What's the cost of emergency measures to free-up intensive care beds for an expected influx of Covid-19 patients? Nicholas Jones reports.
Auckland's frontline health workers can feel a change in weather.
"We are getting ready for the potential storm," one senior specialist told the Herald of the preparations for a rise in Covid-19 cases.
New Zealand is now in a race to vaccinate as many people as possible while trying to hold back a growing Delta outbreak.
Staff at Auckland City Hospital have been told that, while modelling shows a range of scenarios, it seems likely that a surge of cases "will seriously challenge the hospital system but not overwhelm it". At North Shore Hospital, overflow plans are in place for when the Covid ward is expected to fill-up by early next month.
One pressure point will be intensive care. "Surge" capacity plans are being readied to temporarily increase how many patients can be treated.
Using that emergency ICU capacity for any significant length of time would likely lead to a drop in the usual quality of care, overseas evidence shows. It will also cause severe disruption to other services, because surge capacity relies on staff from other areas being seconded into ICU.
The holes they leave in their usual departments - including post anaesthesia and emergency care, and medical and surgical wards - generally won't be filled, leading to postponed elective surgeries and appointments.
ICU doctor Craig Carr, who is the NZ regional chair of the Australia NZ Intensive Care Society, said the example of other countries such as Scotland showed that, even with high vaccination rates, a significant number of Covid-19 patients still required hospitalisation and intensive care.
New Zealand has only around 172 fully staffed adult ICU beds, the society says, and those are often taken up by non-Covid demands, including people recovering from injury or major surgery.
For example, in the month before the Delta outbreak began North Shore Hospital's average monthly ICU occupancy was running at over 100 per cent, figures supplied to the Herald by DHBs show.
"At the moment there is real anxiety that surge capacity will be required," Carr said. "We think it is likely."
A good deal of that stop-gap capacity could be needed on a permanent basis, Carr said, because the virus will regularly circulate in the population, and the unvaccinated minority will be most vulnerable.
"If we had endemic Covid, the way Scotland has with a high vaccination rate, we would need an extra 80 to 100 ICU beds in the country."
Day-to-day, fully staffed ICU capacity has not increased since the pandemic began. Decades of underinvestment means New Zealand has the second lowest number of ICU beds per capita amongst developed countries, bettering only Mexico.
The main obstacle to increasing capacity is a shortage of the highly-trained nurses that provide one-to-one care for each intensive care patient.
Their numbers can't be quickly increased locally - such nurses need up to five years of specialised training and are in demand internationally, with better pay offered overseas.
Last month the Herald revealed some ICU nurses couldn't get into New Zealand even after accepting job offers from hospitals, because of issues including a lack of MIQ spaces.
Health Minister Andrew Little responded last week, announcing a guaranteed 300 managed isolation spots every month for health workers. But there are other examples of how efforts to increase capacity in both the short and long-term have struggled.
Early last year Waitematā DHB asked for funding for a new urgent care ward at the generally run-down Waitākere Hospital. Its chair, Professor Judy McGregor, was dismayed when told that there were other priorities.
"There is no high dependence beds or intensive care at Waitākere Hospital, despite having one of the busiest emergency departments in the country, as well as substantial general medicine, maternity and paediatric services - an issue of significant ongoing clinical risk," McGregor wrote in an April 28 2020 letter, to the committee that had recommended the decision to ministers.
"There is urgent bed demand that will not be met, which we expect to become more pressing with the Covid-19 pandemic impacts."
The DHB asked the committee to urgently reconsider the rejected request, along with extra money for intensive care beds, given "the clear evidence of lack of ICU capacity in New Zealand, brought to the fore with the Covid-19 crisis".
It would be another 12 months and April this year before Little announced $40 million for a new, 30-bed urgent care ward at the hospital.
However, no money was found to include ICU beds. That changed last month when the DHB was told that $20m for the Waitākere Hospital ICU was approved, subject to a satisfactory business case, which it submitted earlier this month.
There have also been challenges in training non-ICU hospital staff to be ready to help. They generally complete a study day, and then orientation shifts buddied up with an ICU nurse.
Some DHBs would also call on nurses from private hospitals, and physiotherapists would help with "proning" ventilated Covid patients who still have low oxygen levels - turning them onto their fronts for 16 hours at a time, something that can take eight people and needs to be done carefully so as to not dislodge tubes and equipment.
Initially surge capacity would rely on part-time staff doing more hours, extended shifts and using nurses and doctors with past experience, including recent retirees. Patients could be sent to other hospitals.
Then a team model would be used, with one ICU nurse overseeing a pod of non-ICU nurses and other staff, such as anaesthetic technicians. Most DHBs plan to move to a ratio of one ICU nurse to two or three other staff. Others would use 1:4 or 1:5.
"All DHBs highlighted the challenges of releasing staff for initial induction/rapid orientation and ongoing upskilling, including because hospitals are now operating at full capacity," a ministry memo from August last year noted.
"Most DHBs agreed that, time permitting, continual practical experience is needed along with theoretical training. Some are aiming for two to three monthly refreshers, others six months, while some had no plans for further training unless required."
In response, the ministry provided a fund totalling $2m to help hospitals backfill the gaps left by staff pulled into ICU surge training. Online training modules were also released.
Early in the pandemic ICUs were overwhelmed in countries including Italy and Spain. That spurred hospitals here to plan for when and how ICUs would react.
At Wellington Hospital, for example, a special committee chaired by the chief medical officer would have overseen triage decisions - effectively deciding who and who doesn't get intensive care - if even surge capacity was overwhelmed.
In this "inundation" stage, triggered when there are about 40 or more ICU patients (both Covid and non-Covid), there would be daily assessment of those already in ICU "to ensure that ongoing treatment is still more likely than not to result in survival".
"It is likely that capacity to care for all patients with a range of illnesses will be severely compromised and that both morbidity and mortality in non-Covid and Covid patients alike will be significantly increased," the plan, written early last year and released under the Official Information Act, states.
"To ensure the most number of lives can be saved once resources are exhausted, the ICU pandemic triage tool will be applied to all subsequent referrals. It can only be activated by one of the ICU clinical leaders who will inform the hospital CEO."
New Zealand's elimination strategy worked and the plans were put away. The pandemic triage tool was based around New Zealand-developed software, "1000minds", which would give each Covid-19 patient a score, calculated from criteria including underlying medical conditions, and extremes of weight and age. That number would then help ICU doctors decide who should get the next free bed.
The ministry never signed it off. "It was very much a tool of last resort, a situation we didn't want to find ourselves in. And it looked like we wouldn't. And hopefully we still won't," Carr said. "It was just causing too much fear and anxiety."
With Delta now in the community hospital ICU plans are being revised.
"Now that we have moved from an elimination to a resilience strategy, the ICU triage committee has been reconvened to consider the entire escalation plan – taking into account the impact of the vaccination programme, and new and evolving national advice in this phase of the pandemic response," Capital & Coast DHB chief medical officer John Tait told the Herald.
"As this work is still ongoing, we are not in a position to provide further detail."
Health Minister Andrew Little told the Herald the increasing vaccination coverage "gives us increased confidence that we can manage any increased Covid-19 infection rates in the community and our hospitals".
"We know we have a good number of ICU-capable beds available, and that we can increase that number if we need to. But if we had to use the maximum level of beds for long periods, this will be a challenge to staff and resource those beds. So we're looking at a range of options to address this," Little said.
"Currently DHBs are reporting they have 325 resourced ICU and HDU beds available...over a matter of weeks and by eliminating a lot of planned care we can further surge to 550 beds for Covid care."
Asked about long-term disruption, Little said most people with the virus would isolate themselves at home.
"In the event that an extreme scenario arises then decisions on prioritising clinical resources and treatment between Covid-19 patients and planned care and other patients is a key role for the health system. Clearly critical patients will always be prioritised first. Unfortunately this may mean that some services may see ongoing cancellations or delays.
"However, over the end of 2021 and into 2022 I expect to see DHBs further improve their critical care capacity and along with care in the community, and potentially new treatments, expect planned care volumes to gradually pick up in terms of delivery levels."
Carr believes hospital inundation can be avoided if high-risk populations are vaccinated in time. Those groups aren't just the elderly or very unwell - the Intensive Care Society put out a recent press release that noted that, with an ICU bed available, a person in their 50s who catches Covid-19 has a risk of dying of about 1:70. With two doses of vaccine that risk falls to around 1:1400.
The odds worsen if someone is male, overweight and has some other conditions including high blood pressure.
"Clearly at those numbers you very quickly get to the stage of problems in hospitals," Carr said.
"My belief is - and I could be wrong - that if we saw we were on that sort of trajectory, the first thing we know from overseas is that people who are high-risk get vaccinated [when] they see people that they know becoming sick.
"And I think if we were getting to those sorts of numbers, the government would put us back into more strict lockdowns again."
(Prime Minister Jacinda Ardern recently told the Weekend Herald that localised lockdowns and surge vaccinations could be used in the new "traffic light" framework.)
New Zealand and the world's path out of the pandemic isn't clear, including how many Covid-19 patients will take up intensive care beds in the months and years ahead.
Even if the storm passes sooner than expected, Carr said adding permanent ICU capacity wouldn't be a wasted investment.
Even doubling New Zealand's staffed ICU capacity would still put us behind Australia and other comparable countries on a per capita basis.
Currently, about 12-15 per cent of elective surgeries that need intensive care recovery time are postponed because there's no bed available, he said. Patients can be postponed several times.
"These things are not without consequence," Carr said. "The social disruption and the stress of patients and whānau who are trying to make sure the children get to school, that there are people are home to feed them, that there's still enough money to keep things ticking over - the social disruption is quite extraordinary."
There's a clinical cost, too.
"If your cancer surgery is postponed we sometimes have to give you extra chemotherapy. But there's always the fear that the tumour spreads," Carr said.
"Once you are getting to the point of having quite a sick heart, delaying things often means that your post-operative period is not as good and straightforward as it otherwise would have been. Likewise, if you are having a coronary artery bypass, if it is postponed too long there's a risk that you will have a heart attack and die while you are waiting."
If ICU surge capacity is needed then similar disruption could be around the corner.