Increasing Covid-19 ICU beds may lead to poorer care for non-Covid-19 patients

SINGAPORE - The government has been assuring people that should push come to shove, Singapore is able to increase the number of intensive care unit (ICU) beds for Covid-19 patients to 1,000.

It has currently ring-fenced 219 ICU beds for such patients, so it would need to add close to 800 more beds to reach that number.

Many people view this promise as a good thing and feel reassured that the healthcare system here can treat increasing numbers of critically ill Covid-19 patients should such an eventuality arise.

But is it really so?

Having the capability to do so is, of course, good. But needing to actually do so would be highly detrimental to the nation as a whole.

Resources, especially experienced manpower, are finite. Increasing their use in one area means reducing it in another.

Tan Tock Seng Hospital (TTSH), which has been sending staff and equipment to the National Centre for Infectious Diseases (NCID) — Singapore's Covid-19 central — to help ramp up ICU beds there, is forced to close roughly four general ward beds for every additional ICU bed it creates.

There are many factors at work. One is the nurse to patient ratio. In the general ward prior to Covid-19, one nurse would look after four patients. In the ramped up outbreak ICU, it is three nurses to four patients.

Patients requiring intensive care generally spend about two weeks in ICU. Some can be there for more than a month.

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Dr Janil Puthucheary, Senior Minister of State for Health, told Parliament on Monday that public hospitals here have added 90 adult ICU beds during the pandemic.

These beds are for both Covid-19 patients as well as patients with other serious illnesses.

The number of non-Covid-19 patients in ICU has fallen dramatically.

In 2019, he said, there were 298 ICU beds with an average occupancy rate of 63 per cent — that is roughly 188 beds occupied.

Now, there are 163 ICU beds for non-Covid-19 patients, with an average occupancy of 80 per cent — or 130 beds occupied.

That is a 30 per cent drop in ICU bed occupancy by non-Covid-19 patients.

There are various possible explanations for this drop. One is that there are fewer critically ill patients today, so the need for ICU care has fallen. That would be a good thing. But, given Singapore's ageing population, how likely is it that the demand for ICU care is falling?

Another possible reason is that people are postponing non-urgent surgery that might require ICU care. Delaying such care will result in a backlog that will eventually need to be met. Some patients who delay treatment suffer no ill effects while others might end up more sick and require longer rehabilitation.

Aside from those needing intensive care, there are also many Covid-19 patients in isolation wards — 548 beds at the NCID and the Communicable Disease Centre 2, also called Ward 86.

TTSH has beefed up staff there by transferring 1,200 from the main hospital. About half are nurses.

Meanwhile, more healthcare professionals have resigned.

Dr Janil said 1,500 healthcare workers resigned in the first half of this year — compared with 2,000 a year previously. Among them are 500 foreign doctors and nurses.

Losing so many trained professionals has also added to the strain for the rest.

On top of that, some healthcare personnel are needed to help out at Covid-19 treatment facilities, which currently have 2,000 beds, of which half are occupied. Another 2,000 beds are being planned.

Patients at these facilities might only be mildly sick, but they are older and have underlying chronic illnesses that put them at higher risk of getting sicker.

All this has stretched healthcare manpower to the limit. Today, in the general wards, one nurse has to care of five patients, instead of four — which was the norm prior to Covid-19. Many have not been able to take leave for a long time.

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As Dr Janil said: "Converting non-Covid-19 ICU beds for use by Covid-19 patients who need intensive care has a limit, as it diverts resources from non-Covid-19 patients who also need care.

"The most important limit is the manpower required to staff ICU beds. Patients in ICU need trained staff, who must be able to provide individualised care, including round-the-clock monitoring and continuous care.

"So, any increase in ICU bed capacity must be supported by an increase in manpower, which has to be diverted from non-Covid-19 ICU duties."

Adding ICU beds will not just take more medical professionals away from treating non-Covid-19 patients, it will take away the more experienced ones.

Fortunately, the private sector has stepped up, as have medical personnel from the armed forces and recently retired professionals who have returned to the workforce.

Even this additional manpower is not enough to ease the massive strain of large numbers of Covid-19 patients requiring infectious control protocols.

Whatever we can do to reduce the need for more Covid-19 ICU beds will be of great benefit to the nation.

It will not only mean fewer people critically ill with Covid-19, but also translate into much needed care for patients with other serious illnesses.