Ontario is in the midst of two parallel COVID-19 epidemics, health experts say: one in the community at large, where there are encouraging signs that physical distancing is working, and one in seniors homes, an ongoing “disaster” whose true scope we are only beginning to see.
The province’s hospital intensive care units, which health officials scrambled to expand and fortify after they were besieged in other countries, are operating well under capacity. Though it’s too soon to declare that Ontario escaped the catastrophic COVID-19 surge seen elsewhere, right now there are more ICU beds and ventilators available than even the best-case modelling scenarios predicted — a hopeful sign.
But the pandemic continues to erupt in long-term-care and retirement homes, where residents are less likely to be transferred to ICUs.
Ontario now has outbreaks in more than 100 long-term-care homes. On Tuesday, Toronto’s medical officer of health announced that 69 of the city’s 115 COVID-19 deaths — 60 per cent — had been residents of seniors facilities. Dr. Eileen de Villa warned to expect a rise in cases in these settings, as newly expanded testing capacity uncovers the true spread of disease.
Premier Doug Ford called the situation in long-term-care homes a “wildfire” and the front line of the pandemic, promising an enhanced plan and new measures to fight the virus in these settings.
“Thanks to our collective efforts, we’ve not seen the surge in our hospitals we were so worried about,” Ford said Tuesday. “As a result we have capacity within the health sector, and I want available resources from our health system to be redeployed to those homes when there’s a serious outbreak.”
While new measures the premier announced Tuesday had been called for by experts, some said the province had adequately readied hospitals but neglected equally obvious signs the virus would ravage nursing homes.
“It’s a sector that has been grossly neglected for years and was ripe for a catastrophe like this,” says Dr. Nathan Stall, a geriatrician and researcher at Sinai Health System.
“We knew that this was going to be a problem, we just chose as a society and as a health-care system to turn our focus to the (hospital-based) acute and critical care resources.”
Stall adds that it was appropriate to prepare hospitals, since they serve the broader population — “but I don’t think it should have been at the complete neglect of the other sector.”
The earliest data on the outbreak from China showed that elderly citizens had much higher chances of severe illness and death from the novel virus. Outcomes for seniors in Italy were even worse.
Nursing homes have several features that amplify that risk, experts say. Ontario’s long-term-care facilities are chronically underfunded and understaffed — a problem advocacy groups had warned of for years. Precarious work conditions force staff to patch together part-time, low-paying work at several facilities. Infection prevention and control is less rigorous than at hospitals, and made more difficult by the design of homes, with shared eating and living spaces.
Ontario faced criticism in recent weeks for not testing widely for the virus in long-term-care homes, and for not supporting staff with sufficient supplies of masks, gloves and other personal protective equipment. Until Tuesday, the province had encouraged limiting staff to one work location but not mandated it.
“We’re seeing a common trend right now, that when a home gets an outbreak, in some homes it can spread quickly,” says Dr. Samir Sinha, director of geriatrics at Sinai Health System and the University Health Network.
“Those homes are more likely to immediately have staffing challenges,” as sick or exposed employees are forced to stay home.
Eatonville Care Centre in Etobicoke announced Tuesday that a total of 27 residents had died from COVID-19 and 53 had tested positive; 70 are awaiting results. Seven Oaks in Scarborough, a city-run facility where inspectors found infection control problems last October, has seen 22 deaths and 82 cases, plus 14 affected staff.
Ford announced Tuesday that as of midnight, the province was issuing a new emergency order preventing staff from working in multiple facilities, as other provinces already have. Ford also announced that new “hospital-based care teams” would be sent to support nursing home staff struggling with outbreaks.
“The sad truth is, our long-term-care homes are quickly turning into the front line of the fight against this virus,” Ford said, promising more resources.
On Friday, the province announced newly expanded testing criteria that would prioritize seniors home residents. De Villa on Tuesday said that the increased testing means numbers in long-term-care homes would go up, and while that may seem concerning, it would help public health guide outbreak control.
“One of my fears in all of this is there’s been a change in messaging over the past few days — that we’re doing a good job,” said Stall. “And there’s been misinformed talk about ending the lockdown.
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“From the perspective of myself as a geriatrician and my colleagues, we’re horrified by what’s going on right now. Yes, our acute and critical care systems might be doing better than expected, but our long-term-care settings are in horrible shape.”
ICU statistics were never going to adequately reflect the outbreak’s toll on long-term-care homes. Even in pre-COVID times, frail and elderly patients from long-term-care facilities were unlikely candidates for invasive ICU care, especially those with serious health conditions, said Dr. Silvy Mathew, a family physician who works at Belmont House, a long-term-care facility and retirement home in Toronto.
“It’s just not considered good care in terms of how to manage illness in the very elderly,” she said. “The likelihood of them doing well is next to none.”
This has been particularly true with COVID-19, where survival rates for ventilated patients are dismal. In a Lancet paper looking at 37 critically ill patients in Wuhan, China, 30 died within a month of being placed on mechanical ventilation, and in another small study from Seattle, only one of the seven patients older than 70 survived after going on a breathing machine.
Most long-term-care facilities had already worked with residents and families to engage in advance care planning, geriatricians say, and the pandemic hastened those conversations. So while 50 per cent of Canada’s COVID-19 deaths have been linked to long-term-care facilities, many were likely people who already indicated they wouldn’t want invasive ventilation.
“That’s why you’re not seeing many of these people flooding the ICUs,” Sinha said. “This is not about denying people access to care, it’s actually about doing things in line with what people want and need.”
That said, there are some concerns about blanket policies or misinterpreted messaging that could prevent long-term-care patients from being transferred to hospitals when resources become strained — a worry reflected by an Ontario Medical Association position statement circulated to members on Monday, which recommended against such blanket policies.
At least one long-term-care physician in Toronto has seen a patient denied the hospital care they were seeking.
“I’ve had one patient go to the hospital and was just told directly that they would not be offered a ventilator,” said Dr. Pamela Liao, a family doctor who specializes in geriatrics and palliative medicine and works in several Toronto-area retirement homes.
Liao is now treating this patient in the community but with “a fraction of the resources that they would have if they were in acute care.” She points out that in long-term-care facilities, there might be one registered practical nurse responsible for 25 to 30 patients; in an ICU, the nurse-to-patient ratio might be one to one.
Experts warn that the province’s flattening ICU numbers and heightened focus on seniors facilities should not be taken as signals to start relaxing social distancing measures. Nobody is ruling out the possibility that ICUs could still reach a critical threshold, especially if people start letting their guards down now.
And beyond beds and ventilators, there are growing concerns over other ICU necessities. On Tuesday, the Canadian Association of Emergency Physicians released a statement warning that crucial medications necessary for supporting COVID-19 patients on mechanical ventilation — like sedatives, paralytics and painkillers — could be “in short supply and may be reaching a critical shortage in the coming weeks.”