Why Ontario transferred thousands of Toronto COVID-19 patients to other city hospitals



Paramedics walk gurneys back to a multi-patient transport bus at Kingston General Hospital on April 30 after dropping off COVID-19 patients from the Toronto area.
THE CANADIAN PRESS/Lars Hagberg


by Stephen L Archer, Professor, Head of Department of Medicine, Queen’s University, Ontario


You can learn a lot from a crisis. During Ontario’s COVID-19 pandemic, over 2,500 patients have required transfer from Toronto to receive life-saving care in other cities.

The egress of COVID-19 patients from Toronto began in mid-November 2020, when the Ontario government activated the GTA Hospital Incident Management System. Transfers peaked in April during the third wave of COVID-19.

At Kingston Health Sciences Centre (KHSC) we have received over 100 Toronto area patients with COVID-19, many on ventilators. They came by helicopter, ambulance and even by bus, unaccompanied by family.

Ontario even put out a national call for health-care workers to help out, and Newfoundland answered.

Why would Ontario need to transfer masses of critically ill patients with a highly infectious disease across the province, even resorting to involuntary transfers? Why would a metropolis like Toronto call on comparatively tiny Newfoundland for health-care workers? Is this simply the unavoidable consequences of a huge third wave of COVID-19?

In fact the root causes began long before the pandemic and originated with a flawed understanding of the capacity (physical and human) of our health-care system.

Two fallacies

I lead the department of medicine at Queen’s University and co-lead the medicine program at KHSC. In these roles I am responsible for hiring doctors and ensuring our medicine beds run efficiently. I have often been confronted by two fallacies relevant to the genesis of our current crisis:

  • Fallacy 1 — Ontario has enough hospital beds because medical care is largely conducted on an outpatient basis.
  • Fallacy 2 — Canada has more than enough health-care workers and doctors.

Both fallacies have been widely embraced by provincial and federal governments. Let’s examine the validity of these beliefs with the goal of designing a more resilient health-care system.

Fallacy 1: Number of hospital beds

A group of health-care workers about to board a plane
Registered nurse Michelle Murphy (left to right), Dr. Arthur Rideout, Dr. Conleth O’Maonaigh, registered nurse Amber Hodder and Dr. Amanda Compton gather for a photo before the medical professionals left St. John’s, Nfld., on May 4, en route to Brampton Ont., to assist with caring for COVID-19 patients.
THE CANADIAN PRESS/Paul Daly

It is popular in Canada to believe that the future of medicine is mostly in outpatient care and that hospital beds are obsolete. In reality, as medicine becomes more high-tech, admissions are shorter but more beds are needed to support procedures that improve the quality and duration of life.

We are now putting heart valves, hips, lenses and more into older Canadians, and performing lifesaving diagnostic and therapeutic interventions on people who 20 years ago would have been considered ineligible because they were too premature, too obese or too high-risk.

Canada’s bed shortage is particularly critical in academic health sciences centres that uniquely deliver advanced forms of care. Pre-pandemic Ontario was running at 96 per cent occupancy.

Our bed capacity was designed for troughs in demand, like summer, not for peaks, as occur each fall when influenza strikes. Every fall, as rates of infections like influenza rise, our emergency departments and medicine wards become congested and admitted patients must be accommodated in hallways. These are the consequences of inadequate numbers of in-patient beds. The COVID-19 pandemic simply made our tenuous reserve capacity more apparent.

 


Ontario has built new bed capacity for COVID-19, but had minimal reserve capacity pre-pandemic.

Ontario Health did three things to deal with COVID-19:

The government views Ontario’s health-care system as “one resource.” That sounds good in principle, but moving patients on ventilators away from their families is a poor way to deliver care. In addition, most of Ontario’s COVID-19 capacity derives from deferring elective procedures, few of which are truly elective.

The simple truth is we were never configured to deal with surges in admissions. We mistakenly focused on the symptoms of bed deficiency, like “hallway medicine” and emergency room wait times and failed to address the root cause: inadequate numbers of beds (in hospitals and long-term care facilities).

Exterior shot of temporary buildings in a parking lot.
A mobile health unit is shown on the grounds of Sunnybrook Hospital during the COVID-19 pandemic in Toronto on April 30.
THE CANADIAN PRESS/Nathan Denette

Several caveats about this bed-centric article are relevant. First, outpatient care is important and when it fails, unnecessary hospitalizations occur.

Second, inadequate long-term care facilities and home care services in the community exacerbate the bed shortage by causing inappropriate hospitalization of people awaiting alternate levels of care.

Third, don’t let the term “hospital bed shortage” mislead you to envision a shortage of mattresses and pillows; a “bed” is a surrogate for the capital and human resources required to provide care in that bed 24/7, 365 days a year.

Fallacy 2: Number of health-care workers

Canada has 86,092 active physicians (excluding trainees), 25 per cent of whom are international medical graduates. When recruiting academic physicians, I often struggle to find a Canadian-trained doctor and rely on our pool of international medical graduates. These doctors are often first-rate, but the fact we rely on other countries to train our doctors is not widely recognized.

Our dependence on international medical graduates does not reflect Canadians not wanting to become doctors. Queen’s University School of Medicine has 5,000 applicants for 100 seats and more Canadians are training abroad as physicians than in Canada. The Organization for Economic Co-operation and Development (OECD) tracks medical graduates per 100,000 inhabitants in member countries. Canada is near the bottom.

Bar graph showing number of doctors trained per capita internationally.
Canada trains comparatively few doctors for its population.
(OECD data)

Our physician-to-population ratio is also low, ranking 29 out of 36 OECD nations. The reality is that doctors and other health-care workers are expensive. Canada’s universal health-care system has many advantages; however, a single-payer system means the provincial governments (the payers) see a whopping human resources bill every year and, in trying to control costs, are invested in keeping numbers of physicians (and hospital beds) in check.

COVID-19 has given us a master class in what is wrong with our health-care system. Admittedly, Canada’s post-pandemic to-do list is long and includes improving the care of seniors, providing affordable child care, fostering a domestic biotech industry, re-establishing a pandemic surveillance system and bolstering public health programs. We also need to legislate good employment practices, such as provision of paid sick days.

Additionally, we need to continue the funding for the new beds created to deal with the pandemic, using them flexibly to ensure we have surge capacity. We should also create an adequate supply of domestically trained health-care professionals.

It is clear what must be done. We must find the funds and will power to meet the post pandemic moment with action.


09/28/2022 Source of data Below: Civil Society Solidarity Partners against COVID-19

Population: 38,749,252 adjusted for estimated real COVID-19 deaths

CanadaCasesDeathsCuredActive
Reported:4,259,37045,180 1.06% CFR4,166,86947,321
Estimate:23,554,31658,734 *0.25% IFR23,042,786261,685

*Inferred IFR is an estimate only. The actual COVID-19 IFR may not be accurately calculated for the entire human race until long after the pandemic has ended.

Canada ProvincesDeathsCFR%CasesCuredActive
COVID-19 Totals:45,1801.064,259,3704,166,86947,321
* Quebec16,7171.401,193,9641,163,98213,265
Ontario14,3420.981,459,3531,428,79816,213
Alberta4,8720.80605,757594,1556,730
BC4,2531.11384,266375,7444,269
Manitoba2,1431.43149,622145,8171,662
Sask1,5071.05143,747140,6431,597
NB4760.6276,31674,992848
Nova Scotia5180.42123,549121,6581,373
NL2350.4651,44650,639572
* PEI570.1151,41050,782571
Yukon310.634,8854,80054
NWT220.1911,51111,361128
Nunavut70.203,5313,48539
Repatriates013130
Sub Totals45,1801.064,259,3704,166,86947,321

Recoveries are estimated using a Canadian-specific algorithm. Canadian COVID-19 Data is weekly by the country. Some data CSPAC obtains from Public Health Units is updated daily.

* Quebec and * Prince Edward Island data is current daily.

Below: Extensive Estimates using data from multiple sources.

Beta experimental estimates for Canada. Reported + unreported mild + asymptomatic COVID-19 infections.

The total actual number of infections in Canada including all the untested, unreported, asymptomatic infections is likely greater than 23,554,316 (60.79% of the population) including mild and asymptomatic cases. That would mean the estimated inferred average Infection Fatality Rate:
(IFR) is likely around 0.25%

Canadian COVID-19 deaths to 2022-09-26 are estimated to be 58,886 Using estimated IFR of 0.25% which is far below global average IFR.

58,886 (0.25% IFR) is the CSPaC estimated number of Canadian COVID-19 deaths (based on the inferred IFR) including those deaths unreported as COVID-19). The IHME estimates excess deaths in Canada to reach much higher than CSPaC estimates.

See The Lancet estimate of excess mortality from COVID-19 (Download PDF) in 191 countries/territories and 252 subnational units of select countries, from 1 January 2 0 2 0, to 31 December 2 0 2 1.

58734 Is the CSPaC estimated number of Canadian COVID-19 deaths based on a modified universal algorithm which factors more sophisticated public health infrastructure and also fewer available urgent care beds and facilities which is a problem in much of Canada in an emergency measures context.

The closeness of the two numbers derived from unique data and methods suggests their high probability. The blended data of three projections from three different biostatistician labs also confirms the estimates +/- .01%.

It is safe to say that Canadians have endured the grief of losing 58734 family members. Every number has a face. May their memory be forever a blessing to their families and friends.

Canada's advanced public health standards.

Canada and the USA both have a significantly lower than global average Infection Fatality Rate. (influenza has an IFR of .1% or 6 per 100k (2019)).

Ontario, Canada Reports


Ontario Regional Public Health Units (PHU) - Reported by Ontario Province.

These reports from the Ontario Provincial government differ significantly (much lower) from the data reported by individual Public Health Units (PHU). CSPaC includes links to each PHU to allow readers of this report to check the latest data from their public health unit.


Health UnitCasesDeathsCFRRecoveriesActive
Algoma District9,647650.7%9,417165
Brant County13,058980.8%12,819141
Chatham-Kent9,7521001.0%9,532120
Hamilton65,3946080.9%64,108678
Ottawa81,9858861.1%80,397702
Durham Region67,6015100.8%66,648443
Eastern Ontario17,9522431.4%17,473236
Grey Bruce9,925790.8%9,705141
Haldimand-Norfolk9,618921.0%9,43690
Haliburton Kawartha Pine Ridge10,8191261.2%10,550143
Halton Region53,4273510.7%52,710366
Hastings & Prince Edward Counties12,340840.7%11,849407
Huron Perth8,3261251.5%8,078123
Kingston Frontenac Lennox & Addington20,403790.4%19,968356
Lambton County12,9421511.2%12,636155
Leeds Grenville And Lanark District11,2831141.0%10,878291
Middlesex-London42,8044451.0%41,850509
Niagara Region45,7935731.3%44,829391
North Bay Parry Sound District7,509620.8%7,306141
Northwestern12,273360.3%12,067170
Oxford Elgin-St.Thomas15,7641831.2%15,245336
Peel Region196,4991,4270.7%193,9381,134
Peterborough County-City8,8061001.1%8,517189
Porcupine8,247770.9%8,09674
Renfrew County And District5,920631.1%5,733124
Simcoe Muskoka District51,0014861.0%50,016499
Sudbury And District18,1421680.9%17,651323
Thunder Bay District15,5151170.8%15,099299
Timiskaming2,345251.1%2,27446
Toronto350,7914,3961.3%344,3242,071
Waterloo Region50,9374730.9%50,118346
Wellington-Dufferin-Guelph24,5281750.7%24,127226
Windsor-Essex County48,1526691.4%46,901582
York Region121,9451,0930.9%120,078774
Last Updated: 2022-09-26 Time 05:20:18 GMT. Source: CSPaC

Below: CSPAC estimated 2022-09-26 05:20 GMT COVID-19 data for India.

EPICENTER-2: India (44,558,425)

Reported*Cases*Deaths*CFR*Recovered
India44,558,425528,4491.2%43,984,695
*Reported by India but understated.

Note: India's reported death sum and cured data are widely seen among epidemiologists and biostatisticians as unreliable. For example, 3,064,951 is CSPAC estimated sum of deaths while India reports 528,449, creating the largest discepency in the world. India might only report hospital tested cases. Sources among hundreds of nurses and other medical practitioners provide a picture that in summary concludes most cases never present in a hospital especially in northern provinces where health care is less available and utilization is low anyway because of poverty, hence most people die at home in India. This theory could explain discrepancies between reported data and algorithmic estimates.

LocaleCasesDeathsActive
India reported:44,558,425528,44945,281
India estimates:246,408,0903,064,951107,775

Data collected and reported by: Civil Society Solidarity Partners against COVID-19