LAST WEEK THE HSE said hospitals had started moving into their intensive care surge capacity as the number of Covid-19 patients requiring advanced care increased.
Last night there were 330 full-staffed critical care beds open, with 310 of those occupied, including 195 by Covid-19 patients.
The system can surge to 350 patients in ICU, providing the same level of care as traditional intensive care settings, but it is now quickly approaching that number as the situation is likely to further deteriorate over the course of this week.
Let’s take a look at what that means for the healthcare system, for the clinicians who are treating patients and for those who are admitted to hospital who may become critically ill.
Permanent ICU capacity in public hospitals is around 286 beds, though this can fluctuate depending on staffing levels available.
The system can scale up to provide critical care to 350 patients. This surge capacity was used during the first wave, when the permanent capacity was 255 and hospitals came under pressure with high numbers of patients becoming critically ill in hospital.
It requires the use of resources in the hospital that are generally used for other purposes such as anaesthetic rooms or post-operative beds.
Speaking last week, HSE Chief Clinical Officer Dr Colm Henry said hospitals using this surge capacity “can continue to provide the same quality of care” as a traditional ICU setting.
Training took place during the first wave – and since then – to ensure there were more fully-trained permanent staff for the additional permanent ICU capacity of 286 beds. But once the system moves into its surge capacity – beyond those 286 beds - it depends on the redeployment of non-ICU staff from other services to help provide care for patients.
“This has been worked through with our intensive care community, critical care program and critical care leads across the country,” Dr Henry said.
“Clearly,we’d be in a better position and it’d be much preferable if we never had to expand intensive care capacity to go into surge, if Covid-19 disease hadn’t reached the level it has. But I’d much prefer to have developed surge activity, and to have redeployed staff into surge beds than to have no surge facility at all.”
Dr Henry said it is “better than the alternative”.
He said permanent ICU staff are supervising and overseeing the care provided to patients, with the assistance of staff who have been redeployed. While these additional staff are not fully trained ICU staff, they do have transferable skills, such as theatre nurses.
Dr Ian Counihan, Respiratory Consultant and Covid Lead at Our Lady of Lourdes Hospital in Drogheda told RTÉ’s Today with Claire Byrne that the hospital has moved into the second phase of its surge plan.
“We move patients who don’t have Covid out of the ICU, because so many patients in the intensive care unit do have Covid, as a way to protect them,” he said.
These patients, he said, have been moved to another unit where they are on ventilators and are monitored.
Louth has the second highest 14-day incidence rate in the country after Monaghan.
“Currently we have ten patients in ICU – eight of those have Covid. We have a capacity in our surge planning for up to 24 ventilated patients.”
Dr Counihan said he, like other consultants across the country, had noted a change in the demographics of admissions compared to the first wave.
“There’s a large group of younger people that are admitted with Covid pneumonia, patients in their 20s, 30s and 40s in the hospital on oxygen. Certainly for the last week we’ve also seen an increase in the number of patients presenting who were in their 70s and 80s who have a lot of comorbidities, just through being older and more likely to have other medical problems.”
Speaking to TheJournal.ie The Explainer podcast, Dr Catherine Motherway, ICU consultant at University Hospital Limerick, described how the decision is made to move a patient into an intensive care unit.
“The patients whom we are admitting to the ICU are generally patients who are very, very short of breath. They are finding it really hard to breathe in. A lot of them have significant chest pain, but their predominant symptom is shortness of breath,” she said.
In the first instance, we asked a lot of people to try and lie on their tummy, it’s called ‘awake self proning’. And in addition to that, we put on a tight mask on their face to give them high levels of oxygen under pressure, and that oxygen is quite hot. I don’t know if you’ve ever been to a country where it’s very humid and very hot, but what we try and do is to get them to breathe warm, humid oxygen so that they can continue to not get dry secretions. It is an uncomfortable process.
“We’ve had some patients in our unit, who have done that for up to four weeks, lying on their tummy most of the time. That’s sometimes – for a lot of patients – means we get more oxygen to them and we can avoid having to what we call invasively ventilate them.”
She said if invasive ventilation can be avoided, patient outcomes are good.
“Obviously, if that doesn’t succeed, then we put patients to sleep and we put them on an invasive ventilator. Then as they wake up, they may or may not – hopefully not – have delirium, but if they do, we try to orientate them,” she explained.
As they’re waking up the tube is in their throat and it is unpleasant but we do our best to make this tolerable for them. We actually use a lot of drugs to try and improve the tolerance to the tube, which is uncomfortable.
Of the almost 2,000 patients with Covid-19 now in hospital, more than 400 are receiving high grade ventilation and respiratory support both inside and outside of ICU.
Health officials have said that for every patient in ICU with Covid-19, there is at least one other patient on a ward who is receiving advanced – but non-invasive – respiratory care. These patients are very ill and if their health further deteriorates they may require a move to ICU.
Dr Motherway said the Covid wards in hospitals, where most of the patients with the disease are being treated, are “under real pressure”.
“We have a lot of people in hospital with Covid – for various reasons – and they need oxygen, they need care and attention, some of them are older patients who are symptomatic,” she said.
While the system is now below that 350 cap on surge capacity, a significant increase in numbers requiring intensive care over the next week could put pressure on even the surge resources.
The HSE has said patients will, of course, continue to receive the best care that healthcare workers can provide if, in a worst case scenario, the entire system moves beyond that surge capacity.
This did not happen in Ireland in the first wave, but it did happen in other countries and officials have said this is likely the reason that their patient outcomes were poorer than ours. Once that capacity of 350 beds is exceeded, it is difficult to provide the same quality of care as a traditional ICU setting.
It also forces healthcare workers who are treating them to make difficult decisions.
Professor Clíona Ní Cheallaigh, a consultant in infectious diseases and internal medicine at St James’ Hospital, recently said she and her colleagues are “terrified” of being in a situation in which people who would normally be sent to ICU cannot be transferred because there are no intensive care beds.
“That didn’t happen in wave one, and we’re really worried that if that happens that’s very difficult to deal with psychologically,” she said.
Some of the things that we’ve talked about about is we’re going to meet our intensive care colleagues in the morning and go through the list. You never want to make the decision around intensive care when somebody is crashing in front of you, you want to make that decision days in advance if you can, so you can do it in daylight and in calmness.
“So we’re going to meet as a group and try to make those decisions as a group, rather than as individuals for many reasons. It’s much psychologically safer as a group, and also medical legally it’s safer as a group.”
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