Ontario doctors prepare for worst-case COVID-19 triage decisions

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Ontario doctors have been taking part in virtual training sessions on the province’s worst-case scenario COVID-19 emergency triage protocol, using role-play to practise telling families their loved ones are ineligible for life-support.

The triage protocol would employ a series of metrics to score incoming patients on their likelihood of survival in 12 months. If COVID-19′s growth outstrips all current efforts to expand the intensive-care system, transfer patients to other hospitals across the province and draft in extra staff, the protocol would reserve scarce ICU beds for those deemed more likely to survive.

The province’s rapidly swelling intensive care units were home to a record 851 COVID-19 patients as of Sunday and some hospitals were still familiarizing their staff with the complex triage system that could be enacted.

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Erin O’Connor, deputy medical director of the emergency departments in the University Health Network, which includes Toronto General, Toronto Western and Princess Margaret hospitals, said her simulation team has been running role-play training sessions on the protocol since the second wave. But now, she is fielding calls from other hospitals that are trying to prepare for the worst.

“Honestly, it’s terrifying for all of us,” Dr. O’Connor said. “And we are all just trying to brace ourselves and prepare ourselves as well as we possibly can to deliver the best care we can in a situation where we don’t have unlimited resources.”

Ontario has ramped down all non-emergency surgeries and procedures to try to accommodate the current COVID-19 surge. It is trying to encourage the shifting of elderly patients from hospitals into empty spaces in long-term care. It has also been moving hundreds of critical-care patients a week – by helicopter, ambulance and even a retrofitted bus – from packed hotspot hospitals in the Greater Toronto Area to ICUs as far away as Kingston.

In addition to military-style tents set up alongside hospitals, the province is installing makeshift ICUs in operating rooms and recovery rooms. And ICU nurses are working with teams of redeployed, less-experienced staff to oversee more patients, said Chris Simpson, executive vice-president of Ontario Health, the government agency that oversees the health system, and a Kingston cardiologist.

Modelling from the province’s COVID-19 Science Advisory table predicted a peak of at least 1,500 virus cases in ICUs by the first week of May, and possibly as many as 2,000. That’s as many ICU beds as Ontario has now in total, filled with more than 800 COVID-19 patients and about 1,200 non-COVID-19 patients.

Theoretically, with the existing ICU system running all out, it could accommodate a maximum of 2,300. On top of that, Ontario Health has told hospitals to find staff and space for more than 1,000 additional beds, many of which would be ICU-like beds operated with fewer staff.

If the system can manage all that expansion, and do it fast enough, officials hope the worst can be avoided. But nobody knows if this is doable – or how long it could be sustained. And everyone agrees that at these numbers, the quality of care would be severely compromised. Most agree it already is.

“I think that’s kind of a stretch goal where we think we could get,” Dr. Simpson said, adding that every corner of every hospital is being scoured for space and staff. “If it does come to using the triage tool, I think we need to be able to say we have absolutely maximized and done everything we possibly could.”

If the system as whole, or a hospital or a regional group of hospitals, completely runs out of space but faces a queue of critically ill patients – whether they are suffering from COVID-19, or car collisions, or heart attacks – drastic decisions may need to be made.

There are actually two protocols, neither of which has been formally made public. Ontario Health Minister Christine Elliott has said repeatedly that no protocols have been approved and refused to release them. Disability rights groups and the Ontario Human Rights Commission have raised concerns about potential discrimination against the disabled.

According to a leaked copy of one protocol, known as the “Emergency Standard of Care” and circulated to hospitals in January, two doctors would evaluate each incoming patient, using a set of criteria to determine their chances of survival. A web-based calculator may also be used to plug in the data about a patient’s condition. Ties could see a randomizer website make the final call.

It would be phased in: At Level 1 triage, all patients with more than an 80-per-cent chance of death after 12 months would be “deprioritized” for ICU beds and instead receive palliative care. At Level 2, the cutoff becomes a more than 50-per-cent chance of death at one year. At Level 3, it moves to just 30 per cent.

According to the leaked copy of the Emergency Standard of Care, it is up to the Ontario-wide Critical Care COVID-19 Command Centre to declare when to use it.

The other protocol is referred to as the “Critical Care Triage Protocol.” According to a document summarizing it and obtained by The Globe and Mail, it is largely the same, but assumes that cabinet issues an executive order overriding the province’s Health Care Consent Act and allowing existing ICU patients to be disconnected from life support without consent. Such an order, some doctors say, would save more lives, as those in ICUs with little hope of survival could be removed to make way for new patients with better chances.

Whether the system can surge enough to avoid either scenario, doctors say, also depends on how quickly the province’s stay-at-home order and retail and restaurant shutdowns – and its hot-zone vaccination push – can start to push down infection numbers. But ICU numbers, which lag those daily new infection counts, are expected to keep rising in the near term. Plus, those who end up in ICU with COVID-19 are now staying longer.

Ontario registered 3,947 new infections on Sunday, pushing the seven-day average down slightly to 4,051 –below the more recent worst-case projections. There were 24 deaths.

Whatever happens, many doctors warn the system is already triaging by another name.

Everything from cancer procedures to heart surgeries are being postponed. Plus, crowded, understaffed makeshift ICUs will result in more deaths for both COVID-19 and non-COVID-19 patients, said James Downar, a specialist in critical care at the Ottawa Hospital who was involved in drafting the triage protocols. Whether it makes sense depends on how long the surge lasts, he said.

“The question isn’t, ‘When do we start triage?’ It’s ‘When do we change the way we are triaging?’” he said.

Already, reports of the surge’s collateral damage are surfacing. Nir Lipsman, a neurosurgeon at Toronto’s Sunnybrook Hospital, posted on Twitter last week that a young patient with head trauma was left without an operating-room slot as the hospital was jammed with COVID-19 patients. After rearranging some patients and bringing in extra nurses, his team was able to make this surgery happen.

“This is the domino effect, the downstream effect, of this wave that we are experiencing,” Dr. Lipsman said.

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