COVID-19 Community of Practice

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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.

The COVID-19 Community of Practice is a space for family physicians across Ontario to connect and learn from each other during this challenging time.

Approximately once a month, practicing family physicians share their perspectives on COVID-related topics ranging from implementing virtual care, to organizing community collaborations, and supporting patients with mental health and addiction. These one-hour webinars are interactive and questions from participants are answered in real-time where possible. Each session is recorded and shared after the event, including links to notable resources.

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 (Friday, December 11, 2020):

We are currently planning our next online discussion. Please join us on Friday, December 11th (8:00-9:00am ET) for the twelfth in our series 'Changing the way we work: COVID-19 vaccine, public health collaboration, and supporting our teams'. Dr. Jeff Kwong, family physician and epidemiologist, will be sharing the latest on the COVID-19 vaccine. Dr. Lee Donahue, family physician, and Dr. Trevor Arnoson,  Associate Medical Officer of Health for Ottawa Public Health, will be sharing how primary care and public health have collaborated during flu season.

Panelists:

  • Dr. Jeff Kwong, Epidemiologist, Family Physician, Toronto Western Family Health Team, Toronto, ON
  • Dr. Trevor Arnason, Associate Medical Officer of Health, Ottawa Public Health, Ottawa, ON
  • Dr. Lee Donohue, Family Physician, Connexion Family Health Team, Ottawa, ON

Guest Speakers:

  • Dr. David Kaplan, Family Physician, North York Family Health Team and Chief, Clinical Quality, Ontario Health, Toronto, ON
  • Dr. Liz Muggah, OCFP President, Family Physician, Bruyère Family Health Team, Ottawa, ON

Moderator:

  • Dr. Tara Kiran, Toronto, ON

Registration details: https://zoom.us/webinar/register/WN_MVbMqYk6R6-WcXhJrpq7qA

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.

Save the date for future COVID-19 Community of Practice sessions:

  • Friday, January 15, 2020 - We are excited to welcome Dr. Trish Greenhalgh, Professor of Primary Care Health Sciences, University of Oxford, UK as our guest panelist for the January 15, 2021 Community of Practice session. Dr. Greenhalgh, a general practitioner and internationally recognized academic in primary health care, will present on “Covid-19, evidence-based medicine and paradigm wars”. Registration details will be available the week of December 14th.

Previous COVID-19 Community of Practice sessions:

November 13, 2020: Supporting patients with COVID-19, evolving guidance, and fatigue

Changing the way we work: Supporting patients with COVID-19, evolving guidance, and fatigue

Please join us for the eleventh in our series on ‘Changing the way we work’; this session focuses on supporting patients with COVID-19, evolving guidance, fatigue and more.

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.

  • Dr. Jonathan Fitzsimon, Arnprior, ON
  • Dr. Payal Agarwal, Toronto, ON
  • Dr. Liz Muggah, Ottawa, ON 
  • Dr. David Kaplan, Toronto, ON 

Webinar Video:

COVID-19 Community of Practice for Ontario Family Physicians

Resources:

October 16, 2020: Rising case counts, respiratory assessment centres, and flu shots during COVID-19

Changing the way we work: Rising case counts, respiratory assessment centres, and flu shots during COVID-19

Please join us for the tenth in our series on ‘Changing the way we work’; this session focuses on rising case counts, respiratory assessment centres, flu shots and more 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. Jeff Kwong, Toronto, ON 
  • Dr. Allan Grill, Markham, ON  
  • Dr. Lisa Habermehl, Red Lake, ON
  • Dr. David Kaplan, Toronto, ON  

Webinar Video:

COVID-19 Community of Practice for Ontario Family Physicians

Resources:

CEP (Centre for Effective Practice) flu shot tool link - https://tools.cep.health/tool/pc-ops-covid-19-context/#wave-2-flu-vaccination-and-flu-vaccination-clinics

Cold Standard toolkit created by CWC & CFPC and supported by PHAC - https://choosingwiselycanada.org/perspective/the-cold-standard/

September 18, 2020: COVID-19 and considerations as we plan for the fall 2.0

Changing the way we work: COVID-19 and considerations as we plan for the fall 2.0

Please join us for the ninth in our series on ‘Changing the way we work’; this session focuses on COVID-19 and considerations as we plan for the fall 2.0’ 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. Jeff Kwong, Toronto, ON
  • Dr. David Kaplan, Toronto, ON
  • Dr. Jennifer Young, Collingwood, ON

Webinar Video:

Resources:

covid-19_cop_-_sept_18_2020_-_resource_list.pdf

August 21, 2020: COVID-19 and considerations as we plan for the fall

Changing the way we work: COVID-19 and considerations as we plan for the fall

Please join us for the eighth in our series on ‘Changing the way we work’; this session focuses on COVID-19 and considerations as we plan for the fall’ 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. Jennifer Bondy,  Amherstburg, ON
  • Dr. David Kaplan, Toronto, ON
  • Dr. Jennifer Young, Collingwood, ON
  • Dr. Jeff Kwong, Toronto, ON

Webinar Video:

Resources:

July 17, 2020: Managing chronic conditions during COVID-19

Changing the way we work: Managing chronic conditions during COVID-19

Please join us for the seventh in our series on ‘Changing the way we work’; this session focuses on managing chronic conditions during COVID-19 and shares how family physicians are working in the community during the pandemic.

Speakers:

  • Dr. Alan Kaplan,  Thornhill, ON
  • Dr. Jonathan Bertram,  Toronto, ON
  • Dr. Tara Kiran, Toronto, ON

Webinar Video:

Resources:

Chronic pain and addiction

COVID-19 OPIOID Agonist Treatment Guidance https://www.camh.ca/-/media/files/covid-19-modifications-to-opioid-agonist-treatment-delivery-pdf.pdf

 

META:  PHI Provider Tools  https://www.metaphi.ca/provider-tools.html

 

Brief Pain Inventory (BPI) https://www.hamiltonhealthsciences.ca/wp-content/uploads/2019/03/Referral-Form-Brief-Pain-Inventory-Pain.pdf

 

Coronavirus Disease 2019 and Opioid Use—A Pandemic Within an Epidemic https://jamanetwork.com/channels/health-forum/fullarticle/2766790

 

Diabetes

Managing Type 2 Diabetes during COVID-19: A guide for Primary Care Providers

https://tools.cep.health/wp-content/uploads/2020/07/CEP_COVID19DiabetesCare_July13-FINAL-FILLABLE.pdf#

 

COPD and Asthma

Canadian Thoracic Society

 

COPD Assessment Test: https://gskpro.com/content/dam/global/hcpportal/en_MT/PDF/Homepage/Products/relvar/COPD_Assessment_Test_(CAT).pdf

 

For those using Ocean - https://ocean.cognisantmd.com/questionnaires/preview/QuestionnairePreview.html?ref=copd_assessment_test

 

  • Asthma:
    • Canadian Thoracic Society – Asthma management during COVID-19

https://cts-sct.ca/wp-content/uploads/2020/04/Final_CTS-COVID-19-Asthma-Position-Statement.pdf

 

Family Physicians Airways Group Resources https://www.fpagc.com/tools-resources

 

Ramping-up in person care

 

General Resources

OCFP COVID-19 Resources:  https://www.ontariofamilyphysicians.ca/

 

Covid-19: a remote assessment in primary care:  https://www.bmj.com/content/368/bmj.m1182

 

Healthy Debate Opinions:  ‘Defund the police, resource our communities:’ A call for structural change

https://healthydebate.ca/opinions/defund-the-police-resource-our-communites-a-call-for-structural-change

 

COVID 19 CoP Resources and Past Sessions:

June 26, 2020: Supporting patients experiencing social challenges

Changing the way we work: supporting patients experiencing social challenges

Please join us for the sixth in our series on ‘Changing the way we work’; this session focuses on practical tips for supporting patients experiencing social challenges and shares how family physicians are working in the community during the pandemic.

 Speakers:

  • Dr. Jonny Grek - Family Physician & Street Doctor with Northern Connections, Kenora, ON
  • Dr.  Ritika Goel – Family Physician, Family Physician, Inner City Health Associates, Toronto, ON     
  • Ms. Dawnmarie Harriott - Patient partner, Toronto, ON
  • Mr. Will Lacy - Patient partner, ON

Webinar Video: 

Resources:

Pekiwewin (coming home): advancing good relations with Indigenous people experiencing homelessness

 

CEP COVID-19 Social Care Guidance

 

Resource Folder – St. Michael’s Hospital (Google Drive)

 

Accessible and Inclusive Mental Health Resources

 

Mental Health and Addictions Services for the Black Community

 

PPE:

OCFP: https://www.ontariofamilyphysicians.ca/tools-resources/timely-trending/novel-coronavirus-2019-ncov/ocfp-ppe-for-hpc-visual-june-2020.pdf

June 12, 2020: Ramping up in-person visits in primary care

Changing the way we work: ramping up in-person visits in primary care 

Please join us for the fifth in our series on ‘Changing the way we work’; this session focuses on ramping up in-person visits in primary care 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. Sundeep Banwatt - Family Physician, Southdown Medical Centre, Mississauga
  • Dr. Kellie Scott - Family Physician, Thames Valley FHT, St. Thomas
  • Dr. David Kaplan, Family Physician, Chief Clinical Quality OH-Quality, Toronto
  • Dr. Jennifer Young, Family Physician, President OCFP, Collingwood

Webinar Video:

Resources:

Soutwestern Ontario COVID-19 tools:


https://swcovidtools.ca/guide-to-re-opening-your-office/
https://youtu.be/_6b694hC0I4


Guidance from other organizations/provinces:


• OMA Guidance:
o https://content.oma.org/wp-content/uploads/private/Reopening-Ontario-5-Public-Health-Pillars.pdf
o https://content.oma.org/wp-content/uploads/private/OMA-Preparing-to-Resume-In-Person-Care.pdf


• OCFP In-person Visit Guidance: https://www.ontariofamilyphysicians.ca/tools-resources/timely-trending/novel-coronavirus-2019-ncov/ocfp-guidance-in-person-visits.pdf
 

• BC Family Doctor Guidance:
o https://kootenayboundarydivisionoffamilypractice.cmail19.com/t/d-l-mduyukk-jrjhkkkyyd-y/
o https://bcfamilydocs.ca/wp-content/uploads/2020/06/The-Doctor-is-In-052120.pdf

 

• Ministry of Health: http://www.health.gov.on.ca/en/pro/programs/publichealth/coronavirus/docs/2019_primary_care_guidance.pdf
 

Ontario Health: Recommendations for Regional Health Care Delivery During COVID-19: Outpatient Care, Primary Care, and Home and Community Care
 

• CPSO: https://www.cpso.on.ca/Physicians/Your-Practice/Physician-Advisory-Services/COVID-19-FAQs-for-Physicians
 

• UofT DFCM/North York General Hospital: https://www.dfcm.utoronto.ca/sites/default/files/primary_care_return_guideline_amended_june_1_final_060520.pdf

 

PPE Guidance:


• SW COVID Tools: https://swcovidtools.ca/ppe-personal-protective-equipment/
Glove Pyramid (World Health Organization)

 

Ramping Up Blog:


• Dr. Tara Kiran’s Blog in CMAJ: https://cmajblogs.com/ramping-up-in-person-office-visits-in-primary-care-in-the-aftermath-of-covid-19/ 

 

May 29, 2020: Embracing virtual care

Changing the way we work: 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

Webinar Video:

Resources:

Resource

Link

OntarioMD

https://ontariomd.news/

K Codes

https://swcovidtools.ca/clinical-tools/virtual-care/

Non-OTN Codes

http://www.health.gov.on.ca/en/pro/programs/ohip/bulletins/4000/bul4755.aspx

OTN Codes

https://support.otn.ca/sites/default/files/virtual-care-billing-information-manual.pdf

PHIPPA Compliant Vendors

https://ontariomd.news/

PEER Leaders Program

https://www.ontariomd.ca/products-and-services/peer-leader-program/overview

Request a Peer Leader

https://www.ontariomd.ca/products-and-services/peer-leader-program/request-a-peer-leader

South West COVID Tools

https://swcovidtools.ca/

Collecting data on race during COVID-19

https://upstreamlab.org/2020/04/15/data-on-race-covid19/

LTC & RH Consult Line

Call 1-8338-2HELPU

For general inquiries or questions: ltcrh.consult@wchospital.ca

VirtualCare App

Watch a demo: https://vimeo.com/415554798

Homes interested may contact Erika Burns, VCSeniors@thinkresearch.com or call 1-877-302-1861

COVID-19 Guidance: Primary Care

Providers in a Community Setting

http://www.health.gov.on.ca/en/pro/programs/publichealth/coronavirus/docs/2019_primary_care_guidance.pdf

Advice for

in-person visits

https://www.ontariofamilyphysicians.ca

 

May 15, 2020: Supporting patients with increased mental distress

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:

May 1, 2020: Supporting our colleagues and community

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.

April 17, 2020: Building a community to share and learn from each other during this COVID-19 time

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”