Omicron in Ontario, Part 2: Anthony Dale on what’s coming for our hospitals

TVO.org speaks with the Ontario Hospital Association CEO about ICU capacity, triage tools, and how to keep our health-care system working
By Matt Gurney - Published on Dec 15, 2021
Anthony Dale has served as president and CEO of the Ontario Hospital Association since 2013. (Courtesy of Anthony Dale)

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This is the second instalment in a three-part series looking at what we do and don’t know about the Omicron variant. Read Part 1 here; watch for Part 3 on Thursday.

In just a few short weeks, the so-called Omicron variant of COVID-19 has swept the globe at a remarkable pace. The virus seems to be extremely contagious. We will have large outbreaks all over the world, including in Canada and in Ontario, specifically, before medical experts and scientists have a good understanding of how lethal it will prove for both the unvaccinated and the vaccinated, whose doses may not fully work against the new, highly mutated variant.

Early indications from South Africa, where Omicron was first identified, do not yet show a clear signal that Omicron is producing serious illness at the same rate it’s producing infections. But it’s far too soon to say anything with confidence. In the coming days, TVO.org will speak with experts about what we know about Omicron and what kind of shape we are in to combat it. 

Today, we speak with Anthony Dale, president of the Ontario Hospital Association.

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Matt Gurney: Let’s not even talk about Omicron yet. Give me an overall snapshot of the state of Ontario’s hospital system.

Anthony Dale: Well, we’re still not anything that looks like normal, and I’d characterize the system as fragile. We have a system that’s battered and bruised. By that, I mean the people are exhausted, burnt out. And there are lots of changes in the workforce, people taking a break or leaving altogether. We still don’t know those exact numbers, but we have enough evidence to know that we’re facing major patient-care pressures because of health-care human-resource issues. We’re making some headway and progress on catching up — at the provincial level, anyway — with respect to cancelled surgeries and diagnostic imaging, but that varies by organization and by what part of the province you’re in. The sector at the outset of Omicron was feeling more stable than it had in some time. You can imagine our sadness and disappointment with the news that this new variant could bring an end to that.

Gurney: How do you get the system back on track after the first three waves? You’ve mentioned the backlogs. What is required to erase them?

Dale: Volume. Huge volumes of procedures and tests. The system adapts and finds ways to increase its throughput. At the moment, our capacity to do so is greatly limited by a couple of things. One is, again, availability of certain personnel — certain kinds of nurses, in particular. There is a shortage of them, especially specialized nurses. So that’s definitely a factor. As well as some of the professions within the sector, quite specialized clinicians often with a technical expertise. That’s definitely a factor. 

And then you pull the camera lens back more and we still have the underpinning issues that we had going into this pandemic. At the beginning of December, we had 5,200 alternate-level-of-care patients in hospitals, and I know you’re well aware of who those patients are and what it means to be an “ALC” patient in a hospital. Think about that in a pandemic. That’s basically at an all-time high.

[Note from the author: an ALC patient is a patient who is awaiting transfer either out of the hospital system or to a more appropriate setting within it — consider a patient who has recovered from an illness but can only be discharged once home-care arrangements have been made. A delay in the home-care planning keeps that patient in a hospital bed that they don’t technically need, until the backlog elsewhere can be addressed. ALC patients awaiting transfer were a major contributor, pre-2020, to delays and “hallway health care” in our hospitals.]

Gurney: I do know what ALC means; you’re right. And that is a number I check occasionally. And, wow: 5,200 is really high.

Dale: It’s about a sixth of our hospital beds.

Gurney: [expletive deleted]

Dale: I know. That number is from late November, so that’s recent and includes all beds — acute beds, plus complex continuing care, rehabilitation, mental health, and other specialties. If you just look at the acute-care beds alone, we actually hit a 10-year high in terms of the number of ALC patients. And that’s because of two factors. We have a very fragile long-term-care sector; that’s self-evident from what has occurred there. And we also have, I would say, an extremely unstable home- and community-services sector, especially home care, which had a lot of its workforce pulled out of it during the earlier waves of the pandemic. There was recently a significant financial injection there to help provide some stability, and there are shortages all across the continuum, but I think home care has suffered greatly. So what that means is the ability to get people home quickly and keep them there has been badly reduced. On the prevention side, supporting people who are living at home independently is also not nearly what it used to be and not nearly what it should be.

Agenda segment, November 25, 2021: Vaccinating Ontario kids against COVID-19

Gurney: These are important points, and they warrant attention, but I want to focus narrowly on the acute-care hospitals. I was talking with colleagues this morning, and we were kicking around a question that I couldn’t answer. I mentioned I was chatting with you later, and I promised I’d ask. So here goes: Is the system, today, more capable, less capable or equally capable to what it was in, say, January 2020?

Dale: That’s a great question, and it’s complicated. You can answer that question in a lot of ways. The size of the workforce overall is bigger than it was at the beginning of the pandemic, because hospitals hired a lot of staff for all the other kinds of activities they were asked to do, especially the vaccination clinics over the last year. Financially, it’s very well-supported by the province of Ontario at the moment; the province has been a strong partner in maintaining financial stability. So you need money to pay people. And people are the biggest costs and expenditure in a hospital setting. So we’ve had financial stability. 

The province has also funded additional beds in key areas, especially critical care. But, again, to our earlier point, a bed requires personnel who staff it and care for the patients. Those different skills mix in different staff ratios for different kinds of care. And, in critical care, we have seen a drop in staffing, and that means a drop in capacity. This might be temporary. Maybe some of the nurses just need a break and will come back. We can’t say yet. But we do know that those professions, as well as the paramedical professions, are where we have the biggest gaps.

Gurney: So even with more money and more staff in some areas, a lack of critical-care nurses and paramedics will affect the volume of patients that can be handled.

Dale: It definitely affects volume, yeah. It’s a major factor in staffing emergency departments; it’s a major factor in certain kinds of surgery; it’s a major factor in critical care. But, again, there are solutions to these challenges — it’s just that it will take time to implement them. It often means introducing new ways of caring for patients in order to adapt to this circumstance. So, anyway, there’s a lot of complexity there. We’re not without solutions. But, to your core point, it has definitely, in the very short term, affected our overall capacity and capability without a doubt.

Gurney: Let’s talk about the new variant now. Omicron is moving fast — very fast — and we don’t understand it. Maybe it’s fine! That would be good. But we can’t assume it will be good. Even if it’s only a tenth as lethal as Delta, if we have 100 times the cases, the math on that sucks. We still lose. What are Ontario’s hospitals doing to get ready for what might be coming?

Dale: There are two major things underway in anticipation of a potential — I underscore potential — huge wave of patients, and we’d expect mainly unvaccinated patients. We are all hoping for good news, but we have a duty to prepare for the worst, and it’s possible that we’re going to see a huge influx of patients in late December and January. So what is going on right now is the hospital system is working with the support of the OHA and also the health minister to plan for a major surge. We want to build on our experience gained in the earlier waves, particularly the huge third wave. We are getting our “Team Ontario” in place, and our critical-care command table is continuing to provide excellent oversight of the situation. Our patient-transport service is ready, willing, and as capable as it can be to transport patients from within a region outside a region, potentially right across the province, in order to save as much human life as possible.

But. Unfortunately, part of our planning is examining the awful reality of our critical-care triage tool. It’s our last line of defence if our ramparts have been breached and the walls are crumbling. It’s how we’d manage the worst kind of decision that any clinician should ever be asked to make. So we’re out of luck if that ever happens.

The second thing that’s going on, on the preventative side, is the government has moved in the last several days to reactivate the province’s various mass-vaccination capabilities. So, Monday, there was a huge communication session between provincial officials in the hospital sector where the sector was asked to do everything it can to activate as much mass-vaccination capability as possible. We were alongside our colleagues in public-health units. There’s also been communication extended to primary care — so, family physicians in their various organizations. There’ll be, I think, an effort to expand capacity in pharmacies. I wouldn’t be surprised if we see additional expectations placed on private-sector employers to support the vaccination of their staff. So this is a huge strategic push by the province to attempt to get as many people their third doses as soon as possible. Our sector is highly motivated and believes strongly in the power of vaccination to keep people safe, to keep this hospital system stable, through the worst of this wave.

I don’t think people should underestimate the extent of the challenges ahead of us, though. I’m hearing from hospitals everywhere that they are facing an ethical conundrum of having to potentially reassign and redeploy health-care workers from, say, a surgical suite or emergency departments to support a mass-vaccination effort. This will weaken the core effort of the hospital, the kind of work we’re supposed to be doing. And there is a deep, deep well of sadness, but also anger. I can understand people wanting to take their time before vaccinating their children. But if you’re an adult over the age of 18 in this province, and you have in the face of overwhelming evidence chosen not to get vaccinated ... [trails off]. There are probably a million unvaccinated adults in Ontario. They are the kindling of our next wave that the Omicron virus is seeking to ignite. This is really tearing people apart. Sadness and anger. This is so fundamentally unnecessary.

Gurney: You mentioned the triage tool. In the third wave, we had about 900 COVID-19 patients in ICUs. That’s actually beyond what I think we thought we could sustain, but we did it. We didn’t cross the red line. How close were we?

Dale: [heavy sigh]

Gurney: Very encouraging.

Dale: [laughs] Yeah. Oh, man. Now I’m laughing, but it’s nervous laughter. We were close. At the red line. Another day, maybe a few days, and, yeah. We were at the edge. Efforts are underway to try to get it established as a legitimate guidance for the field, because, as you may know, it’s still not actually endorsed by any authority in the province, except by the critical-care command. It’s still technically considered a discussion or draft document.

Gurney: I did not know that.

Dale: Yeah. But let’s hypothesize and say the Omicron variant brings us 1,200 COVID patients into critical care, plus all the other patients who need critical care. That would be something that we simply couldn’t mitigate or manage. There would have to be decisions about resources. Right now, obviously, I don’t know if we will get 1,200 COVID patients. We have about 150 now. So we’ll look at our modelling and then track that against the real-world experience. But some of the scenarios I think we will see modelled will be very, very disturbing to people.

Agenda segment, December 2, 2021: COVID-19 drugs and treatments

Gurney: Years ago, before anyone had heard of COVID-19, I read through the federal influenza-pandemic plan. And it talked about some of the stuff we could do if things got really bad. We could convert hockey rinks into medical facilities. Well, guess what. I got both of my vaccines so far in hockey rinks. It talked about using refrigerated trucks as morgues. We’ve done that, too. It also talked a bit — I’m going off memory here; it’s been a long time — about managing parts of the health-care system by trying to have some hospitals become non-flu hospitals. Everyone having a baby, every car-crash victim, goes to some hospitals, and some hospitals try to cope with the flu patients. I’ll have to go dig up the old reports — I wish I remembered this better — but I bring it up to ask, if we do end up with 1,200 COVID patients in ICU, that’s not a functional hospital system. How do you manage something like that?

Dale: There are other people better suited to answer that question — physicians in critical-care services. But we have never supported the concept of having some hospitals only for COVID, though, during the third wave, there were some hospitals, particularly in Toronto, that were de facto COVID-only. But I think it sounds more effective than it actually would be. We have huge concentrations of expertise and experience in all our hospitals now, plus we know how to manage COVID-19 better than we did, so I think we’d avoid doing anything like that.

But you are right about one thing. At the levels that we’re talking about, you’re talking about massive total gridlock in the hospital system. Nothing else happening for a very long time. I repeat again that this is a worst-case scenario, but we do have to plan for it. At those levels of patients, the system doesn’t function properly. We’d try to keep critical-care suites available for someone coming in after a car crash, like you said above, as one good example. But nothing else would really be possible for a long time.

This thing is moving very quickly. It’s got a very quick doubling rate. The future hasn’t happened yet. I think that people are starting to understand the growing risk to the province that Omicron poses. Uptake for boosters is increasing — we had 100,000 people on Monday. So that’s promising news, and we have some tools through mass vaccination within the health system to try to mitigate against this and avoid the worst outcomes. You know, the social contract that exists also pulls us back to the individual. As a resident of Ontario, a citizen of Canada, you need to do your part. No one believes that we should ever return to a lockdown situation again; that is the last thing anybody wants to see. We have antigen tests. We have a huge supply of vaccines available to us. Let’s use these tools.

Gurney: Well, speaking of which. [The author reaches off camera to grab the boxes of rapid tests that just arrived in the mail. He shows them off with a dramatic flourish.]

Dale: I’m glad to see that! I really am. We have some here, too. We have closing on two years of experience of living with this. And even though we’re tired of it, and we want it to go away, we do know what we have to do to change our personal habits and our behaviours in order to support each other. I’m already seeing lots of evidence from people I know and people I speak with that tells me people are understanding, and they’re going to make some smart choices over the holidays and follow the guidance of Dr. [Kieran] Moore. Not everyone can do this, but we are lucky that many people can continue to work from home. Many people can still find ways to communicate, engage, be with their family and friends and adapt to this kind of environment for a little bit longer. 

If we can all do that and take advantage of the things we now have that we didn’t a year ago, especially testing and vaccination, we stand a fighting chance. But no one should be under any illusion about the potential magnitude of the wave. It really means acting right now. Not waiting until after Christmas. It means smart choices, small groups, use of rapid-antigen tests if you do gather with your family or close friends in small groups. But we know about masking and the importance of ventilation and so on. There are plenty of ways we can all act independently to keep each other safe.

Gurney: You know, the last time we chatted on the record, when we hoped Delta would be the last major wave, I asked you about the first wave — the very beginning. I asked you when you and your colleagues had that moment of realization. That this was a thing that was going to happen. And you said that it had been building up throughout February and that, on March 11, 2020, you and your colleagues knew it was tipping over. That we needed to move fast because it was getting out of control. Well, here we are. How are you and your colleagues feeling now, today?

Dale: The esprit de corps in health care, I think, has never been stronger. And not just in the hospitals. We know we’re in a fight, and the ties are now so much deeper. There are a lot more authentic conversations about the situation and what we can do to fight against it. There is a depth of disbelief and sadness about the stubbornly unvaccinated adults who placed themselves and others at risk. Because, again, they’re the kindling that COVID is going to ignite — is already igniting. There’s also deep exhaustion, because we’re tired just like everybody else. And I need to be clear. I mean, the hospital sector generally, but especially the front-line workers themselves, whom we continue to ask so much of. So much.

If we could think about them when we make the decision about whether or not to go to our office Christmas parties or go to a big indoor party at a pub or restaurant. Please think of them and, with any luck, next year will be different.

This interview has been condensed and edited for length and clarity.

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