Our ability as a country to care for critically ill patients in ICUs has been thrust into focus during the COVID-19 pandemic. Ventilators and ‘surge capacity’ have become common topics of conversation. As we emerge from COVID-19-focused hospital reorganisation, a serious vulnerability at the heart of our healthcare system remains.
COVID-19 has undoubtedly taken a major toll on lives and livelihoods. More than 1,700 patients in Ireland have died in hospitals and in care homes around the country. Many others have suffered severe lung damage and will require weeks and months of rehabilitation in order to return to independent function.
In addition to social-distancing measures, the response of our hospitals and healthcare staff has mitigated some of the suffering and death caused by the disease. Directing resources to ICUs allowed us to satisfactorily care for significant numbers of critically ill patients with severe cases of COVID-19. This undoubtedly saved many lives.
Published mortality rates from ICUs in Italy, the UK and the United States are higher than here in Ireland – at least 30% of the patients with COVID-19 admitted to ICUs in these countries during surge conditions died. Mortality rates in the UK were extremely high for patients who received invasive mechanical ventilation in the ICU – more than 50% – compared with other countries. In Ireland, we saw a mortality rate of 20.2% for COVID-19 patients admitted to ICUs, according to data from the Health Protection Surveillance Centre (correct to 1 August).
Ventilator shortages
The emergence of many cases in these other countries concentrated within a short period of time stretched hospitals beyond capacity. The large surge of COVID-19 patients with respiratory failure led to shortages of ventilators in countries such as Italy and the US.
Germany and Italy had similar rates of COVID-19 infection but drastically different mortality rates. An analysis by Harvard Business Review showed that in Germany up to 20 June, 4.7% of patients had died, compared with 14.5% of patients in Italy. Attempts to explain this disparity points to ICU capacity. While both countries have had major outbreaks, Germany had more ICU beds per capita as the pandemic began (48.7 versus 8.6 beds per 100,000 inhabitants), and a national ICU bed registry allowed it to prevent local overloading by swiftly relocating patients. A study by Careggi Hospital and University of Florence analysed the mortality rates in the different regions of Italy and found that availability of healthcare resources, ICU beds in particular, could reduce the lethality of COVID-19.
Our healthcare system was helped enormously by having a head start on other countries and a population that complied with severe restrictions on movement and social interaction. Despite this, ICUs around the country were stretched beyond normal capacity. Patients were ventilated in areas of hospitals that are not normally used for this purpose, such as theatre recovery areas. ICUs begged, borrowed and stole staff and equipment to cope with the increase in numbers.
Historically, intensive care has been underfunded in Ireland. The provision of critical-care beds in Ireland (including beds in private hospitals) is inadequate – there are only six beds per 100,000 population compared with the European average of 11.5. ICU occupancy rates, consistently close to 100% in some units, indicate a system stretched and challenged to provide ICU care in pre-pandemic times (Irish National ICU Audit 2018). The European Society of Intensive Care Medicine recommends an occupancy rate of 75%.
The challenge of COVID-19 remains, and a second peak or ongoing admissions to ICUs around the country remains a certainty. We need to prepare for this by investing more heavily in the staff and infrastructure that ICUs require.
Bed capacity
More than 440 patients suffering from COVID-19 illness have been admitted to Irish ICUs so far. ICU bed capacity in Ireland increased by 39% from 255 at baseline to 354 beds during the pandemic peak, according to the National Office of Clinical Audit. However, at the peak of the first wave, Ireland’s healthcare system was pushed nearly to its breaking point, and hospitals in the greater Dublin area converted areas such as theatre recovery into ICUs to expand their capacity.
Cases of COVID-19 in Ireland have increased over the past several weeks, without an accompanying increase in ICU admissions. Increased testing and the uptake of the COVID tracker app almost certainly has resulted in the detection of a greater number of mild cases. There has been a surge in cases in young people in particular, who are known to be less likely to require admission to ICU. Of course, young people are not invulnerable to death from COVID-19, and the long-term consequences of non-lethal infection with COVID-19 are unknown, but potentially significant. What is clear is that an epidemic among young people will inevitably leak over into older age classes, where critical illness and fatality rates are much higher.
Our system would not be able to effectively treat a larger wave, especially one that disproportionately affects vulnerable groups such as nursing homes, and the ‘surge’ approach to ICU care is suboptimal and unsustainable. Redeployment of staff from one area of the hospital to another impacts the ability to provide non-COVID-19 care.
Elective surgery, for example, has been significantly curtailed during the pandemic. A study published in the British Journal of Surgery by the CovidSurg Collaborative, estimates that more than 28 million operations worldwide have been cancelled or postponed due to the disruption caused by COVID-19.
ICU care outside dedicated ICU units by hard-working, but inexperienced, ICU staff leads to a diminution in quality of care for ICU patients, increased mortality for COVID-19 and non-COVID-19 patients and an overwhelming impact on all other activities in the hospital.
Elective and semi-urgent care requiring admission to ICU should proceed, and every patient who requires access to care should have their needs addressed, now and in the future. In order to ensure that we can provide our patients, those suffering from COVID-19 and other diagnoses, with the world-class intensive care that they deserve, we as a country should insist on investing in the infrastructure and staffing to provide it.
This article was originally published in The Irish Times on 8 September 2020.
Prof. Gerard Curley is Professor of Anaesthesia and Critical Care at RCSI and a Consultant in Anaesthesia and Intensive Care at Beaumont Hospital.