Much has been said around Intensive Care Units (ICU) as we enter our second major outbreak in New Zealand. This is because critical care is one of the key areas that we are trying to protect when officials say that the function of lockdowns and vaccination is to protect the health system. The main end organ for coronavirus is the lungs and as the infection deteriorates this can result in a requirement for assisted ventilation – a ventilator. There are many other variations on this theme but at a basic level that is it, a need for ventilation that requires ICU.
Surge management is the key lever to protect ICUs and works in two ways. First, lockdowns reduce driving accidents which reduces ICU admissions. Second, stopping elective surgery for hips, knees and cancer reduces admissions to ICU. Clearly lockdowns and stopping elective surgery are not at all sustainable options going forward and new resources are required.
An important question is how much capacity do our ICUs have for a coronavirus outbreak. Several red flags have appeared recently, arguably no new ICU beds for Auckland in the past 15 months, an urgent call out for 30 ICU nurses on September 1 when there were just eight active cases, and ICU specialists at Capital and Coast saying there is nowhere in the country with newly staffed ICU beds.
It also seems like ICU capacity under suppression was only addressed late in the piece during the current outbreak although each DHB has been required to have an urgent critical care plan in place. Northland for example has eight ICU beds and an urgent management plan that in a crisis would turn the whole ICU into a Covid-19 ICU only. Other critical care patients would be managed elsewhere such as CCU coronary care.
Capacity for a coronavirus outbreak is mostly a function of the number of resourced ICU beds. Resourced ICU beds are a fully operational bed with an associated ventilator and staff although I dispute the 1 nurse per bed calculation from officials given specialists tell me it is actually 5.3 nurses per bed.
Recalculating this could significantly reduce the reported capacity.
The number of resourced ICU beds varies hugely across DHBs, from four at Lakes, West Coast and Hutt Valley to 94 at Auckland DHB. However, what needs to be taken into account when assessing capacity is the average level of occupancy before coronavirus strikes. People still get kidney failure and cardiac failure quiet aside from coronavirus. By way of example the day that the current outbreak was announced the Department of Critical Care at Auckland DHB was already at 120 per cent capacity.
My concern is also for the small regional DHBs. In the first month of this outbreak lakes DHB had all four standing ICU beds occupied many times even without having any positive coronavirus cases.
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We have an urgent need now to fast-track onshore and offshore ICU nurses through immigration and we need to build new ICU infrastructure. None of this is easy but in the context of $500m economic damage from lockdowns, increasing ICU capacity seems to look a bit easier.