19 Nov 2021

ICU surge capacity: Nurses question training and numbers

6:05 pm on 19 November 2021

ICU nurses are not seeing the level of training for surge capacity the government has talked about, and shifting to that crisis model would lead to worse care, they say.

Hutt Hospital Covid-19 ICU ventilator

Photo: RNZ / Dom Thomas

As Covid-19 cases continue to increase and spread around Aotearoa the health system is expected to come under greater pressure, with intensive care (ICU) and high-dependency (HDU) unit beds a crucial part of the puzzle.

The New Zealand Medical Journal has found New Zealand's ICU capacity is one of the lowest per capita in the OECD, with just four per 100,000 people - compared to 9 per 100,000 in Australia, 16 in France, and 34 in Germany.

College of Intensive Care Medicine of Australia and New Zealand vice president Rob Bevan, who works at Middlemore hospital, said intensive care nurses would typically do 12-hour shifts.

"It's also extremely physically challenging to be wearing tight, fitting PPE for a period of that many hours. So the nurses need to switch in and switch out for their own health and well being and to get breaks," he said.

"Any number greater than 280 [ICU beds], involves what we would call surge capacity ... that is achieved through drafting in non-ICU staff to help us look after these patients by moving extra beds into the spaces that are designed for one bed, and by potentially spilling into spaces that are not normally used for intensive care."

Minister of Health Andrew Little has insisted the 289 ICU and HDU beds could be ramped up to 550 under "surge capacity" if needed.

However, this would rely on surge-trained nurses, who could perform basic care under supervision from an ICU-experienced nurse.

  • Want more on this topic? In RNZ's Focus on Politics podcast this week, Political Editor Jane Patterson and Health Correspondent Rowan Quinn examine New Zealand's ICU capacity. Listen on Friday after 6.30pm and Saturday at 5.10pm, or on our website from 10am Saturday.

College of Critical Care Nurses chair Tania Mitchell told RNZ the training such nurses were receiving was comparatively minimal.

"To get enough experience for an intensive care nurse to be able to look after a complex patient like we would expect to see with Covid, it takes three to five years of experience ... a four-hour training package and a couple of days helping to look after a patient isn't going to equip these nurses to be able to look after an intensive care patient on their own."

Little has stated up to 1400 nurses had been or were being trained so the system could handle this, but Mitchell was dubious.

"I'm not sure the origins of the number of 1400 surge nurses because my colleagues throughout the country are not seeing anywhere near those numbers of nurses being trained," she said.

"Some DHBs might have 30, other DHBs the nurses in intensive cares are telling me that they're not seeing any surge training happening, so there is quite a wide range ... some areas are definitely underprepared."

Under normal conditions, a single ICU bed requires 5.3 staff per bed for round-the-clock care, but Little said the training needed for Covid-19 patients would be less.

"The critical thing is their breathing and their respiratory function, so they need to be properly supervised, but it is not the level of intensity as the patient who typically goes into ICU," Little said.

"Intensive care leaders in our hospitals who were on a webinar with their British counterparts a few weeks ago were assured by their British counterparts ... that is adequate for the Covid-19 patient."

Dr Bevan said surging up would realistically mean a lower standard of care however, including for people who were in ICU without the virus.

"That is a crisis, short term, and largely unsustainable model ... that would most likely achieve worse outcomes for all patients in the ICU compared to our best model of care that we've been able to provide to date."

Mitchell also feared what it would mean for the rest of the health system with resources soaked up by ICU, and people with Covid generally requiring longer stays than other patients.

"We're shortstaffed from a nursing point of view, we're relying on nurses to work on their days off and their annual leave just to continue on with business as usual at the moment and so with Covid on top of that, that's not sustainable.

"The surge nurses, they all have jobs elsewhere. So if the surge nurses are coming to work in intensive care, their job elsewhere is not being done."

Even before the pandemic, in 2018, some 17 percent - nearly one in five - planned surgeries was cancelled in New Zealand because of a lack of available ICU beds, compared to less than 2 percent in Australia.

Mitchell said outbreaks overseas had inevitably made things worse.

"We've seen this internationally, there's data coming out from the UK that shows there is an increase in adverse events ... and patient outcomes are affected," Mitchell said.

"Nurses will end up burnt out and then we will lose more nurses and our already underresourced profession will be in an even worse situation."

Little has argued the high vaccination rates in New Zealand ensure the pressure does not become unmanageable.

"The people who are infected are increasingly the ones who are part or fully vaccinated, and they just don't get sick ... we will have a vaccination level at one of the highest levels in the world before we start to relax restrictions."

That stance was backed by Dr Bevan.

"I want to stress, so far - and the modelling is consistent with this - that we are not expecting to have to move to anything other than the best care model that we have today in New Zealand ... vaccination is largely responsible for that.

"The plan that we have to date ... does provide for the best care for these patients."

He warned however that ICU would need serious funding to reach standards seen overseas and highlighted it was just one part of the Covid response, where investment would need careful balancing.

"I think we need to address intensive care capacity for all of the patients that need ICU. And that should not be at the expense of the emergency departments in the medical wards," he said.

"These decisions are tricky, and planning for the future with limited resources is equally challenging. So I think it's important that we all work together and have a forward focus in this pandemic.

"It's going to take years to get us to the capacity that we need, but the time to start that is now."

  • Want more on this topic? In RNZ's Focus on Politics podcast this week, Political Editor Jane Patterson and Health Correspondent Rowan Quinn examine New Zealand's ICU capacity. Listen on Friday after 6.30pm and Saturday at 5.10pm, or on our website from 10am Saturday.

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