The province’s hospital system is again bracing for an overwhelming wave of COVID-19 patients driven by the highly transmissible Omicron variant, even as it tries to catch up with a backlog of surgeries, cope with diminished staffing levels and manage already crowded emergency departments.
Hospital leaders are being told to extend their “holiday slowdown period” beyond Jan. 1, meaning some diagnostic procedures and non-urgent surgeries would not be booked early in the new year, freeing up staff to help with vaccinations and a potential wave of sick patients.
Some hospitals are collecting names of staff who can be called in to help during what could turn out to be a frantic holiday period, while at the University Health Network, 500 physicians have so far volunteered to return to work if needed — including for nursing shifts — in the coming weeks.
And in a sign that hospital leaders are worried many ICUs may not have enough capacity to meet potential demand, the province’s COVID-19 Critical Care Command Table, which co-ordinated close to 1,000 patient transfers during the deadly third wave, is meeting twice daily to monitor and plan for more patient moves.
“What concerns us about this wave is the sheer speed of growth,” Dr. Chris Simpson, executive vice-president of medical at Ontario Health, told the Star. “Hospitalizations and ICU admissions are a late indicator. We have to be aware that everything will look OK until suddenly it isn’t. It could happen that fast.”
On Friday, Ontario reported 3,124 new COVID cases, the highest daily total since May 9, and more than double the 1,453 cases reported a week ago Friday. The Ontario COVID-19 Science Advisory Table now estimates more than 50 per cent of all new cases are caused by the Omicron variant, which has a doubling time of just 2.8 days.
The worsening outlook prompted Premier Doug Ford Friday to bring back public health restrictions beginning Sunday, limiting indoor gatherings to 10 and outdoor gatherings to 25, as well as reducing capacity limits for bars and restaurants to 50 per cent.
Modelling presented by the science table this week projects, under the worst-case scenario and assuming Omicron has the same severity as Delta, there could be more than 600 COVID patients in provincial ICUs by the end of December.
“That’s on top of existing, non-COVID-related critical care needs, with the curve still climbing,” said Anthony Dale, president of the Ontario Hospital Association. “That is a very serious situation that probably will eclipse the third wave.”
During Wave 3, ICU admissions reached a pandemic high of 900 on May 1.
On Friday, the province reported 157 patients with COVID-related critical illness in ICUs, down from 165 the previous day. Since Dec. 1, the number of ICU COVID patients has fluctuated between a low of 146 and a high of 168.
But even as the province’s health-care system plans for the worst, Omicron’s very recent emergence and a corresponding lack of hospitalization data, relative to other variants, makes it hard to know exactly what to expect.
Results from a recent study in South Africa suggest the variant may cause less severe illness than Delta. But experts caution that it is too soon to make any conclusions, especially since South Africa’s average population is younger than most western and European nations and because many in that country may already have immunity from previous infection. And in recent days, hospitalizations, ICU admissions and hospital deaths from the virus have been on the rise.
In Denmark, which is more analogous to Canada in terms of demographic makeup, there are indications that Omicron is not in fact less severe than Delta. For example, as highlighted by Steini Brown, co-chair of Ontario’s COVID-19 Science Advisory Table, during a press conference Thursday, the percentage of hospitalized Omicron cases in that country is not lower than other variants.
Brown said there is not enough strong evidence to support the suggestion that Omicron is less severe than Delta. But he noted that even if it is, the sheer number of people who will contract the variant means ICU occupancy still rises.
“The high transmissibility means that the decrease in severity has to be so substantial to make up for that high spread of the disease,” he said.
Simpson said health system leaders are closely monitoring provincial data and trends from other countries, including the U.K. and Denmark.
This week, Ontario Health told hospitals to not go back to their usual activities following the “holiday slowdown” period that typically occurs a few days before Christmas until shortly after Jan. 1, during which institutions scale back scheduled activities to allow staff a break.
While the hospital system will follow the same protocols that allowed it to cope with a surge of COVID patients in Wave 3, Simpson said there are two additional challenges this winter, on top of the incredibly transmissible Omicron variant.
The number of hospital employees, particularly those with specialized skills, including registered nurses and critical care nurses, is diminished compared to the third wave, some leaving their professions due to burnout.
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As well, Ontario hospitals are facing a higher number of patients who no longer necessarily need to be in hospital but who have nowhere else to go, known as Alternate Level of Care (ALC) patients. These patients may be waiting for beds in long-term care or appropriate home care before they can be safely discharged.
Simpson said the system will need to start dialling back scheduled surgeries and redeploying staff once there are between 250 and 300 COVID patients in ICUs.
“We’ve learned a lot from previous waves; we know what needs to be done,” he said. “But it’s the magnitude of the wave of patients that’s the big question mark.”
Critical care teams are already concerned that they will again need many of the contingency plans forced into action during Wave 3.
“If the numbers end up as bad as we are projecting, 100 per cent for sure we are going to have to cancel elective and non-emergent surgeries,” said Dr. Kali Barrett, a critical care physician at Toronto Western Hospital. “That is devastating for anyone that needs non-COVID-related surgery or procedures right now.”
Barrett recalled how the hospital had to convert the operation recovery room into an ICU to make space for an influx of critically ill patients during April and May. Nurses who had never worked in critical care and pharmacists from other floors were called on to staff the makeshift ICU, where patients were separated merely by curtains.
“We literally took people to the limits of their clinical training overnight.”
Greater Toronto hospitals were under extreme pressure from COVID patients requiring hospitalization in Wave 3, with Brampton Civic Hospital among those hardest hit. At the peak, the hospital was caring for more than 120 confirmed COVID patients and had to transfer out 10 to 20 patients a day to prevent it from being overwhelmed.
Kevin Smith, president and CEO of UHN, and a member of the critical care command table, said in the coming weeks patients will be moved to make the most efficient use of the province’s critical care beds “so no individual institution is overwhelmed.”
“That means that each hospital at any time needs to be prepared to receive patients with urgent conditions,” he said.
Earlier this month, the table directed the transfer of three patients from Kingston Health Sciences Centre, sending one to Brockville and two to Ottawa. The Kingston area currently has the highest COVID infection rate in the province and is dealing with a surge of Omicron cases on the heels of a large fourth wave fuelled by Delta.
Smith stressed the coming Omicron surge is particularly worrisome given diminished staffing levels that may be exacerbated should large numbers fall ill. Currently, health-care providers at UHN who are considered close contacts of a confirmed case will continue to work while undergoing daily rapid antigen testing for the virus and wearing proper PPE.
Smith says he is particularly concerned for emergency departments, many already experiencing long waits and crowded conditions, should waves of COVID patients require care. He said some hospitals, including UHN, have contingency plans for expanding emergency departments or opening clinics to test and assess suspected COVID patients.
Peter Juni, scientific director of the science table, said three things need to happen immediately to help secure the hospital system.
First, all hospital staff and their families need to get a third vaccine, unless they had their second dose less than three months ago. Second, all hospital workers must undergo rapid testing at least twice a week to catch any cases. Third, consistent masking in hospitals, including areas where staff congregate and eat.
“It’s about playing safe,” he said. “Because otherwise we will lose this workforce. And then, even if there is exposure, we need to have a test-to-stay protocol with rapid testing because we can’t afford to lose them.”
Dale of the Ontario Hospital Association said “hospital services are already heavily disrupted” even before an Omicron wave, as hospitals deal with staffing vacancies and long emergency department wait times. Hospitals in Kingston, Sudbury, Algoma and in the southwest currently face the most pressures from COVID, forcing some to dial back non-urgent services, he said.
“The premier used very strong language this week about the province being on a war footing,” Dale said. “That’s very much the context within which the (hospital) system will adapt. The virus is our enemy and the enemy is advancing very aggressively. The sector will act as best it can to take on these risks.”
Megan Ogilvie is a Toronto-based health reporter for the Star. Follow her on Twitter: @megan_ogilvie
Kenyon Wallace is a Toronto-based investigative reporter for the Star. Follow him on Twitter: @KenyonWallace or reach him via email: [email protected]
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