Peter Spryszynski, Country Manager for Q-bital Healthcare Solutions, looks back at the country’s Covid-19 response over the past 15 months and shares his observations from a healthcare infrastructure provider’s viewpoint.
When many of us think about Covid-19, we think of the pandemic as a single event that started in late 2019 and took hold in most places around the world sometime between February and March 2020 – and has been with us since. However, the health response in terms of physical capacity and infrastructure has varied in rather distinct and identifiable stages and is likely to continue to evolve until the threat is considered over.
Looking at the Covid-19 response from an outsider’s perspective, I suggest there were four rather distinct phases of Covid-19.
Phase 1 – Early Warning
During the early days, just as the World Health Organisation was considering confirming that Covid-19 was indeed a global pandemic, the Australian health response appeared to be early and swift in recognising the potential threat level. Despite this early action, it felt as though there was a delay in commencing preparations for the worst-case scenario; at least that is how it looked to someone on the outside. I suspect the very opposite was true.
Much of Australia was already weary having endured over five months of bush fires, and health services in the most populous quarter of the country were still dealing with the many challenges that such a catastrophe brings.
I don’t think we had yet reached the point of realisation that an immediate emergency response was considered necessary.
Phase 2 – ‘Panic Stations’
Although title of this section is intended to be somewhat sensationalist in nature, there certainly was a sense of a quickening pace in terms of activity in the political and health bureaucratic corridors.
This was brought on by the arrival of what we refer to now as the ‘first wave’, which felt as though it came more abruptly than anticipated. Events like the Ruby Princess did not help matters. As a result, hospitals and health services across Australia scrambled to prepare for as many eventualities as possible.
We saw Canberra Hospital commission a Covid-19 specific ward, while several capital cities were exploring stadiums and exhibition complexes as potential mass treatment and recovery facilities. In some states, like Victoria, recently closed hospitals were revamped. Elsewhere around the country, hospitals ordered refrigerated shipping containers for overflow morgues – some of which, rather confrontingly, remain on their premises to this day.
It is fair to say that the prompt and assertive political intervention in Australia, with closing international borders and reducing hospital case load by cancelling all but the most essential elective surgery, meant that the curve successfully flattened and that much of the additional space in temporary wards and exhibition centres was no longer needed.
Phase 3 – Covid Normal
Across the states, in between the flattening of the first wave and the various localised outbreaks, health services were striving to strike a new balance where hospital capacity, infrastructure and staff resources could be quickly boosted in response to a sudden spike or surge. This meant that some non-essential preventative maintenance was deferred, and some planned facility refurbishment projects were shelved or postponed. Elective surgery resumed in many areas, but only partially.
This had several consequences, which we are starting to see now:
Firstly, from a hospital infrastructure perspective, some of the non-urgent maintenance requirements had evolved into a need for repairs, in many cases resulting in more down time than if the scheduled maintenance had been done when planned. This is not to suggest that deferring was the wrong decision, I believe that history will show that it was indeed the right thing to do, especially given the absence of information about COVID-19 that we have even today versus a year ago.
The second consequence is that it will likely take longer to learn whether the decision to reduce surgical capacity at the height of the pandemic was right. The elective procedure waitlists have blown out, and some patients with disease who had elective procedures and interventions deferred, or who were already on waiting lists before Covid-19 hit our shores, have found the disease has progressed.
Diagnosing later means that disease is more likely to be more advanced. That in turn means therapeutic intervention and treatment may be more complex, leading to a higher burden on operating theatres, and thereby having a net effect of reducing capacity.
Add to this the accumulating backlog, and we can appreciate the ever-present demand on the hospital system to improve waiting times for treatment and surgery. In an effort to address this, some health services have brought in temporary healthcare infrastructure, and this approach is definitively gaining momentum across the country.
For example, a health service in Queensland recently deployed a temporary endoscopy facility to tackle their extensive colonoscopy waiting list. The facility contains two state-of-the-art procedure rooms, an 8-bed recovery ward and a comprehensive decontamination reprocessing facility, meaning the quality of care delivered in the temporary complex can be identical to that delivered in their established endoscopy building.
Elsewhere in the world
Although Covid-19 is a global pandemic and has affected people across every continent in the past year, the impact has not been the same everywhere – and neither have the responses to the challenges healthcare providers have been faced with.
The UK’s NHS is often held up as a strong example of an integrated population-health focussed national healthcare service. The challenges the NHS have been facing are undoubtedly much more acute and severe than Australia has had at the very height of any wave – whether it be our collective first wave, or Victoria’s second wave. The impact on Australian hospitals pale into insignificance compared to what happened across the UK at the height of the pandemic, when there was a shortage of intensive care and high acuity beds in many regions.
Where else in a hospital is the infrastructure needed to deliver high acuity care available? Where else can one find an aseptic space with ready access to medical gasses and suction? The answer was operating theatres.
The NHS, like us, had reduced their surgical caseload to an extent by reducing non-essential procedures, so were able to repurpose some of their operating theatres into quasi-ICU rooms. But some hospitals only have a few operating theatres and they were still required to care for trauma cases and perform critical surgery, so were unable to give up any operating theatre space.
However, temporary facilities were on hand to assist. Suitably designed flexible solutions, such as dedicated mobile operating theatres with the same features as operating rooms inside hospitals, were deployed in a number of locations across the UK. This theatre space could either be repurposed to add high acuity capacity to care for the most ill Covid-19 patients or be used to protect elective capacity, enabling hospitals to continue providing elective surgery despite the additional pressures on the main hospital building.
Phase 4 – Economic Stimulus
In Australia, when the federal and various state budgets were finally handed down, a strong and common theme emerged as our leaders made clear their views on how our economy will climb out of the enormous debt accumulated through the course of the pandemic. Investing in capital works, infrastructure projects and redevelopments as a means of creating jobs, and boosting capability in health, aged care, education, defence, manufacturing and transport are seen as crucial to the country’s recovery.
The acceleration of these investments has meant that hospitals and health services are having to balance the infrastructure stimulus, which inevitably disrupts services, with the pressure to bring down waitlists and catch up on the delays to treatment by keeping all available infrastructure running.
An accepted way to have one’s cake and eat it is to invest in temporary additional capacity; whether it be operating theatres, ward space, sterilisation facilities, endoscopy procedure rooms or allied health clinical consulting rooms. In the United Kingdom, for example, this has been an accepted tool across NHS trusts for over 20 years.
Temporary infrastructure solutions can bring substantial benefits when undertaking infrastructure projects – whether redeveloping space in the hospital or adding new capacity, when catching up on repair and maintenance, and in tackling elective surgery backlogs.
A resilient healthcare system
The impact of Covid-19 in the US and much of Europe has been more severe than in Australia and New Zealand, where the numbers of both confirmed cases and deaths have been significantly lower than in other countries. The UK is a good comparative yardstick. A few decisions were made differently to what we have experienced in Australia, and the outcomes have been very different. This time we got most of our decisions right.
But even so, some elective care was temporarily disrupted across Australia, and the system remains vulnerable to local outbreaks that may occur from time to time.
Despite differences between countries, there are some common observations and potential lessons that can be learned about better modulating health infrastructure capacity. Health services have been trying to strike a balance between keeping as much of the normal throughput going while having enough reserve to cope with a sudden peak in infected patients, but the uncertainty about how the pandemic would develop has made this very difficult.
Recognising that there are many potential rate limiting facets to the problem, such as the availability of clinical staff, the capacity of the hospital ‘support machine’ – think cleaners, laundry, kitchen, patient and family parking – and access to adequate personal protective equipment, there is one aspect that should never be a limitation, and that is interventional and recovery space, and the sterilisation and decontamination facilities that support critical activity.
Global pandemics like the Spanish Flu or COVID-19 are ‘once per 100 year’ events – but so were the 2019 Victorian bushfires and the 2009 Victorian bushfires. Being prepared, and having ready access to surge capacity of beds, ventilators, operating theatres, sterilisation facilities and other hospital infrastructure has been shown to be critical.
The importance of planning
I wonder if there is an argument to be had for governments to have pre-arranged access to critical infrastructure, access to a pool of deployable health capability. It could be used to deploy at speed for additional support in areas prone to natural disasters, or for a localised urgent need, to supplement clinical capacity and enable core services to continue.
Planning early for a range of eventualities means that capacity can be upscaled much more quickly, but also that the pressure on suppliers will not be as great. One does not have to look much further than the global rush for medical ventilators to justify the argument for a proactive disaster contingency provision for when the next inevitable rainy day arrives.
For me, the main observation has been that having access to quality mobile and temporary hospital facilities on demand means that there can be an enormous amount of ‘capacity flex’ in the system, allowing areas with surge demand to be able to respond more decisively and confidently to additional volume demand.
We have seen communities in some states and cities (like Melbourne in the middle of last year) in hard lock down while other cities were able to go about their business almost normally. Should at some point the tables turn where demand for support grows in another part of the country it is a matter of days and a mobile facility can be transported to site, be commissioned promptly resulting in that location immediately having additional capacity to deal with the challenge at hand.
Q-bital Healthcare Solutions