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A fatal flaw
A shortage of beds and ventilators is about to strike Canada as the H1N1 pandemic intensifies — we should have been ready

By Jaro Kotalik, Citizen SpecialJuly 16, 2009
http://www.ottawacitizen.com/health/fatal+flaw/1795251/story.html

While we continue to observe a daily increase in the number of swine flu cases across the country, we take comfort in the fact that our country has been preparing for a pandemic for years. It is true that we have an elaborate, expertly produced national pandemic plan, which in turn gave rise to provincial, territorial, regional and local plans. Canada has even been called a world leader in pandemic preparedness by the World Health Organization.

But there is an inherent weakness in our pandemic planning, a weakness which greatly undermines all the effort put into this enterprise, a weakness which may in the end be fatal.

In 2004, a Canadian pandemic plan was released that did not say a word about the amount of material and human resources that would be required for each of the hundreds of proposed pandemic measures nor about who would provide these resources. When you stop to think about it, it’s almost unbelievable: the largest public health program ever proposed in our national history was launched without any budget or allocation of funds.

Those who disagree will cite that in 2006 the federal budget earmarked $1 billion over five years for this cause. Three years into this budget, we know that the federal government purchased stocks of the antiviral drug Tamiflu and contracted for the production of a vaccine. However, these actions, while important and laudable, are far from meeting all the essential requirements. To date, none of the budgeted money seems to have made its way to the front lines and trenches where the real war against the pandemic will largely be fought, such as the hospitals I am associated with.

This economic blind eye approach has resulted in our lack of readiness to care for those sick with the flu. The sudden emergence of an enormous number of sick people is the hallmark of a pandemic. The national plan for a moderate pandemic estimates that of 4.9 million people who will become ill, 109,000 people, about two per cent, will need to be admitted to a hospital. The plan does not suggest how these additional patients could be accommodated given the fact that in Canada we have just over 100,000 beds and that they are 90 per cent full all the time.

Furthermore, it now appears that the demand for hospital beds may be much higher than what our planning experts had predicted. On June 12, the Public Health Agency of Canada reported that not two per cent, but five per cent of confirmed cases of pandemic flu had to be hospitalized. And not any kind of hospital bed will suffice.

Because the most frequent serious complication of any flu is pneumonia, and in some cases the inability to breathe, these flu patients will require mechanical ventilation in an intensive care unit in order to survive. This fact was foreseeable, and it is well known that these beds (with ventilators) are constantly in short supply, yet no provisions were made to at least partially remedy the shortage.

To their credit, the Ontario pandemic planners went as far as to estimate the required number of beds with ventilators. As the situation stands, it appears that at the peak of demand, pandemic flu patients may need almost twice as many beds with ventilators as are currently being used across the province for all patients. To date, no relief of the shortage has been proposed.

It appears that when hospitals exceed their “surge capacity,” that is, have more patients than they can treat, the province will declare “mass emergency care.” In this case, physicians will be expected to decide who will get a ventilator and who will only receive comfort measures.

A recent situation in Winnipeg highlighted how ill-prepared our hospitals are. In mid-June, at the very beginning of the H1N1 flu outbreak, when the province had only 119 confirmed cases, 31 of them needed ventilators. Winnipeg hospitals were forced to cancel non-urgent surgery, discharge other patients earlier and order 15 additional ventilators.

The fact is that the health care delivery system in Canada is stretched to its limits. As you read this article, wherever you are, at this very moment there is probably a “discharge planner” going around your local hospital trying to determine which patients could be sent home, not necessarily because it would be best for the person, but because unless someone is discharged, it is not possible to get a bed for any of the patients waiting for admission in the overcrowded emergency room. Under these circumstances, how can hospitals, pressed to avoid deficits, and having no dedicated funding for a pandemic even now when a pandemic is here, engage in serious preparation for increased demand?

So all of us are closing our eyes to the unpleasant, unmanageable reality and hoping that, somehow, we will get through this. This is of course not the stuff of press releases, and so the public is largely kept in the dark.

As someone who has promoted for years the idea that the hospital is a moral community, which has an ethical responsibility to our patients, our staff and also the people in the region we serve, I find it impossible to stay silent. The issue is just too big to be confined to the hospital. There is a need for evidence-based political decisions.

I have recommended to our hospital that we should determine what resources we need to provide care at the height of the pandemic to all patients who can be reasonably expected to rely on us. We should then notify our funding agency and include an estimate of the potential human cost of not having the necessary resources. If funding is not received, our hospital has an obligation to inform the public about the lack of resources, which may result in our inability to provide adequate care.

If we fail to do this we will have an ethical responsibility for the harm or deaths which could have been prevented. I appreciate that our funding authority, considering all the needs, may not be able to provide the resources, and may be able to justify that. What I suggest is not a pressure tactic, but a process which is necessary if we wish to respect the values of accountability, inclusiveness and transparency — the values of the Ontario pandemic planning ethical framework.

If given a choice, would Canadians want our health care system to go through the pandemic, the largest threat to the health and life of Canadians in many decades, with no additional resources, scaling down care to what the regular budget provides? Or would they be prepared to pay for the best possible care, knowing that the deaths which will occur were humanly unavoidable?