Health authorities have developed contingency plans for an uncontrolled Covid-19 outbreak that include severely limiting emergency department access and doctors possibly making "ethical considerations as to which patients to treat".
Plans prepared by DHBs and the Ministry of Health, obtained by the Herald under the Official Information Act, set out various scenarios, depending on how widely Covid is circulating and how many people were in hospital battling the virus.
The escalation plans, which were updated last month, provide high-level guidance according to different alert levels - green, yellow, orange and red.
They don't predict the likelihood of ever needing such extraordinary steps but avoiding overloading the health system has been central to Government planning - and one of the main reasons for lockdowns - since the pandemic began.
Prime Minister Jacinda Ardern recently released modelling that showed very high vaccination levels would be needed to avoid a severe burden on health services.
According to the health ministry's guidance, a red alert could be triggered when there is some or all of the following: multiple Covid patients in hospital; ICU and isolation rooms at capacity; uncontrolled community transmission; and all available staff redeployed to critical care.
In that scenario, emergency department services should be limited to "high acuity medical and trauma care", and all surgery cancelled except for those involving severe illness or injury.
People without Covid needing intensive care would be moved to a temporary "green" unit set-up elsewhere in the hospital, or sent to private hospitals. If the ICU still fills up with Covid patients, the ministry guidance states, "as a last resort, move ventilated Covid-19 patients to repurposed ICU/HDU [high dependency unit] theatre complex for overflow; aim is to not impact on the ability to meet non-deferrable, life-saving acute surgery".
More details were provided in specific DHB contingency plans. For example, Whanganui Hospital's high-level plan for ED, inpatients and mental health in the "red alert" level notes assumptions including, "ethical decisions on which patients to treat will be required".
A key objective at the red level - which could be triggered for inpatient care when there are 15 or more Covid patients on the general ward and/or two or more in ICU - is to "maintain focus on life preservation and prevention of disability", the Whanganui DHB documents state, and to "triage to target resources to activities that will deliver the greatest quality of life gains". All inpatients would have a "ceiling of care plan".
Documents relating to intensive care for Covid patients suggest "proning" be considered earlier rather than later. This is when patients with poor oxygen levels despite ventilation are shifted onto their fronts for up to 16 hours at a time.
Safely turning them like this commonly takes eight people, and slighter shifts are needed every couple of hours to relieve pressure and avoid bedsores. The Whanganui DHB document notes, "ability to prone is dependent on size, stability of patient and availability of trained staff", with "a risk of tube and line dislodgment so only prone when resources allow".
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Much of Whanganui Hospital's high-level plan addresses the difficulties in staffing separate "red" (for Covid patients) and "green" (for non-Covid patients) areas, and the need for strict PPE and other measures to stop staff getting infected.
This would likely slow the response to some emergencies. Patients vulnerable to cardiac arrest should be identified as early as possible, the documents advise, because CPR cannot be performed without protective equipment. "It is acknowledged that this may cause a brief delay to starting chest compressions, but the safety of staff is paramount."
The escalation plan for MidCentral DHB, which covers Palmerston North and has six resourced ICU beds, acknowledged that in a pandemic there may be times when "some compromise to the 'normal' standard may be necessary. Delays in the delivery of non-urgent care may be one of these compromises."
Social challenges identified include the potential increase of self-harm, domestic violence, and "panic" linked to misinformation on social media. "Health workers will suffer from fatigue which will need to be managed," the document states.
Taranaki DHB's Covid-19 manual includes advice on managing death: "Infection risk from a deceased person is lower than from a living person. Air movement can still occur from the respiratory tract during moving of the deceased therefore droplet precautions are required when handing the tūpāpaku [deceased] until they are within an impervious plastic body bag."
ICU doctor Craig Carr, who is the NZ regional chair of the Australia NZ Intensive Care Society, told the Herald that having to initiate a surge or crisis-staffing model to cope with Covid numbers would cause massive disruption, including patients needing other treatment having that postponed.
New Zealand needed to avoid doing so, Carr said, through vaccination coverage and strengthening the whole health system to deal with cases that did emerge.
"There is a knock-on effect. You try as long as you can to preserve your essential, life-prolonging surgeries and care - things like cardiac and cancer surgeries - these would be the last forms of elective work to go. There can be a point reached, and we have seen this around the world, where even that has to go."
There is debate about the threat facing New Zealand. Covid-19 modeller Rodney Jones of Wigram Capital Advisors has criticised the Te Pūnaha Matatini modelling recently cited by Ardern, saying it was "overcooked".
In the coming weeks and months New Zealand will keep a close watch on how Covid circulates and puts pressure on health systems in increasingly vaccinated countries, including Australia, where areas including NSW are ready to ease restrictions as coverage rates climb.
What's happening in Alberta, Canada, is an example of what can go wrong. More than 80 per cent of the population aged over 12 have had at least one vaccination dose, but the province's intensive care beds are approaching capacity, even with additional "surge" beds. Doctors have spoken of the fear that they could soon have to ration care to those with the greatest chance of survival.
"Delta is more transmissible," Ardern said last week, explaining why coverage of "90 per cent plus" was needed. "If there is an unvaccinated person, it is very good at finding that person eventually, and then the next one and then the next one, until it has quickly found a lot of people and potentially overwhelmed the health system."