In the early days of Canada’s coronavirus response, when officials were consumed with fears of overwhelmed hospitals and rationed ventilators, a hospital in Oshawa, Ont., discharged an elderly patient named Nina Watt to a nearby nursing home.
Three weeks later, Ms. Watt was dead. Orchard Villa, the nursing and retirement home to which she had been transferred, went on to experience one of the worst outbreaks in the country, with 77 dead of COVID-19, including Ms. Watt.
Ms. Watt, 86, was one of thousands of seniors discharged to nursing and retirement homes as Ontario, Quebec and other provinces rushed to clear beds for a flood of COVID-19 patients that has so far not swamped hospitals, thanks in large part to shutdowns and physical distancing.
At the same time the acute-care sector was searching for space, some hospitals, physicians and long-term care facility administrators were discouraging families from sending infected nursing-home residents to the hospital, saying little could be done to effectively treat COVID-19 in patients who were old and chronically ill.
As a result, it appears most of the nursing- and retirement-home residents who have succumbed to COVID-19 in Canada died inside the virus-stricken, understaffed facilities, while many of the hospital beds opened for coronavirus patients sat empty.
Though well intentioned, the shoring up of hospitals came at the expense of seniors’ homes, which received far less attention before the virus took off in Canada.
“There’s a lot of age discrimination. There’s this presumption that, well, everybody in long-term care is there to die,” said Jane Meadus, a lawyer with the Advocacy Centre for the Elderly in Toronto. “Of course, that doesn’t deal with the fact that, had they moved people out [of nursing homes] when they became aware they were COVID-positive, they might have been able to slow or stop the infections from continuing through the homes.”
An estimated 80 per cent of the Canadians who’ve died of COVID-19 have been residents of seniors’ facilities, according to the Public Health Agency of Canada.
No province has been hit harder than Quebec, where 2,355 long-term care residents and 653 retirement-home residents have succumbed to the coronavirus and its resulting COVID-19.
Ontario has reported 1,427 deaths among nursing-home patients and 125 among residents of retirement homes, while British Columbia and Alberta have each managed to keep COVID-19 deaths at seniors’ facilities below 100 as of Wednesday.
At the start of the coronavirus crisis, the Quebec government justified its decision to move patients out of the hospital network on two grounds.
First, Health Minister Danielle McCann said that during the H1N1 pandemic in 2009, patients with flu-like symptoms flooded emergency wards. In addition, this time, officials wanted to prevent the more pessimistic projections for the impact of COVID-19, what Premier François Legault called “an Italian-style scenario,” in which hospitals would run out of ventilators and intensive-care beds.
During the month of March, Quebec hospitals were directed to do “load shedding,” freeing beds by postponing elective procedures and transferring patients.
Quebec Director of Public Health Horacio Arruda told reporters on March 12 that, as part of the move, the government would reactivate decommissioned hospital buildings or convert hotels into temporary wards.
In Laval, north of Montreal, the local health authority rented a hotel to relocate more than 130 elderly, palliative and mental-health patients from Cité-de-la-Santé hospital.
Other local health authorities turned to private elder-care homes. The health board for Montreal North, for example, agreed to pay a total of $133,800 to three private seniors’ facilities for a dozen residents, “to apply our load-shedding plan because of COVID-19,” the procurement contracts said.
“It had to be done, taking people who could be transferred to LTC homes to free beds in hospital and eventually handle the incoming wave caused by COVID-19,” Mr. Legault later told reporters to justify the decision.
In Ontario, hospitals transferred out nearly 2,200 alternate-level-of-care, or ALC, patients from March 2 to May 3 – 1,589 of them to long-term care homes and 605 to retirement homes, according to the province’s Ministry of Health.
Not all of the patients deemed ALC – a designation that means they no longer require acute care and are waiting for a spot in a nursing home or rehabilitation centre – were moved to make novaroom for coronavirus patients.
Ontario hospitals are constantly transferring out ALC patients, mindful that if such patients stay, they run the risk of declining physically and mentally, while also contributing to overcrowding in the hospital.
Ms. Watt, who had Parkinson’s disease, had been at Oshawa General Hospital, part of the Lakeridge Health network east of Toronto, since a fall in January left her incapable of returning to the apartment where she lived on her own.
She did not want to move to Orchard Villa, but she reluctantly agreed to the transfer on March 23, her son, Andrew Watt, said. Ms. Watt died of COVID-19 on April 15, three days after testing positive.
“When I talked to her at the hospital, she told me she didn’t want to go there,” her son said. “But they were telling her that was the only option she had.”
In preparation for the pandemic, the Ontario government made regulatory amendments on March 24 that allowed placement co-ordinators to send ALC patients to any long-term care home with an appropriate bed, although patients technically had a right to refuse.
Normally, patients choose a handful of preferred homes and wait for an opening. In Ms. Watt’s case, Orchard Villa was last on her list, and she only added it at the urging of the local health authority that co-ordinates placements, Mr. Watt said.
Alberta made a similar change on March 23, suspending a policy that allowed patients in hospital to select their top three homes. Alberta hospitals discharged 901 patients into long-term care and supportive-living facilities in March and early April, a significant increase over the average of the previous 11 months. March transfers were the highest recorded in history, Alberta Health Services said.
Fred Mather, the president of Ontario Long Term Care Clinicians and the medical director of a nursing home in Kitchener, Ont., said he understood why governments, unnerved by Italy’s COVID-19 experience, rushed to empty hospitals.
At the end of March, “all the focus was on the foreseeable surge into acute care, which was predicted to happen somewhere around the Easter weekend ... and that did not happen," Dr. Mather said. "We were under the impression that we wanted to avoid sending people, at least unnecessarily, to the emergency departments in the hospital.”
The instinct to protect hospitals led some, including Quinte Health Care, which operates four hospitals in the Belleville, Ont., area, to ask local long-term-care leaders to talk to families about why they shouldn’t send their COVID-19-positive relatives to the emergency department.
“Our critical-care colleagues are of the strong opinion that ventilator treatment will not make a survival difference to patients who are frail, and ventilator support is very unlikely to be offered,” Quinte Health’s chief of staff and chief of emergency medicine wrote in a March 23 letter to long-term care homes.
The letter also said Quinte Health’s emergency departments would still accept COVID-19 residents if families insisted, and in fact, three of the six COVID-19 patients treated at Belleville General Hospital came from long-term care homes, according to Catherine Walker, a spokeswoman for Quinte Health.
Michelle Snarr, the medical director of Pinecrest Nursing Home in Bobcaygeon, Ont., also sent a letter urging family members to think twice before sending loved ones with COVID-19 to hospital, a missive she said she wrote to protect frail, elderly residents from invasive treatments that would do them no good.
Twenty-eight of Pinecrest’s 65 residents died of COVID-19, all of them at the home.
Deciding when to send elderly patients, particularly those approaching death, to hospital, was fraught before the pandemic, said Amit Arya, a Greater Toronto Area palliative care doctor who specializes in treating patients in nursing homes.
“Transferring long-term care patients to hospital is not always the best thing for them,” he said, especially if those patients are cognitively impaired. “It’s not black and white."
When it comes to severe cases of COVID-19, there is no widely available treatment beyond supportive care such as mechanical ventilation, which hasn’t worked well for the elderly.
A study published this week in The Lancet found that 80 per cent of critically ill patients over 80 who went on a ventilator at two New York hospitals died, a finding consistent with research from Europe and China.
Nursing-home patients infected with the coronavirus were never supposed to be denied hospital care if they needed it, according to Ontario’s Ministry of Health, but it’s not clear how much of that message filtered down to the independent players in the system.
Linda Cottrell, whose 93-year-old father, Manuel Marques, also died of COVID-19 at Orchard Villa, said a doctor at the home called and chastised her for trying to send her father to the emergency room at Lakeridge Health’s Ajax Pickering Hospital, east of Toronto.
It was a step Ms. Cottrell only agreed to after an Orchard Villa nurse called to ask what she wanted done with her father, who had spiked a high fever. Mr. Marques was awaiting his coronavirus test results at the time.
“[The doctor] was angry with me that I had sent him to the hospital,” Ms. Cottrell said, adding the doctor accused her of putting her father at risk with the move. “Then [the doctor] said they didn’t even take him into the hospital. They turned him around, and they sent him back.”
Sharon Navarro, a spokeswoman for Lakeridge Health, said she could not comment on the cases of Mr. Marques or Ms. Watt for privacy reasons. The executive director of Orchard Villa declined to answer a list of questions sent by e-mail, instead referring The Globe and Mail to a statement from Ms. Navarro. The Central East Local Health Integration Network, which co-ordinates placements in long-term care, also declined to speak about Ms. Watt’s case because of privacy.
The Quebec government also tried to cut down on movements back toward hospitals. Clinical guidelines issued on March 23 said that residents in long-term care facilities who contracted the new illness should only be sent to hospitals “on an exceptional basis and after consultation with the doctor on duty.”
Jean-Pierre Ménard, a lawyer specializing in patients’ rights, wrote to the Health Minister, raising concerns about the guidelines. In his letter, Mr. Ménard argued that it was hard to get elderly patients to give proper consent on their level of care since they had been locked down in care homes with no access to their relatives since mid-March.
At first, Quebec’s Premier and Health Minister insisted that it was better to keep elderly residents in long-term care facilities. “It is never good to transfer people, to move people to other facilities, including the elderly, who get settled in and then become distraught when they change locations,” Mr. Legault told reporters on April 2.
A few days later, the Quebec government realized that, with fewer than 700 COVID-19 patients in hospital, the dire forecasts of overwhelmed emergencies and intensive-care units weren’t materializing.
At the same time, the increase in deaths among elder-care-home patients was accelerating at a faster pace. By April 10, more than a month after the first COVID-19 case was identified in the province, the Quebec government ordered an end to transfers from hospitals to elder-care homes.
Ontario’s Ministry of Health followed suit on April 15, asking hospitals to temporarily halt transfers to long-term care in a memo that said only 64.1 per cent of acute-care beds in the province were in use.
It’s difficult to say how many residents of seniors’ facilities actually died inside the homes. Nobody is tracking that figure at a national level.
But the scant hospitalization data that are available, combined with media reports on the worst outbreaks, suggest most died at the facilities.
Toronto Public Health, which reported on coronavirus outbreaks at individual nursing and retirement homes over two weeks in April, found that of as of April 17, only 22 of 899 residents with confirmed cases of COVID-19 were being treated in hospital. That is about 2.5 per cent.
By May 1, when there were 1,691 cases in Toronto seniors’ facilities, 95 residents, or 5.6 per cent, were in hospital.
In Alberta, there had been 364 confirmed cases of COVID-19 in long-term care as of May 12. Of those, 24 had been hospitalized.
In her statement, Ms. Navarro said that Lakeridge Health has continued to admit patients from long-term care during the pandemic, including 26 Orchard Villa residents who were treated at Ajax Pickering Hospital as part of the hospital’s leadership role in stemming the outbreak.
The local medical officer of health asked Lakeridege Health to step in after the coronavirus outbreak at Orchard Villa spun out of control. The military is helping out at Orchard Villa, too.
Now that the coronavirus’s toll on ill-prepared nursing homes is clear, some are sending dozens of residents to the hospitals that were shielded at the start of the crisis.
To take two examples, the Forest Heights long-term care home in Kitchener, where 49 have died of COVID-19, has sent 54 residents to three local hospitals as part of a formal agreement to make infection control and deep cleaning easier at the home, which has many four-bed rooms.
Humber Valley Terrace, a home in Toronto’s Etobicoke neighbourhood where 21 have died, has moved 23 residents to two nearby hospitals for the same reasons.
“The idea was if we could take some of those residents out of those spaces, make those rooms smaller – two beds or one bed – then we could [separate] our positive residents and our negative residents more easily,” said Rhonda Collins, chief medical officer for Revera, owner of both homes.
With a report from Carrie Tait in Calgary
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