Coming soon....

Happy Tuesday.  Lots going on.  Major news is below, including a summary of yesterday’s faculty video meeting.  Daily messages will be limited to key clinical updates; will send longer weekly emails following departmental videoconferences.

As of this morning:

Current confirmed cases in Kingston: 3 positives in KFLA, all outpatients

CURRENT TESTING CRITERIA

1.     If someone is sick and likely to need admission, the decision to swab for COVID should be made by or in consultation with the admitting service unless a clearly at-risk patient

2.     For our ED patients who present for screening of ARI, use the following criteria for performing a COVID swab:

Symptomatic with new-onset COUGH or FEVER or INCREASED DIFFICULTY BREATHING

AND

·      Travelled outside of Canada within last 14 days, OR

·      Been in close contact with someone who has symptoms and has traveled outside Canada in last 14 days, OR

·      Been in close contact with someone who has confirmed COVID19, OR

·      Healthcare worker, OR

·      Resident of LTC facility, retirement home or other institution, OR

·      Members of First Nations living on reserve

Do not swab asymptomatic patients.

All patients with new-onset ARI but no travel or contact history should be advised to self-isolate at home, and not to return to work until 24 hours after complete resolution of all symptoms.

There’s a distinct possibility that we will run out of swabs in the coming days.

CLINICAL UPDATES

Daily huddles:

We ask that you take the lead in bringing together a daily huddle with MD, Residents, and Charge Nurse to go over the day’s plan as things are changing rapidly. This should be done by the A1 physician at 0700 and obviously the day MD at HDH, and by the AB3 physician at 1900.  Review the intubation team; review the current screening criteria; review the state of the department; identify any questions that need to be brought up the leadership chain; and check in with each other about how you’re managing.  Offer support to one another and remember:  WE SET THE TONE.  

COVID-19 Assessment Clinic Update:

The HDH site opened on Saturday and is seeing significant volume (>185 patients on Monday).  Because of the patient volumes, which are likely to increase, planning is actively underway to move the assessment clinic to the Memorial Centre (hopefully open by Saturday).  Nurses at triage are being provided with criteria for patient diversion to the clinic from triage.  Some patients may refuse diversion, and will still be seen at the ED/UCC.  

We are working to figure out the logistics for a “Secondary Assessment Centre” in or adjacent to KGH ED.  I will have more details tomorrow, but the hope is to start by using clinic space on Burr 1 as an assessment area for ARI patients (similar to the back hall at HDH), and as a place where medicine can come see stable COVID consults for admission.  We are also looking at emptying out section C and combining this with B6, B7, B8 as a respiratory isolation unit.  St. Patrick’s Day has given us a chance to decant patients from C in order to start this process.  A lot to still figure out, more details to be released ASAP.

PPE for Intubation:

The PPE for intubation of a COVID19 patient includes the following:

- disposable gown (trauma type)

- hair bouffant cover

- face visor

- booties

- N95 mask (your type)

- Sterile surgical size gloves (“nitrile”)

You can grab pre-made packages of these above the storage cart across from A3. You’ll need to grab your own size gloves and N95 mask to accompany the package.  They will be stocked daily and we will have 10 up there and an additional 3 on the arrest cart. Here are 2 pictures to help you find them.

We will be running simulations of this process in the near future in the ED so stay tuned. This video covers it nicely and is worth watching.

There will soon be a whiteboard in section A up on the wall. At the start of each nursing shift a team of COVID19 intubation team members will be identified and their names put on the whiteboard. There will be 3 RNs, one of whom will be designated “clean” and will act as a runner for the room. This person will also be the “spotter” for others during doffing and will watch for contamination. At the start of every section A shift please add your (the A doctor) name to the board and find the team members – this is an opportunity for mental rehearsal and a prebrief – locate the PPE and N95 masks and learn who else is on your team. Let’s start doing this now so it becomes our usual practice.

Doffing Video:

Sharing this resource from Dr. Karen Graham. Video can be seen here.

Intubation Infographic:

Dr. Tim Chaplin will be working on developing SIM for Intubation for COVID-19 cases.  For now, you can see the infographic here.

Flow Issues:

At KGH - B6, B7 & B8 remain isolation rooms for all ARI or FRI positive and are not to be used for other patient populations. Patients requiring monitoring or critical care that are positive ARI/FRI will require D11/12 or A2/3 as previously planned.   B4 is now the Gyne room.  Our colleagues from OBGYN are working on a plan to help us by assessing all pregnancy-related (including 

At HDH - all COVID / ARI cases to be seen in back hall rooms (Assmt, 6,7,8). There has been confusion about this in the past week.  For clarity:  any acute respiratory illness (COVID risk or not) is to be seen using PPE in the back hallway.  There is now a "COVID/FRI” office in the back hall conference room - it contains a computer (EDIS), printer, phone, swabs and a sink.

COVID Testing Order in EDIS:

COVID testing is now an order in EDIS.  See below note from Microbiology related to COVID-19 testing:

COVID-19 (SARS-CoV-2) Testing at KHSC.

The KSHC Microbiology Laboratory is initiating in-house testing for COVID-19 using a multiplex PCR assay developed at KHSC. The testing at KHSC will complement testing that is occurring at Kingston Public Health Laboratories to reduce turn-around-time.  The expected turn-around-time for COVID-19 testing will be same day for samples received in the Microbiology laboratory between 6:30am and 3:00 pm and next day if received after 3:00 pm. Repeat testing on previously positive patients will require approval by the Microbiologist-on-call.  Please contact the Microbiologist–on–call for any questions regarding COVID-19 testing.

Imaging for COVID-19 Patients:

See below update from Diagnostic Radiology:

Position Statement on Cardiothoracic Imaging for PUI and COVID-19 positive patients

A normal chest CT scan or chest radiograph cannot exclude the diagnosis of COVID-19 especially for patients with recent onset of symptoms.

Chest radiography should not be used to screen for or as a first-line test to diagnose COVID-19.

The Canadian Society of Thoracic Radiology (CSTR) and Canadian Association of Radiologists (CAR) recommend against the use of routine chest CT for screening, diagnosis and surveillance of COVID-19 infection. The CSTR/CAR recommend Chest CT in patients with confirmed COVID-19 infection who may have developed complications.

Therefore, CT should be used sparingly and reserved for hospitalized, symptomatic patients with specific clinical indications for CT including abscess, empyema, and pulmonary embolism.

The Department of Diagnostic Radiology will deploy portable radiography for use when chest x-rays are considered medically necessary. The surfaces of these machines can be easily cleaned, avoiding the need to bring patients into dedicated radiography rooms.

Please indicate clearly on the requisition if a patient is PUI or COVID-19 positive.

ADMINISTRATIVE/OPERATIONS UPDATES:

Weekly Department Meeting via Zoom Call:

Yesterday morning, we hosted the first Departmental Zoom meeting to provide COVID-19 updates to faculty.  A recording of this can be viewed here.  A Zoom meeting will occur each Monday at 9:30 and the recording will be shared via this format.  Jill will send reminder emails and the link to join the call.

Not comfortable with accessing Zoom? Follow this tutorial to learn how. 

Want to schedule a zoom meeting using the department's account? Email jill.mccreary@kingstonhsc.ca who will do this for you and send you the link for your meeting.

Second On-Call Schedule:

In order to avoid email overload, please check Q-Genda which has now been populated with 2nd Call Coverage.  Should you need to switch your availability for this shift, please put it up for swap as you normally would for other shifts. We want to avoid sending out emails related to shifts at this time. Note: some change will be made to the current shift distribution as we await some more physician availability to be submitted to Jill.

Physician Administrator on Call:

Coming soon – a rotating schedule for Physician Admin will be posted on Q-Genda. This will be the most responsible person for clinical operational questions who should be contacted that day.  Dave (613-572-4244) is filling this role for the next week, with an expectation that as the situation evolves, Terry, Karen and others will be sharing this role.

EDUCATION AND RESIDENCY PROGRAM UPDATE

Rounds/Teaching:

All in-person academic teaching events will be cancelled or format-changed, effective today. 

·      Oral exams scheduled can take place via skype, facetime or from your personal zoom account.  Unfortunately the departmental zoom account only allows one user per scheduled time.

·       Grand rounds will be cancelled for the next 4 weeks. This will allow us time to get a better idea of the impact COVID will have on our department. We can restart these rounds via zoom when it seems reasonable to do so.

·       Core rounds and wellness rounds will also take place via Zoom beginning next week (mar 26th) according to our teaching schedule. 

·       Simulation rounds will be cancelled. The faculty member assigned to teach the session will forward 1 or 2 articles relevant to the assigned topic for your self-study.

·       Journal club will also be cancelled. Resident and faculty articles will be sent out along with a critical appraisal of the papers for self-study.

Residents’ academic day will remain protected time. 

Resident Well-Being:

Academic Advisors are asked to make a point to have a routine touch-base with each of your advisees every week to check in and make sure they’re doing OK.  All faculty are asked to keep an eye on our trainees.  If you have any concerns about a trainee, Jaelyn or Joey should be contacted ASAP so that they can offer support and intervention as necessary.

WELLNESS & PROFESSIONAL SUSTAINABILITY

Dr. Louise Rang is heading up a departmental Wellness Task Group focused on COVID-19. If you are interested in helping Dr. Rang with this, please send her your name via email before Thursday 19th of March.

COVID Self Care Plan:

Create a COVID-19 Personal Plan: 

Scrub Access at Both Sites:

We are currently trying to obtain urgent en-masse access to scrubs at both the HDH and KGH site.  In order to do this, the system requires everyone’s badge numbers.  We are trying to find a quick workaround by accessing the security services database.  However, while we are working on this, could you please send your badge number to jill.mccreary@kingstonhsc.ca so that she can note these.  The 5 digit number is located at the bottom right hand side of your badge below your photograph.

Showers at the Hospitals:  

HDH duty room and Empire 3 bathroom showers will be stocked with soap, shampoo and moisturiser as of Wednesday. Towels have been ordered and will be stocked frequently. Please let Jill know if you find there aren’t enough.

Staff Outing – Tuesday 24^th of March – Lemoine point:

Staff outing next Tues 24th will go ahead (barring tsunami arrival) with a walk starting at 10am at Lemoine rather than Little Cat, and residents are welcome too. No lunch. Just a walk with appropriate social distancing. 

Email Etiquette During COVID-19:

·      Avoid all unnecessary emails

·      Avoid hitting reply all whenever possible

·      Use very clear subject lines

Regular Evening Zoom Calls:

Tuesday, Thursday and Sunday evenings at 8:00PM connect with your colleagues on Zoom via this link:  https://zoom.us/j/7437338903

This will provide an opportunity for those who want to connect for 20 minutes.  It will begin with a 5 minute meditation (headspace) and a chance to connect and discuss whatever is on your mind.

Support from Medical Students:

The link below will direct you to a google form for med students willing to help front-line staff by providing help with things like groceries and child care.  They will plan to do child care with one family only to limit spread and those that volunteer for child care have affinity for kids. They’ve asked for ages etc. 

This seems like a great initiative and I bet they are keen to do their part in whatever way they can.   If you would like some help, you can sign up using this link:

https://docs.google.com/forms/d/e/1FAIpQLSfXrWli3AkHZxuH9hFAPt1rtH5rxnGUch-L5QvK7s7PLkVScQ/viewform?usp=send_form&usp=embed_facebook&usp=embed_facebook&usp=embed_facebook

ADMINISTRATIVE STAFF UPDATE

All of the administrative team (with the exception of Jill, for now) will be working off-site.  They are all still working, and are able to access their emails and most documents from home.  Please contact them via email or cell phone. Contact details below. For urgent administrative requests, contact Jill via email or cell at 613 453 2218.