By November, Sydney's critical care units are anticipated to be overcrowded, with the government planning to put overflow ICU beds in operating rooms and abandon current nurse-to-patient ratios.
As Sydney's Delta epidemic develops, the New South Wales healthcare system is under growing pressure, with modelling published on Monday projecting daily cases may reach more than 2,000 in regions of concern, culminating in a spike in hospitalisations.
In recent weeks, medical experts and Sydney nurses have expressed worry that there would not be enough qualified personnel to cope with an anticipated increase in Covid hospitalisations in October.
The Australian Medical Association has cautioned that the state may need to set a higher goal than 80 per cent double dose vaccination to remove the most severe lockdown restrictions whilst still enabling hospitals to function.
The Burnet Institute modelled the NSW government's healthcare capacity and how the system would react to increased strain in the coming weeks.
How far has the modelling progressed?
There are several significant limitations to the modelling. First and foremost, it will alter.
Prof Margaret Hellard, who worked on the modelling for the Burnet Institute, told the Guardian that the projections are based on the existing rate of hospitalisation (about 11% of Covid patients need some kind of hospital treatment at the present) and recent vaccination uptake statistics. Importantly, the model assumes that increased vaccination would be homogeneous across age groups and LGAs.
As fresh hospitalisation and vaccine rollout data is put into the model, it will yield different findings, which should be available in the following weeks.
The Monday modelling is likewise based on health data up to the 23rd of August. Importantly, the number of cases and hospitalisations has risen since that time.
How many instances will be reported daily?
Daily case counts are anticipated to peak in the middle of September inside the LGAs of concern, following which broad immunity from the focused vaccination program is expected to kick in and numbers will fall.
At the peak in mid-September, cases in Sydney's LGAs of concern are expected to increase to between 1,100 and 2,000 per day on a seven-day average.
How many individuals will be admitted to the hospital?
Because of the time lag between patients getting infected during the September peak and the time it takes for the severe disease to develop, the hospitalisation peak is anticipated to occur around mid to late October.
It is expected that between 2,200 and 3,900 individuals in the state may need hospitalisation at any one moment, with this number comprising both Covid and non-Covid patients.
In particular, the modelling predicts that 3,434 individuals will be hospitalised in New South Wales in the last week of October.
How many individuals will be in critical care?
The busiest time for the critical care system, according to the modelling, roughly coincides with the anticipated hospitalisations.
However, a high of 947 ICU patients for both Covid and non-Covid patients is expected around the beginning of November. This statistic is based on 560 Covid patients in ICU and a baseline of 387 non-Covid patients in NSW ICUs.
Can NSW's ICUs handle so many patients?
The NSW government thinks it can, but warns that care will be different than usual.
Despite frequently responding to concerns about its ICU capacity in recent weeks by claiming the state could increase its ICU capacity from 500 to 2,000 ventilated beds, the modelling provided by the government thinks it has a surge capacity of personnel to deal with 1,550 ICU beds filled.
On Monday, Berejiklian said that "our surge capacity, we think, is more than what we'll need."
How would hospitals function amid a surge of cases?
NSW Health has published a proposal outlining how the health network would allocate resources based on ICU pressure, which will be monitored across four distinct levels.
When there are less than 579 ICU patients in the state, a "little" effect on everyday operations is anticipated at level 0. There were 177 Covid patients in ICUs in NSW as of Monday, in addition to the estimated baseline of 387 non-Covid patients. ICU pressure is expected to reach level 0 by mid-September, according to modelling.
ICU patients are categorised based on their degree of care and nurse ratio. The NSW Health plan differentiates between ICU1 patients – those who need a continuous allocation of at least one nurse caring only for them – and ICU2 patients – those who require a ratio of one nurse caring for two patients. Patients in ventilated ICUs need at least one nurse at all times of day, and more if they need to be rotated or watched so they don't tamper with the equipment.
At level 1, which is expected to go into effect in mid-September when there would be 579 to 790 critical care patients in NSW, ICUs will be nearing “maximal operational capacity,” with a “moderate impact” on daily operations. Specifically, NSW guidelines would advise activating surge workforce preparations at this point, which will involve transporting critically sick patients to other hospitals as needed.
At this time, ICU 2 patients who need a nurse ratio greater than one to one will be transferred to locations outside of critical care units.
Dr Nhi Nguyen, clinical director of the Critical Care Network NSW, provided the example that some ICU patients who would typically spend one night in intensive care may instead be cared for by anaesthetists or nurses in an operating theatre or recovery room.
Level 2 pressure is expected to be achieved by the second or third week of October, with 791 to 926 ICU patients in NSW and a "significant effect on everyday operations."
By this point, the total demand for critical care will surpass the capacity of the ICU, necessitating the use of alternative staffing and care methods.
ICU1 and ICU2 patients — those needing lesser but still substantial levels of care – will be cared for in other parts of hospitals rather than critical care units.
At this stage, alternative workforce options will include abandoning nurse-to-patient ratios and transitioning to a “team nursing” model.
Level 3 reflects the greatest pressure on ICU, with over 926 people in critical care throughout the state.
This time, which is expected to start in late October and continue until mid-November, will have an "overwhelming effect on normal daily operations," as "demand for critical care services substantially exceeds organisation-wide capacity."
The NSW pandemic resource-based decision-making process will be triggered at this time. Whilst specifics have not been disclosed, it is believed that this would result in choices regarding which patients to care for depending on their probability of recovery.
Private hospitals will be depended on even more for ICU patients, and patient-to-staff ratios will be pushed even higher to handle workloads.
The NSW plan also mentions "temporary hospital options," but does not go into detail. Susan Pearce, deputy secretary of NSW Health, said that field hospitals were included in planning exercises but that “at this point, we are not expecting field hospitals” but that “you have to prepare for [the] worst-case scenario.”
How will healthcare personnel deal with the situation?
Before the announcement of the surge plan on Monday, private hospital workforce and bed capacity had already been integrated into the public Covid response, with recently retired nurses being recalled and other lower-qualified nurses being upskilled for ICU work.
ICU nurses who talked to the Guardian stated that nurse-to-patient ratios in non-Covid ICUs were not being fulfilled throughout August and that they had to increase sedative dosages for certain patients to manage their workload.
Nguyen, who spoke at the NSW Covid update on Monday, underlined that the NSW health system will function as “one complete unit,” with patients.
