How ready is Quebec to treat critically ill COVID-19 patients?

With Quebec's announcement Wednesday of its first death related to COVID-19 and as the number of confirmed cases continues to grow many people are wondering about the province's critical care capacity.

"The health care system is ready," said Premier Franois Legault.

Right now, six people are in hospital with the virus. Four of those require intensive care.

According to the province, Quebec has 1,000 intensive-care beds and 3,000 ventilators.

"I guess the bigger question is, is that enough? said David Buckeridge, an epidemiologist in McGill University's School of Population and Global Health.

"The short answer is, we don't know."

Buckeridge said much depends on how quickly people requiring acute care start to arrive at the hospital.

Data from both China and Italy shows that about five per cent of patients who become ill there required mechanical ventilation in intensive care to help them breathe.

"The challenge is they are often on those ventilators for a long time," said Buckeridge.

Usually, patients in intensive care are only on ventilators for a few days. With COVID-19, studies show patients needed to be on ventilators for up to 15 days, he said.

"Not only do you have a lot of people who may need ventilators, you can't just think about ventilators and people, you have to think about ventilator time and people time," Buckeridge.

This is where it comes down to staffing.

A limited number of trained specialists are able to operate this equipment. Depending on the severity of the patient's condition, one or two nurses are also needed for each patient on ventilation.

Limiting transmission key

Slowing the spread of people infected with COVID-19 will help hospitals cope and avoid the kind of resource crunch experienced by Italy, which has had to triage its rising number of critical cases.

"If we stop the transmission, or limit it, we will be in a good position to not have too much of an impact on the health care system," said Universit de Montral's Dr. Philippe Jouvet, a critical care physician and director of the Quebec Respiratory Health Research Network.

The effort to flatten the curve or slow down the rate of infection, so that fewer people need to seek treatment, thus overburdening the health care system is behind the measures the province has introduced over the past week.

Those measures include closing daycares, schools and universities, restricting the size of gatherings, and encouraging people to self-isolate and limit any unnecessary outings.

"It is easy to be afraid of what we don't know, specifically when we don't know what will happen," said Jouvet.

He is encouraged by the measures the province has taken to limit the transmission of the virus.

"If we succeed to limit the transmission, we probably won't have these problems we think we might have," he said.

Space can be freed up

Right now, Quebec has three times as many ventilators as intensive care beds, but more beds can be freed up by postponing some elective or non-urgent surgeries, which many hospitals have already been directed to do, said Jouvet.

Of the 1,000 ICU beds, the province said Wednesday it has set aside 20 per cent, or 200 of them, to treat patients with acute cases of COVID-19.

The remaining beds are reserved for patients with other diseases or those who may have suffered trauma, heart attacks or strokes, he said.

Quebec said Wednesday it has freed up an additional 2,300 beds and is poised to free more, for a total of 6,000 beds, if necessary.

As for the ventilators, they are typically located in intensive care units, but ventilators in operating rooms, emergency rooms and neonatal units could be moved to a different area of the hospital to treat COVID-19 patients, said Jouvet.

In terms of staffing, Jouvet said it can take several months to train nurses and respiratory therapists to work in intensive care. Typically, the nurse/patient ratio on an intensive care unit is 1:1 or 2:1.

Keeping in mind how long it takes to train an ICU nurse, Jouvet said, it makes more sense to delegate standard nursing care to nurses that will focus only on that and keep the expertise of ICU nurses for specific tasks, like renal and respiratory support.

In this scenario, Jouvet said, hospitals couldincrease the patient/ICU nurse ratio to 3:1.

Quarantine is a possibility

Benoit Barbeau, a virologist in the department of biological sciences at UQAM, said the province's current restrictions on people's activities will help spread out severe cases and allow the medical system to respond to the demand without becoming overwhelmed.

But he warns that there is the potential for the federal government to step in with even more aggressive measures.

In Italy, the entire country of 60 million was placed under quarantine last week to help the government get control of the outbreak, which has killed more than 2,500 people.

Depending on how the spread of the virus evolves here, Barbeau said, quarantine is a possibility.

"If the increase is sudden, and the virus seems to be showing no sign of slowing down, then that extreme measure will need to be taken," he said.