Critical Care capacity in Canada: results of a national cross-sectional study

Abstract

Intensive Care Units (ICUs) provide life-supporting treatment; however, resources are limited, so demand may exceed supply in the event of pandemics, environmental disasters, or in the context of an aging population. We hypothesized that comprehensive national data on ICU resources would permit a better understanding of regional differences in system capacity.
After the 2009-2010 Influenza A (H1N1) pandemic, the Canadian Critical Care Trials Group surveyed all acute care hospitals in Canada to assess ICU capacity. Using a structured survey tool administered to physicians, respiratory therapists and nurses, we determined the number of ICU beds, ventilators, and the ability to provide specialized support for respiratory failure.
We identified 286 hospitals with 3170 ICU beds and 4982 mechanical ventilators for critically ill patients. Twenty-two hospitals had an ICU that routinely cared for children; 15 had dedicated pediatric ICUs. Per 100,000 population, there was substantial variability in provincial capacity, with a mean of 0.9 hospitals with ICUs (provincial range 0.4-2.8), 10 ICU beds capable of providing mechanical ventilation (provincial range 6-19), and 15 invasive mechanical ventilators (provincial range 10-24). There was only moderate correlation between ventilation capacity and population size (coefficient of determination (R(2)) = 0.771).
ICU resources vary widely across Canadian provinces, and during times of increased demand, may result in geographic differences in the ability to care for critically ill patients. These results highlight the need to evolve inter-jurisdictional resource sharing during periods of substantial increase in demand, and provide background data for the development of appropriate critical care capacity benchmarks.

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Critical Care capacity in Canada: results of a national cross-sectional study
Critical Care Sample
doi:10.1186/s13054-015-0852-6
Robert A Fowler (rob.fowler@sunnybrook.ca)
Philip Abdelmalik (Philip.Abdelmalik@phac-aspc.gc.ca)
Gordon Wood (Gordon.Wood@viha.ca)
Denise Foster (Denise.Foster@vch.ca)
Noel Gibney (Noel.Gibney@albertahealthservices.ca)
Natalie Bandrauk (natalie.bandrauk@med.mun.ca)
Alexis F Turgeon (Alexis.Turgeon@fmed.ulaval.ca)
François Lamontagne (francoislamontagne@me.com)
Anand Kumar (akumar61@yahoo.com)
Ryan Zarychanski (Ryan.Zarychanski@cancercare.mb.ca)
Rob Green (Dr.Robert.Green@Dal.ca)
Sean M Bagshaw (Sean.Bagshaw@albertahealthservices.ca)
Henry T Stelfox (tstelfox@ucalgary.ca)
Ryan Foster (ryan.foster@interiorhealth.ca)
Peter Dodek (peter.dodek@ubc.ca)
Susan Shaw (Susan.Shaw@saskatoonhealthregion.ca)
John Granton (john.granton@uhn.ca)
Bernard Lawless (Bernard.Lawless@uhn.ca)
Andrea Hill (Andrea.Hill@sunnybrook.ca)
Louise Rose (louise.rose@utoronto.ca)
Neill K Adhikari (neill.adhikari@sunnybrook.ca)
Damon C Scales (damon.scales@sunnybrook.ca)
Deborah J Cook (debcook@mcmaster.ca)
John C Marshall (MarshallJ@smh.ca)
Claudio Martin (Claudio.Martin@lhsc.on.ca)
Philippe Jouvet (philippe.jouvet@umontreal.ca)
On Behalf of the Canadian Critical Care Trials Group and The Canadian ICU Capacity Group
Sample
ISSN 1364-8535
Article type Research
Submission date 1 July 2014
Acceptance date 3 March 2015
Article URL http://dx.doi.org/10.1186/s13054-015-0852-6
For information about publishing your research in BioMed Central journals, go to http://www.biomedcentral.com/info/authors/
© 2015 Fowler et al.; licensee BioMed Central.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
(2015) 19:133

Critical Care capacity in Canada: results of a
national cross-sectional study
Robert A Fowler
1,2,*
Email: rob.fowler@sunnybrook.ca
Philip Abdelmalik
3
Email: Philip.Abdelmalik@phac-aspc.gc.ca
Gordon Wood
4
Email: Gordon.Wood@viha.ca
Denise Foster
5
Email: Denise.Foster@vch.ca
Noel Gibney
6
Email: Noel.Gibney@albertahealthservices.ca
Natalie Bandrauk
7
Email: natalie.bandrauk@med.mun.ca
Alexis F Turgeon
8
Email: Alexis.Turgeon@fmed.ulaval.ca
François Lamontagne
9
Email: francoislamontagne@me.com
Anand Kumar
10
Email: akumar61@yahoo.com
Ryan Zarychanski
11
Email: Ryan.Zarychanski@cancercare.mb.ca
Rob Green
12
Email: Dr.Robert.Green@Dal.ca
Sean M Bagshaw
13
Email: Sean.Bagshaw@albertahealthservices.ca
Henry T Stelfox
14
Email: tstelfox@ucalgary.ca
Ryan Foster
15
Email: ryan.foster@interiorhealth.ca
Peter Dodek
16
Email: peter.dodek@ubc.ca

Susan Shaw
17
Email: Susan.Shaw@saskatoonhealthregion.ca
John Granton
18
Email: john.granton@uhn.ca
Bernard Lawless
19
Email: Bernard.Lawless@uhn.ca
Andrea Hill
1,2
Email: Andrea.Hill@sunnybrook.ca
Louise Rose
20
Email: louise.rose@utoronto.ca
Neill K Adhikari
1,2
Email: neill.adhikari@sunnybrook.ca
Damon C Scales
1,2
Email: damon.scales@sunnybrook.ca
Deborah J Cook
21
Email: debcook@mcmaster.ca
John C Marshall
22
Email: MarshallJ@smh.ca
Claudio Martin
23
Email: Claudio.Martin@lhsc.on.ca
Philippe Jouvet
24
Email: philippe.jouvet@umontreal.ca
On Behalf of the Canadian Critical Care Trials Group and The Canadian ICU
Capacity Group
1
Interdepartmental Division of Critical Care Medicine and Department of
Medicine, University of Toronto, Toronto, Canada
2
Department of Critical Care Medicine, Sunnybrook Hospital, 2075 Bayview
Avenue, Room D478, Toronto, Ontario M4N 3M5, Canada
3
Office of Situational Awareness and Operations, Centre for Emergency
Preparedness & Response, Health Security Infrastructure Branch, Public Health
Agency of Canada, Toronto, Canada
4
Medical Director Adult ICU Vancouver Island health Authority, Vancouver,
Canada

5
Division of Critical Care, Vancouver General Hospital, Vancouver, British
Columbia, Canada
6
Division of Critical Care Medicine, Faculty of Medicine and Dentistry,
University of Alberta, Edmonton, Alberta, Canada
7
Memorial University of Newfoundland, St. Johns Newfoundland, 230 Elizabeth
Ave, St John’s NL A1B 3X9, Canada
8
Department or Anesthesia and Critical Care Medicine, and Population Health
and Optimal Health Practices Research Unit, Centre Hospitalier Universitaire
(CHU) de Québec and Université Laval, Québec, Canada
9
Centre de recherche clinique Étienne-Le Bel, Université de Sherbrooke, Aile 8,
Porte 4, 3001 12e Avenue Nord, Sherbrooke, QC J1H 5N4, Canada
10
University of Manitoba, 66 Chancellors Cir, Winnipeg MB R3T 2N2, Canada
11
University of Manitoba, CancerCare Manitoba, 675 McDermot Avenue,
Winnipeg MB R3E 0V9, Canada
12
Trauma Nova Scotia, Department of Anesthesia: Division of Critical Care
Medicine, Department of Emergency Medicine, Halifax, Canada
13
Division of Critical Care Medicine, Faculty of Medicine and Dentistry,
University of Alberta, Edmonton, Alberta, Canada
14
Department of Critical Care Medicine, Institute for Public Health, University of
Calgary and Alberta Health Services, Calgary, Alberta, Canada
15
Critical Care, Kelowna General Hospital, 2268 Pandosy St, Kelowna, BC V1Y
1T2, Canada
16
Critical Care Medicine. University of British Columbia, Vancouver Costal
Health Research Institute, 1081 Burrard Street, Vancouver, BC V6Z1Y6, Canada
17
University of Saskatchewan College of Medicine’s Department of
Anesthesiology, Perioperative Medicine and Pain Management, Saskatoon,
Canada
18
Faculty of Medicine, University of Toronto, Head, Division of Respirology
University Health Network, Mount Sinai Hospital, Women’s College Hospital,
Toronto, Canada
19
Department of Surgery, University of Toronto, Provincial Lead, Critical Care
and Trauma, Critical Care Services Ontario, Toronto, Ontario, Canada
20
Lawrence S. Bloomberg Faculty of Nursing, University of Toronto,
Sunnybrook Hospital, Toronto, Ontario, Canada

21
St. Joseph’s Hospital, McMaster University, Hamilton, Ontario, Canada
22
Keenan Research Centre of the Li Ka Shing Knowledge Institute of St.
Michael’s Hospital. Professor of Surgery, Surgery/General Surgery, University of
Toronto, Toronto, Ontario, Canada
23
Critical Care Western and London Hospitals, Schulich School of Medicine &
Dentistry, Western University Scientist, Centre for Critical Illness Research,
Lawson Health Research Institute, Toronto, Canada
24
Director of the Pediatric Intensive Care Unit/chef de service des soins intensifs
pédiatriques, CHU Sainte-Justine, 3175 Chemin de Côte Sainte Catherine,
Montreal, Québec H3T 1C5, Canada
*
Corresponding author. Department of Critical Care Medicine, Sunnybrook
Hospital, 2075 Bayview Avenue, Room D478, Toronto, Ontario M4N 3M5,
Canada
Abstract
Introduction
Intensive Care Units (ICUs) provide life-supporting treatment; however, resources are
limited, so demand may exceed supply in the event of pandemics, environmental disasters, or
in the context of an aging population. We hypothesized that comprehensive national data on
ICU resources would permit a better understanding of regional differences in system
capacity.
Methods
After the 2009–2010 Influenza A (H1N1) pandemic, the Canadian Critical Care Trials Group
surveyed all acute care hospitals in Canada to assess ICU capacity. Using a structured survey
tool administered to physicians, respiratory therapists and nurses, we determined the number
of ICU beds, ventilators, and the ability to provide specialized support for respiratory failure.
Results
We identified 286 hospitals with 3170 ICU beds and 4982 mechanical ventilators for
critically ill patients. Twenty-two hospitals had an ICU that routinely cared for children; 15
had dedicated pediatric ICUs. Per 100,000 population, there was substantial variability in
provincial capacity, with a mean of 0.9 hospitals with ICUs (provincial range 0.4-2.8), 10
ICU beds capable of providing mechanical ventilation (provincial range 6–19), and 15
invasive mechanical ventilators (provincial range 10–24). There was only moderate
correlation between ventilation capacity and population size (coefficient of determination
(R
2
) = 0.771).

Conclusion
ICU resources vary widely across Canadian provinces, and during times of increased
demand, may result in geographic differences in the ability to care for critically ill patients.
These results highlight the need to evolve inter-jurisdictional resource sharing during periods
of substantial increase in demand, and provide background data for the development of
appropriate critical care capacity benchmarks.
Introduction
Intensive care units (ICUs) provide life-supporting treatments to critically ill patients. ICU
resources are limited and costly in Canadian hospitals. Clinicians must consider the possible
benefits of admission to ICU, and hospital administrators must coordinate the provision of
procedures and surgeries requiring critical care with existing capacity [1,2]. During periods of
increased demand for ICU resources, such as during infectious outbreaks or pandemics, it can
be difficult to match available resources to clinical demands [3-5], resulting in the potential
for rationing of ICU care [6].
There is substantial global variation in capacity to provide critical care [7]. Previous estimates
using national health administrative data indicate that Canada has far fewer ICU beds per
capita than the United States, but similar numbers of ICU beds to those in many Western
European nations [8]. Because healthcare is a provincial portfolio in Canada, differences in
provincial priorities may translate to differences in availability of specific resources.
Moreover, because critical care services represent one of the most expensive components of
the healthcare system [9], cost is an additional reason for regional differences.
Although there have been prior provincial assessments [10-12], our overall national critical
care capacity is unknown. Therefore, during the period after the 2009–10 Influenza A
(H1N1) pandemic, the Canadian Critical Care Trials Group (CCCTG) undertook a national
survey of all acute care hospitals to determine the number of critical care beds and
mechanical ventilators, as well as the availability of specialized support for respiratory failure
in critically ill adults and children. We hypothesized that comprehensive national data on ICU
resources would permit a better understanding of regional differences in system capacity in
Canada, inform the potential need for inter-jurisdictional resource sharing during periods of
increased national and provide background data for the development of appropriate critical
care capacity benchmarks.
Methods
Questionnaire development
We developed a capacity survey to tabulate each hospital’s critical care resources using
rigorous methodology [13]. Questionnaire development consisted of item generation and
reduction with input from critical care physicians, nurses, respiratory therapists, clinical
researchers, and research ethics officers. The questionnaire was subsequently tested for
sensibility and reliability [13]. Final domains included hospital and respondent
characteristics, ICU type, ICU beds, invasive ventilators, availability of specialized supports
for respiratory failure and a field for qualitative comments. Recognizing no uniformly

accepted definition, we used a sensitive definition of ICU and subsequently determined
capacity for ongoing invasive mechanical ventilation in an ICU (i.e., not the emergency
department or post-anesthetic care unit) (see Additional file 1).
Respondents and survey completion
CCCTG members in each province were enlisted as local collaborators and site champions in
order to identify acute care hospitals and ICUs through snowball sampling of colleagues and
relevant government- and hospital-specific contacts. In some provinces, pre-existing lists had
been generated by Ministries or Departments of Health (British Columbia, Alberta, Ontario,
New Brunswick) or critical care societies (Quebec). The search for acute care institutions was
supplemented by a manual search of the guide to Canadian Healthcare Facilities [14], pre-
existing hospital lists of the Public Health Agency of Canada, Google Maps and web searches
for all hospitals.
An ICU physician lead for each hospital was identified and contacted by email or telephone.
Subsequently, nursing and respiratory therapy leaders were contacted by email or telephone
from pre-existing lists, referral from nearby institutions, or through telephone solicitation
directly to the hospital or ICU. The survey was then transmitted by via email or fax for self-
administration, or administered via telephone to physicians, nurses and/or respiratory
therapists. In hospitals with more than one ICU, additional ICU-specific contacts were
established by subsequent telephone or email communication. In rare cases where no ICU-
specific contact could be identified, or the leader did not respond (generally for small
hospitals that had no geographically distinct ICU), we obtained information from an informed
clinician who was primarily affiliated with another nearby hospital.
Respondents were to provide capacity data at the time of the survey. We attempted to
complete data collection for each site within a 3-month time frame to limit temporal changes
in any measure. In some cases, there was uncertainty about the number of available ICU beds
because of staffing shortages. We asked respondents to answer based upon how many ICUs
beds were usually available for admission should staffing not be a limitation. We attempted
to resolve uncertainty about number of ICUs and bed numbers capable of ventilation through
communication with more than one local physician and nurse leader. Respiratory therapy
leaders resolved uncertainty about numbers of ventilators, and availability of inhaled nitric
oxide, high frequency oscillatory ventilation and extra-corporeal membrane oxygenation.
Analyses
Descriptive statistics are presented as counts, proportions, medians (with range or
interquartile range), and means (+/− standard deviation) as appropriate using Microsoft Excel
or SAS. We tested the relationship between number of ICU beds capable of ventilation and
population by health and census regions using the R
2
coefficient of determination. Canadian
and provincial population census numbers in 2009–2010 were derived from Statistics Canada
Census projections [15]. Spatial Analyses were conducted in collaboration with the Public
Health Agency of Canada in order to map the locations of hospitals and facilities across
Canada that had ICU beds with capacity for invasive ventilation. Moreover, the population
within a 40 km service area of each of these hospitals was identified using 2006 census data
[16]. Network analyses using both health region and census division service were performed
using CanMap Route Logistics for road networks and Enhanced Points of Interest [17],
hydrology data from Statistics Canada [18], and Aerial imagery using BingTM maps

aerialand ArcGIS 10.0 (ArcView) with NetworkAnalyst extension from ESRI© (see
Additional file 1) [19].
Confidentiality and ethics
Research ethics approval for this study was granted by Sunnybrook Hospital in April 2009
without the need for consent as only institutional and no individual patient-related data were
collected. Study funders and provincial governmental officials who provided data had no role
in its analysis or publication.
Results
Overall resources
We identified 362 acute care centers in 10 provinces and 3 territories. There were 286
hospitals with at least one self-designated ICU that was capable of providing invasive
mechanical ventilation. ICUs in 22 hospitals had designated beds for pediatric patients, and
15 hospitals had stand-alone pediatric ICUs. The vast majority of ICUs (280; 97.9%) were
capable of caring for mixed, medical and surgical, patient populations. Many (27; 9.4%)
cared for medical, cardiac, or cardiothoracic surgery patients either in isolation or in addition
to other critically ill patients. Two cared exclusively for critically burned patients, whereas 4
routinely cared for some burned patients, and 3 cared exclusively for neurologically injured
or neurosurgical patients.
In hospitals with an ICU capable of providing invasive mechanical ventilation, there were a
total of 4309 beds, 3170 of which were specifically designated for mechanical ventilation.
Among hospitals with an ICU capable of providing invasive mechanical ventilation, there
was a median of 9 (IQR 5–18) ICU beds with 8 (IQR 3–14) available for patients who
required invasive mechanical ventilation. There was a total of 4982 ventilators capable of
providing invasive mechanical ventilation, including ventilators used for patient
transportation (but not those primarily used to deliver inhalational anesthesia during surgery)
and a median of 10 (IQR 5–23) invasive ventilators per hospital (Table 1). In terms of
specialized support for respiratory failure, there were 178 high frequency oscillatory
ventilators in 72 (25.2%) hospitals that had an ICU capable of delivering ventilation; inhaled
nitric oxide in 79 (27.6%) hospitals; and extra-corporeal membrane oxygenation in 39
(13.6%) hospitals. All three were available in 32 (11.1%) hospitals - all being university
teaching centers.

Table 1 Number of ICUs, ventilation and oxygenation capacity across provinces
Region Hospitals with
ICUs with
Ventilation
Capacity
ICU Beds
Capable of
Invasive
Ventilation
Ventilators
Capable of
Invasive
Ventilation
High-
frequency
Oscillatory
Ventilators
Hospitals
with ICUs
with iNO
Hospitals
with ICUs
with ECMO
(N)
(N)
(N)
(N)
(N)
(N)
Newfoundland
14 98 124 7 3 2
Nova Scotia
14
141
191
6
7
2
Prince Edward
Island
2 18 22 0 0 0
New
Brunswick
9
103
113
1
3
0
Quebec
87
885
1197
40
25
12
Ontario
84 1122 2101 65 19 11
Saskatchewan
13 108 235 10 3 3
Manitoba
10
93
151
10
3
2
Alberta
16 292 373 18 8 3
British
Columbia
34 304 460 21 7 4
Territories
3 6 15 0 1 0
Canada
286 3170 4982 178 79 39
Abbreviations: ICU = Intensive Care Unit; iNO = inhaled Nitric Oxide; ECMO = extra-corporeal membrane
oxygenation.
Resources across provinces and territories
There was substantial variation in capacity to provide critical care among provinces and
territories. The median number of ICUs per province was 14 (IQR 10–25). The median
number of ICU beds per province was 122 (IQR 110–337), and the median number available
for mechanical ventilation was 108 (IQR 97–298). The median number of mechanical
ventilators per province was 201 (IQR 131–435). Per 100,000 population in 2009–10, there
were 0.9 hospitals with ICUs capable of providing mechanical ventilation (range 0.4-2.8), 10
ICU beds capable of providing mechanical ventilation (range 6–19), and 15 invasive
mechanical ventilators (range 10–24) (Figure 1; Table 2; Figure S1A in Additional file 1).
Figure 1 ICU beds capable of invasive mechanical ventilation per 100,000 Canadian
population according to health region.

Table 2 ICUs and ventilation capacity according to 2009 population across provinces
Region Hospitals with ICUs per
100,000 Population
ICU Beds with Ventilation
Capacity per 100,000 Population
Invasive Ventilators per
100,000 Population
Newfoundland
2.8
19.3
24.4
Nova Scotia
1.5 15.0 20.3
Prince Edward
Island
1.4 12.8 15.6
New Brunswick
1.2 13.8 15.1
Quebec
1.1
11.3
15.3
Ontario
0.6 8.6 16.1
Saskatchewan
1.3 10.5 22.8
Manitoba
1.0
9.0
14.7
Alberta
0.4 7.9 10.1
British Columbia
0.8 6.8 10.3
Territories
2.7 5.5 13.7
Canada
0.9 9.5 14.9
Abbreviations: ICU = Intensive Care Unit.
Resources according to the type of hospital
There was considerable concentration of ICU resources for mechanical ventilation in
teaching hospitals as compared to community hospitals. The total number of teaching and
community ICUs beds capable of mechanical ventilation was 2027 and 1143, respectively;
with a median number of 20 [11-31] and 5 [2-8], respectively, p < 0.001). There was
moderate correlation between the number of ICU beds capable of mechanical ventilation and
population size for both health region divisions (R
2
= 0.771) and census divisions (R
2
=
0.809) (Additional file 1).
Other qualitative characteristics of ICUs
Complementary qualitative data acquired in our survey shed important insights into critical
care capacity in Canada. Some hospitals with small ICUs (i.e., fewer than 6 ICU beds)
commented that despite their capacity for ongoing ventilation, it was common practice to
attempt to transfer patients to larger ICUs after a variable period of time (many days to a
week). Many hospitals commented that lack of personnel (especially nurses) prevented the
full utilization of ICU beds and ventilator capacity. In hospitals with more than one ICU,
conflicts in admission decision processes prevented optimal ICU bed utilization. For instance,
open beds were maintained in sub-specialty ICUs while general ICUs were at or above
capacity.
Discussion
We found substantial variation in the numbers of ICU beds, as well as the capacity for
mechanical ventilation and specialized support for respiratory failure among ICUs in Canada.
These findings were not fully explained by the size of the population. This variation in
capacity may result in differential decision-making about who can receive ICU support, and
which services can be supported in specific hospitals and regions during times of increased
demand [3,5].

Prior work by our group using health administrative data from the Canadian Institute for
Health Information estimated that there were 319 ICUs, 3388 total adult ICU beds
(representing 3.4% of all acute care hospital beds), and 13.5 ICU beds per 100,000 population
[8]. However, these data were based on a more liberal definition of critical care beds, did not
include data from Quebec, did not include any interprovincial comparisons, did not estimate
the capacity to treat critically ill patients requiring mechanical ventilation, and were
generated one decade ago. Our assessment of ICU beds per 100,000 population places
Canada near the median of high-income and Organization for Economic Co-operation and
Development countries, notably above the United Kingdom, but well below the United
States, Germany and Belgium [8,7,20,21].
Without knowledge of Canadian critical care capacity, and in the absence of provincial,
national or international targets for population-based critical care resources, there has been
limited national attention to ensuring optimal distribution among regions. The results of this
survey highlight expected North–south geography-based capacity trends, but also an
unanticipated apparent East–west gradient with relative increased capacity among the
Atlantic Provinces, in comparison to central and Western Canada. Some members of our
group have previously reported wide variation in ICU capacity within British Columbia and
an inverse relationship between ICU beds, population density and population growth,
highlighting the potential for mismatch in demand and capacity in Canada [11].
Some variation in distribution of health care services likely is a consequence of differential
regional models of health care delivery. For example, there are substantial differences in
population density across Canada, with marked north-to-south increases in density –
approximately 80% of Canadians live within 160 km of the Canada-United States border [23]
– and there is marked intra-provincial urban–rural variability [24]. Many systems of intra-
provincial regionalization of care, that are responsive to population density, geographic
barriers or evolved regional care systems also may lead to differences in the distribution of
critical care services. Moreover, despite provincial administration of most healthcare
services, there is also some well-established inter-provincial ICU care, with regionalized
trauma services, specialized care delivery for northern territories among bordering provinces,
and to populations of one province that are closest to a specialized healthcare center in a
neighboring province. It is not clear however that specialized services referral relationships
work well during times of healthcare crisis such a pandemic, when regions may react to
future uncertainty by trying to conserve resources for more local use.
This study has important limitations. First, this survey was done using existing national and
provincial databases of hospitals, and it is possible that some acute care hospitals may have
been missed. However, we subsequently employed snowball sampling, web and map
searching techniques to identify all hospitals and ICUs in each province, then sought out a
combination of physician, nurse, respiratory therapist and hospital administrator leaders to
derive current ICU beds and ventilator capacity at each hospital. After compiling local data,
each participant and provincial health authority was given the opportunity to critique the
aggregate estimates to improve accuracy. Second, population denominator-based
comparisons may not be the optimal mechanism for normalization in all regions with varying
population density, age demographic differences, geographic barriers and distinct systems of
regionalized care for some tertiary and quaternary services such as trauma and
transplantation. However, our results indicate relatively wide variability in ICU capacity
among provinces and therefore may provide helpful inter-provincial comparisons. Third, this
study focused on a very narrow spectrum of services needed to provide critical care – ICUs,

beds, ventilators, and specialized supports for respiratory failure. It was beyond the scope of
this survey to evaluate personnel (dieticians, nurses, pharmacists, physicians,
physiotherapists, respiratory therapists, social workers) or other resources that are essential to
the care of critically ill patients. Indeed, lack of available critical care clinical staff is among
the most common reason for limitations in bed availability [25-27]. Future resource planning
must address this key knowledge gap. Fourth, ICU resources are not static, and this survey
represents a period prevalence of approximately 3 months at the hospital level and
approximately 1-year among all sites, at a period after the H1N1 pandemic where knowledge
of ICU capacity may have been greatest.
Our results highlight the need to examine capacity both in relation to local needs, and in
comparison to other regions. It is important to note that the organization of critical care
within Canada has not been static since the conduct of this survey. Alberta has re-organized
critical care services under one structure, with a standardized provincial bedside clinical
information system/electronic medical record. [28] Since the Severe Acute Respiratory
Syndrome (SARS) experience, the Ministry of Health and Long-term Care in Ontario has
maintained a Critical Care Strategy to oversee a similar cataloguing of critical care services
including twice daily clinical updates of every patient in ICUs into a centralized electronic
database that facilitates critical care inter-facility transportation services, reporting on quality
metrics and decision-making on surge capacity [29]. British Columbia and Nova Scotia have
recently formed Critical Care Working Groups within the Ministry of Health to coordinate
data collection and reporting, improvement of care processes, transportation of critically ill
patients, and improvement of staffing models in ICUs. In 2011, Quebec created a ‘Groupe
d’Experts en Soins Intensifs’ (GESIQ) working with the Ministry of Health to improve
quality and accessibility of ICUs and a mandate to establish provincial ICU capacity.
One of the lessons learned from the SARS and Influenza A (H1N1) pandemics is that
infectious outbreaks do not respect regional health boundaries [30,31] and that individual
regions may be clinically overwhelmed while others are unaffected. Of relevance to surge
planning, we were able to quantify the excess numbers of invasive mechanical ventilators
relative to ICU beds, highlighting capacity that may exist beyond existing ICU beds. The
ability to provide advanced oxygenation with one of three modes of support was available in
a minority of hospitals. Furthermore, this expertise was unevenly distributed across
provinces, and focused at university-affiliated teaching hospitals. However, we were unable
to gauge experience with specialized ventilation alongside capacity. We did not determine
capacity for other techniques such as prone ventilation, which may be less dependent upon
specific technology, more dependent upon generation of a local experience base, and have a
greater evidence base for efficacy than either early high frequency ventilation or use of
inhaled nitric oxide [32]. This variable and uneven distribution of expertise observed in this
study demands that we evolve a system in which excess capacity in one region may aid
another, either through safe transportation of patients, or short-term movement of equipment
or personnel to existing or temporary facilities [33].
Conclusion
ICU resources vary widely across Canadian provinces, and during times of increased
demand, may result in geographic differences in the ability to care for critically ill patients.
These results may guide future decision-making, but must also be complemented by
estimates of current and future healthcare personnel supply and projections of demand for
critical care from an aging population [34]. Greater ongoing knowledge of regional critical

care resources may help us respond to increases in demand from unpredictable events such as
infectious outbreaks or regional medical emergencies. While some regional imbalances may
persist, there should be deliberate planning for mechanisms to deal with both unexpected and
day-to-day surge in demand. Mechanisms are needed to rapidly share and deploy resources –
both equipment and personnel – across provincial boundaries to deliver a more equitable,
coordinated, and responsive system of healthcare for critically ill Canadians.
Key messages
• We identified all ICU beds and mechanical ventilators for critically ill patients in Canada.
• There was substantial variability in inter-provincial capacity.
• There was only moderate correlation between ventilation capacity and population size.
• During times of increased demand, variability in ICU resources may result in geographic
differences in the ability to care for critically ill patients.
• These results highlight the need to evolve inter-jurisdictional resource, and provide
background data for the development of appropriate critical care capacity benchmarks.
Abbreviations
CCCTG, Canadian Critical Care Trials Group; GESIQ, Groupe d’Experts en Soins Intensifs;
ICU, Intensive Care Unit; IQR, Interquartile range; r
2
, coefficient of determination; SARS,
Severe Acute Respiratory Syndrome
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
RAF, PJ, DC, JM, AT conceived of the study. RF, PJ participated in the design of the study.
RAF, SB, NB, DC, PD, DF, RF, NG, RG, PJ, AK, FL, BL, AH, CM, LR, SS, HS, AT, GW,
RZ, NA, JG, DS, JM collected primary data. RAF, PA performed the statistical analysis. All
authors read and approved the final manuscript.
Acknowledgements
Yukon Collaborators: KD Braden, Nora Tremblay, Bendan Hanley, Rowena Beckett, Karin
Heynen.
Northwest Territories Collaborators: Ivan Russell, Kami Kandola, Kathie Pender, Elaine
Kelly.
Nunavut Collaborators Collaborators: W. Alexander (Sandy) MacDonald.
British Columbia Collaborators: Tracey Miller, Lynn Tran, Lauren Tindall, Michelle Stuart,
Kevin Carriere, Elizabeth Jolley, Gordon Krahn, Jim Fitzpatrick, Lynn Smiley, Coleen Hay,
Ophelia Spencer, Darla Roberts, Christina Gordon, Barb Caldwell, Jo-Annne Rondeau,
Karen L Watson, Morag Mochan, Joanne Cozac, Cheryl Scovill, Kathey Yeulet; Suzanne
Johnston, Ray Taylor, Pat Tresierra, Rob Fingland, Christopher Gagnon, Monique Roy-
Michaeli, Grzegorz Martinka, David Wensley, Peter Skippen, Sneeta Takhar, Don Griesdale.

Alberta Collaborators: Monique Roy-Michaeli, Ari Joffe, Elaine Gilfoyle, P Wickson,
Catherine Ross, Chip Doig, Paul Boiteau, David Zygun.
Saskatchewan Collaborators: Susan Lyons, Anita Sagadahi, Laurie Albinet; Gayle Riendeau,
Pam McKay, Ndrew McLetchie; Barbara Jiricka, Carol Gregoryk, Val Davies, Valerie Mann,
Saqib Shahab, Patrick O’Byrne, Diane Larrivee, Sandy Bradford-Macalanda, Alice Wong.
Manitoba Collaborators: Kimberly Webster, Scott Cleghorn, Gregg Eschun, Allan Garland,
Charlie Penner, Murray Kesselman, Gordon Kasian.
Ontario Collaborators: Carol Moran, Jeff Singh, Judith Van Huyse, Sonny Dhanani, Jamie
Hutchison, John Muscedere, Stephen Lapinsky, Kusum Menon, Karen Choong, Tom Stewart,
Margaret Herridge, Douglas Fraser, Karen Burns, Niall Ferguson.
Quebec Collaborators: Baqir Quizibash, Jean Philippe Garant, Lysanne Desaindes, Vanessa
Dutil, Craig Baldry, Francois Lellouche, Pjil Roula, Ash Gursahaney, Arnold Kristoff, J-S
Bilodeau, Mathieu Bernier, Jean-Luc Houde, Marisa Tucci, Marc-Andre Dugas, Dina Diana,
Miriam Santschi, Denny Laporta, Dominique Piquette; Davinia Withington; Germain Poirier,
Martin Legare, Jacques Lacroix, Stephane P. Ahern, Dr. François Lauzier, Tina Doyle.
New Brunswick Collaborators: Carolin Galvin, Rachel Mallais, Marchel Mallet, Kathy
Kowalski, Claude Violette, Stephanie Perry, Colleen Reinsborough, John Mowat, Todd
Lambert, Krista Chillington, Judy Melanson, Joanne Michaud-Young, Marc Pelletier, Krista
Shillington, Jean Bustard.
Prince Edward Island Collaborators: Judy Adams, Sherry Harris, Kay Kelly.
Nova Scotia Collaborators: Anne McClair, Linda Rouleau, Dietrich Henzler, Rebecca Earle,
Nadine Stevens, Maria Marshall, Jill Smith, Wendy Studley, Norah Doucet, Angela Foote,
Dorothy McCaskil, Sharon McCarthy, Kim Thomasl Kate Mahon, Shauna Best, Chris Soder,
Rick Hall.
Newfoundland and Labrador Collaborators: Jill Barter, Gerry McCain, Kim Aduau, Sharon
Penny, Valery Clarke.
Public Health Agency of Canada Collaborators: Rachel Rodin, Corey Oliver, Ahalya
Mahendra, Joy Pulickal, Marianna Ofner, Kara Hayne.
Funding
Public Health Agency of Canada, Canadian Institutes of Health Research. The Public Health
Agency of Canada assisted in collection and analysis of the data. Funders had no role in the
interpretation of data; in the writing of the manuscript; and in the decision to submit the
manuscript for publication.
Canadian Institutes for Health Research, Public Health Agency of Canada.
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Additional files provided with this submission:
Additional file 1. This file contains: Figure S1A - ICU Beds Capable of Invasive Mechanical Ventilation per 100,000
Canadian Population According to Census Division; Figure S2 - Relationship Between Number of ICU Beds Capable of
Ventilation and Population by Health Region; Figure S3 - Relationship Between Number of ICU Beds Capable of Ventilation
and Population by Census Division; Mapping Methodology Technical Notes; and, the Canadian Critical Care Trials Group
Capacity Survey (3473kb)
http://ccforum.com/content/supplementary/s13054-015-0852-6-s1.pdf