Inventory of Critical Care Services › EN › Toolbox › Overview of...Dr. David Boyle Associate Professor Division of Clinical Sciences Northern Ontario School of Medicine (LHIN

Inventory of Critical Care Services

An Analysis of LHIN-Level Capacities

Prepared by the Ontario Critical Care LHIN Leadership Table

Inventory of Critical Care Services

An Analysis of LHIN-Level Capacities

Published by the Ministry of Health and Long-Term Care

Copies of this report can be obtained from: www.health.gov.on.ca/criticalcare

The Health Information Centre: 1-800-268-1153

Toronto 416-327-4327

TTY 1-800-387-5559

http://www.health.gov.on.ca/criticalcare

Acknowledgements

The Provincial Critical Care Baseline Inventory was a collaborative effort among many individuals and institutions across Ontario; the Ministry would like to acknowledge these contributions. The MOHLTC recognizes and thanks the staff and leadership of the acute care hospital across the province for supporting this initiative. Special acknowledgement is also given to Andrea Hill (Co-coordinator, Research & Evaluation, Critical Care Secretariat). Lastly, and most importantly, the baseline inventory of provincial critical care resources would not have been achieved without the commitment demonstrated by the Critical Care Provincial LHIN Leader Table. The Ministry extends its appreciation to the members of the Table:

Dr. Michael Sharpe Professor Dept Anesthesia Perioperative Medicine, Program in Critical Care Medicine London Health Sciences Centre (LHIN 1 and 2)

Dr. William Plaxton Medical Director, Critical Care Medicine Grand River Hospital (LHIN 3)

Dr. Peter Kraus Chief, Critical Care Medicine Hamilton Health Sciences Corporation (LHIN 4)

Dr. Michael Miletin Medical Director, Critical Care and Respirology William Osler Health Centre (LHIN 5)

Dr. Laurence Chau Medical Director, Intensive Care Unit Halton Healthcare Corporation (LHIN 6)

Dr. Thomas E. Stewart Director Critical Care Medicine Mount Sinai Hospital and University Health Network (LHIN 7)

Dr. Donna McRitchie Medical Director, Critical Care and Chief, Division of General Surgery, North York General Hospital (LHIN 8)

Dr. Howard Clasky Director, Intensive Care Unit The Scarborough Hospital (LHIN 9)

Dr. John Muscedere Assistant Professor of Medicine, Queen's University, Intensivist, Kingston General Hospital (LHIN 10)

Dr. Redouane Bouali Department Head, Critical Care Medicine The Ottawa Hospital (LHIN 11)

Dr. Giulio DiDiodato Director, Critical Care Medicine The Royal Victoria Hospital (LHIN 12)

Dr. David Boyle Associate Professor Division of Clinical Sciences Northern Ontario School of Medicine (LHIN 13)

Dr. Michael Scott Associate Director of Critical Care Thunder Bay Regional Health Sciences Centre (LHIN 14)

Table of Contents Executive Summary .................................................................................................... 1

1.0 Methodology .................................................................................................. 3

2.0 Provincial Overview....................................................................................... 5 2.1 Provincial Critical Care Bed Summary ................................................................5 2.2 Provincial Technology and Specialized Services Summary ...............................8 2.3 Provincial Organization of Critical Care Units ...................................................13

3.0 Erie St. Clair ................................................................................................. 14 3.1 Inventory Data...................................................................................................16 3.2 LHIN Leader Report ..........................................................................................16

4.0 South West ................................................................................................... 20 4.1 Inventory Data...................................................................................................22 4.2 LHIN Leader Report ..........................................................................................23

5.0 Waterloo Wellington .................................................................................... 27 5.1 Inventory Data...................................................................................................29 5.2 LHIN Leader Report ..........................................................................................29

6.0 Hamilton Niagara Haldimand Brant............................................................ 34 6.1 Inventory Data...................................................................................................36 6.2 LHIN Leader Report ..........................................................................................37

7.0 Central West................................................................................................. 39 7.1 Inventory Data...................................................................................................41 7.2 LHIN Leader Report ..........................................................................................41

8.0 Mississauga Halton ..................................................................................... 44 8.1 Inventory Data...................................................................................................46 8.2 LHIN Leader Report ..........................................................................................46

9.0 Toronto Central............................................................................................ 49 9.1 Inventory Data...................................................................................................51 9.2 LHIN Leader Report ..........................................................................................51

10.0 Central .......................................................................................................... 54 10.1 Inventory Data...................................................................................................56 10.2 LHIN Leader Report ..........................................................................................56

11.0 Central East.................................................................................................. 59 11.1 Inventory Data...................................................................................................61 11.2 LHIN Leader Report ..........................................................................................62

12.0 South East.................................................................................................... 66 12.1 Inventory Data...................................................................................................68 12.2 LHIN Leader Report ..........................................................................................68

13.0 Champlain .................................................................................................... 73 13.1 Inventory Data...................................................................................................75 13.2 LHIN Leader Report ..........................................................................................76

14.0 North Simcoe Muskoka ............................................................................... 78 14.1 Inventory Data...................................................................................................80 14.2 LHIN Leader Report ..........................................................................................80

15.0 North East .................................................................................................... 83 15.1 Inventory Data...................................................................................................85 15.2 LHIN Leader Report ..........................................................................................85

16.0 North West ................................................................................................... 90 16.1 Inventory Data...................................................................................................92 16.2 LHIN Leader Report ..........................................................................................92

17.0 Limitations of the Inventory........................................................................ 96

18.0 Conclusion: Next Steps .............................................................................. 98

Appendix.................................................................................................................. 101 Appendix A – Critical Care Baseline Service Inventory Forms................................102 Appendix B – Glossary ............................................................................................111

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Executive Summary From June to September 2006, Ontario’s Critical Care LHIN leaders worked closely with their hospital colleagues to complete a detailed inventory of critical care resources in this province. The data, confirmed by each acute care hospital’s CEO, describes the number, size and type of critical care units, as well as the related specialty services, currently available to meet the needs of critically ill patients. This inventory is an essential step in the implementation of Ontario’s Critical Care Strategy, which is designed to improve access, quality and system integration in the delivery of critical care services (see www.health.gov.on.ca/criticalcare). The Critical Care Strategy is based on a fundamental consensus, endorsed by system managers and health care providers, that critical care is a shared resource and must be carefully managed from a systems perspective. By establishing this agreed-upon baseline, Ontario hospitals have taken another important step in moving beyond working as a mere aggregate of institutions toward establishing integrated service delivery at the LHIN and provincial levels.

Inventory Data Highlights

The inventory data is presented at the provincial level in Section 2 and by individual LHINs in Sections 3 to 16. Overall, Ontario has 213 critical care units spread across 127 acute care hospitals. These units contain 1,789 critical care beds, of which 1,057 are capable of providing patients with invasive mechanical ventilation.

1. Intensivist-led Management of Critical Care Units*

Intensivists are physicians with specialty training in managing patients whose lives are at risk due to multi-system failure. As noted in the Ontario Critical Care Steering Committee Final Report, evidence confirms that involving intensivists in the management of critical care resources improves patient outcomes and results in more efficient use of hospital resources. In a 2004 study, the ministry found that 46 (53%) of 86 Level 3 critical care units with 8 or more beds were managed by intensivists. In part due to Ontario’s Critical Care Strategy, that number has now increased to 56 (74%) of 76 Level 3 critical care units with 8 or more beds. While this is important progress, 26% of many medium/large units are still managed without the benefit of intensivists (see Table 3 in the individual LHIN sections). As the strategy moves forward, the remaining hospitals will be encouraged and supported to adopt this important physician management model, especially where a critical care mass of 8 beds exist.

2. Regional Availability of Specialty Services

The inventory clearly shows that some specialty services integral to managing multi-system organ failure, such as acute dialysis, are not equally available across the province. This can result, sometimes unavoidably, in: i) having to transfer unstable patients and ii) a delay in the timely initiation of dialysis in critical multi-organ failure patients. In the coming months, the Critical Care LHIN Leaders will work with their colleagues in the critical care field as well as the ministry, LHIN and hospital leaders to carefully examine the distribution of dialysis and various specialty services with a view to minimizing the transfer of unstable patients and improving timely access to patient care.

* In an intensivist-led management model all admissions and patient care decisions in the critical care unit are coordinated by a single physician (single point of accountability). This management structure is often referred to as a “closed” model.

http://www.health.gov.on.ca/criticalcare

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3. Distribution of ICU Bed Capacity

The report confirms a degree of variability in distribution of ICU beds per capita across the LHINs. While this seems to suggest a lack of equitable service delivery, in fact, a number of factors play a role in access to critical care which might mitigate this variability including:

Established patient referral patterns, which often cross LHIN boundaries

Variable occupancy rates in critical care units across the LHINs

Efficiency of current resource utilization

Demographic pressures across the LHINs

Value of the Inventory Data

1. Analyzing Utilization and Performance

The inventory provides fundamental, baseline data required for the creation of the new Critical Care Information System (CCIS), scheduled to go live in the first group of hospitals in January 2007. CCIS will collect a minimum dataset to monitor:

Bed occupancy rates

Appropriateness of bed utilization (the right patient in the right bed)

Safety and quality indicators, comparable across critical care units

Patient transfer patterns and triggers

2. Improving Service Delivery

Using data obtained from CCIS, the Critical Care LHIN Leaders will be better able to develop recommendations to achieve improvements at the local level. Key objectives include:

Improving patient outcomes based on quality/performance benchmarks

Improving inter-facility coordination of patient transfers and repatriation

Consolidating/reorganizing critical care units where appropriate

Establishing appropriate management of critical care units

3. Resource Allocation, Transparency and Accountability

Ontario’s growing and aging population will put this province’s critical care resources under tremendous pressure over the next decade. Meeting this challenge will require MOHLTC, the LHINs and hospitals to accept shared accountability in determining how best to use limited resources to meet patient needs. This inventory is a transparent and agreed-upon accounting of what current hospital funding “buys” in terms of critical care resources and is an essential pre-condition for future collaborative discussions.

Several activities naturally flow out of the completion of this baseline. These are discussed in more detail in Section 18 - “Conclusions: Next Steps”.

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1.0 Methodology Objectives of the Critical Care Inventory

The main objectives of the critical care inventory were:

1. To establish the current baseline level of critical care resources within each LHIN 2. To confirm that MOHLTC, the LHIN’s and Ontario hospitals are in agreement with this

baseline 3. To provide evidence for improved planning and delivery of critical care services and

programs

Survey Tool and Data Collection

The survey tool was developed specifically for the purposes of the inventory and included questions on number of critical care units, bed capacities, technological resources, and management structure of critical care units (Appendix A). To capture the range of types and functional levels (Level 2 or Level 3), the inventory used a liberal definition of critical care units. As such, intensive care units, step-down or intermediate care units and subspecialty units (e.g., coronary care, trauma, cardiovascular) were included. The definition of level of care used in the inventory is based on the recommendations made in the Critical Care Steering Committee’s Final Report and is provided in Box 1 as a reference. A glossary of terms used in the inventory is provided in Appendix B.

Information regarding critical care capacity was requested and obtained from all acute care hospitals in the province. The data collection process was facilitated by the critical care LHIN leader for each LHIN, who was responsible for reviewing and vetting the completed forms submitted by each acute care hospital in his/her LHIN.

Results

Section 2 provides a provincial summary of the information generated by the inventory. LHIN level inventory data is provided in sections 3 to 16. The LHIN inventory data is complemented by a synopsis of the current critical care strengths and pressures for each LHIN. The LHIN synopsis (LHIN Leader Report) was prepared by the respective LHIN critical care lead and reflects his/her views and observations regarding critical care capacity within the LHIN.

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Box 1. Definition of Level 3 and Level 2 Critical Care Units

Level 2 Capable of providing service to meet the needs of patients who require more detailed observation or intervention including support for a single failed organ system, short-term non-invasive ventilation, post-operative care, patients “stepping down” from higher levels of care or “step ups” from lower levels of care. These units provide a level of care that falls between the general ward (Level 1) and a “full service” Critical care unit (Level 3). Level 2 units do not provide invasive ventilatory support.

Please Note: Critical care units that provide invasive mechanical ventilation for a short period (for example ≤ 48 hours) but need to transfer those patients who require more long-term invasive ventilation to a Level 3 unit are considered Level 2 for the purposes of the service inventory.

Level 3 Capable of providing the highest level of service to meet the needs of patients who require advanced or prolonged respiratory support, or basic respiratory support together with the support of more than one organ system. This is generally considered a “full service” Critical Care unit despite the fact some specialized services may not be available (e.g. dialysis). All Level 3 units are capable of invasive ventilatory support. Please Note: For institutions that combine Level 2 and Level 3 type critical care service in one geographic area (i.e. unit), we request that the unit designation reflect the highest level of care provided – even if all patients may not be receiving that level of care.

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2.0 Provincial Overview

2.1 Provincial Critical Care Bed Summary A total of 1,789 critical care beds (range 1, 30 beds) were identified in 213 critical care units across the province. Seventy-six hospitals reported having one or more Level 3 unit, for a total of 99 Level 3 units. The remaining hospitals (50) had a maximum of Level 2 critical care capacity. Tables A and B details the location of these hospitals. Map A details, pictorially, the location of all Level 3 and Level 2 hospitals in the province. A list of the 48 acute care hospitals without critical care capacity is provided in Table C.

Table A: Location of Hospitals with Level 3 Unit Capacity*

LHIN Number of Hospitals with Level

3 Unit Capacity

Total Number of Critical Care Beds in

Hospitals with Level 3 Unit Capacity

Total Number of Vented Beds in

Hospitals with Level 3 Unit Capacity

Central 6 105 81 Central East 7 111 68 Central West 2 38 24 Champlain 7 147 92 Erie St. Clair 5 98 71 Haldimand Brant 8 208 135 Mississauga Halton 4 87 80 North East 8 92 50 North Simcoe Muskoka 6 45 23 North West 1 26 13 South East 3 83 28 South West 8 167 97 Toronto Central 7 325 237 Waterloo Wellington 4 85 50 Totals 76 1617 1049*

* 8 of the mechanical vented beds were located in Level 2 units for short-term (< 48 hrs) ventilation.

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Table B: Location of Hospitals with Maximum Level 2 Unit Capacity*

Unit Non-Invasive Ventilation Capable

LHIN Number of Hospitals with a Maximum of

Level 2 Unit Capacity

Total Number of Critical Care Beds in

Hospitals with a Maximum of Level 2

Unit Capacity Yes No Central - - - - Central East 4 17 2 2 Central West 1 4 1 - Champlain 6 20 5 1 Erie St. Clair 1 2 1 - Haldimand Brant 5 41 3 2 Mississauga Halton 1 3 1 - North East 4 11 4 - North Simcoe Muskoka - 8 - - North West 3 - 3 - South East 5 18 3 2 South West 15 40 8 7 Toronto Central 2 3 2 - Waterloo Wellington 3 5 1 2 Totals 50 172 34 16

* This refers to individual hospital sites not hospital corporation.

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Table C: Hospitals without a Critical Care Unit∗ LHIN Hospitals with No Critical Care Unit Number of

Acute Beds Humber Regional Hospital (Keele Street Site) 56 Markham Stouffville Hospital (Uxbridge Hospital Site) 20 Central Stevenson Memorial Hospital 43 Lakeridge Health Corporation (Port Perry) 29 Lakeridge Health Corporation (Whitby) 80 Central East Peterborough Regional Health Centre (Rogers Street Site) 59

Central West Headwaters Health Care Centre (Shelburne Site) 26 Almonte General Hospital 21 Glengarry Memorial Hospital 37 Kemptville District Hospital 23

Champlain

St. Francis Memorial Hospital 27 Bluewater Health (Norman Site) 133 Erie St. Clair Chatham Kent Alliance (Sydenham Site) 49 Niagara Health System (Douglas Memorial Hospital Site) 57 Niagara Health System (Niagara-on-the-Lake Site) 22 Niagara Health System (Port Colborne General Site) 60

Hamilton Niagara Haldimand Brant

The Willett Hospital - Mississauga Halton Trillium Health Centre (Queensway Hospital Site) 47

Anson General Hospital 19 Bingham Memorial Hospital 11 Blind River District Health Centre 16 Englehart and District Hospital 16 Espanola General Hospital 15 Hôpital Notre Dame Hospital 23 Hornepayne Community Hospital 6 James Bay General Hospital 16 Lady Dunn Health Centre 10 Lady Minto Hospital 25 Manitoulin Health Centre 32 Mattawa General Hospital 16 North Bay General (McLaren Site) 64 Services de Santé de Chapleau Health Services 14 Smooth Rock Falls Hospital 14 Sault Area Hospital (Thesalon Site) 4

North East

Sudbury Regional Hospital (Laurentian Site) 170 Atikokan General Hospital 19 Geraldton District Hospital 49 Manitouwadge General Hospital 18 Nipigon District Memorial Hospital 37 Sioux Lookout Meno-Ya-Win Health Centre 103 The McCausland Hospital Corporation -

North West

Wilson Memorial General Hospital - Huron Perth Health Alliance (Clinton Public Hospital) 17 South West Huron Perth Health Alliance (St. Mary’s Hospital) 20 Huron Perth Health Alliance (Seaforth Community Hospital) 18 Grey Bruce Health Services (South Hampton) 16 South West (cont’d) South Huron Hospital Association 19

Toronto Central University Health Network (Princess Margaret Hospital) 115

∗ The comment section of the inventory identified that many of our small hospitals provide important short-term Level 2 critical care services [BiPap and vasoactive meds] in step up beds on their general wards.

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Map A: Location of Hospitals with Maximum Level 2 Unit Capacity and Hospitals with Level 3 Unit Capacity (may include Level 2 units)

2.2 Provincial Technology and Specialized Services Summary

Dialysis service was available in 58 (59%) of all Level 3 units. Of these, 37 could provide continuous hemodialysis. A provincial breakdown of the units with dialysis service is provided in Table D and Map B. Tables E and F summarize the information on specific specialized services available in Level 3 units.

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Table D: Dialysis Resources in Level 3 Units

LHIN Number of Level 3 Units

Level 3 Units with Intermittent Dialysis Capability

Level 3 Units with Continuous Dialysis Capability

With No Dialysis Capability

Central 8 5 - 3 Central East 7 3 4 3 Central West 2 1 2 - Champlain 8 4 4 4 Erie St. Clair 8 2 1 6 Haldimand Brant 13 9 6 4 Mississauga Halton 6 3 2 3 North East 8 5 1 3 North Simcoe Muskoka 6 1 1 4 North West 1 1 1 - South East 3 1 1 2 South West 9 3 2 6 Toronto Central 14 14 11 - Waterloo Wellington 6 4 1 2 Totals 99 56 37 40

Map B: Capacity for Dialysis Services in Level 3 Units

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Table E: Availability of IntraAortic Balloon Pump (IABP) in Level 3 Units

LHIN Number of Level 3 Units Number of Level 3 Units With IABP

Central 8 2 Central East 7 2 Central West 2 - Champlain 8 2 Erie St. Clair 8 1 Haldimand Brant 13 2 Mississauga Halton 6 2 North East 8 1 North Simcoe Muskoka 6 - North West 1 1 South East 3 1 South West 9 3 Toronto Central 14 6 Waterloo Wellington 6 3 Totals 99 26

Table F: Availability of Respiratory Services in Hospitals with Level 3 Unit Capacity*

LHIN Number of Hospitals with Level 3 Unit Capacity *

Number of Hospitals with No RT Services

Number of Hospitals with RT Services

Number of Hospitals with 24/7 RT Services

Central 6 - 6 6 Central East 7 - 7 6 Central West 2 - 2 2 Champlain 7 - 7 6 Erie St. Clair 5 - 5 4 Haldimand Brant 8 - 8 6 Mississauga Halton 4 - 4 3 North East 8 2 6 3 North Simcoe Muskoka 6 - 6 2 North West 1 - 1 1 South East 3 - 3 1 South West 8 - 8 4 Toronto Central 7 - 7 6 Waterloo Wellington 4 - 4 4 Totals 76 2 74 54


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Table G: Availability of Specialized Services in Hospital Corporations with Level 3 Unit Capacity↑

Number of Hospitals with Services LHIN Trauma

Unit Burn Unit

Neuro-surgery

Cardiac Surgery

Invasive Cardiology

Diagnostic Cardiology

Invasive Radiology

Vascular Surgery

Dialysis ENT Paediatrics

Central - - - 1 1 4 3 3 3 3 4 Central East - - - - 1 2 4 4 4 4 1 Central West - - - - - - 1 1 1 2 1 Champlain 1 1 2 2 3 5 4 2 3 4 2 Erie St. Clair 1 1 1 - 1 3 3 2 3 4 3 Haldimand Brant 1 1 1 1 1 1 5 5 3 5 3 Mississauga Halton - - 1 1 1 3 3 3 2 3 3 North East 1 - 1 1 1 2 4 2 7 5 5 North Simcoe Muskoka - - - - - 3 1 1 1 2 2 North West 1 - 1 - - 1 1 1 1 1 1 South East 1 - 1 1 1 1 1 1 1 2 1 South West 1 1 1 1 1 2 3 2 1 5 5 Toronto Central 2 1 3 3 4 6 6 3 6 6 3 Waterloo Wellington - - - 1 1 3 1 2 2 4 2 Total 9 5 12 12 16 36 40 32 38 50 36

↑Information was provided at the Hospital Corporation Level alone.

Note:

1- Invasive Cardiology refers to having angioplasty capability

2- Diagnostic Cardiology refers to having cardiac angiography capability

3- Paediatrics denotes that unit may keep paediatric patients even for short terms.

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MAP C: Location of Neurosurgery and Trauma Services

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2.3 Provincial Organization of Critical Care Units A single physician was involved in coordinating admission and care decisions in 56 (74%) of the 76 Level 3 critical care units with more than seven beds. Table H provides a provincial breakdown of this information.

Table H: Intensivist Led Models in Level 3 Units

Total Number of Level 3 Units in Hospitals with Level

3 Capacity

Intensivist Led Model In Level 3 Units

LHIN Number of Hospitals with Level 3 Unit Capacity <8 Beds 8 - 12

Beds 13+ Beds <8 Beds 8 - 12 Beds 13+ Beds

Central 6 - 5 3 4 3 Central East 7 - 5 2 - 2 1 Central West 2 - - 2 - - 2 Champlain 7 2 3 3 1 1 3 Erie St. Clair 5 2 5 1 - 2 1 Haldimand Brant 8 2 5 6 1 4 3 Mississauga Halton 4 1 1 4 - 1 4 North East 8 5 2 1 1 1 - North Simcoe Muskoka 6 3 2 1 1 1 1 North West 1 - - 1 - - 1 South East 3 - 2 1 - - 1 South West 8 5 1 3 1 1 3 Toronto Central 7 - 2 12 - 2 12 Waterloo Wellington 4 2 4 - 1 3 - Totals 76 22 37 40 6 22 35


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3.0 Erie St. Clair LHIN Board Chair: Mina Grossman-Ianni LHIN CEO: Gary Switzer Critical Care LHIN Leader: Dr. Michael Sharpe

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3.1 Inventory Data Table 1: Hospitals with Level 3 Unit Capacity

Critical Care Beds Hospitals with Level 3 Unit Capacity (5 hospitals)

Number of Acute Beds

Total (Level 2 & 3) Vent Capable

Bluewater Health (Mitton Site) 97 29 14

Chatham-Kent Health Alliance (Public General Site) 229 22 7

Hotel-Dieu Grace Hospital 321 24 29

Leamington District Memorial Hospital 88 4 2

Windsor Regional Hospital 503 19 19

Totals 1238 98 71

Table 2: Hospitals with a Maximum of Level 2 Unit Capacity

Critical Care Beds Hospitals with a Maximum of Level 2 Unit Capacity

Number of Acute Beds

Total BiPap Capable

Bluewater Health (Charlotte Eleanor Englehart) 35 2 YES

Totals 35 2

Table 3: Non Intensivist-Led Level 3 Units (≥ 8 beds)

Hospital Name Unit Name Total Number of Critical Care Beds

Bluewater Health (Mitton Site) Lambton County Critical Care Unit (4 East Acute)

8

Chatham-Kent Health Alliance (Public General Site)

Intensive Care Unit 10

Hotel-Dieu Grace Hospital Coronary Care Unit 9

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3.2 LHIN Leader Report

3.2.1 Overview

The Erie-St. Clair LHIN is in the far southwest corner of Ontario surrounded by the Great Lakes and the associated rivers, and bordered by the United States to the west. Erie-St. Clair is served by 9 acute care hospitals. Seven of these hospitals offer critical care services, of which 5 provide mechanical ventilation.

3.2.2 Critical Care Service Capabilities in the LHIN

Breadth of Critical Care Services in the LHIN

The seven acute hospitals with critical care units have a potential total of 118 critical care beds, including, 71 Level 3 and 24 Level 2 critical care beds. Currently, the actual critical care bed operating capacity of Level 3 beds is only 59 as 7 Level 3 beds in the coronary care unit (CCU) and 5 Level 3 beds in the intensive care unit (ICU), both at Hotel Dieu Grace Hospital, are not utilized due to unavailable staffing, and restrictions of nursing resources in the CCU due to limitations imposed by the geographical layout of the unit. The five hospitals that have critical care beds with ventilating capacity are: Chatham Public General, Hotel Dieu Grace, Leamington District, Windsor Regional, and the Mitton (Bluewater Health Alliance) hospitals. Two acute care hospitals do not have critical care beds; the Norman Site of the Bluewater Health Alliance and the Syndenham District Hospital (Chatham Kent Health Alliance; the Level 2 critical care units at this hospital was closed due to low occupancies and low acuity of patients).

Critical Care Strengths in the LHIN

The Hotel Dieu Grace Hospital and the Windsor Regional Hospital, Metropolitan Campus are the region’s Trauma and Burn Referral Centres, respectively. Both house Level 3 units which are managed by intensivists, have respiratory therapists dedicated to the unit and are therefore capable of caring for most medical and surgical critical illness, including neurosurgical interventions; patients who require cardiac surgical intervention are referred to London Health Sciences Centre in LHIN 2. All technological resources are currently available, including acute dialysis, invasive monitoring and intraaortic balloon counterpulsation. Recently they have received funding for invasive cardiology to be in place in 2007. They are a satellite teaching hospital of the University of Western Ontario, Faculty of Medicine.

The remaining hospitals have respiratory therapists, who are shared with other areas of the hospital with 24-hour day/seven days a week (24/7) support, with the exception of Leamington Hospital; here they are on-call for callback to the hospital on off hours. All critical care units (Level 2 and 3) are capable of non-invasive ventilation.

Critical Care Services Absent in the LHIN

Public General in Chatham, Leamington District and Bluewater Health (Mitton site) in Sarnia, are not supported by intensivists, and do not have acute dialysis capability which necessitates the transfer of any critically ill patient needing urgent dialysis, to a regional referral centre, often when the patient is at their highest acuity of illness. Patients in Sarnia and Chatham are referred to London Health Sciences Centre; Leamington patients are referred to either of the two Windsor hospitals. Neither of these hospitals have neurosurgical support, and therefore

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head trauma patients are also referred to regional hospitals according to the geographical origin of the patient.

Critical Care Challenges and Unique Features within the LHIN

With the exception of the Windsor hospitals, the capability of the remaining hospitals in the LHIN to care for acute critical illness is variable and is dependent on the acuity of critical illness as well as the comfort/experience of the hospital’s attending physicians, which is also quite variable. In a smaller community hospital, such as Leamington, where the volume of critically ill patients is low, it is challenging for the local physicians/nursing staff to attain and maintain a comfort level in dealing with these critically ill patients. Other larger hospitals, such as in Sarnia and Chatham, take care of a larger volume of critically ill patients and therefore their capability to care for higher acuity patients exceed those of Leamington.

The referral patterns of this LHIN are interesting as they are significantly influenced by how patients are able to access the regional referral centres, by land. For instance, patients from Sarnia and eastward, are referred to London Health Sciences Centre in LHIN 2, whereas, patients in the southern half of this LHIN are referred westward to Windsor. There are no direct land routes in the north/south direction within this LHIN. Therefore, consideration of patient transfers in the north/south direction (Sarnia to Windsor), for the purposes of acute dialysis, for instance, would be restricted to air transport only. This would result in significant inconvenience for families, traveling to visit family members. Also, how these patients would be transferred back to their home hospital (repatriation) also needs to be considered.

3.2.3 Opportunities and Priorities for Improving Critical Care Services

Potential for Expansion of Critical Care Services (Accessibility)

In Hotel Dieu Grace Hospital, there are 5 Level 3 critical care beds currently not utilized in the main critical care unit (the ICU at hospital) due to staffing issues, however, these beds are occasionally occupied due to surges in volumes of patients requiring a critical care bed. In the CCU, only 2 of 9 beds are currently ventilated due to staffing constraints. There is also potential to increase the total coronary care bed number to 10 - 11 beds depending on whether they are designated as Level 2 or 3 critical care beds. In Chatham Public Hospital, only 7 of 10 critical care beds are Level 3. Leamington has 2 of 4 beds designated as Level 3. Overall, this results in a potential increase of 17 Level 3 beds. There is no other geographical “space” within these hospitals critical care units to allow expansion or opening of more critical care beds.

Is there a potential/desire of a hospital’s ICU to increase their service capability through hiring of new medical staff? For instance, hiring of intensive care trained nursing, respiratory therapy and physicians (trained intensivists, nephrologists), in order to, enhance hospital’s ability to care for critically ill patients with higher acuity of illness, would improve that particular regions access to critical care, as well as, negate the need for referral to a regional centre.

Improving the Hospitals Critical Care Service Capabilities (Quality)

Increasing comfort/expertise of the critical care team will lead to improved quality of care. This may be achieved by educational programs directed at critical care nurses, as well as, development of benchmarks/care bundles/protocols directed at enhancing patient care. The potential to add new programs to specific hospitals which would augment their overall ability to

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care for the high acuity critically ill patient should be investigated, for example, addition of nephrology, acute dialysis capability at Sarnia Hospital (Bluewater Health).

Improve System Integration

For hospitals that do not have the patient numbers to enable the critical care teams’ comfort/experience in caring for the critically ill, there are opportunities to improve efficiency of patient transfer to regional referral centres. This could be achieved by:

Development of individual hospital patient transfer criteria. These criteria are determined by each hospital’s limitations to meet patients’ needs. Community hospitals rely heavily on referral to regional health centres due to limitation of services/expertise.

Development of transfer partnerships between community hospitals and regional referral centres. These partnerships may be within the LHIN or may require referral to extra-LHIN hospital, dependent upon service need. For example transfer from LHIN 1 to London Health Sciences Centre (LHIN 2) for cardiac surgical referrals.

Educational program aimed at developing guidelines/protocols for “Resuscitation –Stabilization and Transfer of the Critically Ill Patient”; the do’s and don’ts of referring/transferring patients. Particularly important for community hospitals whose experience is minimal due to few patients.

Development of Hospital Repatriation Policy; once the transferred patient’s care can be met by the home hospital, arrangements should be made to repatriate patient as soon as possible. Procedural guidelines for the repatriation of patients should be a component of the Policy.

Optimizing accessibility and transferring patients to the most appropriate hospital capable of caring for their level of acuity of illness is challenging due to the geography and rural distribution of the population. An evaluation of CritiCall (already performed) and the subsequent adoptions of recommendations aimed at improving efficiency is an important component of delivering critical care services within this LHIN. Lengthy delays of patients with lesser acuity of illness, by local ambulances services, are often a problem. Integration of patient transfers to hospitals within LHINS, as well as, between LHINS, needs to be examined.

In terms of quality assurance, opportunities to promote dialogue between centres such as scheduled teleconference rounds between community hospitals and regional referral centres on topics relevant to each hospital’s needs or related to recent patient transfers should be investigated.

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4.0 South West LHIN Board Chair: Norm Gamble LHIN CEO: Tony Woolgar Critical Care LHIN Leader: Dr. Michael Sharpe

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Number of Acute Beds Total (Level 2 & 3) Vent Capable

Grey Bruce Health Services (Owen Sound) 174 20 8 Huron Perth Health Alliance (Stratford General Hospital) 144 5 5 London Health Sciences Centre (University Hospital) 341 67 36 London Health Sciences Centre (Victoria Hospital) 448 54 30 Middlesex Hospital Alliance (Strathroy Middlesex Hospital) 79 4 4 St. Thomas - Elgin General Hospital 166 6 6 Tillsonburg District Memorial Hospital 63 5 5 Woodstock General Hospital Trust 122 6 3 Totals 1537 167 97

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Critical Care Beds Hospitals with a Maximum of Level 2 Unit Capacity

(15 hospitals)

Number of Acute Beds Total BiPap Capable

Alexandra Hospital 39 4 NO Alexandra Marine & General Hospital 61 4 YES Grey Bruce Health Services (Meaford Site) 27 3 NO Grey Bruce Health Services (Markdale Site) 19 2 NO Grey Bruce Health Services (Wiarton Site) 16 3 NO Grey Bruce Health Services (Lions Head Site) 4 2 NO Hanover & District Hospital 49 1 YES Listowel Memorial Hospital 51 2 YES Middlesex Hospital Alliance (Four Counties Health Services) 16 4 YES South Bruce Grey Health Centre (Kincardine Site) 31 3 YES South Bruce Grey Health Centre (Durham Site) 12 2 YES South Bruce Grey Health Centre (Walkerton Site) 31 3 YES South Bruce Grey Health Centre (Chesley Site) 12 1 NO St. Joseph's Health Care, London (St. Joseph’s Hospital Site) 166 2 YES

Wingham and District Hospital 50 4 YES Totals 584 40


4.2.1 Overview

South West LHIN encompasses an area of 22,000 square kilometers with an adult population of 696,150 (population density of 31.5 people per square kilometer) and is served by 28 acute care hospitals, of which all but four small community hospitals, offer critical care services.

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There a total of 224 critical care beds in LHIN 2, of these 99 are Level 3 beds (1 Level 3 bed per 7030 population) and 125 Level 2 beds (1 Level 2 bed per 5570 population). Fifteen of the hospitals with Level 2 critical care beds have non-invasive ventilation capability.

The London Health Sciences Centre (LHSC) Victoria and University Campuses are the region’s Trauma/Burn and Neurosciences/Cardiac surgery referral centres, respectively. They both house Level 3 critical care units that are managed by intensivists and are capable of caring for any medical and surgical critical illness, including neurosurgical and cardiac surgical interventions. All technological resources are currently available, including acute dialysis, invasive monitoring, intra-aortic balloon counterpulsation and invasive cardiology. Both LHSC and St. Joseph’s Health Care (SJHC) centres are the teaching hospitals of the University of Western Ontario’s (UWO) Faculty of Medicine.

The remaining 6 hospitals with Level 3 critical care units are not supported by intensivists, and do not have acute dialysis capability which necessitates the transfer of critically ill patients requiring acute dialysis, to a regional referral centre. Currently, LHSC is the only referral centre in LHIN 2 capable of acute dialysis.

LHSC is the only centre with respiratory therapists dedicated to the critical care unit; respiratory therapy coverage in the other hospitals is usually shared with other areas of the hospital. Eleven community hospitals have no respiratory therapy support.


None.


The actual number of available critical care beds varies over time due to staffing availability/overrun of critical care budgets, and the inability to transfer patients out of these units. These factors impact on the ability to provide immediate care for patients requiring admission to a critical care unit and to accept regional referrals. Occasionally, it results in the need to transfer patients to other remote hospitals. Seven of the nine hospitals do have a potential to increase the total bed capacity of Level 3 beds in this LHIN by 12% (12 beds).

Only 9 of the 28 hospitals in LHIN 2 are capable of mechanical ventilation; Grey Bruce Health Services (Owen Sound), Stratford General Hospital, Woodstock General Hospital, Strathroy Middlesex Hospital, LHSC (University and Victoria campuses), SJHC, Tillsonburg Hospital, and St. Thomas Elgin Hospital. It is therefore challenging to provide immediate access to Level 3 beds, for this population, which is distributed over a large geographical area. An efficient critical care transport system (CritiCall) is therefore mandatory in order to obtain appropriate critical care in a reasonable period of time.

With the exception of the London hospitals, the capability of the remaining hospitals in the LHIN to care for acute critical illness is variable and is dependent on the acuity of critical illness as well as the comfort/experience of the hospital’s attending physicians, which is also quite variable. In the smaller community hospitals such as in the Grey Bruce and Huron Perth Alliances, the volume of critically ill patients is low and it is therefore challenging for the local physicians/nursing staff to attain and maintain a comfort level in dealing with these critically ill

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patients; therefore accessibility of an ICU bed in regional referrals centres, is a necessity. Other larger hospitals, such as St. Thomas Elgin, Stratford General, Woodstock General and Strathroy Middlesex Hospitals, are more self-sufficient and care for critically ill patients with higher acuity. Again, once the care requirements of the ICU patient exceed the resources of the local hospital, transfer to a regional referral centre is a necessity.

There are primarily two regional referral centres in LHIN 2 (LHSC and Owen Sound hospitals), which is primarily determined by geographical location of the transferring hospital, and the support required by the patient. Most patients in the northern half of the LHIN are referred to Owen Sound hospital with the exception of patients who required neurosurgical, cardiac surgical interventions, or acute dialysis; these services are only available at LHSC, which necessitates a number of patients who are acutely ill to be transferred to this centre.

Patients in the southern half of the LHIN are referred to LHSC, which houses all medical and surgical sub-specialities. Since LHSC is the only trauma, burn, cardiac surgery and neurosurgical referral centre for this large region, it is imperative to maintain accessibility of LHSC’s ICU beds for the purposes of receiving referrals to these sub-specialities. Currently, LHSC is experiencing a critical bed shortage, and as of September 5, 2006 was declared a System Crisis 1A Designation. The number of patients admitted in the Emergency Departments continues to exceed available capacity. LHSC continues to be closed to regional referrals with the exception of regional trauma, renal and stroke care. As a result of the inability to transfer patients to the ward from our ICU’s, LHSC is not capable of receiving referrals from hospitals within our LHIN as a result of ‘ward’ patients occupying our ICU beds. This is not an infrequent problem.



There is potential to expand the number of Level 3 beds by 12% (12 beds). This should not require acquisition of support services (nurses/respiratory therapists) as these are currently in place; other than hiring more of these individuals as dictated by the number of Level 3 ICU beds.

Owen Sound Hospital currently has an intensivist who is aiming to change the physician support of the ICU, which includes attracting more intensivists to work at this hospital and eventually develop an “intensivist led’ ICU. Administration is also attempting to attract a nephrologist, which would result in acute dialysis capability. These initiatives should be supported as Owen Sound has the potential and administrative support to become the referral centre for the northern part of this LHIN. It will also result in not having to transfer acutely ill patients to LHSC for the purposes of acute dialysis. With the development of an intensivist led Level 3 ICU, there would be potential to attract other services, including trauma surgery.


Increasing comfort/expertise of the Critical Care Team will lead to improved quality of care. This may be achieved by educational programs directed at ICU nurses, as well as, development of bench marks/care bundles/ protocols directed at enhancing patient care.

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For hospitals that do not have the patient numbers to enable physician/nurse comfort/experience in caring for the critically ill, there are opportunities to improve efficiencies of patient transfer to regional referral centres:

Development of individual hospital patient transfer criteria. These criteria are determined by each hospital’s limitations to provide patient’s needs. Community hospitals rely heavily on referral to regional health centres due to limitation of services/expertise.

Development of transfer partnerships between community hospitals and regional referral centres. These partnerships may be within own LHIN or may require referral to another LHIN hospital, which is dependent upon patient need (e.g. transfer from LHIN 1 to LHIN 2 (LHSC) for cardiac surgical referrals.

Educational program aimed at developing guidelines/protocols for “Resuscitation –Stabilization and Transfer of the Critically Ill Patient”; the do’s and don’ts of referring/transferring patients. Particularly important for community hospitals whose experience is minimal due to few patients.

Development of Hospital Repatriation Policy; once the transferred patient’s care can now be met by the home hospital, arrangements should be made to transfer patient, ASAP. Procedural guidelines for the repatriation of patients should be a component of the Policy.

Optimizing accessibility and transferring patients to the most appropriate hospital to care for their level of acuity of illness is challenging due to the geography and rural distribution of the population. An evaluation of CritiCall (already performed) and the subsequent recommendations aimed at improving efficiency is an important component of delivery of critical care within this LHIN. Lengthy delays of patients with lesser acuity of illness, by local ambulances services, is often a problem. Integration of patient transfers to hospitals within the LHIN, as well as, outside the LHIN, needs to be examined.


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5.0 Waterloo Wellington LHIN Board Chair: Kathryn Durst LHIN CEO: Sandra Hanmer Critical Care LHIN Leader: Dr. William Plaxton

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Cambridge Memorial Hospital 205 7 6 Grand River Hospital (Kitchener Waterloo Site) 301 27 12 Guelph General Hospital 193 22 10 St. Mary's General Hospital 160 29 22 Totals 859 85 50


Critical Care Beds Hospitals with a Maximum of Level 2 Unit

Capacity (3 hospitals)


Groves Memorial Community Hospital 55 2 YES North Wellington Health Care Corporation (Louise Marshal Hospital) 31 2 NO North Wellington Health Care Corporation (Palmerston District Hospital) 31 1 NO Totals 117 5



Guelph General Hospital Critical Care – Acute 11


5.2.1 Overview

The Waterloo Wellington LHIN is immediately west of the GTA, and is characterized by high population growth – second highest in Canada at 3.9% year over year. This growth is in part due to the technology and manufacturing industries within the region. Waterloo Wellington is served by 7 acute care hospitals. Six of these hospitals have critical care units, of which 4 provide mechanical ventilation.

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The six acute hospitals with critical care units have a potential total of 84 critical care beds, including, 52 Level 3 and 32 Level 2 critical care beds. The four hospitals that have critical care beds with ventilating capacity are: Cambridge Memorial Hospital, Grand River Hospital, Guelph General Hospital and St Mary's General Hospital. The hospitals with only Level 2 units are Groves Memorial Community Hospital and North Wellington Health Care Corporation (Louise Marshall Site). Only one acute care hospital (North Wellington Health Care - Palmerston District Hospital) has no critical care service.

All technological resources are currently available, including acute dialysis, invasive monitoring and intra-aortic balloon counterpulsation. All critical units have access to respiratory therapy services.

From a medical and specifically a critical care perspective, LHIN 3 hospitals are also characterized by growth – in efforts to keep pace with ever-rising population demands for clinical care. In the absence of any tertiary care/teaching hospital within LHIN 3, our hospitals have been asked to implement and manage clinical programs, which traditionally have only been found within teaching centres. This has been a growth challenge indeed for affected hospitals. Funding envelopes have made such growth difficult, however, our area hospitals continue to focus upon best practices and evidence-based medicine.

Critical care services across LHIN 3 can best be described as:

Limited in capacity for current regional demand. Limited in scope of existing support services. Limited in resources for the quality changes that have been implemented since 2002 in

some critical care units within LHIN 3. High functioning past performance and current human and technology, and bricks and

mortar resource envelopes.

Overall, enormous strides have been made in taking formerly open access critical care units to intensivist-led (“closed”) models - in line with current evidence and best practice models. Without a doubt, most specialists across LHIN 3 have commented on the rising standards of critical care since 2002, and our increasing ability to care for more complex and high-risk populations. Spin-offs from these administrative changes have also included the recruitment of high quality acute clinical nurse practitioner (ACNP), critical care nursing, respiratory therapist, and new Royal College trained intensivist staff members. Positive momentum appears to be well established in the large critical care units across LHIN 3. However, like all successful programs they require ongoing support for growth.


Regional demand for critical care resources is currently in excess of current supply for staffed, intensivist-led, ‘Level 3’ critical care. This imbalance appears to be widening in LHIN 3. Disequilibrium has resulted in part from new higher throughput volumes for wait time strategy populations - who routinely require critical care support and carry higher burdens of chronic disease and therefore complexity.

Other drivers of LHIN referrals to our “closed” access critical care units include high acuity and complexity programs that are also growing quickly within LHIN 3. Two examples of which include the renal program (intermittent and ICU-based continuous renal replacement therapy)

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and the regional medical, surgical, and radiation oncology programs. The supply/demand service gap can clearly be seen through simple analysis of CritiCall data indicating inter-LHIN transfers to our “closed” access units.

The most stark and troublesome service gap across all of LHIN 3 is the lack of any neurosurgical program or neurosurgical consulting service. Ministry leaders I hope will review the history of neurosurgical care in Waterloo region (which due to fiscal challenges was cancelled in 1991) and the current demands for neurosurgical care as indicated by LHIN 3 transfers out of our region for this specialty service. Many critical care, surgery, emergency medicine, and administrative leaders suggest that the reimplementation of neurosurgery services in LHIN 3 will facilitate the care of our growing trauma, cancer care, and stroke/neurology patients as we grow into the future.


One of strengths of critical care services in LHIN 3 includes recent moves to implement intensivist-led multidisciplinary team-based models. This has been accomplishes at St. Mary’s Hospital and Grand River Hospital. Important and multiple impacts have resulted within and between these hospitals and across LHIN 3 – largely relating to the ability to handle high acuity populations as never before on a local basis. This newfound strength has worked well to enable our oncologists, surgeons, and emergency rooms to handle higher volumes of more unstable and complicated patients.

The LHIN hospitals have been made aware of the above changes, and that the larger critical care units across LHIN 3 are ready and willing to accept transfer patients who exceed local comfort and/or critical care resources. A new culture of cooperation is the goal across our LHIN critical care units, and we continue to reinforce the above message.


The most important challenges/characteristics that impact quality critical care delivery across LHIN 3 include the following:

Lack of a tertiary care centre within LHIN 3. Absence of neurosurgical care within LHIN 3. Limited capacity for “closed” access Level 3 ICU beds. Lack of a high functioning trauma team system across LHIN 3. Operational challenges secondary to limited chronic ventilation beds across LHIN 3.

The intensivist-led critical care units across LHIN 3 are attempting to meet supply with demand for human, physical and technologic resources for our life-threatened patient populations. The former culture of stabilization and transfer to a tertiary care centre for trauma and neurosurgical care is being met with resistance from tertiary care hospitals – who are struggling with their own capacity matters. Inefficiencies often arise for chronic ventilation patients who are unable to wean from ventilatory support within all our critical care units – since lack of downstream beds requires them to occupy acute care Level 3 beds in queue. Overall capacity limitations for Level 3 beds exist and will soon be addressed with new capital projects at the Grand River Hospital site – most critical care delivery professionals across the LHIN hope that this project will receive fast-track attention at a Ministry level.

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Several important priorities should be addressed by critical care medicine, administrative, and ministry professionals. Those which in the opinion of my LHIN colleagues, should receive priority attention include:

Fast tracking of the funded and approved capital project at the Grand River Hospital site for psychiatry, surgical processing and the new 20-bed ICU. This will:

• Increase capacity to reflect current demands across LHIN 3 for high quality Level 3 critical care beds.

• Support our orthopaedic, surgery, and oncology teams to meet wait time agreements.

• Support the growth and demand of complicated patients for renal dialysis, chemotherapy, and emergency medicine.

Re-implement a neurosurgical program within LHIN 3

• Demand is clearly evident – as it was in 1991 not to mention 2006. • Existing tertiary care neurosurgical programs are increasingly unable to accept

promptly transfers from this patient population – and this is likely to worsen in the future.

• The lack of neurosurgery in LHIN 3 is a major barrier to critical care, emergency room (ER) care, trauma management, and any future growth of the LHIN 3 regional cancer/radiation therapy programs in terms of quality or capacity endpoints.

Implement a trauma and trauma team program within LHIN 3.

• The growing demand for high-level expertise is quite clear – timely transfer out of LHIN 3 to tertiary care programs is becoming more challenging.

• The volumes of penetrating, blunt, and motor vehicle collision (MVC) patients across LHIN 3 and in particular the larger centres within LHIN 3 are rising at alarming rates – clearly exceeding our system’s capacity already in 2006.

• Our “closed” access critical care units and intensivists are able to manage our portion of this population’s care needs, but critical care cannot do this alone. General surgical, orthopaedic surgical and neurosurgical support will be required as will a dedicated team-based system on an ‘on-call’ basis.

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Provide funding and administrative support for those LHIN 3 critical care units, which are on the cusp of moving to an intensivist-led management model. This will:

Elevate the complexity capacity for Level 3 beds across LHIN 3. Help manage the service gap as population growth and patient complexity rises within

those centres (Guelph and Cambridge) Assist in attracting high quality professionals to support such units. Example, ACNP’s,

critical care nurses, and intensivists.


Within the past few years there has been strong cooperation among the critical care units in our LHIN to build on patient focused, evidence based care. There are still opportunities to:

Formalize hospital patient transfer criteria. These criteria are determined by each hospital’s limitations to provide patient’s needs.

Development of transfer partnerships between community hospitals and larger referral centres. This will become even more important as new programs such as neurosurgery and trauma are established.

Develop educational program aimed at developing guidelines/protocols for “Resuscitation –Stabilization and Transfer of the Critically Ill Patient”; the do’s and don’ts of referring/transferring patients.

Optimize accessibility and transfer of patients to the most appropriate hospital capable of caring for their level of acuity of illness.

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6.0 Hamilton Niagara Haldimand Brant

Board Chair: Juanita Gledhill CEO: Pat Mandy Critical Care LHIN Leader: Dr. Peter Kraus

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Brantford General Hospital 349 15 7 Hamilton Health Sciences Corporation (General Site) 295 79 55 Hamilton Health Sciences Corporation (Henderson Site) 237 17 9 Hamilton Health Sciences Corporation (McMaster University Medical Site) 317 22 22 Joseph Brant Memorial Hospital 305 14 11 Niagara Health System (St. Catherines General Site) 236 24 12 St. Joseph's Healthcare Hamilton (Charlton Site) 409 33 15 West Lincoln Memorial Hospital 60 4 4 Totals 2208 208 135





Haldimand War Memorial Hospital 35 2 NO Niagara Health System (Greater Niagara Site) 187 14 YES Niagara Health System (Welland Hospital Site) 283 16 YES Norfolk General Hospital 121 6 YES The West Haldimand General Hospital 33 3 NO Totals 659 41

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Brantford General Hospital Critical Care Unit 15 Hamilton Health Sciences Corporation (General Site)

Burn Unit 10

Joseph Brant Memorial Hospital ICU/CCU 14 Niagara Health System (St. Catherines General Site)

ICU/Cardiac Monitored Care 24


6.2.1 Overview

Hamilton Niagara Haldimand Brant (HNHB) LHIN stretches from Fort Erie to Turkey Point and Paris to Lowville and covers approximately 7,000 square kilometres. It has the second largest population of all LHIN regions in Ontario. It is home to 1,352,500 people encompassing the areas of Brant, Burlington, Haldimand, Hamilton, Niagara and Norfolk. There are 17 acute care hospitals, 9 of which offer critical care services.



The HNHB LHIN benefits from superior critical care resources centralized around the academic tertiary care centres at St. Joseph’s Health Care and Hamilton Health Sciences. Overall there is a good mix of these large Level 3 centres, large Level 2 community centres (St. Catherine’s General, Joseph Brant Memorial Hospital and Brant Community Health Care System) and smaller Level 2 community centres (Norfolk General, Welland, Greater Niagara and West Lincoln Hospitals) offering critical care services. There are 25 units in the 9 hospitals offering critical services, representing a total of 249 critical care beds with an average of 9.6 beds (range 2, 25). The majority of units in this LHIN (37%) are mixed ICU/CCU units. There is one burn and one cardiac-surgical unit in this LHIN.


Single physician-coordinated care is in place in only 9 (35%) of the units in this LHIN, 8 of which are the Level 3 units.


Because of the traditional referral pattern within the LHIN, critical care resources operate in basically a hub and spoke mechanism already. The referral system for Level 1, 2 and 3 critical care services is well aligned within LHIN 4 boundaries. In general LHIN 4 is a microcosm of the provincial critical care system and is reflective of most of the wider provincial challenges. Nearby access to Buffalo provides readily available access for extra critical care services when the local system is overloaded.

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Although by no means a comprehensive list of challenges, the most obvious immediate challenges overall involve human resources, units moving to intensivist-led management models, patient transfer issues and clarifying definitions of services capabilities.

As the hub of the LHIN, Hamilton Health Sciences & St. Joseph’s Health Care System continues to have difficulty in providing adequate in-house critical care physician staffing (residents or clinical assistants) in their tertiary referral/quaternary units. This is due to relatively large number of critical care units and lack of seniority among medical residents in Hamilton.

The Brantford General Hospital unit has no ICU/CCU medical director and an aging physician work force. This may be the main reason for “capability” issues. They also suffer from a lack of critical care dialysis facilities. Likewise, West Lincoln Memorial Hospital suffers from Physician workload issues as well.

Although both Greater Niagara & Welland Hospitals could potentially handle Level 3 patients, workload issues bring maintenance of competency into question. These hospitals will become more dependent on St. Catherine’s General Hospital as the NHS continues with their critical care transformation. Similarly, moving from Level 2 to Level 3 capabilities also currently challenges the Norfolk General Hospital unit.

Both Haldimand War Memorial & West Haldimand General Hospital face challenges in transferring patients to Level 2 and 3 units when necessary.

Joseph Brant Memorial Hospital is battling the challenge of setting up an intensivist-led model Level 3 unit. The lack of critical care dialysis facilities is a key barrier. Likewise, internal issues have come to light as St. Catherine’s General Hospital rolls out their critical care transformation strategy, which involves moving to a “closed” ICU with intensivist staffing as well.



Opportunity for electronic ICU (e-ICU) capabilities at Brant Community Health Care System

Improve access to critical care services for Haldimand region and decant Level 2 patients from Hamilton region. Both could be done in intensivist-led or “closed” critical care units or in critical care units where physicians have had Advanced Critical Events Simulation Course (ACES) training.


Potential to run intensivist-led or “closed” critical care units at St. Catherine’s General and Joseph Brant Memorial Hospitals. Financially viable (from physician’s perspective) if coupled with physician-led Critical Care Response Teams (CCRT) at these community hospitals.


ACES training for non-intensivist providing critical care in community level (Level 2) critical care units.

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7.0 Central West LHIN Board Chair: Joe McReynolds LHIN CEO: Mimi Lowi-Young Critical Care LHIN Leader: Dr. Michael Miletin

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7.1

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Inventory Data Table 1: Hospitals with Level 3 Unit Capacity

Critical Care Beds Hospitals with Level 3 Units (2 hospital) Number of Acute Beds Total (Level 2 & 3) Vent Capable

William Osler Health Centre (Brampton Site) 385 20 12 William Osler Health Centre (Etobicoke Site) 262 18 12 Totals 647 38 24



Capacity (1 hospital)


Headwaters Health Care Centre (Orangeville Site) 74 4 YES Totals 74 4


7.2.1 Overview

The Central West LHIN includes the western part of the GTA (northern Etobicoke and Brampton), and extends north to Orangeville. Central West is served by 3 acute care hospitals, all of which have critical care units that provide mechanical ventilation.



The three acute care hospitals with critical care units have a potential total of 42 critical care beds. There are 38 Level 3 beds (at Osler-Brampton and Osler-Etobicoke) and 4 Level 2 beds at Headwaters Health Care centre.

There are two Level 3 medical-surgical ICUs (20 and 18 beds at Brampton and Etobicoke respectively) with 6 beds at both sites dedicated to patients requiring coronary care. The Level 3 units are intensivist-led, with 24/7 respiratory therapist coverage. Due to staffing and funding constraints, each unit can only manage up to 12 ventilated patients. One of the units can provide alternative modes or adjuncts to mechanical ventilation for severe respiratory failure, namely high frequency oscillation and inhaled prostacyclin. Both units can provide invasive monitoring and continuous renal replacement therapy, with one unit also providing hemodialysis. Both sites have on-site access to invasive radiology, computed tomography scanning, bronchoscopy, diagnostic and therapeutic gastro intestinal (GI) endoscopy, ear nose and throat (ENT), and surface and transesophageal echocardiography. Only the Brampton site has magnetic resonance imaging on-site. Both Level 3 critical care units care for postoperative thoracic surgery patients. In addition, the Brampton critical care unit cares for postoperative vascular surgery patients. The Brampton unit also supports a large local oncology program.

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Osler-Brampton has received funding for a diagnostic (but not therapeutic) cardiac catheterization (cath) lab for 2007.

Neither of these units manages neurosurgical, cardiac surgical, trauma, or burn patients. These patients are sent to various referral centres in different LHINs, mostly within the GTA.

The Level 2 unit in Orangeville is not intensivist led. Rather, a variety of specialists (internal medicine and anaesthesia) attend to the patients. Respiratory therapist coverage is limited to daytime with some nights also covered. Arterial and central venous catheters can be used in this unit. On average, a majority of these beds are used by cardiac patients at any given time. The Level 2 unit can provide non-invasive ventilation. Invasively ventilated (intubated) patients and/or patients with multiple organ failure are transferred to other critical care units, usually outside Central West LHIN. No thoracic or vascular surgery is performed at Headwaters Orangeville.


The LHIN lacks invasive cardiology, cardiac surgery, neurosurgery and trauma. CritiCall is used extensively to facilitate timely transfer outside the LHIN for patients requiring these services.


The two Level 3 units have an intensivist-led management model, a total of 10 intensivists, 24/7 respiratory therapist coverage and dedicated multidisciplinary teams. Both units offer continuous renal replacement. Ethics consultation is available in both Level 3 units. Osler-Brampton is planning to move to a new, larger building in the fall of 2007. This move may result in the expansion of critical care resources at this site.


The population of Central West LHIN has increased by 100,000 people (30%) from 2001-2005 and is projected to continue to increase at a rate of 20,000 people per year over the next 10 years (mostly in the Brampton area). However, critical care bed numbers in this LHIN have remained stable over last several years. Central West currently has one of the lowest ICU bed/100,000 population ratios in the province.

Central West has a high rate of utilization of CritiCall services, with patients consequently receiving critical care outside of the LHIN. This is due to the frequent unavailability of open Level 3 beds and a lack of certain services in this LHIN (e.g. invasive cardiology, neurosurgery, and trauma). Avoidable days accrued by CCU patients awaiting invasive cardiology testing (e.g. cardiac catheterization) to be performed outside Central West LHIN impedes access to critical care beds (i.e. CCU beds may go over-census causing a reduction in the number of open general ICU beds in these shared units).

Data collection and analysis, even for a minimum data set, is almost non-existent in the Level 3 units.

The Level 2 unit at Headwaters has not yet entered into a relationship with the Level 3 units at William Osler which could potentially provide support via intra-LHIN transport of patients requiring Level 3 care and e-ICU initiatives. The Level 2 unit is not intensivist-led and faces difficulty recruiting intensivists due to the small size and lower acuity of the unit.

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There are opportunities for expanding the Level 3 units. Even with improvements in efficiency and flow (and these do need to occur), this LHIN will not be able to provide adequate critical care services to an area of massive population growth (Brampton) without more physical beds, critical care nurses, respiratory therapists and intensivists.


Implementation of an e-ICU initiative to support the Level 2 unit in Orangeville would enhance the services provided there. Concerted efforts and adequate resources must be directed to ensuring that the units in Central West are capable of quality data collection and interpretation. Armed with relevant process and outcome data, units can identify areas which require quality and performance improvement initiatives and benchmark themselves against their peers

Improving System Integration

For hospitals that do not have the patient numbers to enable physician/nurse comfort/experience in caring for the critically ill, there are opportunities to improve efficiency of patient transfer to regional referral centres:

Development of partnership between William Osler and Headwaters hospitals in order to maximize service delivery within the LHIN.

Development of transfer partnerships between Level 3 units and regional referral centres for services not available in Central West LHIN (invasive cardiac, cardiac surgery, trauma, and neurosurgery). These partnerships should be formalized and appropriate transfer protocols negotiated.

As part of an e-ICU program, there could be a continuing education component to ensure continued best practice skills of critical care providers at the Level 2 unit at Headwaters.

Surge planning. Both hospital corporations within the LHIN must review their current emergency/pandemic plans and integrate them at the LHIN level. This can serve as a basis for surge planning at the LHIN level.


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8.0 Mississauga Halton LHIN Board Chair: Juanita Gledhill LHIN CEO: Michael Fenn Critical Care LHIN Leader: Dr. Laurence Chau

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Halton Healthcare Services Corporation (Milton District Hospital) 70 6 3 Halton Healthcare Services Corporation (Oakville Trafalgar Memorial) 317 16 12 The Credit Valley Hospital 386 16 16 Trillium Health Centre (Mississauga Site) 632 49 49 Totals 1405 87 80



Capacity (1 hospital)


Halton Healthcare Services Corporation (Georgetown Site) 55 3 YES Totals 55 3


8.2.1 Overview

The critical care services in the Mississauga Halton LHIN are provided in three hospital corporations; Trillium Health Centre, Credit Valley Hospital and Halton Healthcare Services. The first two are essentially single-site corporations (Trillium also has an out-patient facility at Queensway). Halton Healthcare Services has three sites, namely Oakville, Milton and Georgetown.



All three hospital corporations in this LHIN offer Level 3 critical care services. Trillium Health Centre also has invasive cardiac investigations, cardiac surgery and neurosurgery. Because of provision of such services, Trillium Health Centre can receive transfer of patients requiring such services from hospitals within or without the LHIN via CritiCall.

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Credit Valley Hospital is developing into a major oncology centre and has renal replacement services. Trillium Health Centre surprisingly does not offer hemodialysis (except for cardiac surgery patients and only in the cardiovascular ICU) and critically ill patients requiring acute dialysis are transferred to Credit Valley Hospital, if possible, by mutual agreement.

Oakville Trafalgar Memorial Hospital also has renal replacement services and is developing a satellite hemodialysis unit at Joseph Brant Hospital, Burlington (outside the Mississauga Halton LHIN). Because of the renal liaison, critical care patients from Burlington requiring urgent dialysis are currently primarily referred to Oakville.

Milton District Hospital operates a Level 3 critical care unit, although generally more complicated cases are referred to Oakville Trafalgar or are otherwise transferred outside the corporation via CritiCall.

Georgetown Hospital operates a Level 2 critical care unit (Closed Observation Unit). All critically ill patients and patients requiring more than 24 hours of mechanical ventilation are transferred, predominantly directly to Oakville, otherwise CritiCall is contacted to facilitate transfer.


One particular ‘service location’ issue in this LHIN is that Trillium Health Centre does not offer hemodialysis (except for cardiac surgery patients and only in the cardiovascular ICU) and therefore critically ill patients requiring acute dialysis must be transferred to Credit Valley Hospital, when possible. This seems to be mutually amenable for now but is not a sustainable plan for the future.


The spectrum of critical care services provided within the Mississauga Halton LHIN is fairly extensive and comprehensive. The medical surgical unit at Trillium Health Centre and the mixed ICU/CCU units at Credit Valley Hospital and Oakville Trafalgar Memorial Hospital are all intensivist-led units with dedicated intensivists and respiratory therapists. All these units operate at a level that can manage competently the majority of critically ill patients in community hospital setting and transfer is infrequent and mainly due to the lack of beds or requirement for advanced tertiary/quaternary services (e.g. trauma or burn cases). All these hospitals participate in CritiCall and there are also some transfers of critically ill patients between these hospitals as well as from hospitals outside the LHIN due to local environment and mutual agreements as outlined above.


Within the Halton Healthcare Services Corporation, the Oakville site is expected to take the more critical cases from the sister hospitals and sometimes the Oakville site can be inundated with transfer requests. All the corporations are suffering from a shortage of critical care beds and critical care beds “blocked” by stable chronic ventilator-dependent patients are a problem common to all critical care units.

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The creation of a chronic ventilator-dependent patients unit within the LHIN that will accept patients from all three corporations would certainly help with freeing up acute critical care beds.

Critical care surge capacity planning is happening both inside and outside the LHIN and more formal activities should be in place in the next six months.


Strategies to adopt clinical best practices in all critical care units should be developed to improve and standardize quality of care within the LHIN. Currently all three corporations are actively but independently engaged in quality improvement projects associated with the Canadian ICU Collaborative and the Safer Health Network.


Currently the delivery of critical care services in these three corporations is independent of each other. It would be beneficial to have a more transparent and cohesive network of these critical care units to facilitate improved delivery of services. Examples include transfer of patients within the LHIN critical care units in times of crisis, such as acute bed shortage and surge situations. The critical care information system currently under development should facilitate this process.

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9.0 Toronto Central LHIN Board Chair: Daniel Sullivan LHIN CEO: Barry Monaghan Critical Care LHIN Leader: Dr. Tom Stewart

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Mount Sinai Hospital 472 30 16 St. Joseph's Health Centre (Toronto) 387 21 15 St. Michael's Hospital 570 66 54 Sunnybrook Health Sciences Centre (Sunnybrook Site) 446 75 57 Toronto East General Hospital 412 21 21 University Health Network (Toronto General Hospital) 353 80 52 University Health Network (Toronto Western Hospital) 239 32 22 Totals 2879 325 237





Sunnybrook Health Sciences Centre (Orthopaedic & Arthritic Site) 48 2 YES Women's College Hospital - 1 YES Totals 48 3


9.2.1 Overview

Toronto Central is an entirely urban area with the highest population density in Ontario. The LHIN includes several of Ontario’s largest hospitals including the greatest concentration of Ontario’s Academic Health Science Centres. Toronto Central receives a high number of transfer patients from neighbouring LHINs. The combination of the dense urban population, the incoming patient transfers and full range of specialty services means that Toronto Central’s critical care resources are frequently operating at > 95% occupancy.

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The adult acute critical care services in the Toronto Central LHIN are found in Mount Sinai Hospital (MSH), University Health Network (UHN), St. Michael’s Hospital (SMH), Sunnybrook Health Sciences Centre (SB), Toronto East General Hospital (TEGH) and Women’s College Hospital (WCH). The entire spectrum of critical care services is available within the LHIN – with most institutions offering tertiary and quaternary services. The Level 3 medical-surgical ICUs are intensivist-led while there is a heterogeneous approach to intensivist utilization in other units – particularly the Level 2 areas but including some higher level sub-specialty units. There is a variable degree of system integration within hospitals – notably SMH and SB have critical care departments and one administrative reporting structure for a variety of critical care areas. Although it is likely, the extent to which this improves efficiencies and systems-thinking within these institutions is unknown.

Within the LHIN there has historically been little integration of critical care services between hospitals. Notably there is one administrative director for the medical-surgical ICUs at Mount Sinai and UHN and there is cooperation between the units in terms of identifying available beds. In addition across the LHIN there is increased collaboration between units. Notably the 4 larger university teaching hospitals (MSH, SB, UHN and SMH) have the most integration in terms of teaching, quality practices and patient care. However the Toronto East General Hospital has a relatively new ICU director and as a result there is more communication and integration between the medical-surgical ICUs of all the institutions.


None.


The Toronto-Central LHIN is able to offer all the services necessary for critical care within the LHIN up to the tertiary and quaternary levels. In fact this LHIN also serves the needs of critically ill patients from other LHINs – serving as a regional and frequently provincial referral area. Given that many of the critical care areas are intensivist-led and academic centres there is generally openness to utilizing and evaluating cutting-edge technologies and service delivery models (e.g. critical care response teams) – arguably these institutions would fit into the category of “early-adaptors”. There is also improving inter-hospital as well as intra-hospital collaboration for a variety of reasons. Toronto East general offers a specialized weaning centre for patients difficult to wean from the ventilator – this is unique and a definite advantage. The team is quick to respond and is willing to go to other institutions for evaluations. Within the LHIN there is generally good flow of patients to and from this weaning centre. In addition one of the province’s few hospitals with services for chronically ventilated patients is within the LHIN, however this institution has very high occupancies with corresponding long-wait times. As a result the provision of acute care services in the other institutions is hampered by the presence of chronically ventilated patients. This issue is the subject of a recent review and recommendations submitted to the minister of health.

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Given that in general this LHN serves as a regional referral centre and has high volumes, repatriation of referred patients continues to be a major issue. Currently repatriation relies only on direct communication and good will and as a result is a continuous challenge. Repatriation is also hampered by the perception (that may be incorrect and certainly uncertain in the absence of data) that these referral centres offer “better” care. Even when centres that have referred patients to the Toronto-Central LHIN are willing to accept patients back to their institution, they frequently lack availability of a critical care bed. Repatriation continues to be a major challenge that impacts on the availability of unique or higher level services offered by the LHIN.

Another challenge is related to human resources, particularly nursing. The median age of critical care nurses is increasing and with this frequently comes a desire to live outside the city in the 905 region. In addition, the cost of living in the city is also increasing. For both these reasons it is increasingly difficult to recruit and retain health care workers in the city – such individuals choosing to work in outlying institutions.

Data collection for benchmarking purposes and continuous quality improvement is fragmented across the LHIN. Most of the medical-surgical ICUs have developed a local data collection system – however the indicators vary widely. It should be noted that as part of Ontario’s Critical Care Strategy, a provincial approach to data-collection is being developed. All of the institutions with intensivist-led critical care services in the LHIN will be getting critical care response teams operating as of November 01, 2006. The general site at UHN already has such a team operating as part of the ministry’s pilot project.



Surge planning that emphasizes critical care needs and integration with the critical care strategy is essential. This was a significant issue during the SARS outbreak. The Toronto Central LHIN will likely be affected significantly by the next pandemic based on the density of the population, the multi-cultural community and the leadership as well as referral role the institutions have played. As a result it is important that our LHIN gets surge planning right.


An aspect of the Ontario Critical Care Strategy that is especially important is the critical care information system, which will allow for improved understanding and dissemination of the best care.


Systems integration both within hospitals and between hospitals will be an ongoing opportunity. For example, institutions are likely to gain efficiencies by viewing and operating their critical care areas as an integrated system. This is unique to our LHIN in that the size of the hospital has allowed for the development of silos of critical care areas each with unique features and challenges.

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10.0 Central Board Chair: Ken Morrison CEO: Hy Eliasoph Critical Care LHIN Leader: Dr. Donna McRitchie

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10.1

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Humber River Regional Hospital (Church Site) 271 11 11 Humber River Regional Hospital (Finch Site) 219 14 14 Markham Stouffville Hospital (Markham Site) 200 8 5 North York General Hospital 420 21 14 Southlake Regional Health Centre 373 33 23 York Central Hospital 313 18 14 Totals 1796 105 81



Markham Stouffville Hospital (Markham Site)

ICU/CCU 8


10.2.1 Overview

The Central LHIN contains the northern part of the City of Toronto, most of York Region and part of Simcoe County. The Central LHIN is the largest LHIN population wise and is home to about 1.61 million people. It is the third highest in population density and the third smallest in terms of geographic size. The Central LHIN is mainly urban, but has a significant rural component in its northern boundaries. This LHIN is one of the fastest growing in Ontario and has an annual growth rate of 3.3%. Half of the new residents are immigrants and by 2016, it is projected that 13% will be greater than 65 years old. The Central LHIN is served by 8 Level 3 critical care units at 6 acute care hospitals.



In general, the critical care services offered in our LHIN are comprehensive and of high quality. We provide a broad range of services in virtually all of the subspecialties with the exception of neurosurgery, trauma, and burns. The units are improving the quality and efficiency of their work and are trying to hire appropriate, highly skilled individuals to run them. This includes not only physicians, but also nursing and allied health. Virtually all of the individuals in leadership, recognize the benefit and appropriateness of an intensivist-led management model of care in

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their critical units. There is recognition by both the administration and medical leadership that this is “the way to go” to improve access, efficiency, and quality care.


The Central LHIN does not provide specialized trauma, neurosurgical, or burn critical care services.


It has become apparent that we have strong leadership on multiple fronts, including physician and nursing leaders, as well as middle and senior administrators. It is clear that there is a strong will to “get the job done”. There is a sense of a genuine desire to work within the system to make things better. There is recognition of the fact that many of these new initiatives and programs have been driven by the people in the field as opposed to being dictated by agendas elsewhere. There is also a desire to break down the barriers and form new alliances and relationships.

Our LHIN has a diversity of patient population, of medical staff, and certainly geographic location. This diversity could certainly be viewed as a strength as it drives a more flexible and comprehensive care model in many hospitals. There seems to be recognition in virtually all of the institutions that critical care must be a priority. While difficulties can occur due to problems that we all have (for example flow problems) it is recognized by everyone that the critical care environment is where the critically ill patient needs to be. Tremendous efforts are being made to ensure timely access to care and to address problems when they arise in this area. All institutions were open to initiating dialog between the different member hospitals and to providing support for each other as needed. There is a general sense that at certain times we all need the help of other institutions. This may take the form of accepting patients in transfer, accessing specialized services or individuals, borrowing of equipment, etc.

Our LHIN also has the strength of being very broad in the services it provides. With the exception of neurosurgery, burns, and trauma, we have virtually all of the other subspecialty services.


The diversity of our LHIN institutions and the populations they serve is felt to be a strength, but it can also be a challenge. There may be significant differences in needs and in the ability to implement change when the reality is that one institution may serve a relatively elderly population whereas another institution serves a new growth community with young families.

Also, there have been very few pre-LHIN ties and relationships between our various institutions. Most of the Critical Care Units and Emergency Departments have forged their own informal networks and referral lines and there is uncertainty as to whether there should be an effort to abandon those ties and move more towards the LHIN institutions. While most are welcoming the potential to form new relationships, there is uncertainty and hesitation about what will happen to older established networks. This is particularly so if it is perceived that these older relationships are working well.

One of the other challenges is basic geography. Geographically, there is quite a diverse area covered by our LHIN. I think many of the institutions feel there are hospitals much closer to them, but in other LHINs, that are a better fit and these may be institutions that they have already formed ties with.

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It is also important to understand that some of the units are struggling with many difficult day-to-day issues. These include staffing shortages, lack of physician coverage and/or intensivist coverage, difficult obsolete work environments, and operational or institutional stresses that they have little control over. While this is not unique necessarily to our LHIN, there are certainly units within our LHIN that have greater challenges in this regard than others.



The issue of access to and the use of CritiCall also came up in a number of conversations. Once again there was a sense of that there was not necessarily a level playing field with respect to accessing beds in other units. This should perhaps be looked at in an evaluation of CritiCall and how it gathers information from the various units.

A priority for our LHIN is access to what might be considered tertiary services. Specific issues brought up were dialysis and neurosurgery. These two services in particular seem to be problematic for several of our LHIN hospitals.

Another priority over the next few years will be to address the problem of surge capacity. As we all know, Ontario’s Critical Care Strategy was set about due to the SARS crisis and certainly future epidemics, pandemics or perhaps disasters will undoubtedly test our system again in the future. I believe it is imperative that each major unit develops a plan, which they could implement in a facile fashion to deal with this kind of a problem.


I believe it is important for both quality and efficiency to have “closed”/intensivist-led units. Obviously this is not possible for smaller institutions, but certainly for larger Level 3 units and most Level 2 units this should be possible and supported. One of the important ways I believe of doing this is to “incentivize” the system and the players to mutually beneficial outcomes and rewards.

When talking about staffing and coverage the other key component, other than the physician component is critical care nursing. It is extremely important to stabilize and secure the future care of critically ill patients by ensuring that critical care nursing is valued and rewarded accordingly. I think it is imperative that critical care nursing be recognized for the subspecialty expertise that it has. Until this is done closures will continue, dissatisfaction with the work environment will continue, and burnout will persist.


It has come to our attention that virtually all units are concerned about lack of standardization between different critical care units. There is a suspicion that not everyone is being dealt with fairly in terms of allocation of resources. All want to implement information sharing technologies to better communicate both within and also extrinsic to the LHIN. In order to interact in a seamless fashion between institutions even within our LHIN, it would be necessary to have a degree of standardization and communication that we currently just do not have.

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11.0 Central East LHIN Board Chair: Foster Loucks LHIN CEO: Marilyn Emery Critical Care LHIN Leader: Dr. Howard Clasky

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11.1

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Lakeridge Health Corporation (Oshawa Site) 338 16 16 Peterborough Regional Health Centre (Hospital Drive Site) 282 20 12 Ross Memorial Hospital 167 8 6 Rouge Valley Health System (Centenary Site) 337 18 9 Rouge Valley Health System (Ajax & Pickering) 136 8 5 The Scarborough Hospital (General Site) 347 27 12 The Scarborough Hospital (Grace Site) 232 14 8 Totals 1839 111 68





Campbellford Memorial Hospital 34 4 NO Haliburton Highlands Health Services Corporation (Haliburton Hospital Site) 13 2 NO Lakeridge Health Corporation (Bowmanville Site) 75 5 YES Northumberland Hills Hospital 137 6 YES Totals 259 17

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Peterborough Regional Health Centre (Hospital Drive Site)


Ross Memorial Hospital Intensive Care Unit 8 Rouge Valley Health System (Centenary Site)


Rouge Valley Health System (Ajax & Pickering)

ICU/CCU 8


11.2.1 Overview

The Central East LHIN is the sixth largest LHIN geographically. It is the second largest LHIN based on population with a total population of about 1.46 million people or about 12% of the population of Ontario. There are three major population centres: The Scarborough area, home to about 25% of the population of Toronto, the rapidly growing more centrally located Ajax, Pickering, Whitby and Oshawa areas, and the developing Peterborough area located further east. Serving these three overlapping population centres are four high volume corporations offering Level 3 critical care service. This diverse population is expected to grow at a rate of 6.9%, which is higher than the provincial average.



The region consists of eight corporations that provide critical care services. There are a total of 128 critical care beds with 81 Level 3 beds and 47 Level 2 beds. There are three major population hubs: The Scarborough area comprising 40% of the population is serviced by the Rouge Valley Health Centre Centenary Site and The Scarborough Hospital Grace & General sites; the Ajax, Pickering, Whitby and Oshawa area comprising 30% of the population is serviced by the Rouge Valley Ajax and Pickering Site as well as Lakeridge Health Corporation; and the Peterborough area comprising another 15-20% of the population is serviced by the Peterborough Regional Health Centre. All of these corporations and sites offer Level 3 critical care. There is a fourth Level 3 centre servicing 5% of the population located in Lindsay as well as three Level 2 centres located in Coburg, Campbellford, and Haliburton.

A wide range of services and specialties are offered in the region that impact critical care. These include a satellite stroke centre, advanced ventilation, thoracic surgery, interventional cardiology, IABP, vascular surgery, advanced endoscopy, intermittent and continuous dialysis, Obstetrics and Gynaecology, invasive radiology, and a cancer centre.

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These services as well as the large local population and anticipated growth place significant demands on critical care services in the region. The region’s corporations are well placed to serve the community as long as capacity and associated infrastructure are developed to their full potential.


The Central East LHIN does not currently have neurosurgery, cardiac surgery, a trauma centre, a burn unit or chronic ventilation unit services within its region. These patients are primarily referred to the Toronto Central LHIN. Partnership and transfer agreements with other LHINs require development. Local development of these services requires further discussion.

Academic ties between regional corporations and academic facilities do exist and a number of sites have established residency program links. That being said, there is no tertiary care facility located within the LHIN itself.


The region has in general embraced Ontario’s Critical Care Strategy as a template for change. This necessary buy in is both top down and front line. A group of committed providers and administrators have been identified and a strong hub and spoke model of care is already developing in the region.

A key deliverable identified by the LHIN executive is the development of an intensivist–led (“closed”) management model at the 4 largest corporations. Improved access to care and quality of care is anticipated. This concept has been disseminated to the corporations and a timeline has been set. The leadership of the 3 remaining critical care units that should move to an intensivist-led model have firmly committed to this deliverable.

The buy in from administration and front line providers for change is clear. Critical Care Coaching Team applications were accepted for 6 corporations including 2 for the intensivist-led management model. Three corporations within the region are currently participating in the Best Practice Clinical Demonstration Project*. The leadership at Ross Memorial Hospital have self-initiated the development of a critical care response team. These initiatives speak to the region’s commitment to patient care and quality improvement.

Despite the absence of certain services, the Central East LHIN critical care units manage very complex general critically ill patients. Local and provincial data documents relatively high mean Apache II scores† that rival those in academic facilities. The presence of dialysis at multiple centres allow for the highest level of critical care at these sites. This lends itself to putting the right patient in the right bed.

The region and local providers are committed to working as a network managing most patients within the region except for those requiring tertiary services not yet locally available. To support network development, the regional leads have identified the development of an “always” open as an important deliverable. This concept has been disseminated to the local critical care leads as an important piece to improve access.

* The Coaching Teams and Best Practice Project are strategic quality improvement initiatives being led by the Critical Care Secretariat. For more information visit the Critical Care Strategy website: http://www.health.gov.on.ca/english/providers/program/critical_care/critical_care_mn.html † Score used to measure severity of illness of critically ill patients.

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A general analysis of CritiCall data reveals that the Central East LHIN is not yet functioning as a self-sufficient network. Analyzing the data of referrals originating within the Central East LHIN (Apr 05-Mar 06) reveals that 975 patients were transferred out of a Central East LHIN hospital. Only 57 or 6% of these patients were transferred to another Central East LHIN hospital. The remaining 918 patients were transferred from the Central East LHIN to another LHIN. The Toronto Central LHIN was the destination of 818 of these patients. Of the patients transferred to the Toronto Central LHIN, 488 (or 60%) required services not provided within the Central East LHIN (i.e. neurosurgery, cardiac surgery, trauma, burn). That being said, the remaining 330 patients could have conceivably been managed within the Central East LHIN if the network was more developed. It is also important to note that lack of capacity in the Central East LHIN accounted for over 80% of the non-accepted critical care patient referrals originating from a Central East LHIN partner. Improved efficiencies and possible capacity investments should improve network development.

Physician human resource concerns are a critical issue for this region. A single point of accountability and organizational change to develop an intensivist-led management model is dependent on appropriate human resources. The LHIN and local corporations are committed to developing an objective measure as to what the immediate and short term intensivist needs are for the region as well as an objective assessment of available manpower. A corporate as well as a LHIN based manpower structure may be necessary. This LHIN also deals with the unique issue of seasonal demographic due to the summer and winter recreational areas in the area.

The lack of a tertiary care facility within the LHIN may require the development of different models and partnerships to achieve optimal results.

Level of care definitions for Campbellford and Haliburton may need to be revisited. Likewise, complex critical care patient management at Ross Memorial requires further discussion and development. Issues around growing Northumberland and possibly Bowmanville into Level 3 facilities, if needed, requires organizational and human resources development.



Network development through organizational change and investment is needed. Certain high growth areas with relatively smaller critical care units such as Rouge Ajax and Pickering (an 8 bed combined ICU/CCU) require support to develop an optimal intensivist-led model unit.

Development of an intensivist-led model may benefit from critical care response team funding at two very large important centres in the region, specifically Lakeridge Health Oshawa and Peterborough Regional Health Centre.

Measuring the total chronic ventilation patient burden in the region as well as options for management need to be discussed. For example, currently a single corporation’s chronic ventilation census occupies 20% of that facility’s Level 3 beds and 5% of the region’s Level 3 beds.

Optimize management and transport with protocols and procedures.

System level training of generalists.

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Single point of accountability and organizational change to develop intensivist-led “closed” management models and accumulating the necessary human resources s a key deliverable in most centres. This organizational change is critical to develop local and regional performance improvement initiatives, as well as a self-sufficient network with adequate capacity.

Best practice uptake at Lakeridge Health, TSH, PRHC, and Northumberland should be continued. The region should facilitate uptake of the Best Practice Demonstration Project at other sites.

Critical Care Coaching Team uptake has been excellent. Facilitate further Critical Care Coaching Team uptake as needed.


In conjunction with the Provincial Table and LHIN executive, develop local and regional critical care leadership that is non hierarchal and team building in nature.

The LHIN leadership has initiated quarterly teleconference meetings of the region’s critical care leads with a defined action plan focusing on the initiatives outlined in this report. Ontario’s Critical Care Strategy has been taken to ground level.

With respect to CritiCall and transfer patterns, discussion locally and at the critical care LHIN leader provincial table to develop an “always” open-bed concept within the region.

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12.0 South East Board Chair: Georgina Thompson CEO: Paul Huras Critical Care LHIN Leader: Dr. John Muscedere

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Brockville General Hospital 103 9 3 Kingston General Hospital 456 64 21 Quinte Healthcare Corporation (Belleville Site) 210 10 4 Totals 769 83 28





Lennox and Addington County General Hospital 32 3 NO Perth and Smiths Falls District Hospital (Perth Site) 53 4 YES Perth and Smiths Falls District Hospital (Smith Falls Site) 44 4 YES Quinte Healthcare Corporation (Prince Edward County) 38 3 NO Quinte Healthcare Corporation (Trenton Memorial) 70 4 YES Totals 237 18



Brockville General Hospital Intensive Care Unit and Step-down

9

Quinte Healthcare Corporation (Belleville Site)



12.2.1 Overview

The South East LHIN includes all of Hastings County, Lennox & Addington, Prince Edward County, Frontenac County, and the City of Kingston. This LHIN contains most of Northumberland County, as well as Leeds & Grenville and Lanark Counties, which are split

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with the Champlain LHIN. It extends along Lake Ontario and the St. Lawrence River for a total of 215 Km and north from Lake Ontario for 144 Km. Its total population is 442,800.



In the South East LHIN critical care services are delivered in 5 hospital corporations (Kingston General Hospital [KGH], Brockville General Hospital [BGH], Lennox and Addington County General Hospital [LAGH], Quinte Health Care Corporation [QHC] and Perth and Smith Falls General Hospital [PSFGH]), of which KGH is an academic health sciences centre and serves as the regional referral centre. These 5 hospital corporations operate on 8 sites and have a total of 1006 acute care hospital beds. Of these, 101 beds are designated as critical care beds and are located in 17 critical care units (10 at KGH), which vary in size from 3 beds to 21 beds. In the last year for which statistics were available, a total of 8,659 patients received critical care services in the South East LHIN for a cumulative number of over 23,000 patient days.

On examination of the regions critical care units, it is apparent that the total number of critical care beds includes beds that meet the definition of critical care for the purposes of this inventory but essentially only have the capability for patient monitoring, are predominantly oriented to the care of the cardiac patient and may have very limited specialist support. If one removes these (3 from LAGH, 4 from KGH (CCU Step-down) and 3 from QHC (Prince Edward County Memorial Hospital), the total number of what can be considered “true” critical beds in the South East LHIN is 91 beds.

On further analysis, there are 40 critical care beds in Level 3 units but only 28 of these beds can support prolonged mechanical ventilation (28% of the total critical care beds). There are 61 beds in Level 2 units and of these 51 can accommodate non-invasive ventilation. Of the Level 3 units (located at BGH, Belleville General Hospital (QHC) and KGH) and the 28 beds that can accommodate prolonged mechanical ventilation, 21 are located at KGH.

Although critical care can be categorized as Level 2 or 3 units, primarily based on their ability to support mechanical ventilation, further characterization based on the level of support services is required to obtain the true ability of individual ICUs to care for critically ill patients with multi-system organ failure. Some of these support services are: full sub-specialty coverage, ability to do dialysis and 24-hour respiratory therapist availability. ICUs that have these capabilities can be considered tertiary, Level 3 ICUs. The only tertiary Level 3 ICU in the South East LHIN is the ICU at KGH.

In regards to ICU governance, of the region’s 17 ICUs, in 5 ICUs any physician can admit (all 4 beds or less), in 10 ICUs care is by specialists only and in 2 ICUs care is delivered by an ICU attending.

The following referral patterns exist for critically ill ICU patients in the South East LHIN. For the critical care units in LAGH and Prince Edward County Memorial site of QHC critically ill patients are stabilized and transferred. For the critical care units at PSFGH and Trenton Memorial critically ill patients are transferred if they require more than short-term mechanical ventilation, develop multi-system disease or are not improving. The main referral centre is the KGH. For the critical care units in Belleville General Hospital (QHC) and BGH, critically ill patients are treated as required. However, if they develop requirements for specialized services such as dialysis or advance multi-system failure, they are transferred to KGH depending on bed availability.

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The South East LHIN has the majority of critical care services required to meet the needs of critically ill patients. The only critical care service that is not available at the LHIN level is a burn treatment facility. An ancillary critical care support service that is not available in the LHIN is a hyperbaric oxygen facility. The LHIN does not carry out transplant surgery with the exception of renal transplants. The majority of critical services are located at Kingston General Hospital, which is chronically at capacity. As a result, the availability of these services to patients from referring hospitals within the LHIN may be sub-optimal.


The major strength of the South East LHIN in meeting the needs of critically ill patients is the level of inter-hospital cooperation that occurs at the present. Operationally each hospital in the region treats critically ill patients up to their capacity and if that is exceeded, critically ill patients are transferred within the region. The referral institution is KGH, which offers the only tertiary critical care services available in the region. The intensivists at KGH are available for phone consultations in cases where transfers are not necessary. At KGH, transfers to the Level 3 ICU from within the region are given priority for admission.

In addition, the South East LHIN has the availability of all necessary critical care services within the LHIN. These services include full sub-specialty support (dialysis both intermittent and continuous, specialized surgical services such as neurosurgery or vascular surgery, full cardiac services including cardiac surgery and specialized respiratory support services such high frequency oscillation). The regional trauma centre is KGH. The only services lacking in the region are transplant surgery (with the exception of renal transplants), burn treatment facilities and hyperbaric oxygen facilities. With the exception of these highly specialized services, the LHIN should be able to meet the needs of all of its critically ill patients. From CritiCall data, for the fiscal year ending March 31 2006, 97 patients were transferred out of the region for treatment and of these only 18 were identified as requiring ICU care. However, both of these numbers may be underestimates since transfers may have occurred outside of CritiCall, after direct discussions between the referring and accepting institution. In addition, the number of patients requiring transfer for ICU care may be higher, since it is possible that some patients identified as being transferred under an accepting specialty were subsequently sent to the ICU in the receiving institution.


A feature of the South East LHIN is the relatively low population and the large area over which the population is situated. The largest metropolitan centre in the LHIN is Kingston with a population of 156,000. The low population density has resulted in multiple smaller hospital sites (5 of the 7 hospitals have 110 beds or less, one site has 210 beds and KGH has 456 beds). These population and geographic features have led to the following challenges:

There is only one Level 3 critical care unit in the LHIN that is able to provide tertiary critical care (the ICU at KGH). This unit is chronically full and as such bed availability for patients in the region that require this level of support is poor.

Compared to the provincial average, the South East LHIN is short of critical care beds capable of prolonged mechanical ventilation. To bring the South East LHIN up to the provincial average, additional beds capable of mechanical ventilation are required in the region.

There are multiple small critical care units (17 total) in the region and of the 17, 12 are 4 beds or less. Critical care units of this size are difficult to manage from a human

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resources perspective since it is difficult to train and maintain competency in health care professionals. In regards to medical staff, it is difficult to have adequate specialty support in smaller hospitals. A process of restructuring the Step down units at KGH is underway and 4 units will be consolidated into an 18-bed unit to take advantage of the efficiencies that result from increased unit size.

Information on the number of transfers between institutions is not readily available as the majority of critical care transfers inside the region, occur outside of CritiCall and are not recorded or tabulated.

There is currently no surge capacity in the system particularly as it stands for tertiary level critical care services.



Based on the provincial averages, the South East LHIN has a deficit of Level 3 critical care beds capable of mechanical ventilation. If this is borne out on the critical care inventory currently underway, the number of beds capable of prolonged mechanical ventilation should be brought up to the provincial average by increasing the number of beds capable of mechanical ventilation in the region. The mechanism by which this is done would depend on further discussions between the hospitals involved and the availability of intensivist support for the increase at the Level 3 units.

The South East LHIN would benefit from the enhancement of access to chronic ventilation. At present, patients who require long-term ventilation occupy one or two beds, on average, at the KGH ICU. The only availability of institutional chronic ventilation is at Providence Complex Continuing Care; St. Mary’s of the Lake Site. This is limited in scope and capacity. In addition, support for chronic mechanical ventilation at home is inadequate for the vast majority of patients. Enhancement of access to chronic ventilation should be a priority and formal mechanisms on how to deal with these patients on a regional basis should be instituted after consultation with all stakeholders.

The South East LHIN would benefit from the enhancement of surge capacity. Capacity for Level 3 critical care beds capable of mechanical ventilation seems to be seriously constrained within the region.


The South East LHIN has 3 Level 3 critical care units and 14 are Level 2 critical care units. Of the Level 3 units, one (KGH) is large and has an intensivist led model of organization. The other 2 Level 3 units (BGH and Belleville General Hospital) are smaller (9 and 10 beds respectively), combined ICU/CCUs and have approx 800 admissions per year. An unknown number of these admissions are acute care cardiology. In addition, 4 Level 2 critical care units at KGH are being amalgamated into a large 16 bed Level 2 unit. An intensivist led model of management should be strived for in these units. Depending on the number of critical care admissions this could range from a medical director with intensivist training to a formal intensivist led model of unit organization.

The LHIN will benefit from improved information resources and the provincial critical care information system will be an important addition. In this regard, ALL critical care transfers within and to and from the region should go through CritiCall This should commence immediately.

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A critical analysis of the region’s critical care beds should be done to ascertain the number of patients who are occupying critical care beds but who could be cared for in other units or wards of the hospitals. Examples of this are patients who cannot be transferred because of lack of ward beds, isolation issues, chronic mechanical ventilation etc. Actions to be taken would depend on the results of the analysis. Although some of this information may become available from the provincial critical care information system in the future, it would not be detailed enough to act on at the local level.


Although there is a good level of inter hospital cooperation at present, there is an opportunity to increase the level of cooperation between the hospitals in order to establish a formal network of all the critical care units in the LHIN. This network could function as envisioned in the final report of the Critical Care Steering Committee. The size of the LHIN, the currently established links between the hospital and the presence of a single referral centre would facilitate the establishment of a formal network. The level of cooperation in the network could extend but would not be limited to the following:

Developing an “always open bed concept” for critical care within the LHIN.

Protocols for transfer of patients whose acuity level exceeded the capability of the referring centre and importantly repatriation of patients once the level of acuity became appropriate.

Training of health care professionals,

Sharing of information for the treatment of critically ill patients

Standardization of equipment and technology

Increased physician education opportunities through rounds, teleconferences etc.

The conduct of quality improvement activities across the LHIN’s critical care units

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13.0 Champlain LHIN Board Chair: Michel Lalonde LHIN CEO: Dr. Robert Cushman Critical Care LHIN Leader: Dr. Redouane Bouali

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Cornwall Community Hospital 178 12 4 Hopital Montfort 208 7 4 Pembroke Regional Hospital 189 10 2 Queensway Carleton Hospital 248 16 7 The Ottawa Hospital (Civic Campus) 432 43 24 The Ottawa Hospital (General Campus) 476 37 23 University of Ottawa Heart Institute 128 22 28 Totals 1859 147 92





Arnprior and District Memorial Hospital 22 3 YES Carleton Place and District Memorial Hospital 22 4 YES Deep River and District Hospital Corporation 16 2 NO Hôpital Général de Hawkesbury & District General Hospital 69 4 YES Renfrew Victoria Hospital 54 3 YES Winchester District Memorial Hospital 55 4 YES Totals 238 20



Cornwall Community Hospital Critical Care Unit 12 Pembroke Regional Hospital Critical Care Unit 10

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13.2.1 Overview

The Champlain region includes the regional municipality of Ottawa-Carleton and the Ottawa valley from Deep River to the west to Hawkesbury in the east. The region is home to close to 1 million people and has a broad range of services from small community hospitals to the multi-site Ottawa Hospital / University of Ottawa teaching facilities.



We have well balanced coverage of Level 2 and Level 3 critical care beds in the Champlain region. Of the 16 hospitals in the region, 6 hospitals over 7 sites are Level 3 capable and 6 regional hospitals are Level 2 units by definition. In Level 3 beds, 92 are vent capable. In Level 2 defined beds, 147 are in centres where Level 3 care is available, and 20 are in community centres in the region.


There are 4 community hospitals in outlaying areas without critical care services at all. One community hospital (Deep River) does not have BiPap capability in their Level 2 facility.


This LHIN is well organized and has access to the teaching centre of the Ottawa Hospital readily available. The area is patient focused and holds quality of care to great esteem.

The region shares a strong and growing program of increased dialysis capability. The Queensway-Carleton and the Montfort are currently expanding their acute care facilities within the existing framework to meet demand for increased care. The regional trauma program also encompasses the Children’s Hospital of Eastern Ontario and the living donor programs currently available include kidney transplant and bone marrow transplant. Partnership with the Trillium Gift of Life Program is also ongoing


The area encompassed by the Champlain Local Health Integration Network follows the south side of the Ottawa River from the border with the province of Québec to Deux Rivières in the Northwest. To the south, it follows the St. Lawrence River to Iroquois and then stretches across eastern Ontario to Algonquin Park. The region covers a large geographic area, almost 18,000 square kilometres and is home to approximately 1.1 million people. There is a wide range of acute services from the small local hospital to the complex multi-site Academic Health Science Centre in Ottawa.

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Expansion is occurring at the 2 sites of the Ottawa Hospital, Hôpital Montfort and the Heart Institute. An application to Ministry of Health for 2 new beds is under consideration.


Improving critical care services within this expansion is occurring in acute dialysis units at the Queensway-Carleton and the Montfort. A Quality Improvement Fellowship was awarded to the Ottawa Hospital for $50,000.


View ICU as a system has begun to take form by site visits to each hospital in LHIN. The positive feedback received so far is encouraging the leaders to consider a formal partnering with key centres to pilot a program to establish the concept of viewing the ICU as a system. The goal of this is to increase quality of care and increased efficiency in flow of patients through the system.

Increase access to care, repatriation of patients and review of admission/transfer criteria. Repatriation of patients to the community centres has already shown excellent result in the successful repatriation of 2 patients within one week. With a 24 hour turn around in each case, between the Ottawa Hospital and 2 other regional sites, all parties involved were very encouraged by the results. An increased understanding of how this can occur in more cases through these successes is very encouraging.

Education progress will be enhanced with partnership with Canadian Resuscitation Institute (CRI) and increased communication between hospitals.

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14.0 North Simcoe Muskoka

LHIN Board Chair: Ruben Rosen LHIN CEO: Jean Trimnell Critical Care LHIN Leader: Dr. Giulio DiDiodato

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14.1

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Collingwood General and Marine Hospital 70 5 2 Huntsville District Memorial Hospital 66 4 2 Huronia District Hospital 71 8 3 Orillia Soldiers' Memorial Hospital - 8 4 Royal Victoria Hospital of Barrie 299 16 10 South Muskoka Memorial Hospital 73 4 2 Totals 579 45 23



Orillia Soldiers Memorial Hospital



14.2.1 Overview

The North Simcoe Muskoka (NSM) LHIN critical care network is comprised of five hospital corporations, only one of which is able to offer a full range of Level 3 services. The region has both limited infrastructure and human resources to support a regional critical care program. The following summary will highlight our currently available resources, their utilization and our proposals for improving critical care delivery for our LHIN.



The critical care bed ventilator capacity for the region is 23 beds, of which 19 are designated as Level 3. This translates into 1 ventilator bed (Level 3) per 22 000 people, or 1 ventilator bed per 3050 people over the age of 65 (based on 2004 population data for NSM). The cumulative regional critical care expenditure for 2005 was approximately $12 million. As of August 2006, there exist only 2 Royal College Accredited Intensivists who are currently engaged in the care of the critically ill on a fulltime basis. Only one critical care unit is intensivist-led (Royal Victoria Hospital - RVH), and the availability of hemodialysis is limited to a separate critical care unit (Orillia Soldiers' Memorial Hospital - OSMH).

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The region has limited trauma capacity, with no available neurosurgeon, and a single cardiothoracic surgeon. As a consequence of the limited overall capacity of the NSM LHIN, the region is highly dependent on the availability of out-of-region critical care beds for the transfer of critically ill patients for definitive management.


The RVH Critical Care Program has provided the region with a strong foundation for the eventual construction of a regional critical care program. With the recent announcement of funding for a Critical Care Response Team at the RVH, the human resource and program funding capacity required to support a regional critical care outreach program has been realized, and will enable the region’s critical care providers to collaborate on the care of patients, regardless of their geographic disposition, to ensure consistent and optimal outcomes. In this endeavour, there appears to exist uniform support amongst the corporations providing critical care.


Historically, the provision of critical care services in this region has occurred in non-intensivist-led critical care units, resulting in significant variances in resource utilization and patient outcomes amongst the different corporations. As an example, the unit costs of invasive mechanical ventilation across the different critical care units ranged from $300 to $1000, despite insignificant differences between the severity of patient illnesses, suggesting the variance is due to differences between physician and system practice patterns. As a consequence, there is an urgent need for an assessment of the underlying contributing factors responsible for this and other variances, along with the subsequent creation and implementation of a comprehensive regional strategy to ameliorate their impact on outcomes. Another unique resource inequality that exists is the restricted availability of acute hemodialysis services to critically ill patients admitted to Orillia Soldiers Memorial Hospital, despite the ready availability of two staff nephrologists and the presence of an intensivist-led ICU at the RVH; this, again, highlights the significant disconnect that exists between recognized best practice standards and their actual implementation across the region due to corporate isolationism and competition for finite resources. While both corporations have participated in discussions to expand the availability of acute hemodialysis to the RVH, there does not appear to be any agreement on the timing, scope or sustainability of such a program.


There are many areas for improvement in our region. At the current time, critical care is an institutional responsibility; the strategic vision, mission, financing and human resources are all supplied by individual corporations, none of whom, individually, has what would be considered a critical mass of critical care expertise or patient volumes to ensure optimal patient outcomes or utilization of critical care resources. Despite the introduction of an intensivist-led program at the RVH, there remains significant difficulty with recruitment of further intensivists due to the onerous call schedule and lack of on-call support, which is available in most other similar sized critical care units. As a consequence, the RVH critical care program has had difficulty attempting to help organize a regional critical care program. In order to improve critical care delivery in our region, I believe we need to specify the requirements for a regional critical care program. As I see it, regionalization of critical care would require the following:

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The designation of the RVH and OSMH critical care units as a single regional critical care centre.

Appropriate regional funding to support infrastructure and program development at both sites to ensure equivalent availability of resources.

Establishment of a single Department of Critical Care, responsible for the recruitment and staffing of intensivists for both centres and the region.

Extension of the Alternate Funding Arrangement that currently exists for the RVH critical care program to support the regional critical care program, along with concomitant financial support for on-call relief to be provided by the MOHLTC as recommended by the Critical Care Secretariat in order to achieve parity across the LHIN critical care units and ensure patient safety.

Implementation of a regional critical care consultative service, utilizing the Ontario Telemedicine Network, regional critical care rounds, critical care refresher courses and training support, and site visits.

Development of standardized care pathways and transport guidelines, along with repatriation arrangements to ensure efficient utilization of critical care resources and optimal patient outcomes.

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15.0 North East LHIN Board Chair: Mathilde Gravelle Bazinet LHIN CEO: Dave Murray Critical Care LHIN Leader: Dr. David Boyle

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15.1

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Kirkland and District Hospital 47 6 3 North Bay General Hospital (Scollard Site) 124 10 5 Sault Area Hospital 293 19 6 St. Joseph's General Hospital (Elliot Lake) 33 6 3 Sudbury Regional Hospital (General Site) 220 20 12 Sudbury Regional Hospital (Memorial Site) 101 19 15 Timmins and District Hospital 154 6 4 West Parry Sound Health Centre 56 6 2 Totals 1028 92 50





Sensenbrenner Hospital 53 3 YES Temiskaming Hospital 59 3 YES The West Nipissing General Hospital 88 2 YES Weeneebayko General Hospital 42 3 YES Totals 242 11



North Bay General Hospital (Scollard Site)

Critical Care Unit 10

Sudbury Regional Hospital (Memorial Site)

CVT – ICU* 15

*Note the management model is not intensivist-led (“closed”), however, there is 24/7 intensivist coverage of the unit.

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15.2.1 Overview

The North East LHIN covers the vast northeast corner of Ontario. The southern edge starts at Parry Sound-French River and goes north to James Bay; on the east borders the Ottawa valley and on the west at the mid point of Lake Superior borders North-western Ontario. The North East LHIN is served by 27 acute care hospitals. Fourteen of these hospitals contain critical care units, of which 8 provide mechanical ventilation.



Overall critical care services available across the LHIN are very good, well distributed across our large geographic area; however there are some areas of concern. Within the LHIN there are:

4 cities with comprehensive critical care units fully supported by the core specialties (including internal medicine, nephrology, general surgery, orthopaedics, full diagnostics with computed tomography and magnetic resonance imaging) – each is also a district stroke centre.

One of the 4 is a regional centre with availability of all critical care services (intensivists, full cardiac services – including angioplasty and cardiac surgery, neurosurgery, vascular surgery, thoracic surgery, regional trauma centre, regional cancer centre- radiotherapy and systemic, full range of invasive radiology services, short term paediatric critical care services)

Critical care service is distributed in hospitals in 28 different communities as follows:

Level 3 Services

One regional hospital (Sudbury) with 400 + beds (has two large Level 3 units – one 15 beds and one 12 bed unit. Plus has two Level 2 Step-down units – one 8 beds and one 4 beds).

Three communities (Sault Ste Marie, North Bay, and Timmins) with 150-290 bed hospitals; each has a Level 3 unit of 6-10 beds. Each of these centres is the major referral centre for the smaller hospitals with their respective districts.

Three communities (Parry Sound, Kirkland Lake, and Elliott Lake) with 30-60 bed hospitals each with a 6 bed Level 3 critical care unit.

The above communities with Level 3 units are all 100-300 kilometres apart.

Level 2 Services

Four communities with 30 – 50 bed hospitals with 2-3 bed units have Level 2 units.

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Some critical care services are not available in the LHIN: no transplant programs, no major spinal trauma unit, no full service paediatric critical care unit, no hyperbaric chamber, no burn unit, no high risk obstetrics/neonatal services for less than 29 weeks gestation.


The hospitals of the LHIN already have strong working relationships.

• Starting from the smaller front line community hospitals, each of these hospitals offers important critical care services to their communities, including vasoactive infusions and BiPap. Prompt access to these services is a cornerstone of access to critical care services across our large geographic region.

• Each of the 4 larger hospitals with greater than 150 beds act as district referral centres, and readily accept transfer of patients from the smaller hospitals in their district.

• The regional hospital accepts referrals from each of the other larger hospital’s critical care units, plus from smaller hospitals in their own district.

Wide range of critical care services available in the LHIN.

• Within the LHIN there is ready access to full range of critical care services. Critical care services not available in the LHIN are: no transplant programs, no major spinal trauma unit, no full service paediatric critical care unit, and no hyperbaric chamber.

Enthusiasm to enhance critical care services in their community.

• Units within the LHIN are supportive and interested in the provincial critical care initiatives; several hospitals have invited Critical Care Coaching Teams to assist them in moving their units forward. All are interested in the initiatives for enhanced training of critical care health professionals, and eligible hospitals for Critical Care Response Teams are at the planning and implementation stage.


Notwithstanding the above strengths, there are a few challenges:

Managing local surges when the next unit is 130-300 km away is difficult. The shortage of critical care nurses increases the difficulty to manage local surges.

Timely access to the regional trauma program is limited at times because of resource issues.

In most of the larger hospitals of the LHIN there are a large numbers of alternative level of care (ALC) patients occupying acute care beds, This creates downstream bed-blocking, and effectively blocks critical care beds with patients who are awaiting transfer to the ward and prevents timely access for the next critically ill patient. This issue must be addressed.

Geography, distance and weather are unique issues that will always be a challenge in the timely transfer of patients requiring critical care services. The strong working relationships

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between hospitals of the LHIN have enabled us to develop strategies to cope with this ongoing challenge.

The shortages in critical care nurses and the overall physician shortages are even worse in the north than many other regions of the province.



Critical Care Response Teams

There is one eligible hospital currently involved in the critical care response team implementation. As experience with these teams and more specifically as alternative (non intensivist) critical care response team models are developed in the smaller hospitals there will be tremendous opportunity to enhance critical care delivery in several of our hospitals.

e- ICU

The Critical Care Steering Committee’s final report alluded to e-ICUs in the future, whereby smaller critical care units would have seamless access to the expertise in larger units. This may be an important initiative to explore in future years given the number of very small units across our region.

System Level Training Initiatives:

Critical Care Response Team Nursing Training – as programs unfold our nursing and respiratory therapist staff will need to embrace these training opportunities; hopefully courses will be made available locally and/or on line.

ACES course focused on small hospitals will ensure physicians at all our hospitals provide timely and quality critical care to their community. Making access to this program within the region (locally and/or on line) would be an important initiative in the coming year or two.


Intensivist-led Large Level 3 Units

Currently only one hospital has units of 12 beds and greater – one unit is intensivist led, and the second unit has established a Critical Care Coaching Team to explore the issue. For units with 10 beds or less the issue of intensivist led has not been identified as a priority at this time.

Health Human Resource Investments

The nursing training imitative (provincial standards and E-learning solution/OSCE* in critical care nursing) and the staff retention grants are welcomed, and hopefully will help address critical care nursing shortages facing many of our hospitals across the LHIN.

* Objective Structured Clinical Examination

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Quality and Safety Monitoring Initiatives

As the critical care information dataset is initiated, I anticipate that the LHIN and respective hospitals will welcome monitoring and improving their performance in provision of quality care.


Critical Care Coaching Team Opportunities

Already several hospitals have initiated a specific Critical Care Coaching Team to address a need in their unit. I expect that this interest will grow as the positive benefits from the teams become apparent. It will be important for the hospitals in the LHIN to share their experiences with Critical Care Coaching Teams to encourage future uptake and interest by all hospitals with critical care units.

Health Human Resource Investments

The nursing training imitative (provincial standards and E-learning solution/OSCE in critical care nursing) and the staff retention grants are welcomed, and hopefully will help address critical care nursing shortages facing many of our hospitals across the LHIN.

Communication

As the LHIN leader role is new, regular communication with the units across the LHIN, and promoting Ontario’s Critical Care Strategy initiatives are an important step this year. The plan is to build strong connections with all Level 3 units in the LHIN during this fiscal year (this is aligned with provincial priority for the year).

Surge Planning

Several hospitals have acknowledged that strategies to deal with minor and moderate surges are an important issue, hence, there will be an eagerness to formalize plans to deal with mild (local) and moderate (regional) surges.

Provincial Wide Inter-Facility Transport Plan.

Inter-facility transfer is recognized as critical for patients within our LHIN to have timely access to services. Look forward to working on improving inter-facility transport.

Formalizing a Plan to Deal with Access to Critical Care Services not Available in the LHIN

Currently there are informal referral patterns for these services that usually work well - I believe there would be interest in formalizing these referral patterns to ensure continued access to these services consistently in the future. These services include: no transplant programs, no major spinal trauma unit, no full service paediatric critical care unit, no hyperbaric chamber, no burn unit, no high risk obstetrics/neonatal services for less than 29 weeks gestation.

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16.0 North West LHIN Board Chair: John Whitfield LHIN CEO: Gwen DuBois-Wing Critical Care LHIN Leader: Dr. Mike Scott

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Critical Care Beds Hospitals with Level 3 Unit Capacity (1 hospital)


Thunder Bay Regional Health Sciences Centre 375 26 13 Totals 375 26 13





Dryden Regional Health Centre 41 1 YES Lake of the Woods District Hospital 104 4 YES Riverside Health Care Facilities Inc. (La Verendrye Hospital) 60 3 YES Totals 205 8


16.2.1 Overview

Critical Care in North-western Ontario is centralized at Thunder Bay Regional Health Sciences Centre, servicing a population of 242,500. Approximately 50% of that population resides in or around the city of Thunder Bay. The geographical area of the LHIN is approximately 500,000 square km, with most of the population spread across the southern border spanning 820 km.



Level 3 critical care (with the exception of interventional cardiology and cardiac surgery) is available in Thunder Bay (22 ICU/CCU beds, 14 ventilators, 6 Bi-pap vents, plus 4-bed neurosurgical Level 2 unit), with 24-hour in-house intensivist coverage.

Level 2 beds are present in Kenora (4 beds), Fort Frances (3 beds) and Dryden (2 beds). Temporary (48 hour) ventilation supervised by GP anesthetists is available in each of these 3 hospitals.

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Lack of timely access to coronary revascularization (Percutaneous Coronary Intervention (PCI) or Cardiac Surgery) for the entire LHIN. The lack of access to coronary revascularization in this LHIN contributes to the higher mortality rates seen in Northwestern Ontario compared to anywhere else in the province.


Strengths within the North West LHIN include a central newly developed rapidly expanding intensivist-led Critical Care Program at Thunder Bay Regional Health Sciences Centre that has the capacity to service the LHIN. It has immediate access to most (not all) of the range of services noted in the first recommendation made in the Ontario Critical Care Steering Committee Final Report, including Neurosurgery, Trauma, Renal Dialysis, Obstetrics and Gynaecology and has 24 hour intensivist coverage. Another strength within the LHIN includes a very responsive chronic ventilation service at St. Joseph’s Care Group Complex Chronic Care Facility.


Long distances to the nearest critical care unit for 50% of the population. Hospitals and nursing stations within the LHIN rely on CritiCall and air ambulance paramedics to transport critically ill patients to appropriate centres over long distances, (usually over 200 km). There are often significant delays in transportation, preventing timely access for critically ill patients. Regional Coroner’s Reviews have also highlighted the concern regarding adequate and timely transport resources.

Only one Intensive Care Unit and tertiary care centre for the whole LHIN, with issues of access secondary to poor bed utilization and patient flow, and

Human Resource Issues; difficulty in attracting and retaining intensivists, critical care nurses and support staff.



Thunder Bay’s ICU presently has adequate capacity to service the LHIN, however a shortage of available hospital ward beds in Thunder Bay prevents flow from the ICU causing bed blocking on a regular basis, jeopardizing service to the rest of the LHIN. The hospital has requested the assistance of a Critical Care Coaching Team to help promote efficient flow through of beds to resolve this issue. Also, the Integrated Service Plan for North-western Ontario Project Report produced by the Hay Group and submitted to the Special Advisor to the Minister of Health and Long Term Care in June 2005, recommended increasing Long Term Care Places in North-western Ontario by 341 beds, which, by projection, would free up 41 beds at Thunder Bay Regional Health Sciences Centre and allow adequate flow to accommodate all critical care patients in the LHIN. This is yet to be realized. For this reason and also because Kenora is much closer to Winnipeg than Thunder Bay, many critically ill patients from Kenora are sent to Winnipeg where full tertiary services are available.

Thunder Bay’s ICU and patients in the Northwest Ontario LHIN have limited access to coronary revascularization (PCI or cardiac surgery), resulting in a large number of transports

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(over 95% of transports of critically ill patients) from the LHIN for interventional cardiac care. The nearest Canadian PCI Centre is Sudbury, which is 1000 km from Thunder Bay. Preferred centres including Hamilton, Toronto, and Ottawa are over 1500 km away. Rarely accessible are Duluth, MN, 320 km from Thunder Bay and Winnipeg, MB, 600 km away. Thunder Bay Regional Health Sciences Centre has developed a proposal and is partnering with Ottawa Heart Institute to implement a Percutaneous Coronary Intervention program within the next 18 months, responding to a recommendation from the Integrated Service Plan for North-western Ontario Project Report produced by the Hay Group and submitted to the Special Advisor to the Minister of Health and Long Term Care in June 2005. A satellite cardiac surgery site is not planned at present, however this needs to be re-evaluated. This is especially true in light of the reluctance of Cardiologists to perform “elective” angioplasty and stenting with no close surgical backup (backup plan is Duluth, 320 km away requiring border crossing by air transport). This will affect recruitment of specialists to the region and may prevent implementation of the program.


Based on the above challenges, and in light of the agenda set out in the Ontario Critical Care Steering Committee Final Report, the following priorities for improvement have been identified:

Thunder Bay Regional Health Sciences Centre must develop and implement a program for Coronary Revascularization to provide this vital service to the LHIN.

Consultation with Air Ambulance Transport Services must occur to optimize transport services for critically ill patients in North-western Ontario.

Thunder Bay Regional Health Sciences Centre should explore opportunities to support remote hospitals, especially in the pre-transport phase of patient care, through e-ICU technology and telemedicine to improve early goal directed therapy in critically ill patients. This is in keeping with recommendation 5 from the Steering Committee Report.

Thunder Bay Regional Health Sciences Centre should explore opportunities to support remote communities to manage short-term acute patients (i.e. overdose patients) in their district hospitals through e-ICU technology, enabling optimization of transport services. This is also in keeping with recommendation 5 from the Ontario Critical Care Steering Committee Final Report.

Opportunities exist for further formal education of physicians and nurses in Dryden, Kenora and Fort Frances to improve critical care resuscitation skills and allow those hospitals to decrease transports in the region. This may be facilitated through telemedicine and e-ICU technology.

An opportunity exists with the Critical Care Coaching Teams to improve patient flow and access to service for the region.

Recruitment and retention of critical care human resources in the northwest must be considered a priority to maintain service to the population. A relative lack of intensivists is a major area of concern and alternative methods of staffing and payment must be explored to sustain service in the north. Regional considerations must be considered when implementing recommendation 24 of the Critical Care Steering Committee Final Report.

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Other opportunities to improve critical care in the LHIN are centered in Thunder Bay Regional Health Sciences Centre and include the implementation of the Critical Care Response Team, and involvement in the Critical Care Information Systems pilot project.

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17.0 Limitations of the Inventory The baseline inventory provides important information not previously available and is an important step in understanding the critical care capacity across the province. It is important to note that this inventory has the potential for errors related to the data-collection process and transcription of the data into this report. As a result we anticipate modifications will be made as Ontario’s Critical Care Strategy moves forward. Thus the inventory should be considered a “living-document” which will be used to assist the Critical Care LHIN leadership table and the MOHLTC to better manage our critical care system.

It should also be noted that the units were assigned into levels as recommended in the Ontario Critical Care Steering Committee Final Report. Conceptually, assigning service levels to critical care units makes sense. It provides a useful organizing principle for determining what sorts of patients should be admitted to a particular unit, what sorts of staff and technologies are required in that unit and what level of corresponding funding is appropriate. Practically, assigning levels is problematic in advance of having reliable utilization data.

For the purposes of this inventory, an additional proxy measure was used to distinguish Level 3 units from Level 2 units. Units that routinely sustain mechanical ventilation for over 48 hours were considered “Level 3”. By using this proxy measure, the inventory identified a number of units as “Level 3” that do not seem to meet the more fulsome definition of “Level 3” as provided in the Steering Committee report. While this might seem to be merely an issue with the accuracy of the proxy measure, in fact it reveals the reality that some hospitals with very limited critical care resources are managing complex patients with multi-system organ failure.

Other specific data limitations include:

The inventory provided information on the total number of Level 2 and Level 3 critical care beds, however, this does not reflect capability/activity (per cent capacity) or acuity of illness provided at each critical care unit.

The capacity to administer BiPAP within individual hospitals may be underestimated since some patients receive BiPAP on the ward, as opposed to, the critical care unit. This may also reflect different patient acuity in Level 2 units, and different occupancy levels.

The Critical Care LHIN leadership table also identified several important questions that should be answered to inform more appropriately decisions regarding critical care service delivery. These include:

What is the potential to increase the ability to care for higher acuity patients and what is needed to support an increase in activity within each unit?

What is the potential to advance from a Level 2 to a Level 3 capacity? What infrastructure is needed to accomplish this?

If the critical care unit is operating at below capacity (that is less than the ‘number of funded beds’ or less than total capacity of the unit), what are the limitations to achieving full capacity? This may include issues around nursing/physician shortages.

What are the keys ‘triggers’ for transporting critically ill patients between hospitals? This would be important to inform strategies to improve the management of these patients.

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The baseline inventory, along with information regarding critical care unit capacity, represents an important foundation for making appropriate decisions on how to improve the effectiveness and efficiency of critical care services. In the coming months with the rollout of the Critical Care Information System database will be able to build on this baseline inventory, and have ongoing current data to make informed management decisions.

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18.0 Conclusion: Next Steps There are several activities that naturally flow out of the completion of this baseline inventory of Ontario’s critical care resources. Leadership for these activities will fall, as appropriate, to MOHLTC, the LHINs, hospitals or the Critical Care LHIN Leaders.

1. Development of the Critical Care Information System

Having this baseline inventory data is an essential enabler for the creation of the Critical Care Information System, which is scheduled to come on line in the first half of 2007. This new information system will, for the first time, provide hospitals, Local Health Integration Networks, the Ministry of Health and Long-Term Care and frontline critical care providers, with the information they need to support decision-making around critical care resource utilization and capacity planning and management. It will support provincial efforts to improve access to care, standardize the quality of critical care service delivery, and assist in the monitoring and evaluation of critical care services.

The Ontario Critical Care Information System (CCIS) will be managed by CritiCall, the province’s existing and familiar 24/7 critical care referral service for physicians across Ontario. This partnership with CritiCall will allow for the integration of system-wide critical care information and resources and provide a ‘one stop’ point of access for providers.

2. Critical Care LHIN Leader to Recommend Service Delivery Improvements

A key task for the Critical Care LHIN Leaders will be to integrate and analyse several datasets including:

Bed Utilization data provided by CCIS

Quality and performance data provided by CCIS

Patient transfer data provide by CCIS/CritiCall and

LHIN-Level data on demographic pressures provided by MOHLTC.

As these datasets are developed and integrated, the Critical Care LHIN Leaders will be able to make increasingly specific recommendations to their colleagues in the field as well as to LHIN and MOHLTC decision makers regarding potential service delivery improvements.

3. Identifying potential growth capacity in the system.

Having a full understanding of patient acuity, unit infrastructure and the breadth of services at given units, will enable strategies for growing the critical care system to be developed.

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4. Critical Care LHIN Leaders to Advise on Assigning Levels to Critical Care Units

While MOHLTC remains committed to implementing the recommendations as set out in the Ontario Critical Care Steering Committee Final Report, assigning levels to critical care units based on patient acuity (Levels 3, 2 and 1) as recommended in this 2005 report remains premature at this time. As one defines the ongoing critical care dataset, there is recognition that patient acuity even for Level 3's may be different in different units. Moving forward may need to factor in components of patient acuity such as degree of vasopressor support, ventilator days, acute dialysis days, true multi system high Apache score equivalents, and level of subspeciality expertise as better define patient acuity in the different units. As noted above, until CCIS provides data regarding actual utilization, assigning these levels would be arbitrary in many cases.

While the decision to assign levels in order to rationalize funding, service distribution and accountabilities is one of provincial policy, it is the LHINs that would have to work closely with Ontario hospitals to implement such a system. As LHINs take on the responsibility of managing hospital funding allocations across their LHIN, many of the key decisions as to the local arrangement of services will fall to LHIN officials in consultation with hospital leaders and the critical care field.

MOHLTC and the LHINs will look to the Critical Care LHIN Leaders, as key representatives of the field, to review the concept of assigning levels to critical care units as the CCIS data becomes available in order to reconsider whether this is an effective strategy that will help in meeting future access, quality and system integration challenges.

5. Critical Care LHIN Leaders to Champion System Change

Several aspects of the Critical Care Strategy require the on-going support of the Critical Care LHIN Leaders, including the continued movement toward intensivist-led management of the critical care units as well as providing support for the culture change required to implement Critical Care Response Teams, the Critical Care Information System and to drive toward quality/performance improvements.

6. MOHLTC Mandates New Hospital Reporting Requirements

By itself, the inventory data is not sufficient to understand current resource utilization, to make sense of patient transfer patterns, to assess performance across hospitals or to predict future access pressures. However, establishing this agreed upon baseline is an essential pre-requisite for all of these objectives. Unless it is kept up to date, the utility of this important inventory would be lost. As system steward, the MOHLTC has developed and distributed new reporting requirements to Ontario hospitals in order to ensure that our system knowledge remains current.

At the same time, the MOHLTC has communicated new reporting requirements with respect to critical care hospital participation in CritiCall. CritiCall, currently administered on behalf of the entire system, by Hamilton Health Sciences Centre, will be further developed as an official part of Ontario’s Critical Care Strategy and will play an essential role in helping the entire system manage the challenging access issues anticipated in coming years.

7. Identifying critical care support for small hospitals with no Critical Care Unit

The comment section of the inventory identified that a majority of our small hospitals provide important critical care services in step up beds on their general wards. Timely access to these

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services is important from a patient care perspective, especially where remote geography is a factor. In ongoing maintenance of the inventory may need to ensure basic infrastructure (BiPap units, pressor use skills and policies etc) and e-ICU support is also available to these small hospitals.

In closing, this inventory is a baseline from which will now build a 'living dataset' which enable managers of critical care (at local, LHIN and provincial level) to develop informed strategies that will best serve the growing critical care needs of our province.

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Appendix

Appendix A

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Critical Care Baseline Service Inventory Forms

Critical Care Secretariat Secrétariat des soins aux malades en phase critique Health System Accountability Division de la responsabilisation et de la and Performance Division performance du système de santé

Ministry of Health and Long Term Care Critical Care Baseline Service Inventory

THIS FORM INCLUDES QUESTIONS ABOUT YOUR HOSPITAL CORPORATION. ALL QUESTIONS MUST BE ANSWERED. FOR MULTI-SITE HOSPITAL CORPORATIONS, WITH THE EXCEPTION OF QUESTION 2, ALL QUESTIONS ARE ABOUT THE HOSPITAL CORPORATION AS A WHOLE. Hospital Corporation Name: If this is a multi-site hospital corporation please list the names of each site.

Site 1: Site 2: Site 3:

Site 4: Site 5: Site 6:

1. Who may we contact at (your hospital) if we have questions regarding the data submitted

for this hospital?

Name: Title: Telephone: E-mail:

Ministry of Health Ministère de la Santé and Long-Term Care et des Soins de longue durée

Appendix A

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2. On March 31, 2006 what was the total number of inpatient beds in this hospital? _________ Beds. Note: If this is a multi-site hospital corporation, please specify the total number of inpatient beds per site.

Site 1: _____ beds Site 2: _____ beds Site 3: _____ beds

Site 4: _____ beds Site 5: _____ beds Site 6: _____ beds

3. Which of the following best describes your hospital? This hospital is a:

Teaching Hospital

Non-Teaching Hospital 4. Is this hospital a designated trauma referral centre?

Yes

No 5. Is this hospital a designated burn referral centre?

Yes

No

Appendix A

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6. Which of the following specialized services are available within your hospital (i.e. no requirement for patient transfer to another hospital corporation)?

1. Neurosurgery YES NO 2. Cardiac Surgery YES NO 3. Invasive Cardiology YES NO 4. Diagnostic Cardiology YES NO 5. Invasive Radiology YES NO 6. Vascular Surgery YES NO 7. Dialysis YES NO 8. ENT YES NO 9. Paediatrics YES NO

7. Does your hospital have any inpatient care unit that meet the definition of a Level 2 or a

Level 3 critical care unit? Please refer to the Inventory Guide for definitions of a “critical care unit” and unit “Level”.

Yes

No (You do not need to answer question 8. Please return the completed form to your

LHIN critical care lead (as per the instructions in the “Instructions for Hospital Contact” document obtained with your hospital Inventory Package

8. How many critical care units does your hospital have? (Please refer to the definition

provided in the inventory guide) _____ PLEASE COMPLETE A UNIT FORM FOR EACH OF THE CRITICAL CARE UNITS IDENTIFIED IN QUESTION 8 (I.E. ALL CRITICAL CARE UNITS IN YOUR HOSPITAL).

THANK YOU FOR COMPLETING THIS SECTION OF THE INVENTORY FORM.

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Critical Care Secretariat Secrétariat des soins aux malades en phase critique Health System Accountability Division de la responsabilisation et de la and Performance Division performance du système de santé

Ministry of Health and Long Term Care Critical Care Baseline Service Inventory

THIS FORM INCLUDES QUESTIONS ABOUT THE CRITICAL CARE UNITS IN YOUR HOSPITAL. PLEASE COMPLETE ONE FORM FOR EACH CRITICAL CARE UNIT IN YOUR HOSPITAL. ALL QUESTIONS MUST BE ANSWERED. IN ORDER TO ASSIST YOU IN COMPLETING THIS FORM, A GUIDE - GUIDE TO THE LHIN CRITICAL CARE SERVICE INVENTORY - HAS BEEN INCLUDED IN YOUR HOSPITAL INVENTORY PACKAGE. PLEASE REVIEW THIS GUIDE PRIOR TO COMPLETING THIS FORM. Hospital Corporation Name: Site Name: __________________________________ CRITICAL CARE UNIT: GENERAL INFORMATION 1. Name of Critical Care Unit: _______________________________ 2. Is this unit still in operation (i.e. still exists) at this hospital? Please check the appropriate

box below.

Yes

No. You do not need to answer any more questions about this unit. Please return the completed form to your LHIN critical care lead (as per the instructions outlined in the document - “Instructions for Hospital Contact” - which was included in your hospital Inventory Package).

3. Please provide the following contact information for the lead physician for this unit (e.g.

ICU Director):

Name: _____________________________________ Title: _______________________________________ Telephone: __________________________________ E-mail: ______________________________________


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4. Please provide the following contact information for the lead nurse for this unit (e.g. Nurse manager):

Name: _____________________________________ Title: _______________________________________ Telephone: __________________________________ E-mail: ______________________________________ LEVEL OF CARE AND BED CAPACITY 5. Which of the following would best describe the functional level of your critical care unit?

(Please refer to the definitions provided in the inventory guide).

Level 2 Unit

Level 3 Unit (go to question 7) 6. If your answer to question 5 was ‘Level 2 Unit’ please tell us whether this unit is capable

of non-invasive ventilation?

Yes (go to question 8)

No (go to question 8) 7. If your answer to question 5 was ‘Level 3 Unit’, what is the maximum number of

invasively ventilated patients that your unit can support (i.e. total number of beds in your unit that are capable of mechanical ventilation)? _________

8. Over the past year, what was the usual total number of beds in operation in this unit?

_______(Please note that this number represents the normal maximum number of beds outside of periods when beds are closed due to issues such as staffing or infectious situations).

9. Do you have constructed bed space in your unit that is not in use because of lack of capital

or operating funds? (Please note by constructed space we mean a physical space that could be renovated with monitoring equipment, an actual bed and staffing resources to accommodate a critically ill patient).

Yes

No

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10. Which of the following types of patient are cared for in this unit? Please check all that apply.

Medical

Surgical

Coronary

Cardiac surgery

Vascular surgery

Neurosurgical

Trauma

Burn

Paediatric

11. Based on the patient population identified in question 10, which of the following categories would best describe your critical care unit? (Please select only one response – choose the response that best defines the primary mandate of the unit).

General ICU

Coronary Care Unit (CCU)

Cardiac Surgery Unit/Cardiovascular Unit

Mixed ICU/CCU (integrated coronary care and general intensive care unit). Select this category if there are any dedicated CCU beds in this unit.

Paediatric ICU

Burn Unit

Neurosurgical ICU

Other: Please Specify:____________________________

12. If you selected the “mixed ICU/CCU” category in question 11, please tell us whether you

have a specified number of beds in your unit that are dedicated to coronary care (CCU) patients?

Yes No (Please go to question 14)

13. If Yes, of the total number of beds in your unit, how many are dedicated for CCU

patients? _______ 14. If No, please provide us with your best estimate of the average number of CCU patients

that would be in your unit on a typical day. ______

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TECHNOLOGICAL RESOURCES 15. Which of the following technological resources do you currently have in your unit?

Intermittent Hemodialysis YES NO Continuous Hemodialysis YES NO Invasive Arterial Monitoring YES NO Intra-aortic Balloon Pump YES NO

CRITICAL CARE UNIT STAFFING AND MANAGEMENT 16. On any given day, is this unit managed by one physician (i.e. all admission, discharge and

care decisions are managed by a single physician)?

Yes

No (go to question 19) 17. If ‘YES’, please tell us what would best describe the intensivist/physician coverage for your

unit.

24-hr on-site coverage 7 days a week (includes nighttime call back)

24-hr on-site coverage weekdays only (includes nighttime call back)

Weekday and weekend daytime coverage with no night call back

Weekday coverage only, no night time or weekend coverage by intensivists

Other: (Please describe your unit’s current ICU physician staffing model for day, nights and weekends)

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18. If your answer to question 16 is YES, does one or more physician with the responsibility of managing the unit (on any given day) NOT meet our definition of an intensivist? (Please refer to the inventory guide for the definition of an intensivist).

Yes

No

19. Which of the following would best describe respiratory therapy coverage available to your

unit? Please check only one response.

No respiratory therapy coverage is available in this hospital (you do not need to answer question 20)

Respiratory therapy coverage is available but shared with other areas of the

hospital

This unit has dedicated respiratory therapy service 20. Which of the following statements would best describe respiratory therapy coverage for

your unit? Please check only one response.

24-hr in-hospital coverage 7 days a week

24-hr in-hospital coverage weekdays only

Weekday and weekend daytime coverage with no night time coverage

Weekday coverage only, no night time or weekend coverage by respiratory therapists

Other: (Please describe your unit’s current respiratory therapist staffing model

for day, nights and weekends)

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COMMENT BOX Please use the box below to provide any comments you might have regarding critical care service delivery in Ontario.

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Glossary

Critical Care Secretariat Secrétariat des soins aux malades en phase critique Health System Accountability Division de la responsabilisation et de la and Performance Division performance du système de santé GUIDE TO LHIN CRITICAL CARE UNIT SERVICE INVENTORY The LHIN critical care service inventory is being conducted at every hospital in Ontario that provides critical care services. For the purposes of the inventory, a critical care unit is defined as any unit within your hospital that has the equipment, staff, and monitoring devices necessary to provide care for critically ill patients who cannot be managed on the general wards. This includes traditional medical/surgical intensive care units (ICU), burn units, coronary care units, cardiac surgery/cardiovascular ICU, Neurosurgical ICU, Paediatric ICU and intermediate care (stepdown/stepup) units. Please note that telemetry beds are not considered critical care areas for the purpose of this inventory. Please do not include these beds/areas in your response to the data collection forms.

GLOSSARY OF TERMS USED IN THE INVENTORY FORMS Please review these terms prior to completing the inventory forms.

Type of Critical Care Unit: Burn Unit Dedicated unit that is staffed and equipped to provide specialized

care for severely burned patients.

Cardiac Surgery Unit/ Cardiovascular Unit

A unit that is staffed and equipped to provide specialized care to perioperative cardiac surgery patients.

Coronary Care Unit A unit that is staffed and equipped to provide specialized care to patients with conditions threatening to the heart (excluding cardiac surgery /cardiovascular units).

General ICU Medical, Surgical or combined Medical/Surgical units, whether they are managing Level 2 or 3 type patients. This does not include coronary care beds. Critical Care areas with coronary care beds should be classified in the mixed ICU/CCU category.

Mixed ICU/CCU Integrated intensive care/coronary care unit. If you have ANY dedicated coronary care beds in your unit, you should classify the unit in this category.

Neurosurgical ICU A unit that is staffed and equipped to provide specialized care to patients suffering from a range of neurosurgical and neurological disorders (e.g. stroke, cerebral hemorrhage, head injury, spinal cord injury, post-surgical and post-interventional).


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Paediatric ICU A unit that is staffed and equipped to provide care primarily to paediatric patients aged 0 – 17 years (excluding newborns) who, because of their illness require constant care, observation and specialized monitoring and therapies.

Level of Care:

Level 2:

Capable of providing service to meet the needs of patients who require more detailed observation or intervention including support for a single failed organ system, short-term non-invasive ventilation, post-operative care, patients “stepping down” from higher levels of care or “step ups” from lower levels of care. These units provide a level of care that falls between the general ward (Level 1) and a “full service” Critical care unit (Level 3). Level 2 units do not provide invasive ventilatory support.

Please Note:

1. Critical care units that provide invasive mechanical ventilation for a short period (for example ≤ 48 hours) but need to transfer those patients who require more long-term invasive ventilation to a Level 3 unit are considered Level 2 for the purposes of the service inventory.

Level 3

Capable of providing the highest level of service to meet the needs of patients who require advanced or prolonged respiratory support, or basic respiratory support together with the support of more than one organ system. This is generally considered a “full service” Critical Care unit despite the fact some specialized services may not be available (e.g. dialysis). All Level 3 units are capable of invasive ventilatory support.

Please Note:

1. For institutions that combine Level 2 and Level 3 type critical care service in one geographic area (i.e. unit), we request that the unit designation reflect the highest level of care provided – even if all patients may not be receiving that level of care.

Ventilation:

Invasive Ventilation Ventilatory support requiring endotracheal tube or tracheostomy.

Non-invasive Ventilation Ventilatory support via a nasal or facemask or a mouthpiece.

Miscellaneous:

Intensivist For the purposes of this inventory an intensivist is defined as having Royal College accreditation or equivalent training in critical care medicine. Recognizing that there are human resource issues and that this a relatively new accredited specialty, specialists with at least a minimum of six post-graduate months of critical care training are a reasonable alternative.

Documents

Inventory of Critical Care Services › EN › Toolbox › Overview of...Dr. David Boyle Associate Professor Division of Clinical Sciences Northern Ontario School of Medicine (LHIN