FAQS JUNE 26 TOWN HALL (LTC)
Testing, Symptoms and Transmission
- Have any staff contracted the virus after the outbreak was called, or is all the infection linked to transmission pre-outbreak?
We can never be 100 percent sure exactly when and where people contracted the virus. There is community transmission as well; however, it is likely that some of the staff did contract it in the facility. We do know that the residents who were positive shed the virus. None of us is perfect at PPE, and we can always improve. For example, when doffing people could accidentally get a bit of virus on their hands and then touch their face inadvertently. That's why it's very important to reach out to the infection control team and also to support one another if we see each other lapsing in these practices.
As time goes on and we get past that first incubation period, it becomes more likely that if new staff infections develop, then they likely acquired the infection after the outbreak was called. And so at this point, with any transmissions, we need to pay close attention to how they happened and we need to do contact tracing.
We want to support as much as possible to make sure that we help limit the spread of this virus.
- Any plans to routinely test asymptomatic staff?
In the media there’s a lot of concern around asymptomatic individuals. Asymptomatic cases are very rare, we don't see them that often. They do happen, but they're not driving the majority of the outbreak. In a situation such as this, we want to make sure we keep a low barrier for testing. We do blanket testing of the residents, the reason being that older individuals don't tend to show symptoms quite as quickly because they are older and their immune systems don't react quite as much as younger individuals. That is the kind of testing that we will do for long term care facilities. In terms of staff, we don't generally do asymptomatic testing, the reason being that it creates a lot of false positives. There won't be routine asymptomatic testing, but there is always testing available.
The biggest challenge of COVID is that a lot of the symptoms are very mild. Some of the symptoms are very obvious and we can measure them, such as fever, and we can see things, such as cough. But if people have headache and fatigue and a bit of muscle aches, then you can easily access testing. Stay home if you wake up with those symptoms, go to a testing site, and then go back home and wait until you get your results. Testing is available when people need it, and that’s far more effective than offering routine testing, which can give people a false sense of reassurance if they do get a negative. Because if you are negative on a test, that doesn't mean you couldn't get COVID, or that you couldn’t be incubating.
- What is the cause of the most recent transmission of the virus; the newly identified positive tests? What are we missing? residents wandering into other rooms?
During the first incubation period we're going to see an initial cluster, and that's what we're seeing with the epidemic curve, kind of a peak. We have ongoing cases being detected after the first incubation period, however these incubation periods, although we define them as 14 days, are not precise – there is going to be a range. As new residents develop symptoms and acquire infections during the first 14 days of what we think is the incubation period, there's always that possibility of overlapping incubation periods as new residents become infected.
As to the cause of the most recent transmission, at this time it's not entirely certain. As with every case that we identify, we do look back and try to identify all the pieces of data that can help us be more certain of the route of transmission. All outbreaks should be documented, all our interventions are documented, and our plan for infection control is to continue to document this but also share with you the outcomes transparently. In outbreak reporting there is a standard that allows individuals involved in outbreak investigations to transparently document what's occurred, what we think are the routes of transmission, what we've learned so that we can apply those learnings to subsequent outbreaks. Our commitment in infection control is to work with public health and the staff at Holy Family Hospital to provide this information. In the meantime, our focus is on the practices that will prevent further transmission in the facility.
- What was the source and pattern of the virus spread without disclosing confidential information about any person(s)? What has the contract tracing taught us about the outbreak and spread at Holy Family?
As far as we know from the data we have so far, the initial case was identified in a health care worker and the second case was identified in a resident. It appears that there was importation of the virus from a health care worker into the facility.
Because manifestations of the disease are quite variable, and particularly in the frail, elderly, it's not easy to identify one particular sign or symptom that will verify a person has an infection. Through the initial testing of all residents during the first two days after the outbreak was declared, we identified a population of residents who had mild symptoms and had confirmed infection. Subsequently, we did repeat testing on residents who displayed any kind of symptoms of concern and, of course, we identified more. Those initial residents identified in the first 14 days of the incubation period are thought to be related to initial infection and then transmission among residents as well.
We know that with COVID, on average, one individual can infect between two to three others. Because of the close proximity of residents, and despite our best attempts at physical distancing, we know that transmission through fomites, or inanimate objects, as well as contact with individuals, is a risk, and droplets are also a risk.
We identified that after importation of a case from a health care worker, there may have been several residents who had infection and then subsequent secondary transmission from residents to other residents because of the close proximity. This is not unlike other documented outbreaks.
For each of these cases we are trying to identify resonant characteristics. Retrospectively, we'll also be able to gather more information. As we get information about the residents’ comorbidities and their mobility, we may get a better understanding of the links between the transmission.
Some other things we're doing include a whole genome sequencing of the viruses that we have identified. The point of that is to use microbiology to help verify some of our initial hypotheses on how the infection is transmitted. That's just one tool, and in outbreaks it's not possible to be 100 percent certain about transmission routes. However, we know that in general the transmission routes are related to contact and droplet transmission. Using those fundamentals of transmission routes and mapping out the temporal development of symptoms, and proximity of residents and various interactions, we are able to identify retrospectively some of the transmission events that occured within the facility.
- After this outbreak is over is there a way to petition the MOH to lessen the restrictions on family visits, of course in a safe manner? Families are heartbroken. Some families have said that the cure (restricting visitors) was not worth it. Look what happened. They want to see their loved ones.
It is an absolute challenge right now. These policies went in place early on when we wanted to get these outbreaks under control and we wanted to protect our loved ones. The real challenge, now that we're getting through the initial phase of COVID, is how do we move forward? Because we can't eliminate the virus; we have to learn how to live with it. But at the same time, how do we protect vulnerable populations, such as in long-term care. These policies are provincial and so the Provincial Health Officer works with the Ministry of Health to determine these policies. They are planning on updating visitation policies, and Fraser Health released some further details just recently. Hopefully we can follow suit and we can define how we can better allow people to see their family members, while also keeping everyone safe.
Given that this is a situation that isn't going to resolve quickly, we need to make sure that the detrimental effects associated with trying to lock down these facilities to protect people are balanced with the benefit of people being able to see their loved ones and live a good quality of life. We are working very hard behind the scenes to set up practices to make sure that that can happen.
Resident Health and Safety
- Some families are concerned that the MHO has the final say about transfer to hospital. Where does that leave person-centred care? Is there a right to appeal?
It's not our intention to stand in the way of any care that individuals may need if it meets their goals of care and we can't provide it in the facility. The reason why the MHO is involved is because we have to make sure we protect our acute care facilities as well. The MHO coordinates with our hospitals, if an individual needs to go there, to ensure that the hospital is prepared and we don't accidentally expose other people, either in transit or when they get to the facility.
Ultimately, the decision around transferring to acute care is important, and it’s between our GPs, the substitute decision makers and the residents themselves. If it is decided that those services are required, we will facilitate transfer. The job of the MHO is to make sure that it happens safely.
We're not saying the doors closed, but we have to be careful in opening that door. These are individualized conversations and individualized situations. We absolutely want to support the resident in their goals of care as best as we can.
- What more can be done to support the residents who are feeling isolated, bored and fearful? Any thoughts outside the box that we are not already doing?
Something we're always thinking about, even pre-outbreak, is ensuring our residents have meaningful lives and are engaged in daily activities. It's especially challenging now. All the things we normally talk about in terms of the social model of care are just not as easy to achieve right now. Staff are doing everything they can to engage with residents. Our rehab team have adjusted their schedules so that they're available, seven days a week, to support our residents. We do FaceTime calls to family. Just yesterday our social worker had a brilliant idea that our residents FaceTime each other because they're missing each other. We have increased our radio show with Melissa and Brock’s leadership.
The most important thing residents need is some human contact. Even with PPE, the human contact can still exist: the smile behind your mask that they can see in your eyes, the bit of conversation that you have time for. Please take those moments. It's hard when you have so much to do and everything takes longer, but our residents need that human connection.
- To avoid unnecessary hospitalization, why not provide the temporary possibility of administering an IV for rehydration or antibiotics on site?
This is a care home and intravenous antibiotics, or any other medication administered intravenously, even rehydration, is not a service that is done in any long-term care facility. We do have some capacity for hypodermoclysis, but this is only used for a few select cases when consistent with the goals of therapy.
Often these are elderly, frail seniors, which is why they are in the care homes, and intravenous therapy does not necessarily alter outcomes. Generally we don’t give antibiotics or give intravenous rehydration in the care home because it's not feasible staff-wise, and it's not consistent with what we're doing in the home.
In some circumstances, not all, it might be appropriate for acute care hospitalization, but this would be determined in consultation with the resident, the family, the goals of care, and the attending physician.
- Are we starting to look at whether some residents have recovered from COVID?
The way this has worked in a lot of long term-care facilities is that we do clear people, clinically, after a certain amount of time. The majority of people that get COVID, even older individuals, do recover and have generally mild symptoms.
There's different criteria you can use to clear people. A lot of people try to use test-based clearing, but that’s difficult because people will continue to test positive for a very long time, long after they're no longer infectious. So the best way to do this is to pay attention to people's symptoms. Once their symptoms have returned to baseline and everything else is clear, and we're beyond 10 days since the initial infection, then we clear those individuals. Some individuals with weaker immune systems can be infectious for longer than the average individual, so we always add a bit of extra time and we will not clear anybody until we're very confident that they're no longer infectious. There have not been any transmissions from individuals that we have cleared at any other long-term care home so we’re confident with the approach.
We now across BC have a cohort of 2000 people who have recovered from COVID. There is a lot of research from many different disciplines going on to support those individuals, to help them if they have ongoing issues from COVID, and also to learn. The more we learn, the more we can be prepared for second waves and the future of this new world that we live in.
- Is nebulizer use permitted in HFH and if so, are n95 masks being provided?
Nebulizers can generate aerosols, so that means they can make the virus airborne for a period of time. Nebulizer use is permitted if a resident requires it. We identified an individual early on that required nebulizers, so that individual was moved to a private room. Even though they were COVID-negative at that time, it was preemptive to make sure that if they became positive, others would be protected.
We have switched that particular individual to non-nebulizer equivalent therapies. As long as people are able to tolerate those, then that eliminates any kind of risk for aerosolizing the virus. N95 masks of course are provided. That particular room, we've turned it into a negative pressure room with enough air changes per hour to make sure we protect people as much as possible. So nebulizer use is permitted if it's if it's required. We don't want to get in the way of care, but we are also paying attention to the risks that certain types of care can provide.
The list of these aerosol generating medical procedures is very long, but we’ve assessed Holy Family and, other than nebulizer use, we have not seen any other procedures that fall into that list. If you are unsure whether a procedure is aerosol generating, please ask the infection control team or the leadership at Holy Family.
Staff Supports and Wellness
- Can the support line also include a spiritual care therapist for those who would prefer spiritual counselling and prayer? We already have on-site support.
- The Staff Support Line has people who are trained in Psychological First Aid, so not spiritual health and counselling. We do have that support available both on-site and through our Spiritual Health department, and that would be the best way to access this service, particularly as we don’t yet know how long the Support Line will be maintained.
- We want to recognize the outstanding leadership of Rae Johnson. How can we support her? I think she is working 24/7 and would hope that she gets some rest.
- Rae really appreciates that support from her team. There’s an important issue here, though, in terms of working 24/7. None of us should or can do that. There are moments when we all feel like we have to be superhuman and the sad truth is we aren't. So it's incumbent on all of us to ensure none of this is a one man or one woman show. We need to collectively work together as a team because together is the way we get through this.
- We don't have adequate breaks areas? Too small for safe distancing. Summer is not a problem as we can go outside but in the winter? Permanent outdoor tents?
- We will have to explore how breaks can be taken in inclement weather. This won’t be unique to Holy Family Hospital, but will need to be explored at all of our facilities, so we don’t have an answer just yet.
- There are 0 cases on 2nd floor Rehab. Can staff from the 2nd floor still be able to stay at the hotel we are at right now even when the outbreak is over on our floor?
- For now, ‘all staff’ at HFH are eligible for Temporary Staff Accommodation. We will communicate directly with staff using TSA if the criteria for eligibility change.
- Can we employ paramedics to assist us like in parts of Ontario?
We have our physicians following all their cases and talking to our staff. We have our infection control specialists. We have assistance from the geriatric medicine group to provide additional assessment for residents. We're not feeling a gap in terms of the assessment of our residents and haven’t considered paramedics at this time.
The important message is that we're trying to ensure that the long-term care team and Holy Family have every support that is required in terms of staff from a number of different professions.
Staff Health and the use of PPE
- Do you believe that all staff shouldn’t be living at home or seeing others. Do you believe that if we do proper PPE we can continue with BC’s restrictions?
If you're working in the facility and you're using PPE appropriately then you won't be exposed, so there is no risk to individuals. Unless there is an exposure, the same recommendations would apply to our staff as to any other BC resident. It’s important we have that human connection and that sense of normalcy among our staff. This is very much a marathon, not a sprint, in terms of the greater pandemic. We have to learn how to live with that new normal without overly restricting ourselves so we can still function and still feel human. If there are any breaks in PPE, please do let us know. We're all human, we do make mistakes. But otherwise, if you’re using PPE appropriately, there shouldn't be any other restrictions.
Providence has offered hotels for staff to make their lives easier and to reduce some anxiety. Lots of people have taken us up on that offer, but it’s not compulsory and it’s not an instruction from public health. It’s entirely voluntary.
- If PPE practices are done, why would we still have new staff cases? Are we missing any new transmission method to stop, as we learn more about COVID-19?
With infection control we focus on some of the basics: hand hygiene, use of personal protective equipment, and point-of-care risk assessment. These practices have to be done in conjunction because no practice alone is sufficient in preventing transmission, and the degree to which PPE is preventing transmission is only successful when done according to practices and in conjunction with the other practices.
As humans, we make mistakes. This is why we have to remind ourselves that to provide safe care for our residents, and for each other, we have to support each other. Donning and doffing PPE is a challenge so we encourage staff to work with each other and help each other.
When health care workers get infected, each case is reviewed by Public Health. There is a careful interview to explore whether there were any breaks in PPE or other infection control practices that would have led to the infection.
We can't discuss individual cases at Holy Family, but in general the transmission links to the health care workers are related to the facility, except for the index case.
One of the things that makes it challenging is sometimes fatigue. If you're burnt out, or having to do double shifts, that can lead to increased risk of PPE breaks. We've tried to reduce the need for double shifts with extra supports and staff in place so you have the opportunity to take breaks at scheduled times. Hopefully you're getting rest when you're off work.
If at any point you need help with PPE or have infection control questions there are the two teams on site at Holy Family: the rapid response team and the infection control team. Please use those resources and don't feel that you have to deal with this alone.
We're all human. We try to have a non-hierarchical culture in which we can all challenge each other. It's really important because none of us is perfect.
- Any plans to fast track the building of our new Dementia Village on 33rd which will include households of 12, single and double rooms?
This is a project we have continued to work very hard on even throughout the COVID outbreak. We’re working very closely with our partners at the Ministry of Health and Vancouver Coastal Health. We're very optimistic that we will start to see more urgency around the replacement of aging infrastructure in many of the owned and operated and four-bed care homes throughout the province.
We are optimistic that we can start to fast-track this project and want to assure you that, despite all the other work going on in long-term care right now, this work has not been put aside. We’re continuing to advance our plan so that we will be ready and prepared as soon as we can move forward with this.
If you need to reach PHC’s Infection Prevention and Control Team (IPAC), please call local 69357. Do not contact individual IPAC team members.