WTBS 22 The End of The Beginning: What’s Next for EDs in the COVID-19 Pandemic?

As of late May, most countries have falling numbers of new cases of COVID-19 and are at various stages of easing lockdown orders. This seems a good time to look back on the pandemic experience so far and at what lessons we can apply going forward. Waiting to Be Seen will do so in a series of posts looking at lessons learned and innovations that resulted from this intense first phase.

I’d like to start with a focus on ED safety. Back in March, Canadian emergency physicians were anxious; reports from Wuhan, China, and from northern Italy included tales of overwhelmed hospitals, exhausted staff, and illness and deaths among health care workers.[1,2] As Ontario’s “Expert Lead” for emergency medicine, I have been deeply involved in the province’s response to and experience with COVID-19. As of May 26th, we’ve had 26,483 cases and 2,155 deaths in Ontario, which translates to a very high case fatality rate of 8.1 per cent.[3] This likely represents both an undercount of community cases due to testing limitations and a high attack rate among the most vulnerable of patient groups: the institutionalized frail elderly in our long-term care and retirement homes.

Hospitals weren’t overwhelmed

Despite this tragic failing in our senior care sector, our hospitals have not been overwhelmed. The peak number of ICU cases in Ontario hospitals was just over 250, which is well within the available capacity, and the total number of hospitalized patients at any time never got much above 1,000 (also well within the available capacity). Thus, every patient who needed an ICU bed received one, and no “rationing” of ventilators was required in this phase. Currently, we have flattened the curve and as of May 26th the number of hospitalized patients and the number in ICUs have dropped substantially. Data for the province are updated daily on Ontario’s COVID-19 response website.[3]

Overall, our EDs have fared well. There have been only two outbreaks declared fairly recently in Ontario EDs, and these have included only a handful of ED staff.[4.5] I sense that anxiety in our EDs has settled a fair amount and there have actually been fewer staffing issues reported than normal (we have a chronic shortage of both physicians and nurses in Ontario EDs). So, our experience thus far—despite the tragic deaths, morbidity, and economic impact—has not been as disastrous as feared. What accounts for this?

It’s worth looking at some of the reported factors in jurisdictions that fared worse. These included some combination of:

• Crowding in EDs due to a combination of high volumes of patients seeking care and/or high occupancy rates in hospitals and ICUs, which led to COVID-19 patients spending prolonged periods in EDs.[6]
• Inadequate supplies of personal protective equipment (PPE), which led to the use of homemade or inappropriate alternatives.[1,2]
• Staff not adequately familiar with or not applying their knowledge of safe practices. Examples of this include the reported use of high-flow oxygen or non-invasive ventilation, which is thought to have potentially aerosolized droplets carrying the virus. This may have been due to a combination of being hit early in the pandemic, without time to prepare/train; having exhausted staff; recruiting staff such as retired or out-of-jurisdiction volunteers, who may not have been familiar with local infection prevention and control procedures; or just desperately trying to save lives.[7]

What has gone right

From these observations, it is clear that a lot of what has gone right in Ontario involved systemic advantages:

• A relatively late arrival of a higher volume of cases gave us time to prepare and train (and hospitals, departments, and individuals made good use of this delay; the download rates of Emergency Medicine Cases podcasts on this issue reflect that).
• A relatively early lockdown on social and economic activity led to the successful flattening of the curve (partly as a result of the same gift of time).
• The PPE supply has been maintained (although we have been asked to conserve masks through extended use).
• Hospitals were ordered early on to cease all elective procedures and services under Directive #2, which created a great deal of hospital capacity almost overnight.[8]
• The public largely stayed away from EDs, either out of fear, a sense of public responsibility, or both.

The impact on ED volumes can be seen in Figure 1. To reflect the seasonality of ED visit volumes we routinely display month-over-month data, and overall ED volumes had been increasing consistently in Ontario since 2008, with some variation related to the timing of seasonal influenza peaks. In Figure 1 the data points with red circles are record-setting months in fiscal 2019/2020. Then in early 2020, the monthly ED volume went from a record high for January to a record low for March (for the period shown).

Figure 1. Monthly ED volume in Ontario. (Data source: National Ambulatory Care Reporting System (NACRS), Canadian Institute for Health Information (CIHI), provided by Ontario Health (Cancer Care Ontario [CCO]).

Similarly, one measure of the length of stay of admitted patients in the ED—boarded patients—is the number at 8 a.m. (daily) who have been waiting at least two hours since receiving admit orders for beds. After several years of slow improvement in this measure in Ontario, the number of boarded patients had been rising fairly consistently since 2015 until March 2020 when—despite the emergency measure not being implemented until mid-month—volumes plummeted immediately, leading to a record low number for the month (see Figure 2).

Figure 2. Monthly average of the daily number of boarded patients waiting for beds at 8 a.m. in Ontario EDs (Data source: National Ambulatory Care Reporting System (NACRS), Canadian Institute for Health Information (CIHI), provided by Ontario Health (Cancer Care Ontario [CCO]).

In short, since mid-March patients arriving at Ontario EDs have generally been screened and seen promptly by ED staff outfitted with appropriate PPE, who are generally working in a familiar ED with a team they know, and who are applying care processes they have been carefully trained in to keep themselves and their ED safe. Patients requiring admission, including those who have tested positive for COVID-19, have generally left the ED promptly for the ICU or a ward.