What happens if ICU beds run out in Irish hospitals?

Recent predictions that up to 500 coronavirus patients might need intensive care during the current wave of the pandemic have generated considerable concern.

Given that we only have about 300 intensive-care unit beds and there are all the other non-Covid reasons for providing critical care to patients, it is hard to see how even this number could be accommodated.

The National Public Health Emergency Team’s estimate is a worst-case scenario that is unlikely to come to pass given stricter public-health measures and likely changes in public behaviour, but it has focused the minds of health staff and policymakers.

It has also focused attention again on ICU as the potential weak point in Ireland's Covid-19 response, given the lack of beds for the sickest patients in our system. This was highlighted again in the Organisation for Economic Co-operation and Development's recent Health at a Glance report for 2021, which showed that Ireland has relatively fewer beds, and higher bed occupancy, than other countries.

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As for ICU beds, we had just over five per 100,000 in 2019. The UK had more than seven, France had 16 and Germany had 28. (In contrast, both Sweden and New Zealand had fewer beds than Ireland.)

ICU capacity should be thought of not as an inflexible number but as a ceiling that can be adjusted by changing the operating conditions in a hospital

Intensive-care beds are expensive to open and staff, so the health service is used to varying provision according to the season, with peak demand arising in winter.

In the early days of the pandemic the hospital system had a baseline capacity of just 204 ICU beds, but with extra investment this was increased to 280 by last November, and it currently stands at about 300.

In spring 2020 there were widespread fears internationally about a shortage of ventilators to treat seriously ill Covid-19 patients. These have long since dissipated, and now the biggest restraint on ICU capacity in Ireland is the supply of experienced staff, particularly nurses.

ICU capacity should be thought of not as an inflexible number but as a ceiling that can be adjusted by changing the operating conditions in a hospital.

The onset of the pandemic prompted the creation of a web-based ICU bed-management system, which provides a real-time overview of bed availability nationally. This allows hospitals approaching maximum capacity to trigger the transfer of patients to other hospitals, provided they have space.

At the worst of last January’s wave of infections, there were 330 patients in intensive care of a high-dependency unit, including 215 with Covid.

ICU beds are highly likely to 'run out', but as hospitals fill with Covid-19 patients, the overall quality of care will decline and other services will be massively affected

Beyond the baseline capacity, the system operates three levels of surge capacity. This can add hundreds of beds to the baseline figures but at a cost of poorer patient outcomes and the depletion of other hospital resources.

According to the level of surge capacity, non-ICU staff are redeployed to work in intensive care, ICUs are expanded beyond the normal location in the hospital, and staff-patient ratios increase.

So at level 3 surge, ICU care could be provided in operating theatres (so procedures have to be cancelled), primarily by non-ICU staff.

“This will lead to a significant diminution in quality of care for ICU patients, increased mortality in both Covid and non-Covid patients and an overwhelming impact on all other activities in the hospital,” in the words of a recent report.

So far in the pandemic, mortality for Covid-19 patients in intensive care, at 28.3 per cent, is in line with international figures.

Last Wednesday 288 ICU beds were open and staffed, and 279 of them – or 97 per cent – were occupied. Covid patients accounted for 119 of these beds.

Just 10 ICU beds were free for adults, and none for children. (Paediatric hospitals have been largely spared Covid admissions, but children are suffering a big surge of other respiratory conditions.)

Last year the ICU system approached peak capacity because of Covid-19, but it was not overwhelmed, according to the National Office of Clinical Audit. This time around, however, the mass cancellation of other services that occurred in 2020 is regarded as something that will only happen as a last resort.

In summary, this means ICU beds are highly unlikely to “run out”, but as hospitals fill with Covid-19 patients, the overall quality of care will decline and other services will be massively affected.