in Ontario. Although the COVID-19 curve has flattened in Ontario, with a decline in daily cases numbers (see orange bar graph below), there are at least two important caveats. First, COVID-19 remains a huge problem in long term care facilities (LTC) and second, the distribution of the disease varies markedly by region.
To date there have been 60,772 cases of COVID-19 and 3854 deaths in Canada. Once again these numbers are heavily influenced by the epidemic in Quebec and by the mortality in nursing homes across the country. (click link for daily update). Aggregate data (below) from ministries of health, show the ongoing impact of COVID-19, with 30,888 active cases and 3159 hospitalized people, although the percent in ICUs is down from over 20% to 15.6% (see below). Also note the flattening of the slope of the orange line (below). This slowing of the rate of rise of new cases/day is the flattening of the curve we have been working hard to achieve through physical distancing and closing of schools, daycares and non-essential businesses. Canada is heading in the right direction, although there are still major areas of concern and nursing homes are an epidemic within an epidemic.
The graph below shows Ontario data. These data show that the rate of new cases is falling and the rate of COVID-19 testing is increasing (15,000-17,000 tests/day). Ontario has tested 2.36% of the entire population.
The Ontario epidemic remain dire in LTC facilities as discussed yesterday (see updated table from today).
To see where Canada stands amongst nations in the COVID-19 pandemic, click here. To date there have been over 3.68 million cases and over 254,375 deaths globally. There is however continuing evidence that the global incidence of COVID-19 is flattening (blue and gold graphs at bottom of Figure).
Capacity in KGH: KGH continues to have good surge capacity (below). Note that we still have plenty of ventilators and beds available. The dashboard shows testing results are pending for 3-4 patients in our hospital.
Remaining virtually positive: We have over 400 MD signed up on the REACTS virtual video platform and have now added numerous nurses and other allied health professionals. This is allowing us to provide care and perform triage in an era of reduced clinic visits. The vast majority of faculty in the DOM are using REACTS, OTN and asynchronous e-consults to manage patients. I have copied (with modification) the following update on billing information for video visit care from a recent SEAMO memo, for readers who are physicians.
“Physicians can now submit claims for the temporary K Codes for provision of virtual care (K080A, K081A, K082A, K083A and H409A. Details regarding the new K Codes can be found in INFOBulletin 4745. It is business as usual for physicians using the original video visit tool, OTNhub. Physician claims for video visits by OTN can continue to be submitted to OHIP for payment. Visit the SEAMO eVisit page for additional information, including sample billing sheets. Your billing agent is here to help and the SEAMO Digital Health Support Team can assist with onboarding.”
To all my DOM physician and resident physician colleagues, a real thank you for building virtual care into your clinical practice!