By Jessica Smith Cross and David Hains
Ontario announced 4,227 new COVID-19 cases Friday, the highest single-day total the province has experienced, as physicians were warned that the high burden of the virus on the health-care system means they may have to make "incredibly difficult decisions" about their patients' care in the days ahead.
The province reported 4,249 on Jan. 8 but said at the time 450 of those cases were confirmed in days prior and could be attributed to a data catch-up.
The seven-day average of new cases as of Friday is 3,265, shy of the peak of 3,555 reached in mid-January.
As a result of the worsening epidemic, the province has directed hospitals to ramp down all elective surgeries as of Monday in order to redeploy staff and resources to COVID-19 patients.
In a memo, Ontario Health President and CEO Matthew Anderson attributed the decision to "increasing case counts and widespread community transmission across many parts of the province [and] mounting and extreme pressure on our critical care capacity."
Children's hospitals and those in the north are excluded but were warned to prepare to ramp down as well.
Anderson also said Ontario Health could ask that hospitals send staff to other parts of the system. "We will be asking you to identify available staff who might be redeployed to sites requiring support and for receiving sites to help integrate these staff members into their teams," he wrote.
He also acknowledged the toll the decision will take on patients, saying "we understand that deferring scheduled care will have an impact on patients and their families and caregivers."
The memo was sent a day after the province instituted a four-week stay-at-home order. But the decision to take that step was only made after weeks of mounting warnings about ICU capacity from the province's science advisors, intensive care doctors and groups including the Ontario Hospital Association.
"This situation is extraordinarily serious and we ask for patience and support from the people of Ontario as hospitals grapple with this historic crisis. Ensuring equitable access to critical care services is our paramount priority," said CEO Anthony Dale Friday, of ramping down surgeries.
Effective April 12th, hospitals have been directed to ramp down all elective surgeries & non-emergent/non-urgent activities. A major redeployment of staff and resources is required to provide care for a large wave of COVID patients requiring hospitalization. #onhealth #onpoli
— Anthony Dale (@AnthonyDaleOHA) April 9, 2021
Speaking with QP Briefing last week, Dale said hospitals in hard-hit areas had already had to ask some patients to delay life-saving care, including cardiac care, cancer care and organ transplantation.
“So the question becomes, what are the choices that our physicians will be asked to make in the weeks ahead, if and when conditions become so serious that they have to make choices that no physician should ever have to make?” he said at the time.
Dale was speaking about concerns that doctors will have to increasingly triage patients. Delaying life-saving procedures is already a form of triaging patients, he said, but the choices could become even more difficult.
On Friday, the College of Physicians and Surgeons (CPSO) sent a message to doctors about the choices they may have to make regarding their patients' care.
"We appreciate the unprecedented situation our ICUs across the province are managing and that physicians may soon be faced with making incredibly difficult decisions that they never imagined having to make," the regulator wrote.
The province has a draft triage protocol that guides physicians on who should receive critical care and who should be denied it when ICUs are overwhelmed. It is based on an estimation of a patients' likelihood of surviving a year if they are given care with those most likely to survive prioritized over those who are not. It includes different levels of triage. In the highest level, only patients with a 70 per cent chance of surviving the year or better would be prioritized for care.
The CPSO issued a statement of support for physicians who act in accordance with it should it be implemented by the province's command tables, even if that means departing from the regulator's normal policy expectations on medical care.
Worth reading the email every MD in Ontario received last night pic.twitter.com/3uIvn47SIJ
— David Juurlink (@DavidJuurlink) April 9, 2021
"We know you have been working tirelessly to support patients during this time, but now more than ever it's important for us to come together as a system and work collaboratively to meet the challenges of today and the days to come," wrote Dr. Nancy Whitmore, registrar and CEO of the CPSO.
"I am sincerely grateful as are the people of Ontario for the sacrifices you are making. Please remember to do your best to also take care of yourself."
Disability advocacy groups, including the ARCH Disability Law Centre, have raised concerns that use the protocol could discriminate against Ontarians with disabilities. The Ontario Human Rights Commission echoed those concerns in a statement Friday and called on the government to provide more clarity.
"Over the past year, the OHRC has repeatedly raised concerns about various versions of the triage protocol and the Emergency Standard of Care, including writing to the government last November and December," wrote Chief Commissioner Ena Chadha.
She said the commission has raised concerns about "potentially discriminatory content" and called on the government to not implement Emergency Standard of Care without sufficient public input or consultation and to release the latest versions of the protocol to the public.
"We asked the government to do this before a potential third wave overwhelmed Ontario’s health-care system. Regrettably, that did not happen," Chadha wrote.
She also called on the government to ask hospitals to collect data on patients who have care withheld or withdrawn to determine if they belong to vulnerable groups, including older people, people with disabilities, Indigenous peoples and Black and other racialized people.
"As the pandemic continues, the need to reflect human rights principles and respect human rights obligations in every response is greater than ever before," Chadha wrote. "We must ensure that vulnerable groups disproportionately affected by the pandemic are not further disadvantaged by measures taken to manage critical care services in the days and weeks to come."
Despite the steady stream of bad news, Premier Doug Ford struck an optimistic tone, telling Ontarians, "We need to stay positive."
At a photo-op Friday afternoon he was asked about overcrowded ICUs, but pivoted to talking about the vaccine rollout.
"You look around the world, Ontario is doing pretty well right now," he said, a day after declaring a state of emergency due to the dire conditions the province finds itself in.
The premier had received his first dose of the AstraZeneca vaccine earlier in the day and pointed to improving vaccination rates as a sign that the province is turning the corner. He said that he understands the one-shot Johnson & Johnson vaccine will be made available at the end of April.
But critical voices slammed the premier for leading the province into a third wave that experts predicted weeks ago. Doris Grinspun, the CEO of the Registered Nurses Association of Ontario, told QP Briefing that the premier and Chief Medical Officer of Health Dr. David Williams should have acted four weeks ago and that by failing to do so more people will get sick and some will die.
Opposition Leader Andrea Horwath charged that the premier failed to act and that the third wave was on him. "Ontario should never have come back to this point where scheduled surgeries had to be halted again. But this is exactly where experts predicted we would be, and Doug Ford walked us right into it with eyes wide open. The experts warned him, but he refused to listen."
Meanwhile, a new opinion poll from the Angus Reid Institute showed Ontario increasingly agrees with the likes of Grinspun and Horwath.
It found 32 per cent of respondents support the premier's handling of the pandemic, the second-worst level of any province polled. That's down from 78 per cent in the first wave and 55 per cent in the second wave.
Sixty-five per cent of Ontarians said Ford is doing a poor job handling the pandemic, and 61 per cent said more public health measures are needed. The poll was partially conducted before the stay-at-home order was announced. Twenty-six per cent said the province's public health measures go too far and 13 per cent said they were just right.
Ontarians were also the second-least optimistic about their day-to-day lives in the country, according to the poll. The poll also found that out of provincial chief medical officers of health, Williams tied for the lowest support in the country at 46 per cent.