As of late May, most countries have falling numbers of new cases of COVID-19 and are at various stages of easing lockdown orders. This seems a good time to look back on the pandemic experience so far and at what lessons we can apply going forward. Waiting to Be Seen will do so in a series of posts looking at lessons learned and innovations that resulted from this intense first phase.
I’d like to start with a focus on ED safety. Back in March, Canadian emergency physicians were anxious; reports from Wuhan, China, and from northern Italy included tales of overwhelmed hospitals, exhausted staff, and illness and deaths among health care workers.[1,2] As Ontario’s “Expert Lead” for emergency medicine, I have been deeply involved in the province’s response to and experience with COVID-19. As of May 26th, we’ve had 26,483 cases and 2,155 deaths in Ontario, which translates to a very high case fatality rate of 8.1 per cent. This likely represents both an undercount of community cases due to testing limitations and a high attack rate among the most vulnerable of patient groups: the institutionalized frail elderly in our long-term care and retirement homes.
Hospitals weren’t overwhelmed
Despite this tragic failing in our senior care sector, our hospitals have not been overwhelmed. The peak number of ICU cases in Ontario hospitals was just over 250, which is well within the available capacity, and the total number of hospitalized patients at any time never got much above 1,000 (also well within the available capacity). Thus, every patient who needed an ICU bed received one, and no “rationing” of ventilators was required in this phase. Currently, we have flattened the curve and as of May 26th the number of hospitalized patients and the number in ICUs have dropped substantially. Data for the province are updated daily on Ontario’s COVID-19 response website.
Overall, our EDs have fared well. There have been only two outbreaks declared fairly recently in Ontario EDs, and these have included only a handful of ED staff.[4.5] I sense that anxiety in our EDs has settled a fair amount and there have actually been fewer staffing issues reported than normal (we have a chronic shortage of both physicians and nurses in Ontario EDs). So, our experience thus far—despite the tragic deaths, morbidity, and economic impact—has not been as disastrous as feared. What accounts for this?
It’s worth looking at some of the reported factors in jurisdictions that fared worse. These included some combination of:
Crowding in EDs due to a combination of high volumes of patients seeking care and/or high occupancy rates in hospitals and ICUs, which led to COVID-19 patients spending prolonged periods in EDs.
Inadequate supplies of personal protective equipment (PPE), which led to the use of homemade or inappropriate alternatives.[1,2]
Staff not adequately familiar with or not applying their knowledge of safe practices. Examples of this include the reported use of high-flow oxygen or non-invasive ventilation, which is thought to have potentially aerosolized droplets carrying the virus. This may have been due to a combination of being hit early in the pandemic, without time to prepare/train; having exhausted staff; recruiting staff such as retired or out-of-jurisdiction volunteers, who may not have been familiar with local infection prevention and control procedures; or just desperately trying to save lives.
What has gone right
From these observations, it is clear that a lot of what has gone right in Ontario involved systemic advantages:
A relatively late arrival of a higher volume of cases gave us time to prepare and train (and hospitals, departments, and individuals made good use of this delay; the download rates of Emergency Medicine Cases podcasts on this issue reflect that).
A relatively early lockdown on social and economic activity led to the successful flattening of the curve (partly as a result of the same gift of time).
The PPE supply has been maintained (although we have been asked to conserve masks through extended use).
Hospitals were ordered early on to cease all elective procedures and services under Directive #2, which created a great deal of hospital capacity almost overnight.
The public largely stayed away from EDs, either out of fear, a sense of public responsibility, or both.
The impact on ED volumes can be seen in Figure 1. To reflect the seasonality of ED visit volumes we routinely display month-over-month data, and overall ED volumes had been increasing consistently in Ontario since 2008, with some variation related to the timing of seasonal influenza peaks. In Figure 1 the data points with red circles are record-setting months in fiscal 2019/2020. Then in early 2020, the monthly ED volume went from a record high for January to a record low for March (for the period shown).
Figure 1. Monthly ED volume in Ontario. (Data source: National Ambulatory Care Reporting System (NACRS), Canadian Institute for Health Information (CIHI), provided by Ontario Health (Cancer Care Ontario [CCO]).
Similarly, one measure of the length of stay of admitted patients in the ED—boarded patients—is the number at 8 a.m. (daily) who have been waiting at least two hours since receiving admit orders for beds. After several years of slow improvement in this measure in Ontario, the number of boarded patients had been rising fairly consistently since 2015 until March 2020 when—despite the emergency measure not being implemented until mid-month—volumes plummeted immediately, leading to a record low number for the month (see Figure 2).
Figure 2. Monthly average of the daily number of boarded patients waiting for beds at 8 a.m. in Ontario EDs (Data source: National Ambulatory Care Reporting System (NACRS), Canadian Institute for Health Information (CIHI), provided by Ontario Health (Cancer Care Ontario [CCO]).
In short, since mid-March patients arriving at Ontario EDs have generally been screened and seen promptly by ED staff outfitted with appropriate PPE, who are generally working in a familiar ED with a team they know, and who are applying care processes they have been carefully trained in to keep themselves and their ED safe. Patients requiring admission, including those who have tested positive for COVID-19, have generally left the ED promptly for the ICU or a ward.
Based on this discussion, what are the threats on the horizon?
How long will ED volumes remain low? While we can’t say for sure, it seems they are starting to rise, and most expect them to continue to rise. When, or if, they return to baseline levels we can’t say, but after SARS in Toronto in 2003, when a similar drop was seen, I recall ED volumes rebounding very quickly. Given the need to maintain enhanced infection control precautions, which can increase the time required to assess patients, queues may grow. We will then be faced with the choice of seeing crowding in our waiting rooms or putting patients closer together in our assessment areas and hallways, or some other compromise that seems likely to increase contagion risk.
What will happen as hospital services ramp up? Ontario has lifted Directive #2; hospitals, as they must, will start doing more surgical procedures and providing other deferred care. If this leads to higher hospital occupancy rates and longer lengths of stay for admitted patients in the ED, this will further stress spacing in the ED and lead to more crowding and risk.
Will staff get tired of precautions? Or, will they become less vigilant with their practices as new case numbers fall? I wonder if this isn’t a factor in the two recent outbreaks in Toronto-area EDs after seeing none for two months when the virus was actually more prevalent.
Will PPE supplies be maintained? Global demand is certainly not going to fall, and commercial needs for PPE may put a further strain on supplies.
What will happen during flu season? This year’s peak in Canada came toward the tail end of influenza season. A wave of COVID-19 that coincides with a flu peak would put extreme pressure on our systems and capacity. (I’ll explore this further in a coming blog.)
How we can make a difference
What mitigation strategies are available to us? Most of them are systemic and out of the control of ED staff and leaders. As leaders in our communities, however, we can advocate for the public to maintain personal strategies such as staying home when ill, maintaining spacing in public, avoiding large business/social gatherings, and practising good hand hygiene.
We need our hospitals to support their EDs by balancing occupancy and ED crowding and, where possible, increasing the ED space available to avoid crowding.
We can advocate for governments to continue to prioritize the procurement and domestic production of key supplies. We can also ask them to start planning now for the fall flu season, including an aggressive vaccination campaign.
And we must maintain vigilance in our EDs. We must not let our guards down. COVID-19 is not going away anytime soon.
Howard Ovens is the former Director of the Department of Emergency Medicine for the Sinai Health System in Toronto, Canada. He’s a Professor in the Department of Family and Community Medicine at the University of Toronto and a member of the CAEP Public Affairs Committee. He’s also the Ontario Government Expert Lead for EM. He tweets on issues of public policy and administration related to EM (@HowardOvens) and is the lead author for EM Cases ‘Waiting to Be Seen - Where EM Policy Meets Practice', blog series.