[LINK] Burnet Institute Projections

[Stephen Loosley]

How will hospitals cope when NSW Covid cases hit 2,000 a day? Here’s what the modelling says

We examine Burnet Institute projections for how the state’s healthcare system will respond to pressure in coming weeks

By Elias Visontay Mon 6 Sep 2021 https://www.theguardian.com/australia-news/2021/sep/06/how-will-hospitals-cope-when-nsw-covid-cases-hit-2000-a-day-heres-what-the-modelling-says


Sydney’s intensive care units are expected to become overwhelmed by November, with the government drawing up plans to place overflow ICU beds in operating theatres and abandon existing nurse to patient ratios by that time.

The New South Wales healthcare system has been placed under increasing strain as Sydney’s Delta outbreak worsens, with modelling released on Monday predicting daily cases could reach more than 2,000 in areas of concern with a resulting surge in hospitalisations.

Medical experts and Sydney nurses have raised concern in recent weeks that there aren’t enough trained staff to deal with an expected peak in Covid hospitalisations in October.

The Australian Medical Association has warned that the state may need to pursue a more ambitious target than 80% double dose vaccination in order to lift the harshest lockdown restrictions while allowing hospitals to cope.

The NSW government modelling conducted by the Burnet Institute assessed the state’s healthcare capacity and how the system would respond to pressure as cases rise in coming weeks.

Here’s what it tells us.


  *   How advanced is the modelling?

There are some important caveats on the modelling. Firstly, it will change.

Prof Margaret Hellard, who worked on the modelling for the Burnet Institute, told the Guardian the predictions made are based on the current rate of hospitalisation (at the moment about 11% of Covid patients end up requiring some form of hospital care) and recent vaccine uptake figures. Importantly, the model also assumes increasing vaccination will be uniform across different age groups and across LGAs.

As new hospitalisation and vaccination rollout data is entered into the model, it will produce different results, which are expected to be provided in coming weeks.

The modelling released on Monday is also based on health data up until 23 August. Importantly, case numbers and hospitalisations have increased since that date.


  *   Does the modelling take into consideration an end to lockdowns?

No. Hellard stressed that the modelling was based on the “current restrictions remaining as they are”.

“What this is trying to understand is what the impact of sufficient vaccination, alongside maintained restrictions, will have on NSW’s hospitals,” Hellard said.

The modelling predicts a peak in hospitalisations and ICU pressure in late October, and premier Gladys Berejiklian has already foreshadowed that restrictions could be eased in line with reaching a 70% double dose vaccination target at the same time the health system is most stretched.


  *   How high will daily cases get?

Daily case numbers are expected to peak in the middle of September within the LGAs of concern, after which widespread immunity from the targeted vaccination campaign will ideally kick in, and numbers are expected to decrease.

At the mid-September peak, cases are predicted to rise to between 1,100 and 2,000 per day across a seven-day average in the LGAs of concern in Sydney.


  *   How many people will be hospitalised?

The hospitalisation peak is expected to occur in mid to late October because of the lag between cases becoming infected in the September peak and the time it takes for serious illness to develop.

It is anticipated that between 2,200 and 3,900 people will require hospitalisation at any one time in the state, with this figure including both Covid and non-Covid patients.

Specifically, the modelling estimates that 3,434 people will be hospitalised in NSW in the final week of October.


  *   How many people will be in intensive care?

According to the modelling, the busiest period for the intensive care system largely corresponds with the predicted hospitalisations broadly.

However, a peak of 947 ICU patients is predicted at the beginning of November, for both Covid and non-Covid patients. This figure assumes 560 Covid patients in ICU, and a baseline figure of 387 non-Covid patients in ICUs across NSW.


  *   Can NSW’s ICUs cope with that many patients?

The NSW government believes it can, but has warned care will look different from how it normally would.

Despite repeatedly responding to questions about its ICU capacity in recent weeks with the claim the state could expand its ICU capacity from 500 to 2,000 ventilated beds, the modelling released by the government believes it has a surge capacity of staffing to cope with 1,550 ICU beds filled.

On Monday, Berejiklian said “our surge capacity, we estimate, is in excess of what we’ll need”.


  *   How will hospitals operate during the peak in cases?

NSW Health has released a plan for how the health network will utilise its resources depending on pressure in ICUs, which will be measured across four different tiers.

At level 0, when there are fewer than 579 ICU patients in the state, only a “minimal” impact on daily operations is predicted. As of Monday, there were 177 Covid patients in ICU in NSW, in addition to the assumed baseline of 387 non-Covid patients in ICUs. Modelling predicts ICU pressure to exceed level 0 by mid-September.

ICU patients are classified depending on the level of care and nursing ratio they require. NSW Health’s plan distinguishes between ICU1 patients – those requiring a constant allocation of at least one nurse caring only for them – and ICU2 patients – patients requiring a ratio of one nurse caring for two patients. Ventilated ICU patients require at least one nurse at all times of day, and more when they need to be turned or monitored so they don’t fiddle with equipment.

At level 1, predicted to take effect by mid-September when there will be 579 to 790 intensive care patients in NSW, ICUs will be approaching “maximal operational capacity”, and there will be a “moderate impact” on daily operations. Specifically, NSW guidelines will recommend activating surge workforce plans at this stage, which include transferring critically ill patients to other facilities as appropriate.

At this point, ICU 2 patients who require a nursing ratio of more than one to one will begin to be moved to other areas outside of intensive care units.

Speaking generally about what a redirection of staffing resources and ICU care might look like, Dr Nhi Nguyen, the clinical director of the Intensive Care Network NSW, gave the example that some ICU patients who would traditionally spend one night in intensive care may instead be looked after by anaesthetists or nurses in an operating theatre or recovery area instead.

Level 2 pressure is predicted to be reached by about the second or third week of October, when there will be 791 to 926 ICU patients in NSW and a “severe impact on daily operations”.

By this stage, the overall demand for critical care will exceed ICU operation capacity, and alternative staffing and care strategies will be followed.

Instead of being cared for in intensive care units, ICU1 and ICU2 patients – those requiring lower but still significant levels of care – will be cared for in other areas of hospitals.

At this point, alternative workforce strategies will include abandoning nurse to patient ratios, and moving towards a “team nursing” approach.

Level 3 represents the most significant strain on ICU, when more than 926 patients will be in intensive care across the state.

This period, predicted to begin in late October and last until mid-November, will result in an “overwhelming impact on usual daily operations”, when “demand for critical care services significantly exceeds organisation-wide capacity”.

At this point, NSW pandemic resource-based decision making will be activated. While details of this have not been provided, it is understood this would result in decisions being made about which patients to give care to based on their likelihood of recovery.

Private hospitals will be further relied on for ICU patients, and patient to staff ratios will be further pushed to manage workloads.

The NSW plan also outlines “temporary hospital solutions”, but does not elaborate. The NSW Health deputy secretary, Susan Pearce, said field hospitals were included in planning exercises but that “at this stage, we are not anticipating field hospitals” but that “you’ve got to plan for [the] worst-case scenario”.


  *   How will healthcare workers cope?

Before the surge plan was released on Monday, private hospital workforce and bed capacity had already been incorporated into the public Covid response, and recently retired nurses were being recalled and other lower-qualified nurses upskilled for ICU work.

ICU nurses who spoken to the Guardian warned nurse to patient ratios in non-Covid ICUs were not being met throughout August, and reported increasing sedative doses for some patients in order to manage their workload.

Dr Nguyen, who appeared at the NSW Covid update on Monday, reiterated that the NSW health system would operate as “one whole unit” and that patient and staff transfers between facilities should be expected.

However, Dr Nguyen foreshadowed a workforce that would be asked to put in extra hours.

“I can’t emphasise enough though, how difficult and exhausting this is going to be ... You will hear stories, and you know, reflections from staff about having to work double shifts,” she said.

“We know there are nursing and medical staff who will feel a little uncomfortable with what they are being asked, but I’m confident we have such a well-connected and supportive environment that patients will continue to get care.”


  *   Does the model predict an end to NSW’s outbreak or how many people will die?

No. Hellard said the predictions released by the NSW government on Monday were based on a model about the impact of vaccinations.

Predictions about deaths, as well as when or if Covid zero is achievable under existing restrictions, and what hospitalisations will look like as NSW reopens, have not been released in Monday’s data.

“It’s a model, and what’s been provided is a projection that may look different in a few weeks time,” Hellard said.