Regional disparities could cause issues when ICU beds near capacity limits

As Ontario approaches a time when ICU beds will reach capacity levels, health experts are flagging that regional disparities will require the health system to be nimble and respond quickly to data as the situation on the ground rapidly changes.

In its data modelling scenario shared with the public last Friday, the government outlined two possible outcomes in the coming weeks when it comes to intensive care unit beds. One is the best-case scenario, in which the peak of the first wave of coronavirus patients comes in just below the total capacity across the province, after accounting for the 900 additional surge ICU beds that the ministry hopes to create for the crisis. The worst-case scenario, on the other hand, would see the province blow through its capacity, meaning that many patients would not receive the care they need, whether it be through a lack of physician care, ventilators, or other resources.

But the projections provide a provincial outlook, and do not account for regional disparities. Given how close the best-case scenario is to the overall capacity of the province, health experts say that could create extraordinary demands in some places where coronavirus patients happen to be above the Ontario average.

Alfred Whitehead, a data scientist contributing to the collaborative group of Ontario experts at HowsMyFlattening, told QP Briefing last week that the crisis is more granular than high-level numbers. "A pandemic is a million local emergencies that happen everywhere," he described.

Local responses will be crucial to solve those local emergencies, experts say. And part of that is coordinating among different regions to ensure there's appropriate resources depending on where the need is.

Dr. Ben Fine, a physician with an engineering background who is also working on HowsMyFlattening, said that hospitals have worked to add more flexibility in anticipation of the curve increasing, but it relies on the timely communication of impending needs. "For short-term capacity, I would expect that many hospitals could create a small number of beds with two days notice," he estimated, adding that it varies by facility depending on how they're structured.

But for major shifts more notice and coordination is needed to achieve the flexibility required to accommodate a surge of cases. "If there's a tsunami coming they need more notice."

Hospitals can meet capacity needs in a variety of ways. Part of it can be opening up additional beds in their facility — transforming a now-unused operating room into one, or re-purposing an auditorium. In other instances transporting patients may be necessary, depending on the condition and the ability of hospitals to do so.

Fine argued that the best way to ensure flexibility and that scarce resources are most efficiently allocated is by aggressively and transparently sharing data. "COVID-19 is moving fast. We need to move faster. The only way to do that is with radical transparency with data." This should go beyond summary numbers of how many people are in ICU beds, he added, calling for data on the regional and hospital-level breakdown of ICU bed capacity as well as adjacent information, like the number of online symptom questionnaires filled out by area and calls to Telehealth by region.

The Ministry of Health did not respond to questions from QP Briefing in time for publication. We will update this story when they get back.

In his daily afternoon press availability, Dr. David Williams acknowledged that there could be disparate coronavirus effects by region when Ontario reaches its peak. He outlined that the Greater Toronto Area is currently seeing the most cases, but it is also the region with by far the highest population. "The most concerning ones are the regional ones," he said, referring to low-density, rural parts of the province that do not have extensive health-care resources equipped for a pandemic. Williams added that parts of the province with higher numbers of retirees could also see greater need, as seniors fare more poorly with the coronavirus than younger people.

Ontario's top doctor also highlighted just how much capacity the province has cleared to make room for an expected influx of coronavirus patients. He referred to cancelled elective surgeries, which he said are at their lowest point in 15 years. Elective surgeries can require ICU care in the days following them as hospitals provide recovery care and oversight.

But he declined to be definitive about just how flexible hospitals will be when it comes to shifting resources from one region to another, saying that it will depend on the capabilities and needs of each hospital, and that it's a problem that resists "cookie-cutter" solutions.

Dr. Kali Barrett, a critical care physician at the University Health Network who has collaborated on data modelling efforts to project when resources like ICU beds will run out, said that above all Ontarians must remain focused on the big principles. "Extra bed capacity alone is not going to solve our problem," she warned. "If we don't flatten the curve resources are going to be depleted," she cautioned, urging that the aggressive public health measures like social distancing — and traditional responses like frequent hand washing — must remain at the forefront of the public response.

She also highlighted other issues. While ICU beds and ventilators have received significant attention, as they are projected to reach or exceed capacity by mid- to late-April, depending on the scenario, there are also staffing issues. "There are a finite number of critical care-trained physicians in Ontario," she observed. And there's also a limited number of nurses, respiratory therapists and the myriad other staffers that make an intensive care unit work.

She also mentioned that there could be other issues that arise, like drug shortages for medicines and treatments that are frequently used in ICU facilities.

In order to alleviate the pressure on these kinds of issues, Barrett added, one message can provide significant help: "It's up to the public to do its part."