As reported by CTV news on April 23, 2020, the Ontario Nurses’ Association (ONA) won court approval for nurses in long-term care (LTC) homes to gain better access to personal protective equipment (PPE). Ontario Superior Court Justice E.M. Morgan ordered the operators not to impede the nurses’ professional opinions on when PPE are needed. “Nurses are not to be impeded in making an assessment and determination at point of care as to what PPE or other measures are appropriate and required,” wrote Justice Morgan in the decision. The ONA said in a statement that the ruling means homes are required to respect the professional and clinical judgement of nurses when deciding how to protect themselves.
This story similarly reflects some of my experiences on the COVID-19 frontline. The Seniors Mental Health Unit (SMHU) at Mississauga Hospital is similar to LTC homes except that it is much smaller and the patients are much more ill. Vulnerability to spread of infection is even greater than in LTC. That is why, with the announcement of community spread of COVID-19, I implemented a no visitation policy on the unit despite the hospital’s policy at the time permitting one visitor per patient. This was accepted grudgingly by hospital administration, who nevertheless expressed displeasure with my independent decision-making. Two days later, the hospital followed suite with the no visitation policy.
I later recommended that staff wear masks in the SMHU, for fear of potential community COVID-19 exposure by staff who could inadvertently be asymptomatic carriers and expose patients to the contagion. Two days later, the hospital followed suite by upgrading the requirement to staff to wear masks in all clinical areas.
One of our patients who had been recently transferred from a medical floor to the SMHU was ready for discharge back to a LTC home. The MOH & LTC policy at that time was patients returning to LTC from hospital would require isolation in LTC for the next 14 days, but did not require COVID-19 testing if asymptomatic. Nonetheless, I ordered the COVID-19 test to reassure the LTC home. Lo and behold the test came back positive. Soon after, all patients being discharged from hospital to a communal environment were being tested prior to discharge.
A patient on SMHU developed an acute delirium with none of the known COVID-19 symptoms, thus testing was not mandated as per policy at that time. However, reports out of LTC homes was that delirium with no respiratory symptoms could be an initial presentation. We tested this patient for COVID-19 and sure enough the result was positive. Now all elderly patients with abrupt change in clinical status for any reason are tested for COVID-19.
I can understand the concerns the ONA had that required a court action to get access to PPE. My experience is that the response to COVID-19 in healthcare has been incremental, based on administrators’ concern for lack of access to PPE resources. The decision to incrementally increase use of PPE resources as we have done in hospitals was in anticipation of inadequate supplies that would be needed to treat the so-called “surge” of patients – which never came, thanks no doubt to the implemented travel restrictions and social distancing measures.
I fully appreciate the concern that the ONA had that resource allocation by administrators was leading the determination of standards of clinical care rather than the other way around. I was pleased to read the outcome of this case that emphasised the importance of clinical judgement.
Unfortunately, community exposure to COVID-19 amongst healthcare workers undoubtedly lead to asymptomatic carriers who precipitated the introduction of COVID-19 into LTC homes. The lack of initial availability of PPE in LTC compounded by the need for close contact during direct personal care of most patients and the tremendous challenge to isolate exposed patients in LTC as compared to in hospitals, undoubtedly perpetuated the spread of infection.
The SMHU team’s experience on the COVID-19 frontline has included a range of emotions including shock, angst, fear, dread and sadness. However once we were outfitted with full PPE, we quickly accommodated and anxieties came down. The same will be true for the healthcare staff in LTC.
On a final note, working on the frontline has been demanding and stressful. I am the designated shopper while my family is in isolation. Trying to shop for the family after work became too difficult when stores started limiting entry resulting in long lines. One night after work, while desperate to get into Costco and confronted by a line-up that would likely have prevented me from accessing the store before closing, I introduced myself as a healthcare worker and pleaded for mercy to allow me entry, which they did. Two days later, Costco policy was updated to allow immediate access to healthcare workers.