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Corey Gardi pushes for offsite hospital space to manage COVID-19 surges

Idea was discussed at a confidential meeting of the city's emergency management team on Tuesday
20200301-Sault Area Hospital, winter, stock-DT-01
File photo. Darren Taylor/SooToday

Ward 5 Coun. Corey Gardi wants the city to help Sault Area Hospital establish temporary offsite hospital space to ensure capacity to handle any surge in COVID-19 cases.

"Are there any plans to set up any type of hospital setting offsite at Sault Area Hospital?" Gardi asked at this week's City Council meeting.

"Are they confident that they will be able to do everything that they need to do within the confines of that building?"

In an interview on Wednesday, Gardi gave SooToday few details about the kind of offsite facility he wants, but said he'd prefer coronavirus cases be treated in a facility separate from other hospital patients.

And, Gardi said, he'd sooner be overprepared than underprepared.

"You ask if they're confident?," Mayor Provenzano responded. "I don't think there's a hospital in the country that's confident."

"Councillor Gardi, I don't think any hospital in the province of Ontario or the country, is confident that they can handle the potential surge that could occur in respective communities," the mayor said.

"The hospital is very capable of providing great care and I think they are handling things very well as it stands. This virus is very highly contagious and it could very quickly infect a lot of people and put the hospital above its capacity. I think every hospital recognizes that is a potential eventuality."

"We have to stave off that potential eventuality by getting all of our community members engaged and getting them working with us, and getting them to recognize that it's not just a matter of getting a virus and getting over it. It's a matter of a virus that really spreads quickly and can infect a lot of people in a very short period of time."

"There are some people that could be significantly impaired if they get the virus and they will need a high level of care. And the greater the number of people that need a high level of care, the more likely it is that we will be beyond capacity," the mayor said.

Malcolm White, the city's chief administrative officer, told Gardi: "There certainly are some existing plans and protocols for accessing public facilities in any number of emergency needs, so we've got those in place and we'll be ready to respond to Sault Area Hospital."

With surge capacity being increasingly discussed in health care administration circles, the possibility of setting up offsite hospital space in the Sault was also discussed at a meeting of the city's emergency management team on Tuesday.

No immediate decision was reached there, but White repeated a commitment he made the day before to City Council, that the municipality is ready to assist with whatever Sault Area Hospital needs to manage the novel coronavirus.

"I believe that we have some time right now to make those arrangements," Gardi told his fellow councillors.

"There's no sense to waste any time here, to get something offsite set up in the event that we need to use. We may as well overreact."

"Let me assure you that no one's wasting time," Mayor Provenzano responded.

"I trust that those in the leadership at Sault Area Hospital, like any other hospital in the country, are looking at the option of securing offsite space," Gardi told SooToday. "I trust the hospital's leadership that they are probably looking at securing some kind of location offsite."

The following statement about COVID-19 surge capacity was issued Tuesday by the Canadian Association of Emergency Physicians:

Surge capacity and the Canadian emergency department

OTTAWA, ON - The COVID-19 pandemic has rightly called into question the ability of Canadian emergency departments – and the healthcare system as a whole – to handle any potential large surge of patients presenting to our doors.

Even before this pandemic, Canadian emergency patients regularly saw the effects of our crowded hospitals. They waited in the waiting room, on ambulance stretchers, and in our hallways, due to an inability to flow admitted patients from the emergency department to the in-patient wards and ICUs [intensive care units].

Mathematical modelling suggests that, for safety and to provide some capacity for a surge, a hospital’s occupancy rate should be 85 per cent but in Canada, that number routinely reaches and exceeds 100 per cent.

Canada has one of the lowest rates of bed availability in the western industrialized world.

The OECD [Organisation for Economic Co-operation and Development] average is 4.8 beds per 1,000 population; Canada has 1.9 beds per 1,000 (2018).

And 15 per cent of those acute care hospital beds in Canada are occupied by alternate level of care patients [ALC].

These are patients who no longer need to be in an acute care hospital but who cannot be discharged because of inadequate home care and/or lack of access to a rehabilitation or long-term care bed.

The crowded emergency department is therefore a reflection of a crowded hospital and inadequate community resources and it is at the hospital and community level that surge capacity must be found.

Though media and government attention is currently focused on COVID-19, the daily business of providing routine emergency care must continue and we must ensure that our emergency departments are able to satisfy both demands – the pandemic and the daily routine of cardiac and trauma care, mental health crises and substance abuse.

The reduction in many community and ambulatory hospital services directed at mental health and home care for the elderly and the disabled may lead to an increased demand for emergency services.

Government and policy leaders must be mindful of any potential negative health effects with their efforts at containment.

International experience suggests, of Canadians who contract COVID, we can expect: 10 per cent will require general hospital admission, five per cent will require ICU care and three per cent will require mechanical ventilation.

"Flattening the curve" will spread out the demand for these healthcare resources and facilitate the hospital’s capacity to manage.

In the setting of a pandemic, the targets for surge capacity and institutional capability should be, at minimum, 20 per cent beyond usual capacity.

This can be achieved by cancellation of elective surgeries and procedures, aggressive discharge policies and the transfer of ALC patients to alternative settings, such as hotels and community centres.

This has begun to happen in several provinces and regions and has demonstrated a large reduction in hospital bed occupancy.

We acknowledge and thank those who have already taken this action for their leadership.

For those centres that have yet to act, we urge immediate action to increase bed availability.

We do not yet know what lies ahead of us.

With a major pandemic, "contingency care" may be required which represents 100 per cent of the usual capacity or twice as many ICU beds.

This will require the use of alternate treatment areas within the hospital including the operating theatres, post-anesthetic recovery rooms and clinic areas.

At this point, regional planning and the use of regional resources become necessary.

The availability of ventilators becomes a key factor when such a major contingency is required.

In a national "crisis," communities will require greater than 200 per cent usual capacity and three times the number of the usual ICU beds.

The use of national stockpiles under federal control and the use of military resources will most likely be required.

We are not yet at this point but we must be prepared.

In our considered view, the time for serious, definitive and articulated plans for surge capacity is now.

We have already seen the massive efforts that are necessary because of our already existing overcrowding and lack of a "buffer" that the ideal 85 per cent occupancy would have mitigated.

It is important to acknowledge and remember that, after this pandemic is over, we cannot afford to go back to "business as usual."

The emergency department response to surge: The American College of Emergency Physicians has defined surge capacity as "a measurable representation of ability to manage a sudden influx of patients. It is dependent on a well-functioning incident management system and the variables of space, supplies, staff and any special considerations."

Our Australian colleagues have identified several key components to meaningful surge management which are highly relevant to the Canadian emergency department context:

  • recognizing surge: recognizing surge is the key to a prompt response. Emergency department [ED] surge is a significant increase in the demands placed on an ED, given the normal capacity within which an ED can reasonably maintain standards of care. The surge may be reflected in rate of patient presentations, waiting times, patients queued, and ambulance diversions
  • initiating action: initial strategies must be initiated from the ED. In the Canadian context, there should be no hesitation in calling a "Code Orange"
  • maintaining patient flow: there is a need to ensure unidirectional flow through the system and to avoid bottlenecks where possible. In particular, decanting ED patients – sending the "walking wounded’" to another supervised part of the acute care area – may decompress the treatment area
  • setting clinical goals: notification of a surge in demand should prompt immediate review of staff work practices in anticipation of increased workloads. At issue is not that they work faster or harder than normal, but that they work to a different goal. In these circumstances the clinical goal shifts from individual patient satisfaction to doing "the most for the most." This does not obligate a change in the standard of care but does imply a change in the standard of service
  • deploying a surge team for advance triage: triage is fundamental to the efficient and effective management of multiple patients. Routine triage may be maladapted to ED needs in times of surge. Passive reception of patients at triage denies the ED the opportunity to control patient flow before it converges on the waiting room, invites contamination of the premises from patients with transported hazards, and delays initial clinical decision-making. Loss of crowd control in surge has been known to swamp a hospital within minutes
  • providing clinical care: emergency physicians typically focus on finding the pathology, but the demands of surge force the ED to find the "unmade" decision. Surge in demand should prompt clinical rounds of the ED to expose unmade decisions. In a small ED, this is easily organized, but in the large ED, taking all clinicians from their clinical duties to attend these rounds may be counterproductive, and different approaches may be necessary. Senior staff should regularly review patients under their care to ensure that timely decisions are made
  • using external and ancillary personnel: surge situations are characterized more by resource maldistribution than by absence. In those circumstances, planning should include a "corral point" for arriving staff, and a buddy system that partners non-ED staff (medical, nursing, clerical) to work with existing ED staff or supervisors. Medical and nursing students are a source of additional workforce and may assist with minor interventions (intravenous therapies, pathology specimen delivery) or serve as message bearers or scribes. Similarly, allied health staff are often neglected in surge planning, but may be able to fill a variety of valuable roles

Furthermore, for the Canadian emergency physician:

  • it is imperative during the COVID-19 pandemic that the emergency department be well-represented at the hospital board and regional health authority level
  • where available, an emergency physician trained in disaster preparedness should be utilized
  • as a department, emergency physicians should work to reduce unnecessary admissions. Nearly 10 per cent of hospital admissions last less than 24 hours and 30 per cent last less than 72 hours. Homecare supports and alternative care options should remain available to avoid unnecessary or 'soft' admissions
  • non-urgent care should be diverted, where possible, to urgent care centers and alternate sites within the hospital
  • liaison with primary care colleagues to promote greater access to primary care during off-hours and greater medical support for the elderly in the community
  • Canadian emergency physicians should recognize their important role in identification of surge and rapid deployment of necessary resources. There should be no fear of calling for a "Code Orange" or "overcapacity protocol" within a given institution.