The provincial critical care lead for the Toronto Central region found himself doing something this week that he called “extraordinary”: transporting an adult COVID-19 patient through an underground tunnel from Toronto General Hospital to a Sick Kids bed.
For Dr. Niall Ferguson, this is just one illustration of how “strained” the health-care system has become under the pandemic’s third wave. As case counts hit record highs in the province — 4,736 on Thursday — and 644 COVID-19 patients currently requiring intensive care, Toronto hospitals are scrambling to find spots for patients. Sick Kids opened eight beds within its intensive care unit to care for younger adults in order to help alleviate some of the pressure.
And next week, Sunnybrook Health Sciences Centre will begin accepting patients in its field hospital — composed of rows of tents in one of the hospital’s parking lots. Meanwhile, Toronto Western Hospital and Toronto General Hospital are erecting large tents to serve as patient waiting areas to help reduce crowding in overstretched emergency departments.
On Monday, Health Minister Christine Elliott said Ontario will have 350 net new ICU beds by the end of this week.
But what does one ICU bed really mean?
The bed itself is the least important part, said Ferguson, head of critical care at the University Health Network and Mount Sinai and the site lead at Toronto General Hospital. Ferguson works with other critical care leads to distribute resources around the region and prevent hospitals from being overwhelmed.
Each ICU bed requires four to five nurses to monitor the patient, 24/7, Ferguson explained. And if the patient is sick enough to be on a ventilator, a team of physicians, respiratory therapists, physiotherapists, pharmacists and cleaning staff is needed too. Then there’s medications, monitors and other supplies. While access to ventilators was a major problem in the first wave of the pandemic, it won’t be the “choke-point” this time around, Ferguson said. It’ll be the lack of human resources.
At Toronto General, 300 to 400 nurses work to care for patients in 38 ICU beds. And with more people on ECMO (extracorporeal membrane oxygenation) today than ever before — 24 at Toronto General alone as of Wednesday — perfusionists to operate the heart-lung machines are necessary, Ferguson added.
The Star asked Ferguson earlier this week about Ontario’s hospital capacity and what challenges he predicts the next few weeks will bring.
Q: Some reports state the province has 2,500 ICU beds. How many ICU beds do we have in Ontario right now?
A: It’s a moving target to be honest. We can open up additional beds with alternative staffing models, for example, people doing additional shifts. But we won’t do that until we have enough cases to need those beds. I worry about having to tell the team that it’s time to take it to the next step of expanded care. So instead of the usual staffing ratios, moving to more patients per nurse and per physician for example. It’s likely that will happen in the next while. It’s still better than the alternative, which is telling people, “sorry, we don’t have the space to look after you.”
Q: When we see patients being transferred because one hospital is hitting capacity, are you the guy making those calls about which hospital should be decanting and where they should go?
A: There’s a team of us. People might think, “well, there are 1,800 patients in critical care across the province and something like 600 COVID cases.” But remember that COVID is not randomly and evenly distributed around the region or around the province. It’s much more concentrated in the GTA, than other parts of Ontario. Even within the GTA, we’ve seen large disparities between different COVID burdens at different hospitals.
Q: How many transfers are we having to do this week in Toronto?
A: At the acute, medical ward level, I think there’s something like 60 or 70 of those planned this week. At the critical care level, we’re looking at it on a daily basis. I think we have around 15 planned today. This is absolutely unprecedented. It’s also unprecedented that I can walk around the ICU and have almost everybody with the same diagnosis.
Q: If we were to enact all of the measures we need to free up as many beds as possible, what is our max capacity?
A: It depends on what else is going on. In wave one, we were able to redeploy and repurpose both people and spaces. Many centres said that they could double the number of ICU beds they had. But things are more complex in wave three … People that had their cancer and cardiac surgeries delayed are coming in from other hospitals.
Q: What about the cost of running a single ICU bed? Has anyone crunched those numbers?
A: The cost can vary between centres, but the average and the standard rate for an ICU bed comes out to $875,000 a year.
Q: Do you have concerns around nursing shortages?
A: There’s a huge nursing shortage all around the GTA. We’re continually trying to hire and look for new HR.
Q: Are we running out of medications?
A: The one medication we’re tight on is a specific anti-inflammatory medication called Tocilizumab. In the past it was used to treat specific complications of some chemotherapies but it has been shown to reduce mortality if used at the right time. We’re using it as strategically as possible.
Q: What’s something happening today that you never thought you would see?
A: The fact 28 out of 38 patients in our ICU right now all have the same diagnosis; 24 of them being on ECMO. The level of co-operation and co-ordination between hospitals across the region has been pretty exceptional … everyone is trying to step up and help out.
Q: Where do you think Ontario hospitals will be in a few weeks time?
A: We anticipate our ICU COVID numbers will go up for at least the next week or two. We’re getting ready to bring in additional physicians into the ICU 24/7 to look after all these patients, and asking them to do more shifts than normal.
Q: Are the measures we’ve put in place enough?
A: I hope so. But people need to take this seriously. People were more careful in wave one, and more people were staying home than are doing so right now, maybe because they haven’t appreciated we’re in a different situation with the variants.