Adam Vyse is a family physician in High River, Alberta
COVID-19 hit High River, Alberta, a town of 13,000 south of Calgary, with full force in April 2020. Our town is home to the Cargill meat packing plant, which, at the time, was the epicentre of North America’s largest single-source outbreak. Cargill employs ~2000 workers, with 600 living in and around High River and the rest in Calgary. Half of the plant’s workers ultimately tested positive for SARS-CoV-2.
Demographics pointed towards a potentially devastating situation: the workers carpool together, live in multigenerational family homes, and many of their household members perform essential service jobs in health care, often in seniors’ facilities. The potential for overwhelming our local hospital was very real. I am sharing this story because what we experienced with COVI-19 was different from what we had seen in the media from around the world.
I’ve had a unique view of this outbreak. As a leader of our local Primary Care network (CRPCN), I was part of the Calgary Zone group that created a primary care pandemic plan. When the outbreak hit my town, it was my role to help operationalize the plan. As a rural family physician, I was also responsible for caring for SARS-CoV-2-positive patients in my practice, ED and hospital. I experienced first-hand how the plan played out. In the end, I believe that our variation of a COVID-19 strategy has details that made it effective.
THE PANDEMIC PLAN
Our Calgary Zone Primary Care pandemic plan was developed in March 2020. Its central theme is that COVID-19 is largely a primary care disease, with the key to minimizing acute care impact being strict isolation of mild to moderate cases and their contacts. A COVID-19 Primary Care Pathway was created to standardize virtual care. This plan adds Connect and Support to the usual Test, Isolate and Contact Trace keywords.
The model envisioned hubs and spokes. A local hub leverages the family physician workforce as well as existing community organizations. This allows resources to be mobilized locally when and where needed. The local hub coordinates efficient communication with central (Medical Officer of Health, Alberta Health Services (AHS) 811 advice line, AHS tertiary care leadership), as well as local organizations (seniors’ facilities, town staff, aid agencies, etc.).
THE OUTBREAK EXPERIENCE
In early April 2020, the first cases hit our ED. Local physicians recognized that there was a potential for a massive problem and quickly escalated concerns. Partnering with the Town of High River, we activated our COVID Hub, which was staffed by CRPCN nurses, administrators, panel managers and physicians. Through the Hub, we set up a call centre and temporary drive-by testing site. This provided expedited information and local access to mass testing away from the hospital ED.
A larger high-volume AHS testing site opened a few days later. Prior to that, over 900 calls were fielded at our Hub call centre, underlining the concerns of area residents. A Facebook post indicating availability of testing generated 7,000 shares. Over 4 days our team performed over 200 drive-by swabs, of which 50 tests were positive.
Once AHS took over testing, the Hub had two main tasks. First was to identify patients who needed to be followed. This required a direct pipeline for positive results from our central Provincial Lab, which was created by a determined group of senior health leaders over a weekend. By mid-May, our Hub had received COVID-positive swab results for about 500 patients. Second was to connect people with positive tests with Primary Care virtual follow-up. They were all followed by a Hub nurse until care was either transferred with a phone call to their family doctor or, if they had none, they were provided with a physician through the Hub.
The COVID-19 Primary Care Pathway was particularly helpful for virtual care in the community. Red flags (shortness of breath at rest, chest pain, cold, clammy or pale mottled skin, new confusion, blue lips or face) were used to identify medical risks requiring a more detailed history. As an example, one of my patients was followed with the Pathway. On her third day of illness she had mild chest pains, but after a virtual visit it was clear that she did not need acute care. However, after a week of minimal symptoms she deteriorated on day 10. Using the Pathway, by involving EMS in the home, a virtual specialist consult and the local ER, allowed a safe and efficient assessment. Within hours she had reassurance, returned home and resumed care on the virtual pathway.
The Pathway pays special attention to social safety net issues which are critical to maintaining isolation, especially for multigenerational families. As an illustration, one of my patients who works at Cargill became infected with SARS-CoV-2 early in the outbreak. His wife tested positive soon after and we followed them both with the Pathway. Their main problem was caring for her 85 year old diabetic mother, as well as their adult autistic son who both share their home. On the first virtual visit, we identified these issues and reinforced the principles of isolation. We helped them create a plan to obtain food and cleaning supplies, and to make an in-home isolation and hygiene plan. They ended up successfully preventing both relatives from acquiring SARS-CoV-2.
During the outbreak, High River Hospital ED volumes never exceeded half of normal capacity, and frequently were far less. A total of six patients were transferred to acute care in Calgary, with one intubated locally. Once the Hub testing site opened, there were few (<20) SARS-CoV-2-positive patients through our ED for any reason. Other than for a swab, we estimate 98% of local positive patients were cared for exclusively in their home. Patients were invested in following the protocols as they understood the value in staying isolated at home and making sure family members did not get ill.
Another factor contributing to low acute care volumes was the lack of spread among the elderly. In our five local Supportive Living facilities, there were no cases. This was in spite of many staff members testing SARS-CoV-2-positive due to Cargill-related exposure. The early implementation of preventive measures was a clear success.
Long term care was not so fortunate. We had 15 cases and 5 deaths among 55 residents as 2 staff were exposed from Cargill contacts in their households in the first few days of the outbreak. Isolation strategies were very effective after this initial breach.
In our local SARS-CoV-2 outbreak, all levels of the health care system coordinated efforts with the common aim of containment. We collaborated to quickly connect patients testing positive for the virus to a trusted primary care medical home. Relationships with multiple community organizations meant patients were supported in their isolation. Access to specialists for quick advice was available through Specialist Link. The result was an exceedingly low burden on the acute care system, good outcomes and high community satisfaction.
The value of the family physician in our outbreak was clear. Our pandemic plan leveraged the therapeutic alliance that patients have with their family physician. This allowed efficient, effective and compassionate virtual care visits. Patients felt connected and were reassured throughout their illness. Social issues were identified and support was accessed. Families committed to the principles of pandemic management and consequently rapid containment was achieved.
If we see a second wave, we feel ready with infrastructure and plans. Our community has confidence. In the meantime, we are working to solidify and streamline new bridges and connections. The quality of patient care illustrates the value of a Patient Medical Home. The prevailing sense of teamwork is inspiring. If faced with an outbreak, I hope your community, large or small, can do the same.
Clinical Pathways – www.specialistlink.ca
Calgary Rural Primary Care Network – www.crpcn.ca
Calgary Zone Primary Care Network – [email protected]
Submitted on behalf of the CRPCN and Calgary Zone PCN teams by:
Dr Adam Vyse MD, CCFP
CRPCN Governance Board Chair
Family Physician in High River, AB