March 19, 2020
To view archives of all physician resources and communication visit www.cdha.nshealth.ca/coronavirus
COVID-19 Physician Information Update
March 19, 2020
A Message from Dr. Nicole Boutilier, Vice President of Medicine
NSHA is committed to keeping all physicians up to date with information from the provincial incident management team and all clinical information required to assist in our provincial response.

Reminder - Department of Health and Wellness Requests
The Department of Health and Wellness are raising concerns with the high number of requests from many different departments related to physician and medical staff issues. They will be providing us a templ ate to coordinate the multiple requests. Going forward, please send your requests through Grayson Fulmer ( GraysonW.Fulmer@nshealth.ca ) who will ensure the template is updated. This will also ensure that we are supported to coordinate with Doctors Nova Scotia on these issues.

*New* COVID-19 Admission Order Set
The admission order set for suspected cases of COVID-19 are available here.

Virtual Medicine
NSHA is expecting an announcement on a new software option for Virtual Care as early as tomorrow. To gauge physician interest, we will be collecting names tomorrow in our update. To get started early, physicians will require a NSHA email account, the NSHA email of an administrative assistant that may also be scheduling appointments on your behalf (they will require an account as well), Clinician/Patients access to a computer, tablet, smartphone, and audio/video technology.

Stay tuned for more information tomorrow.

Coronavirus Assessment Centres
Coronavirus Assessment Centres are moving locations and opening daily. To ensure you have the most up to date information about resources for your area, visit our website for a listing.

Contact information (fax referrals) and operating hours are now updated daily on www.cdha.nshealth.ca/coronavirus . This information is under the Clinical Pathways resource section.

Infection Prevention and Control
New documents are regularly added to the COVID-19 Physician site. These were added today:

Nebulized Medication Administration
An aerosol generating medical procedure (AGMP) is a medical or surgical procedure that involves manipulation of a patient’s airway in a manner that may stimulate coughing and/or promote the generation of aerosols. AGMPs are associated with an increased risk of infection transmission for diseases transmitted by droplets, such as COVID19.

Administration of medication via nebulization is an example of an AGMP that may increase the risk of infection transmission. Common medications administered via nebulization are the short-acting bronchodilators, salbutamol and ipratropium. Administration of medications via meter-dose inhalers (MDI) with an aerochamber or spacer device or as dry powder inhalers (DPIs) are NOT considered AGMPs and lead to similar improvement in lung function as delivery via nebulizer.

Recommendations and Actions effective March 19, 2020:
  • For patients requiring treatment with inhaled salbutamol or ipratropium, use of an MDI with a spacer will be the preferred mode of delivery.
  • ALL inventory of salbutamol and ipratropium FOR NEBULIZATION will be removed from wardstock and Automated Dispensing Cabinets. Exception: Limited supply in Critical Care units.
  • IF use of salbutamol and/or ipratropium using an MDI with spacer is felt to be not possible or inappropriate, consult Respirology to review on a case-by-case basis.
  • Infection Prevention and Control procedures including appropriate PPE MUST be followed if ANY medication is delivered via nebulization5 (e.g. epinephrine, tobramycin).

Resources

Self Monitoring and Self Isolation Tools

Coping with COVID Resource
For many of us, COVID-19 is creating an uncertain future. People worry about their own health,
the health of their loved ones, school, work, or finances. This is an anxious and stressful time
for everyone. It's okay to take time for your mental health – good mental health and positive
wellbeing can help you better cope during this time.


Taking Care of You
Many of us find this situation stressful. We want to ensure physicians know about supports that are there to help them and those around them.

Professional Support Program
Doctors Nova Scotia’s Professional Support Program (PSP) provides confidential peer-to-peer support for members and their families who are dealing with personal or professional problems. This may include anxiety, stress, burnout, family and relationship problems, substance-use disorders, career and life transitions, workplace conflicts, psychiatric illnesses, concerns for colleagues, and medico-legal issues.

Located across Nova Scotia, the PSP counsellors have no affiliation with licensing and regulatory bodies or related university training programs of the three professions they serve.

Contact the Professional Support Program by calling 902-468-8215 or 1-855-275-8215 (toll-free) or by emailing professionalsupport@doctorsns.com . Calls are triaged 24 hours a day, seven days a week. 
 
Occupational Health information & Guidelines for Healthcare Workers
NSHA’s Occupational Health Safety and Wellness is offering a provincial phone line for symptomatic health care workers to be able to call and be screened and then tested if required.

Video on NSHA Lab Process for COVID-19 Test

NSHA Occupational Health line 1-833-750-0632
Select your zone when prompted. Please do not call all lines.
Provide your name, phone number and brief description of how you meet the criteria for screening. Calls will be triaged based on this information.


*Updated Visitor Restrictions*
Nova Scotia Health Authority has put in place visitor restrictions at all Nova Scotia Health Authority facilities to limit the spread of respiratory illness, including COVID-19.

No visitors are permitted in any of NSHA’s hospitals or facilities except in compassionate and supportive situations in consultation with the care team. Consideration will be given to:

Supports for individuals receiving palliative care or MAID
  • One designated support person per patient for labor and delivery room;
  • Parents/ guardian with pediatric patients;
  • One support person/ substitute decision makers as required for patients needing assistance including but not limited to cancer care, some emergency, outpatient or critical care situations, discharge planning (a healthy individual to pick up discharged patients),

Visitor restrictions are a series of infection control measures put in place to reduce the risk of spreading infectious diseases which are common in health care facilities. They are designed to help keep clients, families, staff and visitors healthy and safe.

Family practice information
An updated quick reference document has been provided for use in family practices. This resource provides guidance on ensuring safety of patients, protection of providers, and reducing community spread of COVID-19. To locate the document, visit NSHA’s corporate website . It’s located under Pathway for Ambulatory Care and Primary Care Referrals to Coronavirus Assessment Centres.

Child care and COVID-19; a joint statement from NSHA, IWK, NSNU & CUPE
We understand that the decision to close schools and day cares has had a significant impact on many frontline staff. We wish to provide support and direction during this time if you are experiencing issues with child care as a result of these closures. For more information, please read this statement

Provincial Update
Measures announced today to help vulnerable Nova Scotians include:
-- investing $2.2 million so that every individual and family member on income assistance will receive an additional $50 starting Friday, March 20, to help pay for food, cleaning supplies and personal care items. People do not need to apply.
-- $1 million to help Feed Nova Scotia purchase food and hire more staff
-- no tenant can be evicted because their income has been impacted by COVID-19, effective immediately for the next three months
-- emergency funding of $230,000 for Senior Safety Programs and Community Links to help vulnerable older adults
-- university students from Nova Scotia who are still living in residences need to go home, to provide space for social distancing for those students from outside the province who are not able to travel
As announced yesterday, personal service and fitness establishments such as hair salons, barber shops, spas, nail salons, body art establishments and gyms must shut down by midnight tonight

The Nova Scotia Health Authority (NSHA) said today there was a case of low-risk public exposure to COVID-19 at two Halifax locations March 5 - 7. People who attended a high school basketball tournament at Halifax Grammar School gymnasium and the Homburg Athletic Centre gymnasium at Saint Mary's University should closely monitor their health for COVID-19 symptoms. More information at http://www.nshealth.ca/news/nsha-advising-potential-covid-19-exposure-two-halifax-locations

Anyone who has travelled outside of Canada must self-isolate for 14 days when they return to Nova Scotia. If you have been in close contact with someone who has travelled and are experiencing fever (above 38 C) and/or new cough should complete the online questionnaire before calling 811. The online questionnaire can be found at: https://811.novascotia.ca/

Nova Scotians can find accurate, up-to-date information, handwashing posters and fact sheets at https://novascotia.ca/coronavirus .


Incident Management Team: Clinical Services Advisory Representation
Central Zone
Dr. Andrew Travers, Emergency Medicine
Dr. John Armstrong, Emergency Medicine
Dr. Kevin Bent, Anaesthesia
Terry Boudreau, Industrial Engineering
Angela Bransfield, Patient Flow
Debbie Burris, Acute Care
Cathy Ann Casault, Interprofessional Practice
Dr. Janice Chisholm, Anaesthesia
Dr. Jeannette Comeau, Pediatrics Infectious Diseases
Katherine Connell, HS Director, MOTP
Dr. Ian Davis, Infectious Disease
Joanne Dunnington HS Director – Periop
Dr. David Dupere,Physician
Dr. Niel DuToit, Intensive Care
Jill Flinn, Cancer Care
Heather Francis, Cancer Care
Dr. Steven Gruchy, Physician – Internal Medicine
Dr. Todd Hatchette, Chief - Microbiology
Dr. Paul Hernandez , Physician - Respirology
Michelle Higdon, Continuing Care
Jennifer Higgins, Continuing Care
Dr. Greg Hirsch, Perioperative Program
Dr. Todd Howlett, Zone Medical Executive Director
Debbie Hutchings, Health Services Cardiology
Glenda Keenan, Continuing Care
Jean Kent, Supply Chain Operations
Jeff Kirby, Quality & System Performance
Dr. Kirk Magee, Emergency
Dr David Kirkpatrick, Surgery
Alyson Lamb, Informatics Officer
Dr. Adam Law, Anaesthesia
Sally Loring, Woman & Child Health
Tammy MacDonald, Performance Excellence
Dr. Susan MacKean, Physician Family Medicine
Dr. Shelly McNeil, Physician Infectious Disease
Dr. Chris MacKnight, Physician
Wendy McVeigh, Continuing Care
Kate Melvin, Patient Flow Cancer Care
Kaitlin Miles, Industrial Engineer – Orthopaedics
Randi Monroe, Rehabilitation
Dr. Ward Patrick, Critical Care
Tanya Penney, Emergency
Dr. David Petrie, Emergency
Allison Stevens, Cardiology
Susan Stevens, Continuing Care
Cynthia Stockman, Acute Medicine
Vickie Sullivan, Zone Operational Executive Director
Shauna Thompson, Pathology & Lab
Cheryl Tschupruk, Palliative Care
Dr. Colin VanZoost, Internal Medicine
Noella Whelan, Interprofessional Practice
Kathleen White, Emergency
Dr. Tony O’Leary, Critical Care
Dr. Ata Quraishi, Cardiology
Dr. Kenneth Rockwood, Physician
Lori Sanderson, Nursing
Marcy Saxe-Braithwaite, Periop/Surgical Services
Dr. Christine Short, Medicine
Dr. David Simpson, Physician
Chris Smith, Project Services & Performance Improvement
Northern
Dr. David Henderson, Senior Medical Director – Palliative Care
Cheryl Northcott, Zone Operational Executive Director
Mark Scales, Continuing Care
Dr. Ryan Sommers, Zone Medical Executive Director, MOH

Western Zone
Dylana Arsenault, Interprofessional Practice
Dr. Lois Bowden, Site Lead – VRH
Dr. Melanie DiQuinzio,Physician
Peggy Green, Admin Site Lead YRH
Andrena Hull, Health Services – AVH
Bob Jenkins, Continuing Care
Dr. Ryan Kelly, Physician
Nancy MacConnell-Maxner, Interprofessional Practice
Wanda Matthews, Zone Operational Executive Director
Dr. Cheryl Pugh, Zone Medical Executive Director

Eastern Zone
Dr. Tania Sullivan, Physician – Emergency
Kathy Chisholm, Administrative Site Lead - SMRH
Samantha Hodder, Mental Health and Addictions
Darlene LaRusic, Patient Flow
Dr. Chris Lata, Physician Emergency
Brett MacDougall, Zone Operations Executive Director
Jennifer MacDougall, Interprofessional Practice
Cindy MacQuarrie, Interprofessional Practice
Bethany MacCormick, Planning, Performance & Accountability
COVID-19 Related Service Delivery Changes
To see a running list of all clinic and services disruptions, visit www.nshealth.ca and seek out the closures link in the bottom left of the page.

General Internal Medicine
Due to our anticipation of an influx of inpatients with COVID-19 infections, the Division of General Internal Medicine will not be accepting non-urgent ambulatory referrals at this time given the urgent need to reallocate our workforce capacity to acute inpatient management. This will be re-evaluated on April 15, 2020 with high likelihood of a prolonged extension. We are also cancelling all non-urgent follow-up appointments.

Semi-urgent and urgent referrals will still be accepted. In order to reduce the risk of transmission, whenever possible non-face-to-face consultations will be undertaken. Please advise your patients that these assessments will be conducted virtually by phone or video visit unless it is certain that a physical examination would alter our recommendations.

We will continue to be available on call in the case that you require our urgent assistance. We will also be offering phone consultations for non-urgent referrals if you feel that specialist advice is required within the coming weeks. If you would like to arrange a phone consultation, please fax a request to (902) 473-8430 with the referral question and your general availability. We ask that you please not page our on-call staff for non-emergent issues given that our limited capacity will be dedicated to the care of acutely ill inpatients.

Common indications for non-urgent referrals to our service include but are not limited to: chronic fatigue, asymptomatic lab abnormalities, palpitations without red flags, chest pain in young people with no risk factors or red flags, chronic stable anemia, hypertension, abdominal pain without red flags, and fatty liver. If a referral is received that we deem to be non-urgent, you will receive a notice from our office confirming that it will not be accepted at the present time.

Thank you for your collaboration and understanding.

The Division of General Internal Medicine
Department of Medicine, Dalhousie University

Frequently Asked Questions
*new* What is the direction for use of Nitrous Oxide?
Infection Prevention and Control asks that use of Nitrous Oxide be prevented.

Is Electroconvulsive therapy (ECT) service in mental health considered elective?
No ECT is not considered an elective procedure. 

Do we have to close clinics that are in buildings attached to the hospital but not NSHA clinics?
Doctors offices can remain open, currently this guidance is just for ambulatory clinics. We are asking doctors to pre-screen patients for COVID-19 to avoid those exhibiting symptoms presence in your offices as much as possible. If you are unable to maintain the 2m distancing required, you must have PPE in accordance with droplet contact precautions. We are aware of PPE shortages and a solution is being explored.

Are we cancelling walk in clinics at hospital facilities?
Further instruction on these care settings is expected tomorrow.

Does a COVID-19 positive patient require an Internist as the most responsible provider?
No. The most responsible provider will be decided dependent on the clinical setting and need of the patient. 

Guidance on particular procedures and timing of checkups for Obstetricians?
See the guidance from the Reproductive Care Program of Nova Scotia above.

We have had some questions from Mental Health and Addictions about provision of ECT and whether it is considered “elective”?
We are currently seeking direction from the Mental Health Working Group on ECT for outpatients. 

What is the update on Nitrous Oxide as an aerosolizing procedure?
We are seeking clarification from the EOC working group on this one.

Are all who may be required to be present during an aerosol generating procedure familiar with correct application and removal of PPE? Would we have enough equipment to carry out mandatory drills? Is this important enough to do in place of elective non-urgent ORs?
There are resources on our physician site with donning and doffing PPE ( www.cdha.nshealth.ca/coronavirus )

NSHA Procurement is looking after supplies and there is enough PPE currently but we are asking everyone to leave stock in place until needed. Re-stocking is taking place throughout the week. 
We are not recommending using PPE for drills at this time to conserve for when needed most.

Equipment: Where is PPE kept and who is responsible for ensuring stock?
PPE is kept in the usual supply areas in each site. Our provincial supply chain group are part of the EOC and they are ensuring adequate stock.

Are health care workers with family members or roommates self-isolating after returning from outside country required to self-isolate if they didn’t travel?
Not at the current time. Please ensure your family member is monitoring symptoms regularly and if they exhibit symptoms be sure to notify Occupational Health Safety and Wellness Line immediately. 1-833-750-0632.
We are asking all staff and physicians to not call 811 and to not present at Coronavirus Assessment Centres.

Will we be able to start moving LTC patients out of our facilities as we plan for surge?
Site teams around the province are working on business continuity plans and this involves moving all patients within the realm of what is possible and safe.

Why aren’t we screening patients who are traveling within Canada, coming from sites with higher incidence of COVID-19?
Current public health guidelines are not calling for this screening as there is low evidence of community spread in Canada. As information is evolving this directive may change and we will keep you up to date.

Is there a resource for Patient Self-Screening for COVID-19?
Self-Screening guidelines are available on 811 website

What is the difference between self-isolation and quarantine?
All NSHA staff and medical staff arriving from out of country travel after March 13, 12 noon, are required to self-isolate for 14 days.
Yesterday we posted definitions from Health Canada that were confusing and contradictory to the directive for health care providers and public servants who have traveled out of country. We apologize for that confusion.

A revised answer as it relates to our situation is below:

Isolation refers to an individual with symptoms and quarantine refers to exclusions in persons without symptoms. However, the mainstream use in the current context has meshed these two terms.

The goal of quarantine is to prevent any transmission if one becomes minimally symptomatic. The measures listed under self-isolation on the Public Health Agency of Canada website would be considered the ‘gold standard’ to prevent transmission. Practically, the full extent of these measures may be unrealistic for the asymptomatic returning traveler. The DHW resource is a more practical example, where the asymptomatic returning traveler would stay in their own home, avoid visitors, and avoid close contact with vulnerable people. https://novascotia.ca/coronavirus/#help

This can be further complicated for health providers who are returning from travel outside the country and have to consider their partners, spouses, or other housemates. The best advice would be to self-isolate from other members of the same home (or at a separate location if possible) or ask those members to self-isolate or work from home and avoid contact with others as much as possible during the 14 day period as well.

To appropriately self-isolate:
  • Avoid close contact with people with chronic conditions, compromised immune systems and older adults.
  • Don’t have visitors to your home.
  • Avoid situations like social gatherings, work, school, daycare, or visiting other people who are in a health care facility or long-term care residence.
  • Limit taking public transit, taxis and ride sharing.
  • Wash your hands often with soap and warm water, for at least 20 seconds. Use hand sanitizer if soap and water are not available.
  • Cover your mouth and nose with your arm when coughing or sneezing.
  • The Government of Canada has additional resources about how to self isolate and how to care for someone with COVID-19.
 
 
Why can’t physicians returning from travel just be swabbed/screened and then return to work sooner than the 14-day advisory?
This is a provincial guideline, similar to other jurisdictions in Canada. Although the incubation period is on average 5 days, there are cases that have presented later so swabbing on arrival cannot predict who might be incubating infection and present at a later date that could lead to exposure of others. We are taking all measures to prevent potential exposure to patients who may be a higher risk of complications and care providers who are crucial to our provincial response.

I’m a doctor and I’ve traveled outside Canada and am now symptomatic, what do I do?
Leave the workplace, self-isolate, and contact Occupational Health and Safety Line to discuss 1-833-750-0632.
We are asking all staff and physicians to not call 811 and to not present at Coronavirus Assessment Centres.