COVID-19 Community of Practice

COVID-19 Community of Practice for Ontario Family Physicians

We have all had to change the way we work in response to COVID-19. Keeping up with new guidance, responding to the changing environment, and navigating uncertainty has become the new normal and at times can be overwhelming.

We have created a space where we hope family physicians across Ontario can come together to learn from each other during this challenging time.

Every two weeks, we’ll bring people together virtually and share perspectives from a few practicing family physicians on topics ranging from implementing virtual care, to organizing community collaborations, to supporting patients with mental health and addiction. These one-hour webinars will be interactive and questions from participants will be answered in real-time. We will also do our best to post answers after the session so that the sharing continues in the time between virtual sessions.

This COVID-19 Community of Practice is a joint initiative from the University of Toronto Department of Family and Community Medicine (DFCM) and the Ontario College of Family Physicians (OCFP).

 

Upcoming COVID-19 Community of Practice session on Friday, May 29 from 8am-9am:

Embracing virtual care

Please join us for the fourth in our series on ‘Changing the way we work’; this session will focus on embracing virtual care and share how family physicians are working in the community during the pandemic.

Moderated by Dr. Tara Kiran, Fidani Chair, Improvement and Innovation, Department of Family & Community Medicine, U of T, and St. Michael’s Academic Family Health Team 

Speakers:  

  • Dr. Steve Klassen, Family Physician, Westview Medical, Thunder Bay
  • Dr. Payal Agarwal, Family Physician, Women’s College Hospital Academic Family Health Team, Toronto
  • Dr. Paul Gill, Family Physician, Maitland Valley Family Health Team, Goderich

Date: May 29, 2020 at 8:00 am

Register in advance for this webinar: https://zoom.us/webinar/register/WN_OVazRLPVS7W6xLuCFVzWwQ

This one-credit-per-hour Group Learning program has been certified by the College of Family Physicians of Canada and the Ontario Chapter for up to 1 Mainpro+ credits. The COVID-19 Community of Practice for Ontario Family Physician includes a series of planned webinars. Each session is worth 1 Mainpro+ credits, for up to a total of 18 credits.

 

Previous COVID-19 Community of Practice sessions:

Webinar #1: April 17, 2020 

Changing the way we work: Building a community to share and learn from each other during this COVID-19 time

Dr. David Kaplan, Dr. Kim McIntosh and Dr. Mercedes Rodriguez engage in an intentional conversation for shared learning to provide insights into how you and your colleagues have adapted to providing care during COVID-19. 

Moderated by Dr. Tara Kiran, Fidani Chair, Improvement and Innovation, Department of Family & Community Medicine, U of T, and St. Michael’s Academic Family Health Team 

Speakers:    Dr. David Kaplan, North York Family Health Team and Ontario Health, Quality

                      Dr. Mercedes Rodriguez, Headwaters Health Care Centre

                      Dr. Kim McIntosh, Couchiching Family Health Team

Webinar Video:

 

Resources: 

During the webinar, participants shared some resources that could support set-up of a virtual office. Here are some relevant links:

https://www.fongo.com/  

https://www.dialpad.com/ 

https://jitsi.org/ 

 http://www.davidkaplanmd.com/virtual-care

 

Questions & Answers:

During the webinar, participants were encouraged to ask questions. Some questions were answered live and can be found on the webinar recording. Others were answered in writing by our moderator or panelists. We have highlighted a few of the written responses here. Please keep in mind that guidance is rapidly changing and what is written may no longer be accurate. 

Question

Answer

When will Family doctors and their staff get tested?

All health care workers and staff can get tested (if symptomatic) at any of the Covid19 Assessment Centres - https://www.ontariohealthcoalition.ca/index.php/resources-list-of-ontario-covid-19-assessment-centres-their-individual-criteria/

Can people get infected by COVID more than once/ is there any talk about checking the immunity, IGg/IGm?

Here is the paper from Nature last week - Humanity tested - The world needs mass at-home serological testing for antibodies elicited by SARS-CoV-2, and rapid and frequent point-of-care testing for the presence of the virus’ RNA in selected populations. https://www.nature.com/articles/s41551-020-0553-6

I think moving forward it would be very helpful as a specialty to start to amass a comprehensive resource of “virtual approach to” common family medicine conditions in order to help guide us from a virtual clinical perspective to help us be more confident in assessing patients in this new method of care. Has anything similar to this initiative been discussed to date in our regulatory body?

 

 

 

Ontario Health (Quality) and OTN have developed this: https://quorum.hqontario.ca/en/Home/Posts/Guidance-to-support-the-adoption-of-virtual-visits-in-health-care

Agreed that we should think about a virtual approach to common family medicine presenting complaints!

A recent email to our members had some resources for remote management of diabetes and CHF and asthma/COPD has just been added.  Here is a link to the information from Dr. Tali Bogler that goes over well-baby and pre-natal visits.

https://afhto.ca/resource/interim-schedule-children-and-pregnant-women-during-covid-19-pandemic

PPE two issues:  Availability and also cost. During SARS we got kits from the government, nothing this time.

A. OMA has a matching service for PPE = https://apps.oma.org/PPEInventory/


B. Regional Leads for PPE - Regional Leads - PPE and Critical Supplies
Toronto
Co-Leads:
1. Rob Burgess (Robert.Burgess@sunnybrook.ca)
2. Nancy Kraetschmer (Nancy.Kraetschmer@tc.lhins.on.ca)
Central
1. Susan Gibb (Susan.Gibb@lhins.on.ca)
West
Lead:
1. Toby O’Hara (Toby.OHara@hmms.on.ca) – SW
Sub-Lead:
2. Doug Murray (Doug.Murray@grhosp.on.ca) – WW
3. Sue Nenadovic (Sue.Nenadovic@niagarahealth.on.ca) – HNHB
4. Katelyn Dryden (Katelyn.Dryden@transformsso.ca) – ESC
North

Co-Leads:

1. Matthew Saj (sajm@tbh.net)

2. Michael Giardetti (giardetm@tbh.net)

East

Co-Leads:

1. Paul McAuley (Paul.McAuley@3so.ca)

2. Leslie Motz (lmotz@lh.ca)

 

C. If none of these actions are successful, please escalate to the Ministry’s Emergency Operations Centre (MEOC). The MEOC will be moving to an on-line request form through EOClogistics.moh@ontario.ca to collect and validate your supply and equipment requests.

Prior to the webinar, a few participants sent in some questions. Dr. Kiran prepared responses after consulting with colleagues and we have summarized these here. Please keep in mind that these are not definitive answers to the questions but the opinions of one or more family physicians at a single point in time.

Question Answer

Recent Article in JAMA re affinity of COVID virus to ACE and ARB medications. https://jamanetwork.com/journals/jama/fullarticle/2763803

Pts are asking to be switched to other agents. Is there any consensus on this?  Is anyone else facing these requests?

We asked Brenda Chang, pharmacist at St. Michael’s Hospital Academic Family Health Team, for advice. Here is what she said:

“There is concurrently no consensus on this though most Cdn and International authorities/societies (e.g. Cdn Cardiovascular Society)  have suggested that patients continue with their current ACEI and ARB medications as prescribed for HTN/CHF unless there is a compelling reason to stop the drugs (e.g. AKI or hyperkalemia etc.)"

 

UpToDate has answers to most Covid-19 related questions, and they are offering free guest passes right now: https://www.uptodate.com/home/covid-19-access.

Here is what UpToDate says on the topic:

“Managing chronic medications

ACE inhibitors/ARBs — Patients receiving angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) should continue treatment with these agents if there is no other reason for discontinuation (eg, hypotension, acute kidney injury). This approach is supported by multiple guidelines panels [26-30].

There has been speculation that patients with COVID-19 who are receiving these agents may be at increased risk for adverse outcomes [31,32]. Angiotensin-converting enzyme 2 (ACE2) is a receptor for SARS-CoV-2 [33], and renin-angiotensin-aldosterone system inhibitors have been shown to increase ACE2 levels in some, but not all, animal and human studies [34,35]. Although cardiovascular disease, hypertension, and diabetes mellitus are associated with more severe disease in the setting of SARS-CoV-2 infection, there is no evidence to support an association with these agents specifically. In addition, stopping these agents in some patients may exacerbate comorbid cardiovascular or kidney disease and lead to increased mortality [36].

Conversely, ARBs have also been proposed to have potential protective effects based on their mechanism of action [37], but there is no empiric evidence to support this hypothesis. We do not use ACE inhibitors or ARBs as potential COVID-19 treatment."

I have some of my patients calling to get pneumonia shots as they think it will help. Of course, pneumonia shot helps for Pneumonia but not COVID-19 pneumonia.

Do we take the risk to give the shots - can we delay it?

 

We reached out to our colleague Jeff Kwong, family physician at Toronto Western Hospital Academic Family Health Team, public health physician at Public Health Ontario, and Senior Scientist at ICES. This is what he said:

“Our clinic is still giving pneumococcal vaccines in adults, but delaying/deferring HPV and Shingrix.”

So many are calling regarding their short-term disability forms and sick notes for staying home from Covid -19

How to handle this?

On March 19, 2020, Ontario passed Bill 186, Employment Standards Amendment Act (Infectious Disease Emergencies), 2020, which provides that an employee will not be required to provide a medical note if they need to take a leave related to COVID-19. Here is a link to more information on employee rights: http://www.ohrc.on.ca/en/news_centre/covid-19-and-ontario%E2%80%99s-human-rights-code-%E2%80%93-questions-and-answers-0

Insurers are still asking for STD forms unfortunately. Ideally patients can scan and send these to you so you can fill remotely. We need more system advocacy around this.

Should patients taking Truvada continue to do their regular blood work (typically HIV q 3 mon + Creat q 6 mon) in order for us to refill their prescriptions?

We asked advice from our colleague Dr. James Owen, a family physician at St. Michael’s Hospital Academic Family Health Team who cares for many patients who are HIV positive. Here is what he said (he also said he would be happy to be contacted directly at james.owen@unityhealth.to):

“There's no guidelines on this so I expect advice is provider-dependent, but here's what I'm doing:

For people on PrEP, it depends if they're still sexually active:

- If they're still sexually active AND still conceivably at risk of HIV, I'm recommending continuing PrEP without interruption. If asymptomatic for STIs, I'm deferring routine PrEP labs in most cases and just providing additional scripts for patients to bridge them till physical isolation has ended (I'm assuming we'll be free in July). What the writer has indicated is reasonable. Of course, if someone is symptomatic I'm inclined to test + treat for the presumptive STI if possible at the same visit, to minimize separate visits eg to clinic, lab, then clinic again.

- If they're still sexually active and NOT conceivably at risk of HIV, they could stop PrEP. The only situation where I think this applies is if someone has a regular household sexual partner ("HSP".. this great new term I'm seeing in some literature) and neither of them has any other sexual partners for the duration of physical distancing. In that case, I'm having a discussion about the pros and cons of "pausing" PrEP for the duration of physical distancing

- If they're NOT sexually active and do not foresee any further sexual activity for the duration of COVID, I'm advising it's also OK to pause PrEP. In all cases, I'm recommending they take PrEP for at least 48 hours after their last sexual activity

There is one clinical trial of COVID prophylaxis for health care providers with TDF+FTC (aka PrEP medications) starting in Spain based on in vitro modeling that suggested that PrEP meds may inhibit COVID replication. It's a limited trial in health care providers only, so I haven't felt (yet) that this impacts my advice to patients about whether to stop or continue PrEP.

Good resources:

PrEP & COVID patient resource: https://ontarioprep.ca/covid/

New York guidance on sex during COVID: https://www1.nyc.gov/assets/doh/downloads/pdf/imm/covid-sex-guidance.pdf

For people who are HIV+, if they are asymptomatic and have no other health concerns and are otherwise just doing regular monitoring b/w, I'm telling everyone to defer routine labs till physical isolation has ended, likely July, and always continue cART”

Webinar #2: May 1, 2020 

Changing the way we work: supporting our colleagues and community

Our second session features three family doctors who are practicing in models that do not benefit from a government-funded interprofessional team. They will describe the unique challenges they are facing and the ways doctors are supporting one another in their community.   

Moderated by: Dr. Tara Kiran, Fidani Chair, Improvement and Innovation, Department of Family & Community Medicine, U of T, and St. Michael’s Academic Family Health Team 

Guest panelists:

  •     Dr. Nadine Laraya, Family Physician, West Toronto FHO and Community Family Medicine Liaison, St. Joseph’s Health Centre
  •     Dr. Daniel Pepe, Family Physician, London Lambeth Medical Clinic
  •     Dr. Arieg Badawi, Family Physician, Kelso Lake Medical Centre and North Halton Ontario Health Team

Webinar Video:

Resources:

COVID-19 Quick Reference Public Health Guidance on Testing and Clearance: http://www.health.gov.on.ca/en/pro/programs/publichealth/coronavirus/docs/2019_testing_clearing_cases_guidance.pdf?utm_source=link.cep.health&utm_medium=urlshortener&utm_campaign=covid-safetyequip

OCFP guidance for in-person visits: https://www.ontariofamilyphysicians.ca/tools-resources/timely-trending/novel-coronavirus-2019-ncov/considerations-for-in-person-visits.pdf

Interim schedule for pregnant women and children during the COVID-19 pandemic developed by St. Michael’s Hospital and available here: https://www.cfp.ca/news/2020/03/25/3-24

Cancer Care Ontario guidance on screening: https://www.cancercareontario.ca/en/get-checked-cancer/screening-during-covid-19

 Meditations by Dr. Sarah Kim on hand hygiene and PPE removal: https://soundcloud.com/sarahkim_md/1min-mindful-hand-hygienehttps://soundcloud.com/sarahkim_md/ppe-removal-as-a-moving

Virtual care:

eConsult EMR integration (currently available through QHR Technologies' Accuro® EMR, OSCAR EMR, KAI Innovations' OSCAR, and YES EMR): signup here - https://www.ontariomd.ca/pages/overview-of-econsult.asp;  general information - https://econsultontario.ca

Healthymyself for asynchronous messaging and health myself blasts https://healthmyself.ca

OCEAN to send forms securely via email (e.g. PHQ9, antenatal, nippising). These are placed directly back in your EMR after patient completes. Visit https://www.cognisantmd.com/ to download the ocean toolbar that will directly integrate. Tablets are not needed, secure email will work well.  

OTN for video visits. Best on google chrome and can be also be used by patients on a mobile device: https://otnhub.ca

PPE:

OMA has a matching service for PPE = https://apps.oma.org/PPEInventory/

You can also contact regional leads for PPE:

Toronto:
Rob Burgess (Robert.Burgess@sunnybrook.ca)

Nancy Kraetschmer (Nancy.Kraetschmer@tc.lhins.on.ca)

Central:
Susan Gibb (Susan.Gibb@lhins.on.ca)

West:
Lead: Toby O’Hara (Toby.OHara@hmms.on.ca) – SW

Sub-Leads: Doug Murray (Doug.Murray@grhosp.on.ca) – WW

Sue Nenadovic (Sue.Nenadovic@niagarahealth.on.ca) – HNHB

Katelyn Dryden (Katelyn.Dryden@transformsso.ca) – ESC

North:

Matthew Saj (sajm@tbh.net)

Michael Giardetti (giardetm@tbh.net)

East:

Paul McAuley (Paul.McAuley@3so.ca)

Leslie Motz (lmotz@lh.ca)

If none of these actions are successful, please escalate to the Ministry’s Emergency Operations Centre (MEOC). The MEOC will be moving to an on-line request form through EOClogistics.moh@ontario.ca to collect and validate your supply and equipment requests.

Webinar #3: May 15, 2020

Changing the way we work: supporting patients with increased mental distress

Please join us for the third in our series on ‘Changing the way we work’; this session focuses on supporting patients with increased mental distress and shares how family physicians are working in the community during the pandemic.

Moderated by Dr. Tara Kiran, Fidani Chair, Improvement and Innovation, Department of Family & Community Medicine, U of T, and St. Michael’s Academic Family Health Team

Speakers:   

  • Dr. Leah Skory, Family Physician, Barrie Community Health Centre, Barrie
  • Dr. Claudette Chase, Family Physician, Primary Care Health Unit, Sioux Lookout
  • Dr. Javed Alloo, Family Physician, Nymark Medical Centre, CAMH, Toronto

Webinar Video:

Resources:

Mental health supports for providers:

 

Resource hubs for practitioners:

 

General links for patients with collated resources:

 

Crisis support for patients:

 

CBT & peer support for patients that are free in Ontario:

 

Mindfulness for patients:

 

Addictions & recovery support:

 

Domestic violence:

 

Resources from Nishnawbe Aski Nation:

 

Measurement-based tools:

 

Resources for child & youth mental health:

 

Resource for physical health:

 

Resource for insomnia:

 

Training for healthcare providers: