Rising intensive care occupancy prompts concern Ontario will implement triage protocol, limiting critical care

In mid-January, as Ontario was approaching the peak of the second wave of COVID-19, hospital staff were trained on how to triage intensive care patients, estimating the likelihood of their death within a year in order to ethically determine who should be denied care when no more beds were available.

It's the nightmare scenario Ontario has feared since the early days of the pandemic, based on horrific reports out of Italy, but has so far managed to avoid.

In January, Ontario's case counts dropped and intensive care occupancy plateaued, and then dipped, as the impact of Ontario's post-Christmas public health restrictions was finally felt.

But ICU admissions are rising once again, causing a critical care doctor to raise the alarm that Ontario will soon have to use the triage protocol for the first time.

Ontario is set to "blow past" the peak of COVID-19 patients in intensive care units (ICUs) that the province experienced in the second wave, said Dr. Michael Warner, a critical care physician at Michael Garron Hospital in Toronto.

That assessment is backed up by occupancy figures shared by the head of the Ontario Hospital Association.

401 people with COVID related critical illness now in Ontario ICUs on a total census of 1,871. It appears probable that in the near future we will eclipse the 420 high water mark for COVID related ICU occupancy. Every day the situation grows more serious. #onhealth #onpoli pic.twitter.com/WYDm8MZ0cq

— Anthony Dale (@AnthonyDaleOHA) March 26, 2021

"In the Greater Toronto Area, just about every ICU is underwater," Warner told QP Briefing. "And the fact that there are beds in Ottawa or Sudbury doesn't help you in Toronto. And that's the challenge."

Patients are already being transferred out of the GTA — Warner said 12 COVID-19 patients on ventilators were been sent to hospitals as far away as Kingston on Friday. When that strategy is exhausted the triage protocol may become necessary.

"Every hospital has a triage team ready to go, should the government tell us that we need to do this," he said. "I'm sure the government does not want to do this, as nobody wants to do this. Politically, this is a nuclear football."

He shared a copy of the triage form online, showing that patients' estimated likelihood of dying within a year despite getting care determines whether or not they are prioritized for a bed in different triage scenarios.

We also get closer to having to use this: https://t.co/dVHyH2QXXg pic.twitter.com/q4Kz0G4ZHa

— Michael Warner (@drmwarner) March 26, 2021

The thought of having to use it is devastating to health-care workers in ICUs, he said.

"We're the ones who are gonna have to say sorry, I can't put your mother on a ventilator because I don't have any beds," Warner said. "I've never had to do that before. No one's ever had to do that before in this province. And that's the reality that is the worst nightmare for a doctor or nurse or any health-care provider and the one that we are so desperately trying to avoid."

Warner said he doesn't know how close to needing triage Ontario is but he doesn't think the province doesn't have enough time left to get ahead of the problem — strict public health measures work but take time before their impact is felt in ICUs. The vaccines work too but, in his opinion, they aren't going to the right people fast enough, and they too take time.

That why he and other physicians tweet and talk to the media, he said.

"It's because we're scared of what could happen," he said. "And people who do what I do and work in the ICU don't typically panic or get scared easily. But the thought of not being able to provide care to patients who need it is the most frightening thing I've ever contemplated."

Ontario has been warned that this would be the effect of the highly transmissible variants of concern speaking in the province, he said.

"The government was told by scientists that the variants would take over and they have, the government was told that these could be more deadly, and they probably will be," he said. "The government was told that younger people could be affected, and they are. So there's no surprise here."

"What's surprising is that the government has somehow assumed that the scientists were wrong, or that Ontario was different, or that our very modest vaccination program would somehow make a difference. And unfortunately, what they had hoped has not come true."

At a media event on Friday afternoon, Health Minister Christine Elliott downplayed the potential for the triage protocol.

"We are not needing to use any protocols with respect to triage because we've been building capacity throughout," said Elliott, adding that the province is continuing to expand acute and ICU beds so that it will be able to admit all patients who need care.

While that press conference was still ongoing, the Ontario Hospital Association released a statement saying the province's intensive care units were reaching a "saturation point."

"These levels are already well beyond the threshold after which hospitals can operate normally," said the statement from CEO Anthony Dale. "If the number of ICU admissions continues to increase in the days ahead, as is expected, Ontario's hospitals will be under extraordinary pressure to try and ensure equitable access to lifesaving critical care."

The transfer of critical care patients between hospitals has been very effective, he said, but many regions have less flexibility to accept patients and there are limits to the capacity of the critical care transport network.

Our @OntHospitalAssn statement about Ontario’s critical care system reaching its saturation point and the actions being taken in an effort to ensure equitable access to life saving health services for COVID and non COVID patients. #onhealth #onpoli pic.twitter.com/BjCgnijdhS

— Anthony Dale (@AnthonyDaleOHA) March 26, 2021