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In 2020 there have been announcements of the expansion of critical care capacity across the NHS, while at the same time headlines have detailed stories of hospitals running out of critical care beds. And this week dire warnings have emerged from places such as Manchester that the increase in Covid patients will soon mean there are no spaces left. So do we have enough beds or not? Like so many things in life, it is more complex than it might at first seem.
A critical care bed is so much more than just a bed. To provide critical care requires physical bedspaces with the right infrastructure, equipment and staff – consultants, junior doctors, physiotherapists, nurses, occupational therapists, pharmacists, speech and language therapists, dieticians, clinical psychologists, ward clerks, data analysts and many more. Increasing the number of physical bedspaces, or the amount of available equipment, is the easy part. The staff are what really matter.
To train an intensive care specialist takes years. In the same way that I cannot be redeployed as a surgeon in the event of a mass casualty event, you cannot rapidly turn a surgeon into an ICU specialist. Similarly, you cannot redeploy nurses from general medical or surgical wards to a critical care unit and expect that they will be able to immediately function in this specialist role – it takes years of training.
During the spring of 2020, hundreds of non-critical care staff joined our ranks to support us to expand capacity, but they were not the specialist staff that you would normally meet during a critical care stay. To expand, we stretched the number of critical care staff we have more thinly than usual. We used non-critical care staff to reduce the impact of that stretch where we could. It is important to highlight that we did not magic up whole new batches of nurses and doctors out of thin air: we borrowed them from other clinical services – meaning that clinical services the NHS would normally provide had to be paused, which came with serious consequences such as increasing waiting lists.
To add to the complexity, not all beds are equal – there are different types of critical care bed. Some are designed to provide mechanical ventilation and other advanced organ support such as renal replacement therapy: these beds are often described as providing level 3 care. Some are designed to look after slightly less sick patients who don’t require invasive mechanical ventilation (level 2 care), and some are super-specialist beds able to provide things such as extra-corporeal membrane oxygenation, or care of patients with head injuries or burns. The total number of available critical care beds hides these nuances.
How many critical care beds do we need? In February 2020, there were 4,122 open adult critical care beds in England, 81% of which were occupied. At the peak of the first wave in April 2020, there were 3,100 patients with Covid-19 in English critical care units. Approximately 58% of all available critical care beds in England, including the surge capacity generated at places such as Nightingale hospitals, were occupied by patients with Covid.
At no point in spring 2020 were critical care services in England overwhelmed, when considered as a whole. However, there was extreme pressure on some individual hospitals and areas, which admitted more critically ill patients than they had resources available to safely manage. The inevitable conclusion of these two facts is that the critical care beds and the patients were not in the same places, which often leads to someone posing the simple solution that we should just move the patients to where beds are available. However, transporting a profoundly unwell patient many miles to another critical care unit is not easy, and can be life-threateningly dangerous. Transferring them to another hospital also takes them away from their loved ones.
So, what does all of this mean for the coming winter? The short version is that it is going to be challenging – in places such as Liverpool, it already is. The winter plan is for the NHS to do everything possible to deliver critical care services for Covid without impacting on non-Covid services. On average, over the past decade, there have been 3,400 patients in English critical care units in January. This winter, we will be aiming to provide critical care for patients with Covid in addition to this normal workload.
Although we now have increased amounts of equipment and physical beds, not reducing other clinical services means we will not be able to borrow all the staff we did during the first wave, as they will be needed to keep non-Covid services functioning. In addition, critical care staff are, like lots of people, exhausted – we have spent months working extra hours to deliver an expanded service for the NHS. We are only human, and we share the worries everyone has during the pandemic – we are parents, siblings and children, and our families get sick and need us too. In addition, many critical care workers were traumatised by their experiences of caring for patients with Covid earlier in the year.
The next few months are going to be extraordinarily demanding for critical care. We have good supplies of equipment and well worked-through plans for where we can locate extra bedspaces. However, having sufficient specialist staff to deliver care for our usual number of patients alongside caring for patients with Covid is going to be challenging. As one of my colleagues recently commented, it is not possible to knit new critical care nurses. Otherwise, we’d have done it already.
• Dr Charlotte Summers is a lecturer in intensive care medicine at the University of Cambridge
Source: The Guardian
Keyword: Without enough specialist staff, critical care beds are useless | Hospitals