Why country’s ICU capacity is a concern amid Delta outbreak
Units still struggling even without pandemic, writes Nicholas Jones
Covid-19 has put an unprecedented focus on New Zealand’s intensive care units, but day-to-day capacity hasn’t improved since the pandemic began and often struggles with “business as usual” demands.
Official documents obtained by the Weekend Herald and interviews with frontline health workers outline how years of underinvestment mean hospitals had capacity problems even without any Covid-19 patients.
There’s an expectation that if the public comply with level 4 restrictions then ICUS won’t be swamped by Delta cases. However, the health system is running at full stretch, meaning there’s little ability to absorb more patients without knock-on effects such as delaying surgeries.
New Zealand has fewer ICU beds per capita than other developed countries. Middlemore Hospital is particularly lacking — an alarming weakness given it serves more patients with underlying health woes, who are most vulnerable to Covid-19 infection and serious illness.
NZ has 284 fully staffed ICU beds across public hospitals, and 629 Icu-capable ventilators, with 133 in the national reserve if required.
But more important than the number of beds or ventilators is whether there are enough skilled staff to treat the patients using them.
ICU nurses provide individual, one-to-one care to each patient, and their numbers can’t be quickly increased — such nurses have five years of specialised training and are in demand internationally, with better pay offered overseas.
In winter the numbers of people needing intensive care jumps, and viral illnesses also mean the limited pool of staff are more likely to call in sick. In a pandemic those absences become worse. Any potential spread means workers are stood down.
“We now have more equipment compared with 18 months ago, but we actually have very few extra staff, and in some instances, we’ve got fewer staff,” ICU doctor Craig Carr told the Weekend Herald this week. “Actual resourced bed capacity on a day-to-day basis, in terms of a bed with a nurse and a ventilator and all the monitors, that has not risen, to my knowledge, in the last 18 months.”
Blunt assessment
Capacity problems were bluntly stated by DHBS when they sent recovery plans to the Ministry of Health about this time last year, and after the first lockdowns had successfully stamped out Covid in the community.
The plans set out how quickly huge backlogs for planned care, including electives, could be reduced. They noted ICU units were full — even without any influx of Covid-19 patients — and that had a flow-on effect.
“Our ICU is currently at capacity with four long-term ventilated patients. We currently are unable to schedule these patients as we are not in a position to have access to a postoperative ICU/HDU bed. ICU capacity is constrained in all NZ DHBS,” Bay of Plenty DHB told the ministry, in documents obtained under the Official Information Act. “We are regularly at capacity and need to cancel planned surgery as a result for those patients with complex health issues requiring postoperative access to ICU.”
Emergency plans
ALL DHBS have plans to scale-up intensive care capacity if a Covid-19 outbreak spreads significantly.
These differ by hospital, but will generally involve steps such as using operating theatres to expand the ICU physical area for patients. Anaesthetists and anaesthetist nurses would be seconded and do the work of their intensivist colleagues, with supervision and support. Patients would go to private hospitals if needed.
Exhaustion could be an issue. Covid patients with low oxygen levels despite ventilation are often shifted into the prone position for 16 hours at a time. Safely turning them like this usually takes eight people. Slighter shifts are needed every two hours to relieve pressure and avoid bedsores.
That physical, demanding work is done in layers of PPE and under strict infection protocols. Any breach or suspected breach would trigger staff stand-downs and testing.
Having all hands on deck in the ICU would seriously affect patients elsewhere, because the unit does crucial work in other areas of a hospital, including helping resuscitate and stabilise patients in other wards, and detect any deterioration in their health.
A widespread outbreak of Delta in a country with relatively low levels of vaccination would quickly swamp hospitals and ICUS, even if capacity was much greater than in NZ.
In early 2020 and as the first waves of the pandemic overwhelmed Italy’s world-class hospitals, a group of Kiwis developed a world-leading piece of software designed to help if such a situation happened here.
The “1000minds” software would give each Covid-19 patient a score, calculated from criteria including underlying medical conditions, and extremes of weight and age. That number would then help ICU doctors decide who should get the next free bed if there aren’t enough for every patient needing intensive care.
The software sits with the Ministry of Health for sign-off. Dr Andrew Stapleton, one of the intensive care specialists involved in designing the tool, said issues around equity were still being worked through, but he no longer expected the software would be needed, in the current outbreak or in the case of future ones.
That was because level 4 should contain this outbreak, he said, as long as the public complied with the rules.
And in the future, once everyone who is willing has had a jab, Stapleton believes the Government won’t allow a situation where hospitals and ICUS can’t cope. (In countries like the United States, the overwhelming majority of Covid-19 patients in intensive care are unvaccinated.)
“I suspect the national strategy, once everyone is vaccinated, will be to continue to use lockdowns in a localised manner to try and prevent individual hospitals being overwhelmed. The goal would be to avoid situations where the triage tool would ever need to be used.”
That view is supported by a new study, published in the Lancet Regional Health yesterday , that estimated reopening New Zealand’s borders without hard measures like lockdowns could lead to more than 11,000 hospitalisations — and more than 1000 deaths — even if we manage to vaccinate nine in 10 of all Kiwis.