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Analysis prepared for national cabinet shows that although states have built up surge capacity for ventilators during the pandemic, they do not have the medical staff to operate them. By Rick Morton.

Exclusive: States unable to staff ventilator capacity

NSW Premier Gladys Berejiklian inspects a locally built ventilator.
Credit: Ryan Pierse / Getty Images News

On Friday, Scott Morrison’s national cabinet met with state and territory leaders to discuss a new paper that details emerging and significant pressure on the country’s healthcare workforce. It is understood the report covers staff surging arrangements, intensive care capacity and the possibility of shifting resources between states.

In New South Wales, which recorded 1029 new local coronavirus cases on Thursday, Westmead Hospital issued an “internal disaster management” protocol this week as it reached capacity for Covid-19 patients.

The hospital reduced ambulance arrivals and transferred critical patients to other sites. A memo said it was “conducting urgent reviews with clinicians around critical care capacity, emergency department flow, Covid-19 wards, ambulance offloading and our Covid patient journey”.

Acting general manager Jenelle Matic said the facility’s management was also “working with our private hospital network to open up to 100 beds”.

Shortly after Westmead established its emergency operations centre, Blacktown Hospital stopped accepting Covid-19 patients.

In mid-August, The Saturday Paper has learnt, another Sydney hospital, St George Hospital, also in a local government area of concern, was forced to “furlough” 90 staff for two weeks of isolation following exposure to the highly contagious Delta strain of the virus.

In Victoria, more than 450 healthcare workers attached to Royal Melbourne Hospital were sent into quarantine last weekend. On Thursday, the state recorded 80 new Covid-19 cases; its worst single day since the tail end of the second wave.

A NSW Health spokesperson told The Saturday Paper “support from private hospital staff will be required to support the large-scale vaccination effort currently under way and workforce demands in the NSW public health system”.

They said: “Staff from many private hospitals across Sydney are already being deployed to assist the NSW government’s response to the Covid-19 outbreak, including intensive care demands.”

The health workforce “furlough” crisis in Victoria and NSW alone is now seven times worse than the national situation on August 10, according to data contained in a briefing to national cabinet. It highlights another issue of vulnerability: although states have substantially increased their supply of ventilators since the first outbreak of Covid-19, they do not have the healthcare staff to operate them, and the staff they do have are vulnerable to exposure and the need to quarantine.

Using figures from the same national cabinet analysis, obtained by The Saturday Paper, the 116 patients in NSW intensive care units on Thursday represented almost 14 per cent of the entire state’s currently staffed and open 863 ICU beds. Including people in ICU for reasons other than Covid-19 complications, the system is at 60 per cent capacity.

Victoria has half that number of ICU beds and half the expansion capacity. This week, the state announced it would fly in 350 medical staff – mostly doctors and specialist nurses – from overseas to relieve pressure on a system that has already borne the brunt of the pandemic in Australia. Since the pandemic began, more than 2100 exemptions have been issued for approved healthcare workers travelling to Australia.

The Saturday Paper can reveal that although the NSW government is physically capable of expanding its intensive care capacity to 2015 beds and ventilators, a document prepared for national cabinet shows it has just a fraction of the staff available to run them. The paper says that “additional nursing staff resources available for bedside ICU care” is just 328. In practice, this is enough staff to add only about 164 extra ICU beds.

Similarly, Victoria had 125 additional staff available for its intensive care capacity. These numbers are able to be increased, but not without significant intervention elsewhere in the hospital system.

National cabinet has been told the country could expand its intensive care beds by 944 places – but at best it has the staff to operate 346 of these.

In the densely populated south-west and Western Sydney regions, where 80 per cent of all cases from the Delta outbreak are located, the clinical chokepoints are even more pronounced.

On Monday, Nepean Hospital intensive care specialist Dr Nhi Nguyen told reporters that patients were being transferred to Wollongong to relieve the pressure on south-western Sydney.

“What has worried us over the last few weeks is the increasing number of patients who are admitted to intensive care,” Nguyen said. “They are younger, they are staying in intensive care for longer and they are needing care that cannot be provided anywhere else on the wards. There are those who are on breathing machines and on heart/lung machines.”

One-quarter of all ICU patients in NSW are now aged 40 and under. The vast majority have not been vaccinated; the rest have received a single dose.

Emergency department specialist Dr Clare Skinner told reporters the current situation in NSW is “the biggest challenge healthcare workers have faced in their careers”.

“Things are tricky,” she said. “While the system is under pressure we are doing everything we can to ensure the care is there for you when you need it.

“Delta is a bit of a game-changer. We need you to take it seriously. It is not a cold. Please get vaccinated as quickly as possible, that is the thing that is going to get us through.”

As hospitals continued to strain, the nation’s leaders squabbled over interpretations of the Doherty Institute modelling, which charts a course to living with Covid-19.

Both politicians and chief health officers agree there must be a way forward. The national plan to transition into “Covid normal” is buttressed by the Doherty vaccination thresholds of 70 per cent and 80 per cent of the adult population. It is clear that, even with these milestones, there will still be a need for ongoing restrictions or public health measures to keep Covid-19 in check.

“Every state is going to have to go through this transition, one way or another,” NSW Premier Gladys Berejiklian said on Monday.

“We are one of the few nations on the planet still living in isolation, but once you start opening your borders every state is going to get case numbers and that is why we just have to get used to the fact that our aim during the pandemic is to keep people safe and healthy, keep them out of hospital.

“Once we get to 70 per cent, the Doherty report says you enter a period of transition. They recommend you don’t even talk about cases. What will be more relevant is how many people we have in intensive care and how many people unfortunately succumb.”

The modellers are clear, however, that the assumptions underpinning the project and the vaccine coverage thresholds are uniform and do not yet account for variations within the population, such as for disadvantaged communities, people with disabilities or others with underlying health concerns.

In any case, the model forecasts a cumulative 1338 intensive care admissions among unvaccinated people in a six-month period if a Delta outbreak is seeded at the 80 per cent vaccination threshold. There would be 673 deaths. Even among vaccinated people, the Doherty team estimates 578 ICU admissions and 306 deaths.

There are differences in Covid-19 that make its demands on the health system peculiar. For instance, there is early evidence that the Delta strain puts pressure on the vascular system. A health source, who cannot be named, says just one vascular surgeon in NSW has performed multiple operations on unvaccinated Covid-19 patients who have blood clots related to the virus.

“Sometimes patients have clots removed several times. He has operated on people from 30 years and up. Amputation has also had to be considered in some cases,” the source says.

“It’s incredibly stressful for all staff – and surgeons are very mindful of protecting the ICU and theatre staff.”

Despite these issues, Prime Minister Scott Morrison is pushing for the country to open and for the hospital system to keep up. “We’ve been through two iterations of the Doherty modelling to produce the national plan targets that were agreed a month or so ago,” he said on Monday. “But once you get to 70 per cent of the country that is eligible for the vaccine, and 80 per cent, the plan sets out that we have to move forward. We cannot hold back.

“And we must adjust our mindset. Cases will not be the issue once we get above 70 per cent. Dealing with serious illness, hospitalisation, ICU capabilities, our ability to respond in those circumstances – that will be our goal.”

The NSW chief health officer, Dr Kerry Chant, has made her own views clear: any uneven application of those thresholds is cause for alarm, she says.

“We know how infectious Delta is,” she said on Thursday. “It will rip through any under-vaccinated areas.”

Earlier in the week, Chant provided a clear summary of the Doherty modelling’s intent. “What they are saying is around 80 per cent you have options and choices. It’s not to say you’re not going to have to calibrate and respond your level of restrictions, what you permit,” she said.

“It may be we actually have indoor mask-wearing for years in certain settings. It may be that you are only permitted to go to certain high-risk venues if you are vaccinated and show proof of vaccination.

“The world is grappling with how we co-exist with Covid and this virus may throw us curve balls. We’ve got the Delta variant. God help us if we have another variant. This is not a one size fits all.

“So my 80 per cent means that I want a strong equity focus across our vaccination coverage and we need to have it very high across the population uniformly … Covid has taught us that it seeks out areas with socioeconomic disadvantage.”

In a private staff briefing obtained by The Saturday Paper, the highly regarded executive director of the Garvan Institute of Medical Research, Professor Christopher Goodnow, produced his own data that reinforces Chant’s view.

The log graph he provided shows the daily case numbers in NSW doubling in 1.8 days near the start of the outbreak, with this doubling rate reduced to 8.8 days following the state’s lockdown. This figure improved again when further restrictions were added to the lockdown, delaying the doubling of case rates to 13.3 days.

“So it’s making a difference but it’s not making enough of a difference,” he said in the presentation on August 18.

“We need vaccines. So, just to share with you my understanding of the situation and why we need layered defences, the R-value [the number of people a single case infects] is around six with this Delta variant under business as usual. So, you go to parties, go to the pub, join the mosh pit, one person infects six, six people infect 36 people and 36 infect 216 and so on.

“Under that situation that log linear scale just goes through the roof and our hospital system will just collapse. Now, with physical distancing alone, you can bend the curve and get that R-value down to around 1.5, or with vaccination alone you can get it down to 1.5. Either of those things alone with this highly infectious variant are not enough.”

But adding those two defences together, he shows, can reduce the reproduction rate of the Delta strain to about 0.5, which means an outbreak will eventually subside.

Referring to published data, Goodnow said the key point is that vaccinations – whatever variety – result in a one-third chance of infection and a one-third chance of hospitalisation.

“Now when you multiply those together it reduces your chance of severe Covid down to one-ninth, or better,” he said in the briefing. “If ever there was a reason to get vaccinated, this is the reason.”

At yesterday’s national cabinet, the urgency of this realisation was recognised. Leaders received a briefing about a “vaccination incentive strategy” previously rejected by the prime minister and a “youth-based vaccination program”.

All chief health officers also provided an update about “addressing vaccine uptake and mandating vaccinations for disability support workers”. This is a strategy that has not been publicly announced. It is also prickly. The same health advisers also provided a “risk and benefit assessment” of the mandatory vaccination requirement for aged-care workers in Friday’s national cabinet.

Whatever the future may look like with Covid-19, there is unanimous agreement that vaccinations are the best shot at normalcy. Right now, as Kerry Chant said on Tuesday, vaccinations are also the key hope in preventing health systems from buckling under the burden of infection.

“We are in here for the long course,” she said. “One day is not a trend. I am not actually expecting to see the impact of vaccination [for at] least two to three weeks. We are obviously seeing some impact but we are not actually expecting to see the impact of that until mid-September.”

This article was first published in the print edition of The Saturday Paper on Aug 28, 2021 as "Exclusive: States unable to staff ventilator capacity".

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Rick Morton is The Saturday Paper’s senior reporter.