Ontario, Canada | 589,041 cases, 9,757 deaths (as at 5 October 2021)

The similarities in systems, geography and federation means that Ontario’s experience has a lot of relevance for Victoria

Currently in the midst of its fourth wave of cases and patients, Ontario’s health system has had to consistently adapt to ensure it is prepared and ready. While, like many other jurisdictions, there was an initial success in preparing the health system for the initial outbreak of cases, the health system has since needed further support to ensure its readiness as there were increased cases.

 

First wave preparedness

To prepare for the first wave of cases, Ontario undertook a range of initiatives to increase capacity in the health system, including: relocating 1,000 people from hospitals; cancelling ‘elective procedures’ and repurposing the resulting 6,849 beds; and opening 2,500 new hospital beds. These changes worked, although this was supported by an initial drop in demand for non-COVID care. Research identified that similar approaches, including expanding hospital capacity, more efficient use of existing hospital capacity, and strengthening the provision of ambulatory care, would be essential components of managing future waves of COVID-19 in Ontario.

However, the success of this initial response created subsequent demand issues. Later efforts to replicate this preparedness approach were less effective. Despite the initial success, hospital occupancy for non-COVID care quickly returned to normal and began to exceed capacity in some areas as surges of COVID-19 hospitalisations occurred in winter 2020/21. This was exacerbated by the impact of delayed care stemming from the initial response, with a backlog of nearly 150,000 surgeries; increasing surgical volumes to recover from this backlog placed further strain on hospital capacity. The impact of the pandemic long-term care and home care, similar to Victoria’s experience with aged care outbreaks, also made it more difficult to discharge patients from acute care.

 

Additional capacity

Ultimately, since the success of the first wave, Ontario’s health system faced two escalating waves of cases, which it struggled to handle, with increasing use and demand on the province’s critical care and capacity. Following modelling that predicted that Ontario would have roughly 1,000 patients requiring critical care by the end of April 2021, there was a focus on increasing ICU capacity – ultimately the state peaked at approximately 920 people in critical care in early May 2021.

A key feature of the attempts to increase capacity during these difficult periods has been a focus on increased collaboration between health services. A distinctive example of this has been the use of patient transfers to create capacity in the health system to handle COVID demand. By April 2021, over 2,500 patients were transferred from Toronto to receive life-saving care in other cities, while Ornge, Ontario’s air ambulance and medical transport service, and local paramedics have transported over 570 in April alone to create ICU capacity. At one stage, an emergency order meant these transfers did not need to be consensual. The province has also created a new time-limited incident management system (IMS) for the Greater Toronto Area to monitor resources and redirect them where pressures are being felt the most, which it never had before.

Ontario has also faced issues around workforce demand, which has been exacerbated by the need to increase critical care capacity and staff the additional facilities. Healthcare workers were infected at an elevated rate compared to the general public, which has contributed to higher rates of burnout. The situation became so serious in April 2021 that an emergency order was released to authorise staff from Home and Community Care Support Services organisations to be redeployed to hospitals, with those organisations authorised to backfill the redeployed staff. But even this was not enough; the province was forced to ask Canada’s other provinces for 620 health professionals, acknowledging that the province’s ICUs are becoming ‘increasingly strained’ leading to an estimated gap in staffing of around 4,145 nurses over the next four months.

 

Failure to prepare

While initially successful, Ontario’s healthcare system ability to be prepared and ready for the pandemic and its impacts were arguably curtailed by longer-term issues.

Ontario did not have a strong base from which to build its health system’s readiness. According to the Ontario Health Coalition, Ontario has the fewest hospital beds and lowest hospital nursing hours per patient of any province in Canada. Capacity in Ontario hospitals has been tight for many years for several reasons, with up to 17 per cent of beds occupied by people waiting for alternate levels of care, which has been exacerbated by a lack of capacity elsewhere in the health system, notably for home care, other community care and long-term care. Up until the pandemic, many hospitals regularly experienced occupancy rates well over 100 per cent, with long-term issues around increased ED wait times and overcrowding. These issues have impacted the health system’s ability to handle the pandemic.

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