By Keegan Guidolin, Jessica Marangos, Fayez Quereshy

University Health Network (UHN) is the largest hospital system in Canada and delivers health services ranging from primary to quaternary care to over six-million people in the Greater Toronto Area and beyond. During the first wave of the COVID-19 pandemic, like many other hospitals and in response to direction from the government, we decreased clinical activity uniformly across all services in the interest of creating flexibility in our resources to respond to the pandemic. With a short amount of time to enact changes, it was initially thought that a uniform decrease would be the most fair and equal with respect to the patients that we serve (i.e., all services were allotted the same reduced proportion of clinical activity). We found that the expected increase in demand for resources to respond to patients with COVID-19 did not materialize and our hospital capacity remained at approximately 60% throughout these periods of service “ramp down”. As the second wave approached, we sought to create a more ethically founded method of adapting to the rapidly changing demands of COVID-19, spurring the creation of the A4R Ethics decision tool discussed in our forthcoming publication in the Journal of Medical Ethics. We have been actively using this tool for nearly six months and have found it very useful in considering the potential effects of decreasing clinical activity across care types and programs. In addition, we have noticed some interesting trends emerging from its use.

First, because our tool considers the urgency and severity of illness of the patients served by a particular care type and program, patients with less urgent or severe illnesses are disadvantaged on an ongoing basis. For instance, one of the guidelines that emerged from this tool was a greater proportion of scheduled activity assigned to performing cancer operations (with curative intent) over non-cancer operations (e.g., joint replacements). While this certainly makes sense in the short term, the protracted nature of the pandemic and overlapping of case waves means that the list of patients waiting for these non-cancer operations grows longer at a greater rate than that of patients waiting for cancer operations. This in turn may affect the health and welfare of these patients for months or years to come and creates a situation in which they are being systematically disadvantaged for “not having a more severe or urgent illness”. Our solution to this issue has been to regularly revise our policies and practices (e.g., when physical capacity is less constrained, and staffing and OR availability exists moving surgeries from inpatient to outpatient) to minimize the impact of the prioritization of care types and services, but we suspect that a similar phenomenon has been playing out in other health centres around the world.

Second, we found that we had to consider UHN as a part of a larger network of hospitals, particularly because of our role in offering specialized care that can not be accessed in other hospitals (e.g., some transplant, neurologic/neurosurgical, cardiac, and oncology care). We found that we could rely on the centres in our community to provide the less sub-specialized services that we typically offer, thereby enabling us to provide the care that cannot be delivered elsewhere. As a result, we were able to preserve our ability to deliver such services without limiting access of the patient population to other services, despite their relative unavailability at UHN.

Finally, while we initially developed the tool for use at the institutional level (i.e., for deciding which services ought to be increased or decreased and to what degree), we have found that the UHN staff have adopted the tool extremely well and have been able to apply it at the departmental level (or more granular levels) as well. At the institution level, a decision is made that a particular department will alter their level of clinical activity (e.g., from 80% to 50%), but it is up to the department head and leadership teams to decide how that change in activity level is carried out (i.e., within the 50% allocated to surgical activity, what cases will be prioritized). Many of our physicians, after receiving training and guidance from our bioethicists, have been using the tool to evaluate resource allocation decisions even within their departments in order to best serve the needs of their patient population.

We continue to learn and adapt our tool based on the rapidly changing challenges posed by the pandemic both directly, and indirectly. We hope that our forthcoming publication in the Journal of Medical Ethics will help to guide the resource allocation decisions that many hospitals and institutions continue to face around the world.

Paper title: Ethical decision making during a health care crisis: a resource allocation framework and tool

Authors: Keegan Guidolin^1-3, Jennifer Catton⁴, Barry Rubin^1,4,6, Jennifer A.H. Bell^3,5, Jessica Marangos⁴, Ann Munro Heesters^4,5,7, Terri Stuart-McEwan⁴, Fayez A. Quereshy^1,3,4.

Affiliations:

1. Department of Surgery, University of Toronto, Toronto, Canada
2. Institute of Biomedical Engineering, University of Toronto, Toronto, Canada
3. Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
4. University Health Network, Toronto, Canada
5. Joint Centre for Bioethics, University of Toronto, Toronto, Canada
6. Peter Munk Cardiac Centre, University Health Network, Toronto, Canada
7. The Institute for Education Research (TIER), University Health Network, Toronto, Canada

Competing interests: None.

Social media accounts of post author(s):

@keeganguidolin

@jessicamarangos

@QuereshyMD