In the coming weeks, the healthcare system in Toronto and across Ontario is likely to be tested like never before as the spread of COVID-19 continues.
Interviews with public health experts suggest there are two fundamental questions that now confront us.
One, how much community transmission of COVID-19 occurred between the time of Canada’s first actual case and the enactment of widespread social awareness, distancing, screening, and testing measures? And two, are those efforts sufficient to temper community transmission to a point where our healthcare system will be able to cope?
We are about to get answers any day now in the form of hospitalizations and ICU (intensive care unit) cases related to COVID-19, says Mark Loeb, the Michael G. DeGroote Chair in Infectious Diseases at McMaster University in Hamilton.
“The real issue is whether the social distancing measures in place now will blunt the impact. I think they will, but to what extent? This is still the quiet before the storm.”
Is the healthcare system prepared for a surge?
Unlike SARS in 2003, which was primarily contained in healthcare facilities, COVID-19 can spread through communities easily and quietly, with serious symptoms manifesting in infected individuals up to 14 days after the acquisition of the virus.
Seventeeen years later, the hospital system still runs at capacity, and sometimes over it.
A 2019 study found Ontario’s biggest hospitals are filled beyond capacity nearly every day. Five hospitals in the GTA were over their funded capacity for more than 160 of the 181-day period reviewed last year.
“There are going to be a lot more ill people in emergency and ICUs,” says Loeb. “As interventions go, we have limited surge capacity.”
There are particularly important questions with respect to the number of available ICUs in the province, including the equipment and staff needed to operate them.
Allan Detsky, a professor of Health Policy Management and Evaluation and Medicine at the University of Toronto, documented outcomes of 144 cases during the 2003 SARS outbreak.
“Ontario, like all provinces, runs without surge capacity,” Detsky says. “So, you have people working in hospitals who can see the ICUs are already full with regular patients, asking themselves, where are they going to go?”
The Toronto Star reported this week that James Downar, a critical and palliative care physician in Toronto, is aware of 1,700 ICU beds and ventilators currently available at hospitals across Ontario based on documents he has read.
But that figure may be misleading, he says.
“These 1,700 are normally operating near capacity, meaning that they are approximately 90 per cent full or more,” explains Downar in an email to NOW, adding that the exact figure fluctuates daily.
He notes that “the wheels are in motion to obtain new ventilators.” The province has an emergency stockpile of 209 ventilators and recently obtained and delivered 300 new ventilators.
“But there are also limits on staff who are trained in ICU,” adds Downar. “This will also change day-to-day if people get sick, and physical spaces to put patients will depend on how many other acute patients are admitted.”
He says that there is a capacity to treat critical care patients in operating rooms. “It would be reasonable to think that we could flex up to 100 per cent additional capacity or more at many sites but certainly not all.”
A group of Toronto scientists and clinicians working on COVID-19 simulations found this week that demand may exceed Ontario’s ventilator and ICU bed capacity in approximately 35 days.
The same analysis found that even if Ontario doubles its number of ICU beds and purchases 600 additional ventilators, it could run out of capacity in two months, depending on the scenario.
The Canadian Association of Emergency Physicians (CAEP) began ringing alarm bells last week.
“While it is necessary to continue our current efforts at containment to limit and delay the spread of the disease, it is equally important to acknowledge that this may well have only a limited effect,” says a CAEP statement.
“Canada has an absolute shortage of trained and qualified emergency physicians and nurses. If we are to succeed as a nation in meeting the challenge of the COVID-19 pandemic then we need to face the realities of the limitations of our hospital system,” the statement goes on to say.
In a press conference on Wednesday, Theresa Tam, Canada’s Chief Public Health Officer, said that the federal government is “pre-empting any need for ventilators” by making purchases.
But another area of concern is personal protective equipment, or PPE, like gloves and N95 masks, for healthcare workers.
According to a Toronto frontline healthcare worker, the opening of the University Health Network’s (UHN) COVID-19 assessment centre was delayed this week because of a lack of PPE.
“The exact root causes of this are complex… but this continues to be a limiting factor and the reason the [Ontario Medical Association] is clamouring for [Ministry of Health] support,” says this healthcare worker, who commented on the condition on anonymity in an email to NOW.
The strain on PPE supplies is also exacerbated by theft.
“Anecdotally, a lot of hospitals here are experiencing the loss and theft of important resources including masks, gloves, even respirators, and it’s quite disheartening to hear that’s going on,” says Toronto ER physician Qassim Tejpar.
Some Toronto hospitals and health networks, including Unity Health Network, confirmed that they are implementing additional security measures in response to increased risk of theft.
Tejpar says frontline healthcare workers are worried about the supply of PPE.
“Prior to this outbreak, we used (PPE) but only for certain patients, but we’re almost at the point where we need to use it for every patient because as it takes off here, we’ll see it in people who don’t have symptoms and transfer to others. Everybody’s cognizant there’s a stockpile but at some point we need to acquire more or we’re going to run out.”
Doctors across the province share these concerns. Ontario Medical Association president Sohail Gandhi says that “We were pleased to hear that the [provincial] government recently earmarked $50 million to address the issue of personal protective equipment, and that the supply of ventilators has increased, but we are anxious to understand how the existing stockpile of expired equipment and any new equipment will be distributed.”
Tam says that the situation is highly fluid, estimating that at present Canada can expect to meet about 75 per cent of requests for protective equipment.
“The reality is there are global challenges in securing certain supplies,” says Tam. “But we’re pulling out all stops to look at any other supplies, suppliers, bulk purchasing and any other means.”
That includes a shift in manufacturing towards the production of needed medical and protective equipment. The federal government has said it is in talks with auto parts makers. But could not offer a timeframe on how quickly a shift can take place. Ontario Premier Doug Ford put out a call to companies with sewing machines to make new medical gowns. Meanwhile, in Toronto, gin distilleries are already starting to produce hand sanitizer.
Securing more protective equipment will be critical to expanding the number of provincial assessment centres, which in turn is vital to increase hospital capacity.
“There will probably be a lot more cases, and the more full hospitals are the harder it is to deal with,” says Tejpar, adding that hospitals should discharge patients waiting for long-term care spaces and increase their number of funded beds.
Hospitals have already cancelled elective surgeries to make more room for the waves to come.
Projecting the scale of any imminent surge depends on a careful reading of available evidence, but any estimate will depend significantly on the extent to which the virus has already spread.