Lessons for hospital care from the first wave of COVID-19 in Ontario, Canada

Introduction

The first wave of COVID-19 and the corresponding social and health system response affected hospitals suddenly, causing massive disruptions in patient care. Across Canada, there were approximately 10,000 hospitalizations for COVID-19 before 30 June 2020 [1]. Hospitals reorganized many aspects of delivering patient care [2], including staffing, physical infrastructure, and supply chain management. Given the unprecedented nature of the pandemic, hospital policies and procedures were developed locally, drawing on relevant evidence and experience from seasonal influenza, prior pandemics, and general principles of infection prevention and control [2]. As a consequence, hospital preparations for COVID-19 varied widely and with little sense of ‘best practices’.

The Ontario General Medicine Quality Improvement Network (GeMQIN) is a provincial program dedicated to improving the quality of general medical hospital care. GeMQIN includes 32 hospitals from all geographic regions of Ontario and represents approximately 65% of the province’s inpatient medical beds. Hospitals in Ontario are publicly-funded and acute care services are universally insured for residents of the province. Ontario accounted for approximately 40% of all COVID-19 hospitalizations in Canada during the first wave [3], and most COVID-19 patients were cared for on general medical wards. To support the COVID-19 pandemic response, GeMQIN hosts monthly webinars that include clinical and operational leaders from participating hospitals. Each session focuses on a specific issue related to the pandemic, such as, ‘ward organization and team structures for COVID-19’. The purpose of this commentary is to summarize several key lessons related to hospital care of patients with COVID-19 based on experiences of GeMQIN members in the first wave of the pandemic, shared during monthly webinars. We also highlight key challenges and uncertainties for future waves of COVID-19.

Hospital capacity

A crucial advantage for hospitals in the first wave of the COVID-19 pandemic was excess hospital capacity. In Ontario, acute care occupancy declined from 102% in the first week of January to 62% in the first week of April [4], which was influenced by many factors including hospitals postponing elective surgical procedures and expediting patient discharges [4] and patient reluctance to seek hospital care which decreased admission volumes [5]. The cumulative effective of these factors allowed hospitals to minimize crowding and in many cases geographically separate patients with COVID-19 from other patients. Reduced patient volumes helped reduce fatigue and stress on clinicians.

Hospital occupancy across the province returned to baseline levels by the fall of 2020 [6] and began to exceed capacity in some areas as surges of COVID-19 hospitalizations occurred in the winter. The first wave of the pandemic created a backlog of nearly 150,000 surgeries [7]. Increasing surgical volumes to recover from this backlog placed further strain on hospital capacity. Pandemic effects on long-term care [8] and efforts to reduce crowding, along with pandemic-induced disruptions to home care, made it more difficult to discharge patients from acute care [4]. Hospital capacity is a serious concern for managing future waves of COVID-19. Hospitals heavily affected by COVID-19 have needed to decant patients to other facilities [9] and once again resorted to reducing the volume of elective surgical procedures [10]. Increased hospital and ICU occupancy has been associated with greater mortality related to COVID-19, perhaps due to diminished ability to provide life-saving therapies [11]. Investments to expand hospital capacity, public health efforts to diminish COVID-19 surges, creative approaches to more efficiently use existing hospital capacity, and strengthening the provision of ambulatory care are essential components of managing future waves of COVID-19 in Ontario.

Physical infrastructure and ward organization

A central challenge for hospitals was determining whether and how to rearrange patient ward assignment for patients with and without COVID-19. In an online poll during a monthly GeMQIN webinar, 17 out of 18 respondents reported that their hospital physically grouped patients with COVID-19 into specific geographic locations within the hospital. Some hospitals allocated specific wards and others cordoned off certain areas to separate patients with COVID-19 from others. Hospitals that elected to do this typically also assigned overflow spaces in case the dedicated unit was full, which was enabled by spare hospital capacity. An important factor underpinning these decisions was the hospital’s physical infrastructure. For example, some hospitals with many private isolation rooms were less focused on geographically separating COVID-19 wards from non-COVID-19 wards.

Patient cohorting

Many hospitals tried to cohort patients with COVID-19 onto single care teams. The rationale for this included minimizing the number of staff exposed to COVID-19, minimizing the potential for staff to spread COVID-19 to other patients, and conserving the use of personal protective equipment (PPE). When the volume of patients with COVID-19 increased, most hospitals began distributing patients with COVID-19 across multiple areas and care teams to make the workload more manageable. Hospitals felt more comfortable distributing patients with COVID-19 across care teams as the mechanisms of COVID-19 transmission became clearer and PPE supply chains became more secure. The effects of patient cohorting on clinical outcomes, patient flow, or healthcare worker safety remain unknown and an important area for future research.

Health human resources and team-based care

Multidisciplinary teams have been adapted to support the care of patients with COVID-19. New roles were created to minimize clinician fatigue and assist with donning and doffing of PPE. Team composition at different hospitals varied based on local resources. For example, some academic hospitals employed a physician buddy system [2], in which one physician managed in-person aspects of patient care and the other physician managed non-patient-facing aspects such as clinical documentation. Other hospitals employed nurse practitioners, physician assistants, or other staff to support clinical activities and/or serve as ‘safety officers’ to ‘spot’ PPE use and contamination risks.

Burnout among health professionals is an important consequence of the pandemic [12]. Wellness resources for physicians [13] and nurses [14] have been widely shared, and the general public expressed appreciation through numerous initiatives, such as providing meals for frontline workers. However, such efforts do not address the underlying determinants of burnout, including workload, fear of personal illness, and the broader disruptions of the pandemic on society. General morale has waned as the pandemic has worn on.

Several interventions have helped address healthcare worker safety and stabilize the workforce. Most notably, SARS-CoV-2 vaccination efforts in Ontario prioritized front-line healthcare workers, including hospital staff [15]. Most hospitals now have clearly established surge policies and back-up clinical schedules to manage sudden changes in patient volumes or staff absence due to illness or isolation. For physician scheduling, this sometimes involved asking subspecialist physicians to participate in general medical ward/hospitalist schedules.

Communication with patients and families

The COVID-19 pandemic has strained clinicians’ ability to communicate with patients and families. Face and eye protection, such as masks and faceshields, hinder communication. Clinicians have also been careful to minimize time spent in close contact with infectious patients. Hospital policies restricting visitation can make it challenging to communicate with patients’ families and caregivers. Some hospitals have invested in tablet and smartphone devices to facilitate remote video discussions with inpatients and their families, whereas others rely on telephone communication. Physicians often telephone patients for daily rounds and avoid direct room entry. A range of ‘low tech’ solutions have also been employed, such as toolkits to assist with communication (https://torontocovidcollective.com/patient-toolkit).

Hospital outbreaks

There were 91 COVID-19 outbreaks in Ontario hospitals prior to June 30, 2020 with approximately 900 people infected [16]. Patients and healthcare workers each accounted for approximately half of the infections [16]. Most initial strategies to reduce hospital outbreaks focused on reducing spread from patients to staff. These approaches corresponded with traditional infection prevention and control practices for other contagious diseases and were informed by experiences with previous pandemics, such as SARS [17]. However, staff-to-staff transmission has emerged as a major source of hospital COVID-19 outbreaks, and this requires encouraging uptake of SARS-CoV-2 vaccination as well as addressing staff behavior in shared spaces, such as break rooms, and minimizing in-person meetings, which were not traditionally an important focus for infection prevention and control.

Testing for COVID-19 and managing patients under investigation

There is variation in COVID-19 testing and isolation policies. This is particularly apparent in which patients are tested for COVID-19 and how they are isolated while under investigation. Some hospitals choose to test more broadly, but only isolate patients in whom there is a clinical suspicion for COVID-19 whereas others only test patients who are suspected of infection. Standardizing practice may be particularly challenging because SARS-CoV-2 infection can be asymptomatic, polymerase-chain-reaction–based virus testing may yield false negative results in 10-30% of cases [18], and test turnaround time may vary from hours to days. This remains an important area for research.

Conclusion

Hospitals in Canada were generally able to manage the first wave of COVID–19, despite confusion and chaos. The most important enablers of success were the reduction in hospital occupancy, relatively strong infection prevention and control teams and policies that had been mandated after SARS in 2003-2004 [17], and timely public health measures, which reduced the number of patients with COVID-19 requiring hospitalization. Based on lessons learned from the first wave, hospitals became better prepared for future waves of COVID-19. Wards and care teams were reorganized to care for patients with COVID-19. Hospital surge and staffing plans were established, PPE supply chains became more secure, and disease transmission, testing, and treatment became better understood. Vaccination against SARS-CoV-2 prioritized healthcare workers in an effort to protect the workforce. However, acute care capacity remains a critical potential failure point. Surges in demand related to COVID-19 may place untenable strain on both physical infrastructure and a workforce that has experienced high rates of burnout. Lessons from Ontario are relevant for many other jurisdictions who have experienced similar cyclical waves of COVID-19. Emerging virus variants, which are more transmissible and severe [19], may exacerbate the pressures on acute care hospitals. Research devoted to understanding how to manage hospital operations during the pandemic should remain an important priority, and communities of practice to support knowledge exchange may help strengthen the hospital pandemic response.

Declaration of funding

This project was supported by CIHR Grant VR4 −172743

Declaration of financial/other relationships

AV is a part-time employee of Ontario Health and the Provincial Clinical Lead for Quality Improvement in General Medicine.

FR is a part-time employee of Ontario Health and the Provincial Clinical Lead for Quality Improvement in General Medicine.

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Acknowledgments

We would like to acknowledge the members of the Ontario General Medicine Quality Improvement Network for contributing to this work through their participation in the community of practice. In particular, the following individuals offered substantial feedback and contributions to the work: Amna Ahmed, Rodrigo Cavalcanti, Beatrise Edelstein, Haseena Hussein, Alison Lai, Cecile Marville-Williams, Nasrin Safavi, Mehdi Somji, and Terence Tang.