he state of medical care in Toronto has been drifting in and out of the news cycle in a pendulum-like fashion for the last few years. This can be traced back to the early days of the COVID-19 pandemic — when stories of worker fatigue, overloaded emergency rooms and mass staff departures dominated headlines.
However, these concerns did not drift off with the early days of the pandemic. Lingering symptoms have embedded themselves within the network of patient care, as hospitals continue to struggle to keep themselves adequately staffed.
This can be attested to the continued loss of available nurses as well as the medical staff themselves being subject to the revolving door of respiratory illnesses. As staff shortages and fatigue continue to bombard hospitals across the GTA, an equally nefarious crisis is impacting those on the patient side, particularly children.
In the past few months, hospitals have become backlogged with paediatric patients who are suffering from a litany of respiratory illnesses, with the primary cases being influenza, respiratory syncytial virus (RSV) and COVID-19.
As two medical emergencies continue to operate parallel to one another, one can’t help but ask the obvious question, how do these two clinical calamities impact one another, and more importantly, are their effects mutually exclusive for patients and care workers alike?
The Holland Bloorview Rehabilitation Hospital is Canada’s largest rehabilitation hospital for paediatric patients.
This centre for patient care has not been excluded from the current difficulties that have been plaguing the medical system.Those working within its network have been taking lessons from the past and implementing them to better fit the struggles of the present and fortify themselves for the difficulties of the future.
Irene Andress and Dr. Alysha Ladha are two major players at Holland Bloorview.
Andress, a career nurse turned administration specialist, is the Vice President of Programs and Services within the hospital and also operates as Chief Nursing Executive.
Dr. Ladha specializes in brain injury rehabilitation and holds years of in-patient knowledge concerning paediatric care.
When it comes to maintaining a through-line between staff and patient wellness, both Andress and Dr. Ladha operate in tandem to ensure no aspect of care gets overlooked.
“We’ve really put a lot of time and effort into hiring and predicting what we might need over the next six months as opposed to managing it from the rearview mirror. Sometimes it’s successful, sometimes it’s not, because there’s just not a lot of people to hire out there,” says Andress.
This lack of available help coincides with staff wellness, as there have been consistent bouts of care workers falling ill, resulting in a never-ending imbalance of available caregivers. According to Andress, this staffing tempo erodes the foundation of reserve staff, as when everyone is covering for someone else, there’s no one to cover for them.
With this bedrock of standby staff existing in a perpetual state of shock, the traditional challenges of educating new hires become even more crucial.
“We have to think about how we recruit new staff and how we support these new staff and help them learn a pretty significant specialty in healthcare, which is paediatric care but also caring for kids with disabilities,” says Andress.
This focused crop of specialists is an already limited reservoir of physicians and nurses, as acquiring those with the right expertise is unlikely when looking for replacement staff.
“We have 20 physicians in total in our general physician group and eight who work in our inpatient unit. Last week, three out of eight physicians were either home with their own illnesses or looking after ill family members,” says Dr. Ladha.
Both Andress and Dr. Ladha stress that anyone working within the purview of Holland Bloorview should be able to work within a system that allows them to regularly look after both themselves and their family. However, given the current state of the hospital system across Toronto, the toll practitioners are facing is becoming increasingly dire every day.
Boiling down patient requirements is not something that can be done overnight as it fluctuates at an irregular rate.
“There is of course a more quantitative aspect, so that’s looking at our data and looking at what needs to be in place every day in order to look after — what would traditionally be — an average number of kids,” says Andress.
However, numbers-driven data can only provide so much peace of mind for caregivers, resulting in Andress and the rest of Holland Bloorview’s staff implementing past lessons to further bolster future strategies.
“Then you have to factor in a little bit of ‘What If?’ What if there’s another crisis? There’s a number of things we’re doing to get better at acquiring timely data,” says Andress.
However, what do doctors and nurses need in order to keep providing the care paediatric patients require? For Andress and Dr. Ladha, it boils down to a network of communication across all teams, above that, access to guaranteed education, benefits and support.
“They need leadership that understands what is happening in their day-to-day, they need to know they have a safe place to come to work, that they will be safe, both physically and psychologically,” says Andress.
This prevalence of worker care comes with its own degree of importance, primarily, regarding how the mental health of care workers operates as a catalyst for how rapidly they can administer care to patients.
“In order to take the best care of the kids you’re looking after, there is a sense of fulfilment that needs to come from your job, and for a lot of people, that comes from being heard and having autonomy within your work and having support within your work,” says Dr. Ladha.
The systems that Dr. Ladha is referring to are facility-wide communication strategies for administrative duties, patient care and staff well-being. Frontline staff relay information to senior leadership, which is then used as a launchpad for future planning.
If successful, all care workers stay on the same page.
However, like any living system, nothing runs perfectly.
“We recently did a pulse survey looking at staff mental health, at the time before the surge in respiratory illnesses, at least thirty-eight per cent of staff were reporting at least one symptom of burnout,” says Dr. Ladha.
Dr. Ladha is also a member of Holland Bloorview’s mental health strategy team, and while many caregivers were experiencing burnout pre-surge, those who were surveyed reported that one of the primary support systems holding off further burnout was an airtight system of communication between hospital staff and administrators.
However, the data presented was taken before the surge in respiratory illnesses among paediatric patients. In light of this, Holland Bloorview has been actively making sure that those who work within the purview of their facility have access to the help they need even when they aren’t wearing their scrubs, in an effort to keep those numbers down.
“People feel vulnerable, you always have to look like you’re in control, so having access to services outside of work is really important. As a consequence, the hospital worked with our extended benefits provider to support people so they can access a larger group of health professionals,” says Andress.
This reformatting has offered Holland Bloorview’s staff a larger pool of staff mental health benefits, including social workers and psychotherapists.
Additionally, this focus of care doesn’t just relay back to those who are on the hospital floor full-time, it is also available for student nurses and physicians. However, in light of the current system-wide stressors, those within management and administration have purpose-built care, in order to account for the compounding mental strain of their staff.
“Managers are also being targeted because their mental health has a tendency to be challenged even further because they’re supporting employees who have their own challenges too. This kind of training helps them support their own mental health as well as support the mental health of their teams,” says Dr. Ladha.
With safeguards ensuring that mental health assistance is available for all caregivers, those imbued with the right kind of support can focus further on those who need care the most — the kids.
Holland Bloorview operates primarily as a rehabilitation hospital, meaning that physicians and nurses work with paediatric patients over an extended period to ensure that they not only receive the care they require but so it can also be sustained over time.
As a byproduct of the current surge in respiratory illnesses a watchtower system has been implemented across hospitals within the GTA. The goal of this focused strategy is to allow hospitals the ability to prioritize paediatric patients, and particularly, understand what level of care is required.
“It allows us to understand which kids are most vulnerable out there in the system, while also ensuring that those kids get to the right places as quickly as possible. So whether that means going to a tertiary hospital, an acute community hospital or coming to Holland Bloorview for continuing care or rehabilitation support,” says Andress.
While this system operates in tandem with paediatric care centres across the city, its rapid response metric indicates that care has to be delivered in a far more immediate fashion. Andress points out that pre-surge caregivers would have roughly two to three days to access a patient’s needs, whereas now it has to be done as fast as possible.
“For example, a child might be in the ICU (Intensive Care Unit) at one hospital and is ready to come out of care. In order for another child to go into that same ICU space, that initial child needs to move out… So our communication has to be really clear about what the priority is,” says Andress.
This line of communication doesn’t stop at in-facility care, as given the current state of the paediatric patient crisis, many caregivers are having to access a patient’s needs after hours.
“We have to have systems in place to support those moves, and for our staff, that’s pressure every day. Not just to look after the kids in front of them, but to also be actively aware of the kids who aren’t in our system yet,” says Andress.
With a system of patient status solutions hardwired in both Holland Bloorview and additional hospitals across the GTA, caregivers continue to try to keep pace with the current surge that is bombarding paediatric departments across the city. However, there is another variable that comes into play when looking after children — the caregivers at home — their guardians.
“I work in brain injury rehabilitation, most of the work I do is with families who have a healthy child and then had something absolutely unspeakable happen,” says Dr. Ladha. “The emotional trauma that comes with that is high enough, however, this isn’t something that is new to us, I would say with this particular set of viruses, not only are we seeing kids with unusual neurological complications from the viruses they’re getting… we’re also seeing kids with respiratory complications who end up in the ICU.”
These complications, according to Dr. Ladha, involve intensive stays for patients, resulting in both ventilator usage and physical therapy.
“There are moments where emotions come out, and we’re managing this by supporting both kids and their families. Kids remember things from intensive care, it has an impact on them and they’re scared. What we do is our best to support them through that,” says Dr. Ladha.
An additional factor that impacts the emotional well-being of paediatric patients and their guardians is the nature of pandemic fatigue, specifically in a hospital setting. Due to the rampant amount of respiratory viruses in play, paediatric hospitals still need to limit both visitation hours and the number of people allowed in to see patients.
This type of caution, coupled with measures that echo the early days of the pandemic, has left many on edge.
“I think sometimes emotions run high because the world inside of a hospital looks really different from the world outside. We continue to say [this surge] is really significant, you do really need to wear that mask at all times. Whereas out in the community, you may not know that, I do think the level of emotional stress and fatigue is making everything even more challenging,” says Dr. Ladha.
As a byproduct of the challenges paediatric care centres are facing, numerous hospitals across the GTA are forming a united front by sharing resources and knowledge with one another. With this kind of cross-communication, specialist allocation is becoming more accessible than ever before.
“It’s not perfect, a lot more work has to be done to hardwire our pathways for people across all sectors. This can be acute care hospitals, post-acute care and at-home care,” says Andress.
Sticker and a Lollipop
The network of care that paediatric centres adhere to is not something that can be sustained on its own, and while Andress, Dr. Ladha and numerous paediatricians across the city are working to maintain this network, it isn’t indestructible.
Holland Bloorview has the benefit of being a rehabilitation hospital, while this doesn’t make the jobs of its staff any easier, the extended process of care they provide gives them more time to strategize. However, not all paediatric centres have this kind of timeline when it comes to distributing care.
“There are lots of children’s treatment centres, if you don’t fund the system, you’re going to create a backlog in these acute high-resource areas,” says Dr. Ladha.
A recent example, according to Andress, is when one hospital ran out of its entire supply of cribs.
“We loaned our hospital cribs, because well, we had them. It sounds really simple but when you know what the system needs, people then work together, and the bottom line is it’s always what works for patients and families,” says Andress.
As for how the current network of paediatric care will continue, both Andress and Dr. Ladha are adamant that as long as physicians, nurses and administrators understand the needs of one another, children who are vulnerable will get the best kind of treatment available.
A belief Dr. Ladha understands completely.
“I want my colleagues to know, my physician colleagues, my nurse colleagues and managing colleagues to know that you’re doing an amazing job, and if you need time to look after your own health or your family’s, do it, we have your back.