Thunder Bay Regional Health Sciences Centre pandemic plan gives estimates on hospitalizations, deaths

The Thunder Bay Regional Health Sciences Centre (TBRHSC) has a guide for the COVID-19 pandemic. Originally written in 2005, the Pandemic Influenza Plan was updated in 2017 and could provide a framework for dealing with the COVID-19 pandemic.

The guide states "...the planning assumptions have been updated to set the best course of action in an uncertain environment by identifying, assessing, acting on and communicating risks."

The hospital's Pandemic Influenza Plan states "...this plan should be considered a 'living document' as it will be updated with new information as further details are considered."

The 92-page document is a far ranging guide touching on a number of areas dealing with the hospital's planning approach, assumptions and processes. According to the guide, these essential planning components include:

• Pandemic planning assumptions (i.e., course of a pandemic, extent and severity of illness, access to vaccines and antivirals).
• Internal and external pandemic and emergency response planning structures.
• Ethical framework (e.g., decision-making principles, core ethical values).
• Legislative authority.

The Pandemic Influenza Plan states the "...spread of influenza will be primarily through the community from person-to-person rather than in a healthcare setting ... a pandemic wave will sweep across Canada in 1-2 months affecting multiple locations simultaneously ... the influenza pandemic will occur in two or more waves. In any locality, the length of each wave of illness will be 6 to 8 weeks and the influenza pandemic will last 12 to 18 months and more than one wave may occur within a 12-month period."

The Pandemic Influenza Plan lays out a number of scenarios based on an estimated population of 146,048 for the Thunder Bay District based on the 2016 census. The plan provides three different attack rates of 15%, 25% and 35%. Using the worst-case scenario of 35%, over 51,117 will be ill enough to stay at home. Of those people 20,932 can manage the illness through self-care, 29,051 will require an outpatient visit to the hospital and 1,082 will be admitted to hospital. Within the 35% attack rate scenario there will be 173 fatal cases. Under an attack rate of 15%, the plan projects the number of deaths at 74 cases.

The Pandemic Influenza Plan also outlines its role in the event of a pandemic. The hospital does not act alone and as the plan notes "...the Canadian pandemic planning framework includes coordination and collaboration among government and jurisdictions at all levels: internationally, nationally, provincially, and locally." The plan goes on to further say "each level of government has different roles and responsibilities depending on their jurisdictional authority."

In Thunder Bay, one of the other key organizationduring a pandemic is the Thunder Bay District Health Unit, and within the plan there are numerous references to the health unit.

Under the Infection Control Practices section of the Pandemic Influenza Plan, there is an explanation of the risk assessment the hospital will use to ensure that all employees are protected, including the availability of personal protective equipment (PPE).The plan states that "...TBRHSC will have/has a stockpile of PPE such as gloves, gowns and N95 masks to last four weeks in a pandemic. The province will provide another four weeks supply once that supply is exhausted."

The pandemic plan states shortages are possible, and to be expected, depending on the pandemic.

If a shortage were to exist, the hospital is to prioritize PPE for staff as follows as listed in the Pandemic Influenza Plan:

• Care for patients with active pulmonary or laryngeal tuberculosis.
• Aerosol-generating procedures on patients with influenza.
• Resuscitation of patients with influenza (emergency intubation, CPR).
• Care of patients with influenza-related pneumonia and other complications of influenza, if the person is still thought to be contagious.

Dr. Stewart Kennedy, who heads up the TBRHSC's COVID-19 response team, told CBC News the facility has a supply of face shields, goggles, surgical masks and gloves that will last several months.

In an earlier statement, Kennedy also noted that the hospital is already preserving its N95 masks, which may be sterilized and reused.

The Pandemic Influenza Plan states "...hygiene and Personal Protective Equipment may be the only significant preventive measures available, particularly early in a pandemic."

The pandemic plan also states an off-site assessment facility would be set up, so patients would not be showing up at the emergency department.

That facility is designated as the 55-Plus Centre on River Street, which would be followed by other assessment centres at the West Thunder Community Centre and Current River Rec Centre.

The plan itself also calls for Public Health Ontario labs, as well as the National Microbiology Lab in Winnipeg to analyze testing samples to confirm cases of the pandemic virus.

In order to deal with the expected increase in hospitalization of cases due to the pandemic, the hospital also looks at its current capacity and how it will deal with a surge in patients.

In the 2017 Pandemic Influenza Plan, the TBRHSC states it has 386 beds, included in that count are 26 negative pressure rooms. These types of rooms are the preferred location for any influenza patients as air from the room is vented to the outside rather than back into the corridors.

The plan says that once negative pressure rooms become full, pandemic influenza patients will be placed into private rooms.

The pandemic plan warns that "...the TBRHSC operates already at full capacity with little accommodation for surge capacity," so the hospital's plan includes information on how it would increase physical capacity. As outlined in the Pandemic Influenza Plan, those measure include:

• Defer any services for non life- or limb cases where no severe adverse health consequences are anticipated from the delay.
• Discharge Alternate Level of Care (ALC) patients to Long-Term Care homes when beds are immediately available.
• Discharge acute inpatients to home care when care can be provided safely in that environment.
• Discharge acute patients to family and self-care when care can be provided safely in that environment.
• Deploy freed-up beds for influenza patients.
• Cohort infectious patients and non-infectious patients. Cohorting of infectious (influenza) patients will take place on the "B" pods.

Patients in the ICU would be re-assessed every four hours to see if they could be moved off of the unit.

The 2B unit would be the first to be utilized, followed by 3B. Currently, the dedicated COVID-19 unit is on 3A.

The Occupational Health and Safety section of the Pandemic Influenza Plan, deals with the health and safety of both healthcare workers and those for whom they care. The plan states no vaccine for a virus would be available during the first phase of the pandemic, however it may be available for the second.

In line with the lack of a vaccine until later in the pandemic, the hospital notes that it keeps a 60-day stockpile of antiviral medications on hand. While that medication would not prevent the virus from taking hold of patients, it may reduce the length of stay required, freeing up beds if needed.

Staffing is another area considered under the pandemic plan.

To accommodate staffing shortages, the TBRHSC keeps a record of its retirees from the past five years, along with their skill sets, and would call past employees to assist in the pandemic.

Even current staff, who may be considered unfit for work due to an illness could also be called in during an extreme shortage to provide care.

One of the final sections of the hospital's Pandemic Influenza Plan deals with assessment and treatment. Within that section of the plan, it deals with emergency services at the TBRHSC which will likely be challenged due to increased volumes of going to the emergency department, and how the hospital will handle critical care triage.

"It is important to note that critical care triage is NOT the same triage as routinely practiced in the emergency department," the plan noted.

Under the Pandemic Influenza Plan three key principles are listed when it comes to critical care triage:

• All patients will be cared for. This does not mean that all patients will receive critical care services, but will ensure that those not appropriate will still be cared for at an alternate level of care.
• Triage protocol will ensure that the criterion is clear and transparent and will protect individuals from inequities.
• Critical care triage is not a first step towards rationing under ordinary circumstances and will be used only under extraordinary circumstances.

The hospital's pandemic plan goes into further detail about its inclusion and exclusion criteria, meaning the plan helps "...identify those patients that may benefit from admission to critical care and those that will not."

"Inclusion criteria are based primarily on respiratory failure because the ability to provide ventilator support is what differentiates the ICU from other areas of the hospital."

According to the Pandemic Influenza Plan, the exclusion criteria are divided into three categories:

• People with a poor prognosis/chance of survival even when treated aggressively in an ICU.
• People that will need a level of resource that can't be met during a pandemic.
• People with underlying significant and advanced medical illnesses whose underlying illness has a poor prognosis with high short-term mortality even without their current concomitant critical illness.