Dear Colleagues,
We are another week into this crisis - I hope you and your families are well. I am so aware of the enormous stress that you (and we) are under as medical communities struggle to keep up with the COVID-19 related issues.
We have been hearing from you; thank you for connecting with us.
PPE - there has been confusion about what is necessary in which clinical scenarios.
CFPC held a webinar on April 2 with me and infectious disease specialist Dr. Allison McGeer, and hosted by Dr. Allan Grill (https://www.youtube.com/watch?v=8npP2VS4-DU) and the OMA Tele-TownHalls have also discussed best practices. We clarified with Dr. Gregory Rose (infectious disease specialist from the OMA Tele-TownHalls) and Dr. McGeer about the following:
- COVID suspects - full PPE including a gown, gloves, surgical (NOT N95) mask and eye protection, patient in mask.
- Asymptomatic patients - surgical (NOT N95) mask and eye protection with meticulous hand hygiene + gloves. If supplies allow, patient in mask.
Other points of clarification on PPE include:
- Keep 2-metre distance during history; examine briefly.
- Mask re-use in our offices - same mask until soiled or wet. There is a handout on removing your mask; and as healthcare providers reusing masks, simply lift by ear loops and place - with patient-facing side down - in breathable container to store overnight. Remember hand hygiene after removal and before re-application next day.
- Office staff - maintain 2-metre distance to patient. If there is a plexiglass or even plastic barrier, then staff do not need PPE. A hands-free phone is helpful.
Of note, is the web page: https://www.conquercovid19.ca - a grassroots incubator that is facilitating access to priority products that are in short supply but essential for the healthcare community during the COVID-19 pandemic.
Hand Hygiene - before and after all patients for 20 seconds, whether soap or hand sanitizer; include your thumbs! This is the most important thing that we can do to prevent transmission.
Cleaning - it is important to clean touchable surfaces after every patient with at least 70% alcohol or 0.5% hydrogen peroxide or 0.1% sodium hypochlorite; this should include computer keyboards in the exam room.
Acute Respiratory Illnesses - DO NOT REFER TO PHARMACIES. See this COVID-19 virtual care infographic to help you assess whether your patients actually need to be seen in person/tested or whether self-isolation for 14 days is the most appropriate disposition.
Also, clinicians from the Greater Toronto Area (GTA) have developed Clinical Practice Guidelines for Antimicrobial and Immunomodulatory Therapy, available here: https://www.antimicrobialstewardship.com/covid-19.
In-office visits - see our considerations for in-person visits when phone/video isn't enough (e.g., non-infectious illness that requires an exam after your virtual visit, and an interim schedule for children and pregnant women).
Work with your community - some family physicians are looking to their local colleagues and primary care providers to pool resources (e.g., respiratory clinics so that PPE can be optimized; well-baby clinics and prenatals in a centralized location).
Income stabilization - the OMA is working hard on this issue on your behalf, please see the OMA Member site for updates.
Doctors helping doctors - the OMA has initiated a custom-designed app called BookJane that matches doctors with hospitals and community-care facilities that are in need. See the OMA website. You need to download the BookJane app, and sign in using "OMA" as the access code.
HealthForceOntario's COVID-19 Health Care Provider Recruitment webpage is also collecting information from individuals wanting to get involved - such as health care providers working part-time, retired or currently inactive - to see how they can be deployed during this crisis.
Sick notes - see CMA statement, urging all employers to discontinue requirement for sick notes during COVID-19. The Ontario Government introduced changes to the Employment Standards Amendment Act (Infectious Disease Emergencies), 2020 - the legislation will also make it clear employees cannot be required to show sick notes: https://news.ontario.ca/opo/en/2020/03/ontario-supporting-workers-municipalities-and-retailers-in-response-to-covid-19.html
When to allow return to work - this quick reference document from the Ministry of Health is to help guide decision making on testing and clearance of individuals suspected or confirmed to have COVID-19. Different scenarios guiding return to work decisions are outlined on page 3. Of note, some workers will refer to their organization's return to work guidance.
Palliative considerations - your role in this conversation is invaluable and helps our hospital-based doctors considerably. Talking with our patients about their goals of care (https://www.advancecareplanning.ca/) has become all the more important. Here are some (approximate, and ever changing) data and tools from organizations dedicated to improving serious illness care and patient communication.
- Palliative Care Resources to Support Frontline Providers during the COVID-19 Pandemic (March 26, 2020): www.ontariofamilyphysicians.ca/tools-resources/timely-trending/novel-coronavirus-2019-ncov/palliative-resources-covid-19-march-2020.pdf
- End-of-life care in the Emergency Department for the patient imminently dying of a highly transmissible acute respiratory infection (such as COVID-19): https://caep.ca/wp-content/uploads/2020/03/EOL-in-COVID19-v5.pdf
- Tips on how to talk about some difficult topics related to COVID-19: https://www.vitaltalk.org/guides/covid-19-communication-skills/
- A sample video on a 'goals of care' discussion with patients in the context of COVID-19 infection: https://www.youtube.com/watch?v=eoPDbMFZ7k4&feature=youtu.be
I know this is a lot, but I hope it highlights some key resources for the day-to-day issues that are arising as we face the many changes this pandemic has brought into our communities and practices.
Once again, I applaud you and am proud of the work that so many of you are doing. We welcome your questions, suggestions, and feedback.
Stay well, stay strong and know that we are in this with you.
Jennifer Young
OCFP President