Victoria and NSW are at a crisis point, with Covid-19 hospitalisations being underreported and cascading impacts on ambulance services and medical staffing. By Rick Morton.
Exclusive: Covid-19 hospitalisations three times higher than reported
The rate of Covid-19 hospitalisations in New South Wales is being reported at one-third of the real figure, with the actual numbers being masked by a decision to only report those who end up in medical facilities, and not the thousands receiving care under the state’s “hospital in the home” arrangements.
On Tuesday, Premier Gladys Berejiklian said the “most recent figure I have for the rate of hospitalisation was 5.5 per cent in terms of cases converting to hospitalisation”. The real figure, however, is about 15 per cent, according to medical experts and a briefing provided to national cabinet.
On Thursday, the state reported almost 1000 people with Covid-19 were in hospital and 160 of those were receiving the most complex form of healthcare in intensive care units.
But that figure leaves out almost 1700 people who are receiving hospital-grade care for coronavirus in their own homes in NSW. Most of those are being monitored by staff from the swamped Westmead Hospital in the state’s Western Sydney Local Health District. Under these arrangements, patients who would otherwise be on the hospital ward are given support at home with scheduled visits from hospital staff.
At least eight people in the state have died at home since the Delta outbreak began. Some, who were being given home care, deteriorated so quickly from mild illness to death that there was no time for even an ambulance to be called. The coroner is investigating these deaths.
The Saturday Paper has also been provided access to the nation’s Critical Health Resource Information System (CHRIS), which provides real-time data on the use of intensive care beds in every state and territory hospital network. On Thursday, 80 per cent or 689 of the 855 staffed ICU beds in NSW were full. Of these, 170 – or one-quarter of the occupied beds – are being used to treat Covid-19 patients. The situation in Victoria is worse. More than 90 per cent of ICU beds are full there. Hospitals are struggling to encourage nurses who worked in last year’s outbreak to help again.
The CHRIS platform, developed last year in response to Covid-19, is the same platform used to prepare briefings for national cabinet. In just three weeks the number of staffed ICU beds in NSW has actually fallen by nine.
In advice prepared for national cabinet, hospital demand in all states and territories was forecast using a “transition ratio” from active Covid-19 case to hospitalisation. In the document, obtained by The Saturday Paper, political leaders were told this ratio was calculated by dividing the number of individuals requiring hospitalisation by the number of active cases in the week before. By this method, the hospitalisation ratio is 0.16 or 16 per cent.
Garvan Institute of Medical Research executive director Professor Christopher Goodnow told staff in a private briefing that “hospitalisation is tracking around 15 per cent in the current NSW outbreak”.
These figures are important because health system workers who have spoken with The Saturday Paper believe clinical care is already being compromised in the NSW outbreak and may have already caused the death of people who might otherwise have been saved.
Australian and New Zealand Intensive Care Society president Dr Anthony Holley, whose organisation is advising national cabinet, is blunt.
“The imposition of Covid on the system and the challenge and the stress that is in place cannot and should not be underestimated,” he told The Saturday Paper. “There will be implications. I am deeply concerned and would never underestimate the situation, but I am also confident the professionalism of the front-line workers is such that they will minimise those implications.”
Intensive care paramedic and delegate for the NSW branch of the Australian Paramedics Association Brett Simpson says the ambulance service in the state has already moved beyond its capacity to cope.
“You can increase ICU capacity all you want but if we can’t get you to the hospital alive then what’s the point? The ambulance service is not coping in any sense of the word. What we are seeing at the moment are outrageous response times,” he says.
“The worst example I was given last week is a crew from Bateau Bay on the Central Coast having to run lights and sirens to South Granville in Sydney for a house of people with Covid who were all short of breath. Ordinarily, that is a 1.5-hour drive. The distance is 100 kilometres. It is far from an isolated incident. Crews are having to drive half an hour to reach a patient in cardiac arrest,” Simpson said.
Time and again healthcare workers have made the point to this newspaper that it is not just Covid-19 patients who are affected by the system pressure. Everyone who needs medical attention is at risk.
In Liverpool, in the South Western Sydney Local Health District, a 50-year-old man fell three metres from the roof of his house and suffered severe leg injuries, including a horrific “degloving” of his lower left leg.
“After half an hour, when the ambulance just simply hadn’t turned up, his wife dragged him to the car and drove him to Liverpool Hospital on her own – and this is happening more and more and more often,” Simpson says. “The entire health system, despite whatever is happening with Covid and bed block [whereby a hospital has no available beds], people are still having heart attacks, they are still having strokes, car and truck accidents, industrial accidents.
“At the moment we are seeing hot jobs [lights and sirens] sitting in the queue waiting over an hour for an ambulance even to be dispatched on it, let alone get a paramedic crew arriving on the scene.”
By Simpson’s telling, the hospital emergency department network is so finely calibrated that when one becomes overwhelmed, the spillover affects another and another. They fall like dominoes.
The Saturday Paper has obtained a new “patient allocation matrix” for emergency admissions in NSW hospitals that dictates what facilities are available for certain categories of illness. On August 25, the document was circulated to paramedics with two new categories: confirmed Covid-19 and suspected Covid-19.
Of the 46 hospitals – mostly public, with some private – in the local health districts covering the Newcastle–Hunter region, the Central Coast, all of Greater Sydney and Wollongong–Shoalhaven, fewer than half, or 19, are accepting confirmed Covid-19 patients.
In the Western Sydney Local Health District, only Westmead is listed as accepting confirmed cases. Auburn, Blacktown and Mount Druitt will not. Similarly, in the Nepean Blue Mountains Local Health District, only Nepean Hospital is taking admissions for the infection. In south-western Sydney, Liverpool and Campbelltown hospitals are taking Covid-19 patients but Bankstown, Fairfield and Bowral are not.
The only health district so far open for all Covid-19 confirmed and suspected cases is the Northern Sydney region. On Tuesday night, ambulance cars trying to get patients into Westmead, but facing severe bed block, were told to go to the Northern Beaches Hospital almost 35 kilometres away.
As hospitals fill, the domino-effect described by Simpson will become more pronounced.
Another person familiar with the situation among paramedics, who asked not to be named, told The Saturday Paper the bed block, or ramping, of vehicles at Sydney hospitals is now so bad that hospital healthcare workers are X-raying patients in the back of ambulances and providing some early treatment before patients can be sorted into those cases urgent enough to warrant entry.
In the final week of August, major hospitals across the network erected tents at their entrances to help triage Covid-19 patients. But their use differs between each facility. At Royal Prince Alfred Hospital in Camperdown, for example, the mini field hospital has spaced seating for about six patients with Covid-19 to be assessed and treated while waiting for admission. At Westmead, one of the largest hospitals in Australia, the Covid tents are being used to assess patients and offer very basic initial treatment, such as fluids or a Covid-19 test, before sending them back into the ambulances in which they came.
A senior health official said there was a delay in erecting the tents because authorities were worried it would be a “bad look” if the public saw hospital staff in full protective equipment treating people in makeshift marquees. This reluctance made the ambulance bed block issue even worse.
Last weekend, 17 ambulances were bed blocked at Westmead Hospital. As another source says: “That has never happened at any time in the history of the state.”
On Wednesday, Gladys Berejiklian told reporters that “the worst hospitalisation rate is likely to be in October”.
She said: “The most recent advice that I have received is that case numbers are likely to continue to rise in the next few weeks. We know that there is always a lag between when someone gets ill and when they end up in hospital and we anticipate that given where the case numbers are, and given the rate of vaccination, that the highest rate of hospitalisation will occur at some stage in October.”
Nursing staff and doctors are worried about what happens between now and then. The health network is already fragile and so finely calibrated that the pressure threatens to cascade without some intervention.
A source familiar with the operation of Lismore Base Hospital in the state’s northern rivers district says the facility, which has been designated the Covid-19 hospital for the Northern NSW Local Health District, has just four ICU beds. Currently, all of these are occupied by patients without Covid-19.
“As it stands, there are only 4.5 full-time ICU nurses to cover 24/7 care, less than half of the staffing that is needed to cover the weekly roster,” the source says. “Two ICU supervising doctors out of four have been redeployed to Sydney and there is currently no formal agreement between NSW and Queensland regarding what happens to all the northern NSW residents that rely on medical care across the border.
“It is a total shitshow. Paramedics, nurses and other operational staff cannot cross the border with ease at the moment and all key services are having major staffing issues.”
Where once a health crisis in one part of Australia could be met with support from other jurisdictions, the Delta variant represents a risk that has never before been seen.
On Wednesday, Victorian Premier Daniel Andrews announced a dramatic shift in the state’s thinking about Covid-19. The Delta variant outbreak that was seeded from NSW can no longer be controlled, he said.
“We have thrown everything at it, but it is now clear to us that we are not going to drive these numbers down, they’re instead going to increase,” he conceded at a press conference.
Behind the scenes, the situation is more severe than even that update allowed. Data from the Critical Health Resource Information System shows that 391 of the 429 currently staffed ICU beds in Victoria – 91 per cent – are occupied. Of these, 20 are being used for Covid-19 patients – but that number is expected to increase sharply.
Even with harsh lockdown measures in place almost from day one of the first case being identified, the outbreak in Victoria is now the fastest growing of any Covid-19 cluster in Australia. At 1pm on Wednesday, the Royal Melbourne Hospital “pushed the button” on its “pandemic mode” operating model, which has already reached a critical point. The Saturday Paper has obtained a copy of the hospital’s “Covid-19 Operational Bed Plan” covering its city and Royal Park campus. It has reached stage 2 of the emergency preparations, with all eight ICU negative-pressure rooms full. A further three Covid-19 patients are receiving intensive care support in the hospital’s ICU “hot zone”.
“We are now sending away patients to other hospitals and not accepting patients from hospitals for whom we would normally be the first port of call,” an intensive care source at the Royal Melbourne Hospital tells The Saturday Paper.
“Elective cardiac surgery has not happened for two weeks, mostly due to the large numbers of ward staff furloughed. We may not have space for emergencies on the wards to come to ICU immediately – they may need to sit in the operating recovery room.
“We don’t know what we will do when the pandemic area is filled. The hospital is clearing wards now to make non-ICU Covid wards, as the dedicated Covid ward is full.”
Some of those who worked through Victoria’s second wave, and its aftermath, are so traumatised and exhausted that they may never come back. Certainly, some have refused. Last year, about 170 nursing and healthcare staff were trained to help expand the ICU capacity. They have been approached to serve again but only five have expressed an interest in returning.
“We were strained last year. However, in many ways this year is worse – we are all tired,” the health source says. “Last year we had an ‘oomph’ to get this done. Now we see this as a never-ending struggle. In the plan, you’ll see that ICU would expand to pods E, F and G. We don’t have the staff to be able to do that. It would take hundreds.”
The source says the emergency arrangements “must necessitate a reduction in usual care, but this has not been spelled out yet by the hospital executive”.
They continue: “I cried when I got home yesterday. We are all in for a very rough time, not just the staff but the community.”
This is not an isolated refrain. Paramedic Brett Simpson said he and his colleagues “have grave concerns” that there have already been avoidable deaths in NSW as a result of the system buckling.
Another says, “Without question, people have already died.”
For intensive care specialist Dr Holley, there is one way out of this crisis. “I truly encourage every single citizen to play their part and get vaccinated and follow the directive of the chief health officer in their state or jurisdiction,” he says. “That is how we stop this thing spreading. We need to do what we can to decrease demand on intensive care beds.”
This piece was edited on September 6, 2021, to clarify that people being treated at home were not being given oxygen.
This article was first published in the print edition of The Saturday Paper on Sep 4, 2021 as "Exclusive: Covid-19 hospitalisations three times higher than reported".
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