Hospital doctors are being told that they should admit only cancer patients and those at risk of dying
The chief executive of the Saolta hospital group had been at his desk since 6.30am on Friday. By 9am, Tony Canavan and a team of hospital and clinical managers were crunching numbers. By lunchtime, he had drafted an email and circulated it to all hospitals in the group.
The essence of the email was an instruction that runs counter to what medical care is all about: doctors should admit only cancer patients and those at risk of dying to the region’s hospitals.
Canavan, who oversees seven hospitals in Donegal, Sligo, Mayo, Galway and Roscommon, did not make the decision lightly. Modelling circulated by the HSE had forecast what was to come. The figures landed on his desk on Monday and a second batch came mid-week.
“The latest iteration of that modelling has given us information, so we know now that we will be working through a wave that will for us probably reach a peak of around 100 and will be sustained over a 10-week period,” Canavan said.
“From today, we started looking at all of our ICUs in unison and asking our hospitals to actively plan what patients are going into their hospitals on the basis that, in the next two weeks, the admitted elective cases are only cancer patients or life-preserving.
"That means that only the most urgent cases are going to get in now.”
The modelling suggests that this fourth wave of the pandemic will be different. Apart from the increase in Covid cases, he says, the modelling “is also saying to us that that level of Covid activity in our hospitals will be sustained throughout the months of December and January.”
This he finds most alarming.
“This is the key message from the modelling for us. The fourth wave is different to the third wave. The third wave accelerated very quickly, reached a peak for us around January 19, and then declined.
"This wave will reach a peak towards the end of this month, but it will be sustained probably until the end of January.”
On the face of it, the numbers seem low. After the post-Christmas surge last January, the numbers of hospitalisations peaked at 394 cases across Saolta hospitals, compared with a predicted peak of 100 this time — largely due to effect of the vaccine in preventing serious illness.
But the numbers predicted by modellers this time around are arguably even more concerning. The pervasive if low-level stream of Covid cases collides with the opening of society, and all of the illnesses, injuries and common-or-garden respiratory viruses that go with it.
In addition, patients treated for Covid-19 in ICU tend to require longer hospital stays, which could lead to a potential logjam of sick patients if the forecasts of a steady, sustained onslaught of cases up to end of January are borne out.
There are not enough ICU beds. ICUs across the country are almost at capacity, and hospital groups will try to manage the situation by transferring critically ill patients to where beds and staff are available to treat them.
In the Saolta Group on Friday, only three of the 39 ICU beds across the region were available. For Tony Canavan, the shortage of staff is a greater concern.
“The key limiting factor is going to be having enough trained staff, having enough ICU-trained staff to open up beds as they are needed,” Canavan said.
“One of the real concerns is that we end up in a situation where we don’t have sufficient staff to care for patients. Particularly in the ICUs,” he said. “I would be concerned that we will be able to do that and sustain it over the next 10-week period.”
And if you don’t?
“Joint working [with other hospital groups] is going to be the key that will carry us through. I think our hospitals and our staff will be under awful pressure, but we will get by.”
The Saolta hospital group’s Covid forecast can be replicated more or less for hospitals around the country. Dr Catherine Motherway, the intensive care consultant at UHL, said the crisis is already there.
“It is profoundly disturbing that we will be seeing a sustained surge until the end of January. That will put enormous pressure on staff, and on patients,” she said.
The latest Nphet modelling suggests a pessimistic scenario where 2,000 people could be hospitalised with Covid-19 in December and 500 of those could need admission to ICU unless the current trajectory of infections is stalled. There are 300 beds in the system.
According to Motherway, the maths do not add up. “We cannot admit 500 people to an ICU if we do not have 500 ICU beds,” she said.
Hospitals can create surge capacity, other parts of the healthcare systems can be shut down. But patients will not get same level of care unless they have experienced and fully trained intensive care nurses. Outcomes will be “less good”.
“If we reach a situation where we have no more beds, then you will get into the triage discussions… about who gets in. Do you decide based on the likelihood of recovery, or do you decide on first past the post? Or do you decide on life lived?” she said.
"”If you have two people with the same illness, do you decide on the 90-year-old or the 20-year-old?” she asks. “There are many different ways to decide how to prioritise a patient when you run out of resources.”
The point is not to get that point. But according to Dr Motherway, we are now dangerously close.
“What people need to understand is that neither I nor any of my colleagues want to be put into a position of choosing between a 40-year-old and a 50-year-old and deciding which of them gets a bed,” she said.
“We have successfully supressed transmission of this virus in our community — not once, not twice, but three times.
"We have already done it as a society, and I fail to see why we cannot do it again,” she said.