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Is Ontario’s ‘unprecedented’ step to move teens to adult ICUs ‘effective planning’ — or something else?


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Is Ontario’s ‘unprecedented’ step to move teens to adult ICUs ‘effective planning’ — or something else?

Doctors and nurses are warning that the “unprecedented” step of moving critically ill teenagers into regular ICUs amid a surge of children suffering from respiratory illnesses at Ontario’s pediatric hospitals lays bare the precarious conditions facing the health-care system.

The move Wednesday by the province’s Critical Care COVID-19 Command Centre to ensure pediatric hospitals are able to care for the sickest and youngest children could further strain regular ICUs and force hospitals to cancel adult surgeries to free up specialized ICU staff.

Already, pediatric hospitals are cancelling non-urgent surgeries amid historically long wait times and overcrowding, with in-patient units well above intended occupancy levels due to a surge in kids with respiratory infections.

The urgent request for teens 14 and older to be cared for in adult ICUs will be reviewed every two weeks, according to a memo obtained by the Star. It states that creating ICU capacity is necessary “for the current and impending surge in pediatric critical care demand” and says such demand will likely last for the next two to three months.

“If this is a two-week directive and very few patients end up moving, this is just effective planning to avert disaster,” said Dr. Michael Warner, medical director of critical care at Toronto’s Michael Garron Hospital, who called the move “unprecedented.”

But if multiple children need to be admitted to adult ICUs, he noted, then it could affect whether hospitals can proceed with surgeries “and affect our ability to care for patients.”

“It just points to the fact that the Ontario health-care system on its best days works on a knife’s edge, at around 100 per cent capacity. And when there is any type of disruption to the system, that causes increased need for critical care. We do our best to accommodate but something has to give.”

New data from a provincial database that monitors real-time emergency department visits and hospital admissions related to respiratory illnesses paints a troubling picture of what hospitals are facing.

In the past week, an average of about 1,241 children age four and younger with respiratory-related complaints were brought to emergency departments across Ontario every day. That’s more than double the historical moving seven-day average for this time of year, according to the database, known as ACES (Acute Care Enhanced Surveillance).

An average of 968 children ages five to 17 visited Ontario emergency departments every day in the past week — more than triple the historical weekly trend around this time.

The trends for admissions, while lower in number, are no less alarming. Daily average admissions for four-year-olds and under, at 28.6, are nearly triple the historical seven-day moving average of 9.7 for mid-autumn.

In the five-to-17 age group, daily average admissions are about 10, more than double the historical seven-day trend of about four for the same period.

“I’ve been talking about this since August, saying we’re going to have a terrible season,” said Dr. Anna Banerji, a pediatrician and an infectious disease specialist at the Termerty Faculty of Medicine and Dalla Lana School of Public Health at the University of Toronto. “Kids are going to school unmasked, COVID’s not over, we know it’s airborne, we don’t have good ventilation”.

Banerji said while she expected a bad RSV season, she is surprised by how early it has arrived. RSV, or respiratory syncytial virus, is common in children under two and usually presents symptoms of fever, sore throat, dry cough, nasal congestion and headache. For some children it can cause breathing problems, leading to hospitalization.

“It’s only going to get worse as we go into the peak of not just RSV,” she said, “but we also really haven’t started much of the influenza season. It’s starting and kids are coming into the hospital with influenza, but the peak of the influenza isn’t there yet.”

Dr. Chris Simpson, executive vice-president of medical at Ontario Health, told the Star on Thursday that while the hospital system often implements surge plans during a typical winter viral season, this is the first time health leaders have had to contemplate “how the adult system is going to need to be leveraged to help with the pediatric system.”

He said this year’s pediatric surge is at a “magnitude that we haven’t seen in a long time” because of the “1-2-3 punch” of RSV, influenza and, to a lesser degree, COVID.

Health officials predict both RSV and influenza to peak in December, meaning there will be a two-month period of sustained pressures on critical care capacity, Simpson said.

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Some hospitals may have to postpone scheduled surgeries to ensure there are enough ICU beds — and enough specialized staff to care for critically ill patients. But Simpson said urgent and emergency surgeries, including those for cancer procedures and for patients with major injuries, such as those from vehicle crashes, will be maintained.

“It remains paramount that ICU capacity is protected for those surgeries,” he said, adding that pediatric ICU beds for the sickest kids who need to be intubated will also be safeguarded.

Simpson said he doesn’t anticipate the province will impose a directive to cancel scheduled surgeries across the system, as it did at three other points during the pandemic. Rather, he said, hospitals and regions will ramp surgeries up and down like “a dimmer switch” based on demands and staffing constraints.

Ontario has about 100 pediatric ICU beds at its five pediatric hospitals, though Simpson said the system is able to surge up to 130 beds. He said that postponing surgeries, pulling staff with critical care skills from other areas of hospitals, and more quickly moving pediatric ICU patients who’ve completed their stay to community hospitals are strategies to help create capacity during the viral surge.

In April 2021, during the third pandemic wave, critically ill adults with COVID were transported out of overwhelmed hospitals in the Greater Toronto Area, some as far away as London and Kingston.

That same month, Toronto’s Hospital for Sick Children started accepting younger adult COVID patients into its ICUs to help take pressure off neighbouring hospitals, a move health leaders at the time called a “watershed moment.” In the three-month span of April and June 2021, SickKids cared for about three dozen critically ill adults with COVID, ranging in age from their early 20s to their mid-50s.

Warner said older teens are similar to adults in their physiology and it will be safe for them to be cared for in adult ICUs. However, he said, the training required to care for young children who need critical care is highly specialized

“An adult ICU nurse can care for a 16-year-old patient with an asthma exacerbation much in the same way they care for an 18-year-old patient; it really isn’t very different,” he said. “But that adult ICU nurse or doctor could not care for the five-year-old with RSV. We don’t have those skills.”

In a statement Thursday, the Ontario Nurses’ Association, which represents some 68,000 registered nurses, nurse practitioners, registered practical nurses and health-care professionals, said it was “appalled” at the “continuing erosion” of Ontario’s health-care system and the government’s “failure to take meaningful action to address ongoing capacity issues and nursing shortages.”

“Children are not just small adults. Pediatric patients have a significantly different set of care needs that considerably vary from those of adults and require RNs with specialized skills to provide the most optimal and safest care,” the ONA statement said, adding that Ontario Health must ensure that “pediatric patients can receive the best care possible under these circumstances by setting very clear and specific criteria around who will be transferred to adult ICUs.”

Dr. Mona Jabbour, interim chief of the department of pediatrics at CHEO, a pediatric hospital and research centre in Ottawa, characterized the pressures her hospital is facing as “the perfect storm.”

On Nov. 2, CHEO saw 246 visits to its emergency department, which was built to handle 150 visits a day. The hospital as a whole that day was at 113 per cent occupancy, while its pediatric ICU reached 186 per cent occupancy by 1 p.m. Thursday.

“We’re having RSV, influenza and COVID all happening at the same time,” she said. “So we’re seeing babies getting very sick, we’re seeing toddlers, younger children and older children as well getting sick. It’s all happening at the same time.”

In a Thursday evening statement, SickKids said while it has capacity in its ICU at this time, the possibility of moving older kids into adult ICUs is “an important step to help ensure SickKids and other children’s hospitals can maintain ICU capacity for those who require specialized pediatric critical care.”

The hospital anticipates the request for adult hospitals to care for older teens will “impact a small number” of its patients 14 and older who “can be effectively and safely treated at adult hospitals,” said spokesperson Sarah Warr.

Like other hospitals, the increase in patient volumes, combined with staff shortages, is affecting their “capacity to perform surgeries that require post-operative ICU-level care,” she said. This has decreased the number of surgeries at SickKids during the pandemic, she said.

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: kwallace@thestar.ca

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