How an ‘unprecedented response’ helped Ontario children’s hospitals survive viral surge

When Ontario’s pediatric intensive care units started to overflow, teenagers were sent to adult ICUs to create space for critically ill children.

When kids with respiratory infections continued to flood emergency departments, pediatric transport teams were forced to move more and more young patients in the search for hospital beds.

And when that still wasn’t enough, the Hospital for Sick Children cancelled surgeries — except for life-saving and the most urgent procedures — in a desperate attempt to bring more staff to its struggling ICUs.

It was a full-out push to free up enough hospital staff and beds during the months-long viral surge that has sent a record number of infants and children to hospital.

Hospital leaders say this “unprecedented response” saved lives. They say it also reveals the precariousness of the province’s pediatric hospital system, long undersized to meet the demands of a growing population.

“The unprecedented response … it prevented a sentinel death event for children,” SickKids president and CEO Dr. Ronald Cohn said during the Star’s visit to the hospital.

“It’s the single reason why this crisis hasn’t become a catastrophe.”

Ten weeks after the province told children’s hospitals to send teenagers 14 and older to adult ICUs, pressures inside the pediatric system are starting to ease. But conditions remain strained and hospital leaders warn the winter viral season is far from over, and that recovery from the surge will not be easy.

“We are still very, very busy,” says Dr. Steven Schwartz, chief of SickKids’ department of critical care medicine. “We still have plenty of concern. And there’s still plenty of room to fix things in the pediatric health-care system, and particularly in critical care.”

Between early November and the end of December, more than 100 teens received care in adult critical care units, Schwartz says. Before the viral surge, it was not routine for teenagers to be in adult ICUs.

“It was well over 100 by the end of December,” Schwartz says, noting Ontario has about 100 pediatric critical care beds but can add more during surges.

“Those (teenage patients) were spread out over time but that’s essentially the entire province’s worth of pediatric ICU beds,” Schwartz says.

The Star asked the Ministry of Health for figures showing the number of teens 14 and older who received care in adult ICUs since Nov. 1. The Star also asked whether general hospitals are still providing critical care for older teenagers.

Despite repeated requests, the ministry did not answer the questions.

Instead, a spokesperson for Health Minister Sylvia Jones sent a statement detailing how, in response to a “triple threat of respiratory viruses” this fall and winter, the province took a “team Ontario approach to ease pressures in our pediatric hospitals and across the entire health system.”

At SickKids, the number of infants and kids who need critical care for respiratory infections has fallen, though numbers are still at the high-water mark typical for a winter viral season.

The hospital’s ICUs, which for weeks operated at 120 per cent capacity — and some days higher — are now hovering at 100 per cent, about normal for this usually busy time of year.

And staff from other parts of the hospital, who had been redeployed to SickKids’ ICUs, are returning to their regular roles. SickKids announced Thursday that some scheduled surgeries will resume starting Jan. 16 and teams will begin to work through a backlog of more than 6,000 procedures.

Cohn says the hospital had no choice but to cancel scheduled surgeries in November to create more ICU capacity by adopting a team-based model of nursing. This model of care allows critical care nurses, assisted by redeployed colleagues with little ICU experience, to care for multiple patients at a time instead of a single child.

“This was necessary to ensure no child was left behind,” Cohn says.

But, he adds, team-based nursing came “at a big price” and could push experienced and senior nurses to leave the hospital.

“The stress on the staff and the burnout of the staff; they are really challenged by the team-based model.”

As she walks through the ICU — a maze of corridors and rooms on SickKids’ second floor — Jackie Hubbert sums up what it’s been like to work through the fall and winter’s viral surge.

“It’s exhausting,” she says. “We made plans for a regular cold and flu season. But did we think the surge in activity would be like this? No, we didn’t see this coming.”

As executive director of the hospital’s heart centre, critical care services and Acute Care Transport Services, or ACTS, Hubbert sees the many stressors — on staff, on families, on hospital operations. She says it takes an extraordinary amount of resources to care for the hospital’s sickest patients, such as those who need to go on a life-support machine, a consideration that sometimes gets lost in bed count and capacity discussions.

“It takes a village to save that patient,” she says. “Never mind the physician and the surgeon, you’re going to need at least five expert nurses … the impact on the team to care for someone so sick is significant.”

In her 23 years in critical care, Frances Barry has experienced periods when the ICU was brimming with patients. But she’s never seen such high numbers of patients, sustained over so many weeks.

“We’re all so stretched,” says Barry, a registered nurse and pediatric ICU charge nurse. “Everybody does their best shift to shift. But when you come in, and there aren’t any options for extra staff or beds, and you know that kids are going to keep coming in, it’s hard.”

On one of the busiest days in December, SickKids received 12 calls in 12 hours from doctors at community hospitals who had patients needing critical care.

“We plan and we strategize but even then some days can be incredibly challenging.”

Barry says some of the joy of the profession is stripped away when nurses don’t have the time to get to know their patients and to speak with families, or when they feel like they can’t, no matter how hard they work, keep up with the hectic pace.

“We all love our jobs, and we really like working in this dynamic environment. But when we can’t do our jobs, or can’t offer those bed spaces for kids who need them, that’s morally distressing.”

The week the Star visited SickKids — on a snowy day in December — a room typically used for cardiac patients had been converted for infants with respiratory infections who need ICU care. The hospital found ways to stretch its spaces, says Hubbert, adding it needed to open a satellite ICU in the neonatal intensive care unit during an especially busy period.

“We had to do that because we didn’t have enough beds,” she says, noting the hospital also prepared to open additional ICU beds in its operating room recovery areas.

Standing in an empty ICU room — a rarity during the viral surge — Hubbert explains what it means when she says the care teams, primarily nurses, are exhausted.

“I see people at the end of their shift, worn, worried, concerned, hoping they didn’t miss anything with their patients,” she says. “I see it in morale. People are finding it harder to garner what they need to get here for their next shift. People are more negative.

“This is an amazing team; they’ve been unbelievably resilient … But people’s reserves are low. They desperately want things to be different.”

Hubbert adds that while team-based nursing saved lives, it placed enormous strain on critical care nurses, who became responsible for multiple critically ill infants and children.

“The cognitive burden is immense to switch from one patient to the next patient to the next patient and to always feel like you have a sense of what’s happening in each room, with each patient.”

Schwartz agrees that team-based nursing and the exceptional measures taken by SickKids and other hospitals working together to move patients to open beds prevented the worst possible outcomes.

In November, as such measures started to roll out, there were children in community hospitals that needed critical care but could not come to SickKids or other children’s hospitals because they had run out of room, he says. And while care teams at those hospitals, sometimes under the guidance of SickKids physicians, ended up keeping children safe, they were still caring for patients at significant risk.

“We were pushing the absolute border of what could be done. And things did continue to get worse for a time after that, too,” Schwartz says. “So there’s no doubt these measures saved lives.”

He recalls the moral distress that he and the other SickKids physicians felt during the height of the viral surge.

“It was a constant worry that some kid who we could have saved was going to die somewhere else because we couldn’t take them. We’re at least not worrying about that anymore.”

And while the hospital’s critical care team is cautiously hopeful the worst of the viral season is behind them, Schwartz says they don’t want governments and health system leaders to look away from the pediatric crisis.

“They can’t say, well it’s back to normal and it’ll take care of itself. Because normal wasn’t great. Normal was, every year, all of us worrying about our capacity. There’s still a lot of rightsizing to be done in pediatric health care.”

Megan Ogilvie is a Toronto-based health reporter for the Star. Follow her on Twitter: @megan_ogilvie