‘Pretty scary scenarios’ as COVID-hit ICUs to begin measures including forced transfers, training doctors to be critical-care nurses

Ontario’s hospitals are confronting a crisis point in the pandemic as the ongoing crush of COVID-19 patients threatens to outpace their ability to cope.With a record 552 COVID-19 patients in ICUs — a number predicted to escalate to 600 within the next week — the province directed hospitals to postpone non-urgent procedures, including cancer and heart surgeries, for the first time since last March.Late Friday, the province issued two emergency orders that will see health workers, including nurses and care co-ordinators, be redeployed as needed, and allow overwhelmed hospitals to transfer patients to other sites without first gaining consent.Since April 1, 130 COVID-19 patients have been transferred out of overloaded hospitals, some transported as far away as London and Kingston, while the Hospital for Sick Children, which this week opened a critical care unit for younger adults with COVID-19, has already admitted four patients. And starting this weekend, at least one Toronto-area hospital will begin training physician volunteers so they can help critical care nurses in the ICU, as a way to immediately add more staff to keep up with a flood of severely ill COVID-19 patients. “We are at the most threatening point in the pandemic,” said Dr. Chris Simpson, executive vice-president of medical at Ontario Health. “The potential for bad things to happen is more than hypothetical and the response has to match the gravity of the situation.”As the third wave rushes ahead, with no signs of slowing, the province logged more than 4,000 new cases on Friday — the highest daily count in the pandemic.The ever-soaring case counts signal to medical leaders that hundreds of hospitalizations will soon follow, placing a devastating and uneven burden on many GTA hospitals that never fully recovered from the second wave.“We’re seeing the daily growth of new cases start to hit that kind of vertical part of the curve,” said Simpson. “When we start to project what the next two, four and six weeks look like, it starts to get us to some pretty scary scenarios where the numbers in ICUs and hospitals get to the point where it’s going to overwhelm some parts of the system.”Simpson said the medical community is working “system-wide and all-hands-on-deck” to avoid a triage situation that would force physicians with limited resources and staff to choose which patient would receive life-saving intervention. Given current trends, the triage tool — if needed — would first be used in struggling GTA hospitals, he said. “Imagine coming into work one morning and you’ve got 25 patients with COVID in your emergency department who need to be intubated and you’ve got absolutely no room, then this triage tool starts to be considered,” he said. “Making a decision that this person lives, and this person doesn’t get a chance … that is a devastating point I hope we just don’t get to. If we’re ever going to do something really dramatic and big to prevent that, it’s got to be now. “We have to create as much capacity as we possibly can in the moment.”Between mid-November and April 5, about 1,400 patients, including general medicine patients, have been transferred, according to a spokesperson from Ontario Health. So far in April, 130 COVID-19 patients have been moved, including 51 by Ornge critical care land ambulances and four by the service’s helicopters, a spokesperson for the air ambulance agency said. Mass patient transfers out of hard-hit hospitals helps share the burden across the system. Friday’s provincial emergency order to allow physicians to transfer patients to other sites without requiring patient or family consent is meant to help an overstrained hospital quickly move patients to where there is capacity, Simpson said. Dr. Niall Ferguson, head of critical care medicine at the University Health Network and Sinai Health System, said the regional command centre is co-ordinating patient transfers within the GTA and — more recently and with greater frequency — outside the region to ensure capacity in case of a local patient surge.“We’re trying to decompress the region a little bit … so that we’re more prepared if a crunch comes at an individual site,” said Ferguson, critical care lead for Ontario Health’s Toronto Region.Though moving patients far from home puts a strain on families, the goal is to be fair and equitable at a system level and to maximize health outcomes, he said.“Right now, in some instances, transfers are the way people are going to get the best care … they are moving to a place where a health-care team is not overwhelmed.”Peel’s William Osler Health System has 132 COVID-19 patients across its two sites — the most so far in the pandemic — and its emergency departments at Brampton Civic Hospital and Etobicoke General Hospital are at or above pre-pandemic patient volumes.On Thursday, Osler transferred 10 acute care patients and five critical care patients, and in recent days its emergency departments have been crowded with patients, said Dr

‘Pretty scary scenarios’ as COVID-hit ICUs to begin measures including forced transfers, training doctors to be critical-care nurses

Ontario’s hospitals are confronting a crisis point in the pandemic as the ongoing crush of COVID-19 patients threatens to outpace their ability to cope.

With a record 552 COVID-19 patients in ICUs — a number predicted to escalate to 600 within the next week — the province directed hospitals to postpone non-urgent procedures, including cancer and heart surgeries, for the first time since last March.

Late Friday, the province issued two emergency orders that will see health workers, including nurses and care co-ordinators, be redeployed as needed, and allow overwhelmed hospitals to transfer patients to other sites without first gaining consent.

Since April 1, 130 COVID-19 patients have been transferred out of overloaded hospitals, some transported as far away as London and Kingston, while the Hospital for Sick Children, which this week opened a critical care unit for younger adults with COVID-19, has already admitted four patients.

And starting this weekend, at least one Toronto-area hospital will begin training physician volunteers so they can help critical care nurses in the ICU, as a way to immediately add more staff to keep up with a flood of severely ill COVID-19 patients.

“We are at the most threatening point in the pandemic,” said Dr. Chris Simpson, executive vice-president of medical at Ontario Health. “The potential for bad things to happen is more than hypothetical and the response has to match the gravity of the situation.”

As the third wave rushes ahead, with no signs of slowing, the province logged more than 4,000 new cases on Friday — the highest daily count in the pandemic.

The ever-soaring case counts signal to medical leaders that hundreds of hospitalizations will soon follow, placing a devastating and uneven burden on many GTA hospitals that never fully recovered from the second wave.

“We’re seeing the daily growth of new cases start to hit that kind of vertical part of the curve,” said Simpson. “When we start to project what the next two, four and six weeks look like, it starts to get us to some pretty scary scenarios where the numbers in ICUs and hospitals get to the point where it’s going to overwhelm some parts of the system.”

Simpson said the medical community is working “system-wide and all-hands-on-deck” to avoid a triage situation that would force physicians with limited resources and staff to choose which patient would receive life-saving intervention. Given current trends, the triage tool — if needed — would first be used in struggling GTA hospitals, he said.

“Imagine coming into work one morning and you’ve got 25 patients with COVID in your emergency department who need to be intubated and you’ve got absolutely no room, then this triage tool starts to be considered,” he said.

“Making a decision that this person lives, and this person doesn’t get a chance … that is a devastating point I hope we just don’t get to. If we’re ever going to do something really dramatic and big to prevent that, it’s got to be now.

“We have to create as much capacity as we possibly can in the moment.”

Between mid-November and April 5, about 1,400 patients, including general medicine patients, have been transferred, according to a spokesperson from Ontario Health. So far in April, 130 COVID-19 patients have been moved, including 51 by Ornge critical care land ambulances and four by the service’s helicopters, a spokesperson for the air ambulance agency said.

Mass patient transfers out of hard-hit hospitals helps share the burden across the system. Friday’s provincial emergency order to allow physicians to transfer patients to other sites without requiring patient or family consent is meant to help an overstrained hospital quickly move patients to where there is capacity, Simpson said.

Dr. Niall Ferguson, head of critical care medicine at the University Health Network and Sinai Health System, said the regional command centre is co-ordinating patient transfers within the GTA and — more recently and with greater frequency — outside the region to ensure capacity in case of a local patient surge.

“We’re trying to decompress the region a little bit … so that we’re more prepared if a crunch comes at an individual site,” said Ferguson, critical care lead for Ontario Health’s Toronto Region.

Though moving patients far from home puts a strain on families, the goal is to be fair and equitable at a system level and to maximize health outcomes, he said.

“Right now, in some instances, transfers are the way people are going to get the best care … they are moving to a place where a health-care team is not overwhelmed.”

Peel’s William Osler Health System has 132 COVID-19 patients across its two sites — the most so far in the pandemic — and its emergency departments at Brampton Civic Hospital and Etobicoke General Hospital are at or above pre-pandemic patient volumes.

On Thursday, Osler transferred 10 acute care patients and five critical care patients, and in recent days its emergency departments have been crowded with patients, said Dr. Andrew Healey, Osler’s chief of emergency services.

“Those patients are now mixed with COVID-19 patients who have very high-acuity disease and who are deteriorating very rapidly,” Healey said. “Last evening, we had four intubated and ventilated patients occupying all four of our resuscitation bases at one time. We’re relying upon minute-to-minute updates from our partners — Ornge and other hospitals — in order to transfer those patients out.”

On April 6, Osler put out an urgent call for “approximately 100 physicians across the departments of medicine, surgery, anesthesia, pediatrics, emergency medicine and family medicine to help staff ICUs and COVID wards as physician extenders,” according to a memo obtained by the Star.

So far, more than 80 Osler physicians have volunteered, with doctors from other hospitals also offering help, Healey said. Training begins this weekend, and physicians will next week be working alongside ICU nurses and respiratory therapists to add more bedside care for critically ill COVID-19 patients.

It’s the first time in the pandemic Osler has needed physicians to augment nursing staff in its ICUs and COVID wards, Healey said.

“Our health-care system is pressured today, more than ever before. And we are going to be pressured tomorrow, more than today. And the prospect that this will grow is frightening.

“We have never faced a challenge like this. Can we do it? We can. But we will need every lever within the health-care system … and every health-care professional to be ready to help.”

Joseph Brant Hospital in Burlington is moving to team-based care in its ICU and acute care wards in anticipation of a further surge in patients. This means physician and nursing staff who don’t normally work in the ICU will be paired with an experienced ICU doctor or nurse to work as a team, said the hospital’s chief of staff, Dr. Ian Preyra.

“We might have one of our anesthesiologists who, instead of working in the operating room, will come and work with one of our intensive care physicians so that together, they can take care of more patients,” he said.

Already at critical care capacity, the hospital is planning for additional ICU space by taking over its endoscopy unit and post-operative unit to accommodate more patients should there be a surge, Preyra said, noting the plans have been in place since March 2020.

“This is the first time we have had to deploy it on a large scale in the pandemic.”

The province’s two temporary emergency orders — effective as of Friday evening — are valid for 14 days unless revoked or extended. Along with other measures, these orders “are expected to increase ICU capacity in the province by up to 1,000 patient beds,” according to a news release by the Ministry of Health.

Dr. Barry Rubin, medical director of the Peter Munk Cardiac Centre and co-lead of University Health Network’s clinical activity recovery team, said UHN is implementing its plan to further ramp down surgeries to accommodate the growing need for critical care beds.

The plan, designed in consultation with an ethicist, considers more than just the number of available beds, but also staffing levels and the impact on patients, including the severity of their need and how long they’ve been waiting.

Rubin said UHN’s hospitals will continue to provide access to patients in the most serious situations.

“If somebody has a life-, limb- or vision-threatening problem, we’re going to be there and we will be able to take care of those patients,” he said. “Unfortunately, there are some patients that have diseases where we are going to have to pause.”

Megan Ogilvie is a Toronto-based health reporter for the Star. Follow her on Twitter: @megan_ogilvie

Source : Toronto Star More