Abstract
Challenges in the delivery of high-quality patient centric care in Canada is plagued by staff and medical supplies shortages and spiking burnout rates leading to closures of more than a thousand emergency rooms in 2023. A literature review was conducted to examine the crisis preparedness and responsiveness of healthcare establishments in Ukraine in a warfare context, with the intent of exacting recommendations to respond to shortages in Canadian hospitals. Utilizing queries on distinct databases, more than 17,500 entries were found, narrowed, and selected for review. Managerial implications for Canadian establishments include: (1) adapting a change management approach, (2) capitalizing on existing assets, resources, and networks, (3) recognizing cyclical patterns to prevent negative outcomes, (4) planning for and attending to the vulnerabilities of specific sub-population groups, (5) utilizing geolocated analytics, and (6) exploiting external expertise and volunteer network through tailored working conditions.
Introduction
The COVID-19 pandemic resulted in 18 million overtime hours worked in Canada’s public hospitals in 2020-2021, generating unprecedented pressures on healthcare workers. The Ontario Medical Association further reported in August 2021 that almost three-quarters (72.9%) of physicians surveyed experienced some level of burnout 1 and the staggering rate was associated to the “crushing administrative burden.” 2 The menu of added crisis pressures to the healthcare workforce was exhaustive: scientific unknowns3-5 as the pandemic progressed globally; quarantine measures stemming from a federal Emergency Order; 6 increased hospital security needs; quickly emerging complexities in-patient screening, monitoring and visitor screening; spike in coronavirus vaccination rates and impact on routine immunization programs;7,8 ill, injured and even dead personnel;9,10 and the constantly evolving media coverage. 11 Altogether, the unprecedented crisis requirements drew clear distinctions from baseline surges.
Thus, in 2023, the spiking rate of burnout has been declared “past the point of exhaustion.” 12 The long-term effects of the annual growth rate decrease in the number of family physicians (from 3% to 1% between 2012 and 2021) 13 combined with the job vacancies in health occupations in the first quarter of 2023 (estimated at 93,000 which is more than double the number of vacancies at the onset of COVID-19) 14 left health system survivors overwhelmed. The continued staffing shortages 15 and funding pressures 16 prompted 190 Emergency Room (ER) doctors in Calgary 17 to publish an open letter in May of 2023 18 outlining the “collapse” of the sector and confirming the state of crisis. 19 It was announced early in the fall of 2023 that Canadians would suffer 1,284 ER closures before the end of the year. 20 Through provincial and territorial data received, the report was able to track 76 partial closures in Prince Edward Island, respectively, 484 and 37 ER closures in Ontario and Quebec, 311 full or partial closures in Manitoba, and more than 100 temporary closures in Alberta.
From staffing shortages at small town hospitals to changing demographic needs, health leaders must face the challenges posed by adjusting collectively the patient-centric health services delivery parameters in such unfavourable conditions.
Unsurprisingly, as a strong body of research confirms, the maintenance of the Patient-Centred Care (PCC) model is dependent 21 on quality of the relation between the patient and the healthcare providers, ensuring notably optimal responsiveness of patients’ informed wishes through informed interactive sessions and shared decision making. 22 When a healthcare establishment undergoes resources scarcity, it takes away PCC effects leaving inadequate working conditions, inability to establish meaningful relationships with healthcare providers and patients, and delays in the delivery of goods, supply, and medical assets. 23 There is a significant body of knowledge, research and literature designed to bring the clinical solutions of civilian establishments to the medical field hospital, but there is little research about how to review and transfer lessons learned from combat medical support in war zones to civilian establishments operating in non-conflict areas. Despite advances made after 2019 to rethink traditional ER emergency-workforce-extenders 24 or patient-flow modelling, 25 little research has been done about how healthcare facilities in war zones, such as in the Ukraine, have prepared for and responded to crises and how their actions can inform our own here in Canada.
Methods
A systematic search of two electronic databases was conducted (PubMed and Google Scholar) using the search terms hospital preparedness medical crisis response in Ukraine from 24 February 2022 and beyond, at the onset of the Russian-Ukrainian War. To detect additional accounts and stories, the author searched two international governing body databases (NATO and the United Nations High Commissioner of Refugees (UNHCR) databases) as well as the Internet news archives. The following types of articles were included: news reviews, editorials, general discussion papers, commentaries, letters, and reviews. The data extraction was based on their relevance and the final selection on the author’s unique healthcare leadership experiences in both military combat and civilian non-combat environments.
Results
With a period scope limited from 2022 to now, on PubMed 5,354 articles were found with the keyword “Ukraine” and narrowed to 1,175 results when adding “hospital” and restricted to 14 results when adding “preparedness.” On Google Scholar, a search with the term “hospital response in Ukraine” led to 17,100 results while “hospital preparedness in Ukraine” led to 3,400 articles. On NATO’s search engine the same terms, respectively, led to 164 and 31 entries. On the UNHCR site, the same research produced 4 and 0 results. Using the common Google search engine, the terms resulted in 164 million and 12.2 million and when narrowed down to news content, they led to 128,000 and 6,190 articles, respectively.
Discussion
Since Russia invaded Ukraine on 24 February 2022, the Associated Press (AP) and FRONTLINE (PBS) have gathered, verified, and documented evidence of potential war crimes perpetrated in Ukraine. As of 24 February 2023, it was alleged that 66 attacks had been deliberately made against medical facilities, 17 of which had reported civilian deaths. 26 Each account in this database was documented by several sources, giving a realistic portrait of the challenges the Ukrainian healthcare institutions had to face concurrently. Maternity wards and Red Cross vehicles had been shelled, along with psychiatric hospitals, regional trauma centres and paediatric dental clinics. Meanwhile, the World Health Organization (WHO)’s Surveillance System for Attacks on Health Care (SSA) had recorded, by 10 August 2023, its 68th attack on healthcare assets in Ukraine in 2023, regrettably a significantly low levels in comparison to the 1,079 recorded attacks in 2022 alone. Official report from Ukraine’s Minister of Health 27 confirmed early in 2023 that 1,218 healthcare establishments have been damaged with another 173 destroyed completely and the numbers have been increased, respectively, to 1,409 and 186 in August 2023. 28 Other report indicated that nearly 1% of medical personnel left the country with hundreds killed. 29 If the overall health worker density 30 in Ukraine prior to the war was around half that of Western European countries like Germany and Norway,31,32 the war only aggravated matters.
Aside from difficulties in caring for patients suffering from chronic illnesses comes the daily horror of those in need of acute trauma care due to intense combat activities, from severe open blast injuries33-35 to burns to traumas related to gender-based violence.36,37 Across Ukraine, its healthcare system trying to deliver care to those patients in need, despite daily air raids, occasional rocket attacks, and Russian troops marauding. Adding the acute shortage of medicine, 38 impacting long-term therapies 39 and all other related care supplies all strictly being limited due to the obliteration of logistic systems and the destruction of the main accessible roads or simply aggravated by Russian blockades by sea and land. 40 Then, reports on the basic utilities (electricity and water) and infrastructures being destroyed by air bombings stemmed almost immediately, in the first 30 days of the conflict.
How did the Ukrainian healthcare establishments adapt to a crisis which forced their entire healthcare sector to be consumed by war and can we derive leadership and managerial lessons from it?
Analysis: Lessons from Ukraine
Adopt a change management approach
The first takeaway lesson is the ability to adopt a change management approach. Certain Ukrainian hospitals have realigned the scope of the services provided and prioritized their activities grounded on renewed epidemiological analysis and studies, for those proper to the war injuries sustained in their operating area for example. On the same perspective, the epidemiological projections were amplified with forecasted disaster risks estimates leading more than 2,000 clinicians and emergency medical service first responders to be trained in chemical preparedness and response, to ensure proper use of personal protective equipment and the decontamination of patients after exposure to toxic chemicals. 41 On the civilian end, historical epidemiological data could be used to reconcile projected clinical needs and identify for example demographic changes leading to a shift in supporting simple chronic disease to multiple and/or complex comorbidities in an ageing population. 42
Capitalize on existing assets, resources, and networks
The second takeaway lesson is that they also adapted the means to the needs. Capitalizing on the presence of scalable military resources and agile expertise, they have operationalized mobile modular services which brought the delivery of care to the patients, circumventing the challenges paused by broken roads and its impact on trajectory of services. The methodologies from the combat medic corps were taught to Ukrainian medical personnel who had not been previously exposed to war traumas and did not know how to coordinate the medical supply system under constraints. 43 Similar efforts through partnership with a trauma expert establishment could benefit rural healthcare facilities in reconciling clinical methodologies with administrative parameters under resource constraints.
Recognize cyclical patterns to prevent negative outcomes
The third adaptation they have implemented was in simply recognizing that cyclical patterns of clinical training did not provide an efficient preparation for the management of complex wounds, leading to an initial spike in technical errors. 44 Once again, adaptive clinical training programs implemented locally would enable the healthcare workforce to feel supported by management, alleviate performance pressures while enabling collective training and development. Another example would be to recognize severe injury patterns associated with seasonal activities such as lumbering or industrial endeavours.
Plan for and attend to the vulnerabilities of specific sub-populations
When treating gender-based violence, the disaggregated data led to observe that young women were at risk for sexual violence and exploitation while older women were subjected to economic violence, humiliation, and neglect. The healthcare establishments’ response teams were specifically trained and equipped to ensure a provision of care tailored to the specific needs of these sub-groups at risks. Another initiative was to institute a five-step burn prevention program adopted nationally to help in targeting paediatric scald injuries and first aid, alleviating gravity when this sub-group of vulnerable casualties made it to the hospitals. In the end, this administrative measure lessened the critical care needs under scarce clinical resources across the entire Ukrainian system. For example, the clinical community of specialist on kidney disease had extended their collaboration with external organizations to specifically help people living with kidney disease. 45 An outreach to national specialist communities could help in the support of emergency care delivery response to similarly vulnerable groups.
Utilize geolocated analytics
Considering that exposure to war-factors would vary from region to region, and thereby generate geolocated differentials in clinical epidemiology, multinomial logistic model of diagnosis status were used to project statistically significant estimates of clinical morbidity variability across the Ukrainian landscape and to map out team response patterns and routes in accordance to the statistical projections. For example, it has been reported in 2021 that most injury deaths in Ontario prevailed in locations out-of-hospital settings or were managed at non-trauma centres, leaving access to specialized injury care despite public health’s efforts in developing effective “trauma systems.” 46 Utilizing publicly available findings, dedicating resources to integrate health data 47 into hospital board decisional process could generate powerful insights to generate evidence-based managerial projections of clinical resources allocations. This is of significant importance considering emergency department visits have been outpacing population growth for years now.48-52
Exploit external expertise and volunteer network through tailored working-conditions
From Odessa to Moldova, Ukrainian health authorities have been expanding the delivery of services through external partnerships or by creating small mobile units sustained by external health professionals on retirement. 53 This enabled the establishments to project their efforts and mitigate the overflow in the core facilities and several distinct examples have been widely covered in the news.54-59 Another example is the partnership with the Imperial College in London with the British Red Cross in gathering Ukrainian clinicians in April 2023 to outline a concerted development of new primary care infrastructures 60 or the recent International Medical Partnership Program. 61 Other avenues were explored for healthcare policy-makers 62 and include extension of inter-regional medical evacuation and cooperation. A similar approach could eventually be discussed among regional authorities or even with Canadian provincial authorities to facilitate the development of memorandums of clinical collaboration.
Conclusion
Lessons provided from Ukraine outline the importance for health leaders to act both internally and externally in the provision of a managerial framework which impacts the system across all institutional levels in maintaining patient-centric care. If, for example, family doctors in Ontario are spending 19.1 hours per week on administrative duties instead of clinical care, the system is spending the wrong amount of money on people being trained and educated for administration and not care, which may cause administrative fatigue and burnout.
In the end, health leaders must ask the critical questions about how they employ healthcare providers in their clinical roles and validate if their healthcare delivery parameters can match both the immediate and projected population’s needs. In the context of significant inter-generational changes like the one we are experiencing now, preparing the next generation of leaders and healthcare workforce stakeholders to adapt and face new emerging trends and their respective challenges becomes of critical relevance. In the end, we can never prevent another crisis but we can always ready ourselves to be more prepared and responsive by integrating lessons learned from other organizations and situations.
Footnotes
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Ethical approval
Institutional Review Board approval was not required.
