Hospital News May 2020 by Hospital News

Inside: From the CEO’s Desk | Evidence Matters | Ethics | Long-term care

M ay 2 020 EEdition dition May 2020

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Contents May 2020 Edition

IN THIS ISSUE:

Prioritizing PPE in and outside of hospital walls

▲ Cover story: Preparing the front lines for COVID-19

▲ New research to better diagnose COVID-19

▲ Mental health services go virtual at SickKids

COLUMNS Editor’s Note ....................4 In brief .............................6

From the CEO’s desk .....18 Long term care ..............38 Evidence matters .......... 44 Ethics .............................46

▲ Laboratory first responders

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Deploying virtual care in the battle against COVID-19

▲ Researchers use robots to accelerate COVID-19 testing

Rationing care in Canada and U.S. in the face of COVID-19 By Jennifer L. Herbst and Frank H. Netter s an American health law and ethics scholar, I have spent the last several weeks working with colleagues in U.S. hospitals, medical schools and state legislatures trying to provide guidance and assurance to frontline healthcare workers anticipating the surge in COVID-19-related patients. We’re trying to figure out the best way to allocate critical care resources like ICU beds, ventilators and resuscitation teams when there aren’t enough for everyone who needs them. The same need to prepare for the triage of scarce health resources is happening in Canada too. As a visiting Fulbright scholar to Canada, where I’ve been based in the nation’s capital for the last several months, I’ve noticed that the U.S. has more of the things that complicate these allocation decisions than Canada – more COVID-19 cases, more extremes of haves and have nots, more uninsured and underinsured people, more distrust of our health care system and of our government’s ability to provide equitable care, more legal and cultural variety amongst our states than Canada’s provinces. But both countries share similar challenges – and pitfalls – in determining who gets care when there’s not enough to go around. And the problem is that even our best evidence-based, data-driven triage protocols still reflect and exacerbate historic and systemic inequities outside the hospital.

UPCOMING DEADLINES

Triage protocols can’t solve long-standing inequities. COVID-19 triage requires us to use imperfect tools and incomplete information to directly compare patients and pick the ones most “deserving” of critical care resources. Unfortunately, our most familiar rules for picking or prioritizing people have always perpetuated and exacerbated existing power imbalances. When picking teams on the playground (and our various personal and professional circles in adulthood), most of us pick our friends, those most likely to help us win and those we feel for. Some patients are more likeable, influential and sympathetic than others. Frontline clinicians, like the rest of us, are human and prone to the same biases as the rest of us. Likeability, influence and sympathy should not guide triage decisions if we want to fairly and consistently allocate resources to those most likely to survive their illness. Similarly, our usual rules for “objectively” allocating resources don’t work fairly either. A “first come, first served” queue, where patients receive critical care resources in the order they arrive at the hospital, tends to prioritize well-insured people with better access to information, reliable private transportation and time to stand in a line over the likelihood of actually benefitting from critical care. Flipping coins and lotteries risks wasting resources, leading to more people dying. Continued on page 6

JUNE 2020 ISSUE

JULY 2020 ISSUE

EDITORIAL: May 14 ADVERTISING: Display – May 22 | Careers – May 26

EDITORIAL: June 12 ADVERTISING: Display – June 19 | Careers – June 23

Monthly Focus: Personalized Medicine/Volunteers and Fundraising/Pharmacy: Developments in the field of personalized medicine. Innovative approaches to fundraising and the role of volunteers in healthcare. An examination of safe and effective use of medications in hospitals.

Monthly Focus: Cardiovascular Care/Respirology/Diabetes/Complementary Health: Developments in the prevention and treatment of vascular disease. Advances in treatment for various respiratory disorders, including asthma and allergies. Prevention, treatment and long-term management of diabetes and other endocrine disorders. Examination of complementary treatment approaches to various illnesses.

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NEWS

New research to better diagnose COVID-19 By Carrie Stefanson

adiologists at Vancouver General Hospital (VGH), The University of British Columbia (UBC) and Vancouver Coastal Health Research Institute are leading an international study to better predict the presence of COVID-19 based on CT scans. “Everyone in BC is doing what it takes to protect our families, our Elders, our health-care workers and our communities,” says Adrian Dix, Minister of Health. “I’m proud of the work that physicians and researchers in British Columbia are leading in our global fight against COVID-19.” Radiologists, fellows, residents and UBC medical students are collecting, analyzing and labelling thousands of CT scans and in some cases chest X-rays, from COVID-19 patients around the globe, including Canada, the Middle East, South Korea, and Italy.

“WE KNOW THE LUNGS OF COVID-19 PATIENTS ARE WHITE AND HAZY, LIKE A WHITE-OUT OR BLIZZARD.”

Information gleaned from the scans will form the basis for an open source artificial intelligence (AI) model to predict the presence, severity and complications of COVID-19 on CT scans. The model will integrate clinical data to help support and supplement existing tools to improve patient care. For example, it could help physicians determine whether individuals are best treated at home or whether they may require hospitalization/ventilation. It will not replace current testing. “The model will also assist in detecting similarities and differences in variations of patterns across different www.hospitalnews.com

The lungs of a patient with COVID-19 vs clear lungs. cultural and ethnic groups, and help us understand early and late stages of patterns of disease,” says Dr. Kendall Ho, VGH emergency physician and Academic Director, UBC Cloud Innovation Centre. It could also help flag those who may ultimately develop permanent lung damage/fibrosis. “We know the lungs of COVID-19 patients are white and hazy, like a white-out or blizzard,” says Dr. Savvas Nicolaou, Director of Emergency and Trauma Radiology at VGH. “Currently, we can’t predict disease severity and its clinical impact in different patient populations. We’re confident this new tool will help us do that.” Dr. Nicolaou is leading the project with Dr. William Parker, a radiology resident at VGH/UBC. Once developed, the new AI model will be piloted at Vancouver General Hospital with an aim to embedding it in routine diagnostic procedures to improve the accuracy of COVID-19 diagnostics. “We’ve seen patients present in the emergency department with non-typical symptoms such as severe abdominal pain, stroke and acute chest pain, and upon reviewing their

CT scans for those conditions, we see the tell-tale haziness of COVID-19 in their lungs,” says Dr. Nicolaou. Funding for this project is provided by the UBC Community Health

and Wellbeing Cloud Innovation Centre (UBC CIC), powered by Amazon Web Services (AWS), as well as the AWS Diagnostic Development H Initiative (DDI). ■

Carrie Stefanson is Public Affairs Leader at Vancouver Coastal Health.

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IN BRIEF

Recovering from COVID-19:

the role of rehabilitation s we continue to learn more about treating COVID-19, the role of rehabilitation in supporting better outcomes for patients is becoming clear. Many people who are hospitalized with COVID-19, especially those with long ICU stays, will need rehabilitation to address the physical, cognitive and psychosocial effects of their illness. Rehab professionals assess patients’ overall function and work with them to establish patient-directed goals. Physiatrists, physiotherapists, occupational therapists and speech language

pathologists, along with other members of the interprofessional team, will all play a role. In hospital, rehab professionals work with patients to improve their bed and seating positioning, prevent and manage delirium, assess and maintain mobility and cognitive functioning, and enhance communication skills and strategies. In the community, providers assess all aspects of functioning and work with patients to develop rehab plans that promote their independence. Rehab is also provided to address the psychosocial needs of patients, while

Rationing care We have spent weeks identifying and weighing “clinically relevant criteria” with consistently measurable information. Criteria include the amount of oxygen getting into a patient’s bloodstream, blood pressure, eye movement, liver function, kidney function, verbal and motor responses to stimuli, and more, in an attempt to predict whether critical care, including mechanical ventilation, will eventually get someone home. Unfortunately, because we’re still learning how COVID-19 progresses and affects different patients, we don’t have good data yet on whether this information reliably predicts survival for all patients. What we do know, though, is that the inequities outside the hospital affect how well care works within the hospital. In the U.S., we’re seeing that our Indigenous, Black, brown, and rural patients are getting sicker and dying more than our urban and suburban White patients because of our historic systemic inequalities in housing, education and health care. We see this only because some of our cities and states are gathering and releasing de-

Continued from page 4

mographic data with our COVID-related hospitalization and death counts. The U.S. federal government should be doing this. Canada should do this, too, to inform and focus the policy decisions for increasing stable housing, effective education and culturally relevant health care moving forward. Unsafe and unpredictable housing makes social distancing more difficult, if not impossible, especially for larger households living in smaller spaces. Historically under-resourced schools and health care in these communities increases distrust of governments and health care systems and makes it easier for these communities to fall prey to misinformation. Distrust and misinformation often mean that these patients, especially those dependent on prescription drugs for effective management of chronic conditions like asthma, diabetes, and hypertension, will be sicker when they get to our hospitals. These systemic problems are not uniquely American. Canada has them too. And they make all of us less safe in H a pandemic. ■

Jennifer L. Herbst is a Professor of Law & Medical Sciences at the Quinnipiac University School of Law and Frank H. Netter, MD, School of Medicine and the 2019-2020 Fulbright Research Chair at the Centre for Health Law, Policy and Ethics at the University of Ottawa. 6 HOSPITAL NEWS MAY 2020

taking into account the needs of family/caregivers.

RESOURCES ON COVID-19 AND REHAB

To help hospitals and other health care providers, the Rehabilitative Care Alliance (RCA) and GTA Rehab Network have created an online collection of resources at gtarehabnetwork. ca providing rehabilitation for patients with, or recovering from, COVID-19. The resources include recent publications from China and Italy specific to COVID-19. Others are previously published studies and

resources on rehabilitation for patients following critical care/ICU admission that demonstrate the important role of rehabilitation in helping patients recover. The COVID-19 resources can be found at rehabcarealliance.ca or gtarehabnetwork.ca. The RCA and GTA Rehab Network have also established a new Rehab and COVID-19 Community of Practice (CoP) on Ontario Health’s Quorum platform (quorum.hqontario.ca) to allow health professionals to share information and resources on rehabilitative H care in the context of COVID-19. ■

Don’t stop high blood pressure medications because of COVID-19 ommonly prescribed drugs to treat high blood pressure and diabetes, called renin– angiotensin–aldosterone system (RAAS) inhibitors, should not be discontinued because of COVID-19, explains a commentary in CMAJ (Canadian Medical Association Journal).

EVIDENCE THAT RAAS INHIBITORS FACILITATE INFECTION BY SARS-COV-2 OR INCREASE THE RISK OF HARM IN PATIENTS WITH COVID-19 “Although high-quality studies are urgently needed to inform prescribing decisions for RAAS inhibitors in patients with, or those at risk of, COVID-19, guidance from international societies unanimously recommends not altering treatment at this time,” writes Dr. Kieran Quinn, Sinai Health System and University of Toronto, Toronto, with coauthors.

Cardiovascular, hypertension and kidney organizations in Europe, Canada, Australia, the United Kingdom and the United States issued recent recommendations to continue hypertensive medications during the COVID-19 pandemic. Emerging evidence suggests that people who develop COVID-19 and have hypertension or diabetes are at an increased risk of respiratory failure and death, and some have suggested that this may be related to use of RAAS inhibitors. However, older age is a strong risk factor for death from COVID-19, and many older people who have died have multiple health issues, such as diabetes and other diseases. RAAS inhibitors also have proven benefit in patients with diabetes and cardiovascular disease.“[T] he totality of current clinical and experimental evidence that RAAS inhibitors facilitate infection by SARS-CoV-2 or increase the risk of harm in patients with COVID-19 is insufficient to suggest altering current use,” the authors conclude. “Renin–angiotensin–aldosterone system inhibitors and COVID-19” was H published April 24, 2020. ■ www.hospitalnews.com

IN BRIEF

Learnings from

Hong Kong’s response to the COVID-19 pandemic ong Kong’s success at limiting the spread of COVID-19 may provide insights for other countries as its aggressive containment approach appears to have succeeded, describes an analysis article in CMAJ (Canadian Medical Association Journal). Hong Kong has one of the highest population densities in the world and shares a border with mainland China, yet between January 22 when the first case was reported and April 14, the region reported only 1010 positive cases and four deaths from COVID-19. “Hong Kong’s experience of the 2003 SARS epidemic may explain both the government and residents’ enhanced public health preparedness and willingness to respond quickly in the face of the COVID-19 threat,” writes Professor Samuel Wong, The Jockey Club School of Public Health

and Primary Care, Chinese University of Hong Kong, with coauthors. It took early, decisive action to contain the spread of the coronavirus including border control, contact tracing, mandatory quarantine and widespread closures, such as the following: • Noncontact temperature screening in early January before any cases were reported in Hong Kong • Border closures with only essential travel allowed • School closures nine days after the first reported case, followed quickly by college and university suspensions • Mandatory 14-day quarantine for anyone entering Hong Kong • Aggressive contact tracing and quarantine of close contacts of confirmed cases • Transparent communications with the public, including websites list-

ing buildings and flights in which there were positive diagnoses of COVID-19 • High level of infection-control measures by citizens, including handwashing reported by 95% of the population and mask-wearing by 99%, the latter having become a cultural norm. The authors suggest that other countries may learn from Hong Kong’s actions and apply them in local contexts. “[A]s all public health interventions have potential benefits and risks, a balanced analysis that takes local contextual factors into account is needed so that the most appropriate actions are taken,” the authors conclude. “What can countries learn from Hong Kong’s response to the COVID-19 pandemic?” was published H April 24, 2020. ■

Free online crisis training for essential workers during COVID-19 n response to added pressures on essential workers during COVID-19, the Mental Health Commission of Canada (MHCC) has developed a trio of free crisis response training programs designed to help front-line workers deal with the stress of these exceptional circumstances. “I believe in paying it forward,” explains Louise Bradley, president and CEO of the MHCC. “We’re seeing all kinds of organizations stepping into the breach to do their part, from making protective gear to building ventilators. We asked ourselves, ‘What is it that we can offer?’ and the answer was clear: mental health training.” Not only are those working in essential roles during COVID-19 at increased physical risk, they may also be experiencing mental health chal-

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lenges or be called upon to support a person experiencing a crisis. The three new online programs Caring for Yourself, Caring for Your Team, and Caring for Others are designed to help people deal with these new challenges and are based on the MHCC’s successful in-person courses: Mental Health First Aid and The Working Mind. Caring for Yourself and Caring for Your Team focus on understanding, assessing, and improving mental health, both as an individual and within group settings. Caring for Others focuses on how to confidently engage in conversations about mental health during a crisis, whether it’s with your family and friends or in your communities and workplaces. Participants will be introduced to the Mental Health Continuum Model, the “Big 4” coping strategies, and

other tools to foster mental wellness and improve resiliency. “We saw a need and were able to quickly pivot from our usual in-person, in-depth courses, and adapt our skills-based approach to this new context,” said Mike Pietrus, director of the MHCC’s Opening Minds anti-stigma initiative. “As we paused our traditional course delivery, it was quickly evident that we could harness the tremendous skills of our trainers to bring some useful, hands-on coping strategies and practical stress-management skills to a community that is doing so much to keep the country up and running and safe.” Registration for these time-limited courses is on a first-come, first-served basis. For essential workers, as defined by the government of Canada, H they are being offered at no cost. ■

Diagnosing COVID-19 not always straightforward case study of a patient with multiple symptoms compatible with COVID-19, a history of potential exposure to a positive case, and 4 negative nasopharyngeal swabs with later confirmation of COVID-19 illustrates the challenges that can occur in diagnosing this disease. The article is published in CMAJ (Canadian Medical Association Journal). Testing for COVID-19 is not always straightforward, as the sampling technique and timing within the clinical course can influence diagnostic sensitivity. A 76-year-old man who had a potential exposure to COVID-19 in a classroom, presented to hospital with a 6-day history of progressive respiratory symptoms, fatigue and an episode of fainting. Yet, an outpatient nasopharyngeal swab for COVID-19 was negative. He underwent three further nasopharyngeal swabs in hospital, which were also negative, and required invasive mechanical ventilation for worsening oxygen requirements. Bronchoscopy conducted six days after admission was positive for SARS-CoV-2 infection. The authors note that he may have acquired the disease in hospital, perhaps from asymptomatic health care workers, which highlights the need for universal precautions in patient care.”The early identification of patients with COVID-19 is crucial to starting appropriate isolation and management. Our case illustrates some diagnostic challenges for COVID-19 and the resulting implications for infection management, including the control of nosocomial [hospital] transmission,” writes Dr. Divjot Kumar, a respirology fellow with the Division of Respiratory Medicine, University of British Columbia, Vancouver, BC, with coauthors. “SARS-CoV-2 infection in a 76-year-old man with negative results for nasopharyngeal swabs and possible nosocomial transmission” H was published April 24, 2020. ■

MAY 2020 HOSPITAL NEWS 7

Thank you

to our biggest heroes from your littlest supporters. SERAYA RAJENDRA, AGE 4

JEREMY WANG, AGE 7

8 HOSPITAL NEWS MAY 2020

LUKIS HO, AGE 9

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AINSLEY CABALLES, AGE 6

ISABEL RAMOS, AGE 9

ADDISON SPARKS, AGE 3

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GABBY SINGH, AGE 5

MAY 2020 HOSPITAL NEWS 9

BENNETT SPARKS, AGE 2

ADENA WANG, AGE 6

BRIAR BRYSON, AGE 6 MONTHS

10 HOSPITAL NEWS MAY 2020

BRYAN CLARK, AGE 7

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To everyone on the front lines and behind the scenes, you have our unending gratitude.

PIPER BLERSCH, AGE 7

ISLA FREY, AGE 9

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LUNA WILLIS, AGE 8

MAY 2020 HOSPITAL NEWS 11

NEWS

Researchers join the fight against COVID-19 By Jennifer Ganton and Amelia Buchanan s hospitals and communities band together to fight COVID-19, researchers at The Ottawa Hospital are harnessing their unique expertise and resources to help. They are ramping up research on possible treatments and vaccines, while also offering lab resources and personal protective equipment to help with clinical care and diagnostic testing. Some research staff with clinical expertise are also prepared to move to the front lines and care for patients if needed. At the same time, other researchers are working from home in order to stay safe and allow The Ottawa Hospital to focus on the challenge at hand.

“Our researchers are doing everything they can to help our hospital, our community and the world in the fight against COVID-19,” said Dr. Duncan Stewart, Executive Vice-President of Research at The Ottawa Hospital and professor at the University of Ottawa. “The Ottawa community has been so supportive of research and our teams want to give back in any way they can.” Researchers at The Ottawa Hospital are exploring more than a dozen different research projects related to COVID-19, a few of which are highlighted below. Many of these projects are being done in partnership with other hospitals and universities around the world.

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Our researchers are doing everything they can to help our hospital, our community and the world in the fight against COVID-19,” says Dr. Duncan Stewart, Executive Vice-President of Research at The Ottawa Hospital.

WORKING TOWARDS A VACCINE

Researchers at The Ottawa Hospital are harnessing their expertise in making cancer-fighting viruses to develop a possible vaccine against COVID-19, in partnership with scientists and clinicians within Canada and around the world. The vaccine would contain small parts of genetic material from the COVID-19 virus, embedded into a different virus that does not cause human disease. This replicating viral vaccine would also produce its own adjuvant a substance that stimulates a stronger immune response to the vaccine and makes it work better. Once a promising vaccine is created, the team will be able to make large quantities in The Ottawa Hospital’s Biotherapeutics Manufacturing Centre. This facility is the only hospital-based lab in Canada capable of producing virus-based vaccines and therapies for clinical trials. Partners on this project at The Ottawa Hospital and the University of Ottawa include Drs. Carolina Ilkow, John Bell, Taha Azad, Stephen Boulton, Mathieu Crupi, Nikolas Martin, Joanna Poutou, Ragunath Ragaravelu. The list of partners at other institutions is still being finalized. Another technology developed at The Ottawa Hospital that could help with the development of a COVID-19

vaccine is referred to as a “viral sensitizer”. Developed, by Dr. Jean-Simon Diallo, this technology can speed up the production of viral vaccines by more than 1,000-fold in some cases. This technology is now available commercially through Virica Biotech. Finally, researchers at The Ottawa Hospital are also collaborating with Dr. Marc-André Langlois of the University of Ottawa on the development of a nasal spray vaccine and therapeutic antibodies against COVID-19.

LEARNING FROM OUR COVID-19 PATIENTS AND TESTING THERAPIES

Researchers around the world are sharing their experiences and results and working together to determine the best approaches to treat patients with COVID-19. To help with this global effort, infectious disease researchers at The Ottawa Hospital and the University of Ottawa are working locally and with networks to create a registry of COVID-19 patients. Under the leadership of Dr. Michaeline McGuinty and Dr. William Cameron, the researchers plan to look for patterns among cases and determine how well treatments are working. They will also use blood samples to study the virus and the body’s response. www.hospitalnews.com

NEWS The researchers are also exploring clinical trials of existing therapies that may be helpful in treating COVID-19.

CALMING THE IMMUNE SYSTEM IN CRITICALLY ILL PATIENTS

The immune system plays a crucial role in defending the body against COVID-19, but sometimes it can become overactivated, resulting in severe damage to the lungs (called Acute Respiratory Distress Syndrome or ARDS). In COVID-19 patients, ARDS is the major cause of severe illness and death. Previous studies have shown that mesenchymal stromal cells (MSCs) can dampen an overactive immune response and help patients with ARDS related to other kinds of infections. Very early studies from China suggest this approach might work for COVID-19 patients as well. The Ottawa Hospitalâ&#x20AC;&#x2122;s Dr. Duncan Stewart is leading a team of researchers working to launch a clinical trial of MSC therapy for COVID-19 patients with ARDS. They will build on their extensive experience in manufactur-

ing MSCs and leading the worldâ&#x20AC;&#x2122;s first clinical trial of MSCs for septic shock. This project will likely involve partners in Ontario and Europe, working in a concerted effort to find novel therapies to improve outcomes in COVID-19 patients. Partners at The Ottawa Hospital and the University of Ottawa include Drs. Dean Fergusson, Shane English, David Courtman, Bernard ThĂŠbaud and Manoj Lalu.

Researchers at The Ottawa Hospital, including Dr. Carolina Ilkow (above), are harnessing their expertise in making cancer-fighting viruses to develop a possible vaccine against COVID-19.

REPURPOSING EXISTING DRUGS AND FINDING NEW ONES

Drs. Taha Azad, Ragunath Singaravelu, Jean-Simon Diallo and John Bell of The Ottawa Hospital and the University of Ottawa have developed a novel bio-sensor that can identify small molecule drugs that block the COVID-19 virus from attaching to cells, thereby preventing infection. First, they plan to test this novel approach on a library of more than 1,000 small molecules that have been approved to treat other diseases. Then they will attempt to identify novel antivirals drugs from a library of more than 200,000 small molecules.

COMMUNITY SUPPORT ESSENTIAL

All of the COVID-19 research projects being explored at The Ottawa Hospital will make use of shared research equipment, resources and facilities that have been developed over many years, thanks to generous support from donors through The Ottawa Hospital Foundation. â&#x20AC;&#x153;Thanks to generous support from the community over the years, weâ&#x20AC;&#x2122;ve

been able to develop unique research facilities and technologies that we are now rapidly applying to the fight against COVID-19,â&#x20AC;? said Dr. Stewart. â&#x20AC;&#x153;Similarly, todayâ&#x20AC;&#x2122;s community support for research means we will be ready for tomorrowâ&#x20AC;&#x2122;s health challenges, whatever they may be.â&#x20AC;? Researchers at The Ottawa Hospital are also applying for peer-reviewed grants to directly support their H COVID-19 research projects. â&#x2013;

Jennifer Ganton and Amelia Buchanan work in research communications at The Ottawa Hospital.

THANK YOU

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MAY 2020 HOSPITAL NEWS 13

NEWS

Ornge: COVID-19 transport, planning and collaboration By James MacDonald t the best of times, coordinating and carrying out critical care patient transports by air and land across the 1 million square kilometres of Ontario involves an abundance of real-time problem solving. Identifying the right crew and vehicle capable of providing the appropriate level of care, communicating with facilities, coordinating with paramedic services to provide ground transport from the airport, and watching weather patterns are just a few of the minute-by-minute tasks required to successfully complete a critical care transport. When you add a global pandemic to the mix, the complexity of this process increases exponentially. This is particularly significant when you consider the potential for a surge of COVID-19 patients within remote northern communities. Even a relatively small number of infected patients could quickly overwhelm small medical facilities such as nursing stations. This would likely lead to a sudden demand for aeromedical transport, with multiple patients requiring timely air ambulance service to a larger centre capable of delivering the care they need. With limited air resources available, this is no small task. Such challenges have been a primary focus at Ornge, Ontario’s provider of air ambulance and critical care transport services. Aside from the day-to-day mission of providing Ontario’s patients with safe and timely access to health services, the onset of COVID-19 has resulted in a number of special projects and a considerable amount of surge planning – very little of it done in isolation. A number of system partners and allied agencies have collaborated with Ornge on innovative solutions to support the needs of communities across the province. Any surge would undoubtedly put a strain on physicians as they cope with

Photo credit: Tom Thomson

Ornge Kenora based paramedics training using a donning and doffing checklist for personal protective equipment.

MOST COVID-19 TRANSPORTS BY ORNGE TO DATE HAVE BEEN CARRIED OUT BY THE ORGANIZATION’S CRITICAL CARE LAND AMBULANCE. an influx of patients, while at the same time arranging for transports. In April, Ornge began providing additional telemedicine support for emergency or critical care patients through CritiCall Ontario. Under this arrangement, hospitals can reach out to Ornge Transport Medicine Physicians and Pediatricians through CritiCall to receive assistance in managing the patient as they await transport. This support is also available if transport is not immediately available due to weather or volume. It is not specific to COVID-19 – the service can be used for patients with general acute and critical care needs. Another significant challenge in the north involves the transport of COVID-19 tests to regional and provincial laboratories, when commercial

air carriers are decreasing services to small communities. Ornge has made a contracted aircraft available on specific weekdays and weekend days – when commercial carriers are unavailable – to transport COVID-19 tests from several northern communities to Toronto labs for processing. This allows for faster results, which is critical at this time for preventing further outbreaks. Most COVID-19 transports performed by Ornge to date have been carried out by the organization’s Critical Care Land Ambulance (CCLA) program. Recognizing the need for critical care capacity in Southern Ontario at this time, Ornge has opened two temporary CCLA bases in Hamilton and Chatham-Kent to serve the Niagara Peninsula and Southwestern Ontario respectively. This resource

provides timely transport for patients to tertiary care centres and timely critical care repatriations. In what is surely is a model of inter-agency cooperation, the Paramedic Services in each of these communities stepped forward with their support by providing facilities for ambulances and crew members. Ornge is also excited to be cooperating with Toronto Paramedic Services on a model for staffing an ambulance bus with Critical Care Paramedics to transport by land multiple intubated patients in southern Ontario. Among the many lessons learned over the course of the past few months is the importance of supporting our own staff, particularly from a mental health perspective. Even with proper Personal Protective Equipment (PPE) and training, transporting COVID-19 patients can be unsettling for front line paramedics and pilots and their families. As part of a broader mental wellness program, Ornge has established a procedure where upon completing such a transport, the crew is automatically put on an ‘operational pause’. The crew is taken temporarily off-line in order to facilitate a debrief and check-in on their well-being. A final piece involves leveraging the well-equipped and trained staff who are prepared for meeting today’s unique circumstances. The pandemic has accelerated Ornge’s plans for a Special Operations Team, one staffed with senior Critical Care Paramedics, which would be tasked with carrying out low frequency high acuity transports including those related to infectious diseases, but also Extracorporeal membrane oxygenation (ECMO), bariatric and other specialized cases. Like other healthcare and first responder organizations, Ornge is proud of our staff in responding to the challenges presented by COVID-19, and doing so with professionalism, courage H and compassion. ■

James MacDonald is Director of Communications and Public Affairs for Ornge 14 HOSPITAL NEWS MAY 2020

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Mental health services go virtual at SickKids and SickKids CCMH during COVID-19 pandemic By Jane Kitchen he mental health teams at The Hospital for Sick Children (SickKids) and SickKids Centre for Community Mental Health (CCMH) in Toronto have had a rapid advance into virtual care in response to COVID-19. SickKids TeleLink Mental Health Program, SickKids CCMH and SickKids are part of the SickKids mental health enterprise dedicated to the care and treatment of children and youth with mental health disorders. “Building on the TeleLink program’s extensive experience of delivering video-based mental health services for the past two decades, virtual care is now part of the strategic plan and includes SickKids and SickKids CCMH,” says Christina Bartha, Executive Director of the Brain and Mental Health Program, SickKids and SickKids CCMH. “The current pandemic has moved up the timeline on our planned innovations and led to some rapid, creative problem-solving.”

SICKKIDS: COMBINING IN-PERSON AND VIRTUAL CARE

At SickKids, there are three mental health skeleton crews circulating, each consisting of a psychiatrist, a nurse practitioner and other allied health professionals. The teams support the mental health inpatient unit and provide mental health services to the medical-surgical floors, and the emergency department. Other services, such as new psychiatric assessments, individual and group therapy, and connecting with families of inpatients moved to PHIPA-compliant videoconferencing within days of the emergency measures associated with COVID-19 being implemented. “In conjunction with the recent move in the Emergency Department towards more virtual consults, we’re now moving forward on developing the appropriate safety measures to ensure that a thorough psychiatric

SickKids CCMH staffers Rebecca Hsiang (on screen) and Joanne Wilson demonstrating a videoconference therapy session

OTHER SERVICES, SUCH AS NEW PSYCHIATRIC ASSESSMENTS, INDIVIDUAL AND GROUP THERAPY, AND CONNECTING WITH FAMILIES OF INPATIENTS MOVED TO PHIPA-COMPLIANT VIDEOCONFERENCING WITHIN DAYS OF THE EMERGENCY MEASURES ASSOCIATED WITH COVID-19 BEING IMPLEMENTED. assessment is conducted when children, youth and families present to the ED in crisis,” says Dr. Suneeta Monga, Associate Chief of Psychiatry, SickKids. The change in the service delivery model has created a new service as well: A research-focused clinic for children with Autism Spectrum Disorder (ASD) was converted to a preventative virtual clinic to support these families as they face a sudden change in routine, and to help prevent their children from tipping into crisis; planned development of further levels of care is about to be launched.

SICKKIDS CCMH: TRANSITION TO STAFF WORKING FROM HOME WHILE STILL CARING FOR CLIENTS

Within five days of COVID-19 being declared a global pandemic by the

World Health Organization, the two locations of SickKids CCMH transitioned to a work-from-home model to curb the spread and minimize risk to clients, families and staff. As part of the transition-in-service model, staff communicated to clients that while the treatment centres would be physically closed, they would keep appointments via telephone. Before the pandemic, only a handful of staff had ever remote-accessed in to their work desktops. The Information and Communication Technology team worked diligently to extend remote access to all staff, with training guidelines sent out to staff setting up at home within hours. The following day, an updated remote desktop server that had been in testing was rolled out ahead of schedule to provide faster access to the network.

Videoconferencing platforms were introduced within days into the workfrom-home model for staff meetings, including virtual staff Town Halls. Two weeks into the physical closure, SickKids CCMH had a PHIPA-compliant videoconferencing platform available to clinicians with which to conduct therapy sessions, thanks to technical support from their IT colleagues at SickKids. Videoconferencing has been adopted by every department at SickKids CCMH, from helping staff and trainees continue with more intensive individual or family therapy sessions to youth group therapy sessions and offering Families First workshops to parents. It has also allowed staff to remain connected through virtual wellness activities such as a pet meet n’ greet and stretch and movement sessions.

NEXT STEPS

“Virtual care will not disappear when COVID-19 is done,” says Bartha. “It won’t replace in-person interaction, but provides a supplemental level of care in-between visits, or for those who can’t come into the sites in person.” Both SickKids and SickKids CCMH are sharing their expertise and learnings through the pandemic. The Department of Psychiatry at SickKids updated the COVID-19 Learning Hub on the AboutKidsHealth website (www.aboutkidshealth.ca/COVID-19) with tips on how to help children stay healthy through a pandemic, how to talk to your child about COVID-19 and how to support children with ASD. Registered nurses and occupational therapists at SickKids CCMH have developed a document for staff providing care in residential settings during a pandemic, and the SickKids CCMH Learning Institute and SickKids CCMH will be collaborating on a series of webinars on virtual care and best practices for physicians, therapists and intensive services (launching in May; check www. H sickkidscmh.ca for details). ■

Jane Kitchen is Communications Advisor at The Hospital for Sick Children. 16 HOSPITAL NEWS MAY 2020

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COVER

Preparing the front lines

for COVID-19 By David Musyj was looking back at my first memo to our team at Windsor Regional Hospital, dated January 22, 2020. It states, “Recently there has been a Novel (new) Coronavirus first identified in Wuhan, Hubei Province, China. There are estimates of over 400 people infected worldwide and nine reported deaths. The first case was confirmed in the United States yesterday.” It goes on to provide clinical details known at the time and ends with, “Our pandemic response team will be meeting regularly as the situation evolves to ensure we are ready and provide updates on a regular basis.” Closing in on three months later, it feels like a decade has passed. Since January 22, 2020, through to today, I start off my day by sending a daily update to the team on what is now known as COVID-19 with local updates, international updates and things for the team to remember or get ready for. Ever since January 22 through to today, our team has responded with flying colours. They have applied their years of experience, education, training, drills and table-tops to be in the best position possible to address what is in front of us and our community, province and nation. Our motto from the start has been from the words of Maya Angelou: “hoping for the best, prepared for the worst, and unsurprised by anything in between.” We have not only been preparing for the possible surge of local patients in the various models and projections, but also preparing to help support the rest of the province if there is a “hot spot” elsewhere in the province

A team of Windsor Regional Hospital staff pose inside St. Clair College’s Sportsplex. The indoor athletic facility was shifted into a field hospital in mid-April to accommodate COVID-19 patients from local long-term care facilities. Staff as pictured regularly work wearing Personal Protective Equipment (PPE) given the highly contagious nature of the virus. that needs our support. By the time this article is printed, we should have a better sense of whether we have been able to individually and collectively #flattenthecurve. For our region, the impact of not flattening the curve would be dramatic. With a population in Windsor and surrounding Essex County of approximately 400,000, having 50 per

cent of the population infected with COVID-19 and even the five per cent of that number being hospitalized into critical care is staggering. As one of our team members stated, “We are not preparing for a battle. We are preparing for a war.” On an infrastructure side, from massive internal changes in order to maximize capacity, pausing scheduled surgeries, to creating

tarpaulin tented isolation rooms and converting them into negative pressure rooms, to creating a COVID-19 assessment centre in a weekend, to creating screening stations for all staff and visitors/patients when they enter, to creating a field hospital at a local community college, to addressing possible limited morgue capacity, the war preparations were well under way. Continued on page 20

David Musyj is President and CEO of Windsor Regional Hospital. 18 HOSPITAL NEWS MAY 2020

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HEALTHCARE HEROES MAKING A DIFFERENCE IN EVERY WAY POSSIBLE

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COVER

Preparing the front lines Continued from page 18 On a staffing side, to educate all of our staff on the pandemic plan, hiring recently retired staff, cross-training staff into medicine/critical care areas, hiring current nursing students to help support the team, and completion of mask fit testing for some 5000 staff members, the war preparations were under way. At the same time all this was happening, Ontario health care was undergoing a dramatic change in operational structure moving towards an Ontario Health model, with the province divided up into five regions. One would think this would be like changing a tire on Highway 401 going 100 km/ hour. However, this transition to Ontario Health could not have come at a better time. Ontario created a provincial command table made up of two representatives from each of the five new Ontario Health regions. The West region, which our hospital is now a member of, is one of the largest

EVEN THOUGH IT LOOKS LIKE WE HAVE COLLECTIVELY DONE WELL TO STEM THE TIDE OF WAR ON THE FRONT LINES WE ARE BEING HIT WITH A FLANK MANEUVER TRYING TO ATTACK OUR MOST VULNERABLE POPULATIONS IN LONG-TERM CARE ETC. geographical regions in the province reaching from Windsor to Mississauga and through the Bruce/Grey peninsula. Under the expert stewardship of West region CEO, Bruce Lauckner and Dr. Thomas Stewart, St Joseph Health System and Niagara CEO, who sit on the provincial command table, a group of three other hospital CEOs, including myself, non-hospital sector leaders and public health meet daily and share issues back with their sub-regions and vice versa. Within the former Erie St Clair LHIN sub-region, all hospitals and non-hospitals have various “tables” that meet multiple times a week

Health Care Workers and Michener Alumni on the Front Lines The Michener Institute of Education at UHN sincerely thanks health care workers for their exceptional effort during the COVID-19 pandemic. Michener alumni work across health care, from imaging to critical care to labs, CPF YGoTG RTQWF QH VJG TQNG [QWoTG RNC[KPI KP VJKU ƂIJV

to share information and consistency in the sub-regions, across the greater West region and then across the whole Province. These “tables” ensure voices on topics like operations, critical care, ER, communication, human resources, bio-ethics, infection control, supplies and lab are sharing information, are heard and are consistent. At the same time, on the non-hospital primary care, long term care/retirement homes, EMS, home care/community care, digital and mental health and addiction are in lock step. This is replicated in all five regions. The future for Ontario Health looks bright.

Even though it looks like we have collectively done well to stem the tide of the war on the front lines by stabilizing acute care admissions and

COVER Windsor Regional Hospital President and CEO David Musyj at the field hospital.

critical care admissions, we are being hit with a flank maneuver trying to attack our most vulnerable populations in long term care, retirement homes,

homeless populations, migrant workers and other congregate settings. We have to take this issue head on. We cannot afford to sit back and have our

most vulnerable become, as Governor Cuomo has stated, a “feeding frenzy” for COVID-19. Action needs to be taken.

The community support for health care workers has been breathtaking and will not be forgotten. They have rallied around a team who are “people too” and have the same anxieties and concerns of the general public. However, our health care team knows this is the time for them to stand strong for our community and lead them through this pandemic. We have cried together, laughed together, but kept our social distancing in doing so. Having been around for SARS, the difference from that era to COVID-19 in information sharing, communication, teamwork and speed of making changes is staggering. I read a funny yet truthful tweet the other day: 2020 is a unique leap year. It has 29 days in February, 300 days in March and five years in April. Let’s hope the months feel shorter as the days get longer this summer. H #togetherWEstaystrong. ■

THE YEAR OF

THE NURSE 2

COVID-19

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KNOWLEDGE COMPASSION COURAGE

MAY 2020 HOSPITAL NEWS 21

NEWS

Laboratory first responders By Roger Boyle s recently as eight weeks ago, Ontario had no established method for COVID19 testing in hospitals. Since then, the shared Microbiology Lab of Sinai Health and the University Health Network (UHN) established itself as the first Ontario hospital lab to go live with testing, and continues to lead the way expanding test capacity to meet the needs of patients and healthcare centres across the province. “They have been seamless and relentless,” says Dr. Kathryn Tinckam, Interim Medical Director, Laboratory Medicine Program, UHN, who describes the requirements for expanding lab operations as – needing the instruments, the supplies for the instruments, the people to perform testing and then the resources for analysis and reporting. “What they’ve really done, in an extraordinary way – is ramp up all of those in parallel,” says Dr. Tinckam. “All while still maintaining outstanding microbiology support and routine care for the rest of the hospital and its partners.”

ESTABLISHING TESTING

Preparation for the lab began in the last week of February, with Dr. Tony Mazzulli, Microbiologist-in-Chief, Sinai Health - UHN and Christine Bruce, Administrative Director of the Sinai Health - UHN Microbiology lab determining preferred testing platforms, navigating available supply chains, and validating tests to ensure accuracy. Within two weeks, the lab went live and operationalized a diverse range of testing platforms to ensure sustainability. “What we tried to do is look at the instrumentation we already had to give us a starting point to build on,” says Dr. Mazzulli. “We didn’t want to put all of our eggs in one basket given potential problems with accessing supplies – so

Photo credit: UHN

(Left) The shared Microbiology Lab of Sinai Health and the University Health Network continues to expand its testing capabilities and targets a nearly 11,000 test per day capacity by end of May – more than 18 times its initial go-live volumes. (Right): Medical Laboratory Technologists and Technicians work around the clock in the shared Microbiology Lab of Sinai Health and the University Health Network to ensure COVID-19 testing meets the needs of patients across the province. when we determined we had three viable testing platforms, we decided to move forward with all three.” The lab initially validated its COVID-19 tests by comparing inhouse testing to Public Health results, but then took it a step further introducing external controls to ensure results are both highly sensitive and specific, minimizing the risk of false negatives and false positives. Despite all these efforts, Dr. Mazzulli says, “If you don’t have people, you aren’t going anywhere.” Adding that, while he is largely working on making sure the tests are functional, Christine is addressing staffing, training, scheduling, and all the pieces needed to go live with 24-7 testing and increased capacity. Since launching in March with a capacity of 600 tests per day, the lab has grown to test upwards of 2,000 patients per day, and has had to hire an additional 15 staff to meet testing

demands. The lab also expects to hire another 15 staff as operations continue to increase and the lab targets a nearly 11,000 test per day capacity by the end of May. Among the new hires are former staff who have come out of retirement to offer help, as well as residents and medical students who are volunteering their time to help keep things flowing and limit interruptions that could delay analytical staff. “We realized that every time a laboratory technologist on a COVID line had to stop to answer the phone or an incoming request, it completely upheaved our workflow,” says Christine. “So we’ve taken all of those distractions off our technologists’ shoulders, so they can just focus on getting the test loaded, running and delivering accurate results, so we can maintain what have been the best turnaround times in the province.”

NAVIGATING SUPPLY CHAINS

In addition to sourcing supplies for in-lab instrumentation, the Sinai Health - UHN shared Microbiology Lab has supported the challenging task of procuring swabkits to collect patient samples for COVID-19 testing. “What we have to remember is – by the time Canada was facing community spread, much of the supply chain for swab testing kits globally had already been exhausted,” says Rebecca Repa, Executive Vice-President, Clinical Support and Performance, UHN, and one of the leads for UHN’s COVID-19 response. “So the question we had to ask the microbiology team is – what’s a substitute product? What could perform the same way in terms of making an accurate diagnosis, but still have available supply.” Continued on page 24

Roger Boyle is a Communications Specialist, UHN Laboratory Medicine Program . 22 HOSPITAL NEWS MAY 2020

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Thank you for your sacrifice during this crisis

It’s no easy task to sacriﬁce your own wellbeing to protect that of your community. At Teva Canada, we are so thankful that we can trust heroes like you to ﬁght on the frontlines of the COVID-19 crisis. And it’s our promise to stand behind you through it all.

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What is COVID-19 teaching us about our health care system? By Dr. Sandy Buchman o one could have predicted the impact and repercussions that COVID-19 would have on the world. The current pandemic is disrupting most industries or sectors, including health care. We’ve all seen how the health care system has responded. Hospitals were reconfigured to handle an expected surge in COVID-19 patients. Virtual care was introduced in the majority of doctors’ practices. Testing centres were opened across the country. As we witness the rapid mobilization of resources and models, I can’t help but ask myself, if these changes pave the way for a better or different health care in the future? Let’s look at the facts. We’ve seen more progress on virtual care in the past two months than we have in decades. Just a couple of months ago, the Virtual Care Task Force, a collaboration between the CMA, the Royal College and the College of Family Physicians, issued 19 recommendations to help expand virtual care across the country. In a nutshell, the report con-

in virtual care visits where appropriate. We need to put in place national standards for patient health information access as well as a framework to regulate the safety and quality of virtual care services. And, of course, we need to update education at medical schools and continuing education for health professionals to reflect this way of delivering care. Prior to COVID-19, we knew that our health care system was strained.

Being able to offer more care virtually can help alleviate some of these pressures going forward, but it’s only part of the equation. The pandemic has exposed a serious gap in seniors care in this country, with more than half the deaths from the virus occurring in long-term care homes. It’s time to renew the discussion about a coordinated, national seniors care strategy should look like in this country. We know that our population is aging and that more is needed to appropriately care for and protect our elderly. What this period has also demonstrated is how incredibly resilient our health care workers can be. You’re facing unheard of stress levels every day throughout this pandemic, and your efforts are not going unnoticed. Like you, I do worry about the impact of COVID-19 on the mental health of workers and how we will move forward together out of this crisis. We must put in place resources and programs to support the well-being of our health care providers, as they put themselves H at tremendous risk to care for others. ■

“Nowhere has this been better demonstrated than in the microbiology lab, which is accepting tests from centres all over the province to support vital public health measures.” To this end, Dr. Mazzulli and Christine are participating on provincial calls every morning with microbiology labs from across Ontario, discussing best practices, current volumes, supply shortages and coming together to tackle issues related to COVID-19 testing. Additionally, the microbiology lab is working closely with referring centres to report out test results, Toronto Public Health for confirmed case tracing, and Ontario’s Medical Officer of Health to provide test volumes and confirmed cases for provincial review.

The labs’ success so far in responding to COVID-19 has largely been a collaborative effort of so many throughout Sinai Health, UHN and health organizations across the province. However, laboratory professionals in particular deserve special recognition for their commitment, especially as their response coincides with National Medical Laboratory Week, celebrated the last week of April every year. “Our laboratory staff are scientists at heart,” says Rebecca. “They understand the science behind disease and are able to methodically walk us through challenges in testing to help find solutions. I just can’t say enough.” “They are the ones that truly unH derstand the nature of the beast.” ■

Dr. Sandy Buchman cluded that it wasn’t technology that was standing in the way. It wasn’t resistance from physicians. They’ve always wanted to expand access to care. And it wasn’t patients who weren’t interested. They were. So, what was in the way? The release of the Virtual Care Task Force report proved very timely as social distancing became critical to contain the spread of COVID-19. Let’s make sure we retain the uptake

Dr. Sandy Buchman is President, Canadian Medical Association.

Laboratory first responders Continued from page 22

The most-common swabs for COVID-19 testing around the world are nasopharyngeal, which are inserted about six centimeters into a patient’s nose to collect a sample. What the team ended up finding was a swab diagnostically similar to these standard kits, however lacked the flexibility to make them safe to bend through a patient’s nasal passage. Dr. Mazzulli says, “It then became a question of, can we still use them?” “So instead of collecting at the back of the nose, we started collecting samples from the top of the throat as well as both sides of the nose to try and 24 HOSPITAL NEWS MAY 2020

maximize our yield - and so far results have all been successful.” Ultimately, the labs inventive thinking led both Sinai Health and UHN to two essential shipments of swabs that arrived just prior to the U.S. restricting exports of medical supplies. Now the lab plans to go another step with this thinking, and is exploring the use of saliva – where swabs wouldn’t be a requirement, and patients would simply spit into a testing container to be sent to the lab.

COMING TOGETHER

“Just like people coming together around the world,” says Dr. Tinckam, “we are no longer practicing in our historical silos limited by institution, or limited by specialty.”

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Thank you for taking care of so many

You mean the world The world of healthcare as we know it may never be the sameâ&#x20AC;&#x201D;and the role you are playing in it is invaluable. You are tireless. You are selfless. You are brave.

NEWS

Pandemic: Time for reflection By Barbara Catt andemic! This is our reality here and now. Here and now Infection Prevention and Control Professionals are essential and necessary in healthcare and industry and asked to be leaders at the table for so many decisions. Decisions and constant questions such as what isolation precautions are required; what personnel protective equipment is needed to keep staff safe; can we reprocess our N95 respirators; and so on. Reflecting on the initial early news back in December 31st, 2019 (feels like ages ago) about a pneumonia-like illness of an unknown cause detected in Wuhan, China, my early thoughts were, “it must be a coronavirus much like the 2003 SARS virus”. On January 12th, China shared the genetic sequence of the novel coronavirus so

that countries could prepare and develop specific diagnostic kits. As more cases appeared and transmission was apparent, the World Health Organization (WHO) declared a public health emergency of international concern on January 30th, 2020 in order to support countries with weaker health systems. Who knew we would reach close to three million cases globally and we are still counting! In February, I was away in Nairobi, Kenya, working with colleagues, teaching IPAC and ensuring that they too have safe donning and doffing techniques as they were getting prepared for COVID-19 cases. Fortunately, my colleagues and I were able to make it home safely and luckily we did not receive notifications from local public health authorities that our flight was one of many reported to have a person with COVID-19 on board.

What is our new norm? Well currently, I am one of many who work from home as I know some of you are too. What does this mean? It means longer hours because we are being reactive to the multiple demands of what is needed and/or requested from teams as well as from stakeholders. However, there are many of you who have rolled up your sleeves and are working in the trenches with many of those frontline workers. This brings a new level of anxiety as you consider how it will affect your family/friends and those with whom you reside in your household. Keeping up with the science in these times can be a challenge and yet, this is becoming increasingly important with the many discussions and decisions. Every day, there are more and more scientific papers “hot off the press” and it becomes difficult to sort through what is good science and what

Barbara Catt RN BScN MEd CIC is President of Infection Prevention and Control Canada.

is not. For example some papers have a clear focus on Ebola measures which is so different than the science with this coronavirus. This is when it is important to reach out to our local scientists, research coordinators and perhaps even within our network of Infection Prevention and Control Professionals. Your frontline workers depend on you to provide your rationale and/or the science behind some of these difficult decisions. We are in this together, so if you are in need of support here are a couple of suggestions: • Connect with colleagues • Reach out to your local IPAC Chapter • Access IPAC Canada’s Coronavirus webpage • Access Public Health Agency of Canada (PHAC) Coronavirus Disease Outbreak Update Continued on page 27

NEWS

Temporary clinic to support those needing mental health services during COVID-19 By Andrea MacLean n an effort to support healthcare facilities and care providers that are addressing COVID-19, The Royal has established a temporary, urgent care mental health clinic called C-PROMPT. The C-PROMPT clinic is a temporary clinic staffed with a multidisciplinary care team that will provide a range of services including assessment, medication management and support, as well brief counselling. Care is provided by appointment via telemedicine or telephone depending upon the nature of the issue and accessibility. It’s designed to help people like Georges. Georges was diagnosed with schizophrenia 21 years ago, just shy of his 19th birthday. The first 10 years were challenging for him, and for his family. “Being a single parent with two teenagers was not easy, and finding out that my first-born was afflicted with a mental illness was an incredibly difficult reality to face,” recalls his mother, Marie-Alice. “From the beginning, the assistance and support we received by the nurses and doctors at The Royal has always been impressive.” As the coronavirus rolled in and through our community earlier this year, health care organizations like The Royal had to make some difficult decisions as it pertained to individuals like Georges. As physical distancing became increasingly critical, how would the hospital maintain services to both inpatients and community? For Georges and other people who live with mental illness, COVID-19

brings additional challenges. Many are isolated and alone. When paired with reduced access to mental health supports and services, urgent needs can quickly become emergencies. That’s where The Royal’s C-PROMPT clinic comes in.

An urgent appeal The hallways are nearly empty and inpatient units have been quiet. All patients are practicing physical distancing in their rooms and no visitors are allowed. “Just that lack of family, that lack of social interaction, it’s very difficult for our patients,” says Shelley Hale, director of The Royal’s C-PROMPT Clinic. The community can help by purchasing portable DVD players, webcams and tablets for patients to help communicate with loved ones and pass the time in isolation. For more information or to make a donation, go to theroyal.ca.

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During that first decade after his diagnosis, Georges did not accept his disease and stopped taking his medication on two separate occasions – both which resulted in hospitalization. “Even though the two relapses were difficult for our family, it was made easier by the way Georges was treated by the medical staff at The Royal with such respect and dignity,” says Marie-Alice. “Today, he needs regular injections to help curb his symptoms. Along with psychiatric therapy, medication helps him stay on the path to a stable, successful life.” “Things are going well and it’s due to the help, assistance, compassion and understanding of the out-patient medical staff at The Royal,” says Marie-Alice. “We are so grateful to the C-PROMPT clinic for ensuring the well-being of people in our community H afflicted with mental illness.” ■

Andrea MacLean is Director, Donor Marketing & Communications at The Royal.

C-PROMPT is referral-based and accepts individuals (aged 18+) from psychiatrists and Nurse Practitioners. “Primarily on a virtual platform, we are able to provide assessments by psychiatry and psychology, and social work,” says Shelley Hale, the director of the C-PROMPT clinic. “We are also providing medication consultation, brief psycho-therapy, and support to help get our community through until they can access the services they had been accessing previously.”

Time for reflection Continued from page 26 Also at this time, I want to express and commend the reaction and communication from our national leaders such as Dr. Theresa Tam, Chief Public Health Officer of Canada and Patty Hajdu the Minister of Health. They, and others provincial and territorial leaders, have shown stellar responses and did not sway from the science of COVID-19. Canadian leadership has been impressive and again responding to the science. It has been extremely important that we all take a responsi-

Located at The Royal’s main campus in Ottawa, the C-PROMPT clinic is not a walk-in or emergency service, as proper advance screening is vital in determining appropriate healthcare needs. People who require emergency mental health care should present to the nearest emergency department. The C-PROMPT clinic supports individuals like Georges and his family amid increased healthcare demands, resource reallocations, and service closures. C-PROMPT clinic services are also available to first responders, essential and health care workers in our region who need to see a mental health professional during these unprecedented times. “The Royal is here for them when they need support,” says Shelley. “Although we don’t have secured funding for this clinic, we are asking for support from the community. In the meantime, we’re just making this work.”

bility and follow the guidance and advice from what our leaders are telling us. “STAY HOME” for example to flatten our Canadian curve is working when you compare the numbers with so many other countries. And finally, great news! Canada’s income tax deadlines have been delayed to June 1st, 2020. My final words – keep up the great work! We will get through this! And WE will be a stronger as a team – The H IPAC Canada Team. ■

THANK YOU

NURSES

For demonstrating incredible resilience, dedication and expert care in the response to COVID-19

MAY 2020 HOSPITAL NEWS 27

NEWS

Deploying virtual care in the battle against COVID-19 oronto’s Michael Garron Hospital (MGH) has swiftly deployed virtual care in its fight against COVID-19. There, a team overseen by Dr. Christopher Smith joined forces with Ontario Health (OTN) to launch a program that leverages a provincial remote monitoring solution to follow patients with COVID-19 at a distance. “The goal is to ensure symptoms are stable or improving for those who do not require hospitalization or who have been discharged,” says Smith. “We want these patients to know that someone is keeping a close eye on them – something that can be immensely reassuring given how quickly this disease can potentially progress.” The team developed protocols for intake, assessment, secondary assessment, and escalation – and trained staff across both MGH and South East Toronto Family Health Team (SETFHT). COVID-19-positive patients discharged from hospital or deemed to be at risk because of underlying conditions are enrolled in the program and monitored remotely, at home. They answer questions about their symptoms and condition twice a day through an app or over the phone. At the first sign of concern, a nurse follows up by phone with the patient for further assessment and advice by phone, and can escalate to a family physician or internist consultation. “We recognize that recovering from COVID-19 is a very stressful experience,” says Smith, “and we want to help our patients be as comfortable and confident in their recovery as possible.” The Central East Local Health Integration Network (LHIN) and Lakeridge Health have launched a similar “virtual ward” for patients with probable or confirmed COVID-19 infection living in the Durham region, with support from RNs and Central East LHIN Home and Community Care Support Services. They can escalate to a virtual video or phone visit and then, if needed, connect patients with

28 HOSPITAL NEWS MAY 2020

a Lakeridge doctor for further assessment. “This approach, while driven by the conditions around COVID-19, represents the type of patient-focused approach that will serve us well as we continue to transform our health care system with digital tools beyond our current crisis, ” says Renato Discenza, Transitional Regional Lead and CEO of Ontario Health East.

VIRTUAL CARE GROWTH

Virtual care has seen incredible growth during the pandemic. Ontario Health (OTN), which operates the provincial telemedicine network and is just one of several solution providers, has seen about a 25 per cent increase in total active accounts in the last month, from just over 41,000 to about 50,000. And direct-to-patient video visits have risen from about 1,000 per day in late February to about 10,000 a day since March. “We’ve known for some time that virtual care can be a win-win for patients and care providers alike,” says

Dr. Ed Brown, CEO, Ontario Health (OTN). “But with COVID-19, everything has shifted into high gear. People are working harder and faster than ever before to leverage existing technologies to continue to provide needed care while helping to slow the rate of infection and keep Ontario safer.” Direct-to-patient video and audio visits enable primary and specialty care providers and patients to connect safely, at a distance, and relieve pressure on hospitals, walk-in clinics, and other care facilities. Virtual care solutions support providers to screen patients, assess symptoms and treatment options, and monitor progress, as well as communicate and information share with family members, caregivers, and colleagues.

ONTARIO VIRTUAL CARE CLINIC

Virtual care is also supporting nonCOVID-19 related care delivery. The new Ontario Virtual Care Clinic (OVCC) – seethedoctor.ca – was

launched swiftly as a temporary resource for those who don’t have a family doctor or who are unable to access their doctor during the COVID-19 outbreak. The OVCC is a partnership between the Ontario Medical Association, OntarioMD, and Ontario Health (OTN), with funding support from Canada Health Infoway, and technology provided by Novari Health. It is just one of many examples of how virtual care, with its ability to remove the face-toface component of care delivery, has become an increasingly critical part of the strategy to “flatten the curve” and support safer care delivery across sectors during the pandemic. The service is designed to take the primary care load off the health care system, particularly when it comes to ERs but also as a means of reducing face-to-face contact whenever possible. The OVCC connects patients 24/7, and at no charge, to an on-call doctor by video or audio for non-emergency care. All that’s needed is an OHIP number, and the access code provided on the landing page (“health”) and contact information. Once registered patients are placed in the virtual queue to meet with the next available doctor. Brown expects even more virtual care innovations in the days ahead. Special funding has been allocated to virtual care expansion in the province – and several regional projects have already been approved. “The current level of interest in virtual care is unprecedented,” says Brown, who encourages interested physicians, Ontario Health Teams and hospitals to reach out to Ontario Health (OTN) for advice and support. “If there is one silver lining in this terrible pandemic, it’s that it’s pushing health care delivery everywhere into the 21st century. With the commitment of government and the passion of health system partners across Ontario, I think the cycle of innovation is just beginning, with many opportuH nities for new ideas ahead.” ■ www.hospitalnews.com

The Hands That Help Us All Some hands help. Some heal. Others carry the entire world. Healthcare workers do it all. And because of you, during these uncertain times, the world is in very good hands. Thank you.

NEWS

Pandemic palliative care: Building capacity to manage COVID-19 By Donna Harris t’s only May, and yet 2020 is already a year for the history books. For hospitals, the past few months have required heightened responsiveness and careful planning in the face of a virtually unprecedented global pandemic. As the potentially devastating impact of COVID-19 became clear earlier this year, William Osler Health System (Osler)’s palliative care team implemented a proactive, multipronged plan to respond to the pending crisis. “We expected that as the number of people with COVID-19 increased, many of those individuals would require palliative care and we began preparing to compassionately serve the needs of COVID-19 patients, in addition to the other patients

with palliative care needs who would require care throughout the pandemic and beyond,” says Dr. Martin Chasen, Osler’s Medical Director of Palliative and Supportive Care. Dr. Amit Arya, a palliative care physician at Osler, agrees a proactive approach can ensure the needs of patients are met. Recently, Dr. Arya was the lead author of Pandemic Palliative Care: Beyond Ventilators and Saving Lives in the Canadian Medical Association Journal (CMAJ). The article details eight critical elements for providing palliative care during COVID-19, including supplies, staffing, systems and communication – all components that have been taken into consideration in Osler’s planning. “This comprehensive approach is necessary to help

Dr. Martin Chasen, Medical Director of Palliative and Supportive Care at William Osler Health System, conducts a virtual palliative care visit from his office at Brampton Civic Hospital. Virtual visits are an important part of Osler’s palliative care strategy. ensure patients continue to receive high-quality care,” says Dr. Arya.

SUPPORTING CARE IN THE COMMUNITY

While Osler’s palliative care team has always worked closely with its health care partners, collaboration took on an enhanced focus in light of the new virus. “It has never been more important to ensure that people receive the care they need in the most appropriate setting throughout their health care journey,” says Dr. Chasen. “While we certainly want people who need emergency care to access the Emergency Department (ED), we also don’t want them exposed to the possibility of a hospital-acquired infection. In many cases, unless patients are truly in need of emergency care, they are better served to receive treatment outside of the ED, in the community.” To facilitate this, Osler’s palliative care team contacted primary care and home care providers to relay the support Osler could provide, educate them about how to provide basic endof-life care themselves, and reassure them that the palliative care team is available to support them 24/7. 30 HOSPITAL NEWS MAY 2020

In addition, the team consulted with long-term care homes caring for COVID-positive residents, some of whom also require end-of-life care, and began working with long-term care staff to reduce unnecessary resident transfers to hospital. Three Osler palliative care staff have been seconded to support palliative care needs in long-term care homes virtually and are available on-call to provide in-person consults at the homes. That is in addition to visiting and treating COVID-19 patients directly in other areas of the community.

PROVIDING VIRTUAL CARE OPTIONS

Leveraging technology to provide care offers enhanced protection for patients and families, as well as health care providers who risk spreading COVID-19 further as they travel between facilities. And technology is helping Osler address another challenge: families unable to visit loved ones during their end-of-life journey. “Visiting policies have become necessarily much more restrictive at all Osler sites,” says Dr. Arya. “We recognize that these measures, although necessary, are extremely difficult for www.hospitalnews.com

NEWS the app has also been shown to prevent unnecessary hospitalizations and visits to the ED, as well as reduce distress. It allows health professionals to closely monitor the symptoms of both palliative and COVID-positive patients – and provide care for more people.

INCREASING CAPACITY TO PROVIDE MORE CARE

Dr. Amit Arya, Palliative Care physician, is a part of William Osler Health System’s Palliative Care team which has adapted how they deliver care in the face of COVID-19. many families and we are arranging virtual family conferencing whenever possible.” Patients with palliative care needs are using Osler’s award-winning RE-

LIEF app to virtually self-report their symptoms to clinical teams on a daily basis. Nurses monitor patient data in real time and intervene if symptoms become more troublesome. Use of

A teaching site for the University of Toronto and McMaster University medical students, Osler has partnered with both schools to formulate best standards of practice for delivering care during the COVID-19 crisis. When complete, the standards will be available to health care organizations around the world – a contribution with potentially global impact. To help meet the rising demand for care locally, Osler invited physicians and surgeons who specialize in other fields and are not currently practicing palliative care to participate in focused palliative care training to sup-

port the growing needs of COVID-19 patients. The goal is to increase palliative care capacity within the community by two thirds, and care for more people. “As physicians, our first duty is to save lives,” says Dr. Arya. “However, just as important is our duty to reduce suffering. Palliative care can – and must – support patients, caregivers and medical professionals in reducing suffering. It is a human right.” With so much uncertainty ahead, Osler’s palliative care team continues to work with its partners to collaborate, innovate, and provide appropriate, safe and compassionate palliative care. The team is working with the local Public Health unit to support the needs of homeless and marginalized in the community who require care. “Right now, things are changing almost daily,” notes Dr. Chasen. “It’s a new reality, but with it, we continue to adapt. We are confident we’re prepared to serve our community in the H weeks and months ahead.” ■

Donna Harris is Manager, Public Relations and Digital Media at William Osler Health System.

www.hospitalnews.com

MAY 2020 HOSPITAL NEWS 31

NEWS

Unprecedented collaboration:

Will the way we work together be forever changed for the better? By Neil Fraser t’s easy to look back at the days before COVID-19 with a sense of nostalgia. They may only have been a few months back, but they are already looking like “the good old days” compared to the health crisis unfolding now. But not everything was easier before the pandemic. If there is a silver lining in these challenging times, it’s that Canadians are now collaborating in ways that were more difficult – or even unheard of – before the COVID-19 pandemic, with a greater appreciation of the contributions of different stakeholders. One obvious example of enhanced collaboration is the use of digital technologies that enable doctors to safely connect with patients virtually and to monitor them remotely. These technologies have been available for

a while, but without doctors being reimbursed for their time, adoption, understandably, was limited before COVID-19. There are other, less obvious, examples of unprecedented collaboration underway that are worth noting.

UNPRECEDENTED PROCUREMENT

Before COVID-19, government was primarily focused on procuring products. Now, the federal government and various provincial governments have calls to action, with a focus on procuring solutions. I’ve written about the need for demand-side healthcare innovation policies before, but never would have imagined that a few months later there would be a forcing function for such drastic changes. My hope is that those seeking to improve the health of Canadians leverage the lessons learned during this crisis to fo-

cus on value-based procurement and procuring solutions. After the crisis, we will likely return to having third party procurement agencies responsible for choosing which medical technologies doctors can choose from. The opportunity for those agencies is to gain a better understanding of the clinical needs on the ground, to understand why certain products offer more value to patients and clinicians than others, and to focus on the total cost of care, rather than just focusing on price.

To all our frontline healthcare workers

UNPRECEDENTED CONVERSATIONS A hero is a real person who, in the face of danger, combats adversity through feats of ingenuity, courage, or strength. From our team to yours… Our heartfelt gratitude for your dedication, bravery and selflessness.

32 HOSPITAL NEWS MAY 2020

The government’s focus on solutions has meant people who historically had a rule about steering clear of speaking with industry, are, for the first time, having conversations about technologies, supply chain, and allocation. And they are discovering that industry players are not only keen to help but are also willing to work with each other through Medtech Canada (our industry association). Most importantly, they are discovering that we have missions and values similar those of the healthcare customers we serve

and are committed to being part of the solution to enhancing our cherished public healthcare system. Industry partners bring a unique perspective because we are forced to be lean and innovate to survive. We have experience with health systems across the country and around the world, and we know how to spread and scale new processes and innovations.

UNPRECEDENTED MANUFACTURING OF VENTILATORS

The surge in demand for ventilators in Canada and around the world spiked so quickly during the pandemic, it has been impossible for traditional ventilator manufacturers to keep up with the demand. Medtronic has been rapidly ramping up production of its ventilator portfolio, including the Puritan BennettTM (PB) 980 and PB560 models. Today, Medtronic ships more than 300 ventilators per week from Ireland to customers around the world facing the highest risks and highest needs. We expect these numbers to climb to more than 1,000 ventilators per week by the end of June. To ensure Medtronic is maximizing the production of its critical care ventilators, it is partnering in new ways with new partners. Two such partnerships include one with U.S.based SpaceX, which is leveraging its expertise in valve production to manufacture a critical component for Medtronic’s critical care ventilators, and Canada-based Celestica, which began producing subassemblies for the PB 980 in April.

UNPRECEDENTED SHARING OF IP

Before COVID-19, it was inconceivable that medical technology companies would share their intellectual property, but several open source IP projects are underway. As part of its own open source initiative, Medtronic publicly released the design specifications for its PB560 www.hospitalnews.com

NEWS

Keeping healthcare workers safe during COVID-19 s the cases continue to climb, COVID-19 has greatly impacted hospitals and healthcare providers across Canada as they join in the effotrt to minimize the spread of the pandemic while keeping their organizations operational. People caring for individuals with COVID-19 are at the greatest risk for contracting the disease, such as health care workers and others who work close to their clients or patients. However, all workplaces need to adopt good hygiene practices and practice physical distancing in order to help keep staff safe and reduce the potential for infection. Have a policy in place that outlines the requirements to follow when staff may be sick, or when they are absent because they are caring for others. This policy should indicate how the individual will notify the workplace of their situation, and how sick leave time will be managed. Let workers know they can and should stay home if they are not feeling well,

or if they have returned from international travel where they may have been exposed. Workplaces must plan for these absences and for changes in how they do their work. Provide cross-training for coverage of job duties, and make sure that the staff are comfortable performing these added job tasks and responsibilities. Employers should also stay up to date on the latest situation by monitoring public health agency websites and keep everyone informed of any changes. Instructions from provincial and federal government officials might require flexibility and quick adjustments to your workplace policy. In addition to having a policy in place, having an infection control plan that includes guidance for employees is also a good practice. For example, in emergency and patient intake settings, hospitals should: • increase ventilation rates and fresh air return where possible. • only allow essential visitors into the hospital and screen all visitors before they enter.

• install physical barriers such as clear plastic sneeze guards, glass or plastic windows, and curtains between patients. • post signs to remind patients to alert a healthcare worker immediately if they experience any symptoms. • consider a separate area or entrance for those needing a respiratory virus evaluation. • provide tissues and alcohol-based hand sanitizer at entrances. • be aware of cross-contamination through staff, equipment (stretchers, wheelchairs, stethoscopes, blood pressure cuffs), patient belongings, patient records, linens, clothes, and surfaces such as counters, chairs, handles, and doorknobs. • clean shared equipment, phones, tablets, etc. with alcohol or disinfectant wipes. • make sure workers are trained to work safely before replacing the duties of others. Workers should wear required personal protective equipment and wash their hands frequently, including at the

start of a shift, before eating or drinking, after touching shared items, after using the washroom, and at the end of each shift, remembering to remove any jewelry before doing so. They should also avoid touching their face. If a worker has been suspected or identified with an infection, they should immediately self-isolate and their health provider or local public health authority should be contacted for next steps. When it comes to the spread of any infection or virus, including COVID-19, maintaining defensive hygiene habits is key to keeping everyone healthy and safe. The Canadian Centre for Occupational Health and Safety (CCOHS) promotes the total well-being – physical, psychosocial, and mental health – of workers in Canada by providing information, advice, education, and management systems and solutions that support H the prevention of injury and illness. ■ This article was submitted by The Canadian Centre for Occupational Health and Safety (CCOHS).

collaboration Continued from page 32

on March 30 and since then it has received more than 100,000 registrations for the design specifications available at Medtronic.com/openventilator. By the end of April, progress has already been made by three largescale manufacturers including Canada-based Baylis Medical, which is working with Ventilators for Canadians. Taiwan-based Foxconn Technology Group (which manufactures parts for Apple) will be making a version of the PB560 in Wisconsin, and VinGroup Joint Stock Co. of Vietnam will also be leveraging the design files.

UNPRECEDENTED TRAINING

The rise in demand for ventilators has had a significant impact on the need for training among those less familiar with their use. To help address

this need, ventilator manufacturers have formed the Ventilator Training Alliance. The alliance has partnered with Allego to create a mobile app that frontline medical providers can use to access a centralized repository of ventilator training resources. What is not unprecedented is the commitment of healthcare workers and other essential workers who are tackling this pandemic and putting the needs of patients first. What is not unprecedented is Medtronic’s continued resolve to work with the health system to alleviate pain, restore health, and extend life, as outlined in our Mission. I sincerely hope we can continue to collaborate in new ways after the pandemic to further transform healthcare and help improve the health of CanaH dians, together. ■

Neil Fraser is president of Medtronic Canada and co-chair of AdvaMed’s Medtech Conference, coming to Canada for the first time Octo 5-7, 2020. He is co-author of the paper Imperative for Healthcare: To Lead with Outcomes & Value published in Longwoods.com. www.hospitalnews.com

OUR DEEPEST

GRATITUDE TO THOSE ON THE FRONT LINES Protecting the patient, the caregiver and the healthcare environment.

www.scjp.com

MAY 2020 HOSPITAL NEWS 33

NEWS

Supporting mental health of front-line health professionals By Arthur C. Evans Jr very night, thousands of New Yorkers step out on their balconies and break into a round of applause as the city’s nurses, doctors and other healthcare professionals head home from work. This new tradition underscores the fact that New Yorkers and many around the world understand that healthcare professionals are putting their own health and that of their family members at risk to help us survive COVID-19. It is also recognition that in many cases, these professionals are suffering through a private agony as they juggle scarce PPE, and resources like ventilators that keep their patients alive.

PSYCHOLOGISTS ARE HERE TO HELP

Years of psychological research on trauma, depression, and anxiety provide a great deal of information on how to help healthcare professionals cope with the overwhelming emotions they may be feeling during the COVID-19 crisis. Psychologists across the U.S. have been using these findings in programs designed to provide mental health support to healthcare workers. Research tells us that human connection is healing, and many of these programs include personal contact with a psychologist or mental health professional, including: • Resilience trainings that allow medical professionals to learn how to spot signs of stress in themselves and in their team members. Typically, these trainings come with a resilience roadmap, which outlines coping mechanisms for medical personnel as they work with patients. • Support groups that are being hosted by psychologists, usually at least once a week, allowing medical staff to share their concerns about COVID-19, their work, family, and other stressors. Psychologists lead the calls and provide evidence-based

guidance to participants. Many of these groups are online, but some are in person in hospital units that are operating. • One-on-one support sessions that are made available by psychologists to help individuals on the front lines. These online meetings are not formal therapy sessions. Rather, they are focused on providing participants with support and coping mechanisms. Psychologists can encourage participants to seek additional help should the need arise. Psychologists associated with hospitals and healthcare facilities are working closely with administrators to provide mental health support to frontline healthcare professionals. Examples include: • Embedding psychologists in key meetings to advise administrators on behavior change strategies, staff wellness, or communication. For example, psychologists on hospital ethics committees help physicians and administrators navigate challenging decisions when resources are too low. At one medical center, a psychologist encouraged administrators to send short motivational notes to staff through a newly developed newsletter called “Breath of Fresh Air.”

• Deploying psychologists to departments throughout the hospital or medical facility to talk with those on the front lines during staff meetings and offer support during the staff’s time of need. This allows psychologists to gauge how well healthcare professionals on the front lines are doing, so that the psychologists and administrators can adjust their support accordingly. • Emphasizing the importance of good mental health and encouraging staff to take advantage of the mental health support that is available to them. Many administrators are mindful that their employees could have mental healthcare needs well beyond this crisis, as many of them could grapple with PTSD or moral injuries.

ONLINE RESOURCES FOR FRONTLINE HEALTHCARE PROFESSIONALS

Healthcare professionals can also develop their own coping mechanisms by taking the following steps: • Review the wealth of information on the American Psychological Association website. Our website includes tips for coping during the COVID-19 crisis, including a list

of seven research findings that can help medical professionals during this pandemic. • Tap resources that have been posted online by other hospitals and healthcare facilities. For example, McClaren Health Care in Michigan provides online information for healthcare providers. The information covers everything from assessing stress levels to explaining how to relieve stress during these difficult times. • Seek professional mental health support. Healthcare professionals who find that their stress is unmanageable, or they are not functioning effectively should consider scheduling an appointment with a psychologist or another mental health professional. The stress of the current pandemic could trigger a recurrence of a past mental or physical health problem, or lead to new ones, such as trauma, depression, anxiety, and compassion fatigue, which may require more support than an employer can provide. Potential first steps are requesting an appointment through your employer’s Employee Assistance Program, talking with your family doctor or checking your insurance company’s list of mental health providers.

CALL TO ACTION

As a society, we must commit to care for the physical AND mental health of our frontline healthcare workers. During this pandemic, we are applying a population health framework to disseminate and implement mental health tools and knowledge across the country. Psychological researchers are developing even better coping strategies for this crisis and for future ones. We encourage every public official, every healthcare executive, and every healthcare provider to prioritize not just physical safety and wellness, but also mental wellbeing during and after H this crisis. ■

Arthur C. Evans Jr is CEO and executive vice president of the American Psychological Association. 34 HOSPITAL NEWS MAY 2020

www.hospitalnews.com

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NEWS

Caring for moms-to-be during COVID-19

Clinic gives isolating pregnant women access to prenatal care regnant women who are self-isolating due to COVID-19 symptoms can receive the obstetrical services they need at a Prenatal and Postnatal Clinic recently opened by the Lois Hole Hospital for Women at the Royal Alexandra Hospital. The clinic opened March 30 and has seen 10 patients so far, but has the capacity and resources to see up to 500 patients weekly, should the need arise. “There was an interest from physicians and staff for a space like this and we had full support to go ahead,” says Tracee Pratt, Executive Director of Women’s Health at the Lois Hole Hospital for Women. “There are a lot of fears with pregnancy, especially during COVID-19

and we knew we needed a safe space where staff and patients felt protected while we linked them to the resources they need.” The referral-based clinic – which sees women who are 24 weeks or greater gestation, or six weeks postpartum – is a collaboration between obstetricians, obstetric medicine, maternal fetal medicine, family practitioners, registered midwives, nurse practitioners and the public health antenatal home care program. Joni Warnock was 39 weeks pregnant when she visited the clinic after returning from a trip with a dry cough. She spoke to The Edmonton Journal about her experience, explaining that she was referred to the clinic by her doctor, who was unable to see her due

to COVID-19 restrictions. When she arrived for her appointment, she was asked to sanitize her hands and wear a mask. Healthcare workers all wore personal protective equipment while giving Warnock’s maternal exam. “They were fantastic. If they were nervous about me being potentially COVID-19 positive, I didn’t get that feeling,” Warnock says. She tested negative for the virus. Patients can be seen at the clinic for the duration of their isolation and will be able to return to their regular provider afterwards. “We want to reassure people that we are here to help,” says Pratt. “Although we are in a pandemic, we can still make sure obstetrical needs are H being met. ■

Adapting practices to protect expecting parents, newborns cross Canada and around the globe, physicians and health care professionals are rapidly adapting practices as they look to find effective ways to deliver care while minimizing the risk of contracting COVID-19 for patients and health care providers. To help keep regular pre- and post-natal care and routine well-child visits on track, Dr. Tali Bogler came up with an alternative to the typical schedule to keep these patients safe during the pandemic. “Pregnant women, newborns, and children due for vaccinations still require care during the pandemic. Given the need to reduce the number of visits…the timing and frequency of visits can be adjusted,” the physician in St. Michael’s Family Health Team (FHT) and Chair of Family Practice Obstetrics says in a new paper published by Canadian Family Physician.

Photo credit: Unity Health Toronto

By Emily Dawson

Dr. Tali Bogler. “The first thing we did was provide protected time for more vulnerable patients,” Dr. Bogler says. “We have reserved the 9-11 a.m. window every day to have appointments with the

elderly, immunocompromised, expecting moms and newborns.” While much of the conversation on how best to safeguard vulnerable populations speaks to care for the elderly and people with compromised immune systems, Dr. Bogler says pregnant and newborn patients should not be overlooked. “My pregnant patients often feel vulnerable at the best of times, particularly first-time parents,” she says. “Now they worry about what the pandemic means for their health, their pregnancy and their baby. They’re asking questions like, ‘Should I be coming in for my prenatal ultrasound?’ or, ‘What happens if I get COVID-19 and how will it impact my baby?’” The FHT has also transitioned to virtual care appointments whenever possible, including phone and video calls, and has implemented new ways to communicate with their patients. “Patients are relieved to know that they don’t necessarily have to come in and that we can manage their care in a

safe way, and we can also answer their immediate questions,” she says. In cases where a visit can’t be done virtually – certain prenatal visits, those requiring a vaccination and the like – they are bundling visits to reduce trips into the clinic and hospital. They’re also finding a way to create a virtual community for their patients. Prenatal classes, which usually allow new parents to come together, share resources and form a community, have been cancelled for the time being – in person. “Along with a couple of other St. Michael’s physicians and incoming residents in obstetrics and gynecology, we’re starting a virtual platform through Instagram to have these conversations,” says Dr. Bogler. “It’s like a prenatal class but with a focus on COVID-19, where parents can ask questions and connect with others who might be delivering at the same time. At a time when we’re not able to physically meet with people, it’s our H way of bringing them together.” ■

Emily Dawson is a senior communications adviser at Unity Health Toronto. 36 HOSPITAL NEWS MAY 2020

www.hospitalnews.com

15th Annual Hospital News!

NURSING HERO AWARDS Happy Nursing Week to all Nursing Heroes!

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edition We are pleased to announce that we are proceeding with our Nursing Hero in our coming July edition. Nominate your Nursing Hero today!

ers during this challenging time!

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LONG-TERM CARE NEWS

COMPAs:

A path to person-centred communication for people living with dementia

By Arielle Townsend hen one of her family members began experiencing communication challenges as a result of dementia, Dr. Ana Ines Ansaldo started using old family photos to engage and interact with them. “I began noticing an improvement in communication and overall quality of life when we shared these photos, despite the advanced stage of their illness,” she recalls. The moments shared with her loved one inspired Dr. Ansaldo, a professor at the School of Speech Pathology and Audiology at the University of Montreal, to develop a tool that would help caregivers and family members better communicate with people living with dementia. What followed would be

named the COMmunication Proche Aidant (COMPAs) app. COMPAs works like an online treasure chest to store images, music and videos from significant moments in a person’s life. Family members and caregivers can use these special moments to spark genuine, person-centred moments of engagement with people experiencing verbal communication challenges as a result of advanced dementia. “Many caregivers told me they had difficulty communicating with residents, but with COMPAs their ability to connect with them improved almost instantly,” Dr. Ansaldo says. The app is easy to use, with an intuitive interface and comes complete

with hyperlinked guides and YouTube tutorials. Dr. Ansaldo believes the app’s ‘secret sauce’ is the emotional weight each memory carries. “The app is effective because it’s based on empathy and sharing emotions. It takes the conversation out of the realm of care and focuses it on the person, not the illness.”

FROM BENCH TO BEDSIDE

When the Centre for Aging + Brain Health Innovation (CABHI) announced a call for innovators to apply to their Spark Program for early-stage aging and brain health solutions, Dr. Ansaldo saw an opportunity that would help get her innovation into the

hands of those who needed it most. Through the Spark Program, CABHI connected Dr. Ansaldo to the Centre d’hébergement Paul-Bruchési, where she tested and validated the app. The validation process included stakeholder feedback and testimonials from family members. Thanks to user feedback, Dr. Ansaldo now knows that the app can be used successfully by people living with dementia at home. “We heard from a family caregiver who says her mother learned to use the app on her own. This is exciting because now we know that there is the potential for those with cognitive impairment to gain independence and confidence from navigating the app.”

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LONG-TERM CARE NEWS

SUPPORTING SENIORS AND THEIR FAMILY MEMBERS DURING COVID-19

Today, Dr. Ansaldo and her team are getting ready to expand the app into 11 long-term care settings in Montreal in response to COVID-19. The expansion will include a video call component and training for longterm care staff members on how to use the app. “Since the lack of communication is one of the main causes of cognitive and physical deterioration, COMPAs could even be thought of as a way of preserving a person’s mental health during the current health crisis. It could support not only the person (resident) but the family that are distressed because they cannot see their loved ones.” There are also plans to develop the Android version of the app since it is currently only available on iOS. Even with plans to expand the app

in the works, Dr. Ansaldo maintains that at its core, COMPAs’ chief function is to trigger an emotional response in people living with dementia that goes beyond words.

“It’s all about the intention to communicate. Sometimes, spending 15 to 20 minutes of quality time allowing a person to relive pleasant moments from their life can establish more of a

connection than words ever could. Visit www.cabhi.com to learn more about innovations that are supporting seniors and caregivers during H COVID-19. ■

Arielle Townsend is the Marketing & Communications Content Specialist, Centre for Aging and Brain Health Innovation (CABHI).

Care after hospitalization

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MAY 2020 HOSPITAL NEWS 39

LONG-TERM CARE NEWS

Partners combine efforts to enhance care for long term care residents By Lillian Badzioch network of healthcare providers are bringing more care to residents in Hamiltonâ&#x20AC;&#x2122;s long term care (LTC) homes. Using telephone connection or secure videoconferencing, LTC residents and their care teams will have access to emergency department (ED) physicians and follow-up by other medical specialists and nurses when required. The new service will reduce the risk of exposure to Covid-19 to LTC residents by removing the need to travel and wait in an emergency department. â&#x20AC;&#x153;A tremendous level of teamwork has made this service a reality in record time and one of the first of its kind in Ontario,â&#x20AC;? says Dr. Mohamed Panju, A-CTU Director at Boris Clinic, and Virtual Care for LTC Initiative Co-Lead. â&#x20AC;&#x153;We all know that keeping

our most vulnerable populations safe is critical now during the pandemic and beyond. Together, we will be able to bring more resources to these individuals in the comfort of their homes.â&#x20AC;? Primary care physicians, nurse practitioners and community paramedics caring for LTC residents now have the ability to call a central number to request a virtual visit or telephone call with an ED physician (this excludes

emergency situations). ED physicians from both Hamilton Health Sciences and St. Josephâ&#x20AC;&#x2122;s Healthcare Hamilton will be available on a rotating basis 24/7 to respond to these requests. This model will enable the team to work together to identify the best care path for each resident including services that can be administered in the LTC home with access to diagnostics as appropriate.

â&#x20AC;&#x153;This care initiative is just another way that the health care system is transforming to have a direct and positive impact on vulnerable seniors,â&#x20AC;? says Renee Guder, CEO, Shalom Village, which includes two long term care residences. â&#x20AC;&#x153;It is a win-win for the entire Hamilton community. With access to critical services now available for those who need it most, we can make a dramatic difference for those we serve.â&#x20AC;? The initiative was piloted prior to the pandemic and officially launched in early April. â&#x20AC;&#x153;Our goal is to optimize the health and well-being of those living in LTC homes and in other community settings going forward,â&#x20AC;? says Kelly Oâ&#x20AC;&#x2122;Halloran, Director, Community and Population Health Services. â&#x20AC;&#x153;We are grateful to all of the individuals and organizations that have stepped forward H to make this happen.â&#x20AC;? â&#x2013;

Lillian Badzioch works in communications at Hamilton Health Sciences.

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LONG-TERM CARE NEWS

Researchers use robots to accelerate COVID-19 testing By Elaine Mitropoulos n a tucked-away lab at St. Joseph’s Healthcare Hamilton, a handful of scientists – and their robot “colleagues” – are leading the race to scale up COVID-19 testing to meet the demand of a surge in cases. Alongside his team of molecular microbiologists, Dr. David Bulir of The Research Institute of St. Joe’s Hamilton is automating COVID-19 testing for greater volumes and faster turnaround times. For every 100 samples, Dr. Bulir’s robotic liquid handling system will be able to confirm results in just two and a half hours. Once the system is developed and optimized, it will be rolled out for clinical use at the Hamilton Regional Laboratory Medicine Program (HRLMP) to

enable COVID-19 testing to jump from 700 samples per 24 hours to about 1,500 samples over the same timeframe, and eventually more than 3,000 per day. “These robots will help us get to the testing numbers that clinical labs are going to need in the next few weeks,” Dr. Bulir says. “They will alleviate the amount of processing humans do, while increasing the throughput at the clinical level.” Dr. Bulir first started developing ways to detect the virus in January, at the cusp of the COVID-19 outbreak in China. From that, he has designed a highly sensitive test, which is now used by the HRLMP, and is sought after by – and implemented in – hospital labs across Canada and internationally. Continued on page 42

Dr Buir loading the testing robot.

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MAY 2020 HOSPITAL NEWS 41

LONG-TERM CARE NEWS

St. Joe’s dementia patients have powerful virtual visits with loved ones By Elaine Mitropoulos ementia patients at St. Joseph’s Healthcare Hamilton are having powerful virtual interactions with their loved ones – so much that some patients are hugging their iPads. Owing to COVID-19 and the hospital’s no-visitor policy, Arlene Jeffery hasn’t physically seen her husband, Bill Jeffery, in more than a month. Bill is a patient in the hospital’s seniors mental health program. Arlene says she relies on St. Joe’s Virtual Visits program, which has been rolled out across the hospital, to take comfort in knowing her husband is doing OK during the pandemic. “Bill’s disease is advanced, so we don’t have the best conversations to begin with,” says Arlene. “The other day when he looked at the screen, he said, ‘Hey, I know that lady.’ That made my day.” Likewise, Ana Yurgan-Rotella hasn’t seen her father, Peter Jurgan, who is less advanced in his illness, since the pair last shared a pizza in the hospital cafeteria. “The past month has been one of the most difficult as we go through this journey of my father’s illness,” Ana says. “I know these virtual visits have made survival through this pandemic and his illness easier.” For Ana and Peter, virtual visits provide the pair with the opportunity to stay in touch, and plan their next

Peter Jurgan, a patient with dementia in St. Joseph’s Healthcare Hamilton’s seniors mental health program, interacts with his daughter over virtual visits. The Virtual Visits program has been rolled out across the hospital to allow patients and loved ones to connect while a no-visitor policy is in place to curb the spread of COVID-19.

meal together, once it’s safe to see each other again. “My father has something to look forward to now,” Ana says. Dr. Jonathan Crowson, a psychiatrist at St. Joe’s specializing in seniors mental health, says family contact is especially important for people with dementia. “Family visits enable people with dementia to access their memories and remain connected to their own past – which really means connected to their

own personhood,” he says. “We have witnessed people whose illness is so advanced hugging the iPad when they heard their family speak to them. “It is those moments that really underline how important it is for us to make every effort to maintain those contacts at this time.”

ABOUT THE VIRTUAL VISITS PROGRAM

Through the program, inpatients have access to hospital-supplied iP-

ads loaded with video-call software to keep in touch while in hospital. Two generous donors have made the Virtual Visits program possible at St. Joe’s. With more than $85,000 contributed by the Ever Hopeful Fund and the St. Elizabeth Home Society, St. Joseph’s Healthcare Foundation was able to grant funds towards purchasing dedicated iPads – enough to provide one device for every eight patients in H the hospital. ■

Elaine Mitropoulos works in Public Affairs at St. Joseph’s Healthcare Hamilton.

Robots to accelerate COVID-19 testing Continued from page 41 “Located right here in Hamilton, our research and clinical labs have worked tirelessly to develop tests that are now being deployed locally, throughout Canada, and beyond,” says Dr. Marek Smieja, the interim chief of laboratory medicine at the HRLMP. Dr. Bulir’s test is unique because it

detects a part of the virus that is less likely to mutate, and is very effective at distinguishing between COVID-19 and other coronaviruses. This also means that as the virus evolves, changing its genetic code, Dr. Bulir’s test is expected to remain effective. “Now that we can detect COVID-19, and detect it really well,

our goal is to identify more people that have the infection. To do that we must increase the volume of testing, and the capacity to test quickly,” Dr Bulir says. “That’s our focus right now.” Dr. Bulir’s work shows so much promise it was selected by a Scientific Committee at the Juravinski Research Institute to receive a boost of more than half a million

dollars in funding thanks to a new $3.3 million gift from Hamilton philanthropists Charles and Margaret Juravinski. The couple’s most recent donation, announced April 3, was designated in part to accelerate COVID-19 research across St. Joseph’s Healthcare Hamilton, McMaster University, and HamH ilton Health Sciences. ■

Elaine Mitropoulos is a Public Affairs Specialist at St. Joseph’s Healthcare Hamilton. 42 HOSPITAL NEWS MAY 2020

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EVIDENCE MATTERS

Stereotactic ablative body radiotherapy: A paradigm shift – or even a potential cure – for oligometastatic cancer? By Brit Cooper Jones hen you or a loved one is diagnosed with cancer – particularly cancer that has metastasized, or spread, to other sites – it can be a devastating diagnosis. Typically, once cancer has spread throughout the body, there are fewer treatment options available. It often means a cure is not possible. But there may be some hope on the horizon for patients with certain types of metastatic disease. “Oligometastatic disease” is defined as a cancer that has metastasized to a limited number of sites. Sometimes surgery can be used to remove oligometastatic disease. But what about when surgery is not possible – perhaps because the location is too difficult to access, or because a patient’s age or other health conditions may make surgery too risky? In cases like these, stereotactic ablative body radiotherapy might represent a new option. And what exactly is “stereotactic ablative body radiotherapy” (SABR) – also known as stereotactic body radiotherapy (SBRT)? It is a form of radiation therapy that precisely delivers high doses of radiation to specific body sites, and over a shorter treatment period than with conventional radiotherapy. The method of delivery – which relies on image guidance (e.g., X-ray,

CT, or MRI) as well as a method of keeping the patient still (e.g., compression, a body frame, or an immobilization device) – is what allows these high doses to be delivered while sparing normal tissue. SABR holds promise because of its potential to treat metastatic tumours that would be impossible to surgically remove. This, in turn, may offer a potential cure for certain types of oligometastatic cancer. (And, if not a cure, it might offer prolonged survival or, in more severe cases, palliation and symptom relief for metastatic tumours causing pain or other complications.) However, despite the hope and promise of SABR, there remain key questions. What does the research show about the clinical effectiveness of SABR for different types of cancers and metastatic tumours (e.g., cancer that has spread to the lungs, liver, bones, or lymph nodes)? If SABR were to be funded in Canadian jurisdictions, which patients should be eligible to receive this treatment? If most of treatment centres were in urban areas, how would access to treatment be made equitable to all patients? What would the staff training requirements, equipment purchasing requirements, economic considerations, and implementation considerations be?

To help answer these questions, and to guide decisions about the optimal use of SABR for oligometastatic cancer in Canada, decision-makers and the health care community turned to CADTH – an independent agency that finds, assesses, and summarizes the research on drugs, medical devices, tests, and procedures – to find out what the evidence says. CADTH started with a Rapid Response report (a rapid literature review with critical appraisal) that was published in February 2019. However, the report was inconclusive. Three low-quality retrospective studies and one economic evaluation were identified, but these likely did not represent the full breadth of research on the topic for two reasons. First of all, the search criteria were limited to studies that explicitly described the patient population as “patients with oligometastatic cancer.” This approach would have missed studies that did not use that exact terminology. Secondly, SABR for oligometastatic cancer is a highly active area of research with over 60 clinical trials currently underway; so additional, potentially high-quality studies may be published soon. In a supplementary literature search conducted by CADTH since the publication of the initial Rapid

Response report, additional citations were already identified as the body of literature continues to grow. CADTH is now proceeding with a health technology assessment (HTA) on the topic of SABR for oligometastatic cancer. Given the rapid evolution of this particular field, the clinical component of the HTA will take the form of a “living systematic review”. That is, CADTH will continually look for new clinical research to ensure the HTA findings remain current and reflect the most up-to-date evidence. The HTA will also include an Environmental Scan of current implementation status and practice uses, as well as barriers and facilitators to implementing SABR Subscribe to New at CADTH to stay updated on CADTH’s latest reports, including the SABR Health Technology Assessment when it becomes available. See CADTH’s Rapid Response report on the topic of SABR for oligometastatic cancer as well as CADTH’s Scoping Brief for the Health Technology Assessment. If you would like to learn more about CADTH, visit cadth.ca, follow us on Twitter @ CADTH_ACTMS, or speak to a Liaison Officer in your region: cadth.ca/ H Liaison-Officers ■

Brit Cooper Jones is a knowledge mobilization officer at CADTH. 44 HOSPITAL NEWS MAY 2020

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NEWS

Practicing self-care

on the frontlines By Dagmara Maria Urbanowicz n hospitals across the country, patients and those who treat them are adjusting to a formidable new normal. That includes ensuring some of the most fragile members of our society still receive the life-sustaining treatments they need despite a century-worst pandemic. Holland Bloorview Kids Rehabilitation Hospital sits at the epicentre of managing that new normal for children and youth with disabilities. In our complex continuing care unit, COVID-19 has meant that our clients – most of them on life-sustaining technology – remain in strict isolation. Hospital environments have, of course, become more tightly regulated due to the novel coronavirus, and our staff ensures the high level of care necessary to keep these young children on ventilators, tracheostomies and gastronomy tubes safe. Our unit is in fact a training ground for family members to develop the skills and knowledge to bring these children eventually home. Children with complex medical needs require 24-hour eyes-on care, and we prepare their families for everything from operating life-supporting technology to bathing and transferring them from bed to stroller, or stroller to car. As a social worker, my main role is in helping our families access resources such as funding, and to come to terms with a new reality at home. Amidst the COVID-19 crisis, anxiety levels are heightened for my clients already going through intensely difficult situations. They are in survival mode, which for us means consistent care is imperative. Like all hospitals, we had to do our part to prevent infection spread by adjusting our caregiver and visitor policy. Now, just one caregiver can now stay bedside for a 24-hour period, with just two for every patient overall. This

necessary step has meant it is harder for these anxious families to step away from the stress, and breathe.

HEALTH-CARE WORKERS BEAR A HEAVY MENTAL HEALTH BURDEN

That inability to step away, of course, goes for most hospital workers as well. Stress from COVID-19 is coupled with a job where we often walk toward those that need help, and it is all too easy to become overwhelmed. Most hospitals are redeploying staff to meet evolving models of care. Notably at Holland Bloorview, we extended our five-day model of inpatient service to a full seven days. This means that clients who would normally go home on weekends as part of their rehabilitation now stay in the hospital seven days a week. The increased programming in a seven-day model means our team is working harder and longer than ever – and mitigating the stress of it all is not easy. With so much out of our hands, I’ve found mindfulness and compassion to be profound tools for health care workers – anyone – to use to cope.

EMBRACING MINDFULNESS

Mindfulness and compassion have been a central part of my life for over a decade, and my foundation during difficult times. In training programs, workshops and in private practice, it is remarkable to watch these concepts empower the lives of others. So without being too esoteric, what is mindfulness? And why is it valuable right now? Mindfulness is, essentially, being aware and present in any moment, without judgement. By practicing it, we can reduce stress at any moment of a busy day – even while brushing teeth, walking down a hallway, writing an email.

Dagmara Maria Urbanowicz urges health care professionals to use mindfulness and compassion as strategies to cope with the challenges and pressure of COVID-19. Mindfulness is about focusing on one thing – to train our minds to be less full. Inviting yourself to stay in a moment helps slow down life. And when one is breathlessly busy, the slow lane offers respite. That lane opens even during the simplest of activities. You can practice mindfulness even while: Breathing: Your breath is the anchor to being in the present moment. In the most hectic moments during your day, try to pause and focus on your breath. That will give you a moment of peace, refuge and calm inside. Walking: Focus on the sensation of each foot connecting to the ground. How your breath synchronizes with each step. Engage all senses as you open to your surroundings, no matter where you are. Eating: Hone in on the senses. Or, focus on physical acts such as raising a fork to your mouth. Chewing. See what you eat and how you eat it. Hand washing/sanitizing: Feel the water, hear the sounds. If your

thoughts wander, invite them back to focus on what you are actually doing. Mindfulness is best paired with the practice of self-compassion, especially while coping with a crisis. We struggle; we fail; we could have done more. Life is hard: we deserve to offer only kindness to ourselves. How? Be honest in asking yourself: what is the most self-compassionate thing I can do for myself right now? Call a trusted friend, zone out with Netflix, read a graphic novel, seek a hug, jog… no matter the answer, act upon it. Self compassion involves listening to yourself, and understanding what you need. During these times, practising self care along with health care is more important than ever. As the saying goes that we’ve all heard on a flight: put your own oxygen mask on first. Doing so may be the most important gift you H give to yourself – and others. ■

Dagmara Urbanowicz is a social worker at Holland Bloorview Kids Rehabilitation Hospital, an adjunct lecturer at University of Toronto’s Faculty of Social Work and has over a decade of experience working with children and families. She is also a mindfulness practitioner, teacher and facilitator with a focus on supporting professional caregivers in developing their well-being through mindfulness. www.hospitalnews.com

MAY 2020 HOSPITAL NEWS 45

ETHICS

Prioritizing PPE in and outside of hospital walls By Aamir Khan, Andria Bianchi and Angela Gonzales ioethicists support clinicians, patients, families, and staff who encounter ethical dilemmas (i.e., situations in which it is difficult to determine how one ought to/should respond when multiple options can be pursued). When a person asks, “How should I respond to this situation? Should I pursue option A, B, or C?” then they may be experiencing an ethical dilemma. Upon being consulted, ethicists typically try to facilitate fair decision-making processes so that an ethically defensible decision is agreed upon. Sometimes, however, even the most defensible option is not ideal. Depending on the circumstances, decision-makers must sometimes make decisions by determining which option

46 HOSPITAL NEWS MAY 2020

is the least bad amongst a list of unfavourable options. An example of where this kind of decision-making has potentially had to occur is in the dissemination and use of personal protective equipment (PPE). As a result of COVID-19, PPE is in short supply. This is problematic insofar as healthcare workers need PPE to prevent exposure to and transmission of COVID-19. The scarcity of PPE has forced organizations, leaders, and healthcare providers to make difficult decisions about how PPE ought to be used. While a best-case scenario would be to provide all providers with enough PPE so that they can work in accordance with best practices, the resource shortage has made this option nearly impossible.

Consequently, some providers have been advised to extend their use of PPE beyond a single patient interaction (i.e., under circumstances that would typically warrant changing equipment) and to return some of their used masks to be sterilized and reprocessed. One reason that the above decisions may, from some perspectives, be ethically defensible is if the potential benefits to society outweigh the possible harms and if there are no better alternatives available (i.e., if it is the least bad option given the current context). For instance, if it is known that using PPE in accordance with best practices will result in a rapid elimination of useable PPE from which healthcare workers will not be protected at all, then altering standards may be deemed justifiable.

In addition to the use of PPE, its dissemination is also worth exploring. In order to ensure that frontline staff are provided with a fair and equal opportunity to protect the health and safety of themselves (as essential care providers), as well as the people they care for, we ought to ensure that those who are situated both in and outside of hospital walls are recognized. Several campaigns are presently occurring to solicit PPE for healthcare professionals; these campaigns are primarily focused on hospital settings. One group outside of hospitals that has made news headlines is staff working in long-term care. According to the Ontario Nurses’ Association, long-term care staff are working in unfathomable conditions and require acwww.hospitalnews.com

ETHICS cess to appropriate PPE immediately. Because of the number of COVID-19 cases occurring in long-term care amongst residents and staff, as well as a lack of available PPE, facilities are substantially understaffed and require human resources as well as equipment. In addition to long-term care (and plausibly many other settings and professions), one group’s need for PPE that has failed to be sufficiently acknowledged is staff and residents who live in group homes. Group homes offer housing arrangements and shared personal care resources for specific individuals who require a certain level of support (e.g. people with developmental disabilities and other complex needs). It has been noted by those working in the field that staff at some group homes do not have access to appropriate PPE, making it such that the risk to both them and residents is present. Consequently, some staff may decide that the risk of working is too high to take. In addition to group homes, there are many other environments in which

care staff are working with vulnerable people. These environments include homeless shelters and family homes. Without appropriate PPE being available in these settings, workers, supported persons, and people in close physical proximity are also exposed to risks that could be mitigated with PPE. Consider also that at least some of these individuals may need to go into the community after being exposed to unsafe conditions. Additionally, if vulnerable people are exposed to COVID-19 due to a lack of equitable access to PPE for their care staff, then they may need to go to the hospital. If caregivers are unable to enter emergency departments due to precautionary restrictions, this could place vulnerable patients and healthcare staff under further strain as at least some of these patients may not be able to communicate their unique needs to staff, resulting in confusion, extra effort, and possibly harm. Similar to those in long-term care, if staff working in these environments are

unable to protect themselves, then some of society’s most vulnerable citizens who require support will either be insufficiently cared for (because staff may choose not to work in such risky conditions) and/or be at an increased risk of harm from COVID-19 from not having PPE. Both consequences could result in preventable hospital admissions that our healthcare system may not have the capacity to sufficiently manage. Here are some possible recommendations to consider in response to the described challenges above: 1. The Ministries of Children, Community and Social Services (MCCSS) and Health and Long-Term Care (MOHLTC) could partner to coordinate & consolidate supplies of PPE and allocate distribution to mitigate the impact of COVID-19. 2. The MOHLTC could review processes for supporting vulnerable patients when they arrive at emergency departments. It may be more prudent from a resource allocation and risk mitigation perspective to allow one caregiver to enter emer-

gency departments with some vulnerable patients. 3. Workers that support vulnerable clients (i.e., personal support workers, developmental service workers, and other paraprofessional staff working in environments such as group homes and homeless shelters) should be considered as vital and as deserving of protection (i.e., by being provided appropriate PPE) as staff working in hospitals and longterm care. This consideration could be formalized at a policy level in order to ensure that staff and residents/clients are protected. Ultimately, it is important to ensure that healthcare providers in both hospital and non-hospital settings are offered a fair and equal opportunity to protect themselves and those to whom they provide care. Given that the developmental services and healthcare sectors are interconnected and in order to be responsible stewards of a scarce resource, it is necessary for our system to provide PPE to at-risk staff H in both contexts. ■

Aamir Khan, M.ADS, BCBA, is a Behaviour Facilitator at Surrey Place; Andria Bianchi, PhD, is a Bioethicist at the University Health Network; and Angela Gonzales is a Health Care Facilitator RN at Surrey Place.

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