Setting: Primary care is the first line of defence in healthcare, particularly during the coronavirus disease 2019 (COVID-19) pandemic. In the London–Middlesex region of Ontario, a critical shortage of personal protective equipment (PPE) was identified among primary care physicians (PCPs).
Intervention: With the help of the London–Middlesex Primary Care Alliance, volunteer administrators, physicians and medical students coordinated the acquisition and redistribution of community-donated PPE to PCPs across London–Middlesex. Our scope evolved to include PPE reusability and stewardship and PCP wellness.
Outcome: Beginning on March 16, 2020, our initial four-week operation provided PPE to over 200 PCPs. We received 60 donations, including over 118,000 gloves, 13,700 masks, 700 wellness kits and reusable cloth masks and gowns. Each delivery included educational pamphlets, and our online PPE stewardship session was attended by over 30 physicians.
Implications: In response to the PPE shortage in COVID-19, our efforts evolved into a complex adaptive system, supported by an organizational body with a pre-existing communication infrastructure, to great success. Our scope extended beyond simple PPE provision to PCPs. Furthermore, our initiative established a framework for a centralized response to PPE shortage in Ontario Health West.
Coronavirus disease 2019 (COVID-19) was designated by the World Health Organization (WHO 2020) as a pandemic on March 11, 2020. Although there were no more than 100 Canadian cases in January and February 2020, the number of cases increased sharply in March from recognized community spread (Government of Canada 2020). On March 17, owing to the number of cases in Ontario and the impact that COVID-19 had had on other countries, the Ontario provincial government (Government of Ontario 2020) declared a state of emergency with significant implications for healthcare practice.
It has been well established that strengthening primary care is essential for pandemic preparedness (Clark 2015; Rust et al. 2009; Vasan 2020; Wynn and Moore 2012). Gaps in access to primary care during pandemics can lead to delays in the management of chronic conditions and the diagnosis and treatment of new ailments (Rust et al. 2009; Vasan 2020; Wynn and Moore 2012).
While physicians play an integral role in evaluating suspected cases and servicing the population, it is important to consider their safety. Historically, and in COVID-19, physicians have been vectors of transmission given inadequate testing and personal protective equipment (PPE) (Ahmed et al. 2020; Hashikura and Kizu 2009). There has been worldwide reporting of critically low supplies of ventilators and PPE during this pandemic (Eggertson 2020; Newman 2020; Ranney et al. 2020). In particular, Canadian primary care physicians (PCPs) are reporting critical PPE shortages without recourse from their standard suppliers. During the severe acute respiratory syndrome (SARS) crisis of 2003, healthcare practitioners received PPE kits from the government to support continued clinical care; however, during COVID-19, no such support has been initially demonstrated (Eggertson 2020). While primary care has adopted virtual models through telephone visits, online platforms, etc., there remains a significant need for in-person visitation, especially among the homeless, mothers and babies, palliative patients requiring home visits and those with significant comorbidities and for home visits.
The London–Middlesex Primary Care Alliance (LMPCA) is a network of PCPs within the South West Local Health Integration Network (LHIN) that was established in 2017. This group had previously been supporting the provincial transformation toward Ontario Health Teams and was developing governance structures to strengthen the local primary care sector, which includes family physicians, nurse practitioners, etc. During COVID-19, the LMPCA was made aware of a projected shortage of PPE supply in the region and was concerned about the impact on the ability of PCPs to safely provide care.
In response to the shortage, a unique complex adaptive system emerged in collaboration with the LMPCA, the Thames Valley Family Health Team (TVFHT), the Middlesex–London Health Unit, medical student volunteers from the Schulich School of Medicine & Dentistry and London–Middlesex community members. The scope of this initiative was to provide PPE to PCPs in the London–Middlesex region. Our innovation arose organically in a time of need to support healthcare workers in their commitment to patient care while further solutions were developed. This article addresses the challenges we faced and the opportunities that arose and offers guidance for future efforts.
The LMPCA had already established a network within the primary care community. Therefore, it was well situated to be the lead organization to start collecting donations and procure PPE from non-traditional sources. The local public health unit at this time was focusing on the development of COVID-19 assessment centres, testing and community education. This left a void that allowed for the LMPCA, through its transformation lead for primary care, to help establish a PPE response initiative working with local individuals and businesses. This position was developed to engage and support PCPs with their integration into the London–Middlesex Ontario Health Team. The resources and support for this role were provided by the London InterCommunity Health Centre, Health Zone Nurse Practitioner-Led Clinic, London Family Health Team, Four Counties Family Health Team and the TVFHT. As such, the transformation lead was well positioned and critical to managing and providing leadership to the emerging PPE needs of PCPs in this region.
Operation logistics and personnel
Our operation started on March 16, 2020. The transformation lead began to process PPE donations and delivery requests. The earliest PPE donations came from physician offices that had a surplus of PPE supply. The TVFHT graciously provided the operation with offices and a boardroom for workspace and storage of PPE supplies. Two medical student volunteers from the local university were initially recruited to help with inventory, packaging and delivery of PPE.
Within the first week, initial outreach to local businesses, community leaders and communication blasts over e-mail and phone calls resulted in a significant donation response from the community. As the operation became more established as a source of PPE for healthcare providers, the number of donations and orders became untenable to handle with three volunteers. Other facets of this operation, such as social media and accurate inventory practices, required more dedicated roles. As such, several changes were made to our operation at this time to ensure timely processing and delivery:
- Additional volunteers were brought into the operation, including a retired PCP and four medical student volunteers to process and deliver PPE requests and administrative personnel within the TVFHT to assist with project management and communications.
- To adapt to ongoing changes in needs, we established that any revisions to our operations would be made using a three-day change re-evaluation system (similar to a quality improvement Plan-Do-Study-Act [PDSA] cycle), where we would revert to previous practices if a specific change was detrimental to the operation.
- Inventory was moved to an online spreadsheet format, including dates and identifiers for each donation and delivery for accountability, as well as automatic daily summarization.
- A dedicated e-mail address and shared online drive were created to centralize all e-mail communications and documents.
- Daily informal check-ins were established to allow volunteers to troubleshoot or implement new changes.
- An online PPE request form was created for PCPs to fill out; this was retracted as per our change re-evaluation system because use of the form did not provide straightforward collection of information and required extensive e-mail communication regardless.
To comply with Public Health Ontario (2020) guidelines (i.e., social distancing and cleaning practices), TVFHT's Occupational Health and Safety drafted and approved a standard operating procedure, which the PPE volunteers adhered to. The number of volunteers and TVFHT staff on site was limited to eight per day, with six-feet distancing when possible. All working areas were wiped with sanitation wipes regularly, and masks and gloves were worn at all times when working in proximity to or handling PPEs. Finally, all visitors and guests picking up supplies were not permitted past the entrance.
By week 2, roles within the operation had been established (Table 1). Weekly meetings were scheduled to keep all members updated on the status of the operation and discuss any further changes. Using our change re-evaluation system, our operation expanded to address issues of PPE reusability, PPE stewardship and PCP wellness (discussed below). A full breakdown of our organization at the end of four weeks can be found in Figure 1.
|Table 1. Stakeholders in the operation|
|Role title||Role description|
|Thames Valley Family Health Team||
|Transformation Lead: Administrative and Project Manager||
|Primary Care Physician: Senior Advisor||
|Community of South West Region Pandemic Planning Table||
|Medical student volunteers|
|PCPs = primary care physicians; PPE = personal protective equipment.|
As our operation progressed, two areas of PPE-related concerns arose: PPE education and conservation strategies. PPE stewardship is important to address repeatedly among PCPs and their staff, especially with respect to new COVID-19 infection control protocols. In response, we began to include PPE instructional pamphlets alongside deliveries based on guidelines set by the Centers for Disease Control and Prevention (CDC) and information on appropriate chemical cleaning agents as recommended by the American Chemical Society.
We also found that many clinicians were erroneously requesting N95 masks. Therefore, we referred PCPs to a local physician educator and shared guidelines set by the Ontario Ministry of Health and the Ontario Medical Association. This helped demystify misconceptions on N95 mask use in primary care, and inappropriate PPE requests decreased.
In addition, we began incorporating principles of PPE conservation in our process for PPE allocation. For example, surgical masks with visors were highly requested as these protect the entire face from droplet spread. However, owing to limited donations of visored masks, such requests were substituted with visorless surgical masks and safety glasses, which were donated more frequently. Furthermore, safety glasses could be reused, and this substitution was endorsed by the CDC to have equivalent efficacy.
Finally, to further engage local PCPs and provide information on best practices for PPE use, we partnered with a local PCP, the transformation lead and the COVID-19 community pandemic planning clinical lead for London–Middlesex to host a recorded town hall session via a web conferencing application. This session provided details to clinicians about the practical application of PPE guidelines and examples of how to implement these in their offices. COVID-19 resources for PCPs were also shared on the London–Middlesex Primary Care website (LMPCA 2020) and sent out in weekly communiqués.
Exploration of reusable PPE options was necessary to increase self-sufficient use by PCPs and to prevent clinic closures due to a lack of supplies. Partnering with a local fabric supplier and the organization Canada Sews, prototypes for cloth gowns and masks were developed using models from the local hospital and standardized designs in consultation with Created for Crisis, an international research and design team, for quality control (Canada Sews 2020).
Cloth masks and gowns were provided to PCPs who were comfortable using these and had adequate laundering facilities. The LMPCA worked to provide discounted fabric to sewers from the local fabric supplier, which allowed PCPs to purchase additional cloth gowns at a significantly reduced cost for their clinics and staff. Reusable PPE provided PCPs with longer-term solutions and options to address PPE challenges.
Three-dimensional-printed PPE, donated by the Faculty of Engineering as well as the Physics and Astronomy Department at Western University and local businesses, also became an important source of reusable PPE. We were provided with face shields, eye goggles and mask holders to distribute to PCPs and the non-hospital community.
As a grassroots initiative, we depended on public outreach to garner community awareness and donations. We were able to expand our donated PPE supply substantially through coverage of this initiative on various platforms (such as The London Free Press newspaper and Twitter) and leveraging connections within the LMPCA. Conventional media sources such as CBC News and local radio channels were later used to continue community awareness of our project and share our outcomes, which helped build buy-in and trust in our centralized operation.
With the involvement of the medical students, this initiative was highlighted through The Western News as well as the Schulich School of Medicine & Dentistry, which provided additional outreach. The initiative was very fortunate to receive grants through the Ontario Medical Students Association (OMSA) and Canadian Federation of Medical Students, allowing us to spread further awareness of this initiative, especially to medical students across the province and the country. Aspects of the London–Middlesex PPE initiative were integrated into other independent medical student-led initiatives across the province and discussed at PPE town halls held by the OMSA.
Care provider morale
Our operation was unique in also focusing on PCP morale with PPE supply. We wanted to thank PCPs for their commitment to patient support during the COVID-19 pandemic. Initially, we began by attaching thank-you cards to deliveries. This wellness addition was noticed on Twitter, and as a result, we received generous community donations of hundreds of wellness kits with snacks and handwritten notes of appreciation.
Over four weeks, there were 60 unique donations to our operation and 113 deliveries of PPE to PCPs. We received a large variety of items, including over 118,000 gloves, 13,700 masks, gowns, facial protective equipment, wipes and sanitization supplies, scrubs and lab coats, bouffant caps, shoe covers and 700 wellness kits. In terms of reusable PPE, we received 160 face shields, 148 cloth gowns and 1,110 cloth masks.
We delivered PPE to over 200 PCPs working at a total of 54 clinics across London–Middlesex, Strathroy, Lucan and St. Thomas. This included a palliative care physician, a neurologist, a pediatrician, an allergist, an addictions medicine consultant, an endocrinologist and 190 family physicians. We also made deliveries to many other healthcare workers, including a nurse practitioner clinic, three hospices, a COVID assessment centre, a homecare service, the Middlesex–London Health Unit, the London InterCommunity Health Centre and the Southwest Ontario Aboriginal Health Access Centre. Over four weeks, we donated over 40,000 gloves and 8,000 masks, alongside many other items, to PCPs across the region. A breakdown of our major items can be found in Table 2.
|Table 2. Donations and deliveries from the LMPCA for selected items between March 16 and April 9, 2020|
|Item||Donated to LMPCA||Delivered from LMPCA|
|Masks (×50 box)||274||164|
|Face shields (×1)||160||42|
|Wipes (×1 can)||97||48|
|Hand sanitizers (×1 bottle)||68||41|
|Isolation gowns (×10 pack)||217||112|
|Cloth gowns (×1)||148||130|
|Cloth masks (×1)||1,110|
|Wellness kits (×1)||700||700|
|LMPCA = London–Middlesex Primary Care Alliance.
Note: Cloth masks had been a recent donation and not yet delivered.
All PPE items were delivered with informational pamphlets on proper PPE use, preservation and cleaning recommendations, as well as wellness kits for staff members. The virtual town hall session regarding PPE stewardship was held on March 31, 2020, and attended by over 30 physicians.
This operation created a skeleton framework for a larger regional system. Subsequently, our operation was integrated into the emerging government-driven PPE supply system (the Ontario Health West COVID-19 Regional Allocation Committee) on April 13, 2020, and as of May 22, 2020, we continue to provide both donated and government-supplied PPE to PCPs across southwestern Ontario.
In the face of a PPE shortage in primary care during the COVID-19 pandemic, we were able to rapidly set up a grassroots organization that successfully provided PPE to PCPs in the London–Middlesex region by securing donations from the community.
Our initiative was very fortunate to be supported by the LMPCA and the TVFHT. Their pre-existing infrastructure facilitated easy communication and coordination with our local network of PCPs and local business leaders, allowing for significant PPE donations. In addition, the TVFHT office allowed our operation and PPE inventory to be housed in a secure location and provided processing volunteers with adequate space to work while upholding social distancing measures as recommended by public health authorities. With this infrastructure, our diverse team was able to produce a complex adaptive system that was well situated to respond to the pandemic rapidly, appropriately and flexibly.
Another strength of our operation was in striving to improve PPE stewardship among PCPs in a variety of ways. Through PPE instructional pamphlets, video demonstrations and a virtual town hall, we explored different ways to encourage stewardship around disposable and reusable PPE. This component of our operation was critical to prevent wasteful or inappropriate use of PPE in a time of shortage and maximize the distribution of our limited donated supplies. In addition, providing PPE education allowed our operation to engage with healthcare providers on a more personal level. While pamphlets relayed information from trusted sources such as the CDC, our instructional videos and virtual town hall featured local physician leaders and trusted members of our local medical community. Furthermore, we uniquely supported PCP morale with our wellness kits, which is important in this time of stress.
Given the rapid need for PPE solutions in this unpredictable pandemic, our initiative was able to implement a change re-evaluation structure modelled on the PDSA framework from quality improvement initiatives. This allowed us to adapt to an ever-changing pandemic landscape. Our organization was able to remedy the PPE shortage in London–Middlesex among PCPs. To support a larger geographical area spanning four former LHIN regions (Waterloo–Wellington, Erie–St. Clair, Hamilton–Niagara–Haldimand–Brant and South West), Ontario Health West leadership endorsed and leveraged the initial successes from our work to create a PPE hub model.
We faced many challenges during our operation. A major challenge was appropriately assessing the demand for PPE from one request and determining the duration of support the supplies would provide. We did not have a defined ethical framework that could be followed to assist in PPE allocation amid limited supply. Although the literature offers recommendations on the quantity and types of required PPE during pandemics (Hashikura and Kizu 2009), because of urgency, we often relied on the honesty of PCPs in their requests. One solution we attempted was a Google survey to be used with PCPs at the time of PPE delivery or pick up, assessing their clinical practice and the number of supplies used per week. However, in many cases, the point of contact was not the physician but another staff member instead. Furthermore, many PCPs represented large teams with inconsistent schedules, which resulted in further inaccuracies. As such, we stopped our survey within three days. As our PPE initiative received support and oversight from the pandemic planning table and Ontario Health West, we were able to rely on them for this decision making.
In the initial stages of our operation, we also encountered other healthcare providers requesting PPE, such as pharmacists, long-term care and nursing homes and community care clinics. Although our scope was initially for PCPs only, we attempted to deliver PPE to the other healthcare providers as much as our limited resources were able to handle. As the government-driven PPE supply was established, we advocated for provision of supplies to these other providers as well.
Another significant challenge was practising safety precautions with the evolving public health recommendations in COVID-19. Maximizing social distancing meant limiting the number of PPE orders that could be delivered by volunteers, limiting the number of volunteers who could work simultaneously at our collection centre, implementing PPE use among volunteers (for the safety of volunteers and for minimizing contamination) and implementing regular disinfection of surfaces at our worksite.
Our initiative continues to grow and incorporate changes. For example, we introduced a medical student-run donation subcommittee on April 8, 2020, modelled off work by medical students in the Greater Toronto Area. This group assisted with e-mailing/calling local businesses to bring in further donations.
The COVID-19 pandemic has impacted all facets of our modern world and healthcare systems. Disruption to manufacturing and worldwide supply lines has led to an immediate critical shortage of PPE that has threatened the provision of primary care. This was especially challenging for PCPs as many of them were independent practitioners not privy to other options for PPE in the pandemic. The LMPCA PPE Initiative represents a complex adaptive system in response to an urgent problem, made possible through a diverse team of individuals and an organizational body with pre-existing communication infrastructure. The success of our operation is predicated on not only our PPE donation and delivery but also the ability to adapt to changes and provide PCPs with additional support beyond supplies. This organizational model is an effective approach to solving urgent problems, and its framework can be used as a basis for other such efforts.
About the Author(s)
Meera Shah, BMSc, is a third-year medical student at the Schulich School of Medicine & Dentistry in London, ON.
Jordan Ho, BSc, is a third-year medical student at the Schulich School of Medicine & Dentistry in London, ON.
Adrina Zhong, BSc, MPH, is a third-year medical student at the Schulich School of Medicine & Dentistry in London, ON.
Matthew Fung, BSc, is a third-year medical student at the Schulich School of Medicine & Dentistry in London, ON.
Mario Elia, MD, CCFP, FCFP, is a family physician in London and an adjunct professor of family medicine for the Schulich School of Medicine & Dentistry in London, ON.
Janet Dang, BHSc, MA, is the transformation lead, primary care supporting the London–Middlesex Primary Care Alliance and Western Ontario Health at the Thames Valley Family Health Team in London, ON. She can be reached by e-mail at firstname.lastname@example.org
Thomas R. Freeman, MD, MCISc, CCFP, FCFP, is a retired family physician and professor emeritus of family medicine at the Schulich School of Medicine & Dentistry in London, ON. He can be reached by e-mail at email@example.com or by phone at 519-661-2111 ext. 22077.
The authors would like to thank the following individuals in their contribution to the London–Middlesex Primary Care Alliance PPE Initiative: Mike McMahon, Drina Silva, Jill Strong, Lisa Vreugdenhil and staff (Thames Valley Family Health Team leadership); Jielin Lu, Asher Frydman, Jonathan Hu and Tori-Rose Javinsky (medical students); Kathleen Klement (regional coordinator, Canada Sews, London and Middlesex) and volunteer sewers from Canada Sews; Diana House, Dr. Colin Dombroski, Ciara Walsh, Kate Goodwin, Donna and Randy Ladouceur, Dr. William Abbott and Dr. William Frydman (community members); Rodney Lover and Heather Reid (wellness kits) and community wellness kit preparers; Dr. Cathy Faulds and Dr. Gordon Schachter (London–Middlesex; COVID-19 community pandemic planning physician leads); and all the business owners and community members in the London–Middlesex community who have donated to this effort.
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