Our hospital ward is only half full. We have not consistently seen, in more than a decade of training and practice, so few patients in hospital as in the last two weeks. And we are not alone – this experience is being shared by our colleagues across the province. Hospital occupancy in Ontario is just 77 per cent, down from 97 per cent a year ago.
We do not expect this situation to last, as the number of patients with COVID-19 is increasing. But this phenomenon of under-capacity hospitals is important to reflect on.
In part, this represents an enormous success of hospitals in creating capacity for the anticipated surge of COVID-19 patients. But we are worried this also means that people who need hospital care are staying home.
Clinicians, administrators, and policymakers have been working furiously to move patients from acute care hospitals to their homes or other care facilities (like rehabilitation hospitals or nursing homes). Primary care and specialist physicians are redoubling their efforts to help people manage chronic and acute illnesses to avoid hospitalization. Our health system is acting with unprecedented urgency, creativity, and cooperation. Two of our colleagues who were waylaid abroad noted that, “health care in Canada changed more during the two weeks we were away than it did during the two decades since we were medical students.”
But the reduction in hospitalizations might not be all good. Although 20 to 30 per cent of hospital admissions might be avoidable, actually reducing hospitalizations has proven to be extremely challenging. Most efforts report no benefit or only modest success at reducing hospitalization. Even if we assume that all preventable hospitalizations are being avoided, this does not account for the entire reduction in hospital volume that we have seen.
Most likely, people who need hospital care are not coming in. Some people may avoid hospitals because they fear contracting COVID-19 or they want to save scarce hospital resources. Others may have unrecognized illnesses because of disruptions in their usual care. For example, nurses who attend to people with chronic wounds sometimes recognize early signs of infection and send them to the hospital for treatment. If such services are disrupted or people are hesitant to come to the emergency department with serious symptoms, illnesses will not be recognized until they are more severe and harder to treat.
Modern healthcare systems in high income countries, like Canada, have not seen the kind of healthcare shock that COVID-19 is creating. SARS killed 44 Canadians and infected fewer than 500. Emergency department visits in Ontario decreased sharply during the SARS outbreak, and remained depressed for 10 months after the outbreak ended. COVID-19 has already infected many more Canadians than SARS and its effects are likely to last far longer.
Studies from the 2014-15 Ebola Virus outbreak in West Africa offer important lessons. Routine medical care suffered greatly during the outbreak: vaccinations decreased by nearly 70 per cent and 35 per cent of women missed their first antenatal visit for pregnancy. It took more than one year after the outbreak for primary care to return to normal levels. The number of deaths related to conditions other than Ebola increased during and after the Ebola outbreak.
The lessons from the SARS and Ebola Virus outbreaks are clear. First, people who have concerning medical issues must not avoid healthcare. This is an important public health message that has not been communicated widely. People should not confuse “social distancing” and calls to “stay home” as messages to stay away from necessary healthcare.
Second, preparations for COVID-19 are an opportunity to improve the way we deliver healthcare. The current all-out effort to enhance health system capacity should also strengthen our ability to provide routine and acute care for illnesses not related to COVID-19.
Cancer and heart disease are by far the most common causes of death in Canada, accounting for nearly half of all deaths, whereas infectious respiratory illnesses, like influenza and pneumonia, account for less than five per cent. Even if COVID-19 is as challenging as expected, it is unlikely to come close to cancer and heart disease as a major cause of death in our country.
Canadian healthcare is among the best in the world, particularly because of our strong systems of primary and preventive care and acute care. Maternal and newborn care, cancer screening, diabetes care, and the many other services our system provides must continue to function effectively during the COVID-19 outbreak.
We are not being pessimistic when we see hospital wards as half empty. But we must ensure that our efforts to prepare for COVID-19 allow for the ongoing routine and acute care that has given us one of the best healthcare systems in the world.
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“Even if COVID-19 is as challenging as expected, it is unlikely to come close to cancer and heart disease as a major cause of death in our country.”
Bingo.
Can we discuss the major discrepancies in expected COVID-19 hospitalizations from epidemiological models versus actual data? Perhaps we can get an update on your article.
Is there any effort to minimize cost in vacant hospitals to reduce to looming tax burden to come?
Thank you Drs. Verma and Razak for helping to raise awareness of this alarming (yet predictable) development. I quoted you and this article in my Heart Sisters blog post this week (“Empty Beds: When Heart Patients Are Afraid To Seek Help” – https://myheartsisters.org/2020/04/12/covid19-heart-patients-afraid-to-seek-help/ Cardiologists in several countries are now reporting a dramatic drop (as high as 40 per cent) in cath lab activations for STEMI even in high-volume heart hospitals, for example, suggesting as you say that people are so worried about the corona virus that they’re making the dangerous decision to stay away from the hospital.
This morning, one of my readers commented in response to this new post about her own experience years ago (which mirrors my own) of being misdiagnosed in mid-heart attack and sent home from the Emergency Department (in her case, remaining “persistent” and ultimately appropriately admitted to hospital for triple bypass surgery).
Do you know yet how many of those included in this drop in non-COVID19 admissions to hospitals may be occurring in those who DID seek help, but have been turned away from Emergency?
I don’t have concrete data about that but I can tell you anecdotally that volumes in the Emergency Department are lower as well. And I can also say that COVID is making it more challenging for clinicians to make diagnoses of other conditions because of all the precautions that need to be taken.
Thank you Dr. Verma and Dr. Razak for raising the red flag on such a vital issue. My prediction is that it will take us quite a while to combat and conquer Covid 19. By the time we have dealt with this pandemic, our healthcare workforce (and the entire system along with long-term care) will likely be exhausted – both physically and mentally.
Due to the shutdown, we may regress to an economic recession or at a minimum, a slow down in GDP growth. The effect of all the financial packages and subsidies may result in us having huge budgetary deficits both at the provincial as well as federal levels. To deal with these deficits the respective governments will be forced to cut back on governmental expenditures and that may lead to cuts in healthcare spending. This post Covid 19 period will coincide with the “bounce back” in patient volumes, both in the emergency as well as medical admissions. Exacerbating this volume explosion would be the pent-up demand for all the elective procedures that are currently on hold.
Unless we have the vision to think of the long-term consequences of Covid 19, and plan ahead to build capacity in our healthcare system to deal with the challenges above, I am concerned that we will fail the nation and healthcare in Canada will fall significantly behind.
I can speak to direct experience with this. My elderly neighbor fell and hit her head. She reported temporarily blacking out, along with suffering a serious laceration. I told her I would call an ambulance as she was in clear need of emergency care. She became panicked and utterly refused citing fear of contracting Covid-19. I called her family and shockingly, they agreed with her and declined to take her to hospital OR even a walk-in clinic. MORE alarming is they expressed concern that I risked exposing her to the virus by coming to assist as she lay crumpled and bleeding on her front walk. The fear narrative around this has escalated to hysterical proportions. I am not remotely surprised our ERs have seen troubling decreases due to patients so afraid that they would rather risk death/serious complications rather than be exposed to the threat of contagion
Your mother died from the covid ‘situation’ – not from covid, not even with covid, just how we managed things overall.
Nice, real nice for modern healthcare in 2020
Hi,
Very interesting analysis but you have apparently overlooked a significant reason for decreased hospital admissions – the suspension/cancellation of all elective surgical procedures. What percentage of hospital admissions prior to the current situation were related to elective interventions such as joint replacement?
Thanks James. We are talking about medical admissions, which are down much lower than you would expect, even if you consider potential admissions related to procedures or post-procedural complications.
At a meeting of diabetes-related NGOs and Diabetes Action Canada yesterday, it was reported that a Canadian with Type 1 diabetes had died in diabetic ketoacidosis after failing to seek emergency care. Drs. Verma and Razak are correct that persons with chronic conditions who suffer acute illness are particularly vulnerable at this time and must receive necessary urgent care without fear of overloading the system or contracting COVID-19. Messaging within the healthcare community should include assurance that hospitals including their emergency departments are looking after those without COVID-19 symptoms.
Thank you for sharing. This message is so important and is somewhat counterintuitive to the ‘social distancing’ messages that are predominating but it’s important they not be seen as conflicting. They are not.
Thank you for sharing. I work with both Drs Amol and Razak on internal medicine at UHT and both are superb doctors. I will say that the messaging of fear around Corona virus has been expressed profoundly by our leaders. Dont get me wrong, it’s a very deadly virus however, I beleive there are lots of people home that are getting more sicker and sicker and not getting early or the appropriate treatment. As mentioned in the article, for example infections (diateties and pressure ulcers), cellulitis, UTI’s etc because of the fear of getting the virus. I beleive that after Corona virus, emergency department will be filled with people that are more sicker, therefore more interventions and longer stay and recovery.
Thanks Phyllis – you’re so right and it is our pleasure that we get to work with colleagues like you!
I totally agree with you Catherine that messaging by our leaders should also include assurance that they are important and healthcare professionals are available to look after them before it gets worse. I bet there are people home now with abnormal electrolytes and other lab values.