COVID-19 Physician Information Update
May 2, 2020
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The Clinical Medical Advisory Committee of the EOC will be taking a well-deserved rest tomorrow. We are currently not planning to issue an update tomorrow but will if new clinically relevant documentation or information arises throughout the day.
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Updated Clinical Documents
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Note: Some users have reported issues accessing links in Google Chrome. IT is seeking a solution to this issue but until then, if your link doesn't work please try another browser alternative.
Order Sets, Procedures, Clinical Pathways, Guidelines and Policies
COVID Primary Assessment Centres and Secondary Assessment Centres
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Prone Positioning from Acute Admission to Critical Care for the COVID-19 Patient
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For full document with full size images and all references, click
here
Although there remains limited evidence on the best therapies for patients with COVID-19, what has been demonstrated repeatedly across the world is the prevalence of Acute Respiratory Distress Syndrome (ARDS) in this patient cohort.
Clinical diagnosis of ARDS in the Covid patient population range from 17% to 41%. Globally, critical care clinicians have noted that patients with moderate to severe ARDS appear to have responded well to invasive ventilation in the prone position; this has led to prone positioning being recommended in international guidelines for the management of COVID-19. This is consistent with previously published
evidence on the benefits of early prone positioning in patients with ARDS to improve oxygenation and reduce overall mortality.
The traditional supine position leads to:
- Over-inflation of the ventral alveoli and atelectasis of the dorsalalveoli.
- Compression of alveoli secondary to direct pressure from the heart and the diaphragm being pushed cranially by the intra-abdominalcontents.
- V/Q Mismatch – As dorsal alveoli are preferentially perfused due to the gravitational gradient in vascular pressures they are poorly ventilated and highly perfused which manifests as hypoxaemia.
The benefits of prone positioning include:
- Improved VQ matching and reduced hypoxemia (secondary to more homogeneous aeration of lung and improved VQ matching)
- Reduced shunt (perfusion pattern remaining relatively constant while lung aeration becomes more homogenous)
- Recruitment of the posterior lung segments due to reversal of atelectasis
- Improved secretion clearance
Given the evidence-informed benefits of prone positioning in the invasively ventilated patients, and the reported chest x-ray findings suggestive of early on-set of pulmonary changes in the Covid-19 patient; adopting and trialling the prone position for conscious COVID-19 patients is recommended in all in-patient care areas.
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Right/left side slightly supported to be up with pillows to the leg/hip, neck, and arm (instead of completely doing 1)
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Screening Asymptomatic Patients from a Community or Facility Cluster Prior to Surgery, Procedure, or post Ambulatory Appointment
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Patients who reside within a COVID community or facility cluster and have booked surgeries or procedures in the near future should be swabbed prior to surgery/ procedure.
Complete the
Fax Referral Primary Assessment Centre, the PAC will call the patient with an appointment to be swabbed. The referral should be sent NO MORE than one week before surgery or booked procedure. The PAC will book the appointment a couple of days in advance of the surgery or procedure/appointment date to ensure that the results are available before surgery/procedure date. Please ensure the patient knows you are referring them for swabbing because they reside in a community or facility cluster.
Patients who have attended an ambulatory appointment and have been identified as living in a facility or community cluster and have not yet been swabbed:
Complete the
Fax Referral Primary Assessment Centre, the PAC will call the patient with an appointment to be swabbed. Please ensure the patient knows you are referring them for swabbing because they reside in a community or facility cluster.
Please provide the patient with a Patient Information Sheet (Consult COVID-19 Hub for most recent version).
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Priority COVID-19 Testing Update from Pathology and Laboratory Medicine
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May 1, 20202
Priority COVID 19 testing on the GeneXpert platform is now available but with very limited availability. Instruments are in place in Aberdeen, CBRH, IWK, QEII and now at Valley Regional Hospital (VRH) and Yarmouth Regional Hospital. Note: priority testing for South Shore Regional Hospital will be provided through VRH. Colchester has received their instrument and are in the process of validating. Although the assay can provide testing results within 1 hour, total turnaround time involves collection, transport and reporting of results which is closer to 2-4 hours.
Note: NP swabs must be used however, the number of swabs are very limited and the decision to order priority testing must be carefully considered using the criteria below. The alternate throat/nares swab (Aptima) is 100 times less sensitive. GeneXpert is not validated for sputum testing.
Due to the limited availability of tests, the decision to use these tests will be managed locally and should only be used when results are required within a 6 hour time frame and cannot wait for the results from the QEII (whose TAT is < 24 hours once it arrives in the laboratory).
The guidelines for test usage below will be updated when greater numbers of tests are available. There is no backlog for the routine COVID test.
GeneXpert testing should focus on:
- Intensive care settings – discuss with IPAC before removing patients from precautions. Patients with lower respiratory tract COVID 19 infection can have negative NP results. Lower respiratory tract specimens (ET secretions, BAL) are more sensitive in this setting.
- Residents in LTC (maximum of 3) – the remainder can be tested using the routine process
- Results required by Occ. Health to make decisions regarding management of HCW (requests must be requested directly to the laboratory by the Occ. Health physician)
- Pre-transplant donor or recipient screening
Decisions will be made on a case by case basis. Once our supply chain has improved we can
revisit this guidance.
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Guidance for Removal of Droplet and Contact Precautions for COVID-19 Patients in Hospital
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Droplet and contact precautions can be discontinued for inpatients with COVID-19 a minimum of 10 days from the date of first symptom onset, provided they are clinically improved and have two consecutive negative COVID-19 swabs no less than 24 hours apart.
Patients with COVID-19 requiring ICU/IMCU care may experience complications resulting in ongoing respiratory symptoms and/or fever (e.g. ventilator associated pneumonia, line infection). These patients will be reviewed by IPAC and Infectious Diseases on a case by case basis and will require two negative COVID tests (at least one from a lower respiratory tract specimen in patients who are still intubated or have a tracheostomy) before discontinuation of precautions. Click
here to view document.
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Income Stabilization Program
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Physician Reassignment Opportunities
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In response to the unique demands of providing care during COVID-19, NSHA is organizing opportunities for physician redeployment or reassignment. These opportunities are shared to physicians by your local leadership (ZMED, Department/Division Heads, Chiefs, Network Leads, and Site Leads).
The intent in all reassignment is to match physicians to the areas and needs that best match their skills, interests, and abilities. Physicians will be matched as needs arise across the province.
To date, the following areas have provided opportunity for physician reassignment:
- Long term care
- Inpatient care
- Secondary assessment centers
- Access Clinics – Primary Care
- Emergency Medicine
- ICU/Critical Care
- Primary Assessment Center
- Virtual Care
Current needs are met but we expect these needs to fluctuate in the future. It is important to build a robust roster of available resources in the event that care needs change quickly. However, in some cases, physicians who volunteer for redeployment may not be matched as there is no current need identified.
The following guiding principles are to be considered:
- All programs will endeavour to continue current service delivery (reduced/unchanged/increased) and assist with COVID-19 care.
- Each physician has the ability to contribute to our combined effort to support pandemic response.
- Clinical work for COVID-19 patients will be performed by physicians who best meet the required skillsets and who would typically provide this level of care.
- Physicians reassignment is a voluntary program.
- Department Head (s), Site Lead(s), Zone Medical Executive Director will make every effort to fairly and equitably reassign work between departments when required.
- Reassignment request (s) may exist to provide support in another zone and will only occur if there is a critical need. Participation in these opportunities is voluntary.
- Physicians who are quarantined or ill, they may be requested to support virtual care assignments or COVID-19 planning if they are well enough to contribute.
- Please see Occupational Health guidelines for staff with chronic conditions as well as pregnant staff. These will be considered in reassignment opportunities.
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Congratulations to the team who recently opened up a Drive Thru testing centre in Dartmouth, NS.
This crew is comprised of a wide inter-professional group of nurses taking reassignment from many areas across the zone, and even coming back from retirement to pitch in. Thanks for all your hard work to get this assessment option up and running!
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The team at Valley Regional Hospital painted a Wall of Hope to help boost morale after a particularly challenging couple of weeks. The mural includes a beautiful quarantined themed poem, "Enlightenment" written by Dr. Lynne Harrigan.
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Johnny Reid's
People Like You
video dedication to NS
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Provincial COVID-19 Status Update
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Today, May 2, Nova Scotia is reporting two additional deaths related to COVID-19, bringing the total to 31. The deaths occurred at the Northwood long-term care home in Halifax Regional Municipality.
"On behalf of all Nova Scotians, I want to offer my condolences to the families of the residents of Northwood who have died due to COVID-19. I am very sorry for your loss," said Premier Stephen McNeil. "I ask Nova Scotians to continue to fight this virus through diligent social distancing, hand washing and common sense. When you are outside this weekend, taking care of your physical and mental health, please keep these things top of mind."
As of today, Nova Scotia has 963 confirmed cases of COVID-19. Four new cases were identified Friday, May 1.
"We are working very hard with the Northwood team and the health authority to isolate the virus to protect the residents and staff at Northwood," said Dr. Robert Strang, Nova Scotia's chief medical officer of health. "Please continue to follow public health directives and advice. We must all keep working as one to fight COVID-19."
The QEII Health Sciences Centre's microbiology lab completed 866 Nova Scotia tests on May 1 and is operating 24-hours.
As of May 1, there were 10 licensed long-term care homes and unlicensed seniors' facilities in Nova Scotia with cases of COVID-19, involving 239 residents and 109 staff.
If you have two or more of the following symptoms, visit
https://811.novascotia.ca to determine if you should call 811 for further assessment:
- -- fever
- -- new or worsening cough
- -- sore throat
- -- runny nose
- -- headache
To date, Nova Scotia has 29,406 negative test results, 963 positive COVID-19 test results and 31 deaths. Confirmed cases range in age from under 10 to over 90. Nine individuals are currently in hospital, three of those in ICU. Six-hundred and nine individuals have now recovered and their cases of COVID-19 are considered resolved. Cases have been identified in all parts of the province. A map and graphic presentation of the case data is available at
https://novascotia.ca/coronavirus/data .
Public health is working to identify and test people who may have come in close contact with the confirmed cases. Those individuals who have been confirmed are being directed to self-isolate at home, away from the public, for 14 days.
Anyone who has travelled outside Nova Scotia must self-isolate for 14 days. As always, any Nova Scotian who develops symptoms of acute respiratory illness should limit their contact with others until they feel better.
It is now more important than ever for Nova Scotians to strictly adhere to the public health orders and directives - practise good hygiene, maintain a physical distance of two metres or six feet from others, limit essential gatherings to no more than five people and stay at home as much as possible.
Quick Facts:
-- a state of emergency was declared under the Emergency Management Act on March 22 and extended to May 17
Additional Resources:
Government of Canada toll-free information line 1-833-784-4397
The Mental Health Provincial Crisis Line is available 24/7 to anyone experiencing a mental health or addictions crisis, or someone concerned about them, by calling 1-888-429-8167 (toll free)
Kids Help Phone is available 24/7, by calling 1-800-668-6868 (toll-free)
For help or information about domestic violence 24/7, call 1-855-225-0220 (toll-free)
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This section of our update is a list of helpful resources updated daily for physicians.
Please reach out to
Shawn Jolemore with your suggestions for additional content.
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Leadership and Wellness Poster
Updated for Week of April 27- May 3
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Individual Executive Coaching for Physician Leaders with Executive Coach Lorie Campbell
Are you struggling to lead yourself or your team(s) well during this pandemic?
Take advantage of 30 or 60-minute focused, one-to-one virtual executive coaching sessions for formal physician leaders only. Email
Lorie Campbell to book a time for this free service, provided by NSHA Medical Affairs Leadership Development.
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SAVE the DATE: Special Webinar for NSHA Physician Leaders
May 6 from 7-8 p.m.
“COVID – What’s normal? Leading through crisis and change” with Dr. Jackie Kinley and Tony Case. Presented by Medical Affair’s Physician Leadership Development
Invitation and Zoom link to be sent out to formal physician leaders via NSHA email, by Monday.
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Daily Physician Wellness Check In - COVID-19 What's Normal?
Join Drs. Jaqueline Kinley and John Chiasson for daily online meetings to chat about coping strategies and mental health concerns. Meetings are daily M-F at 12 NOON. and are open to all physicians. Click here for the
*updated* Zoom -
Join Zoom Meeting Link
New Local Website offering Support and Resources for NS Physicians
Please visit a new
website full of helpful resources and important contact information for NS physicians and their families, brought to you by volunteer members of the Dalhousie University Department of Psychiatry and Doctors Nova Scotia’s Professional Support Program.
Charge Your Battery: Introduction to Self-Care Skills Training for Healthcare Providers
With Dr. Dayna Lee-Baggley, Monday May 4, 4-5 p.m.
Communication about Substance Use
With Dr. David Saunders, Wednesday, May 6, 4-5 p.m.
Mindfulness for Physicians: Incorporating Self-Compassion
With Dr. Nicole Herschenhous, Friday, May 8, 4-5 p.m.
Addressing Grief within our Healthcare Community: Mine, Yours & Ours
Weekly on Thursdays from 9:30 a.m. to 10:30 a.m.
Join Serena Lewis and Roy Ellis (NSHA Bereavement & Grief Coordinators) as we begin the conversation of grief in our current and future workplace. This discussion will provide information on recognizing and understanding how loss is intertwined in our lives, as well as the current landscape of our community of care providing. Roy and Serena want to hear what topics will benefit you in the upcoming weeks that will support you - as you care for yourselves, your own families and within patient care.
DNS Professional Support Program
Feeling overwhelmed or need to talk to someone?
As we try to wrap our heads around the weekend’s tragic events and the senseless loss of so many innocent lives, I want to remind you that help is available. Whether you were directly connected to it or not, the tragedy intensifies the stress of the pandemic and the pressure on our lives due to the measures we are all following.
Contact the Doctors Nova Scotia (DNS)
Professional Support Program at 902-468-8215 or 1-855-275-8215 (toll-free) mail or via
email. LifeWorks by Morneau Shepell is also available to members and their families affected by the events in Portapique and surrounding communities. The crisis support line is open 24-7. Call 1-844-751-2133.
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Physician Screening for COVID-19
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Call 1-833-750-0632 to speak to Occupational Health and Safety for your screening options.
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