Ontario hospitals told to ‘ramp down’ all elective, non-emergency surgeries due to COVID-19


The president of the Ontario Hospital Association says hospitals have been directed to “ramp down” all elective surgeries and non-emergency activities starting Monday amid the third wave of the COVID-19 pandemic.

“A major redeployment of staff and resources is required to provide care for a large wave of COVID patients requiring hospitalization,” Anthony Dale tweeted.

In a memo dated on Thursday, Matthew Anderson, Ontario Health’s president and CEO, said effective Monday, April 12 at 12:01 a.m. hospitals are instructed to ramp down on non-urgent activities, including surgeries.

“Given increasing case counts and widespread community transmission across many parts of the province, we are facing mounting and extreme pressure on our critical care capacity,” the memo read.

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The memo noted the scale back does not apply to the Northern Ontario Health Region but cautions the region should be prepared to do so in the near future if needed.

Hospitals that specialize in pediatric patients were also advised to not ramp down any capacity and continue with plans to care for children and youth.

“These are very difficult and challenging times for all Ontarians, and we understand that deferring scheduled care will have an impact on patients and their families and caregivers,” the memo read.

As of Friday, there are 541 patients in Ontario’s ICUs with COVID-19 according to Critical Care Services Ontario’s daily report — the highest number seen in the entire pandemic. Patients admitted to ICUs in the province have surged in the last couple weeks.

The province also reported more than 4,200 new COVID-19 cases on Friday, the second highest increase in a case count since the pandemic began.

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“This situation is extraordinarily serious and we ask for patience and support from the people of Ontario as hospitals grapple with this historic crisis,” Dale said. “Ensuring equitable access to critical care services is our paramount priority.”

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Following the scale back directive, another physician Dr. Naheed Dosani said he has received calls from concerned patients living at home with serious illnesses who are “understandably upset that their surgeries/procedures will be canceled.”

The memo from Ontario Health prompted the College of Physicians and Surgeons of Ontario to issue a statement of support for doctors citing provincial consideration to enact critical care triage protocol.

“We firmly believe physicians need to be supported if they are required to make extraordinary decisions about which of their patients will be offered critical care resources that are in short supply,” Nancy Whitmore, CEO of the college said in her statement.

“Once the critical care triage tool is initiated by the command tables of the province, we are supportive of physicians acting in accordance with this protocol even when doing so requires departing from our policy expectations.”

Whitmore said these are extraordinary times requiring extraordinary decision-making. Despite no official word on triage from the province, the college said it would provide clarity and support to Ontarian physicians if the protocol is enacted.

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In an email to Global News, Dr. Mary Grant, a radiologist in Ontario, said the college’s letter about possible critical care triage was upsetting to receive and she is urging the public to do their part in these “unprecedented times.”

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“We all believe that the public needs to be made aware of our reality in the medical world,” Grant wrote. “We need public buy-in for this stay at home order, we need those who are eligible to get vaccinated, and we need folks avoiding activities for the short while that could result in trauma (need for an ICU bed).”

Premier Doug Ford declared a third state of emergency and implemented a stay-at-home order in effect for the next four weeks as the province struggles to bring down rising COVID-19 infection rates and hospitalizations.





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Coronavirus: Ontario patients to be ranked for life-saving care should ICUs become full


Hospitals in Ontario have received a much-anticipated document that lays out the criteria to be used if intensive care units fill up and medical resources are scarce.

According to the document, titled “Adult Critical Care Clinical Emergency Standard of Care for Major Surge” and prepared by the province’s critical care COVID-19 command centre – patients will be scored by doctors on a “short-term mortality risk assessment.”

“Aim to prioritize those patients who are most likely to survive their critical illness,” the document notes.

“Patients who have a high likelihood of dying within twelve months from the onset of their episode of critical illness (based on an evaluation of their clinical presentation at the point of triage) would have a lower priority for critical care resources,” the document reads.

It lists three levels of critical care triage:

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“Level 1 triage deprioritizes critical care resources for patients with a predicted mortality greater than 80 per cent,” the document notes.

“Level 2 triage deprioritizes critical care resources for patients with a predicted mortality (greater than) 50 per cent.”

At Level 3 triage, patients with predicted mortality of 30 per cent – or a 70 per cent chance of surviving beyond a year – will not receive critical care. At this stage, patients who have suffered a cardiac arrest will be deprioritized for critical care, as their predicted mortality is greater than 30 per cent.

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At this level, clinicians may abandon the short-term mortality predictions in favour of randomization, which the document notes is to be used “as a last resort” and should be conducted by an administrator, not by bedside clinicians.

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The protocol, dated Jan. 13, says there are three steps on the road to critical care triage:

Step 1 says hospitals should build surge capacity.

In Step 2 , “if demand still exceeds capacity, the hospital will adjust the type of care being provided to focus on key critical care interventions,” which include basic modes of ventilation.

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Step 3 is the initiation of critical care triage. Once that process kicks in, “all requests for ICU admission are managed by an administrator on call who supports the bedside clinicians.”

At the moment, there are 416 patients with COVID-19 in ICUs in Ontario, which has a total of 1,800 total ICU beds.

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Modelling released by the province last week show that about 700 ICU beds will be used by COVID-19 patients by the first week February.

Dr. Andrew Baker, the head of the critical care COVID-19 command centre and director of critical care at St. Michael’s Hospital, said the triage protocol contains information and tools that are a standard way for physicians to conduct an assessment for a patient upon arrival at an emergency department.

“They were shared with the critical care community as background only and to ensure a common approach across the sector, so physicians and other health professional staff can learn how to quickly operationalize an emergency standard of care for admission to critical care, if ever needed,” he said.

Baker said an emergency standard of care is not in place, but will be enacted if needed.

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He said there is an “extensive, sophisticated, provincewide effort” to transfer patients out of hospitals that are at capacity.

Dr. Michael Warner, the medical director of critical care at Michael Garron Hospital in Toronto, said the hospital is running at 105 per cent capacity, but has cancelled surgeries in order to keep some spots open in the ICU.

“I sincerely hope we never need to use this because it is terrible for patients, terrible for their families, causes moral distress for health-care workers, and it’s something that we should do everything possible to avoid having to implement,” Warner said.

David Lepofsky, the chairman of Accessibility for Ontarians with Disabilities Act Alliance, said the triage guidelines are discriminatory.

He pointed to the clinical frailty scale, a prognostic tool doctors use in cases of progressive illnesses to assess a patient’s general deterioration over time.

“This is disability-based discrimination and that’s against the law in the Constitution,” Lepofsky said.





© 2021 The Canadian Press





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Medical staff need guidance on life or death triage decision as Ontario ICUs fill up: experts


TORONTO — As intensive care units in Ontario hospitals continue to fill up with COVID-19 patients, the province has yet to finalize a plan on who should get life-saving care when health resources are limited.

The latest COVID-19 projections show the province’s ICUs could reach “gridlock” by mid-to-late February.

At that point, health-care workers will have to decide who gets an ICU bed and who doesn’t – a practice known as critical care triage. It’s a heart-wrenching decision doctors in a number of countries with hospitals overwhelmed with COVID-19 patients have had to make.

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“It’s really concerning to not know what the plan is and transparency around that would go a long way towards everyone’s ability to prepare and everyone’s mental well-being,” said Dr. Samantha Hill, the president of the Ontario Medical Association, which represents more than 40,000 physicians.

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The province has stumbled in its efforts to get the critical care triage ethical framework out to doctors.

Ontario Health sent out a critical care triage protocol on March 28, 2020, but retracted it several months later after an outcry from human rights organizations.

“The first protocol was horrifically discriminatory against patients with disabilities,” said David Lepofsky, the chairman of Accessibility for Ontarians with Disabilities Act Alliance.

One problem with that proposal was the use of a “clinical frailty scale,” or CFS, Lepofsky said.


Click to play video 'Kingston prepares for out-of-region COVID-19 patients'







Kingston prepares for out-of-region COVID-19 patients


Kingston prepares for out-of-region COVID-19 patients

The scale is also part of a proposed framework sent to the government by the Bioethics Table, which advises the province on the health system’s response to COVID-19.

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The document – titled “Critical Care Triage during Major Surge in the COVID-19 Pandemic: Proposed Framework for Ontario” – lays out how a patient would qualify or be excluded from critical care and was sent to the province in September.

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The clinical frailty scale is used as a prognostic tool for progressive illnesses that assesses a patient’s general deterioration over time, the Bioethics Table notes in the document, which was obtained by The Canadian Press.

However, the proposal acknowledges that the CFS “would seem to conflate disability with frailty and hence would contribute to over-triaging of persons with disabilities.”

It further notes that the CFS “illustrates how clinical evidence and experience are not sufficient alone to establish the justifiable use of a clinical tool and calls attention to the embedding of social norms within clinical tools and in their application in practice.”

The Ontario Human Rights Commission has also expressed concern about the recommendation that patients be evaluated for their survival potential over the next 12 months.

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Under the Bioethics Table’s proposed protocol, patients would be evaluated and assigned into colour-coded categories based on the predicted percentage of short-term mortality risk over the next year.

There would then be three levels of triage depending on demand and availability of beds.

In Level 1 triage, patients who have greater than 20 per cent chance of surviving 12 months should be prioritized. In Level 2, patients with greater than 50 per cent chance of survival in a year should be prioritized and, in Level 3, patients who have a greater than 70 per cent chance of survival should be prioritized.

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Ena Chadha, the chief commissioner of the Ontario Human Rights Commission, said the 12-month time period is troubling.

“A doctor can make a decision in the short term: is this person going to survive next week, the next two weeks,” she said.

“But when you start looking at one year…you are going to be infused with discriminatory ideas about the person’s disability and age. Our stakeholders would like to see a much shorter time frame.”

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Both Lepofsky and Chadha, along with the Bioethics Table, said there must also be due process — an appeal process — so that life or death decisions aren’t made by one person.

Another major concern for both Lepofsky and Chadha is the province’s lack of transparency on such an important issue.

“This process is very opaque as to who are the decision-makers, what is the process and where are we at right now?” Chadha said.

“This is distressing for our community stakeholders. They are very worried that their dignity and life is at stake and that when it comes to making decisions about a very horrible death, the health-care decision-makers may not understand the value of their life.”

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The Ministry of Health said the Bioethics Table will continue to talk to various stakeholders.

“These conversations are ongoing to ensure that the proposed framework reflects the best available evidence and advice,” said spokesman David Jensen, noting that nothing has been approved by the ministry.





© 2021 The Canadian Press





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