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In the past two years, 28 burn patients were sent to hospitals in New York State because there were not enough beds in Ontario and nearly all of them returned infected with the deadly superbug MRSA, according to Canada's largest burn centre.
Patients with severe burns and open wounds are vulnerable to blood infections, such as methicillin-resistant Staphylococcus aureus, a hospital superbug that can cause nasty complications and lengthen hospital stays. MRSA is a strain of S. aureus that is resistant to a large group of antibiotics.
Burn patients are sent to the United States for care when the Ross Tilley Burn Centre does not have a free bed or enough staff and the centre is closed to new admissions. The Tilley, a 14-bed burn centre where the sickest patients in the hospital lie in isolation, is located at Sunnybrook Health Sciences Centre.
When a spot opens up at the Tilley, Ontario patients are normally repatriated for treatment and "close to 100 per cent of the time" the patients arrive at Sunnybrook with MRSA, said Dr. Robert Cartotto, the Tilley's acting director.
"It is endemic in many hospitals in the United States and we are headed that way because of overuse of antibiotics," he said. "It's a big problem. It creates a big issue for everyone."
By the end of the year, the Ontario health ministry will post online the MRSA rates of each provincial hospital as part of its patient safety push. All of Ontario's 157 hospital corporations will update monthly their number of cases and rate per 1,000 patient days.
Death rates are not yet available. Last month, C. difficile infection rates – the first of eight patient safety indicators that are now publicly shared – were posted online.
Ontario burn patients are usually referred to Strong Memorial Hospital in Rochester or to Erie County Medical Center in Buffalo. According to Ontario's health ministry, which has figures only for 18 emergency patient transfers, the cost of treatment to taxpayers has been more than $1.3 million.
The Tilley treats approximately 135 patients each year – nearly three-quarters of burn victims are men and the average age of a patient is 43. Ten of the 14 beds are for intensive care burn patients, each of whom requires around-the-clock nursing care. Specially trained burn surgeons, physiotherapists, nurses, occupational therapists and a full-time social worker staff the centre.
Patients with severe burns can spend weeks or months in medically induced comas so doctors can excise and replace burned skin. They are at risk of organ failure, have weakened immune systems, are prone to infections and often experience a roller-coaster ride of setbacks.
These patients can get stuck in the U.S. for weeks before they are sent back to Ontario, said Dr. Joel Fish, a burn surgeon at the Tilley.
"The ones that tend to go, these are not the people who are in a hospital and then out 10 days later. They are in hospital for months," said Fish. "This becomes a major issue for us. Even though we can send them over, it increases risk and prolongs length of (hospital) stay. And we have problems with skin graft loss."
And it's not just doctors that are needed on both sides of the border. The problem of insufficient nurses can lead to patients being sent south.
"In the overwhelming majority of cases, we had to turn people away because of nursing shortages," said Cartotto, who figures that is the case two-thirds of the time. Lack of doctors available to care for the patients or an overwhelmed staff already handling an acute patient load are some other reasons.
"We are strapped," said Cartotto. "We are barely managing with the existing complement of surgeons and if someone gets sick or leaves, it's the same thing."
The shortage of surgeons who specialize in burns is nationwide, said Fish, who added there are less than a handful of dedicated burn specialists in Ontario.
At the Tilley there are three: Fish, Cartotto, and Dr. Shahriar Shahrokhi.
Fish was the director of the Tilley until March when he became the chief medical officer at St. John's Rehab Hospital, site of Ontario's only burn rehabilitation program. Fish is still a surgeon at the Tilley.
"The fact is, in the province of Ontario there are three burn specialists," said Cartotto. "That is all we do for the entire province. That is the issue."
In the burn unit, patients are even more at risk for MRSA infection because severely burned patients are like "Petri dishes," said Dr. Andrew Simor, head of microbiology and infectious disease at Sunnybrook. "They are so prone to infection."
Beginning in the 1980s, MRSA rates rose in American hospitals, said Simor. It wasn't until the mid-1990s the superbug crept into Canadian hospitals. In reaction, Canadian hospitals began screening their patients for MRSA – something all U.S. hospitals still don't do, he said. For that reason, Canadian MRSA rates are not nearly as high as they are in the U.S.
Screening for MRSA not only picks up those who have an active infection but also those who are colonizing or carrying the bacteria. Both types of patients are infectious and MRSA can be spread by skin-to-skin contact.
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