NURSES WORKING IN intensive care units have warned that another long winter looms as Covid-19 cases continue to rise amid ongoing staff shortages in hospitals.
Yesterday a further 3,893 new cases of Covid-19 were confirmed in Ireland, with 43 deaths notified in the past week.
As of 8am yesterday, there were 611 Covid-19 patients in hospital, of whom 132 were in ICUs.
HSE figures released last Wednesday showed that 288 ICU beds were open and staffed. Of these beds, 279 (97%) were occupied, including 119 with Covid patients.
Nurses working in the intensive care unit at a busy Dublin hospital told The Journal they are “absolutely exhausted and we haven’t even hit the winter peak”.
“Basically we feel like broken records. The ICU is full and over capacity, as always. We’ve not enough staff and sadly we’ve lost a lot of senior and experienced staff during the pandemic to other roles in the hospital.”
The nurses said they are “highly-skilled people” but “overworked and underpaid”.
“We feel like there is no respect for us from hospital management and the Government at this stage. We all feel very undervalued. The hospital management are recruiting as best they can but you can not replace an experienced staff member with a new nurse, there is no comparison.”
The nurses said ICU treatment is so highly specialised it requires staff with extensive training and experience.
However, due to staff shortages, they claim that nursing colleagues are being seconded to the ICU from other areas of the hospital, without proper training, and are unable to fulfil their duties through no fault of their own.
One nurse said: “There is no recognition for the advanced skills that ICU nurses have to have. All nurses are paid the same regardless of their role around the hospital. The pay scale doesn’t work.”
They said that bed capacity is naturally an issue but a bigger concern is staff retention – you can increase capacity but if you don’t have nurses to look after the patients, it’s pointless.
The nurses said: “We’d love to hear what the Government would like to do to help with the recruitment of nurses as what they are doing is failing. We need to be valued and we need to see it in our wages.
We are in crisis mode and we should be getting extra pay for all the extra work we are doing. At times we’re doubling ICU patients which is unsafe. In a private job people get rewarded for their performance and for extra work. We’ve got nothing, absolutely nothing.
“We are all burnt out. The mood is so low again and we’re all trying our best to rally each other through the days.”
The nurses said that while they are very grateful for all the public support they have received since the start of the Covid-19 pandemic, good will alone is not enough.
“It’s time we got some proper recognition for what we do. No more clapping from the public or lighting candles. At this stage, it’s an insult to us. And the bank holiday that has been promised for frontline workers, seriously? We work every day of the year.
“The ICUs are drowning and no-one seems to care. The ICU nurses and doctors are absolutely exhausted and we haven’t even hit the winter peak. We are all so tired and just so exhausted and it hasn’t even fully kicked off yet.”
‘Firmly in the midst of a fourth stage’
There are concerns that certain sections of the healthcare system will have to shut down temporarily – such as the postponement of elective care – if Covid cases continue to increase and more ICU capacity is needed.
Modelling by the National Public Health Emergency Team predicts that, in the worst-case scenario, between 400 and 500 patients with Covid-19 could need intensive care treatment in December. In this scenario, around 2,200 people with the virus could end up in hospital.
This is unlikely to happen but, as Ireland only has about 300 ICU beds, is still a cause for major concern.
The best-case scenario would see between 200 to 220 patients with Covid-19 needing ICU beds, with 1,100 to 1,200 people requiring hospital care next month.
Throughout the pandemic, there has been a focus on the capacity in Irish hospital’s intensive care units and trying to make sure these facilities don’t become overwhelmed.
Winter is always a busier time of year for hospitals and the pandemic has only exacerbated that fact.
Addressing the Oireachtas Health Committee yesterday, HSE CEO Paul Reid said Ireland is “firmly” in the midst of the fourth wave of the pandemic.
He told the committee the HSE is increasing its surge capacity via measures such as staff redeployment and using prviate hospitals when needed.
“We are now firmly in the midst of a fourth surge in Covid-19 infections. The entire health system, both acute hospitals and community [services] are now under very serious pressure,” Reid stated.
He noted that pressures typically associated with the winter season are “further compounded by the massive increase in Covid-19 infections we are currently experiencing, and the resulting presentations in our emergency departments and onward into our wards and, critically, our intensive care units”.
“Emergency Departments continue to operate distinct pathways of care for Covid and non-Cocvid patients, and this places a huge demand on staffing and space available,” Reid added.
When asked about increasing surge capacity in the Dáil yesterday, Taoiseach Micheál Martin said the Government would not be nationalising any private hospitals.
Consultant Dr Catherine Motherway, head of the ICU at University Hospital Limerick and a past president of the Intensive Care Society, summed up the situation in intensive care units this week by saying: “This is wartime.”
She told Morning Ireland on Tuesday that half of the ICU beds in UHL are currently occupied by patients with Covid-19. Half of those are elderly people with reduced immunity, while the other half are younger unvaccinated people, she said.
“If you are younger and vaccinated you are very unlikely to meet me. It would be far better for you not to meet me,” Motherway said.
Capacity
Pre-Covid the national ICU capacity was 225 beds. There are currently around 300 ICU beds in the country, with 288 open and staffed as of last week.
This number can be increased to about 350 by redeploying staff and resources when needed, though this results in non-emergency procedures being deferred.
If more than 350 ICU beds are required at any one time, the health system risks becoming overwhelmed, according to a HSE report into critical care capacity from January.
This report notes: “Although peak occupancy did not ‘breach’ the 350 figure at a national level (to date) nevertheless, many hospitals experienced overwhelming surges of critically ill Covid patients exceeding critical care nursing staff availability. Surges of critically ill patients occurred locally following geographic clusters of Covid patients.
“In these hospitals appropriate critical care nursing staff ratios were unavailable, the care of critically ill patients was not assured and the clinical situation in these hospitals quickly became overwhelming. In rapid response,the Mobile Intensive Care Ambulance Service (MICAS) transported 100 critically ill adult patients in January 2021. If MICAS was unavailable, an overwhelming clinical scenario would persist at these hospitals.”
So, how does Ireland’s ICU capacity compare to other countries? In short, we’re below the Organisation for Economic Co-operation and Development (OECD) average.
The most recent OECD figures show that Ireland had 5.2 adult intensive care beds per 100,000 of the population in 2019, compared with an average of 14.1 per 100,000.
However, the OECD’s Health at a Glance report notes that it’s difficult to accurately compare certain countries due to the way they count hospital beds.
ICU beds are classified by the level of care provided to the patient. Commonly, this falls into three levels – with level three providing the most intense monitoring and level one the lowest.
Ireland, England and Latvia, for example, only count critical care beds (levels two and three), whereas most other countries also count level one beds. Some other countries also include paediatric and neonatal ICU beds in their figures.
According to the 2019 figures, the UK had more than seven beds per 100,000, France had 16 and Germany had 28. Only Sweden, Mexico, New Zealand and Costa Rica had fewer beds per capita than Ireland.
Prior to March 2020, Ireland had just 225 ICU beds. With the increased capacity provided in 2020 due to the pandemic, Ireland had 7.1 ICU beds per 100,000 people – still below the average but an improvement on the 2019 figure.
In the early 1980s there were over four ICU beds per 100,000 people but this steadily declined as the population increased over the years, hitting a record low of 2.37 per 100,000 in 2012, according to OECD figures.
Staff retention
In relation to staff retention, the OECD has noted that the Irish health sector is “facing challenges in recruiting and retaining health professionals”.
A recent OECD report states: “The number of doctors in Ireland has increased in recent years but remains relatively low, at 3.1 per 1,000 population in 2017 compared to the EU average of 3.6. This is related partly to restrictions in the training capacity of new doctors.
“Despite having the highest number of medical graduates per capita in Europe, the limited internship opportunities for new graduates create a bottleneck for many of them to complete their training, and the country is increasingly dependent on foreign-trained doctors to respond to its needs.
“Conversely, the number of nurses is comparatively high, at 12.2 per 1,000 population in 2017 compared to the EU average of 8.5, but the number has decreased since 2010 and many nurses only work part time. There are growing issues over recruitment and retention that have led to severe shortages within the nursing workforce.”
The 2021-2023 implementation strategy plan for Sláintecare – an ambitious cross-party plan to reform the Irish health service – states that “focused recruitment and retention policies to attract and retain health and social care workers” will be developed.
The document adds that officials will “work with professional bodies and all key stakeholders to make appropriate utilisation of clinical and healthcare talent”.
Staff on the ground say they want these reports turned into action. As one nurse said: “We don’t blame [colleagues] for leaving, we’re actually the fools for remaining in ICU if you ask us.”
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