When will ICUs go into 'code black' mode and what does that mean?

PRESSURE: Hospitals in Sydney are expected to be in code black mode from late October to mid November, under modelling produced for the state government.
PRESSURE: Hospitals in Sydney are expected to be in code black mode from late October to mid November, under modelling produced for the state government.

This week the NSW Premier Gladys Berejikilian released the bare bones of a plan for how our healthcare system is going to cope under the growing pressure of COVID-19, particularly in Sydney and its 12 LGAs of concern.

The intensive care demand and capacity modelling, produced by the Burnet Institute for the state government, provides a small piece in the strategic puzzle for how our healthcare system is expected to manage peak demand for services. It has not yet grappled with what that looks like if the state starts to open back up when 70 per cent of the state's population is fully vaccinated.

At that point, health authorities will decide which restrictions may be eased and where. The mantra rolled out at 11am each day is that it comes down to how many people will need to be cared for in hospitals, how many people will need to be in an Intensive Care Unit (ICU) and how many of those will require ventilation.

What is the modelling based on?

The Burnet Institute was asked to provide projections to the NSW government based on the state's case numbers to date, taking into account anticipated vaccine rollout, ongoing lockdowns, and assuming an 18-day average stay in hospital for people requiring hospitalisation. It is based on data available as at August 27, and in the reported scenario, public health restrictions are maintained. The calculations are based on the current rate of hospitalisation of COVID patients of about 11 per cent, as well as the pressure mounting on the NSW Ambulance Service, and the possible need to transfer patients into hospitals further from home.

It also considers the number and proportion of people receiving care in their homes, and underlying/ongoing activity in emergency departments, ICUs, and in hospitals generally.

The key findings

It predicts that, within Sydney's LGAs of concern, cases are expected to continue increasing until mid-September to between 1100 and 2000 cases per day when it is anticipated sufficient vaccine-acquired immunity will kick in. It says a corresponding peak in hospital and ICU utilisation will follow, with between 2200 and 3900 people in the LGAs of concern requiring hospitalisation.

Critically, it suggests the city's health system will go into 'code black' mode in mid-October, when ICU occupancy across the state hits 947. That is a combination of the estimated number of people in ICU for non-COVID related issues (387), plus estimated COVID ICU demand (560) just after a peak in hospitalisations of 3434.

The premier says the state's ICU surge capacity is 1550 beds - way beyond the estimated demand of 947 beds. She has also flagged that this is the time she expects we will reach 70 per cent and start opening up.

What is 'code black'?

The modelling involves a stepped approach, with four steps in a traffic light system from, green to black.

The health system is expected to enter 'code black' mode when the demand for intensive care units beds exceeds 947 patients, sparking the introduction of strategies including the possible ventilation of patients in operating theatres and nurses being asked to supervise more than one patient.

Level 0: Green - Minimal impact on daily operations of ICU- Less than 579 cases per day. The model suggests ICU pressure to move beyond Level 0 by mid-September.

Level 1: Yellow - ICU approaching maximal operational capacity - Moderate impact on daily operations of ICU (between 579 cases and 790 cases in ICU) Transfer of critically ill patients - who may be moved into other areas outside of ICU and may be cared for by non-ICU staff such as anaesthetists or nurses in an operating theatre or recovery area.

Level 2: Red - Severe impact on daily operations of ICU - Overall demand for critical care exceeding ICU operational capacity(791 to 926 cases) At this point, 'care alternative workforce strategies' will mean nurses care for more than one patient in a 'team nursing' approach, perhaps in operating theatres or other unused areas of the hospital.

Level 3: Black - Overwhelming impact on usual daily operations of ICU - demand for critical care services significantly exceeds organisation-wide capacity (more than 926 cases). At this stage, "NSW Pandemic Resource-based decision making" is activated but the details have not been released. It will include greater use of private hospitals, but health officials have said that field hospitals were not part of the plan, except in the worst-case scenario.

The response?

Healthcare professionals have called on the state government to reveal more details of its planned 'roadmap' out of COVID-19 lockdowns, as well as how the healthcare system overall is going to cope, including those in rural and regional areas.

NSW President of the Australian Medical Association Danielle McCullen said on Tuesday there was no detail on what coping with COVID-related demand looks like if the state starts opening up with a vaccination rate of 70 per cent. "The government has released its modelling for ICU demand and capacity, and it has a plan for phased reopening based on vaccination numbers, but where is the plan for non-COVID care?"

Nurses, too, are concerned. Brett Holmes, General Secretary NSW Nurses and Midwives' Association, has said intensive care nurses were calling out, even before this latest wave of COVID-19, for improved staffing in ICU.

This story What does code black mean for our hospitals? first appeared on Newcastle Herald.