At the regular Monday morning meeting of North York General Hospital’s senior leaders, chief executive officer Joshua Tepper asked a question that was on everyone’s mind after a weekend of frightening coronavirus news from the United States and Europe.
When would the hospital add Germany and Washington State to the list of places that prompt staff to isolate patients and test them for COVID-19?
As the countries have continued to increase, the staff have had some discussions about flagging all patients with a cough and fever who had travelled anywhere outside Canada. “In my mind, that is a massive pivot,” Dr. Tepper said.
The hospital has not yet scrapped location-specific screening, but by midday Monday it had added Washington State, Germany and France to its roster, bringing the total to 15 countries, states or territories – twice the number of places that the Public Health Agency of Canada has on its list of countries of concern.
As the new coronavirus has swept across the globe, infecting more than 90,000 and killing more than 3,000 worldwide, Canadian hospitals have been hustling to avoid the fate of their peers in Washington State and parts of Europe, sometimes taking decisions well in advance of official advice from provincial and federal public-health authorities.
So far, they’ve succeeded. There is no detected community spread in Canada, and no outbreaks at hospitals or long-term care homes. But infectious-disease experts don’t expect that success to last.
In the meantime, North York General Hospital (NYGH) is one of the few hospitals in Canada where preparations for COVID-19, the respiratory illness caused by the new virus, have been put to the test. Of the 33 cases in Canada, four were diagnosed in patients who came through the emergency department at NYGH, a 430-bed acute-care centre where the memory of SARS still lingers, 17 years after the epidemic shut down part of the hospital and took the life of nurse Nelia Laroza.
All four coronavirus cases at NYGH could be traced to out-of-country travel – one to China, two to Iran and one to Egypt – and all the patients were initially well enough to be sent home to self-isolate. One returned to NYGH Tuesday after taking a turn for the worse and is now in stable condition in an isolation room at the hospital.
At least 90 NYGH in-patients with respiratory illness and no recent travel outside Canada were tested during the weekend as part of a fledgling sentinel surveillance program in Ontario. None had COVID-19.
That came as a relief to Kevin Katz, NYGH’s medical director of infection prevention and control, a plain-spoken expert whose coronavirus webinars have made him a minor celebrity within North York General’s walls.
Still, Dr. Katz and his colleagues are preparing as though it is only a matter of time before the hospital is in the grip of a major coronavirus outbreak.
“The pieces that cause me angst are around capacity issues,” Dr. Katz said. He wondered: Would NYGH – and the health-care system as whole – have the beds, ventilators, laboratory capacity, supplies and staff to fight a pandemic?
NYGH’s Incident Management Team, an ad hoc group of 19 hospital leaders, has been working since the third week of January to try to answer those questions.
During a meeting on Monday, the group voted to adopt a policy banning work-related travel to countries currently under a federal government travel advisory because of endemic COVID-19. The policy also “strongly suggested,” that NYGH employees cancel work-related travel to anywhere outside Canada.
Personal travel was trickier. “I think the generic question people will be asking is, ‘Should I cancel my March break trip?' " said Phil Shin, NYGH’s chief of medicine and director of the hospital’s critical-care unit, where coronavirus patients will end up if they become severely ill.
Dr. Katz replied that Taiwan, as an example, had asked all health-care workers to stay close to home, lest they catch the virus or wind up in quarantine.
“On the flip side, this is going to be a marathon, not a race. It hasn’t quite taken off here," Dr. Katz said. “And so if people can get vacation in before – fill in your proverb for the next part – then maybe people should take a break.”
Other hospital leaders were looking at what would trigger reductions in elective surgeries and tests for infections other than COVID-19. Others were monitoring supplies of crucial equipment, such as N95 masks and disposable circuits for mechanical ventilators.
The Incident Management Team also voted on Monday to spend roughly $40,000 converting 36 rooms across two units of the hospital into negative-pressure rooms, which are usually reserved for patients with airborne infections, such as tuberculosis and measles.
Although the vast majority of the evidence points to the new coronavirus being spread through droplets such as sneezes, not through the air, NYGH was already whisking all patients suspected of having COVID-19 into 12 negative-pressure rooms in the emergency department.
One such patient was isolated in a negative-pressure room on Monday as the 19-member management team met upstairs.
Immediately inside the department’s door, a triage nurse sat beyond a pane of glass clad head-to-toe in protective gear, including a gown, face shield, hair bouffant, purple gloves and an N95 mask.
If a patient turns up with respiratory symptoms and a history of recent travel to any of the countries on NYGH’s list, a warning box pops up on the triage nurse’s computer screen: “If travel within 14 days, cough, fever, cold-like symptoms, place in negative-pressure room, apply droplet/contact precautions with N95 and call [Infection Prevention and Control].”
NYGH emergency staff have followed those instructions as many as 117 times since the coronavirus outbreak began, including in the cases of the four patients who tested positive.
They’ve purchased disposable stethoscopes, practised donning and doffing their personal protective equipment and run simulation after simulation, probing their infection control practices for weak spots.
During one dry run, a visor fell off a nurse dressed in full protective gear as the nurse practised CPR on a mannequin, said Andrea Ennis, clinical team manager for emergency services.
“Now we have new visors,” she said.
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