Photography and video by Cole Burston/The Globe and Mail
“Want to talk about my weekend?” Susy Hota says, with a good-natured laugh.
Dr. Hota is the medical director of infection prevention and control, or IPAC, for Toronto’s University Health Network, the largest teaching and research hospital in Canada. In normal times, Dr. Hota and her team of IPAC specialists are responsible for keeping dangerous bugs and viruses out of eight sites that fall under UHN’s umbrella, including the Princess Margaret Cancer Centre and the Toronto General and Toronto Western hospitals.
But these aren’t normal times. Instead of focusing on her hospitals, Dr. Hota spent the weekend dialling into meetings and answering e-mails about outbreaks at a handful of the 15 long-term care homes UHN has promised to help through the second wave of the pandemic.
She and her team are also responsible for five retirement homes and more than 30 congregate-care settings, including group homes, as part of a new “hub-and-spoke” model that barely had time to get rolling before the virus swept through two of the sites on UHN’s roster, Fairview Nursing Home and Vermont Square. UHN’s IPAC professionals were supposed to be at the centre of the plan, with their expertise radiating out to places less equipped to contain the virus.
“Unfortunately, we didn’t have a lot of time – we had no time – to build the hubs and formalize that relationship before we hit outbreaks in some homes,” Dr. Hota says.
The fact that UHN’s head of infection control is handling outbreaks at two private, for-profit nursing homes highlights how hospital staff have become the Swiss Army knives of Canada’s pandemic response.
Hospitals are being asked to fight the coronavirus in ways that extend well beyond caring for the sick. On top of supporting outbreak-prone congregate settings outside their own walls, some are running COVID-19 assessment centres and processing thousands of coronavirus tests daily in their labs.
At the same time, they’re scrambling to catch up on thousands of surgeries postponed during the spring shutdown. In-patient units are once again filling up with seniors awaiting long-term care placements, which are harder to come by now that Ontario has barred admission to three-and-four-bed rooms in nursing homes. Many hospitals are bursting at the seams, just as they were before the pandemic.
To be sure, UHN and other hospitals are infinitely better prepared than they were in the harried early days of the pandemic, when doctors didn’t understand much about the enigmatic virus. In early October, staff exuded a competence that made the outside world – with its collapsing testing and tracing systems, and its bumbling public health leaders – seem chaotic by comparison.
But as The Globe and Mail’s week inside UHN wore on, and as Ontario’s case counts hit record highs, it became clear UHN wouldn’t be able to keep the fall wave at bay forever. Eight patients died of COVID-19 at UHN in the first 11 days of October, all but one of them residents of long-term care.
Margaret Herridge, a veteran critical care doctor, is beginning her morning rounds in Toronto General’s medical-surgical intensive care unit, where some of the sickest COVID-19 patients in Ontario are fighting for their lives.
Surrounded by nurses, resident physicians, a respiratory therapist and a pharmacist – all clad in scrubs and masks – Dr. Herridge reviews the case of a woman in her early 50s. The patient was transferred to TGH from another Toronto-area hospital for extracorporeal membrane oxygenation, or ECMO, a last-ditch option for patients who are failing on the maximum amount of mechanical ventilation.
She’s one of four COVID-19 patients in the 30-bed ICU this morning. All of them are racialized. Next door is another coronavirus patient on ECMO, a woman whose husband calls every day to read to her over an iPad while she lays unconscious.
Dr. Rishad Khan, a second-year internal-medicine resident, provides a rundown of how Dr. Herridge’s patient is faring, mentioning drugs and rhyming off vital signs. “That’s a bit better, isn’t it?” Dr. Herridge says.
Later, she confirms the patient is having a good day, relatively speaking. “But these sorts of sick COVID folks can spend weeks on ECMO, weeks on the mechanical ventilator and then weeks in hospital – and then many months recovering,” she says.
If the woman survives, it will be due in large part to TGH’s ECMO program, the biggest in Canada. The life-support technique involves siphoning a patient’s blood, replenishing the blood-oxygen supply and returning it to the body, allowing the lungs of critically ill COVID-19 patients to rest as their bodies fend off the virus. During the spring wave, TGH treated 33 patients on ECMO, 20 of whom survived.
Because so few other facilities offer ECMO, most of the COVID-19 patients in TGH’s critical care unit come from elsewhere. In the spring, managing transfer requests could consume a critical care doctor’s entire shift.
“It was all COVID, all the time – you were either the point person on the phone or you were looking after COVID patients on the unit,” says Niall Ferguson, head of critical care for UHN and Mount Sinai Hospital. “We had a 22-year-old on ECMO in the first wave. That patient did okay, but we’ve had other young patients die.”
As nurse manager Denise Morris recalls, the first COVID-19 patient admitted to the unit was an elderly woman transferred from another hospital. The night of her arrival sticks out in Ms. Morris’s memory because it was the first time the unit tried shifting the intravenous pumps outside the doors of an ICU patient’s room, an experiment inspired by a photo from a New York City ICU. The change, designed to reduce the amount of time staff spent near infectious patients, required significant “MacGyvering,” Ms. Morris says. Six-foot tubes had to be replaced with 25-footers, all of it pressure-tested to ensure they delivered the right amount of fluids and medicine to patients on the brink of death.
Restless and worried for her staff, Ms. Morris called the unit’s night clerk at 4 a.m., asking if the pumps worked outside. They didn’t. By 6:30 a.m., Ms. Morris was back on the unit, helping solve the problem. “That was my biggest concern in the beginning,” she says. “How do I keep my staff safe?”
Those concerns linger, but Ms. Morris and her colleagues are now better versed in protecting themselves. The three TGH ICU workers who tested positive during the first wave caught the virus in their off-hours, not while caring for COVID-19 patients. Toronto Western, a community-focused hospital west of downtown, fared worse: 61 staff and 35 patients tested positive during five outbreaks in the first wave.
Critical to keeping UHN staff safe is a reliable supply of personal protective equipment. The network’s PPE working group is meeting virtually to deal with the problem of N95 respirators – the circular masks that have been in short supply since the start of the pandemic.
Thousands of staff have to be fit-tested for back-up models, a 20-minute process that involves breathing through a sample N95 while wearing a hood that looks like a cloth astronaut’s helmet. A fit-tester sprays a bitter mist through an opening in the front of the hood. If the employee can taste it, the N95 doesn’t fit well enough to protect against virus-bearing aerosols.
“We can see some of the larger departments and higher-risk departments struggling to get their staff sent for fit testing,” Frank Tourneur, UHN’s senior director of safety services, tells his colleagues as he presents the latest numbers. “Unfortunately, I think the managers are so overwhelmed, they’re struggling even with the delegation of that task.”
A group of managers from UHN’s major sites are in the midst of their daily patient-flow huddle, providing rapid-fire updates on volumes in their emergency departments, ICUs and in-patient units, as well as staffing shortfalls.
“Surgery is in trouble today,” says Brenda Kenefick, UHN’s director of patient flow, after the virtual meeting ends. A handful of nurses have called in sick.
Absenteeism is up. Like everyone else, nurses are having to self-isolate after possible brushes with COVID-19, or stay home with children barred from school because of coughs and runny noses.
UHN has about 220 nursing vacancies. Recruiting stalled during the spring wave, and some nurses took early retirement. Many of those who remain are burned out. “Frankly, our staff has been amazing,” says Ms. Kenefick. “But what I’m hearing now is people saying, ‘I don’t want to work overtime anymore. I’m tired.’ At this point, I get it.”
A former director of process improvement for McCain Foods, the pink-haired Ms. Kenefick brings a supply-chain manager’s acumen to her work. Seven days a week, she e-mails UHN’s senior leaders before 7 a.m. with the number of COVID patients, occupancy rates at each of the network’s four major sites and other metrics that set the stage for each day.
She also keeps an eye on the big picture. In about a month, UHN has gone from zero COVID patients to 24. If the increase continues at that pace, the network will have to consider “service adjustments,” which could mean cutting back on non-urgent surgeries (though not stopping them outright, like in the spring) or asking nurses to look after five patients instead of four.
UHN executives wouldn’t take any of those steps lightly, says Ms. Kenefick. They’ll monitor staffing shortfalls and patient volumes in all categories to determine whether the pressure on any one grows severe enough to trigger the dreaded adjustments. Ms. Kenefick predicts staffing will be the first to fall into the danger zone. “That’s where I’d put my money,” she says.
Ms. Kenefick follows up with an e-mail: Seven operating rooms are on hold because of staffing shortfalls.
Debra Davies, the long-time nurse manager of Toronto General’s emergency department, is wearing a surgical mask and goggles as she gathers her staff for a morning huddle. She fills them in on the surprising ways the virus has resurfaced. The department had been swabbing about 40 suspected COVID-19 patients a day for weeks without finding a case until Sept. 21, when a positive test result popped up. Now, two or three swabs taken in emergency are coming back positive every day.
“We are seeing a lot more people coming in with odd-ball complaints – not the standard shortness of breath or fever, not the slam dunks,” Ms. Davies tell her team. Five patients in a row came in complaining of radiating back or abdominal pain. Another had eye pain and a migraine. All were positive for SARS-CoV-2, the virus that causes COVID-19.
The shape-shifting nature of COVID-19 means emergency physicians and staff have to be on guard at all times. Anyone could be infected. That realization sank in for Erin O’Connor, deputy medical director of UHN’s emergency departments, on a Saturday in mid-March. She was making pancakes for her two young kids when someone called to say a patient who hadn’t travelled outside of Canada had tested positive.
The patient had, however, been in contact with someone who attended a Toronto mining conference. Dr. O’Connor called Dr. Hota, who had just heard a similar story from another hospital. “We both said, ‘This means there’s community spread, and the definitions need to be changed.' ”
Not long after, UHN’s emergency departments – like most in Canada – experienced an unprecedented lull as fear of the virus kept patients away.
Staff used the time to procure wireless headsets and microphones that would allow doctors and nurses to talk to one another through closed doors and PPE when resuscitating suspected COVID-19 patients.
“Protected code blues,” as those emergencies have come to be called, are now routine, with every patient treated as a suspected coronavirus carrier, says emergency physician Alia Dharamsi. Dr. Dharamsi demonstrates how she and her colleagues practise their code blues, her ponytail bouncing as she straps a mechanical CPR device called Lucas to a mannequin they’ve named Roger. (“I’m working on the feminist piece, trust me,” Dr. Dharamsi jokes, promising to name future technology after women.)
As Ms. Davies wraps up the morning huddle, she warns her team that the hospital will make a significant policy change on Friday in response to Toronto’s spiralling case counts, and its struggles to test and trace. A few days earlier, Toronto’s overwhelmed public health unit had quietly decided to stop contact tracing outside of outbreak settings.
“Because they’re not doing contact tracing, and because it’s difficult to get tested for symptoms, this puts us at a bit of a risk,” she says. With rare exceptions, patients who aren’t critically ill and are expected to stay in the hospital for less than two weeks won’t be allowed any visitors at all.
Over at Toronto Western, visitors are already barred from the eighth-floor COVID-19 ward, except when a patient is about to die. The dedicated ward was opened a week and a half earlier in response to an influx of infected patients from local long-term care homes.
Nurses and other staff say this new wave has been emotionally draining in a way that feels different from the spring. Most of their COVID patients have dementia, and several have died in quick succession – alone, save for a PPE-clad nurse holding their hand.
In some cases, families are afraid to enter the COVID ward. In others, dying seniors have no loved ones in the first place, their care entrusted to the province’s Office of the Public Guardian and Trustee.
Nurse Mack Deocares was in the room when a woman died of COVID-19 a few days ago. “I took extra time to stay with the patient until the last breath,” he says, turning to his nursing colleague, Katrina Arroyo. “Katrina was encouraging me from outside the room.”
“It’s hard for us, obviously,” adds Ms. Arroyo, “but I tried my best to be there, at least at the door, reassuring the patient, ‘You’re not alone – we’re here with you.’”
Janet Pilgrim, the unit’s nurse manager, gushes with pride when she talks about the nurses, social workers and occupational therapists putting themselves at risk to treat patients with cognitive impairment. Infected patients can’t be allowed to wander, she says, so some have to be restrained and outfitted with mittens to prevent them tearing off their masks in confusion. Ms. Pilgrim is visibly pained as she describes the measures.
Elaine Nagy, one of the hospital’s spiritual care practitioners, gathers staff around the nursing station for a brief ceremony to remember six patients who died on the eighth floor – three of them victims of the virus’s second wave.
“We’re acknowledging that this is a new set of circumstances for this team,” Ms. Nagy begins. “You care for many, many people, day in and day out, but with this wave we know there are many people coming from nursing homes – sometimes people who don’t have family – and you become the family. You become the close ones. You’re the ones who witness that journey from life to death.”
Ms. Nagy rings a singing bowl six times, once for each departed patient, as monitors beep in the background. Later, she reflects on how different this wave feels from the first, when patients admitted to the COVID-19 wards tended to be younger travellers who were more likely to survive. (It’s not clear why the hospital is admitting more patients from nursing homes this time around. About 80 per cent of Canada’s first-wave deaths were residents of seniors' facilities, most of whom died in their homes. One study found that in Ontario, “the majority of COVID-19-related deaths have occurred in patients with no record of hospitalization.”)
Of the 12 patients on the COVID unit today, only one is healthy enough to be interviewed. Onofrio Suppa came to Toronto Western on Sept. 30 with a cough and shortness of breath. The next day, the 92-year-old’s COVID test came back positive.
Mr. Suppa pulls a button-down cardigan over his hospital gown for a virtual interview conducted via an iPad-on-a-stand. The woman at the controls is social worker Laurel Franks, who is dressed in a gown, gloves, mask and face shield. Ms. Franks also has an Italian interpreter on the line.
“I have a lot of thoughts in my mind, but basically I feel well. I feel a little bit weak, but I feel okay,” Mr. Suppa says, his voice slightly raspy. He was on oxygen earlier, but he’s breathing well on his own now. “It’s a type of disease you can die from. So many people have died from it. I try not to think about it.” (Mr. Suppa would be released a week later, on Oct. 14, to a recovery program at the Toronto Grace Health Centre; after that, he hoped to return to the home he shares with his wife and son.)
They call it “the hive.” In a refurbished classroom just down the hall from the Mount Sinai microbiology lab (which also serves UHN and Women’s College Hospital), white-coated workers are typing in demographic information attached to thousands of swabs destined for the coronavirus testing queue.
Already, 11 square blue buckets filled with swabs in test tubes are awaiting data entry – some from as far away as Bracebridge and Huntsville. Still, it’s manageable compared to the previous week, when a massive spike in testing demand flooded Canada’s largest hospital lab with thousands more samples than it could process in a day.
“It was all hands on deck,” says Tony Mazzulli, microbiologist-in-chief for UHN and the Sinai Health System. During the worst of the onslaught, Dr. Mazzulli did data entry in the hive before dawn.
Today, the backlog is gone, and Dr. Mazzulli has returned to as much of a regular schedule as possible during a pandemic. The backlog wasn’t cleared because his or any other lab in the network sprouted new testing capacity overnight; instead, the provincial government suppressed demand by tightening testing criteria, shutting COVID-19 assessment centres for a day and then reopening them on an appointment-only basis.
Dr. Mazzulli and Christine Bruce, the department’s administrative director, say it didn’t have to be that way – at least in the case of their lab. In early July, Sinai Health submitted an expansion proposal to the provincial government with an eye to eventually performing 17,400 gold-standard PCR tests a day, up from their current maximum capacity of 10,000.
On Aug. 4, Ms. Bruce says, the province approved $1.6-million in capital expenses for six new testing machines and related equipment, including more biosafety cabinets and refrigerators. But it wasn’t until Sept. 23 that the government approved about $500,000 to knock down a wall and make space for the new equipment. As a result, the machines sat in storage while a tsunami of back-to-school testing demand washed over the province. (David Jensen, a spokesman for the Ontario Ministry of Health, declined by e-mail to explain the delay, responding instead that Mount Sinai’s project was one of a group of proposed testing projects that was expedited once capital expenses and budgets were confirmed.)
“It still boggles my mind,” Dr. Mazzulli says from his office next to the lab, “because had we and other labs been able to move forward, I don’t think we would have necessarily been scrambling as we were this past week and a half or so.”
Fayez Quereshy, a surgical oncologist and UHN’s clinical vice-president, is taking part in a virtual meeting of UHN’s Clinical Activity Recovery Team, or CART. The team was established to guide the resumption of scheduled surgeries at UHN – but there was always the possibility it would be asked to oversee another ramp-down, Dr. Quereshy says. On the agenda today is a draft version of an ethical framework for doing just that.
If it comes to that, how do they decide which surgeries to cancel? Should it be based on medical need? Impact on life? The length of time a patient has already been waiting? Members of the committee, including a patient and a caregiver, weigh in.
Shortly before the meeting started, the Ontario government revealed that 939 tests had come back positive for the coronavirus in the last 24 hours, smashing the previous record. The government had already leaked that new restrictions were coming for the hot spots of Toronto, Ottawa and Peel Region, which includes Brampton and Mississauga.
For Dr. Quereshy, the leader of the surgical recovery effort, it’s difficult to face the prospect of reducing surgical procedures, even on a small scale. But he hasn’t been caught off guard. “I remember back in July and August thinking that October and November were going to be tough months for us,” he says.
Dr. Hota is in a boardroom in UHN’s infection prevention and control department. Both of the long-term care outbreaks she’s been managing have “reached a point of some stability.” Preparations are in place for tighter visiting restrictions, which will be made public that afternoon.
“I try not to get too anxious about looking at the numbers day to day,” she says. “It doesn’t surprise me that they’ve been going up, because short of instituting broad public health measures – restrictions, closures – like several of us have been advocating for, you’re not going to get the numbers down.”
Dr. Hota flicks on the giant TV and watches as Premier Doug Ford announces that indoor dining, gyms and movie theatres will be shut down for at least 28 days.
“Hospitalizations and the number of people in intensive care have increased by 250 per cent,” the Premier says. “If current trends continue, Ontario ICU, intensive care unit, admissions are predicted to more than triple in less than 30 days. Our hospitals will be overwhelmed. We can’t let this happen."
On Oct. 15, an outbreak was declared at Toronto Western’s eighth-floor COVID unit. The first case was detected in a staff member on Oct. 12. A total of three patients and six staff have since tested positive. An early investigation has determined that one possible route of transmission was the hospital itself.
As of 8:30 a.m. on Oct. 16, the number of COVID-19 patients at Toronto General had fallen to five, with one in the ICU. At Toronto Western, cases had dropped to 10, with two in intensive care.
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