Fahad Razak and Amol Verma are internal-medicine physicians and professors at the University of Toronto
Hospital capacity is a major concern for infectious-disease experts preparing for COVID-19 in Canada. Based on early estimates, one in five patients who are infected with COVID-19 may require hospital care. Other countries are taking extreme measures to handle a surge in patients. China built new hospitals in a matter of weeks. Washington State has purchased a motel that it is urgently retrofitting into a medical facility.
In Canada today, many hospitals already operate at the limits of capacity, with almost no ability to handle increased demand in the event of a COVID-19 outbreak. A recent survey in Ontario noted 40 hospitals that averaged 100-per-cent capacity or higher over a six-month period.
Hospital capacity strain in Canada has been widely discussed, with concern about patients being cared for in hallways and other “non-traditional” spaces. An emerging public-health challenge like COVID-19 places a sharper focus on these issues. Overcrowding in hospitals reduces our ability to treat the sickest patients or apply the best standards of infection control. This could increase the risk of spread of infections to other patients, family members and health-care staff, a phenomenon noted in seasonal influenza and prior coronavirus infections such as SARS.
Long-term solutions to address hospital capacity strain have been well considered. They involve reducing demand for hospital care by improving preventative medicine, primary care and home care, and increasing capacity in hospitals and long-term care facilities. These solutions will likely take years to implement and are crucial to long-term sustainability of the health system – but they do little to address a potential surge of hospital patients in the coming weeks and months.
What can be done in the short term? Reducing non-urgent use of hospital services, such as cancelling elective surgeries, is likely to be part of the solution. Creative preliminary proposals to maintain emergency-room capacity and reduce the risk of infectious spread through off-site locations for rapid COVID-19 screening are also important.
As internal-medicine physicians and scientists who care for and study hospital patients, we believe there are also several ways that existing capacity could be used more efficiently. Importantly, If there is a decision to allocate federal funding to help bolster preparations, some of these steps could be immediately implemented without the need for new buildings, equipment or medication.
First and most importantly, hospitals and health-care facilities must consider whether providing more services on weekends and holidays would help patients move through hospitals more quickly. During those times, many operating rooms are closed, tests like endoscopy or ultrasounds are often not available, physiotherapy services are reduced, and some rehabilitation facilities do not accept transfers from hospitals.
Our preliminary estimates from medical wards at seven Ontario hospitals suggests that the cumulative effect of these bottlenecks is a nearly 50-per-cent drop in hospital discharges on weekends. Considering the reduced services on two days every week, our health system functions suboptimally nearly 30 per cent of the time. Providing normal hospital and posthospital care on weekends and holidays may improve efficiency and better reflect the 24 hour, 7-day-a-week nature of human illness.
Second, inpatient facilities can focus on the relatively small number of patients who occupy hospital beds for a very long time. About 15 per cent of hospital beds are occupied by people waiting to be transferred to another facility, such as a nursing home. A much smaller fraction of patients (less than 1 per cent, according to our research) stay in hospital for more than two months.
Consider that one person who stays in hospital for 365 days has a similar effect on capacity as 365 patients who stay in hospital for one day. Helping one long-stay patient leave the hospital can free up as much bed space as shortening the hospital stays for hundreds of patients. One temporary solution, while more long-term care capacity is being built, is to move very long-stay patients out of hospitals into other care facilities.
Third, hospitals can expand efforts to reduce unnecessary admissions. Nearly one in ten hospital admissions lasts less than 24 hours and one in three lasts less than 72 hours. Some of these patients may not need to be admitted to hospital. For example, fainting episodes and high blood pressure are common causes of very short hospital admissions. Some hospitals are implementing programs to avoid admitting these patients, such as ambulatory urgent-care centres or rapid-access clinics. These initiatives can be quickly spread to more hospitals.
A stable and resilient health system requires the capacity to deal with the ebb and flow of human health needs. As we race to prepare for COVID-19, there are rapidly deployable initiatives that may help us care for a potential surge of patients. These can also contribute to a broader strategy to strengthen our hospital system so we are better prepared for the next global pandemic and the myriad other health-care demands we face. As the proverb states, the best time to plant a tree was 20 years ago, but the second-best time is now.
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