HFAM understands that these can be difficult times.
Primary care has changed in many ways in response to the COVID-19 pandemic. HFAM is working to help ensure family doctors in Hamilton have the best and most up-to-date information as we work together in providing the best possible care to our community.
- COVID Update 19/05/2020
COVID Testing Criteria for Primary Care
Dear Primary Care colleagues,
We are at a phase in our pandemic response where community wide testing is paramount.
Physical distancing, widespread economic and social closures as well as emphasis on hand hygiene, respiratory etiquette and masking have been hugely successful in reducing community spread of COVID-19. The resources for testing (PPE, lab capacity) have gradually increased. Over the past 8 weeks, we have used the ingredients of social isolation and testing in a variety of “recipes” – testing criteria have been targeted to specific populations and to an ever increasing list of symptoms. You have played an essential role in helping inform, support and direct your patients to appropriate testing resources.
Our goal in this next phase of pandemic response to is detect as many people with symptoms as quickly as we can, test them and perform appropriate case isolation and contact tracing for those who test positive. Rapid testing, appropriate social isolation and contact tracing is the response needed for successful “re-opening” of our economy and social spaces.
In other words, any person with symptoms that could be related to COVID should be encouraged to go for testing, regardless of any other risk factor.
So – your job in primary care is now twofold. Actively encourage anyone with symptoms, however mild, that could be related to COVID to be tested. Only test asymptomatic individuals where indicated by Public Health, especially close contacts of confirmed cases. The list of potential COVID symptoms follows.
(Your clinical judgement is still called for – a pattern of seasonal allergy that is the same this year as all previous years does not require a referral for COVID testing. But a new set of symptoms involving conjunctivitis, runny nose and a change in smell warrants a test.)
- Fever (temperature of 37.8°C or greater)
- New or worsening cough
- Shortness of breath (dyspnea)
Other symptoms of COVID-19 can include:
- Sore throat
- Difficulty swallowing
- New olfactory or taste disorder(s)
- Nausea/vomiting, diarrhea, abdominal pain
- Runny nose, or nasal congestion – in absence of underlying reason for these symptoms such as seasonal allergies, post nasal drip, etc.
Atypical symptoms can include:
- Unexplained fatigue/malaise
- Delirium (acutely altered mental status and inattention)
- Unexplained or increased number of falls
- Acute functional decline
- Exacerbation of chronic conditions
- Multisystem inflammatory vasculitis in children
A Reminder on how to access testing – (please note: backline phone numbers for the assessment centre cannot be included in the publicly-available HFAM website. It may be useful to print this email or note them somewhere for your reference)
- If your patient qualifies for COVID 19 Testing and is a community-based health care worker, first responder, a child under the age of 4, or is unable to access the mountain drive through testing site, please call the St Joe’s Assessment centre at (see hfam email May 19 for number)* to book an appointment. (Health care workers within either hospital system will continue to access testing through their occupational health services).
- Any patient who screens positive and is not part of the groups mentioned in #1 may be booked at either the drive through testing site or the St Joe’s Assessment Centre
- Drive through testing site appointments may be booked by calling (see hfam email May 19 for number)* .The site is located within the Dave Andreychuk Mountain Arena, 25 Hester Street. (just off Upper James and south of Mohawk).
- Testing appointments for St. Joe’s Assessment Centre may be booked by calling (see hfam email May 19 for number)*.
Finally, patients may also be referred to public health for screening. The Public Health Covid-19 Hotline 905-974-9848 will do the screening and book appointments for people with a positive screen.
- Call to Action: Importance of Advanced Care Planning and Goals of Care Discussions with Patients during the COVID-19 Pandemic
We are reaching out to you because of the important issue of Advanced Care Planning (ACP) and Goals of Care (GOC) discussions with patients during the current COVID-19 pandemic. This is potentially the most difficult conversation that we can have with patients, but during these dire times, this discussion is important now more than ever. We are requesting that all physicians, particularly the frontline doctors working in primary care (Long-term Care physicians, Family Medicine physicians, and Emergency Medicine physicians) immediately initiate ACP/GOC discussions with their patients who are at high risk for poor outcomes from this virus (elderly, multiple comorbidities, immunocompromised, etc.). We recognize that this is extremely difficult, especially with the use of virtual visits and that in a busy practice, these conversations may consume our visit times.
However, we strongly believe that planning ahead will be key in providing patient centered emergent care when clinical deterioration occurs. As you all may know, Italy, the United States, and much of the globe, are enduring a crisis where ED and hospital physicians are left to make tough decisions regarding mechanical ventilation and life sustaining therapy (on who to ventilate and keep alive) due to the limitation of resources. We may be confronting this in Canada and we will likely not have enough hospital resources to tend to all of our extremely sick COVID-19 patients. We need to be proactive and have these discussions so that our frontline healthcare workers can effectively triage and take care of these patients in accordance with their wishes. Thus, community awareness and comprehension of the disease and its outcomes is essential.
This will be tough on everyone. ACP is extremely challenging even when we are not in a pandemic. However, meaningful and timely discussions can save lives. It also has the potential to:
- Provide dignity and empower patients to make an informed decision before they get sick.
- Avoid the difficult conversation in the ED and hospitals where it is not ideal to have the discussion, due to time pressures and that most physicians do not have long term relationships with these patients. (Due to the physical restrictions in the hospitals for families to be with their patients, this will become even more difficult).
- Alleviate an extremely challenging decision for the family to make when a patient is unable. We sincerely hope that as leaders and respected caregivers in your community, you can put this into action and be proactive in the current critical situation. Together, we can help to make a difference for our patients and for our frontline health workers.
Here are a few suggestions that you can implement in your practice immediately.
1. Primary Care Physicians
During your scheduled televisits and clinic visits, if you identify that an individual is elderly or high risk (immunocompromised or multiple comorbidities), please try bringing up goals of care and advanced care planning discussions with your patients and families. If possible, clarifying code status will be vital during this epidemic. Although these conversations are tough to initiate, when presented in a compassionate manner by physicians who know their patients well, these discussions are usually well received and appreciated.
We will be sending you a physician toolkit which includes:
- A custom form to guide you in this process on your respective Electronic Medical Records
- Please download and use as the standard tool
- The form includes information on how to approach the topic and resources for you and your patients to aid the process
- Suggested billing codes for phone counselling
- An ACP/GOC resource sheet to provide you with the tools specific to COVID-19
2. Long Term Care (LTC) Physicians
It is imperative that LTC physicians revisit GOC discussions with your patients. LTC patients are extremely high risk, as many get sent to the ED for their illnesses (such as sepsis), however code status (Official DNR forms) is not clearly set, and thus it places the ER physicians and families with difficult decisions. Additionally, patients are at a tremendous risk for contracting the virus in the ED and bringing it back to LTC leading to massive outbreaks, thus having clear expectations outlined with the patients and families during this pandemic will be critical to keeping all of our patients and health care workers safe.
3. All other Physicians
You may be asked to provide guidance to individuals and families making these difficult decisions. Please review the documents provided above to help mentally prepare. All physicians share a responsibility to advocate for their patients. This is an important topic that must be addressed by all specialties of medicine. Please help in raising awareness and promote these discussions when possible.
We will be continuing to advocate for our patients to consider this important topic. Our task force will be contacting the media to inform the public and bring awareness and resources through multiple channels. We are working with you to make a difference in our community. Time to act is now. Thank you for your time and please be safe.
Members of the Advanced Care Planning and Goals of Care Task Force