With the marked increase in Covid-19 cases announced on Thursday and our first indication from the National Public Health Emergency Team of ICU bed usage by patients with the novel coronavirus, many challenges lie ahead.
Doctors here are likely to face some very difficult decisions involving triage and the rationing of resources. Rationing is defined as the allocation of healthcare resources in the face of limited availability, which means that beneficial interventions are withheld from some patients.
Triage is the process of deciding who gets treatment priority; it is used in war zones by medics to decide which wounded soldiers will be transported to hospital first. Less dramatically, triage is used to decide who gets priority in overcrowded emergency departments.
We can learn a lot from the Italians. They are about two weeks ahead of us in the pandemic process. They have the highest number of coronavirus cases (and deaths) in Europe and as a result have seen unprecedented demand for intensive and critical care facilities.
This week the Italian College of Anaesthesia, Analgesia, Resuscitation and Intensive Care described how some hospitals in Northern Italy are so overwhelmed that they simply cannot treat every patient. They have had to engage in ‘wartime triage’.
Noting the difficult choices that have faced doctors and nurses, the College said it is a matter of giving priority to those with ‘the highest hope of life and survival.”
“In a context of grave shortage of medical resources, the allocation criteria need to guarantee that those patients with the highest chance of therapeutic success will retain access to intensive care”, their document states.
Starkly, the specialist group says it may be necessary to establish an age-limit for access to intensive care. “This is not a value judgment but a way to provide extremely scarce resources to those who have the highest likelihood of survival and could enjoy the largest number of life-years saved.”
“In addition to age, the presence of comorbidities needs to be carefully evaluated. It is conceivable that what might be a relatively short treatment course in healthier people could be longer and more resource-consuming in the case of older or more fragile patients.”
Ireland’s intensive care unit/high dependency unit bed capacity is one of the lowest in Europe. We have 50 beds per million people; Italy has 125 beds per million. If northern Italy has run out of intensive care facilities and we get the same surge in very ill coronavirus patients as it has, then some very difficult challenges lie ahead.
For us to avoid an epidemic peak that overwhelms the health system we must flatten the curve of transmission. The Government decision on Thursday to introduce measures in order to increase social distancing is an attempt to do just that. As the European Centre for Disease Control has advised, “measures taken at this stage should ultimately aim at protecting the most vulnerable population groups from severe illness and fatal outcome by reducing transmission and reinforcing healthcare systems.”
The other side of managing what lies ahead is to increase our intensive care capacity. One major teaching hospital here has doubled its number of ventilators in the last few days. These “breathing” machines are vital in managing coronavirus patients who develop severe pneumonia.
Sources have praised the HSE for short-circuiting the equipment purchase process to enable emergency funding to be spent rapidly. And having a medical device manufacturing capacity in Ireland has also helped, they say.
But you cannot build new units in the short time we have available. What is being done is the realignment of ICUs here to increase the number of beds in each. Plans are also in place to convert operating theatres into temporary ICU capacity. Doctors and nurses who are not specialists in critical care medicine are being formed into teams led by experienced intensivists to meet the surge.
Unless we are extraordinarily lucky, however, frontline health professionals are likely to face considerable dilemmas and challenges. For example, how to decide, in an ethically appropriate way, to remove one patient from a ventilator so another person can use it? Or which of two patients should be admitted to the last ICU bed? It will be important to explain and communicate to the patient and their relatives why they have reached a ceiling of care and won’t be offered that bed.
The absolute best way for us to spare patients and healthcare workers such traumatic decisions is to embrace, with vigour and good humour, the social distancing measures that have got underway.