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Covid crisis Doctors told ‘save oxygen’ as Irish hospitals prepare for coronavirus surge

Another email circulated to staff at Beaumont identified oxygen as an issue of critical importance, such that "oxygen needs to be conserved" and patient prescription for oxygen should be regularly reviewed".

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FIGHTING COVID: Professor Peter McMahon, emergency radiologist at Dublin’s Mater Hospital, reviews a chronic infected lung scan of a patient with Covid-19. Photo: David Conachy

FIGHTING COVID: Professor Peter McMahon, emergency radiologist at Dublin’s Mater Hospital, reviews a chronic infected lung scan of a patient with Covid-19. Photo: David Conachy

FIGHTING COVID: Professor Peter McMahon, emergency radiologist at Dublin’s Mater Hospital, reviews a chronic infected lung scan of a patient with Covid-19. Photo: David Conachy

Hospitals have been preparing for worst-case scenarios ahead of an expected influx of Covid-19 admissions in the coming days. One busy Dublin hospital asked staff to prepare 'ceiling of care' forms for all patients.

The 'ceiling of care', which is agreed with patients and families, determines a threshold of medical intervention should a condition deteriorate. An email circulated by Beaumont Hospital in Dublin said it was critical that staff should complete such forms for all hospital patients before the weekend.

Another email circulated to staff at Beaumont identified oxygen as an issue of critical importance, such that "oxygen needs to be conserved" and patient prescription for oxygen should be regularly reviewed".

The hospital has experienced the highest Covid-19 admissions in the country as the numbers have risen exponentially over the past week.

In a statement Beaumont Hospital said its procedures in relation to clinical care pathways and Covid-19 patient management adhere to relevant national policies and practices, and it is not just Beaumont preparing for the worst, but the entire health sector.

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BALANCING CARE: Dr Catherine McGorrian, an acute physician and cardiologist and the Mater’s clinical director for emergency and speciality medicine. Photo: David Conachy

BALANCING CARE: Dr Catherine McGorrian, an acute physician and cardiologist and the Mater’s clinical director for emergency and speciality medicine. Photo: David Conachy

BALANCING CARE: Dr Catherine McGorrian, an acute physician and cardiologist and the Mater’s clinical director for emergency and speciality medicine. Photo: David Conachy

The Health Service Executive has recirculated guidance documents on treating critically ill patients outside of an intensive care setting in recent days.

They include a document issued by Nphet in the first wave of the pandemic, following harrowing scenes in Italy of patients being administered oxygen in tents. It had lost its relevance in recent months.

It reminded doctors that where ICU resources are limited because of increased demand, the continued provision of critical care will be "subject to the regular assessment of the patient's response to the treatment".

"Each patient is different; their clinical status and care needs should be evaluated holistically, and interventions provided on a rational, evidence-based and ethical basis."

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Northern Italy was at the epicentre of the coronavirus pandemic earlier this year

Northern Italy was at the epicentre of the coronavirus pandemic earlier this year

Northern Italy was at the epicentre of the coronavirus pandemic earlier this year

The Medical Council has meanwhile reissued its pandemic advice that doctors may have to perform duties outside of their current scope of practice.

Doctors are once again having to prepare for difficult decisions over who gets treatment as resources dwindle.

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There are 282 intensive care beds across the system with the capacity to increase to 350 intensive care beds. But in a worst-case scenario painted by the HSE, an estimated 400 critically ill Covid patients may need an ICU bed by mid-January.

At one point on Friday, there were only 21 intensive care beds available across the country and none were available in 13 hospitals.

Health officials hope case numbers and the numbers requiring hospital admission will start peaking towards the end of this week.

But the drain on intensive care beds is likely to drag on. It can take some time for Covid-19 conditions to deteriorate to a point where the patient requires an ICU bed and once there, the average stay can be up to 14 days.

Most hospitals already have modified ward space from the first wave where they can treat patients on ventilators outside of the ICU.

But Dr Colm Henry, chief clinical officer with the HSE, said last week that treating patients in need of ICU outside of the ICU setting is not desirable. He suggested that if the numbers of patients in ICU exceeded 350, that "staff will do what they can and try to make the maximum use of resources for those ... most likely to benefit."

On Wednesday, HSE chief executive Paul Reid said 2,500 people could be hospitalised with Covid-19 by mid-January.

This weekend the numbers are shy of those worst-case scenarios but they are climbing steadily. By 8pm on Friday night, 1,214 people were in hospital with Covid-19.

Cork University Hospital shouldered the burden of admissions with 118 patients. There were 96 patients with Covid at University Hospital Limerick, followed by 94 at Beaumont hospital in Dublin.

Hospitals are working around the clock to free up space for patients being admitted with Covid. Most already created extra capacity where they can treat patients on ventilators outside of the ICU. There are 1,800 ventilators across the healthcare system. But as Dr Henry said, treating patients outside of ICU is not desirable.

The Mater hospital in Dublin has allocated 200 beds, including ICU beds, in the 700-bed hospital for Covid-19 patients. The figure is considerably higher than in the first wave of the pandemic when the number of Covid-19 patients in the hospital at any one time was 120.

Alan Sharp, the chief executive of the Mater hospital, said that 200 is a "daunting number". If numbers go beyond that, the hospital teams will simply "reconfigure again", he said.

"There is a limited number of beds in hospitals and you will get to a point where the hospitals will get overrun. That is the concern that I hear being communicated out by the health leaders in this country," he said.

"We are coping but we are concerned. At the moment, for us the numbers are manageable. We have moved a lot of our elective activity into the private hospitals."

The biggest issue for the hospital is balancing routine care for emergencies such as strokes or cardiac problems with Covid-19 patients. There are 36 ICU and 12 cardio ICU beds - bringing the total close to 50 but as of Thursday, 39 were occupied across both, mostly with non-Covid cases.

In the A&E department, the number of very sick patients attending on a daily basis has been steadily increasing too. The numbers had been averaging eight to 12 in the early part of last week before rising to 16 on Wednesday.

Shocking

Dr Catherine McGorrian, an acute physician and cardiologist and the Mater's clinical director for emergency and speciality medicine, said: "The increase that we're seeing even over the last week is certainly very shocking. We anticipated that there would be an increase in cases, but the scale was unexpected."

Despite these numbers, she added that it is "really important for people to know that the hospital is absolutely open for people with other non Covid-19 health concerns."

The pressure on public hospitals will be marginally eased by a deal the HSE has agreed with 16 private hospitals to take cases. The deal, announced by Health Minister Stephen Donnelly, on Friday will see private hospitals provide up to 30pc of their capacity for public work.

This latest surge presents other worries for hospital workers beyond capacity.

For those working on the frontline, in emergency departments and on Covid-19 wards, the new strains of the virus identified by the National Virus Reference Laboratory are a worry, health sources say.

A UK-identified strain of the virus, that has been credited with an explosion of cases in that country, was identified in around 20pc of samples in Ireland.

On Friday it emerged that three cases of the highly transmissible South African strain of the virus were also confirmed here. Dr Cillian De Gascun, director of the National Virus Reference Laboratory at UCD, said the South African variant was a big concern.

Around 2,500 hospital workers are currently off work because they are sick or self-isolating due to Covid-19

The Irish Nurses and Midwives Organisation (INMO) has called on the HSE to implement new "critical emergency" protocols for the oncoming surge and the chronic staff shortages that are further disabling the health service. It is demanding plans that would reduce footfall in hospitals, ensure additional PPE and for senior managers to be on the ground.

"It is time for the HSE to ramp up safety plans and introduce critical emergency protocols," INMO general secretary Phil Ní Sheaghdha said.

"We have safety protocols that have been tweaked since March last year - the level of pandemic we face now means many need a total overhaul or serious upgrade."

Hospitals and staff are braced for what is to come but some believe there is still room for optimism.

"For me, the key to protecting the hospitals comes from the community. It will all stem from how the public follows the public health advice and adheres to the restrictions," said Alan Sharp.

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