Original author: Amol Verma & Fahad Razak
Published: April 9, 2020
Our hospital ward is only half full. We have not consistently seen, in more than a decade of training and practice, so few patients in hospital as in the last two weeks. And we are not alone – this experience is being shared by our colleagues across the province. Hospital occupancy in Ontario is just 77 per cent, down from 97 per cent a year ago.
We do not expect this situation to last, as the number of patients with COVID-19 is increasing. But this phenomenon of under-capacity hospitals is important to reflect on.
In part, this represents an enormous success of hospitals in creating capacity for the anticipated surge of COVID-19 patients. But we are worried this also means that people who need hospital care are staying home.
Clinicians, administrators, and policymakers have been working furiously to move patients from acute care hospitals to their homes or other care facilities (like rehabilitation hospitals or nursing homes). Primary care and specialist physicians are redoubling their efforts to help people manage chronic and acute illnesses to avoid hospitalization. Our health system is acting with unprecedented urgency, creativity, and cooperation. Two of our colleagues who were waylaid abroad noted that, “health care in Canada changed more during the two weeks we were away than it did during the two decades since we were medical students.”
But the reduction in hospitalizations might not be all good. Although 20 to 30 per cent of hospital admissions might be avoidable, actually reducing hospitalizations has proven to be extremely challenging. Most efforts report no benefit or only modest success at reducing hospitalization. Even if we assume that all preventable hospitalizations are being avoided, this does not account for the entire reduction in hospital volume that we have seen.
Most likely, people who need hospital care are not coming in. Some people may avoid hospitals because they fear contracting COVID-19 or they want to save scarce hospital resources. Others may have unrecognized illnesses because of disruptions in their usual care. For example, nurses who attend to people with chronic wounds sometimes recognize early signs of infection and send them to the hospital for treatment. If such services are disrupted or people are hesitant to come to the emergency department with serious symptoms, illnesses will not be recognized until they are more severe and harder to treat.
Modern healthcare systems in high income countries, like Canada, have not seen the kind of healthcare shock that COVID-19 is creating. SARS killed 44 Canadians and infected fewer than 500. Emergency department visits in Ontario decreased sharply during the SARS outbreak, and remained depressed for 10 months after the outbreak ended. COVID-19 has already infected many more Canadians than SARS and its effects are likely to last far longer.
Studies from the 2014-15 Ebola Virus outbreak in West Africa offer important lessons. Routine medical care suffered greatly during the outbreak: vaccinations decreased by nearly 70 per cent and 35 per cent of women missed their first antenatal visit for pregnancy. It took more than one year after the outbreak for primary care to return to normal levels. The number of deaths related to conditions other than Ebola increased during and after the Ebola outbreak.
The lessons from the SARS and Ebola Virus outbreaks are clear. First, people who have concerning medical issues must not avoid healthcare. This is an important public health message that has not been communicated widely. People should not confuse “social distancing” and calls to “stay home” as messages to stay away from necessary healthcare.
Second, preparations for COVID-19 are an opportunity to improve the way we deliver healthcare. The current all-out effort to enhance health system capacity should also strengthen our ability to provide routine and acute care for illnesses not related to COVID-19.
Cancer and heart disease are by far the most common causes of death in Canada, accounting for nearly half of all deaths, whereas infectious respiratory illnesses, like influenza and pneumonia, account for less than five per cent. Even if COVID-19 is as challenging as expected, it is unlikely to come close to cancer and heart disease as a major cause of death in our country.
Canadian healthcare is among the best in the world, particularly because of our strong systems of primary and preventive care and acute care. Maternal and newborn care, cancer screening, diabetes care, and the many other services our system provides must continue to function effectively during the COVID-19 outbreak.
We are not being pessimistic when we see hospital wards as half empty. But we must ensure that our efforts to prepare for COVID-19 allow for the ongoing routine and acute care that has given us one of the best healthcare systems in the world.