The weekend brought good news and early signs the COVID-19 curve may be flattening. The number of new cases has slowed and the numbers of COVID-19 patients hospitalized and in the ICU have stabilized.
Current ICU utilization remains well under the best-case scenario projections, and while it’s still early, it appears likely that we will not have the same surge that overwhelmed New York and Italy.
Canada has avoided the fate of other jurisdictions through strong public health measures and physical distancing. Flattening the curve has involved shutting down or moving large portions of our society online: schools, universities, retail, and the justice system.
In the healthcare sector non-emergency ambulatory care was halted for two weeks and has now moved to virtual care. Ontario’s hospitals have reduced non-COVID volume, including elective visits, procedures and surgeries to create capacity for a potential surge in COVID-19 patients.
Historically these hospitals run occupancy rates over 95 per cent, many are now operating at occupancy rates of 65-70 per cent. Thirty per cent of hospital beds are held open and thousands of people who would “normally” be in an Ontario hospital today are somewhere else.
Creating this surge capacity was the right thing for the health system to do, but it has come at a cost.
Hip replacements, cataract removals, aneurysm repairs, and even some cancer surgeries are all postponed. The same is true for patients with mental health challenges and other patients suffering from chronic diseases.
Virtual care is now the norm for these chronic conditions and will be for many months to come. After SARS, research studies did not suggest an adverse impact when hospital services were substantially reduced. But public health projections and international experience suggest a much longer time horizon for COVID-19.
While it may be early to ask, there is a real question for decision makers about when we open up the healthcare system again. And how do we reorganize it for the long interim “second-wave” period?
This will force a conversation about tradeoffs. The clear peak of the surge remains in doubt, and the lack of population-based testing in Ontario leaves us with no clear view of disease activity. Yet, remaining closed has real risks for the thousands of Ontarians with active medical conditions or aggravated chronic diseases. The choices are not easy, but we would like to offer several preliminary suggestions.
First, continue to defer care of questionable benefit. Choosing to not overtreat has never been more important, as the risks of in-person contact with our healthcare system are now very clear.
Second, providers should offer as many services virtually as possible. By continuing the billing codes for virtual services, doctors are encouraged to provide services virtually, reducing the risk of transmission. Refining the virtual system for stable chronic care management, mental health and primary care will add capacity and maintain physical distancing.
Third, government should take a coordinated and prescriptive approach towards hospital utilization. An average of 800 beds is two to three moderate size hospitals. We should consider designating some hospitals COVID-only, where we can develop expertise in treating these complex patients, with the appropriate levels of PPE, trained staff and ICU capacity.
This would allow other hospitals to resume full services to non-COVID patients. Meanwhile, another tier of hospitals should be designated and organized to become COVID-19 institutions in the event they are needed. This approach is taking shape in different jurisdictions from Wuhan to New York. While we support independent hospital governance, some designations should be made for COVID-19 specialty care facilities. Some semblance of normalcy could then return to clinical care for patient groups whose care cannot be deferred.
Finally, we need to put real community care into action. This requirement has become distressingly clear in long-term care and nursing homes over the past few weeks. The homeless and prison populations are also at risk.
Taking care of the social needs of vulnerable populations and protecting them from COVID-19 has always been the right thing to do. The pandemic has shown us it is also in society’s interest in order to stop further spread. We need to reorganize our resources so that we can and manage outbreaks in these vulnerable sectors. This will require a thoughtful population health approach over the next year.