National cabinet has been briefed on new data that represents a dramatic shift away from managing a short-term “disaster” overwhelming intensive care units, as is forecast to happen soon in New South Wales, to a scenario where serious pressure on hospital networks is sustained “for a protracted period of time”.
Although initial modelling was built around one month of crisis, the strain on the system is more likely to last half a year. What this means for an already exhausted hospital workforce is yet to be seen.
The briefing, provided to national cabinet on Friday, represents a realisation that a longer-term health system shock is now the most likely outcome from the national plan to gradually end lockdowns while chasing vaccination targets of 70 and 80 per cent of the adult population.
Although it is not yet clear how long hospital systems can sustain consistent, elevated levels of pressure, the Australian and New Zealand Intensive Care Society (ANZICS) sent surveys to more than 180 intensive care directors and nurse unit managers to gauge capacity for a marathon instead of a sprint.
The Saturday Paper understands these projections are more “realistic” than the “optimistic” numbers provided during pandemic planning last year, precisely because they will need to be stretched over a longer period of time. Under these arrangements, shortfalls will increasingly occur outside the intensive care units and ripple through the rest of the hospital system.
Non-urgent elective surgery has been halted in Greater Sydney since the end of July. In late August, some major private hospitals were restricted to performing “category 1” procedures only, as 600 private hospital staff were redeployed into the public sector and certain public patients were sent to private facilities.
In Victoria, these surgeries have been off and on since the middle of last year, with a halt on all but the most urgent operations being reinstated for the public system on August 23. Category 2 and 3 surgeries in the state, which can happen only subject to a “risk assessment” and tend to fluctuate with the threat of the virus, include hip and knee replacements, cataract surgery, colonoscopies and even the amputation of digits.
Noting these flow-on effects, the Victorian Agency for Health Information says: “The limits put in place in response to the Covid-19 pandemic have had significant, enduring effects on the volume, type and timing of elective surgery procedures undertaken at hospitals.”
In Sydney’s south-west, a Campbelltown Hospital source told The Saturday Paper “there are four full dedicated Covid wards that were once surgical wards”. This is only the beginning of these changes, they say: “There are plans for another two wards.”
Essentially, the need to divert resources towards the management of Covid-19 patients is creating issues elsewhere in the health network – which will continue for months, leading to the possibility of compromised care.
A day before revised capacity data was presented to national cabinet, NSW Premier Gladys Berejiklian announced the state government’s plan for a gradual granting of “freedoms” for fully vaccinated residents from October 22.
Nationally, and in particular in NSW and Victoria, where Delta variant outbreaks have surpassed efforts at full control, a two-speed debate is happening about short-term disaster management as well as longer-term sustainability issues.
On Monday, Berejiklian released forecasts for the hospital system capacity over the coming months, with a peak demand for ICU beds of 947 in early November. The model suggested 560 of these would be used by Covid-19 patients. In total, the modelling, conducted by the Burnet Institute and augmented by state government health system data, estimates the number of people in hospital with and without Covid will peak at 3434.
But that modelling was done on the assumption that all current restrictions in NSW would remain in place. It does not factor in ongoing issues and how Berejiklian’s Thursday announcement will affect them.
The premier has previously said that at any one time there are about 400 non-Covid patients in the state’s intensive care units. The modelling allows for a peak of 387. But on September 2, for example, there were 519 patients in NSW ICU beds who did not have Covid-19, according to the real-time monitoring platform nicknamed CHRIS.
The Critical Health Resource Information System was developed last year to aid decision-making for state and federal leaders and has been used to routinely update national cabinet about the situation in Australia’s intensive care wards. On the same day in early September, the Burnet model forecast a total of about 515 patients with and without Covid. The actual number on that day was 689.
Late on Wednesday, Victoria released its own projections for hospital demand, with figures detailing the state will reach 18,000 cases by mid-October, 800 of which would be hospitalised. According to the CHRIS platform readout on Thursday morning, there were 31 patients in Victoria’s ICU wards with Covid-19.
Although officials say the state can surge to a similar number of emergency ICU beds as NSW – about 1500 – that figure represents a more than fourfold increase on the ordinary operating number. In NSW, reaching that surge capacity equates to slightly less than a doubling of the usual ICU beds.
Plans have already been drawn up for a worst-case scenario in the health network. In NSW, doctors and nurses have been told by hospital managers that life-saving support may not be provided, or potentially even be withdrawn, for those with a median age of 72 during the “overwhelming” phase of the current Delta outbreak – which is forecast for late October and early November.
The NSW Health protocol for the triage of intensive care resources, updated for this wave of infections in July, notes that “complex ethical and clinical treatment issues can occur during a pandemic, especially when healthcare demand exceeds supply”.
The guideline states: “It may be necessary at some point to begin prioritising limited critical care resources to those with a need for treatment and those who are most likely to survive.
“Such prioritisation decisions would need to take into account all patients’ probability of survival, as well as the availability of limited critical care resources.”
This protocol – which will be activated uniformly across the entire state – is based on a 2010 policy document that details arrangements for an influenza pandemic.
While guidelines and other governing documents are drawn up for this outbreak, the ability to find staff to realise these goals is still in question.
NSW Nurses and Midwives’ Association secretary Brett Holmes tells The Saturday Paper the union is “still having discussions” with the NSW Health Department “to understand just where they are at in terms of their plan”.
“We are still looking for more detail,” he says. “I think more detail is being developed. When the premier says it is all planned, well, there is a plan. It’s a piece of paper. Then it is about operationalising the plan, and they certainly have not fully operationalised.”
The challenge, he says, is that the healthcare workforce has to come from somewhere. For example, there are more than 2000 registered nurses currently working in NSW Health vaccination centres.
“So they have got to stand up a new workforce to release some of these RNs,” Holmes says. “They cannot release them all, obviously, because they are putting undergraduate health students into vaccinator roles and they will still need some level of supervision.”
Some of these RNs may be intensivists or critical care nurses – a skill set similar but not equal to ICU nursing – but as many as possible will still be needed.
“What is important is that in order to operate the rest of the hospital you still have to backfill people who are going to be taken out of other critical care areas or ward areas,” Holmes says.
NSW Health has not disclosed in any of its plans or guidelines what the patient care ratios are likely to be under the surge arrangements, although it is clear in the original influenza pandemic plan adapted for Covid-19 that “it is expected that existing staffing ratios will not be maintained during the peak surge in demand”.
The Saturday Paper understands some patients in intensive care have already had their 1:1 care ratios diluted to 1:2, although the surge model is likely to preserve physical ratios as much as possible by using less qualified healthcare workers.
Under ordinary arrangements, ventilated ICU patients or those with complex care requirements are overseen by a single intensive care nurse working under layers of medical supervision. According to a NSW Health guideline updated in late June, the second stage of its emergency plan would see these nurses supervise two other critical care nurses, who would be drawn from other hospital functions such as anaesthetics, emergency, operating theatres, recovery and coronary care units.
Under the third and final phase of the surge plan, which is triggered by “extreme compromise and overwhelming impact with local workforce exhausted”, these nurses might be a combination of both ICU specialists and critical care staff who will oversee four other nurses from anywhere else in the system.
In this setting, one “whole of hospital duty intensive care consultant” will work “with other medical specialists to support intensive care triage and decision-making on resuscitation and goals of care”.
In at least some cases, these consultants have verbally advised ICU nurses about the cut-off criteria for triaging scarce resources.
An intensive care specialist who spoke to The Saturday Paper on condition of anonymity said these protocols are not new and have been used in all health systems around the world.
“What is different, particularly for an advanced system like we have in NSW, is the frequency with which such decisions might need to be taken and the potential for fairly blunt, quick turnarounds on those life-or-death discussions,” they said.
“Now, you can argue we might have done more to prepare in NSW and I think that is true. You can argue we should have done more to suppress this outbreak, but there is less evidence for that. You need only look at Victoria to witness the way this variant confounds our best efforts.
“What is beyond doubt is that we would not have been forced to make as many or maybe any decisions about who should be saved if we had more people vaccinated more quickly. That is simply a fact.
“But we can still shift the shape of this. Please, get vaccinated. At this point we are begging.”
The Australian and New Zealand Intensive Care Society wrote its own guideline on “complex healthcare decisions” for members last year and notes “the need to make challenging decisions cannot be avoided”.
Such considerations should assess patients clinically, at first, including “the likelihood of long-term patient survival, with an attempt to assess both the quality and the potential quantity of that life”.
But there may come a time when clinical risk is similar for a range of patients who all require care, the guideline says. In these circumstances, doctors might consider “advocating that younger patients who have lived through fewer life stages are prioritised over older patients”.
Most triage protocols use some form of matrix that includes a scale to measure organ failure, age and other comorbidities or, in the language most often floated at health updates in Australia, “underlying conditions”.
An August study, led by Dr Jai Darvall from the Royal Melbourne Hospital’s department of intensive care, notes current ICU pandemic triage protocols that use such scores “exclude patients with a close to 80 per cent hospital survival [rate] and a more than 30 per cent five-year survival”.
Put another way: the triage protocol would see care denied to people who otherwise have an eight in 10 chance of survival.
“Short lengths of stay were observed for admissions associated with mortality in these groups, implying that a large reduction in ICU bed-days ‘wasted’ on patients who would ultimately go on to die is not realised by such a low prioritisation strategy,” the paper, published in the scientific journal Chest, says.
“Finally, our findings imply that a more complex assessment of ICU admission candidates, which might involve a risk score based on a combination of frailty, age, comorbidities, organ dysfunction, and admission diagnosis, is needed to inform triage decisions.”
Nepean Hospital intensive care specialist Dr Nhi Nguyen, who has been among high-level “community of practice” working groups developing contingency plans for the NSW government, told reporters on Monday the entire state is being treated as a single ICU facility.
Moving patients from one hospital to another is a sign the system is working, she said.
“So we’ve been signalled over the last week that the number is going to rise,” she said. “Does it worry us as a critical care community? Of course it does. Is it the biggest challenge that we are going to have as a health system and will we be in crisis? I’m really confident that we have plans in place.
“We know that there are nursing staff and medical staff who will feel a little bit uncomfortable with what they are being asked, but I am really confident that we’ve got such a well-connected and supportive environment that patients will continue to get care when they need it.”
But there was one glaring omission in the modelling released by the NSW government this week, on which these projections are based. Not once does it mention paramedics.
As one source tells The Saturday Paper, the crews and vehicles have to come from somewhere. In all but the final stage of the surge planning, one of the “key management strategies” for demand is transferring critically ill patients across the network. That can only be done via the ambulance service.
While Nguyen says this is a sign the system is working, the unprecedented numbers of hospitalised and critically ill patients, combined with the overwhelming number of infections in a relatively small geographical area, have placed more strain on this method of operating than at any time in the state’s history.
NSW Ambulance has begun hiring students and graduates on casual 12-week contracts to meet the staff demand, but there are no new ambulances. They are a finite resource in the state.
Last Friday night more than 60 emergency ambulance jobs were waiting for a response from ambulance crews in south-west Sydney alone. On Monday morning, a crew waited 11 hours on a single job. On Tuesday night a patient in an emergency waited for 90 minutes for a response from NSW Ambulance.
There are less obvious implications here, too. A source in a birthing unit at a Sydney hospital said that pregnant women who have Covid-19 must be taken to and from hospital by ambulance. It is a state policy. Some have been stuck on a ward for up to two days following an official discharge because there is no slack in the system for a vehicle to take them home.
“Partners are usually positive as well and can’t leave the house due to isolation requirements,” the source said.
As national cabinet turns its attention to managing hospital capacity in a half-open, largely vaccinated world – little more than two months after the transition plan was agreed to – there is still tension within NSW about the level of caution needed. That tension exists in other states, too.
On Thursday, The Australian reported that the NSW chief health officer, Dr Kerry Chant, strongly argued in the state government’s crisis cabinet for reopening in NSW only when 80 to 85 per cent full vaccination coverage had been reached. She was apparently talked out of it, reluctantly agreeing to a 70 per cent double dose goal on the condition the effective reproduction value of the virus in the outbreak was below one.
When asked if her advice had been ignored, Chant did not respond to the question.
“I’m really very excited by the way that the community is embracing immunisation,” she said in response. “Please do not take risks while we’re in this period. We do not need any super-spreading events. We do not need any seeding in the regions. We just do not need anything else as we work to drive the case numbers down and leverage our response off the back of the vaccine uptake that we’ve seen.”
Even after this acute disaster is over, the hospital system will remain critically strained – and will likely stay that way for several months or even half a year.
Much of the talk so far is about maintaining capacity in intensive care, but healthcare workers are worried about the necessary compromises that will be made to keep the system operating as close to normal as possible in the crucial transition period between crisis and learning to “live” with Covid-19.
“When you delay elective surgeries that are not currently urgent, there are still consequences,” one doctor tells The Saturday Paper. “We still need a vaccination workforce, staff still need time off. In order to support the demand at the pointy end, we are robbing other parts of the entire healthcare system.”
As Nguyen said on Monday, the whole system is connected. When the burden of this disease is shared among hospitals, that is a sign the system is working. It is not, however, a system enjoying its natural equilibrium.
The question Australia’s leaders now need to answer is this: how long can any healthcare system sustain this elevated, prolonged demand?
This article was first published in the print edition of The Saturday Paper on September 11, 2021 as "Exclusive: National cabinet told hospital crisis could last six months".
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