At the start of the COVID-19 pandemic this spring, the emergency room of St. Michael’s Hospital was so inundated with the homeless that they put patient beds into old storage rooms.
At times, there were a couple of dozen homeless patients waiting for test results in the emergency room, with nowhere else to go, ER chief Carolyn Snider said.
Staff were swamped, and were recording what information they could about their patients — which shelters they had been staying at, what symptoms they were reporting, whether they left against medical advice — on a spreadsheet.
Then, in early April, the St. Michael’s team noticed a curious pattern: There had been about 20 people, over the course of a few days, coming in from a single downtown shelter.
During a phone call with Toronto Public Health, discussing how the hospital would know when there was an outbreak in a shelter, Snider recalled raising that facility as an example — and being met with surprise on the other end of the phone line. “This person said, ‘What do you mean, X shelter?’” Snider said.
“Only for me to realize, we were the warning sign.”
Spurred by the call, Snider appealed to the hospital’s team of data scientists for help.
And last month, as the city announced its plans to handle the first winter of the pandemic in the shelter system, St. Michael’s rolled out a new tracking tool in its emergency department.
According to Muhammad Mamdani, the hospital’s vice-president of data science, the idea was to centralize information about their homeless patients that would previously have been scattered between clinicians’ memories, their social work team’s records, “clunky” makeshift spreadsheets and verbal notes.
The tool pulls up a patient’s prior hospital visits, past symptoms, shelters they’ve used, whether they had been tested for COVID-19 before, their results, and if they’d left against advice.
And they can now report to public health daily about what they’ve seen in the emergency department, Snider said. Though shelters have seen just a handful of outbreaks recently, she hopes the tool can provide early warning to public health if things take a turn for the worse.
“It’s the kind of tool I don’t want to have to test out to its full capacity, because if we have to … then things have gotten really bad again. But we’re ready for that, should we need to.”
There’s currently one publicly reported shelter outbreak in Toronto — at a Good Shepherd Ministries site. It was detected after one resident reported a fever, and another a scratchy throat, said Brother David Lynch, executive director. Four residents were initially thought to be infected, but only three were ultimately deemed sick. All were sent to the city’s COVID-19 isolation site.
Lynch believes regular check-ins with counsellors and case managers meant those cases were detected quicker than they might have otherwise been — but worries now about safeguarding some of the older residents. Homelessness and health vulnerabilities went hand-in-hand, he explained. “It’s an ongoing struggle, especially when we’re in outbreak,” Lynch said.
Snider, who has spent more than a decade in emergency medicine, said inequalities in Toronto are laid bare on the front lines of the health-care system. Between March 1 and Nov. 6, St. Michael’s alone saw more than 1,500 homeless patients through the ER, she said — and many have cycled through repeatedly, with more than 11,000 individual visits from that population.
Clinicians were inundated with information while trying to make critical decisions about people’s care, Mamdani said. The tracking tool was to make sure key information about vulnerable patients was clear in front of them. It was “probably pretty disappointing” they needed the tool at all, Snider said, arguing its development should serve as a “wakeup call.”
Things had gotten better since the spring, she said — fewer homeless patients were coming through their emergency department since testing processes were updated.
Now, when someone shows symptoms, the shelter coordinates with public health and the city to transport them to an assessment centre, then to the isolation site. If that person tests positive for COVID-19, their close contacts are identified and assessed, to see if they need testing too.
Shelter users can still show up in the ER. But the entire process seems more organized, Snider said. They might now see six people with no fixed addresses at a time, instead of 20 or 30.
Though the tool is limited, in that it doesn’t capture interactions shelter users may have with other hospitals, both Snider and Mamdani believe the tool could be used beyond the pandemic — to detect outbreaks of illnesses like influenza in the shelter system.
For now, it’s in place if COVID-19 cases among shelter residents show up first in their ER. “We’re not relying on clinician memory, or some astute clinician to say I’m noticing some patterns,” Mamdani said.
“We actually have a system, that routinely tracks this in a systematic way, to alert the right people.”
Victoria Gibson, Local Journalism Initiative Reporter, Toronto Star