Is Ireland seeing the calm before the storm?

  • Dawn O'Shea
  • Univadis Medical News
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Ireland was one of the last countries in Europe to enter the COVID-19 pandemic. The first confirmed case was reported on February 29 – almost two months after the first case was reported in Italy and three months after the virus first emerged in China. This has given the country the advantage of time to prepare for the inevitable pressure on the healthcare system and healthcare professionals, and the tragic loss of life. The government strategy has focused on extensive testing, contact tracing, and social distancing.

The first COVID-19-related death was reported on March 11. The following day, the Taoiseach (Ireland’s prime minister) announced significant measures to tackle the outbreak, including the temporary closure of schools, colleges, and universities. Stricter measures were introduced on March 27, including a stay-at-home campaign urging people to self-isolate in their homes. On April 8, Irish police were given the power to enforce the COVID-19 rules.

Despite the measures, 20,253 COVID-19 cases had been confirmed in the country as of April 28, including 1,190 deaths.

Follow the leader

Another advantage for Ireland is that the Taoiseach, Leo Varadkar, is a general practitioner and comes from a family of healthcare professionals. His father, partner and two sisters all work in healthcare. His medical background has proved to be crucial to the country’s response, introducing measures based on the emerging science. On March 17 - St Patrick’s Day – the Taoiseach somberly addressed the nation, giving assurances that “we will always put your life and your health ahead of any other concern”. But he warned that Ireland was experiencing the “calm before the storm” and there would be dark times ahead, with significant loss of life.

On call for Ireland

Ireland has a national health service funded by the State and a private healthcare system of GPs, specialists and hospitals. The national health service has suffered persistent problems with staff shortages and hospital overcrowding. The pandemic threatens to overwhelm the already struggling health system.

In an effort to address the first problem, the Health Service Executive (HSE) of the national health service launched a campaign to encourage non-practising healthcare staff to re-join the service. The call was targeted at retired professionals and those practising abroad.

The ‘On call for Ireland’ campaign was launched on March 17. By March 23, more than 60,000 had signed up to the campaign. Varadkar was among those who returned to clinical practice to support colleagues on the frontline. He is assisting with triaging patients and carrying out SARS-CoV-2 testing.

The second problem the country faced was ICU bed capacity. The European Centre for Disease Prevention and Control (ECDC) identified Ireland as being at extremely high risk of exceeding ICU capacity. The country has 5.2 ICU beds per 100,000 people, dramatically lower than the European average of 11.5 per 100,000.

By April 8, many of the country’s ICU units were full. To increase capacity, the government struck a deal with the private sector, which recruited private hospitals to operate as public hospitals for a three-month period. Private facilities would be used to see both COVID-19 and other emergency patients. The deal added around 17 per cent extra capacity to the public health system, including 11,000 in-patient beds, 47 ICU and 54 high-dependency beds, as well as 194 ventilators and nine laboratories. The hospitals will be reimbursed for operating costs after the emergency has ended.

As of yet, the additional capacity has not yet been required but there is an acceptance that Ireland is very much in the early days of this pandemic and the situation is precarious.

Nursing homes

While efforts were hurriedly being put in place to curb community transmission, increase testing and in-patient capacity, and recruit additional staff, long-term residential care homes began to emerge as virus hotspots.   

As of April 27, a total of 211 clusters had been reported in nursing homes, with a further 144 outbreaks in other residential facilities. Of the 425 residential care facilities in the country, 75 have been given a status red designation. Almost half of COVID-19 deaths in the country have occurred among nursing home residents.

Speaking to the State broadcaster RTÉ, Dr Jack Lambert, an infectious disease consultant at Dublin’s Mater Hospital, said the focus on acute hospitals meant Ireland "never put together a battle plan for community care facilities". He said the government and HSE have reacted too late to help nursing homes.

Dr Lambert described the spiraling number of COVID-19 cases and deaths in nursing homes as a “huge disaster”.

“I think there was a lack of thought as to what needed to be done to prevent us from being in the same position as Spain and Italy, and unfortunately, we are approaching it, and we need to act quickly,” he warned.

“It’s the number one priority," he said. “We are seeing people [from nursing homes] dying in hospital. We are seeing people dying with suspected COVID-19 in nursing homes, who are not even being counted because they are not being tested.

“It’s a catastrophe in the making and the government needs to get on board and reallocate all under-utilised staff, with strict directions of what they need to do, to every single private and public nursing home in Ireland today,” he said.

Nursing homes have now become the focus of the COVID-19 pandemic in Ireland. As the situation worsens, Dr Colm Henry, Chief Clinical Officer for the HSE, said: “We intend to aggressively test and pursue all suspected cases in nursing home settings and staff. This is the biggest at-risk setting for us at the moment.”

He expressed relief that intensive care units in hospitals did not get the predicted surge in cases, and said: “Clearly, the priority now is to tackle outbreaks in nursing homes, which have become a hazardous environment, with the dangers that presents for patients and staff.”

Where does Ireland stand?

To date, the country has not seen the anticipated surge in ICU demand, possibly because of public social distancing measures, or possibly just blind luck. However, there is still an atmosphere of foreboding. All non-emergent hospital services have been scaled back and the health system will face significant demand for these services if or when the acute phase of the pandemic passes.

Of particular concern at the moment is the low number of patients seeking care for non-COVID-19 emergencies, with a major drop off in attendances at emergency department and GPs. The Chief Medical Officer Dr Tony Holohan issued a public health warning after he arrived at a near-empty emergency room after falling ill at the daily public briefing. He has urged people to continue to seek care for non-COVID-19 health problems.

Existing lockdown measures are in place until May 5. The restrictions will be reviewed at that stage but it is likely that the lockdown will be extended, at least for a few more weeks. The fight continues.

In that memorable address to the national on St Patrick’s Day, the Taoiseach set out the country’s goal for this pandemic. “In years to come let them say of us that when things were at their worst, we were at our best,” he said. It remains to be seen if their best is good enough.

Dawn O'Shea