‘Slow-motion mass-casualty event’: Anthony Dale on ICU capacity and COVID-19

TVO.org speaks with the CEO of the Ontario Hospital Association about the “single biggest crisis in our modern hospital sector’s history”
By Matt Gurney - Published on Apr 05, 2021
Anthony Dale has served as president and CEO of the Ontario Hospital Association since 2013. (Courtesy of Anthony Dale)

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On the weekend, I noticed some tweets from Anthony Dale, the CEO of the Ontario Hospital Association. He noted that, due to surging ICU occupancy in the third wave, 88 patients would be transferred from GTA hospitals this week to hospitals better able to care for them. Many of these transfers are within the GTA; some are heading farther afield, to London and Kingston. I spoke with Dale about this transfer, what is involved in such an effort — and what it tells us about the course of the third wave.

Matt Gurney: In basic terms, why are we moving these patients?

Anthony Dale: Ontario’s hospitals, and their intensive-care units in particular, are facing historic pressures because of the COVID-19 pandemic. The transfers are consistent with the Team Ontario approach that was set in place in January. All hospitals in the province, especially those with critical-care capacity, are expected to essentially work as a single integrated organization and help each other deal with extraordinary pressures. The technical term for it in critical areas is “load balancing.”

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To date, we estimate that some 1,400 patients have been transferred to different hospitals under this system. They are a combination of patients requiring intensive-care services, as well as other very, very sick patients in acute care. This is probably one of the largest transfers in a single week. But it’s an example of the system attempting to make sure that patients get equitable access to care. It’s all a sign of a system dealing with extraordinary stresses. This is an effort to make sure that our sickest patients get equitable access to the health services that they need, many of whom need it to stay alive.

Gurney: As you’ve said, these are very sick patients. The decision to move them can’t be taken lightly. How does that happen?

Dale: The decisions are made by Ontario’s critical-care command system. Ontarians should be grateful for those professionals. Ornge and other paramedic services will transport these patients — some by land, and some by air. Ornge will transfer the most critically ill. This has been going on since November. This is one of the largest planned transfers we’ve had to date. 

Gurney: I live near Sunnybrook Health Sciences Centre, in Toronto. We often see Ornge choppers coming in low and fast, even sometimes military helicopters after a search-and-rescue. The neighbourhood kids love it; the adults realize that each one of those flights represents the worst day in someone’s life. I bring this up because Toronto is supposed to be the hub of the most sophisticated facilities. Other places in Ontario send to us. If we’re sending out, that’s ominous.

Dale: A lot of these transfers are staying within the GTA. The load balancing can be done partially locally. But you’re right. Some patients are going to Kingston, London, or the Niagara Region. And it’s not just Ontario that sends to GTA hospitals. We take patients from all over Canada who need specialized treatment. Sunnybrook, for example, is also a trauma hospital, so they can receive patients from wherever there has been an incident. 

Gurney: How much time are we buying ourselves in terms of avoiding an overloaded system by moving these patients around?

Dale: That’s an important question. As of this morning, we have 482 COVID patients in Ontario ICUs, out of total ICU occupancy of approximately 1,800. That’s about 85 per cent of our nominal capacity.

People ask this a lot. They can check occupancy numbers and they say, hey, you’re only at 80 per cent. There are two things people need to remember. We need some flexibility in our system. We need “standby capacity” — the ability to receive patients without warning. If someone has a heart attack or is in an accident, that 15 per cent capacity is what saves them. So even at 85 per cent, we’re basically running at full.

And the other thing people should know is that “funded” capacity is never the same thing as “real” capacity. This pandemic has been going on for a year now. This is a slow-motion mass-casualty event. We have about 200,000 people employed in our hospitals, a range of workers: nurses, doctors, technicians. And many of them are reassigned right now to deal with the pandemic. All of the COVID-19 testing centres are run by hospitals. The hospital labs are part of the provincial COVID-19 testing strategy and have staff reassigned to run them to cope with huge testing volumes underway right now. I’m so pleased that our long-term-care residents are much safer now that they’ve been vaccinated. But, you know, many, many thousands of hospital staff were either volunteered or reassigned to support those long-term-care homes. And now, of course, hospitals are running many large mass-vaccination clinics.

So our staff are doing all sorts of things that have to get done to fight the pandemic. This is cannibalizing all the other services that actually also have to take place, like cancer care, cardiac care — even organ transplantation has been disrupted through the pandemic. There’s really just a fixed number of health-care professionals and workers to draw from. Many kinds of hospital-based services require the efforts of specialized physicians, specialized registered nurses, respiratory therapists, and so on. We have a set amount, a set number of those kinds of remarkable professionals. It’s a fiction to think that we could staff a critical-care system at 100 per cent occupancy on a sustained basis; there’s just nowhere near the staff. And remember: we are a year into this — this slow-motion mass-casualty event.

Gurney: Just a few weeks ago, within a few days, I knew of a woman who had a high-risk delivery of a baby that needed extraordinary medical care. The mom needed a lot of help, too. I knew a guy who survived a terrible cardiac emergency against long odds. And an old colleague of mine slipped on some ice and very, very badly broke his leg — he needed surgery and pins put in. And every one of these people, including the baby, is okay today because there was a hospital that could take them at short notice. None of these things was scheduled or planned. They all just happened, and there was a hospital ready to jump into action. 

Dale: People should come to the hospital if they feel sick, and they need access to, say, the emergency department. Do not hesitate: if you must come in, the system will do everything in its power to look after you. But we are seeing the kind of consequences of this pandemic and the cannibalization of other services. “Elective” services and diagnostic services can be delayed in theory, but they’re certainly necessary in many cases to maintain or improve one’s quality of life. There’s cancer care, there’s cardiac care, and, again, organ transplantation is technically considered elective or scheduled.

Right now, we have about a quarter-million surgeries backlogged from the first wave and continuing since then. That’s the hidden legacy of COVID-19. You have one health-care system with a relatively fixed number of people who are doing very different and necessary tasks on top of their regular day jobs in order to keep this province fighting in this pandemic. And, at the end of the day, it’s selective and scheduled care that pays the price.

Gurney: I’ve been trying to think of how to ask this. Trying to come up with the right balance of directness and nuance. I can’t. So I’m just going to spit this out: How close to a disaster are we? We avoided a hospital meltdown the first two times, and I think that people assume we can just keep on avoiding it. Can we?

Dale: [pause] Well. Adalsteinn Brown’s modelling lays this out pretty starkly. I expect within a day or so that we will have 500 patients in critical care with COVID-19-related critical illness. Each day, the number goes up. Even on a day where the occupancy number only goes up by maybe 15, that might be dozens of new patients — dozens of new come in, and some come out because they’ve recovered or, sadly, they have died. So we’ll hit 500 in perhaps even the next 48 hours.

For the first time in this pandemic, I am seeing so much fear and worry about the trajectory. Community spread is clearly completely out of control. The new variants are cutting people down more easily. It looks like we’re seeing a kind of acceleration in the number of patients requiring admission to ICU. Every day, I wake up and I look at the Critical Care Services census, and I wonder to myself, is today the day we’ll level off? And it just keeps getting higher.

So if we end up in the kind of high 600s, even the 700s, we are now talking about an enormous disruption to critical care. The funding for more beds exists, but we don’t have the people — with 1,800 patients, the system feels pretty full already. It’s entirely possible that we are two or three weeks away from being — well, certainly acute and critical-care services, the most complex patients in a hospital — the access to care could be even more heavily disrupted. 

Gurney: And two weeks is about the earliest we could hope to see much improvement based on our current public-health measures. We are cutting it a bit close.

Dale: Absolutely. This is what happened in January. The stay-at-home order worked. It reduced community spread. But hospitals kept getting fuller for a few more weeks. And ICU occupancy remained very stubbornly high for weeks. This was a very precarious position in which to start the third wave. It’s important for the readers to know that if they need help, they should come. Our hospitals will move heaven and earth to take care of you. But, in this situation, with the scarce resources, we’re going to have to use them in the most efficient and effective manner. That’s what it boils down to.

Gurney: That is a very benign-sounding statement. I’ve heard doctors making similar ones. I don’t think the general public realizes how chilling that is.

Dale: I feel that there is some Canadian exceptionalism that might be happening here. Our hospital system is a foundational aspect of our society. It’s reliable; it’s always been there through thick and thin. And I think people are tired of this pandemic. I don’t blame them. But the pandemic isn’t tired of us.

And this system that I’m so proud to represent as the head of the association is now being tested in a way that it never has been tested before. This is the single biggest crisis in our modern hospital sector’s history. And the situation will absolutely get more difficult before it gets better. But, again, the system is committed to patients and is committed to doing everything it can to remain resilient through this time, but we should not kid ourselves and think that this is somehow guaranteed, either. This is a very challenging time.

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

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