Thank you, Mr. Chair and members of the committee.
The Canadian Association of Emergency Physicians is the national specialty society for emergency medicine. Our 2,500 members provide front-line emergency care to the millions of Canadians who make over 15 million emergency department visits each year.
In our belief, Canadians have a right to receive timely access to quality emergency care, but the decades-long neglect of our emergency health care system has made this largely an aspirational goal rather than a reality. Emergency departments are crowded because of our inability to transfer admitted patients to the wards and the ICUs in a timely fashion, leading to care routinely given in hallways, with increases in risk of contagion and in unnecessary morbidity or mortality.
The safe occupancy rate of a hospital is known to be 85% to allow for efficient operation and to provide surge capacity. However, Canadian hospitals routinely operate at over 100% capacity. In order to achieve needed surge capacity, our provinces have had to drastically cut back on scheduled surgeries and routine ambulatory care. However, we are now extremely grateful to be at about 75% occupancy across the country. That's a good thing.
The other major chronic challenge is insufficient human resources. We are chronically short of trained emergency physicians and have insufficient residency positions across the country to alleviate that shortage. Our collaborative working group on the future of emergency medicine identified in 2016 that Canada had a shortfall of around 500 emergency physicians, estimated to increase to about 1,100 by this year, and no changes have been made in the intervening years.
With respect to the COVID-19 pandemic that was declared by the World Health Organization in March, the novel coronavirus has lived up to the phrase “novel”. Though we are slowly coming to an understanding of its epidemiology and its transmission, we are already aware of its potential to rapidly evolve and cause serious respiratory illness and death. There is no cure for COVID-19, and management at this point is purely supportive.
It's important to keep a perspective. While it appears to be a mild illness for the majority of people infected, hospital admission rates of over 10% have been reported, with an ICU admission rate of approximately 3%. The overall case fatality rate for the population is estimated to be between 1% to 3%, but the total rises as the individual ages, with a case fatality rate of at least 13% to 14% in those over age 80.
For those who require a ventilator, the case fatality rate is extremely high, and the time on the ventilator is often long, measured in weeks. For survivors, the extent of persistent health problems beyond their time of ventilation is unknown.
The challenge facing us in Canada is that we have been provided with a very precious window of opportunity to learn from the lessons of our colleagues in Italy and New York and those other areas that were hit hard early, and to use that time wisely to maximally prepare for what may befall us should the curve not be flattened appropriately.
In our view, there are three main components of the overall challenge we may face as a nation, but all can be encapsulated by the word “capacity”. This falls, then, into three components: health human resources, technology and physical space.
With respect to health human resources, our first challenge will be to maintain adequate human resources in the emergency departments. Emergency physicians and nurses on the front lines are clearly at increased risk of exposure and thus of being unable to work because of quarantine and/or infection. Staffing, particularly in rural departments with a smaller pool of physicians to draw upon, is tenuous on a good day, and given our overall shortage of emergency physicians, this will undoubtedly be a major issue for them.
The only way to maintain such capacity in emergency departments is to provide sufficient quantities of personal protective equipment to staff. Our members are sharing with us disturbing reports, as you're aware, of insufficient quantity, rationing or uncertain availability. The pandemic has not yet peaked and the virus will be with us for some time, so we need to continue to build our supply and distribution chains coast to coast so that all front-line staff have the appropriate protective equipment to provide care safely.
With respect to technological resources, there are two major concerns: access to adequate and appropriate laboratory testing and screening, and access to ventilators.
By necessity, current testing has needed to focus on the highest-priority groups, including health care workers and patients in hospitals, long-term care facilities and other facilities, but we must radically increase capacity to allow us to expand testing to all who are symptomatic, as well as develop a well-designed surveillance strategy to complement this testing. Public Health will need to increase capacity to react to an increased testing volume to ensure we promptly contact and isolate trace positives. Only when these two steps are in place should we safely loosen current public restrictions on gathering and movement.
The second concern, as you are undoubtably aware, is the availability of life-saving equipment, most notably ventilators. We know, following the H1N1 pandemic in 2009, that the Canada-wide ventilator supply was about 5,000, with regional disparities such that in Alberta there were 10 ventilators per 100,000 people, while in Newfoundland it was as high as 24.
Worryingly, when the Ontario government developed a plan for an influenza pandemic in 2005 and used a standard modelling exercise and an attack rate of 35%, it was estimated that at the peak of an influenza pandemic, patients would require over 170% of available ICU beds and about 120% of the ventilators in Ontario. Sobering also was the estimate that up to 50% of health care providers could become infected. This model envisioned an almost apocalyptic, but now very realistic, scenario in which more than twice as many patients would require intensive care with less than half the usual staff available to provide it, underlining the aforementioned critical need for personal protective equipment, surge capacity and a stockpile of ventilators.
With respect to space, we've talked about ICU space and we've talked about emergency department crowding, but hospitals will also need to provide space for those patients requiring supportive and/or palliative care. No Canadian should ever be allowed to die in a hallway.
We also need adequate space to continue to care for other patients needing acute care. They cannot be forgotten.
I am now going to pass you over to Howard Ovens.