By Dr. Victoria Lee

British Columbia (BC) managed to flatten then bend the COVID-19 curve.  Some of this may be due to luck and some due to being prepared.  BC has certainly benefited from strong provincial leadership and exemplary communication from the Provincial Health Officer, Dr. Bonnie Henry, and the Minister of Health, Hon. Adrian Dix.  I believe the way in which BC’s health system is organized, with the Ministry of Health, two provincial and five regional health authorities, also played a significant role.

Having experienced SARS, the H1N1 pandemic, avian influenza, Ebola and an opioid overdose crisis in different roles and settings, I know that these emergencies test the capabilities of our health system and, at the same time, test our society to reveal our strengths and vulnerabilities.  I offer the following observations from a unique vantage point as a public health physician with comparative health system knowledge now serving as the CEO and president of a large health service organization – Fraser Health.

Fraser Health serves over 1.8 million people across 20 diverse municipalities, 32 First Nations and five Métis chartered communities.  Nearly 90 per cent of refugees and over 40 per cent of newcomers to BC settle in the Fraser Health region. As one of five regional health authorities in BC, Fraser Health provides a wide range of health services – 12 acute care hospitals as well as community-based long-term care, home health, mental health and public health services.  As of June 16, 2020, over 51 per cent of COVID-19 cases in BC were in our region.

• Integrated health system responses played a critical role in preparing for and responding to outbreaks in high-risk settings

The Fraser Health region includes 203 owned and operated, contracted, and private Long-Term Care (LTC), Assisted Living (AL), and Independent Living (IL) facilities. As of June 20, 2020, there had been 22 COVID-19 outbreaks in these three settings. Establishing a region-wide and integrated coordination centre with LTC-AL-IL, home health, infection prevention and control (IPC), communication and public health (PH) was essential in ensuring both large scale and coordinated responses.  With the regional coordination centre, enhanced prevention and outbreak management strategies were promptly developed, communicated and reinforced with a Public Health Order. Bi-weekly communication forums took place with all providers to problem-solve.  Most importantly, proactive supports and prevention audits covered the full continuum from acute to community services. Some examples include medical advisory committees, training of nurses to acquire nasopharyngeal swabbing competency, critical care supports and deployment of SWAT teams within 12-24 hours (infection prevention expert, clinical nurse educator, patient care and quality, screeners, public health).

• Acute care capacity was well protected throughout COVID-19 response and now into recovery

There are 12 hospitals in the Fraser Health region with 2618 beds including 134 in critical care.  Based on provincial modeling work across the Korea, Hubei and Italy scenarios, we utilized regional networks to develop extensive pandemic planning for critical care and acute care.  This included preparing for the worst-case scenario by finding an additional 350 beds within existing capacity across all sites as well as in a new hospital that was under construction and at a LTC facility.  During the COVID-19 response period from March to May, we maintained acute care occupancy at 50-70 per cent and critical care at 60-90 percent.  This required the coordinated efforts of the full system including a nearly 52 per cent decrease in visits made to hospitals by LTC patients, historic lows in CTAS (Canadian Triage Acuity System) 4s and 5s and a significant reduction of Alternate Level of Care (ALC) days (41 per cent). This was enabled by mobilizing regional transfers, enhancing home support/home health services, partnering with divisions of family practice, rapidly accelerating virtual health services for ambulatory services and postponing elective surgeries and procedures. It absolutely required support and sacrifice from our patients, families and communities, and we are grateful for the part they have played in our response.

• Regional structures and processes enabled rapid decision-making and mobilization of resources

There are 40,000 staff, medical staff and volunteers who work in the Fraser Health region. As the pandemic progressed, emergency operations centre (EOC) structures were promptly implemented. Mobilizing Human Resources to ensure adequate staffing has proven to be critical to not only providing safe care for patients but also to protecting our providers. During the pandemic response, Fraser Health hired over 600 staff, trained over 400 existing physicians and staff, deployed over 480 staff to vulnerable settings such as LTC-IL-AL sites through SWAT teams and deployed over 230 staff to facilities to ensure direct care was provided in outbreak facilities. In addition, central coordination of resources enabled reviewing staffing information for 15,449 employees of LTC-AL-IL facilities, and then implementing a single site order for those facilities, affecting 3,165 staff. Provincially and nationally procured Personal Protective Equipment (PPE) was distributed in settings that normally procure their own such supplies. In addition, our experts in public health, primary care, critical care and infection prevention and control rapidly mobilized both virtual and onsite support in the largest federal corrections outbreak that occurred in Mission Institution.

• Partnerships protected some of the most vulnerable populations in high-risk settings

Partnerships with divisions of family practice and family physicians enabled the establishment of 11 testing and assessment sites for COVID-19.  Mass testing occurred in settings that we do not normally work directly in such as meat processing plants and federal correctional facilities. Working with BC Housing and municipalities, emergency coordination and isolation centres were established to protect street-entrenched populations. Municipalities, foundations and auxiliaries were instrumental in garnering community and philanthropic supports. Frequent channels of communication were established to promote engagement and decision-making.

There is no perfect design for health services. In fact, there are varying strengths and weaknesses in how we structure our health system. During the COVID-19 pandemic, the regional health authority structure was beneficial in demonstrating flexibility and agility, addressing existing and long-standing silos in the health system, rapidly connecting experts across public health to critical care, enabling daily and weekly communication with widely-ranging internal and external stakeholders groups and reducing timelines from decision-making to scalable actions in clinical and operational areas.

I am grateful to BC’s leaders at all levels of government, my health authority leadership counterparts, my Fraser Health colleagues, the staff and medical staff, and all of our partners who continue to work collectively with dedication, compassion and humility to provide the best care possible to our patients, families and communities.

Dr. Victoria Lee is President and CEO of Fraser Health, and as such leads the overall management and delivery of health programs and services in one of the largest and fastest-growing health networks in Canada. Prior to joining Fraser Health she worked in collaboration with national and international organizations including the United Nations Development Programme and the World Bank in the areas of comparative health systems, health policy, health financing and ecohealth.