As Alberta’s COVID-19 cases continue to rise, the province’s health authority released a “last resort” emergency triage protocol for the bleak scenario where the system is overwhelmed and doctors are forced to direct resources and staff to the patients most likely to survive.
The Alberta Health Services (AHS) document, posted Thursday, lays out the gut-wrenching choices health care workers will have to make if the pandemic’s third wave reaches a point where there are no additional resources available. Similar to protocols in Ontario, the document says if the system is swamped by COVID-19 patients, doctors would assess whether to continue life-saving care based on a patient’s likelihood of living at least a year.
The triage protocol was released the same week Premier Jason Kenney enacted new regional health restrictions in the face of record-breaking new case counts. Many doctors and health researchers say the measures announced Thursday still won’t be enough to stop a wave of hospital and ICU admissions.
AHS stresses it doesn’t anticipate needing the emergency protocols, as the health care system has so far been able to cope.
Curtis Johnston, deputy medical director for the Edmonton health zone, was among the health experts who worked on the plan. He said if the province ever found itself in a scenario in which the health care system was completely overwhelmed, doctors would be forced to make tough decisions regardless. The triage plan, he said, provides an objective tool for health care teams to work together to make “distressing” decisions.
“The reality is that if you ever got to that point, you wouldn’t have a choice but to make [such] choices,” Dr. Johnston said in an interview.
“This framework allows individuals to hopefully make choices in a well-thought, preplanned way – rather than ad hoc – so people can feel supported in the decisions that they make.”
Dr. Johnston said the protocol could be implemented if the health care system reaches 90-per-cent capacity – including surge capacity – although it’s not a hard trigger and will depend on how the system is coping.
If the province reaches this dire stage, initially patients with an 80-per-cent chance of dying in the next 12 months based on those criteria would be excluded from intensive care. If capacity was stretched further, potentially at 95 per cent, that threshold would be lowered to 50-per-cent chance of mortality and the protocol would also apply to patients under 18.
Patients who have an equal likelihood of benefiting from critical care would be admitted to critical care on a first come, first-served basis, and patients with poor expected outcomes would be reassessed daily.
There would be no chance for a patient or family to appeal a decision.
Dr. Johnston said the triage document is necessary for disaster planning, but stressed the health care system is nowhere close to needing to implement it, and that everything would be done to ensure the situation doesn’t come to that.
“We really don’t anticipate the need for this during the pandemic,” he said. “Our plea to everyone would be: Take that responsibility – do your part and we will avoid a situation of triage.”
There were 152 patients in provincial intensive-care units as of Friday, surpassing the peak of the second wave. AHS’s own forecasts present a range of potential scenarios over the next two weeks, with ICU admissions increasing to as high as 200 patients by May 14 in the highest scenario. The best-case scenario shows ICU admissions dropping to 130.
AHS says it currently has a capacity of 240 ICU beds across the province that can be expanded to 425 beds.
Hospital admissions lag behind infections by a few weeks because it takes time for someone to be infected by COVID-19 and become sick enough to require medical care. That means even if the latest measures are able to decrease infections, hospital admissions will inevitably keep climbing.
The province’s Chief Medical Officer of Health, Deena Hinshaw, said the triage plan was based on work done during the 2009 H1N1 influenza pandemic and AHS has worked over the course of the pandemic to update it.
On Thursday, Dr. Hinshaw said the emergency plans can seem daunting, but said the document is an important planning tool.
“We are not at the point now of needing to use this protocol, and I hope that we never reach it,” she said.
Joe Vipond, an emergency-department doctor in Calgary, said the situation in Alberta’s hospitals reflect what forecasts predicted when the government eased restrictions in February.
“I am just personally super distraught by the fact that we are having this conversation,” Dr. Vipond said of the triage plan. “All of this is completely preventable. We’ve been put in this place by bad decisions.”
He said Ontario’s experience has given Alberta doctors a glimpse of what may hit them should life-and-death triage become a reality.
Alberta’s rate of cases over the past 14 days is 510 for every 100,000 people, compared with 379 for every 100,000 residents in Ontario, according to federal data. Alberta has seen high per-capita numbers compared with other provinces, but its hospitals have held up better than those in Ontario, where admissions have climbed to dangerously high levels.
Lynora Saxinger, an infectious-disease specialist at the University of Alberta, said a combination of factors explain why Alberta has fared better than Ontario so far. ICU occupancy in Ontario did not drop to the same extent as it did in Alberta between the second and third waves, she said.
“They were kind of running full when their surge started,” Dr. Saxinger said, adding the crush in Ontario started about ten days before it hit Alberta.
Alberta also started vaccinating people with underlying health conditions, such as organ-transplant recipients, on March 30, while Ontario did not get to its vulnerable populations until April 6. Alberta’s head-start on vaccinating high-risk individuals ahead of the hospitalization crunch may have given the province a cushion, she said.
The median age in Alberta is 37.5, while Ontario’s clocks in at 40.4, according to Statistics Canada. Alberta’s relative youth may also be working to its advantage, Dr. Saxinger said.
Noel Gibney, professor emeritus at the University of Alberta’s medical school and co-chair of the Edmonton health zone’s medical staff association pandemic response committee, said the situation the province finds itself in was entirely preventable.
Dr. Gibney said the provincial government failed to put in strong measures as cases accelerated during the third wave, just as it waited too long to step in during the fall as infections skyrocketed.
He said the Premier should have returned the province to the type of widespread shutdown that was in place last spring during the initial wave.
“This is a conscious decision by the Alberta government to let large numbers of people become infected and become seriously and critically ill,” he said.
Dr. Gibney said the Premier’s plan appears to be to hope vaccinations arrive in time to blunt the third wave, but that is not realistic, he added.
“You can’t just manage a pandemic locally with vaccine at the rate that we’re currently seeing the cases increase.”
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