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Quebec has a plan to radically change the approach in hospitals | Coronavirus


the Guide for prioritizing and managing short-term hospitalizations in the context of the COVID-19 pandemic, dated January 12, provides for four lines of action.

According to our sources, the plan was presented to the high authorities of the Ministry of Health on Wednesday, to the minister on Friday, as well as to the COVID-19 clinical steering committee yesterday. The tone of the discussions on the subject suggested that its application was imminent. And several doctors are calling for it to be put in place quickly.

The minister’s office ensures that it is not about to be applied. It is rather an approach by the Ministry of Health to guide doctors in the field and prepare them for any eventuality., explains the press officer Marjaurie Côté-Boileau.

Before arriving at difficult choices, the teams of the ministry have the responsibility to equip the doctors on ethical and clinical bases. This is not an immediate course of action. »

A quote from Marjaurie Côté-Boileau, press secretary to Minister Christian Dubé

Either way, the guide’s authors warn that the capacities of the Quebec health network could be exceeded and the consequences of the worst projections would be terrible: a large number of people will not be able to be treated and will be offered palliative care.

Despite the optimism displayed by François Legault last week, the peak of hospitalizations (excluding intensive care) has still not been reached. Load shedding is no longer enough in some regions, cancer operations are being postponed and the authors of the plan believe that the increase could continue until the end of the month.

The health system has never been so close to not being able to fulfill its duties, said in the last few days, Dr. Mathieu Simon, head of intensive care at the University Institute of Cardiology and Pneumology of Quebec.

The objective of the guide is therefore to establish new temporary standards for four to six weeks, in all the establishments of the province, in order to reduce the harm of this wave and the “anticipated risk of increased morbidity and mortality”.

The exceptional measures taken here aim to abandon no one, but rather to provide a minimum of care to as many people as possible. »

A quote from Extract from the Guide for the prioritization and management of short-term hospitalizations in the context of the COVID-19 pandemic

Making “compromises” on the quality of care

The objective of the plan is to encourage the medical councils of each establishment to “redefine the minimum quality of care”, with the perspective of “treating the most people at lower intensity rather than treating fewer people at optimal quality”. .

For example, it will be necessary to “review certain medical practices” such as the frequency or the relevance of certain diagnostic tests, the time of these four to six weeks of crisis.

It appears ethically justifiable to treat more people at lower intensity rather than treating fewer people with optimal intensity and thus leaving many patients without treatment. »

A quote from Extract from the Guide for the prioritization and management of short-term hospitalizations in the context of the COVID-19 pandemic

The document notes that these new temporary standards could “pose medical-legal risks to caregivers who follow them”.

Under these conditions, it is written that “Quebec must use the legislative tools at its disposal to support the application of these four areas of intervention”. According to our information, it would be a decree.

The Ministry of Health has also begun to collaborate with professional orders to “promote the adoption of these axes as acceptable temporary standards”.

Healthcare professionals are not trained to apply such minimalist standards […] The application of such temporary standards risks causing moral distress and worsening the feeling of burnout among staff. »

A quote from Extract from the Guide for the prioritization and management of short-term hospitalizations in the context of the COVID-19 pandemic

Even if given legal and ethical free rein, health care workers may demonstrate “some level of resistance” to this plan and apply it unevenly, the authors say. Moral support measures are recommended.

Accepting to live with the virus in the hospital

We must “change the perspective of controlling the pandemic”, explain the authors of the guide, moving “from the objective of zero risk to that of harm reduction”. Clearly, this means dealing with the fact that the virus manages to enter the hospital, despite our best efforts.

First, the plan calls for making maximum use of the possibility of putting infected staff to work in order to reopen all closed beds, which is currently not being done as much as possible in several regions. About 50,000 healthcare workers are currently absent, including 15,000 due to COVID-19.

A nurse holds the arm of a patient lying in a hospital bed in intensive care.  The patient's face is hidden by a computer screen.

If one facility is overwhelmed while another has capacity elsewhere, patients will have to be transferred.

Photo: Associated Press/Keystone/Laurent Gillieron

At the same time, it would be necessary to agree to reduce infection prevention and control (IPC) measures, which could include stopping mass screening for asymptomatic workers, but also stopping transfer to a dedicated unit for asymptomatic COVID patients admitted for another diagnosis.

The committee believes that in a crisis situation, the staff does not notify the patient whether or not he is infected unless there is a breach of protective measures. »

A quote from Extract from the Guide for the prioritization and management of short-term hospitalizations in the context of the COVID-19 pandemic

The guide goes in the same direction as recent statements by the president of the Federation of Medical Specialists of Quebec, Vincent Oliva. “Let’s consider other ways of operating,” he told TurnedNews.com. “Let’s accept to take a little more risk, in a population that is widely vaccinated”.

He recalls that half of the patients who occupy a hospital bed dedicated to COVID-19 have presented to the hospital for something else and most are not very bothered by the Omicron variant, “a little less virulent”. .

Dr. Oliva proposes no longer systematically isolating these infected patients from others, while continuing to protect the most fragile, such as immunosuppressed, but “without expending energy on making COVID floors and COVID wings”.

You have to live with the virus because basically, the virus is more livable. »

A quote from Dr. Vincent Oliva, President of the Federation of Medical Specialists of Quebec

Dr. Germain Poirier, head of the Intensive Care Service at Charles-Le Moyne Hospital, went in the same direction this weekend in an interview with TurnedNews.com. According to him, if we accept to consider the Omicron variant as the seasonal flu in hospitals, we could perhaps take the risk of no longer screening asymptomatic patients and staff, knowing that zero risk does not exist.

The intensivist thinks that we could take the risk of “putting triply vaccinated with patients in the yellow zone [possiblement infectés] or in the red zone [infectés] “.

Maximize load shedding

While level 4 load shedding has not made it possible to curb the overcrowding of short-term hospital beds (excluding intensive care), the guide asks to push the postponement of all non-urgent and semi-urgent operations as far as possible. possible.

To mobilize as many health workers as possible, it is thus a question of including private medical clinics, fertility clinics and specialized medical centers in the load shedding.

In family medicine groups (GMF), appointments will have to be cancelled, except those of chronic clients with signs of decompression.

The patients who will be prioritized are those suffering from heart failure, myocardial infarction, stroke and chronic lung disease.

The plan recommends not transferring to hospital patients who have little chance of survival.

At the same time, it will be necessary to “promote the early discharge of patients”, by “lowering the thresholds for hospital leave”. The authors suggest thus reducing the duration of hospitalization by 48 hours on average, “in order to free up the beds more quickly”.

If one establishment is overflowing while another has capacity, patients will have to be transferred.

Families called upon to contribute to care inside or outside the hospital

The plan calls for “asking caregivers to come and take care of their loved one in the hospital 24 hours a day”, giving “basic care”, in order to allow professionals to carry out more specialized tasks or s take care of those who do not have a caregiver available.

Hospitals could reopen closed beds with a minimal staffing ratio “to provide minimum accommodation and care” for these patients, as long as their families cooperate. Currently, several establishments limit or even prevent access by relatives.

In addition, hotels have also already agreed to accommodate patients who do not require acute care.

Health students could lend a hand in these non-traditional sites, as “non-reserved labor”.

person at the end of life

There should be no compromise on dying with dignity, warn the authors.

Photo: iStock/iStockPhoto

The return of the patient to his home or that of his family will also be encouraged, when possible. The guide plans to “ask caregivers to take their loved one back and wait four to six weeks before admission” to a CHSLD or intermediate resource.

There are even plans to increase the use of palliative care given at home or in an alternative environment, in collaboration with the family.

Failing to offer palliative care in adequate conditions, provide access to palliative care as a last resort to respond to the large volume of patients who require comfort care. »

A quote from Extract from the Guide for the prioritization and management of short-term hospitalizations in the context of the COVID-19 pandemic

The guide encourages the use of ‘alternative treatments’ available ‘to relieve pain and suffering’. However, there should be no compromise on the concept of “dying with dignity”, reassure the authors.

The authors of the document insist that the public be informed of the content of this plan by “transparency” and that they get involved, by accepting, for example, to bring a loved one to the hospital only as a “last resort”. “.

Also, the guide provides that a call be made to “mobilize volunteers and other bodies that can help”.

Already, the Ministry of Health has launched a call for volunteers on the Je Contribue platform and is looking for more than 2,000 civil servants ready to act as service assistants in hospitals.

The authors of the plan want to try everything and “hope that it passes quickly”.

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