In a global pandemic, one might imagine chaos in Island hospitals. But outside intensive care units, where doctors fight to save patients from a virus not fully understood, there is an unusual calm.
The hustle and bustle in the public areas of hospital hallways have been hushed, in the same way city streets have fallen silent. Visitors are prohibited. Administrative staff who can work from home, do.
In some hospitals, volunteer-run coffee shops and gift shops are closed.
At all hospitals, an “ambassador” meets people at the main entrance to ensure they’re there for a very good reason, said Ben Williams, Island Health’s interim vice-president of medicine, quality and academic affairs.
The ambassador will stop you if you’re trying to visit a patient. “It’s an awful thing to do for patients who have to be alone, but it’s the right thing to do for minimizing community spread of the disease,” said Williams, a family doctor specializing in rural emergency medicine, urgent care and end-of-life care.
On Vancouver Island, the two designated COVID-19 hospitals — which take Island patients requiring intensive treatment — are Royal Jubilee Hospital in Victoria, and Nanaimo Regional General Hospital.
So far, the numbers have been low. Unlike on the Lower Mainland, where COVID-19 outbreaks in long-term care and assisted-living facilities have claimed many lives, there are no such outbreaks here. As of Friday, the Island had seen 94 confirmed cases, with 33 people spending time in hospital. Seven people were still in hospital as of Friday, including two in intensive care. Of B.C.’s 78 deaths, only three have been on the Island.
The relative calm in Island hospitals and emergency rooms is the result of other factors, too. One of the main ones is the fact that the occupancy rate dropped after non-urgent elective procedures and surgeries were postponed to make room for a possible influx of COVID-19 patients. By early this past week, almost 14,000 surgeries had been cancelled across the province, including more than 2,700 on Vancouver Island.
On Wednesday, there were 4,632 empty hospital beds in B.C. — an occupancy rate of 59 per cent. At Royal Jubilee and Nanaimo General, the occupancy rate is typically between about 70 and 80 per cent.
An unexpected positive aspect of having beds cleared is that staff now have more time for bedside care for the patients who remain in hospital, Williams said.
While all the clinical staff are working, some are doing things differently. Someone who normally work in an operating room might be redeployed to serve as an ambassador. “We’ve reshuffled the resources quite a bit,” he said.
Emergency-room visits are also down across B.C. — on Tuesday, there were 3,595, compared with 6,559 on March 9, before the outbreak ramped up. Ambulance calls are also dramatically down.
One concern is that people are avoiding hospitals despite needing medical care because of fears of catching the coronavirus, which prompted provincial health officer Dr. Bonnie Henry to assure British Columbians that it’s safe to go to the hospital.
“If you have diagnostic tests that have been booked, that you have been waiting for, it is safe to go for those,” Henry said. “It is safe to call 911 if you need that urgent medical care. Do not hesitate to call for help if you need it.”
Island Health last week issued an advisory thanking people for not making unnecessary trips but reassuring them that strict infection-prevention and control protocols are in place, and anyone experiencing symptoms such as chest pain, shortness of breath or serious abdominal pain should reach out for help. Call 811 for advice, 911 for emergencies and go to the ER when necessary, said the health authority.
“Our emergency rooms are open for business and they are an incredibly safe place to come,” Williams said. “I’m worried that some patients who should be coming into the emergency room are not coming in. I’m worried that there’s people out there who have chest pain, or who have been experiencing shortness of breath, or who have terrible abdominal pain, or think they may have broken their ankle, who are sitting at home worried about how safe it is to come in or because they don’t want to overburden the system.”
Health Minister Adrian Dix has noted in recent daily media briefings that surgeons are still treating patients: More than 9,500 scheduled urgent and unscheduled emergency surgeries were completed from March 16 to April 12, he said. That includes about 2,040 on the Island.
Surgeons are reviewing their postponed lists “every day,” said Williams, to balance efforts to stop the spread of the virus with the need to care for other patients. “We respect the opinion of our surgeons for what surgeries need to be done and which can be postponed,” he said. Those deemed necessary are going ahead.
Under the direction of the former president of the Fraser Health Authority, Michael Marchbank, a plan is being developed to resume some elective surgeries in May, Dix said Friday. “That will be a very challenging plan to put together, one that will require working with surgeons and many others in the system, as we plan to implement it,” he said. Still, the system will continue to reserve as many beds as possible for a potential surge in COVID-19 cases.
So far, B.C. is not having the same experience as places like Hubei, China, and northern Italy, but Island Health is still making preparations for the worst-case scenario.
Royal Jubilee and Nanaimo General are Vancouver Island’s two designated COVID-19 hospitals because they have the highest level of intensive-care capability, including around-the-clock respiratory therapy and renal dialysis staffed by people with special training working with critically ill patients.
Royal Jubilee Hospital is also the referral site on Vancouver Island for critical and complex-care patients — the sickest of the sick. It has three critical-care units: the intensive care unit, with 11 beds for patients typically needing multiple organ support, and two others, with eight beds each, for coronary care.
For now, it is prepared to care for severe COVID-19 cases in the main ICU. The health authority is currently planning to build an eight-bed high-acuity unit that could serve as a backup unit in a possible second wave of the pandemic in the fall.
Nanaimo General, meanwhile, is building a new 12-bed intensive care unit with a high-acuity unit that could also serve as a backup ICU, although it won’t be ready to help in this pandemic, said Williams.
The ICUs care for patients who cannot breathe on their own without life-support measures such as ventilators, those who are unable to maintain their blood pressure without medications, or those who are so sick, their kidneys can’t function and need dialysis.
As COVID-19 has only been around for four months, infectious-disease specialists are still struggling to determine how the virus works and how to treat it. In the most severe cases, ICU doctors are reporting adult respiratory distress syndrome — inflamed, stiff or “hard lungs” — heart problems, low blood pressure that causes patients to be breathless and seem disoriented, and kidney failure requiring dialysis.
“As more people are being infected, we do see that there’s many different manifestations of this disease,” Henry said during a daily briefing. Some have neurological issues, affecting the nerves or the brain, even after recovery.
“I know that the critical-care doctors are monitoring this carefully.”
In Island Health, 11 critical-care physicians are regularly on schedule on the south Island, and there are another two available. In Nanaimo, seven critical-care physicians are on schedule, with an additional doctor available, for a total of 21 on the Island.
The Island also currently has 178 ventilators: 86 designed for adult critical care, 70 “everyday” ventilators used in hospital operating rooms during surgeries and 22 transport ventilators to help move patients from place to place, via ambulance, for example.
Based on modelling, the worst-case Northern Italy-style scenario for Island Health suggests that on the peak day of the epidemic, there could be about 60 critical-care COVID-19 patients and an additional 25 non-COVID-19 patients in the ICU, Williams said.
If 60 to 80 per cent of patients who end up in intensive care usually require mechanical ventilation, 67 patients would require ventilation in a worst-case scenario, “so we are probably really well-positioned,” he said.
“We could manage that whole group on the critical-care ventilators we have, but we could double that capacity to 178 if we really had to, using the other machines.”
On any given day, Royal Jubilee has about 21 critical-care ventilators and Nanaimo General would have 18, “and we can move them around,” said Williams. There are 681 adult critical-care ventilators in B.C., according to Dix.
Together, Royal Jubilee and Nanaimo General can accommodate about 40 critical-care patients. (On Friday, there were two COVID-19 patients in critical care within Island Health.)
In a worst-case scenario, if Royal Jubilee and Nanaimo General were overwhelmed by critical-care patients in this current wave of the pandemic or a second wave in the fall, Victoria General Hospital, the Island’s trauma centre, would take the overflow, then North Island Comox Valley hospital.
After that, hospitals in Campbell River and Duncan would be utilized. “We are very lucky and grateful that we don’t have that level of disease, but we’re still ready,” said Williams.
Worst-case scenario planning also includes The Summit, the recently completed long-term care home at 955 Hillside Ave. near Blanshard Street in Victoria. The 320-bed new facility was awaiting residents from Oak Bay Lodge and Mount Tolmie long- term care when that move was put on hold.
Now The Summit is being considered as a kind of field hospital, much like how the Vancouver Convention Centre is serving as an emergency operations treatment centre.
The idea is that people who do not have homes who test positive for COVID-19 could be accommodated safely in the single-bed rooms on the Summit’s first floor. Long-term care and assisted-living patients with the virus who opt not to have further life-saving interventions could be accommodated on the second floor, and those in acute-care hospital beds awaiting placement in other facilities could be moved onto the remaining floors.
“It’s complex, but that’s what we are getting it ready for,” said Williams. “All this preparation we’ve done, we don’t even know if we’ll need it.”
Every single hospital site on the Island is prepared and ready for COVID-19 patients, said Williams.
“Hopefully, people will keep physical distancing and keep us from needing it.”
On Friday, Henry said cases of COVID-19 in B.C. have plateaued and started to decline, and that the number of critical care cases has remained well below projections based on other hard-hit areas.
“We have had success in B.C. by being diligent and being thoughtful and working together and supporting each other to get through this, and we need to continue that,” she said. “This is not the end for us. It’s not even the beginning of the end. To quote Churchill, it is perhaps, maybe, the end of the beginning. But it is a thoughtful process that we need to continue for the coming weeks and months.”
