How medical advances and shortsighted cuts led to crisis in Canada’s children’s hospitals

Second intensive care units. Heated trailers outside emergency rooms to handle a crush of sick children. A message to doctors that, should they be asked to provide care outside their usual scope, the body that defends them against accusations of malpractice will be “there for you.”

The unprecedented overcrowding in children’s hospitals across the country is being called the worst pediatric-care crisis in memory.

It didn’t come out of the blue. There have been calls for years to right-size a children’s health system that was too small, pre-COVID. In 2018, a year before SARS-CoV-2 showed itself to the world, critically ill babies and toddlers in need of an empty ICU bed were shipped around Ontario “like Amazon packages,” Alex Munter, president of Children’s Hospital of Eastern Ontario recently tweeted. That same year, only 65 per cent of “elective” surgeries for children were completed within windows considered safe. Today, because of more surgeries postponed owing to COVID, it’s closer to half.

How did we get here? Partly because of the wonders of modern medicine. The system might be overwhelmed, but, for decades, science has been winning — beating back disease and allowing babies who once never would have survived to live to be bundled up and taken home.

Advances in surgical techniques have meant operations that once resulted in overnight hospital stays now see children go home within hours. Innovative therapies have cut down on hospitalization times. Kids are better off for it, the system is better off for it, and parents are happier. It is the good news story at the root of a medical revolution, but equally embedded in that story was a conscious decision to cut back on hospital beds for children, convinced there wouldn’t be the same need for them.

This was a risky calculation to make, because the other side of the baby born extremely preterm or with a neurological condition beating the odds and making it home, is that their medical care needs going forward can be significant. Sometimes, they need a bed, and in this desperate time, there are none.

“These are not children who are just totally healthy now,” said Dr. Beth Foster, pediatrician-in-chief at Montreal Children’s Hospital. “They still need quite a lot of care.”

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There are other looming cracks in the façade. The number of school-aged kids with moderate to severe chronic conditions like asthma, diabetes, kidney disease and obesity has increased over the past decades. ER visits among kids for mental health conditions were already rising before COVID hit. The pandemic has thrown more into crisis. Children who do need to be in a hospital today are sicker, stay longer and need more specialists involved in their care. Then along came overlapping viruses and a nationwide shortage of children’s Tylenol, let loose on a system that had long since shrunk capacity, cut staff and closed beds.

CHEO in Ottawa has fewer than half the number of beds compared to when it opened in 1974, Munter said, yet the city’s child and youth population is growing at a rate nine times the provincial average. This, at a moment when an aging healthcare workforce, burnt out by a pandemic entering its third winter, is retiring early, or leaving the profession. There is no slack built into the system, and now it is being tested by a perfect storm.

How to right-size the system? It’s not just money. What’s needed is a systems-lens approach, said SickKids president and CEO Dr. Ronald Cohn. Where do we actually need to make targeted new investments, he said  — specialized pediatric hospitals? Community hospitals, where most kids in Canada outside large urban areas are seen? Primary care? — “versus changing some of the models of care that we have practised for decades.”

Children live their lives across a continuum of care, Cohn said, from primary care to community hospitals that can handle ear tubes and tonsillectomies and appendectomies, to big, expensive, high-tech referral hospitals like SickKids that do heart operations, transplant surgery, surgeries for brain and solid organ tumours. Create a seamless connection between all of these, “then I think this can be solved,” Cohn said.

Decades of poor planning has left us with not enough trained nurses. Canada lost older nurses and other health-care workers who were already close to the breaking point before COVID hit, who may have stuck around longer. But the health human resources crisis has been talked about for 30 years. It shouldn’t be a surprise to anyone, said Foster.

“We need to train more nurses, train more physicians, loosen up the barriers to entry for physicians from other countries,” Foster said. “We need to put those things in place for the future.”

Foster and other medical leaders and children’s advocates are calling on the federal and provincial governments to earmark funding for kids’ health care, capture better data on the health of Canada’s children and for a commissioner for children to be appointed.

“I’ve had people say to me, ‘This is what the adult side has been living with for years.’ People on stretchers in the emergency room, waiting days for a bed. That’s true,” Foster said. “But do we really want that to be the bar? Do we really want to say, ‘Yeah, things are bad for adults, and so we’ll just let them be equally bad for children?’”

In the short-term, parents can help prevent children from becoming sick with a viral infection, Dr. Stephen Freedman said in an earlier interview with National Post.

“Encourage them to mask up when appropriate, ensure they and their friends are not going to school and not getting together when they’re sick. Encourage vaccination — there are very, very few indications for not receiving COVID boosters, or a basic COVID series, or influenza vaccination,” said Freedman, an emergency physician at Alberta’s Children’s Hospital in Calgary.

Vaccination “is our number one means of protection at this point in time that’s independent of masking and others being sick around you,” he said.

Parents can use local resources to decide whether they need to take their child to an emergency department, he said.

“Use your family physicians, primary care providers and pediatrician as a resource as well, particularly for chronic complaints,” Freedman added. “Coming to an ER now with a chronic complaint that does not require either urgent surgery or medical treatment is going to wait a very long time to be seen. We are really focusing on those who are urgently in need of care.”

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