What Made the Difference in Canada’s Worst COVID-19 Outbreak?

By Dr. Adam Vyse, the Calgary Zone PCN, and the Calgary Rural PCN

In April 2020, the Cargill Foods meat packing plant was the epicentre of one of North America’s single largest outbreaks of COVID-19. With 2,000 employees, 932 were confirmed positive, with one-third living in and around High River, a town of 13,000 just south of Calgary.

Demographics indicated a devastating scenario was coming. Workers carpool together, live in multigenerational family homes and their household contacts perform many of the essential services jobs in our health care sector. What happened was quite different from what we anticipated.

Based on data we were seeing from around the world, we anticipated an overwhelming acute care burden of up to 10-20% of the COVID-positive patients. In High River, that was not the case for the 488 positive patients we were able to track. Only nine people were hospitalized (1.8%), and six transferred to tertiary care. Two people died in High River.

The Pathway Was Key

Part of what we attribute our low numbers to was the successful virtual care patients received. With a family physician at the centre of care, patients were assessed using a virtual COVID-19 Primary Care Pathway Other than for a swab, 98% of patients we tracked never had a face-to-face encounter with a health care professional.

A team that included specialists from Respirology and Infectious Disease, the AHS Primary Care team, Primary Care Networks and members of the Calgary Zone developed the Pathway to help support family physicians to care for their patients. It was intended to be followed for patients who:

• Were presumed or confirmed COVID-positive, or
• Had influenza-like illness (ILI) symptoms, until a swab result is obtained, or
• Had tested negative, but present with strong clinical suspicion

The Pathway gave health care providers structure and confidence – especially early in the outbreak. It was effective amongst the entire team, from office assistant, to nurse, to family doctor.

Across the Zone, there are no known cases where the Pathway failed to identify a deteriorating patient. Even if a patient sounded sick on the phone, Pathway flags reassured that most were not critically ill. In the rare instance when a visit to acute care was warranted, it was done in a controlled fashion with complete communication.

I had a patient who had called 811 and was given the advice to head to acute care. I happened to call her shortly after, and ran through the pathway with her. After assessment, we agreed that she should stay at home to be closely monitored instead. Later, after an uneventful week, she took a turn for the worse with increasing shortness of breath. This time, she met criteria for further evaluation. I was able to talk to EMS in the home and to a specialist via Specialist LINK. With enough concerning features, we asked EMS to transport her to hospital for tests and face-to-face evaluation. All tests were negative and she subsequently recovered fully.

*See a case study on one patient at the end of this article.

Education and Early Intervention Prevented Higher Numbers

Even though Cargill workers were healthy, with lower-risk ages of 30s and 40s on average, there were many instances of multigenerational families living together. Many had the full range, from young children to parents or grandparents in their 70s and 80s. These household contacts were widely variable in age and risk status.

Surprisingly, many household contacts that isolated in the home did NOT become symptomatic. Strong primary care led to good outcomes. Residents were educated on how to self-isolate, and how to protect the vulnerable members in their household. Strict isolation protocols were reinforced for family members.

One of my patients, an 85-year-old diabetic grandmother lives with her daughter and son-in law – who works at Cargill – and both got sick. They managed to isolate the grandmother within the home, and she never got sick.

Relationship with Family Doctor

Because family doctors hold their patients’ trust, we were able to alleviate anxiety and panic. Moderately ill patients could be evaluated and reassessed at intervals that provided reassurance to both patient and provider. Many symptoms that the pathway indicated as red flags (shortness of breath at rest, chest pain or pressure, cold, clammy or pale mottled skin, new confusion etc.) could be downgraded with a good virtual history, thereby averting visits to clinic or the emergency department. (Examples of red flags are blue lips or face.)

Lessons Learned

First, the pandemic plan in the Calgary Zone was created by a consortium of the local Primary Care Networks (PCNs) in partnership with Alberta Health Services. This plan posited that COVID-19 is mainly a mild to moderate illness and can be cared for in the Primary Care setting. Good primary care would keep infected people out of acute care facilities, preserving capacity. (Capacity in acute care and ICU is one of the main determinants for judging the degree of lockdown needed in society.)

Second, the Zone team created Clinical Pathways based on Best Practices around the world. The Pathways provide a framework and consistency for the Virtual Primary Care management of COVID-19. There is a built-in link to specialist advice through a central access service developed over the past five years. Webinars explaining the Pathways were provided in early April.

Third, in the first week when High River doctors started seeing cases, the Calgary Rural PCN developed a temporary call centre/testing clinic using PCN nurses and admin staff, as well as local doctors. This was created in three days offsite from other medical facilities, while AHS readied its test site. The call centre took in over 900 calls, did 254 swabs and detected 52 COVID-positive cases.

Fourth, there is no provincial linkage of patient to family physician in Alberta. A Calgary Zone collaboration between AHS, the MOH and PCNs was rapidly pulled together to allow flow of results. The PCN call centre became the Hub for tracking, collating, and disseminating positive swab results to primary care clinics. This connected positive patients with their Medical Home for follow up with the Clinical Pathway. If patients had no family physician, they were connected to a roster of willing clinics. If this was not possible, the PCN Hub followed the patient with the Virtual Clinical Pathway. A silver lining in this pandemic may be that COVID-19 has created a situation where partners across the health system work more effectively together. Health system integration is a key part of a high-performing health system.

Fifth, the local physicians are closely connected with community resources. This facilitated the timely integration of community supports where needed. The nursing staff provided a lot of navigation to community resources as well, and were able to alleviate anxiety by connecting patients to the most appropriate resource – whether that was the isolation hotel, financial support, food security concerns, etc. Isolation can be difficult. Providing individualized support is key in preventing patients from breaking quarantine for essential needs, and thereby spreading the virus.

In summary, our pandemic plan had:

• An early rapid response to identify cases with a local solution for access to testing
• A collaboration to disseminate positive tests to Primary Care
• A Virtual Clinical Pathway to standardize and inform care between a multitude of providers
• Early connection of positive patients to a trusted voice in Primary Care
• Reinforcement and support of isolation of patients
• A means of connecting family physicians to Specialists and acute/emergency care when required
• Collaboration at all levels of the health care system striving for a common goal

Much of this plan is simple. The ability to operationalize it in a short amount of time depends on the level of preparedness. We created much of the detail in real-time. If we are affected again, the infrastructure is in place and it will be far less stressful. We hope this information will be helpful to communities large and small. Our solution seems to have worked well in many aspects.

Case Study – The Pathway in Action

April 17   Wife – a healthy 57-year-old female
Husband (a Cargill employee) tests COVID-positive, but with mild symptoms
April 18   Wife has mild hot/cold symptoms, and though no other symptoms, is anxious, so is swabbed, which returns negative
April 21   Because of the negative swab, and feeling better, wife goes to work at grocery store
April 22   Wife reports nasal congestion and a mild cough
April 22   Wife connected when using pathway for husband
April 22   Quarantine reinforced for husband and wife, 811 assessment recommends repeat swab for wife
April 24   Wife’s swab confirms COVID-positive
Symptoms are mild – some coughing, no shortness of breath. 811 says go to ED. FP assessment concludes home treatment is effective, and makes a promise to follow up the next day
April 25   Symptoms are better
April 26   Symptoms improve again
April 27   Mild shortness of breath once while walking, but no problems otherwise. The recommendation is to stay home.
April 28   Symptoms are better
April 30   Better again

May 1      Day 10 – Symptoms are worse.

• Shortness of breath at night, and during minimal exertion. Seems like a red flag
• Speech sounded ok, but Roth scores were 8 and 25 (on 2 tries)
• EMS was called, and ER notified to prepare
• EMS (talked to me via husband cell) – HR 72, RR 20-24, BP 145/70
• SpO2 98%, walk test 1min SpO2 97%, so, per EMS protocol, there was no transfer
• In the meantime, EMS gave the wife IV hydration at home while I called Specialist LINK
• With red flags, and the late deterioration, the decision was a transfer for x-rays/lab work
• ER: X-ray normal, labs normal, discharged home after four hours
• The ER doctor provided a warm handoff to me to close the loop

On day 10, there was communication with a specialist, the EMS, and the ER in real time, which is unprecedented in my 25 years as a physician. Care was coordinated, calm, and rational. The result was that the patient and her family were very happy with the care they received.

May 2      Day 11 – Feeling much better, no dyspnea at all
May 3      Day 12 – Feeling better still. Up and about.
May 4      Day 13 – Well, mild residual cough, tired
May 6      Day 15 – Well – recovered

Resources:
Clinical Pathways –  www.specialistlink.ca
Calgary Rural Primary Care Network – www.crpcn.ca
Calgary Zone Primary Care Network – info@calgaryareadocs.ca