Queen’s University Department of Medicine chief says root causes began long before pandemic
You can learn a lot from a crisis. During the COVID-19 pandemic in Ontario, more than 2,500 patients had to be transferred from Toronto to receive life-saving care in other cities.
The discharge of COVID-19 patients from Toronto began in mid-November 2020, when the Ontario government activated the Greater Toronto Area Hospital Incident Management System. Transfers peaked in April during the third wave of COVID-19.
At the Kingston Health Sciences Center (KHSC), we have seen more than 100 Toronto area patients with COVID-19, many on ventilators. They came by helicopter, ambulance and even bus, unaccompanied by their families.
Ontario has even launched a national appeal for healthcare workers to help, and Newfoundland has responded.
Why would Ontario need to transfer masses of critically ill patients with highly infectious disease across the province, even through involuntary transfers? Why would a metropolis like Toronto call on the relatively small Newfoundland for health care workers? Is it just the inevitable consequences of a huge third wave of COVID-19?
In fact, the root causes began long before the pandemic and stem from a misunderstanding of the capacity (physical and human) of our health care system.
I head the Department of Medicine at Queen’s University and co-lead the KHSC Medicine Program. In these roles, I am responsible for hiring doctors and making sure our medicine beds are running efficiently. I have often been confronted with two errors linked to the genesis of our current crisis:
- Error 1 – Ontario has enough hospital beds because much of the medical care is provided on an outpatient basis.
- Mistake 2 – Canada has more than enough health workers and physicians.
Both errors have been widely adopted by the provincial and federal governments. Let’s examine the validity of these beliefs in order to design a more resilient health care system.
Error 1: number of hospital beds
It is common in Canada to believe that the future of medicine lies primarily in ambulatory care and that hospital beds are obsolete. In fact, as medicine becomes more high-tech, admissions are shorter but more beds are needed to support procedures that improve quality and length of life.
We are now installing heart valves, hips, lenses and more in older Canadians, and performing life-saving diagnostic and therapeutic procedures on people who 20 years ago would have been considered ineligible because they were too premature, too obese or at too high risk.
The shortage of beds in Canada is particularly critical in academic health science centers that offer only advanced forms of care. Pre-pandemic Ontario was operating at 96% occupancy.
Our bed capacity was designed for lows in demand, like summer, not peaks, like every fall when the flu hits. Every fall, as the rates of infections like the flu rise, our emergency rooms and medical wards become crowded and admitted patients have to be housed in hallways. These are the consequences of an insufficient number of hospital beds. The COVID-19 pandemic has simply made our low reserve capacity more apparent.
Ontario built new bed capacity for COVID-19, but had minimum reserve capacity before the pandemic.
Ontario Health has done three things to fight COVID-19:
- Relocated 1,000 people from hospitals, including alternative level of care patients;
- Canceled “elective procedures” and reassigned the resulting 6,849 beds for possible patients with COVID-19 (necessary but dangerous to the health of 99% of Canadians who do not have COVID-19; and
Opening of 2,500 new hospital beds.
The government views Ontario’s health care system as “one resource.” It sounds good in principle, but keeping ventilator patients away from their families is the wrong way to provide care. Additionally, most of Ontario’s COVID-19 capacity stems from postponing elective proceedings, few of which are truly elective.
The simple truth is that we have never been configured to deal with increased admissions. We mistakenly focused on the symptoms of bed shortage, such as ‘hallway medicine’ and emergency room wait times, and failed to address the root cause: insufficient beds. (in hospitals and long-term care facilities).
Several caveats to this bed-centric article are relevant. First, outpatient care is important and when it fails, unnecessary hospitalizations occur.
Second, inadequate long-term care facilities and home care services in the community exacerbate the bed shortage by causing inappropriate hospitalization of people awaiting alternative levels of care.
Third, don’t let the term “hospital bed shortage” mislead you into imagining a shortage of mattresses and pillows; a “bed” is a substitute for the capital and human resources required to provide care in that bed 24 hours a day, 7 days a week, 365 days a year.
Error 2: number of health workers
Canada has 86,092 active physicians (excluding trainees), 25% of whom are international medical graduates. When I recruit academic physicians, I often struggle to find a Canadian-trained physician and rely on our pool of international medical graduates. These doctors are often top notch, but the fact that we rely on other countries to train our doctors is not widely recognized.
Our dependence on international medical graduates does not reflect the desire of Canadians not to become doctors. Queen’s University School of Medicine has 5,000 applicants for 100 seats and more Canadians are receiving medical training abroad than in Canada. The Organization for Economic Co-operation and Development (OECD) tracks medical graduates per 100,000 inhabitants in member countries. Canada is near the bottom.
Our doctor-to-population ratio is also low, ranking 29th out of 36 OECD countries. The reality is that doctors and other health care workers are expensive. Canada’s universal health care system has many advantages; However, a single-payer system means that provincial governments (payers) see a huge human resource bill every year and, in trying to control costs, invest in controlling the number of doctors (and hospital beds). ).
COVID-19 has given us a master class on what is wrong with our health care system. Certainly, the list of things to do in Canada after the pandemic is long and includes improving care for the elderly, providing affordable child care, promoting a national biotech industry, reestablishing a pandemic surveillance system and the strengthening of public health programs. We also need to legislate on good employment practices, such as the granting of paid sick leave.
In addition, we must continue to fund the new beds created to deal with the pandemic, using them flexibly to ensure we have surge capacity. We must also create an adequate supply of nationally trained health professionals.
What needs to be done is clear. We must find the funds and the will to face the post-pandemic moment with action.
Stephen L Archer, Professor, Head of Department of Medicine, Queen’s University, Ontario
This article is republished from The Conversation under a Creative Commons license. Read the original article.