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INMO warns staffing levels in the Irish health service are in 'freefall'

Worst case scenario projections put numbers requiring critical care beyond even our surge capacity.

Professor Clíona Ní Cheallaigh said these types of decisions are psychologically very difficult to deal with.
Professor Clíona Ní Cheallaigh said these types of decisions are psychologically very difficult to deal with.
Image: Leon Farrell/RollingNews.ie

Updated Jan 7th 2021, 9:05 PM

THE IRISH NURSES and Midwives Organisation (INMO) has warned that staffing levels in the nation’s health service are in “freefall”. 

The union’s elected executive council will hold an emergency meeting tomorrow to discuss the crisis and receive updates from across the country.

The union pointed to staff rosters “decimated” by Covid absences, surging patient numbers, and a lack of childcare for frontline staff.

Earlier today, it emerged the health service is preparing itself for a surge in Covid-19 hospitalisations over the next ten days, with an expected 400 people requiring critical care in the worst-case scenario.

Speaking at the HSE’s weekly Covid-19 briefing, Chief Clinical Officer Dr Colm Henry said on the optimistic scale of projections, there will be 1,500 Covid-19 patients in hospital in mid January.

A more pessimistic scenario would see hospitalisation numbers at 2,500 and intensive care admissions at up to 400.

The increased transmissibility of the new coronavirus variant is a concern for health officials, as it may mean numbers creep beyond their already worrying projections.  

The current ICU capacity is around 286 and this fluctuates depending on staffing levels, which have been threatened by outbreaks of the virus in hospital settings. The system can scale up to provide critical care to around 350 patients, but this would involve the use of surge capacity, such as anaesthetic rooms or post-operative beds.

Dr Henry said during the first surge back in April 2020, hospitals here managed to deliver the bulk of critical care within conventional settings with trained staff. As a result, he said, outcomes were favourable compared to other jurisdictions where hospitals were overwhelmed beyond their ICU capacity.

He said the surge this time in intensive care units may exceed numbers seen in the first surge in April 2020, as hospital numbers have already gone beyond those seen in the first wave. Today there are 1,022 Covid-19 patients in hospital, with 95 in intensive care. There are 400 beds in the system available and just 21 unoccupied adult ICU beds. 

Dr Henry said reaching the maximum number in the system can have “quite significant implications for those who are sick”.

“Once you go beyond the 350 beds, staff will do what they can, which we saw in other countries, try their best to make the maximum benefit over the resources they have to those most likely to benefit,” he explained.

“We never had to enter that scenario in the first surge – other countries did. What we saw in other countries was that the outcomes for those critically ill people were much poorer than our outcome and we don’t want to see that happen.”

A significant increase in patients requiring critical care, beyond 350 people, will also force healthcare workers who are treating them to make difficult decisions. 

Professor Clíona Ní Cheallaigh, a consultant in infectious diseases and internal medicine at St James’ Hospital, said she and her colleagues are already used to weighing up the potential benefits for patients, as intensive care can take a huge toll on a person’s body.

“This is something that I really want the public to hear; going into intensive care is a massive burden on that person. You’re very unwell you’re paralysed, you have tubes down your throat, you potentially come out with a tracheostomy (a hole in the windpipe), you have a huge mountain to climb when you come back out of ICU to get back to where you were,” she said.

So you never want to end up needing it in any case. As practitioners in Ireland, certainly somebody who is in their late 90s and or is already frail, putting them in intensive care to leave them with that massive hill to climb at the end at that age from that starting point is not a kind thing to do. We don’t do that anyway.

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She said if patients are well enough, they are involved in the decision-making process, but if they are not, it is ultimately down to clinicians. 

“We would discuss it with each other, we would discuss it with the nurses, we would just make that decision as a team,” she said.

“I think we’re all terrified of being in a situation in which people that we normally would definitely be sending to ICU – people who are relatively young, who have a good baseline, who we think would be able to climb that hill at the other end – where we’re not going to have enough beds. That didn’t happen in wave one, and we’re really worried that if that happens that’s very difficult to deal with psychologically.

Some of the things that we’ve talked about about is we’re going to meet our intensive care colleagues in the morning and go through the list. You never want to make the decision around intensive care when somebody is crashing in front of you, you want to make that decision days in advance if you can, so you can do it in daylight and in calmness.

“So we’re going to meet as a group and try to make those decisions as a group, rather than as individuals for many reasons. It’s much psychologically safer as a group, and also medical legally it’s safer as a group.”

Dr Henry said an ethical framework was developed in the first phase of the pandemic to enable clinicians to make the best possible decisions.

“I can’t sugar coat this, I can’t say it’s easy,” he said.

“At the same time I want to assure people who are sick and may become critically unwell that at this point in time we can provide care. I don’t want them to be frightened that our hospitals are not safe places to come to.

“Those scenarios, we have prepared for but we don’t want to realise them.”

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