Auckland City Hospital couldn't use one out of every five intensive care beds during the Delta outbreak because of a lack of staff.
Documents obtained by the Herald also show staffing problems predated the Delta outbreak and meant some patients were caught in delays, including for heart surgery.
The three Auckland region DHBs - Counties Manukau, Waitematā and Auckland - in September called for intensive care nurses to be sent from hospitals from around the country to help with the Covid-19 response.
Those reinforcements arrived, and the Government and the DHBs say they are now well placed to cope with any rise in the number of Covid-19 patients, including because double dose vaccination coverage in all Auckland DHBs is climbing.
Modelling has suggested a peak of Covid hospital admissions of about 100 to 120 across the Auckland region in early to mid December, with 15 to 20 needing intensive care. If that's accurate, there won't be a need for "surge" measures to expand capacity, such as seconding staff from other departments.
As of Sunday afternoon, there were 74 people in hospital with Covid - the highest number since the pandemic began. Five of those people are in ICU or on a high-dependency unit.
Documents and emails released under the Official Information Act show how ICU under-staffing has already led to treatment delays, even without the added burden of any Covid-19 patients.
On August 28 a briefing was put before Auckland DHB's Covid-19 response team that outlined staffing shortfalls in the Department of Critical Care Medicine ICU (DCCM), and the Cardiothoracic and Vascular ICU (CVICU).
In the former there were 24 physical beds, 17 resourced beds, but only 14 could be staffed. The CVICU had 26 physical beds, 22 resourced beds, and 17 were staffed.
The reason was a lack 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 years of specialised training and are in demand internationally, where better pay is offered, including in Australia.
"Nursing vacancies, high levels of sick leave and recruitment challenges are constraining current adult ICU capacity, creating a daily risk of insufficient acute ICU capacity," the briefing warned. "In addition to this the lack of rooms that provide protection from airborne infectious diseases is also a risk to Covid management and surge plans."
The three Auckland DHBs asked the country's other hospitals to temporarily send ICU nurses, and 14 stepped up to help. The last placement ended in October.
Auckland DHB director of provider services Dr Mike Shepherd told the Herald on Sunday staffing had now increased to 17 beds in DCCM, and 21 in CVICU (both intensive care and high dependency beds.)
"Recruitment of highly-trained ICU nurses has been an ongoing challenge for us as a DHB, due to the effect of a national shortage of intensive care nurses, with border restrictions making it more challenging to recruit nurses from outside of New Zealand. We welcome the Government's recent announcement of 300 MIQ spaces per month for health workers."
New Zealand ICUs often struggle with non-Covid demands, particularly in winter, and about 12 to 15 per cent of elective surgeries that need intensive care recovery time are postponed because there's no bed available.
In June and July the country was hit by a particularly severe outbreak of respiratory illness, including RSV (respiratory syncytial virus).
On July 7 Shepherd emailed his chief executive, Ailsa Claire, to report that "Starship Hospital and PICU [Paediatric Intensive Care Unit] is currently so significantly over capacity that we are implementing a series of measures which we recognise will have significant other health system effects".
PICU had six more patients than physical capacity; children were being placed between usual bed spaces and there were two patients in a single room. Referrals from less specialised hospitals around the country were being declined.
Shepherd proposed cancelling all day surgery and "non-time critical" planned care. High-risk children who had cardiac surgeries cancelled would need to be closely monitored, he wrote. "Noting that cardiac surgery waits are a significant safety risk. We are currently unable to do urgent cardiac surgery (needing surgery within the next 3-7 days) which has high risk."
"We have similar staffing and overall capacity challenges through our adult hospital which are affecting patient safety, experience and impacting on planned care delivery," Shepherd warned, although this was less critical than at Starship.
"Of particular concern are our cardiac surgery wait lists, primarily due to ICU and OR [operating room] staffing constraints."
Starship is increasing PICU by 10 beds, and there are plans to staff all or the physical adult ICU bed spaces.
Surgery patients now being tested for Covid-19
All patients coming in for surgery and outpatient clinics in greater Auckland will soon need to have a negative Covid-19 test beforehand.
The change is underway and will affect surgical patients first, and be extended to other patients in the coming weeks.
PCR testing will be used mostly, but rapid-antigen testing can also be used on admission. The testing is to protect staff but also other patients; in the United Kingdom about one in five patients hospitalised with Covid-19 caught the virus in hospital.