Article body

introduction

During the global COVID-19 public health emergency, healthcare systems struggled to meet the overwhelming surge in demand for critical care resources (1). In Canada, where many intensive care units (ICUs) operated near capacity even prior to COVID-19 (2), decision-makers sought to develop strategies to optimize critical care resource use. Addressing increased demand for limited critical care resources took two broad approaches: 1) prioritizing certain patients for critical care over others (“triage”) or 2) to avoid triage, surging above normal capacity by redeploying non-ICU staff to the ICU, and transferring ICU patients over large distances to available beds. Many jurisdictions developed resource allocation frameworks (3-8) or applied existing triage tools to the COVID-19 context to manage the unprecedented surge in demand for ICU resources (9,10). Ontario, Canada’s most populous province, developed the “Critical Care Clinical Emergency Standard of Care for Major Surge” framework (8), which included three system-wide triage levels to maximize the number of lives saved while avoiding or mitigating potential discrimination and bias (8). Quebec (11) and Israel (12) both adopted similar frameworks, although they were never deployed.

To avoid deploying triage frameworks, hospitals and healthcare jurisdictions adopted a series of triage-avoidant strategies such as cancelling non-emergent procedures, redeploying non-ICU staff to the ICU, and moving patients from overwhelmed hospitals to hospitals with available resources. While triage-avoidant strategies likely saved lives by allowing acutely ill patients to receive ICU care for COVID-19 and avoid adverse outcomes including death, these strategies may also have led to negative consequences for patients, family members, staff, and healthcare organizations, particularly for individuals among equity-deserving groups. Consequences may have been clinical (e.g., delayed care) (13), organizational (e.g., healthcare provider moral distress) (14), and/or equity-related (e.g., reduced trust in healthcare) (15). Equity-deserving groups, as defined by the Government of Canada, are “A group of people who, because of systemic discrimination, face barriers that prevent them from having the same access to the resources and opportunities that are available to other members of society, and that are necessary for them to attain just outcomes” (16). Examples of equity-deserving groups include women, Indigenous peoples, racialized/visible minority persons, persons with disabilities, and LGBTQ2S+ individuals (16), who experience sexism and gender discrimination, racism, and ableism, among other often co-occurring and mutually reinforcing forms of discrimination and oppression in healthcare and community settings.

Previous studies have suggested that individuals among equity-deserving groups may be more susceptible to harm from triage-avoidant strategies because they already face structural barriers to equitable care (i.e., care delivery adjusted to meet the unique needs of individuals and communities with the aim to support similar health outcomes across groups with different social circumstances) (17) including racism, poverty, gender bias, and geographic isolation (18,19). In addition, mistrust of the healthcare system may lead to avoidance of formal care, contributing to delayed diagnoses and reduced opportunities for early intervention (18,19). However, these studies focused on general healthcare use (not specific to triage-avoidant strategies) (18,19), were conducted prior to the pandemic (18,19), and primarily explored the association between racial discrimination and delayed or forgone care, and experiences of racial discrimination and beliefs about coronavirus-related racial bias (20).

Future surges in demand for critical care will likely lead to the use of triage-avoidant strategies like those used during COVID-19. However, the potential negative effects of these strategies are not well understood, especially as they concern equity-deserving groups. Limited research reports directly on the views of these groups themselves (5), yet inclusion of perspectives among those equity-deserving groups is critical to develop relevant and inclusive approaches (5). These groups have largely been excluded from discussions about how triage-avoidant strategies disproportionately harmed them compared to the general population; from insights on organization-specific actions that were implemented to mitigate these effects; and from recommendations at the system level for future strategies to reduce harm. Incorporating these perspectives is essential for developing resource allocation frameworks that are more equitable and responsive to the needs of all populations.

OBJECTIVE

Our study had three objectives:

  1. Understand perspectives and experiences among equity-deserving groups of the disproportionate effects of triage-avoidant strategies on communities with whom they work, relative to the general population.

  2. Explore organization-specific actions implemented during COVID-19 from the perspectives of individuals representing equity-deserving groups — such as Black, Indigenous, and People of Colour (BIPOC), persons with disabilities, and disease-specific organizations — as well as staff from healthcare organizations and government agencies.

  3. Identify system-level recommendations for future pandemic strategies that can minimize harm, improve equitable access to care, and enhance organizational preparedness.

METHODS

Study Design

Between July and December 2023, we conducted a qualitative descriptive study (21), using semi-structured interviews and focus groups via videoconferencing platforms (e.g., Zoom and Microsoft Teams), with individuals from across Canada about experiences related to their specific organizations. Guided by a post-positivist epistemological stance, interviews and focus groups were conducted with decision-makers, clinicians, and individuals among equity-deserving groups. Post-positivism focuses on the experiences of the majority and asserts that there is no universal truth and that multidimensional evidence can be inferred by perceived data (e.g., data obtained in focus groups/interviews) (22,23). The Bruyère Health Research Ethics Board approved this study on July 17, 2023 [Study #M16-23-007].

Participant Recruitment

Maximum variation (24) sampling was used to understand a wide range of perspectives and experiences, including participants who represent a variety of equity-deserving groups, such as BIPOC, persons with disabilities, and disease-specific organizations. We also included participants from healthcare organizations and government agencies. The aim was to engage participants who could describe how COVID-19 was managed in hospitals and how these strategies affected the individuals and communities served by their organizations.

To identify potential participants, we leveraged community-, provincial-, and national-level contacts from among our broader study team’s existing networks (i.e., project principal investigators, co-investigators, knowledge users, and collaborators). A Google spreadsheet was circulated to the broader study team, who were asked to provide the name of persons at the organization, the respective organization, the type of organization (e.g., BIPOC, persons with disabilities, disease-specific organizations, healthcare organizations, and government agencies) contact information for the individuals, and whether the research coordinator (JR) could mention the study team member’s name in the initial recruitment email. JR contacted the individuals listed in the spreadsheet via an email invitation that included an overview of the study purpose, inclusion criteria, and procedures. The email asked the recipient to share the recruitment email and poster with other representatives within their organization. After each interview/focus group, participants were asked to circulate the study poster to their colleagues who met participant criteria (i.e., snowball sampling) (25).

Prior to inviting representatives among Indigenous organizations to participate in the study, we invited representatives to engage in a preliminary conversation to ensure our research vision and goals were both sensitive to and respectful of the organization, and more broadly, to Indigenous communities. Then, we asked for letters of support (drafted by the organization) that expressed approval for the research coordinator to invite representatives from the organization to participate in the study. Eligible participants were 19 years of age or older, fluent in English, and represented decision-makers, clinicians, healthcare organizations, and/or equity-deserving groups.

Data Collection

The research team collaboratively created a single interview/focus group guide (see Appendix 1: Supplementary File A). The core research team drafted the questions, then circulated them to the broader team for feedback. We refined the guide after the first few focus groups/interviews. Prior to study commencement, participants completed a written consent form via email, then an online demographic questionnaire using Microsoft Forms. All focus groups and interviews were conducted and audio-recorded using Microsoft Teams and Zoom, and recordings de-identified and transcribed by the company, PlayWrite. Data collection ended when no new themes or insights emerged, i.e., we achieved data saturation, and recruitment was therefore concluded (21,26).

Analysis

Thematic analysis (27,28) was used to analyze focus group and interview data. We first engaged in close readings of transcripts to thoroughly understand the dataset, and then developed a preliminary codebook using inductively derived codes. Code saturation was reached once no new codes were developed based on review of the transcripts (28). The finalized codebook and interview transcripts analyzed with the aid of MAXQDA qualitative analysis software (29). JR and TS consensus-coded the first two transcripts to establish intercoder reliability and finalize the codebook, independently coding and then comparing their work to ensure alignment. The remaining 10 transcripts were double-coded: each coder worked independently on a subset of transcripts, after which they reviewed each other’s coding through discussion to ensure consistency and agreement. We reviewed the coded segments and explored preliminary patterns, and then identified core themes and exemplary quotations.

RESULTS

Eight focus groups and four interviews were conducted. Nineteen participants took part in the focus groups, and four participated in the interviews, for a total of 23 participants from Ontario (n=12), British Columbia (n=4), Saskatchewan (n=4), Nova Scotia (n=2) and New Brunswick (n=1). Seven participants (31%) identified as persons of colour or as from an equity-deserving group; 13 (57%) participants worked within organizations representing decision-makers, clinicians, and/or groups that represent people from equity-deserving groups (see Table 1 for participant demographic characteristics).

Table 1

Participant Characteristics[1]

Participant Characteristics1

-> See the list of tables

We identified three major themes related to participants’ perspectives of, and experiences with, triage-avoidant strategies implemented during COVID-19: 1) triage-avoidant strategies had disproportionately harmful impacts on equity-deserving groups and healthcare providers; 2) organizations attempted to mitigate negative effects of triage-avoidant strategies; and 3) system-level actions could help mitigate the negative effects of these strategies in the future (see Table 2).

Table 2

Exemplary Quotations

Exemplary Quotations

-> See the list of tables

Triage-Avoidant Strategies had Disproportionate Harmful Effects on Equity-Deserving Groups and Healthcare Providers

Participants discussed the effects of triage-avoidant strategies, including adjusting the standard of care, patient relocation, postponing/cancelling non-emergency procedures and specialist treatments, decreasing staffing ratios and staff redeployment. Though effects may not have been directly related to any one triage-avoidant strategy and may have occurred with triage as well (e.g., visitor restrictions), these are nonetheless important to acknowledge for any future surge in critical care demand.

Adjusting the Standard of Care

When experiencing an overwhelming surge in demand, participants noted that healthcare facilities adjusted their standard of care to meet patient needs by cancelling rehabilitation services, implementing visitor restrictions, and using unconventional hospital spaces to accommodate patients receiving emergency care. However, adjusting the standard of care corresponded with decreased quality of care. For example, individuals requiring rehabilitation services (e.g., physiotherapy, occupational therapy), did not receive the services required to support their activities of daily living. Moreover, visitor restrictions affected services and accommodations (e.g., interpreters, personal care attendants, family networks) required for people with diverse needs to receive adequate care in hospital spaces. Hospital spaces, such as non-ICU wards or floors, were adapted to meet the overwhelming surge in demand, but often fell below the traditional standard of care. As a result, participants felt as though persons with diverse needs might have avoided healthcare facilities out of fear that healthcare providers would focus on their acute needs, and neglect their functional needs, leading to inadequate care.

Cancelling/Postponing Non-Emergency Procedures and Specialist Treatments

Non-emergency procedures were postponed and/or cancelled to reallocate resources to ICUs and to redeploy staff (e.g., nurses, therapists, physicians) to provide acute frontline care. However, conditions previously deemed non-urgent often then evolved into more complex, urgent conditions. For example, one participant highlighted that delayed diagnostic imaging could result in patients being more ill in the long term (FG9-1). Further, seniors who did not receive non-urgent care for their conditions experienced challenges in their daily living activities. Similarly, children who missed non-urgent care experienced negative effects on their overall development. Participants also noted that cancelling some specialist treatments led to delayed diagnosis and treatment trajectories, and that more patients subsequently presented with increased illness severity that then required more aggressive treatment.

Patient Relocation

Patients were often relocated to different hospitals in various regions or across provinces to receive adequate care. Participants reported that relocating patients posed barriers for families, including transportation logistics and relocation costs, and resulted in patients being separated from family members who provide essential, daily support. Families were often not consulted during these decisions. The process for selecting patients for relocation was not standardized or transparent, and the rationale for relocating patients was not conveyed to receiving physicians. Participants also noted that people from equity-deserving groups were overrepresented in patient relocations, potentially because non-marginalized individuals had more health literacy and privilege to better advocate for themselves or their family members to receive care closer to home.

Staffing Ratios/Staff Redeployment

Participants also expressed that staffing ratios were altered, and healthcare providers were redeployed into new roles in hospital settings to meet patient needs. Increased provider-patient ratios resulted in decreased quality of care, particularly for patients requiring accommodation (e.g., meal support, mobility support). Participants also noted that families felt patients were discharged from the hospital too quickly due to staffing shortages.

Participants discussed how healthcare provider shortages in hospital and a lack of primary care providers in community settings resulted in overworked, burnt-out healthcare professionals being more likely to express unconscious biases and discrimination in their care delivery toward equity-deserving groups. Participants also noted that healthcare providers often experienced moral distress when redeployed to ICU environments. For example, some healthcare providers felt motivated to assist in the ICU but did not feel adequately trained with ICU-specific skillsets.

Organizations Attempted to Mitigate Effects of Triage-Avoidant Strategies

External-Facing Strategies

To mitigate negative effects of triage-avoidant strategies, participants described various external-facing strategies that their organizations employed during COVID-19. For example, some organizations consulted with government officials to discuss recommendations surrounding triage protocol. Other organizations leveraged media outlets to disseminate knowledge and advocate for their community members. Several participants noted that their organizations facilitated conversations among community members to share their lived experiences and enabled collaboration with other organizations. Some participants representing healthcare organizations noted that healthcare providers, both within their institutions and across regions, built capacity by engaging in consistent communication, coordinating advocacy strategies, and providing consultative services to ensure high-quality care delivery.

Internal-Facing Strategies

Organizations also employed internal-facing strategies to mitigate the effects of triage-avoidant strategies. For example, some healthcare organizations employed healthcare provider resources, such as response teams and system navigators, to support patients and families navigating the healthcare system during COVID-19 in both hospital and community settings. Other organizations employed culturally focused strategies, including culturally specific healthcare spaces and vaccine clinics within community settings, and community-based interpreter services to mitigate feelings of community distrust in healthcare systems and spaces, and reduce structural barriers to healthcare services.

System-Level Actions Could Help Mitigate the Effects of These Strategies in the Future

Participants suggested several system-level actions to be implemented to mitigate the effects of triage-avoidant strategies.

Increased Collaboration and Consultation When Developing/Implementing Protocols

When developing a triage protocol, further consultation is needed between medical professionals (e.g., healthcare providers, academics), healthcare system users (i.e., patients) and healthcare system user advocates (e.g., family members, friends, community-based advocates). Participants explained that increasing consultation and collaboration can help to ensure that policies are developed using an equity-based lens, and account for diverse populations’ needs.

Increased Healthcare Provider-Oriented Training

Participants also expressed that further training in hospital environments, particularly within ICUs, is required for high-quality care delivery and system user satisfaction. Moving forward, increased human rights, cultural safety, and trauma-informed care training for healthcare providers was deemed necessary to support healthcare system service provision. Participants stated that increased training in ICU environments may increase high-quality care delivery, as well as healthcare systems and user satisfaction.

Increased Patient/Family Education and Support

To ensure that patients and families are educated about the patient’s condition and healthcare trajectory, participants reported that healthcare providers need to collaborate with patients and families to ensure they have the necessary information to inform and empower them in subsequent decision-making. In addition, visitor restrictions during COVID-19 negatively affected patients’ ability to carry out activities of daily living and resulted in dissatisfaction with care delivery as their support systems (e.g., family members, friends) were unable to assist them while receiving care in hospital. Moving forward, participants suggested patients require in-hospital social support while receiving healthcare to alleviate communication barriers and ensure care needs are being met.

Increased Public Education

Lastly, participants noted that during COVID-19, members of the public felt uninformed about the mechanisms and current constraints of the healthcare landscape. Moving forward, they suggested that further public education about these constraints and transparent engagement between healthcare providers and healthcare system users could alleviate distrust in the healthcare system.

DISCUSSION

Our study gathered experiences and perspectives of decision-makers, clinicians, and equity-deserving groups from across Canada regarding the effects of triage-avoidant strategies used during COVID-19. Participants perceived that triage-avoidant strategies had disproportionately harmful effects on equity-deserving groups and healthcare providers; shared how organizations attempted to mitigate negative effects of triage-avoidant strategies; and suggested system-level actions that could help mitigate the negative effects of these strategies in the future.

The Unintended Yet Harmful Effects of Triage-Avoidant Strategies on Equity-deserving Groups

Equity-deserving groups experienced several unintended yet harmful effects from the use of triage-avoidant strategies. For example, they faced exacerbated barriers to access and availability of healthcare services, including delayed or cancelled procedures and specialist treatments, as well as logistical and financial challenges related to patient relocation. They perceived that quality of care, and consequently health outcomes, were also negatively affected. Participants noted that adjustments to the standard of care contributed to reduced rehabilitation services, decreased attention to diverse patient needs, and increased illness severity due to postponed interventions. Social support was similarly compromised, with participants highlighting separation from support networks due to isolation or relocation, and reduced access to essential services such as personal support workers or interpreters. Participants perceived that systemic inequities were further amplified by the overrepresentation of equity-deserving groups in patient relocations and the exacerbation of unconscious bias or discrimination stemming from staffing shortages and redeployment.

COVID-19 Amplified the Effects of Existing Inequities in Access to Emergency Care

Respondents felt that COVID-19 heightened the effects of existing inequities on people’s abilities to access emergency care. For instance, participants highlighted that equity-deserving groups often avoided seeking care in formalized healthcare spaces due to previous experiences of racism and discrimination. Some patients felt that their conditions were dismissed (e.g., were not admitted to emergency care, symptoms were unrecognized) resulting in exacerbated underlying conditions and, in some cases, participants reported resulting fatalities. Financial factors further affected healthcare users’ ability to access supplementary private care outside of the publicly funded healthcare system. Additionally, geographical location, transportation challenges, and isolation restrictions significantly affected the ability of patients living in some communities to access care.

Equity considerations can be overlooked when the healthcare system becomes strained. Existing inequities are compounded by a lack of support to improve access and quality of care for people among equity-deserving groups. For example, interpretation services are essential to achieve effective communication, complex decision-making, and provide therapeutic management for linguistic minorities (30). During COVID-19, both formal and informal (e.g., family member/friend) interpretation services were depleted due to overwhelming hospital demands and visitor restrictions (31), transforming a routine aspect of care into an exception, and negatively affecting overall care standards. Some Canadian hospitals have implemented technology-driven interpretation services (32) and virtual care (31) to reduce linguistic barriers moving forward.

Although Ontario’s Triage Framework was never deployed, studies have shown that some triage tools might have inappropriately deprioritized Black patients, patients with disabilities (33), and Indigenous patients (34,35) because screening tools indicated these individuals have a lower chance of survival than was actually the case. These effects may be mitigated in the future through avoidance of tools with poorer (or unknown) prognostic value in equity-deserving groups, when possible.

Participant Considerations for Future Resource Allocation Frameworks

Participants outlined several considerations for future both resource allocation frameworks and triage avoidant strategies. First, they emphasized the importance of collaboration and consultation with relevant parties when developing frameworks, highlighting the use of an equity-based lens to account for the needs of diverse populations. They also stressed the need for increased healthcare provider training, particularly in the areas of human rights, cultural safety, and trauma-informed care. Participants noted that clear communication regarding diagnoses and care trajectories is essential, as is the inclusion of in-hospital supports to assist with daily living needs and communication barriers. Public education and transparency were also highlighted, with participants emphasizing the importance of educating the public about healthcare system constraints and mechanisms, as well as fostering transparent engagement between providers and system users to build trust. Broadly, resource allocation frameworks should anticipate surges in demand and potential inequities, aiming to mitigate the negative impacts of triage-avoidant strategies on equity-deserving groups.

A Resource Allocation Framework Reflecting the Experiences of Decision-Makers, Clinicians, and Equity-Deserving Groups is Required

Our participants felt that COVID-19 exacerbated existing inequities in access to emergency care, and argued for an equitable approach to managing limited healthcare resources, whether triage or triage-avoidant strategies are used. A resource allocation framework grounded in equity-based principles could provide actionable strategies to mitigate inequities during demand surges, helping to ensure that equity-deserving groups are not disproportionately affected when resources are scarce.

While some frameworks cite the importance of equity in triage and triage-avoidant strategies, implementing equity-based decisions is challenging. For example, the American Medical Association provides suggestions on embedding equity in crisis preparedness and response in health systems, including a “shift to race and identity-explicit approaches that promote equitable crisis response processes and outcomes” and “embed[ding] equity in all emergency response structures”, but practical implications are not discussed (36, p.8). Complementing this, Downar et al. (8) developed a multi-level critical care triage framework that incorporates fairness, consistency, and equity considerations across hospitals, emphasizing consultation with Indigenous, Black, racialized, older adult, and disability rights stakeholders.

Our participants’ experiences echo this framework, highlighting the value of stakeholder engagement in shaping protocols. Building further, the Accountability for Reasonableness (A4R) framework argues that legitimacy and fairness in resource allocation require a deliberative process that is transparent (37), based on reasons stakeholders can agree are relevant, revisable in light of new evidence, and enforceable (38). Applying A4R to our findings emphasizes that procedural justice, such as clear reasoning, transparency, and mechanisms for revision, is crucial for embedding equity-oriented principles in practice, especially when healthcare providers are faced with rapidly evolving crises.

Representation and Power within Equity-Focused Organizations

While our recruitment included organizations among government, healthcare, and advocacy sectors, it is important to note that those contributing to decision-making discussions may not have been individuals among equity-deserving communities. This raises important questions about how equitable power structures are within organizations that aim to promote equity — specifically, whose voices are centred in decision-making and whose perspectives may remain underrepresented. For instance, the development of healthcare frameworks and strategies is often led by healthcare professionals and/or leaders with limited direct involvement of patients, family caregivers, or members of the general public (39). Indeed, engaging equity-deserving groups in these processes presents both opportunity as well as complexity: engagement can help ensure that frameworks and strategies reflect lived experiences and mitigate structural inequities, yet it also requires careful attention to tokenism, accessibility, and the distribution of decision-making authority (40,41). The fact that both the triage framework and triage-avoidant strategies were developed as the pandemic was unfolding created a time-pressure that precluded extensive consultation and engagement.

Strengths and Limitations

This project engaged representatives among a variety of organizations, including governmental, educational, and non-profit sectors. A notable strength of this work is the documented perceptions of a broad range of interested parties on the effects of efforts to avoid triage, which can inform future considerations for framework development. Additionally, we have identified several system-level recommendations that can be brought forward when developing and implementing future frameworks.

We nonetheless encountered recruitment challenges engaging participants on a national scale; we were only able to secure representation from five provinces. Additionally, we faced difficulties recruiting individuals who could both articulate the experiences of equity-deserving groups during COVID-19 and had an in-depth knowledge of the healthcare system. This limited representation may hinder our understanding of how changes within the healthcare system affected individuals and communities beyond COVID-19. Moreover, because our findings represent participants’ perspectives, we cannot confirm that these perspectives are reflected in empirical data from the pandemic (e.g., whether marginalized individuals were transferred more often than non-marginalized individuals in the same situation). We are studying this data in a separate study.

Finally, we had poor representation from First Nations, Inuit, Métis and urbanized Indigenous peoples. Recognizing the First Nations principles of Ownership, Control, Access, and Possession (OCAP) in data collection processes (42), we invited representatives to engage in a preliminary conversation before the recruitment phase and requested letters of support from organizations to indicate their approval for the research coordinator to invite representatives from the organization to participate in the research study. We also faced challenges engaging other members of equity-deserving groups, as only approximately 30% of participants identified as a person of colour or among equity-deserving groups. This limited representation may influence the extent to which our findings reflect the experiences of all equity-deserving groups and underscores the importance of developing more inclusive recruitment strategies in future studies.

CONCLUSIONS

This study contributes to the literature by documenting the perspectives of representatives of diverse organizational backgrounds, as well as members of equity-deserving groups, on how triage-avoidant strategies disproportionately harmed their organizations and the populations they serve. The study also gathered insights on organization-specific actions that were implemented to mitigate these effects, and we identified system-level recommendations for future strategies to reduce harm. The synthesized findings highlight key elements that should be considered when developing equitable resource allocation frameworks. Our findings can inform the development and implementation of triage-avoidant (and triage) strategies that better reflect the views and experiences of decision-makers, clinicians and/or groups equity-deserving groups, and ensure that care is delivered more equitably while trying to maximize lives saved. Future research is necessary to explore the practical implementation of equity-focused triage-avoidant strategies.