It’s 1:50 p.m. on a recent weekday at the intensive care unit of Toronto’s Hospital for Sick Children as a trio of women try to solve the latest problem.
There are three children who need to be in SickKids’ ICU but are not.
One is waiting in the emergency department and two others are at community hospitals. There’s currently no space for them at the intensive care unit, so staff need a plan on how to care for them until beds open up.
“At this particular moment, I don’t have physical capacity to admit them,” says Lee-Anne Williams, the charge nurse for the ICU, who is primarily responsible for managing the flow of patients in and out of the unit.
“This is the worst I’ve seen,” she says of her 21 years in the hospital’s intensive care unit.
While they work to open up spots, SickKids has dispatched mobile critical care teams to be with the two children at the other hospitals while another team is closely watching the child in the ER.
For now, all are safe.
“We have SickKids eyes, ears and hands on the patients, and it’s a really good assessment that we can trust,” Williams says. “Hopefully it just buys us a little bit of time so we can then transfer patients out of the ICU to accommodate patients coming in.”
The SickKids ICU is at 120 per cent capacity and has been under immense pressure for weeks.
Pediatric hospitals across the province are in similar situations as they’ve seen a huge surge in children with respiratory illnesses. A severe staffing crunch, especially in highly specialized units such as intensive care, has compounded the problem.
The Canadian Press spent several hours inside SickKids recently to understand the crisis and examine the ways in which the Toronto hospital has worked to ensure it can keep caring for young patients who need its specialized care.
“The big thing right now is staffing and being able to provide safe care for our patients,” says Sandhaya Parekh, the senior clinical manager of the ICU at SickKids.
The hospital has 42 physical pediatric ICU beds – not counting its neonatal intensive care unit – but struggles to staff more than 36 on any given day. The number of patients who can be cared for depends on how many staff might call in sick.
The ICU – currently filled mostly by children under five years old – has been over capacity for the last month. More than half of the respiratory patients are on ventilators as the hospital has seen a huge number of cases of flu and respiratory syncytial virus, or RSV.
Those patients are almost all otherwise healthy kids. The flu is hitting especially hard. The hospital has seen kids with the flu who have gone into heart and other organ failures at a much higher rate.
At the ICU, the unit’s senior clinical manager, the clinical director of the ICU’s cardiac unit and the charge nurse meet daily to figure out staffing.
They first look within the ICU’s staffing pool and then turn to other departments for help. On this day, they put a call out for six nurses to work overnight. Thankfully, enough stepped up.
The hospital has lost a lot of nurses during the pandemic to retirement and other nursing jobs, especially less stressful ones. The departures have hit the ICU hard since it requires nurses with specialized skills.
Over at the front desk of the unit, the chief of critical care takes a deep breath.
“It never ends,” says Dr. Steven Schwartz.
Halls of the department snake off from the front desk, which sits under a blue skylight painted with fluffy clouds. Computers on mobile carts pack the hallways as nurses and doctors go to and fro. Other nurses stand watch outside isolation rooms, eyes on the vitals of little ones.
The situation on this day is at least better than the first week of November.
“We were either on the verge, or maybe slightly past, out of control,” Schwartz says. “Now we’re back to being manageable.”
The hospital’s emergency department began seeing higher-than-normal patient volumes in September that grew through October until daily records kept being broken – more than 300 children were showing up at the ER daily, with another 200 seen through the hospital’s virtual emergency department.
The ICU gradually came under greater pressure, both from SickKids patients and as other hospitals needed to transfer children in for specialized care.
By the first week of November, the SickKids ICU had to do something it’s never done before: it had to say no.
“It very quickly got to a point where we were having to say, ‘We can’t take this person right now,’” Schwartz says.
“That was getting very scary because then we’re asking people, ‘Can you take care of this kid for one more day?’ Maybe they’re not the one who needs the breathing tube right now, but everybody’s worried they will. That’s where it started to feel very unsafe.”
Anxiety and moral distress skyrocketed among staff.
The ICU needed to be saved.
Senior management dusted off a surge plan that was created, but never used, for COVID-19. It meant a seismic shift in patient care, away from its one-nurse-to-one-patient model.
“The only way for us to be able to work within this model is to redeploy resources,” says Jackie Hubbert, the clinical director of the cardiac unit of the ICU. “And the only way to do that is to stop doing something else.”
On Nov. 11, CEO Ronald Cohn sent out an email to staff about cancelling surgeries and redeploying staff to the ICU. A new team-based model that changed nurse-patient ratios would start three days later.
“It literally saved lives,” Schwartz says.
Merit Hayden-Town put up her hand when the hospital called for volunteers to boost ICU staffing under the new model.
“I knew that the situation in our ICU was desperate and I wanted to step up,” she says.
She’s worked at SickKids for 16 years, 15 of those in the pediatric ward. That became a COVID-19 ward during the pandemic. With so much fear about the virus early on, Hayden-Town shipped her then-eight-year-old boy to his grandmother’s for three months.
“It was traumatic,” she says as she plays with her necklace that reads “Mama.”
A year ago, she moved to the post-anesthetic care unit, where she helps children recover from surgeries.
Now, in her new role in the ICU, she teams up with at least one experienced ICU nurse as they care for three or more patients. The hospital says they’ll use the model until the surge abates.
Hayden-Town is learning on the job and takes heart in helping her young patients, although the need for more staff remains.
“To be with a family when their child is sick, at the darkest time of their life, is so meaningful to me,” she says. “We are fighting the fight, but there’s just not enough staff.”
Hayden-Town rubs her necklace again as she leaves to take a nap – the night shift begins in a few hours.
Liam Casey, The Canadian Press