How doctors and nurses view the shift from adolescents to adult ICUs in Ontario

How doctors and nurses view the shift from adolescents to adult ICUs in Ontario

Doctors and nurses warn that the “unprecedented” step of moving critically ill teenagers to regular ICUs amid a surge of children suffering from respiratory illnesses in Ontario children’s hospitals exposes the precarious conditions faced by the health system.

The measure of Wednesday of Critical Care of the province COVID-19 Command Center to ensure pediatric hospitals can care for the youngest and sickest children could further overwhelm regular ICUs and force hospitals to cancel adult surgeries to free up specialized ICU staff.

Already, Pediatric hospitals cancel non-urgent surgeries amid historically long wait times and overcrowding, with inpatient units well above projected occupancy levels due to an increase in children with respiratory infections.

The urgent request for adolescents aged 14 and over to be treated in the adult ICU will be reviewed every two weeks, according to a memo obtained by the Star. He asserts that ICU capacity-building is necessary “for the current and imminent increase in demand for pediatric intensive care” and says such demand will likely last for the next two to three months.

“If this is a two-week directive and very few patients end up moving, this is just effective planning to avoid a disaster,” said Dr. Michael Warner, medical director of critical care at Michael Garron Hospital in Toronto, who called the measure as “unprecedented”. .”

But if multiple children need to be admitted to adult ICUs, he noted, it could affect whether hospitals can proceed with surgeries “and affect our ability to care for patients.”

“It just points to the fact that Ontario’s healthcare system on its best days is running on a knife edge, around 100 percent capacity. And when there is some sort of disruption to the system, the need for intensive care increases. We do our best to accommodate, but something has to give.”

New data from a provincial database that tracks emergency department visits and hospital admissions related to respiratory illnesses in real time paints a worrying picture of what hospitals are facing.

Last week, an average of about 1,241 children ages four and younger with respiratory problems were brought to emergency departments across Ontario every day. That’s more than double the historical seven-day moving average for this time of year, according to the database, known as aces (Improved critical care surveillance).

An average of 968 children ages 5 to 17 visited Ontario emergency departments every day over the past week, more than triple the historical weekly trend at this time.

Admissions trends, although smaller in number, are no less alarming. The average daily admissions for children four and under, at 28.6, is almost triple the historical seven-day rolling average of 9.7 for mid-autumn.

In the five- to 17-year-old age group, average daily admissions are about 10, more than double the historical seven-day trend of about four for the same period.

“I’ve been talking about this since August, saying we’re going to have a terrible season,” said Dr. Anna Banerji, a pediatrician and infectious disease specialist at the Termerty School of Medicine and the Dalla Lana School of Public Health at the University of Toronto. “Children go to school without a mask, COVID is not over, we know that it is transmitted through the air, we do not have good ventilation.”

Banerji said that while she was expecting a poor season for RSV, she is surprised at how early it has come. RSV, or respiratory syncytial virus, is common in children under two years of age and usually presents with symptoms of fever, sore throat, dry cough, nasal congestion, and headache. For some children it can cause breathing problems, leading to hospitalization.

“It’s only going to get worse as we get closer to the peak of not only RSV,” he said, “but we haven’t started much of the flu season either. It is starting and children are being admitted to the hospital with influenza, but the peak of influenza has not yet arrived.”

Dr. Chris Simpson, executive vice president of medicine for Ontario Health, told the Star Thursday that while the hospital system often implements surge plans during a typical winter viral season, this is the first time health leaders have they’ve had to contemplate “how it’s going to be necessary to leverage the adult system to help with the pediatric system.”

He said this year’s pediatric increase is of a “magnitude we haven’t seen in a long time” due to the “1-2-3 hit” of RSV, influenza and, to a lesser degree, COVID.

Health officials predict that both RSV and influenza will peak in December, meaning there will be a two-month period of sustained pressures on critical care capacity, Simpson said.

Some hospitals may have to postpone scheduled surgeries to ensure there are enough ICU beds and enough specialized staff to care for critically ill patients. But Simpson said urgent and emergency surgeries will remain, including those for cancer procedures and for patients with serious injuries, such as those from car accidents.

“It remains paramount that ICU capacity is protected for those surgeries,” he said, adding that pediatric ICU beds for the sickest children who need to be intubated will also be protected.

Simpson said he doesn’t anticipate the province imposing a directive to cancel scheduled surgeries systemwide, as it has in three other locations during the pandemic. Rather, he said, hospitals and regions will scale surgeries up and down like “a dimmer switch” based on demands and staffing constraints.

Ontario has about 100 pediatric ICU beds in its five children’s hospitals, though Simpson said the system can grow to as many as 130 beds. He said postponing surgeries, pulling staff with critical care skills from other areas of hospitals and more quickly moving pediatric ICU patients who have completed their stay to community hospitals are strategies to help build capacity during the viral surge.

In April 2021, during the third pandemic wave, Critically ill adults with COVID were transported out of overwhelmed hospitals in the Greater Toronto Areasome as far away as London and Kingston.

That same month, Toronto’s Hospital for Sick Children began accepting younger adult COVID patients into its ICUs to help ease pressure from neighboring hospitals. a move health leaders at the time called a “watershed moment.”” In the three-month span of April and June 2021, SickKids treated about three dozen adults in critical condition with COVIDaged between 20 and 50 years.

Warner said older teens are similar to adults in their physiology and will be safe to be cared for in adult ICUs. However, he said, the training required to care for young children who need intensive care is highly specialized.

“An adult ICU nurse can care for a 16-year-old patient with an asthma exacerbation the same way she cares for an 18-year-old patient; it’s really not much different,” she said. “But that adult ICU nurse or doctor couldn’t take care of the five-year-old with RSV. We don’t have those skills.”

In a statement Thursday, the Ontario Nurses Association, which represents some 68,000 registered nurses, nurse practitioners, registered practical nurses and allied health professionals, said it was “appalled” by the “continued erosion” of the health care system. of Ontario and the government’s “failure to take meaningful action to address capacity issues and nursing shortages.”

“Children are not just little adults. Pediatric patients have a significantly different set of care needs that vary considerably from those of adults and require registered nurses with specialized skills to provide the most optimal and safe care,” the ONA statement said, adding that Ontario Health should ensure that “pediatric patients can receive the best possible care in these circumstances by setting very clear and specific criteria for who will be transferred to adult ICUs.”

Dr. Mona Jabbour, interim chief of the department of pediatrics at CHEOa children’s hospital and research center in Ottawa, characterized the pressures facing his hospital as “the perfect storm.”

On November 2, CHEO received 246 visits to its emergency department, which was built to handle 150 visits per day. The hospital as a whole that day had 113 percent occupancy, while its pediatric ICU reached 186 percent occupancy as of 1 p.m. Thursday.

“We’re having RSV, influenza and COVID all at the same time,” he said. “So, we’re seeing infants getting seriously ill, toddlers, younger children and older children getting seriously ill as well. It’s all happening at the same time.”

In a statement Thursday night, SickKids said that while it has capacity in its ICU at this time, the ability to move older children to adult ICUs is “an important step in helping to ensure that SickKids and other hospitals for children can maintain ICU capacity for those requiring specialized care. pediatric critical care.

The hospital anticipates that the request for adult hospitals to care for older teens “will affect a small number” of its patients over the age of 14 who “can be effectively and safely treated in adult hospitals,” spokeswoman Sarah Warr said. .

Like other hospitals, the increase in patient volume, combined with staff shortages, is affecting its “ability to perform surgeries that require ICU-level postoperative care,” he said. This has decreased the number of surgeries at SickKids during the pandemic, she said.

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