ER doctors in Canada feel strain as patients with flu-like symptoms flood hospitals

CANADA - Hospitals are scrambling to prepare for more COVID-19 cases as Canada's count climbs past 100, and emergency departments are already feeling the strain.

Increased visits by coronavirus-fearing patients may soon overwhelm the system, warn doctors who would like to see public health officials find out-of-hospital solutions for COVID-19 testing.

"We're already seeing an impact on the pediatric emergency department," says Dr. Jocelyn Srigley, medical microbiologist and clinical assistant professor at the University of British Columbia.

The number of children registering in the emergency department with flu-like symptoms is far above what is expected for this time of year, says Srigley. According to data from the BC Centre for Disease Control, this has been the case for the past five weeks.

"I think it's being driven by media and fears about COVID," says Srigley.

On Thursday, COVID-19 was confirmed for a child who attended a Calgary daycare. Ontario is also reporting positive tests for a male and a female under the age of 18, both in the Greater Toronto Area. Published international data show that children tend to develop mild illness with the virus.

Hospitals that treat adults are having the same issues with high demand on their emergency departments.

In Ontario, when COVID-19 cases started to be seen in January, government statistics show that emergency rooms were already experiencing high volumes with patients waiting an average of 1.8 hours to first be seen by a doctor, the longest wait time for the past year. And those patients needing admission to hospital spent 18.3 hours in the emergency department.

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In Ottawa, Dr. Brandi Read says fears and confusion about the infection are having an impact on her department as well.

People who have travelled to affected areas or who need testing for other reasons are coming for tests based on messaging from public health officials, said Read, the emergency department lead for COVID-19 strategy at the Ottawa Hospital.

Although the public has been directed to call public health hotlines instead of going to the emergency department, the hotlines often send them to the hospital anyway.

This places a toll on the system as these patients need to be managed in a unique way. They are sent immediately to a special waiting area and also require a separate assessment area.

"We need to stop encouraging people to go to the hospital if they aren't sick because it puts a whole bunch of people at risk," Read says.

As chief of staff for the Scarborough Health Network and former chair of the 2003 Ontario SARS Scientific Advisory Committee, Dr. Dick Zoutman knows the challenges that lie ahead.

"We're up to our necks," in COVID-19 surge planning, says Zoutman.

Scarborough's three hospitals have tested about 355 people so far, with two patients testing positive. But many more have come to the emergency department with concerns about COVID-19 and have not needed testing.

"It has been a significant amount of extra activity which we expect is going to increase," said Zoutman. "It's a big job."

A recent Canadian Medical Association Journal article showed that of the 135 patients tested in eight Toronto hospitals for COVID-19 in a one-month period, 95 per cent presented to the emergency department with no need for emergency medical services. The authors called on public health officials to find ways to assess and test patients outside of hospitals.

Jerome Leis, one of the study authors, said there are many barriers to diagnosing and managing cases in the community and that the current approach that relies on hospitals will make it difficult to screen, diagnose and manage the projected volume of patients that are likely to be seen in the coming weeks.

He explains that early on in the spread of COVID-19, it made sense for patients to be referred to emergency departments, where there is a relatively high level of preparedness for assessing and managing serious infections.

But continuing to rely mainly on hospitals for this pandemic will cause additional problems, he says, including crowded emergency departments, difficulties for other patients to access care and issues with both patient and health-care worker safety.

"There is work to do on our community-based capacity for the individuals who are not sick enough to be assessed in hospitals and I think this will be crucial. This is urgently needed, because patient volumes are ramping up right now. And so there's a lot of work that needs to happen in a short period of time."

Zoutman agrees. He describes his network's emergency departments as being very tight and says, "We want to make sure that we are preserving the emergency department space for our cases that really need that level of attention, who are having more severe symptoms and not cases with mild symptoms that can be managed in an assessment centre outside the emergency department."

He says the increasing volume of people with symptoms of COVID-19 are coming at a time when emergency departments are already full with high patient numbers from influenza, other respiratory viruses and chronic lung diseases.

Many doctors are now saying that the answer lies in working with community partners to create assessment centres where people who are well but may need testing can go for assessment, testing and direction as to what to do next.

Health officials in several provinces have announced plans to conduct screening away from hospitals, including Ontario, Alberta and Quebec.

And Read says other options, such as having paramedics be part of the solution or using telehealth capabilities to assess patients remotely, are being considered.

Zoutman says hospitals have to deal with many issues that can't be turned away, such as women in labour, people with serious injuries or critical and life-threatening illnesses, and people needing dialysis or other care that is only available in hospitals. And most of these patients come through the emergency department. So, he says, "As much as we can do at the community level, the better."

Hospitals across the country are already planning for the ripple effect of high patient numbers beyond the emergency department, says Zoutman. With the potential for more patients needing admission to hospital and some who may need intensive care services, his network, like others, is looking at which work can be deferred.

He expects to see cancellations and re-booking of elective procedures.

"We also have to contend with the fact that while we will have an influx of more patients, we will also have staff who will get ill or will have to look after their own families," he says. "So we have to figure out how to manage that and how to re-direct staff to do different things that they might not usually do."

— Michelle Ward is a pediatrician, associate professor of pediatrics and journalist in Ottawa

This report by The Canadian Press was first published March 12, 2020.