Monash researchers outline predictions, and some answers, to the expected COVID tsunami into our hospital system
A paper outlining the severe problems facing Australia’s hospital system in the coming months as COVID-19 cases increase – as well as some solutions – has been published in Emergency Medicine Australasia.
The authors – Drs Rob Mitchell, Peter Cameron, Gerard O’Reilly and Biswadev Mitra, all from the Monash University School of Public Health and Preventive Medicine, are emergency physicians and researchers in emergency system design. The plan incorporates practical steps to manage what is expected to be thousands of people in the hospital system, both with COVID-19 and with other non-COVID health issues.
"The number of severe cases of COVID-19 may be mitigated by vaccination, but 'living with COVID-19' will be associated with a higher number of patients seeking emergency care. This impending impact on the emergency care system requires recognition, monitoring and coordinated management," the authors state.
Current challenges include a lack of emergency care system monitoring, staff shortages and patient flow processes that are quickly overwhelmed by large numbers, particularly in a system already operating at capacity.
The authors argue that the following steps are integral steps to increasing capacity within the emergency care system:
- Effective monitoring systems are required for the acute health sector to proactively detect and respond to stresses
- Improved public health messaging
- Clinical innovation to facilitate care of the right patient to be in the right place at the right time
- Optimising staff numbers and morale
- Efficient patient flow
On 30 July 2021, the Prime Minister and National Cabinet reached a consensus decision that Australia will move towards ‘living with COVID-19’ once certain vaccination thresholds are reached. These have been based on modelling from the Doherty Institute, and are fixed at 70% of the eligible population (>16 years) for partial reopening and 80% for increased freedom of movement.
The authors warn that: "although the risk of critical illness and death because of COVID-19 among the vaccinated population may be dramatically reduced, significant numbers will still be expected to experience mild and moderate disease, and some will require hospitalisation. Disadvantaged groups are likely to be disproportionately affected."
The experience from Israel, which reopened after 78% of the eligible population was vaccinated, suggests that a surge in hospital presentations and admissions is to be expected in Australia. The impact on primary and emergency care sectors will be substantial, adding further stress to a system that is already overburdened. "Plans to mitigate this impact are yet to be agreed, published and implemented," the paper states.
The authors predict that – once lockdowns are lifted – patient attendances will increase and possibly 'overshoot' because of the pent-up demand. A similar pattern was seen in April-June 2021, when restrictions were eased – when an additional 122,148 patients sought emergency medicine care compared to the same period in 2020.
According to one of the authors, Dr Rob Mitchell, "If nothing is done to plan or respond to this expected impact, EDs across Australia will face markedly increased demand from non-COVID-19 related presentations, along with potentially large numbers of patients with COVID-19. This will include unvaccinated patients at risk of critical illness as well as vaccinated patients with milder disease. Many will be suitable for community-based management, but large numbers are still likely to require admission," he said.
Combined with an increase in patient numbers there will be a paradoxical decrease in hospital staff, with healthcare workers being furloughed, with those remaining burnt out with exhaustion, a sense of depersonalisation and lack of personal accomplishment.
More staff may opt to go on leave when restrictions are eased, which may result in further gaps in rosters while immigration of skilled workers has virtually stopped, further reducing staff availability.
Additionally, many skilled clinical staff are being deployed in areas that could be performed with less skilled people, including vaccination centres and contact tracing.
The paper warns that most hospitals are not engineered to manage large numbers of COVID positive patients safely because:
- The supply of negative pressure rooms is limited
- Ventilation and air exchange designs are generally sub-optimal
- Retrofitting safe clinical spaces will be a challenge
- And in some hospitals, temporary structures will need to be erected for safety.
The paper outlines ways to mitigate the ongoing understaffing of EDs combined with an expected influx of thousands of patients:
- Protocols for the management of those COVID positive people who can be managed at home via virtual care programs need to be standardised across all states and territories.
- Increased access in EDs for rapid diagnostic testing so that EDs can stream patients more effectively, ensuring those that present who are positive can be isolated from other patients. "Currently, many hospitals have limited access to rapid testing and turnaround times for results are slow," the authors state.
- There is still no optimal model for the streaming of selected patients to COVID-19 designated hospitals though differing programs are being trialled in several states and territories.
- Limited access to inpatient beds is the major cause of overcrowding in EDs, and a significant contributor to preventable mortality. "This has been exacerbated by isolation and quarantining protocols associated with COVID-19, and is likely to worsen on reopening when a higher number of COVID-19 patients, albeit with disease of lesser severity, are expected to present. Up to 30% of hospital bed days are the result of waiting for imaging, consults and other waits that could be reduced. Discharge from hospitals to residential aged care facilities (RACFs) and disability care packages are a major cause of extended length of stay. With reopening, the public will also expect hospitals to catch up on elective surgery, putting further pressure on inpatient beds," the report states.
Importantly the authors argue that the healthcare system is preparing itself with modelling that underestimates the true impact of COVID-19 in coming months.
"As the Doherty Institute modelling foreshadows, there will be large numbers of COVID-19 cases and some deaths – even among the vaccinated population. The true numbers will be higher than those reported, because the simulations in the Doherty Institute modelling only extend to 6 months post reopening. Furthermore, the Doherty report focuses on the outcomes of mechanical ventilation in ICU and deaths; it does not model the predicted demand on the emergency care system, namely EDs and ambulance services, and the complications that may result," the report states.
"If the health system becomes overwhelmed, the number of preventable deaths may increase dramatically. Cancer deaths will go up. Cardiac arrest survival will go down. Patients requiring a high level of support for respiratory or cardiovascular disease will not receive treatment quickly. Cross infections will occur between patients because of inadequate clinical spaces, and overburdened staff may not have capacity to ensure optimal infection control. Detailed analysis of mortality data will help detect these trends."
The paper states that monitoring is the key to knowing whether the health system is overwhelmed by demands for care. While getting baseline and ongoing data such as ED attendance, ED admissions, ED occupancy, ambulance ramping and ICU admits/delays will offer some indication, the authors warn that they are unlikely to provide a complete picture of health system stress. What is needed is a national dashboard for the emergency care system. Additionally, registries will need to be utilised to measure the delays to care in high-risk groups, such as patients with stroke, trauma and acute coronary syndromes.