British Columbia's COVID-19 Experience
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CLINICAL Sonny Thiara, MD, Bonnie Henry, MD, David Patrick, MD, MHSc, Hussein Kanji, MD, MSc, MPH British Columbia’s COVID-19 experience BC’s success in managing COVID-19 to date can be attributed, in part, to a timely and comprehensive public health response. ABSTRACT: Since the emergence of COVID-19 in than described in initial reports from China, Italy, and an 88.1% mortality rate for patients who late 2019, health care systems around the world and New York. This is likely due, in part, to a timely required mechanical ventilation.6 have been dealing with the pandemic. Mortality public health response that included broad early The experience with COVID-19 in BC rates of patients admitted to ICUs and placed on testing and case and contact management, travel has been different than in other jurisdictions. mechanical ventilators were a concern initially. We and mass gathering restrictions, physical distanc- Although BC has approximately 13.4% of the sought to compare the burden of disease that BC ing measures, and prevention of “superspreader” Canadian population,7 on 20 March 2020, the has experienced with that of other Canadian prov- events. BC has also benefited from decisive action province recorded 29.0% (n = 271) of Canada’s inces and other countries. In March 2020, 66.7% by hospital administrators, and the sharing of data COVID-19 cases and 66.7% (n = 8) of the of the COVID-19 deaths in Canada had occurred and resources such as ventilators and personal country’s COVID-19 deaths.8 However, by 11 in BC, but by 11 July 2020, the proportion had protective equipment. To ensure that inpatient July 2020, BC had recorded 2.8% (n = 3053) declined to 2.1%. In April 2020, critical care mor- mortality in ICUs does not increase in the event of Canada’s COVID-19 cases and 2.1% (n = tality and mechanical ventilator mortality of New of another wave of COVID-19, contingency plans 187) of the country’s COVID-19 deaths.9 As York patients with COVID-19 was 78.0% and 88.1%, must be put in place. Capacity should be built into of 8 July 2020, 16.6% (36 of 217) of critical respectively. As of 8 July 2020, critical care mortality the system so that staff-to-patient ratios allow for care COVID-19 patients in BC had died, and and mechanical ventilator mortality of BC patients optimal patient care, personal protective equip- 15.4% (20 of 130) had died while mechanically with COVID-19 were 16.6% and 15.4%, respectively. ment is available to protect staff, and isolation ventilated, according to Provincial Health Ser- Overall, BC has experienced a lower burden of dis- room availability is increased. vices Authority data. ease and significantly lower critical care mortality Initially in March 2020, BC testing focused novel coronavirus, SARS-CoV-2, was on sicker patients and health care workers. This first identified in December 2019 and led to concern that subsequent case counts resulted in cases of pneumonia in Wu- could underestimate the size of the epidemic; han, China.1 Since then, SARS-CoV-2 has however, universal testing of suspect patients Dr Thiara is an intensive care specialist A spread rapidly around the globe. On 11 March resumed on 21 April 2020. As of 11 July 2020, in the Department of Critical Care at 2020, the World Health Organization declared the cumulative testing rate in BC was approxi- Vancouver General Hospital and the COVID-19 a pandemic.2 As of 6 September mately 3.6% of the population, compared with University Hospital of Northern British 2020, more than 27 million people worldwide 10.9% in Ontario and 7.9% in Quebec.9 Columbia. Dr Henry is the Provincial have been infected and more than 900 000 have Hospital admission rates, which may rep- Health Officer, Ministry of Health, for died.3 resent a more accurate, albeit delayed, account British Columbia. Dr Patrick is the director of COVID-19 trends in BC than confirmed of research for the BC Centre for Disease Jurisdictions compared cases, have not dramatically increased as ini- Control. Dr Kanji is an intensive care Initial reports from China showed mortality tially projected. During May and June 2020, specialist in the Department of Critical rates ranging from 38.0% to 97.0% for patients admission rates decreased or were constant, Care at Vancouver General Hospital. in ICUs.4,5 On 22 April 2020, Richardson and likely the result of timely and stringent physical colleagues reported that 320 of 2634 patients distancing measures.8 This article has been peer reviewed. It was with COVID-19 in the New York City area Overall, BC has experienced a lower burden written in April 2020 and accepted for (12.2%) required mechanical ventilation.6 In of disease and significantly lower critical care publication on 26 June 2020, and figures that case series there was a 78.0% mortality mortality than described in initial reports from were last updated in September 2020. rate for patients who were admitted to the ICU China, Italy, and New York. BC MEDICAL JOURNAL VOL. 62 NO. 8 | OCTOBER 2020 277 CLINICAL British Columbia’s COVID-19 experience Public health response Decisive action by hospital administrators a vaccine is likely many months away, and we BC’s success in limiting the spread of and a collaborative provincial response allowed are almost certainly well below a herd immu- 16 COVID-19 and avoiding an initial hospital bed hospitals in BC to create capacity by limiting nity threshold. Governments will be forced to resource crisis is likely due to a timely public the number of elective surgeries and transplant balance the benefits of public health measures health response and some unknown variables. programs. This process was aided by multi- and their economic and physical health/mental The public health response included broad ear- ple collaborative groups and committees with health impacts. ly testing and case and contact management, widespread representation of various specialties, While necessary in the short-term, the travel and mass gathering restrictions, physical including the BC COVID-19 Therapeutics diversion of ICU capacity to COVID-19 distancing measures, and prevention of “super- Committee. Also, new physical space and capac- care has jeopardized our standard of care and spreader” events. ity for ventilated and critically ill patients was resulted in a backlog of testing and therapies for The first case in BC was recorded on 28 created by restructuring other illnesses, which may January 2020 and involved a traveler return- areas of care. Having criti- Planning is imperative result in worsening prog- ing from Wuhan.10 On 7 March 2020, the first cal care nurses, respiratory noses and morbidities, and two cases at the Lynn Valley Care Centre in therapists, physiothera- to ensure that inpatient a late increase in critical 17,18 North Vancouver were reported.11 One resi- pists, dietitians, and phar- mortality in ICUs care admissions. Prior dent and one staff member were diagnosed; the macists working alongside in BC follows the to the COVID-19 pan- staff member was likely Canada’s first case of intensive care specialists current rates, which demic, most ICUs oper- community transmission. By 13 March 2020, who had a manageable ated near 100% capacity are in stark contrast the Canadian government had recommended patient load and were not year-round, and capac- against international travel.12 On 17 March limited by the number of to those reported ity was often crippled by 2020, a BC public health emergency was de- critical care beds may have around the world. the lack of isolation room clared, and a province-wide state of emergency resulted in lower mortal- availability. Now that was declared the next day.13,14 Since May 2020, ity rates than previously some of the capacity for there have been very few new hospitalizations reported. As a result of diligent preparation and handling COVID-19 cases has been released or critical care admissions in BC. PPE training by ICU managers and directors, for other care, contingency plans must be put in Case fatality, critical care admission, the the largest ICU in BC, which employs more place in case another large wave occurs. need for mechanical ventilation, and the dura- than 200 allied health practitioners, had zero In the future, capacity should be built into tion of mechanical ventilation are important confirmed cases of COVID-19 transmission the system so that staff-to-patient ratios allow indicators of the severity of illness, the burden from patient to staff from late January to late for optimal patient care, PPE is available to on the health care system, and the ability of June 2020. protect staff, and isolation room availability 19 patients to regain quality of life postinfection. BC was also able to mobilize intensivists is increased. Such planning is imperative to Management of patients who are critically ill from its various health authorities through the ensure that inpatient mortality in ICUs in BC with COVID-19 is emergent and based mostly coordination of the British Columbia Critical follows the current rates, which are in stark n on first principles, with clinicians around the Care Working Group supported by the BC contrast to those reported around the world. world collaborating and sharing their experi- Patient Safety and Quality Council. Mobiliz- Acknowledgments ence because of a lack of high-quality ran- ing the previously created provincial network We would like to thank the Provincial Health Ser- domized control trial data. Most COVID-19 allowed for the sharing of data and resources vices Authority for providing overwhelming sup- patients in BC are cared for in tertiary or such as ventilators and PPE, and supported the port and data that was critical to the creation of quaternary critical care units and are man- creation of a real-time provincial COVID-19 this article, and in coordinating a response to the aged by specialty-trained (fellowship) inten- capacity and resource critical care dashboard.