Critical care nurses the key to surviving COVID-19 surge

CRITICAL care nurses – their numbers, pay, conditions, training, and flexibility – are key to Australia coming through the predicted surge in COVID-19 cases relatively unscathed, say experts.

At the beginning of the COVID-19 pandemic, the catchphrase “flatten the curve” became part of the popular lexicon. Australians were told to stay at home to avoid infection and not overwhelm our health care system.

There were concerns about the amount of available critical care beds and ventilators. According to research about intensive care unit (ICU) capacity recently published in the MJA:

“[In March 2020,] a total of 2378 fully staffed ICU beds, configured and equipped to ICU standards, were available, with a maximum surge capacity of 4258 additional ICU beds in a potential disaster scenario. However, the number of available ventilators was insufficient to equip this number of beds, and the need for up to 40 000 additional nurses to staff these beds also made the maximal surge bed number unfeasible.”

Almost 2 years since the start of the COVID-19 pandemic, Australia has acquired more than enough ventilators, with 7196 available, which exceeds the maximum number of ICU beds. We have also overcome multiple outbreaks and now have a double dose vaccination rate of 81.5% of the eligible 16 years and over population.

However, the staffing issues remain.

“ICU capacity can be increased in response to greater demand, but is ultimately constrained by the availability of appropriate staff. Fewer than half the potentially additional physical ICU beds could be opened with currently available staff levels while maintaining pre-pandemic models of care,” Litton and colleagues wrote.

Nursing shortages are not new and have only been exacerbated by the pandemic. Nurse shortages leading to heavy workload and burnout of the existing workforce are of critical concern.

“Ensuring healthy and sustainable staffing models should be a health policy priority, and urgently requires further consideration, both for the short and longer terms,” the authors wrote.

Dr Anthony Holley, one of the study authors and President of the Australian and New Zealand Intensive Care Society, pay could be one area to address, particularly for critical care nurses.

“The problem is the award for all nurses is the same, it doesn’t really specify,” Dr Holley told InSight+. “A critical care nurse would probably earn substantially more by virtue of the overtime and weekend work than the standard nurse performing 8–5 duties. But to some people, that’s not enough of an incentive,” he said.

While doing more to attract nurses to the industry is key, Dr Raymond Raper, Senior ICU Staff Specialist from Royal North Shore Hospital, wrote in an MJA editorial, that we need to find ways to better work with the resources we currently have.

“What are our options should the demand for intensive care exceed supply? Few, it would seem. Recruiting supplementary staff, including re-employing retired nurses, may help. Changes in models of care can increase staff efficiency, but any systematic increase in capacity requires training new staff or upgrading the capabilities of those in related practice areas but with reduced demand during the pandemic.”

Dr Holley said it was important to understand staffing options as state borders open up and international travel resumes.

“One of the concerns would be perhaps that some of the non-metropolitan areas have lower vaccination rates and their facilities might not be sufficient to deal with the patient load,” he said.

It takes 18 months to train a registered nurse to become a critical care nurse. However, if there were to be a surge in coming months, that time frame obviously isn’t ideal.

Dr Holley explained there were several strategies being looked at to increase the supply of critical care nurses if needed.

Recruiting nurses from overseas is being looked at, as is reemploying critical care nurses who have recently retired or gone to another point of employment. The third strategy is repurposing nurses from other disciplines.

“Some disciplines are very closely allied; for example, perioperative nurses, or post-anaesthetic unit care nurses, where they’re used to managing people on ventilators and monitoring. It’s a lesser of a requirement to bring them closer to a critical care nurse standard. But it’s still a challenge,” Dr Holley explained.

Another alternative is to change the model of care.

“We might suggest that you use one critical care nurse to oversee two standard nurses in their practice of critical care. We’re determined to maintain the one-to-one ratio because we know that results in better outcomes. But it might be that we have to use less experienced or less fully trained nurses to be overseen by critical care nurses,” he said.

In this model of care, there could also be a “team approach” to critical care.

“The team approach is when we create teams to be more efficient than they normally are. Because patients can’t turn themselves, they would get pressure sores if they didn’t get turned. And every single day, those patients need to get bathed and cleaned and their teeth brushed. You could use less specialised staff to execute some of those less skilled tasks,” Dr Holley explained.

The fifth option is transferring patients between facilities.

“That’s extremely challenging, and it’s a high-risk evolution for the patient. And it is very resource-demanding and, therefore, you can only really achieve relatively small numbers of transfers,” he said.

The last option is cross-jurisdictional support.

“For example, say the Northern Territory was overwhelmed by COVID-19. Their resources are very finite, in that they don’t have a whole range of intensive care facilities in Darwin. So, under those circumstances, it might be prudent to consider shifting staff from an area that’s less affected. Now that’s going to rely on volunteer work. It’s a complex evolution and may incur a whole lot of restrictions on those individuals,” Dr Holley said.

For the states that are yet to open up, a COVID-19 outbreak may seem daunting. However, Dr Holley said our experiences show we can overcome it.

“New South Wales and Victoria have demonstrated with a lot of fortitude, courage, hard work and commitment that critical care health professionals have been able to deliver and deal with a significant crisis,” he said, “even at a time when vaccination rates were lower.

“It doesn’t say we’re not going to experience a challenge. But it does say that it’s probably doable,” he concluded.

Also online first at the MJA

Editorial: On entering Australia’s third year with COVID‐19
Duckett and Sutton; doi: 10.5694/mja2.51328 … FREE ACCESS permanently.