Ringing the alarm bells on critical care beds
Yesterday, Friday, April 3, was an important marker in tackling COVID-19 in Ontario as public health officials released modeling projections for the remainder of the month of April. The government’s presentation can be found here. It is good the premier and public health authorities are hearing the advice from RNAO and others to engage in honest and transparent communication with the public. In our Recommendation #2, below, we write: “Don't try to gloss over issues, don't minimize them, be transparent when decisions are driven by lack of resources (such as shortages of PPE), acknowledge we may be entering into more difficult scenarios.”
The numbers are sobering, as the government is expecting 1,600 deaths by end of April and between 3,000 and 15,000 over the 18 to 24 months course of the pandemic. RNAO’s concern is that this planning still happens under a “best-case scenario”; from the outset, RNAO has been calling not to make that assumption. The death toll numbers could be much higher if we are not prepared for a less beneficial scenario. If you look at the planning for Ontario ICU capacity in page 14 of the presentation (here), you will see that avoiding a shortage of ICU capacity is based on that “best-case” assumption. Under a “worst-case” assumption, by the end of April, there will be about 2,200 patients that required an ICU bed and were not able to obtain one – in other words, they will die. The current planning of 900 additional planned ICU beds for COVID-19 patients is insufficient for the needs in the month of April – much less for the needs beyond that date under certain scenarios. RNAO calls for an immediate reconsideration of the plan for only 900 additional ICU beds, which almost assuredly means that people who could live, will die.
Our concerns are aggravated by the lack of transparency on a central issue: planning for ventilators. The government’s presentation is silent on that crucial aspect, which contradicts the purpose of transparency and accountability on – literally – life and death decisions. Why is there no account of the actions, plans and projections on ventilators? Moreover, the government released internally on March 28, but did not disclose to the public, a document entitled Clinical Triage Protocol for Major Surge in COVID Pandemic. The document is “intended to outline criteria to be used for the allocation of critical care resources (especially mechanical ventilators) in a scenario where the need for ventilator support is greater than the existing resources,” adding that “The use of a triage protocol should be considered a last resort…” The problem of planning for an insufficient number of ICU beds and ventilators, as we are doing, is that the likelihood of having to make use of “clinical triage” becomes almost certain – not a last resort.
In short, the modeling projections presented by Ontario’s government officials today leave us gravely concerned about the current planning for critical care capacity expansion. RNAO has been speaking for months against applying assumptions of “low risk” or a “best case scenario.” South Korea is considered a best-case scenario, but we escalated our action relatively late compared with that comparator, and we have not engaged the actions they used to bring down the curve, such as early, extensive and rigorous testing, tracing contacts, and isolation. At this point we should expect a massive surge in critical care patients, and in particular those that require ventilation.
When you combine this reality with the application of “clinical triage” recommendations, it appears – shockingly -- that vulnerable populations will become the real casualties of the COVID-19 pandemic in Ontario. These are persons who would likely score low under the clinical criteria specified in the Clinical Triage Protocol document, but who in normal times would be treated in critical care beds. In a scenario of ICU shortage, likely they will not. Nurses, cannot and will not accept such a painful reality, unless government officials explains why, given the available evidence, it will not engage NOW and URGENTLY -- in further measures to increase critical care capacity beyond those currently planned, and address all other measures we have been urging for weeks.
The expansion of critical care in Ontario is small compared with what other jurisdictions are doing. So many seriously ill patients are anticipated that New York City is preparing to turn all its 20,000 permanent hospital beds into intensive care ones, while trying to add 65,000 temporary beds for other patients. London, UK, is just launching the largest critical care unit in the world with 4,000 beds, only one project among many others in that country. A group of Toronto researchers have been predicting a “critical shortage of ventilators” in Ontario since mid-March; their research can be found here. Researchers at the Imperial College London wrote in a devastating new analysis that even stringent mitigation measures of case isolation, home quarantine, and social distancing “would still result in an 8-fold higher peak demand on critical care beds over and above the available surge capacity.” Although the analysis relates to the UK and US, a similar logic applies in Ontario. We have had the luxury of being able to learn from the tragedy in Italy, which is now counting about 15,000 official deaths (unofficially, the real death toll is much higher), with lack of ICU beds, ventilators and nurses as key factors. Are we heeding the advice?