March 24, 2020
To view archives of all physician resources and communication visit www.cdha.nshealth.ca/coronavirus
COVID-19 Physician Information Update
March 24, 2020
A Message from Dr. Nicole Boutilier, Vice President of Medicine
Updated Clinical Documents
Critical Pathway for COVID-19 Positive
Pediatric Care
Virtual Care Update from DHW
To help support continuity of care for patients by their health-care provider during the COVID19 pandemic, a secure virtual care tool has been approved for use on an interim basis for all physicians and their staff, as well as nurse practitioners and allied health professionals.

Zoom for Healthcare, a secure video conferencing platform, provides high quality video even in low-bandwidth environments. Currently, about 70 per cent of homes and businesses have access to high speed internet in Nova Scotia. The tool is an easy to use telehealth solution; NSHA will provide access to online training and other supports to enable you to confidently provide virtual care appointments. It may be right for you if you:
  • need the enhancement of video to deliver patient care
  • are in self-isolation and/or available to practice remotely
  • can provide patients currently using smart phones and computers for other online services like banking, shopping and internet with the instructions they need to connect for care using the secure video tool
  • can take an online training tutorial.

Additional support is also available by phone (toll free) or by chat (within the Zoom application) if you need additional technical or training supports. NSHA will support physicians by providing language that can be used during a patient encounter to ensure patients are consenting to the telehealth visit.

Physicians are also reminded that all telehealth visits need to be charted in the medical legal record (standards of practice, medical records, NSCPSC). For information related to custodial responsibility related to personal health information in Nova Scotia, please visit the PHIA website ( https://novascotia.ca/dhw/phia/ ).

Both health care providers and patients will need access to a computer, tablet or smartphone with audio/video technology, internet or cell service and an email address. If you wish to submit an account request, visit NSHA’s website at: https://www.cdha.nshealth.ca/telehealth-zoom .

Requests will be prioritized based on immediate need. For further questions, please contact VirtualCare@nshealth.ca.

Please note that the Department of Health and Wellness has approved fee code changes to compensate physicians for providing clinical care to their patients using telephone, Telehealth and PHIA-compliant virtual care platforms. Detailed information on the fee code changes are included in MSI’s March 24, 2020 Physicians’ Bulletin.

Doctors Nova Scotia has provided a two-pager on all Virtual Care Options for Health Care Providers, view it here.
Special Bulletin
Dr. Rob Strang, Chief Medical Officer of Health
Today Dr. Strang, Chief Medical Officer of Health issued a special bulletin on COVID-19.

Updates:
- Geographic areas expanded to any travel outside of Nova Scotia due to spread within Canada
- Health Protection Act order in effect as of March 23rd
- Patients to complete the online 811 questionnaire prior to calling 811

Read the full bulletin here
PPE Update
Many physicians have expressed concern about a shortage of personal protective equipment (PPE). We have heard those concerns. Here’s what you need to know at this point in time: 
  • Supply Chain has started taking strict conservation measures to help ensure we can meet identified needs over an extended period of time. For example, stock is being distributed in quantities sufficient for one to two weeks rather than your usual supply. 
  • NSHA currently has enough PPE to meet demands.
  • Supply Chain has been planning since January for this outbreak and have been increasing and stockpiling PPE.
  • NSHA is projecting and planning for the surge in cases we know is coming. These projections are based on a number of factors, including number of expected patient encounters, settings of care, predicted number of hospitalizations, predicted length of stay, numbers of staff caring for each patient, etc. We must take steps to ensure our supply meets the coming need. 
  • Projections about need are based on appropriate use of PPE.
  • There have been some surges in demand that cannot easily be explained. ALL requests for PPE will be evaluated on the basis of reasonableness. We cannot afford to be distributing more than is needed to meet current demand, or to be using PPE inappropriately – we will need it when there is a surge in cases.

Supply Chain is taking the following steps to increase supply of PPE: 
  • Working to access federal supply of PPE
  • Reaching out to non-traditional international markets to import additional PPE
  • Preparing additional warehouse and distribution capacity to support COVID-19 needs

A working group, co-led by Dr. Alex Mitchell and Lewis Bedford, is working to ensure a provincial approach to this work. In addition, an Emergency Innovation Team led by Gail Tomblin-Murphy, VP of Research and Innovation, is exploring possible innovative solutions to help meet the need.

We will continue to keep you updated on PPE supply as this situation develops. 
NSHA Operational Update
On March 24, NSHA released its latest operational update. Read the full update. Highlights include:
  • Mental Health and Addictions 
  • Cancer Care 
  • Northside General Hospital closed until further notice
  • Cape Breton Regional Hospital ambulatory care scheduled relocating to New Waterford Consolidated Hospital
  • Blood collection 
  • Sites designated for inpatient care of patient with COVID-19
  • Assessment centres
  • Facility entrances reminder
  • Border closures 
  • Free parking reminder
Seeking Physician for Occupational Health, Pandemic Support
Expressions of interest are being sought for an NSHA physician to serve as NSHA’s COVID-19 Occupational Health, Safety and Wellness physician.

The Occupational Health, Safety and Wellness Physician will provide operational surveillance, screening and management of healthcare workers who are off work due to travel-related isolation requirements or potential exposure.

All interested parties to apply by way of resume submission and expression of interest to Katrina Philopoulos, Director Physician Recruitment at physicianrecruit@nshealth.ca. Application Deadline: March 26, 2020 (posting will be removed when filled, if sooner).
FAQ from Health Canada on Prescribing during Coronavirus Pandemic
Subsection 56(1) Class Exemption for Patients, Practitioners and Pharmacists Prescribing and
Providing Controlled Substances in Canada during the Coronavirus Pandemic

The World Health Organization’s declaration on March 11, 2020, that the novel coronavirus (COVID-19)
is now a pandemic and has marked a significant shift in the response from communities across Canada
and at all levels of government.

In response to this evolving health risk, the Office of Controlled Substances has issued a short-term
subsection 56(1) exemption from the Controlled Drugs and Substances Act in the public interest. This
exemption authorizes pharmacists to prescribe, sell, or provide controlled substances in limited
circumstances, or transfer prescriptions for controlled substances.

Specifically, and subject to the laws and regulations of the province or territory in which the pharmacist
is entitled to practice, this exemption will:
  • Permit pharmacists to extend and renew prescriptions;
  • Permit pharmacists to transfer prescriptions to other pharmacists;
  • Permit practitioners to verbally prescribe prescriptions with controlled substances; and
  • Allow pharmacy employees to deliver controlled substances to patients (at their homes or
  • an alternate location).

Health Canada will continue to work closely with stakeholders to ensure that any concerns are adequately addressed, and will continue to support the implementation of the exemption.
The following aims to further clarify the scope of the exemption on providing controlled substances during
the Coronavirus pandemic.

The use of couriers to ship controlled substances is a well-established practice. For clarity on other
options to transport prescriptions with controlled substances, please refer to the document
“ Transportation of Controlled Substances in Canada” found on Health Canada’s website. The intention
of this exemption is to enable pharmacy employees (e.g., pharmacy technicians, pharmacy staff, etc.) to
be able to assist in delivering controlled substances to those patients in self-isolation or in other similar
situations.

Updated - Lopinavir/Ritonavir and Hydroxychloroquine Approval
(Kaletra) and hydroxychloroquine (Plaquenil) are being investigated in an experimental/off label capacity for patients with confirmed COVID-19 in the setting of clinical trials. These are NOT proven to have any effect in prophylaxis or treatment at this time. Supportive care is the mainstay of therapy.

Both lopinavir/ritonavir (Kaletra) and hydroxychloroquine (Plaquenil) are currently available in limited supply and our inventory is becoming depleted in many areas of the province. To preserve our supply, we need to reserve lopinavir/ritonavir (Kaletra) and hydroxychloroquine(Plaquenil) for individuals that may require experimental treatment for COVID-19.

Patients previously taking lopinavir/ritonavir (Kaletra) for HIV have been changed to alternative therapy. Please consider transitioning patients currently receiving hydroxychloroquine (Plaquenil) for chronic conditions to alternative therapy.

Medication orders for lopinavir/ritonavir (Kaletra) and hydroxychloroquine (Plaquenil) now require approval by an Infectious Diseases (ID) specialist in the context of a clinical trial. These medications will not be dispensed unless they are ordered by an ID specialist for use in a clinical trial or ordered with approval from ID specialist for a condition other than COVID-19.

If you have any questions please do not hesitate to contact Tasha Ramsey (Infectious Diseases pharmacist) at 902-441-8181, Sarah Burgess (Infectious Diseases pharmacist) at 902-266-2703, or a member of your local pharmacy team.
Phishing Opportunities on the Rise during COVID-19
Please remember that cyberattacks like Phishing are on the rise with the COVID-19 Pandemic. NEVER enter your user name and password into a link that comes through an email. These phishing attempts are convincing and often have familiar names and even familiar email addresses. Sometimes they ask you to login to receive updates to Outlook or Microsoft programs. Our IT updates will never ask you to enter information to register for updates, they will contact you to push them out.

If you receive an email with a link that seems suspicious, it most likely is. Please send all questionable emails to reportphishing@nshealth.ca.
Beware of COVID-19 Fraud
There are situations where misinformation about COVID-19 cases is being reported in communities and to businesses, as well as fraudulent calls from people claiming to be Public Health and asking for credit card/financial information. 
  • Any notification of potential exposures to COVID-19 that need to be shared with individuals, businesses, organizations or communities will be shared officially by Public Health. 
  • When Public Health calls people to discuss COVID-19 test results or to follow-up through our investigations, financial information is NEVER asked for. If you receive a call like this asking for financial information, please do not provide your financial or personal information. 
New Occupational Health and Safety Guidelines for Staff and Physicians
This document provides instruction and guidance for physicians who are symptomatic and looking for screening or return to work advice.

View the document here
Ordering Technical Equipment
Staff and physicians in the zones are reminded to use regular procurement processes when procuring IT equipment like tablets instead of reaching out to vendors directly. There are risks associated with contacting vendors directly so all staff and physicians are reminded to submit all requests for IT equipment via the IT Service Desk so the IT Team can collect them and ensure solutions put in place are supportable.
Spectrum MD - Antimicrobial Stewardship App
Spectrum MD, an antimicrobial stewardship app, is now live and available to NSHA physicians, pharmacists and nurses. The app contains current management guidelines for COVID-19, Community Acquired Pneumonia and Influenza. 
 
These guidelines are for adult patients in NSHA. Please refer to the IWK Spectrum app for information on managing pediatric, obstetrical, or gynecologic infections.
 
You can download the Spectrum MD app to your Android, iPhone or hand-held device at www.spectrum.app/nsha.

Please note: If you do not have access to an Android, iPhone or other hand-held device, you can download the app to a computer, but you must download Google Chrome first. The app does not work with Internet Explorer.
 
The app has the feature of ‘push notifications’, which enables the posting and automatic notification of up-to-the-minute treatment guideline updates to all who have downloaded the app. The Spectrum app also contains a full listing of formulary antimicrobials with dosing guidelines and local pathogen sensitivity information. Additional treatment guidelines will be added as they become available.
Provincial COVID-19 Status Update
Measures announced today include:
  • increased testing for COVID-19 -- public health officials have begun testing all close contacts of positive cases
  • lab capacity is doubling to accommodate increased testing 
  • expanding virtual care for physicians, nurse practitioners and others so they can offer appointments to patients through telephone or video, minimizing the need to leave the house; more than 80 providers have signed up for video so far
  • 811 has increased staff and technology and is now answering 50 per cent more calls; on April 3, 811 will again double its capacity
  • enhanced infection control measures at hospitals to protect health-care workers and the public include reassigning and adding new staff to increase the frequency of cleaning and disinfection; focusing on high-risk areas and high-traffic areas and high-touch surfaces; using stronger cleaning products
  • regulated health professions can only stay open for emergency or urgent cases or to provide virtual care, as long as they can meet social distancing requirements in their waiting room or other non-clinical areas and follow the cleaning protocol
  • non-regulated health professions (such as naturopaths) must close. One exception is podiatrists who must follow the directive related to regulated health professions
  • Access Centres and Registry of Motor Vehicle Offices will start to resume operations in a scaled back, limited contact business model. Staff working out of Access Centres and Registry of Motor Vehicle offices in Amherst, Bridgewater, Dartmouth, Kentville, Stellarton, Sydney and Yarmouth will be available to help people with urgent matters by calling 1-800-670-4357. In addition, government has extended deadlines for more vehicle permits, registrations and renewals until Aug.31. Drop-off boxes for applicable services will also be available at Access Centres in Amherst, Bridgewater, Dartmouth, Kentville, Stellarton, Sydney and Yarmouth. Many of the services are also available online.

Essential service sectors in Nova Scotia, which are exempt from the five-person-or-fewer gathering rules, have been clarified and are:
  • health
  • food, agri-food and fisheries
  • transportation, including trucking, rail and transit
  • construction and manufacturing
  • IT, telecommunications and critical infrastructure
  • public services, such as police, fire and ambulances

Individual business in these sectors must still maintain social distancing and other public health protocols.

Ten new cases were identified Monday, March 23. The cases are travel-related or connected to earlier reported cases. Several of the new cases are connected to groups or families who have returned to Nova Scotia following travel outside of Canada. None of these cases are from spread within the community.

The 51 individuals affected range in age from under 10 to mid-70s. Cases have been identified in all parts of the province. One individual remains in hospital. One individual has recovered and their case of COVID-19 is considered resolved.

Public health has been in contact with these individuals and is working to identify others who may have come in close contact with them. Those individuals are also being directed to self-isolate at home, away from the public, for 14 days. 

To date, Nova Scotia has 2,474 negative test results and 51 confirmed cases.

Anyone who has travelled outside of Nova Scotia must self-isolate for 14 days. If you have travelled outside of Nova Scotia or been in close contact with someone who has travelled and are experiencing fever or new cough you should complete the online questionnaire before calling 811. The online questionnaire can be found at: https://811.novascotia.ca/

Government of Canada: https://canada.ca/coronavirus
Message from CMPA
Supporting CMPA members during the COVID-19 crisis
There’s no question that during the current COVID-19 crisis life for physicians has changed drastically. Each day, we hear from members who are going above and beyond to care for their patients and slow the spread of the virus. Please know that the Association and our over 50 physician advisors are here for you, and we empathize with you as you face this unprecedented situation. We appreciate your incredible efforts, and we recognize the stress the physician community is under.

We know that many of you are practising with scant resources. You are having to make decisions about cancelling or rescheduling routine care. You are concerned about the lack of access to appropriate personal protective equipment (PPE), and many of you are suddenly having to navigate virtual care. We know that many of you are also concerned about potential medical-legal issues arising from these difficult decisions and situations. 

We hear you, and we understand your concerns. While we do not have all the answers, please know the CMPA will be there to assist you should medical-legal issues arise from the medical care you are providing during this pandemic.

Last week, we launched the CMPA COVID-19 Hub to provide you with up-to-date medical-legal information, advice and support. We are monitoring your questions daily and we are updating and adding to the Hub as regularly as possible to respond to your concerns like the ones above. We will aim to provide clarity during this uncertain time. Moving forward, we will continue to work on the answers you are seeking.

I encourage all of you to visit the Hub when you can, and continue to contact the CMPA to let us know how we can best support you during this time.

On behalf of the CMPA, thank you to all our members for your tremendous and tireless efforts to fight COVID-19 and to care for patients across Canada.