March 23, 2020
To view archives of all physician resources and communication visit www.cdha.nshealth.ca/coronavirus
COVID-19 Physician Information Update
March 23, 2020
A Message from Dr. Nicole Boutilier, Vice President of Medicine
*Updated* Pre-printed Order Sets for Admitting COVID-19 Patients
These documents are changing regularly, please check www.cdha.nshealth.ca/coronavirus for the most up to date clinical support documents daily.

Clinical Guidance Documents Posted

Physician Referral to Coronavirus Assessment Centre Resources


Emergency Department Clinical Flow Pathway for Enhanced ED Testing
In addition to those people who have symptoms and clear risks of exposure to COVID-19 (travel or contact with a case or suspect case), Emergency Departments across the province have begun testing patients who present with symptoms of respiratory viral infections (fever or cough) for  COVID19 regardless of travel or exposure history as part of enhanced surveillance. This is an attempt to detect a signal suggesting community spread.
 
Public health will follow up on all COVID test results and patients should remain in self-isolation until contacted by public health who will give further direction on isolation once the test result are available. 
 
Influenza test results will be reported back to the Emergency Department who will follow up with patients as necessary as per current practice .
 
We will continue to monitor testing volumes to determine if this approach needs to be modified.

Page 2 (Image below)
This diagram provides guidance as to how patients who have suspected and confirmed COVID should be placed within the COVID unit. The principle of separating suspected and confirmed patients on a unit and having separate direct care provider teams caring for these patients should be applied to minimize cross contamination. There may be slight differences depending on zonal and operational requirements in application of these principles.

Naming of COVID-19 Health Services and Inpatient Units
The Medical and Clinical Advisory Group of the provincial Incident Management Team have refined the terms to be used in the documentation of guidelines, communications, and any NSHA related material.

Here are terms to ensure common language:
  1. Primary Assessment Centres: These are the centres within (or near) our facilities that receive 811-referred patients for assessment and testing for COVID-19. 
  2. Community Primary Assessment Centres: These are centres in the community that receive 811-referred patients for assessment and testing for COVID-19. 
  3. Secondary Assessment Units: These are units, centres or wards for further assessment of patients who were tested for COVID-19 and referred for further follow up and assessment before being referred to convalesce at home. 
  4. COVID Inpatient Units: these are units to support COVID-19 patients who require admitting to hospital for stabilization and treatment. 

Family Practice Update
Tonight, the Department of Family Practice issued an update for primary care physicians that included advice on:
  • Telephone triage of patients before attending clinics
  • Telephone prescribing
  • Virtual care update
  • Altering office schedules and limiting physical exams
  • Advice on PPE and office cleaning

View these details and more here.

*Updated* Family practice screening guidelines
New screening guidelines for family practitioners are posted here. Note: These documents change frequently, if you want to ensure you are seeing the most recent copy, visit www.cdha.nshealth.ca/coronavirus

Personal Protective Equipment Update
We are receiving lots of questions and concerns about the use and availability of personal protective equipment. We understand your concerns and want to assure you that your health, safety and wellness is, and will continue to be a top priority as we respond to this pandemic.
                                  
We understand how important it is that we consistently use the right protective equipment in the right situation, and that our teams have confidence that they can get the equipment they need when they need it. We have put a number of processes and protocols in place to protect staff and physicians and are actively working to address your outstanding concerns. An operational and medical co-lead working group are being brought together to identify what equipment is required for various procedures and what are our supply options, as well as providing clear direction on who and when to use it. This is an organizational priority and we will share more details as decisions are made. 
Virtual Care
To help support patient care and health care providers in the current COVID-19 pandemic, Telehealth Zoom has been approved as a virtual care platform for use on an interim basis for all health care providers (physicians, nurse practitioners, allied health professionals and staff). Telehealth Zoom is a secure, web-based virtual care video conferencing platform. For more information, please visit https://www.cdha.nshealth.ca/telehealth-zoom. Questions can be directed to VirtualCare@nshealth.ca. 

Invitation to Apply - NSHA Occupational Health Physician - 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).


Advice to Family Practices regarding Social Distancing in Office Settings 
A Message from Dalhousie University Department of Family Medicine

Social distancing in all settings including health care is an essential strategy to reduce the spike and flatten the curve of COVID 19 cases in Nova Scotia.

To support this strategy and protect our communities and residents, family physician teaching practices and clinics that have residents must ensure virtual/phone contact by health professional with booked patients prior to their appointments or upon request for appointment. This virtual/phone contact would enable deferral of routine visits, provision of advice where physical exam is not required, renewal of prescriptions, direction to COVID-19 sites as appropriate and clinical assessment of the urgency to be physically examined and seen in person. Our clinic’s experience is that this would result in very limited occasions for in person care thus maintaining social distancing.

This virtual/phone care provided by resident physicians will continue to provide important educational opportunities, while ensuring that we as first line providers are following best practices for social distancing.

Thank you for your attention to this important strategy. Please let us know of ideas and approaches that you have found that enable this so we can share with others.

*Updated* Traveling Airway Management RoadShow Just in Time for Truro 
Last evening we ran a story about the team of individuals in Truro who took part in airway management training and simulation. We received excellent feedback and a request to give credit to the many dedicated members of the training team, including physicians from emergency, internal medicine, anesthesiology, respiratory therapists and nurses. 

“Anesthesia are the first line intubators on most if not all COVID-19 intubation teams and I feel they really deserve the “ shout out” in this story.”  

The team also wanted to bring mention to Dr. Tania Sullivan at St. Martha’s Regional Hospital in Antigonish for all of her work and leadership around ED simulation.  

“Dr Tania Sullivan has been doing simulation training of teams of doctors, nurses, and RTs on Covid intubation. She has worked tirelessly to bring the Covid policies and protocols into play at St Martha’s Hospital.” 

Thanks Dr. Sullivan and all our exceptional physicians and physician leaders across the system. If you have stories of great team members across the province, please share! 

Lopinavir/Ritonavir and Hydroxychloroquine Now Requires Approval from Infectious Disease
(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.

Fit Testing Challenges
With guidelines changing so rapidly, there are increasingly new groups of physicians and health professionals who will require fit testing. This is a high priority and a working group has been formed to help address the challenge of our need to have all required care providers fit tested. Infectious Disease, Ethics and Infection Prevention and Control will support Occupational Health and Safety and provide a plan in the coming days. 

Canadian Society of Physician Leaders Daily Zoom Check In 
As a psychiatrist who treats physician colleagues, Mamta Gautam says she feels there is little she can do to help in the front lines. She has decided to begin hosting free daily Zoom calls to offer mutual peer support to colleagues as we deal with COVID-19.  Zoom call, at 4 pm EST for 1 hour - email mgautam@rogers.com for access. Please feel free to drop in, as often as you want, for as long as you want. No commitment. This is not therapy or psychiatric care, just peer support.
Feel free to share information and invite others, but ask them to email me directly for entry information.

Status Update 
To date, Nova Scotia has 2,308 negative test results and 41 confirmed cases.Thirteen new cases identified Sunday, March 22. Cases are travel-related or related to earlier reported cases. Several of the new cases connected and involve groups or families who have returned following travel outside of Canada. 41 individuals affected are between under ten to mid-70's. Cases identified in all parts of the province. One individual remains in hospital. At this point, there has been no confirmed spread within communities. Public health has been in contact with these individuals and are 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.

QEII Health Sciences Centre's microbiology lab now certified to report positive and negative tests for COVID-19. Tests no longer sent to National Lab in Winnipeg. 

Please use Appropriate Process to Procure IT 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.
 
Enhanced Teleconference Line Commands
For those using Bell’s conferencing service during this time, a variety of commands are available to enhance your teleconference experience. View commands. If you need further information, please see this in-depth guide.

Medical Equipment Inspections 
All medical equipment technology purchased and supported by the Biomedical/ Clinical Engineering department entering NSHA facilities must be subject to an incoming inspection to ensure safe operation prior to use by clinical personnel.

The incoming inspection checks will ensure:
  • That the equipment meets the manufacturer’s specifications,
  • Compliance with federal and provincial regulatory requirements and NSHA Standards, and
  • Patient safety

Please inform all departments to notify Biomedical/Clinical Engineering if medical devices were received directly by the units.