More than a year into the COVID-19 pandemic, Ontario doctors and nurses may have more experience treating the disease but are increasingly staring life-or-death decisions in the face.
The spike in cases has strained intensive care capacity across the province. There are about 875 COVID-19 patients in Ontario hospital ICUs as of Tuesday — an all-time high — and 589 people in intensive care units (ICUs) on a ventilator. With staffing shortages — particularly the lack of ICU-trained nurses — and beds rapidly filling up, discussions about the possible need to triage life-saving care are mounting.
A “critical care triage protocol,” something that was not done during earlier waves of the virus, could be enacted, meaning health-care providers may have to decide who gets potentially life-saving care and who doesn’t.
“If you’ve ever participated in a fire drill, you understand what we’re talking about here,” said Dr. James Downar, a palliative and critical care physician in Ottawa who co-wrote Ontario’s ICU protocol.
“The purpose of training is to be prepared because if a crisis arrives and you run out of your resources and you don’t have a plan and you’re not prepared to institute your plan, things will get very, very bad.”
No formal plans
Ontario hospitals received a document in January laying out guidelines on how to deal with critical care triage. In other words, what to do if there aren’t enough ICU beds.
Under those guidelines, patients are essentially ranked on their likelihood to survive one year after the onset of a critical illness. The process came under criticism from human rights advocates, saying it is discriminatory, particularly toward people with disabilities and seniors.
At this point, the province has not finalized the protocol nor has it officially been published, but a widely circulating draft — titled “Adult Critical Care Clinical Emergency Standard of Care for Major Surge” – said patients could be scored by doctors on a “short-term mortality risk assessment.”
The aim would be to “prioritize those patients who are most likely to survive their critical illness,” the document reads.
“Patients who have a high likelihood of dying within twelve months from the onset of their episode of critical illness (based on an evaluation of their clinical presentation at the point of triage) would have a lower priority for critical care resources,” it said.
The lists three levels of critical care triage:
- Level 1 triage deprioritizes critical care resources for patients with a predicted mortality greater than 80 per cent.
- Level 2 triage deprioritizes critical care resources for patients with a predicted mortality greater than 50 per cent.
- At Level 3 triage, patients with predicted mortality of 30 per cent — or a 70 per cent chance of surviving beyond a year — will not receive critical care.
At this level, clinicians may abandon the short-term mortality predictions in favour of randomization, which the document noted is to be used “as a last resort” and should be conducted by an administrator, not by bedside clinicians.
The leaked document was prepared by the province’s critical care COVID-19 command centre, which would ultimately declare when to use it.
The College of Physicians and Surgeons of Ontario told doctors on April 8 that the province was considering “enacting the critical care triage protocol,” and that it would support such a tool once it is “initiated by the command tables of the province” and “even when doing so requires departing from our policy expectations.”
Downar emphasized that the protocol has not been instituted, echoing Ontario Health Minister Christine Elliott, who on April 7 said “there are some emergency protocols out there” but they “have not finalized any of that yet.”
“None of us want to be in this position, none of us want to be doing this,” said Downar. “We are prepared for it if it comes to that, but we are focused on not letting it come to that.”
Preparing for the worst
While a standard provincial protocol has not been formally established, some Ontario hospitals have been preparing anyway.
The University Health Network (UHN), which includes Toronto General, Toronto Western and Princess Margaret hospitals, have started virtual training sessions for staff on what to do if the virus’ growth gets the better of all other efforts to expand and accommodate the ICU system.
Dr. Niall Ferguson, the head of critical care at UHN, said while preparations for worst-case scenarios are happening, it doesn’t necessarily mean they’ll be enacted.
“We’re not expecting to be implementing them anytime in the near future… I think the likelihood is probably low,” he told Global News.
“COVID is more like a controlled train crash as opposed to an actual train crash where you’ve got a thousand critically ill people all on the same day — then triage is inevitable. When you’re getting a thousand critical care patients over the course of weeks, which we are here, then there is an opportunity to adapt the system and grow capacity and do things differently.”
Ontario’s latest modelling predictions cast doubt on short-term improvements. Even as cases slow or plateau, hospitalizations and ICU numbers are so-called “lagging indicators” of the severity of the virus in a certain jurisdiction. The provincial data predicts a peak of at least 1,500 virus cases in ICUs by the first week of May — that’s next week — and it could be higher, pushing Ontario’s total 2,000-ICU-bed capacity over the edge.
Downar said some training around emergency care standards has been “going on for months.”
He said avoiding the worst-case scenario depends on a lot of things and is not as simple as “staring at the number of COVID cases.”
“It’s tough. Everybody wants to know a number and everybody wants to know where that line is, but it’s just not something that is easily put into numbers at the moment.”
Adapting and expanding
What’s unfolded over the past few weeks exemplifies just how bad it’s gotten — but also how the system has been forced to adapt, as Ferguson said.
Hundreds of patients from already over-capacity hospitals in the Greater Toronto Area are being transferred to other hospitals hours away. The province has directed hospitals to “ramp down” all elective and non-emergency surgeries to help alleviate pressure on the health-care system.
“Transfers are not completely benign. There is a risk when we transfer people from one place to another,” Downar said. “It’s important for everybody to recognize that there already consequences to what we’ve been doing.”
But as Downar and many other health-care experts have stressed — providing critical care is more than just equipment and medications, it’s about having ample trained and available staff.
Some Toronto-area hospitals have installed tents outside emergency room areas to accommodate more patients — and abide by COVID-19 safety protocols, like physical distancing. Others, like Sunnybrook Hospital, have built a self-contained mobile health facility in one of its parking lots to take excess patients.
On top of that, this week the federal government has deployed up to three Canadian Armed Forces medical assistance teams, made up of critical care nursing officers and technicians, which will be rotated across hard-hit jurisdictions in Ontario. The feds will pay for Canadian Red Cross staff to provide support or relieve staff.
Both Downar and Ferguson welcome the help.
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Ferguson said gradually declining case counts may be an early sign that recent public health restrictions enacted by the Ontario government are working.
“Things may still get tighter in the next week or two, but hopefully we will see a subsequent fall in ICU admissions,” he said.
The hope is a triage strategy won’t be needed, said Downar, but “at least having an approach” to a worst-case scenario could “go a long way towards mitigating.”
He insists the plan, should it see the light of day, has “no focus on any other consideration than straight mortality risk,” despite criticism from human rights groups and bioethicists about potential discrimination the yet-to-be-finalized protocol could stir.
“None of us wants to be in this scenario but we can’t pretend our way out of it,” said Downer.
“We can’t ignore it and pretend or it won’t happen or pray it won’t happen, that’s not a strategy… The only thing worse than being in these scenarios is being in them without a plan.”
–With files from the Canadian Press