Finally, we have a chance to deal with the "elephant in the room": hospital capacity!

It has been about 2 months since the COVID-19 pandemic began, and over this time it has dominated the public discourse. For those who are involved in healthcare, from front-line care providers to system administrators, it has simply consumed every last ounce of attention, energy and resolve. Over a short period of time, we have witnessed possibly the largest revamping of our healthcare system in modern times.  This includes how we deliver care, where we deliver it, who provides it, and even how we utilize everyday “tools” like masks, ventilators etc.

Health systems have completely revamped their processes on a scale that is unprecedented in living memory. Whole hospital wards have been quickly re-purposed to care for increasing numbers of COVID-19 patients. Large number of staff, from front-line nurses to physicians to pharmacists, have been redeployed to areas that they typically have not had much contact with. Moreover, we have had to re-imagine how to best utilize everyday equipment, from re-using masks to splitting ventilators.

While this degree of mobilization of healthcare resources is certainly impressive, the pandemic has also brought to the forefront a number of issues that have plagued our healthcare systems for a long time. We have found ourselves asking many questions about how we can ever get back to normal, and how we can be better prepared for future pandemics (or even future surges of SARS-COV-2 itself).

One of the fundamental questions that we are grappling with is how are we going to ensure that our acute care hospitals have the necessary capacity to deal with future pandemics? 

For years, the “elephant in the room” in any discussion about hospital care has been the shortage of beds in Canadian hospitals. Those advocating for more hospital beds were pointing to data that showed Canada had one of the lowest numbers of acute care beds per capita among the OECD countries, and one of the highest bed occupancy rates as a result. They would point out that running hospitals at more than 100% capacity all the time compromised efficiency and quality, arguing that non-healthcare operations (eg. manufacturing plants or hotels) aim to run their operations at 85-90% capacity in order to maintain quality of products and services.

On the other hand, healthcare administrators and political operatives ( who would be the ones who have to ultimately fund any increases in hospital capacity) argued that we already had enough hospital beds, but that our bed base was not being used efficiently due to high numbers of patients waiting for long term care placement (ALC patients) or other forms of inefficiencies in our processes. The argument was that any additional investment in healthcare should go towards providing services in the community (such as home care) so that unnecessary hospitalizations can be avoided in the first place.

Here in British Columbia, we have been able to open up significant levels of hospital capacity in anticipation of the pandemic surge. In the hospitals where I work, whole wings of our buildings are now empty, ready to accommodate patients with COVID-19. However, this increased capacity has come at a significant cost: all “elective” surgeries have been cancelled, and the number of people coming into the emergency rooms has dropped significantly to dangerously low levels. 

“Elective” procedures do not mean that they are not necessary. If you are waiting to have an operation to remove your gallbladder that is full of stones, and have already been hospitalized a few times because the stones caused an infection, having your surgery postponed indefinitely means that you are walking around with a ticking time bomb in your abdomen! Similarly, there is increasing concern that fear of not coming into the ER may mean that many patients who have been suffering life threatening medical conditions (like heart attacks and strokes) are not receiving the care they need urgently, potentially resulting in more severe complications down the line. Once the pandemic is over, our systems may well experience even higher stress levels than before as they struggle to cope with the high numbers of really sick patients who have developed significant complications, either because they had to wait for their elective surgeries or because they did not seek urgent medical care when they should have.

The current pandemic has demonstrated that our healthcare systems are grossly under-prepared to deal with immediate large-scale challenges. While our efforts to redesign our systems and redeploy our resources have been impressive, they have come at a huge cost. The pandemic has shown that addressing system capacity is not an “either/or” proposition. The need for more acute care beds does not mean that we should not invest in community-based services, and vice versa. While the pandemic has also uncovered significant vulnerabilities in the long-term care system, and may change that sector forever, I am still seeing many patients who are being admitted because of inability to manage their care needs in their homes due to various forms of dementia, frailty and medical complexity. Even as many families may think twice about sending their elderly loved ones into nursing homes, I doubt that will be sufficient to decant our ALC patients sufficiently to free up much needed bed space (and even if it does, the response from health administrators has typically been to reduce funding and staffing such that what remains is still operating at 100% capacity). We now have an opportunity to make some bold decisions about increasing our funded acute care beds while we work to revamp our community care delivery systems (e.g. through better use of telemedicine tools). The question is whether we will revert back to our ideological paradigms once this is over, or conveniently sweep these issues under the rug (as we have for over three decades) because the decisions that need to be made can be costly politically. Only time will tell.