Hungary dangerously close to running out of ICU, ventilation capacities

Coronavirus-related hospitalisations: Where do we stand now?

According to the official report on Tuesday morning, 4,522 people with SARS-CoV-2 were in hospital, with 452 of them on ventilator. It took both numbers 11 days to double. The exponentially growing number of new cases is already making a significant impact on the health care system.

The tables below show how the changes in the number of daily new confirmed COVID-19 cases, hospitalisations and the number of ventilated Covid patients in 2021 and 2020.

In the top chart we compared the figures of 8 November to one, two, three, and four weeks earlier. The bottom chart shows the week-on-week changes. The red cells make it evident that the epidemiological situation has been worsening at a more alarming rate in almost every aspect than in the base period.

Should the virus keep spreading at its current rate, there will be twice as many people in hospital and on ventilator two or three weeks from now. This is also reminiscent of the immense load on hospitals a year ago.

On charts below the 0% line is important. When the curves are under 0% there’s a decline, when they go over 0% it’s an increase. The changes show that the situation in terms of hospitalisations started to worsen after 20 August.

More importantly, when a value is north of 0% but the curve descends, it means an increase at a slowing rate, rather than a decrease. If the curve is above 0% and ascending, it is an increase at an accelerating rate. When we are under 0% and the curve goes lower, it translates into an accelerating decrease, and when it goes up it marks a decelerating decrease.

Where is the end of hospital capacities?

Every ‘2021 vs. 2020’ chart shows the gravity of the current ‘wave’ clearly, but the relation between the above figures and current hospital capacities are also foreboding. The problem is that lacking official figures we can only estimate the top capacity of hospitals, based on various methodologies. Using these estimates we can have at least some idea on the current load on the health care system and about the point where hospitals will no longer be able to cope with the inflow of COVID-19 patients.

1. Number of ventilated patients in hospitals

One of the hints was made by Béla Merkely, rector of Semmelweis Medical University, almost a year ago. He said that the Hungarian healthcare system can effectively care for a total of 1,000 people on ventilators, but more cannot be tended to for an extended period. (Rather unexplainably, a few days later he modified his estimate to between 1,250 and 1,500.)

Since last December, however, changes occurred and were made in the health care system. There was the ‘third wave’ raging and straining hospitals and health care workers. New service rules came into effect in health care on 1 January this year, and vaccination has been mandatory for health care staff since the start of autumn. These factors led to a further erosion of human resources in the sector. Some estimates say several thousand people in health care left their profession. This means that Merkely’s estimate of hospitals having the capacity to tend to 1,000 patients in critical condition may no longer hold. In reality, the top capacity could be closer to 900 or less.

Now, let’s see how we stand currently compared to this number we have just established. According to the latest official report, there were 452 people with coronavirus infection on ventilator (on Monday evening), but let’s not forget that patients with various other diseases are also in critical condition and need mechanical ventilation. In ‘peace times’ there are generally 150 to 200 of them, and we use the same number for our estimates now.

In a worse-case scenario, there are about 650 patients on ventilator currently. This implies that 72% of the maximum load capacity of the Hungarian health care system has been reached as of 8 November. It is a huge red flag, though, that even as recently as last Friday, this ratio was only about 66%.

2. Number of ICU beds

The other approach is to determine the maximum number of patients that can be effectively treated in intensive care units. We presented estimates in this regard in the spring but new official data have been released since then on the implications of the pandemic peak in March and April on hospitals.

Note that there are always more patients in ICUs than on ventilator even when there’s no global pandemic, as not everyone in critical condition has problems breathing. Authorities, however, do not disclose data on ICU usage; they only say in the daily reports (that are not published on weekends) how many COVID-19 patients were on ventilator.

The National Health Insurance Fund (NEAK) does publish, even if with quite a delay, statistics on in-patient care in a monthly breakdown. This way we can see how hospital bed capacity was used during the peaks of the previous ‘waves. These fundamental processes are depicted on the graph below.

The columns show that last autumn, in the second ‘wave’ of the coronavirus pandemic (with which the current ‘wave’ shows an eerie similarity) ICU bed capacities were increased enough to prevent the system from being overloaded.

Hospitals used 83% of the 1,585 available ICU beds in December 2020, and that was the peak of their load. In the ‘third wave’ raging in the spring of 2021 the health care system was obviously overloaded. By April, the ICU bed capacity was upped to 1,677, while the system showed 1,930 in-patients treated in intensive care units in that month. The ICU bed occupancy rate was over 115% at that time, up from 92% in March.

Considering the deep sea of requiescence the government has submerged into in the summer, the lack of any visible precautionary measure taken in the face of a possible ‘fourth wave’, it is fair to assume that the ceiling of intensive care capacities is around the same level it was in the spring.

The facts we have taken into consideration and the assumptions we have made to conceive an outlook are the following:

• there are 1,677 ICU beds available;
• there are 452 COVID-19 patients currently on ventilator;
• there are 250 to 300 patients in severe condition in the ICUs of Covid wards;
• there are 600 to 620 people with other diseases in ICUs (estimate made from NEAK stats between April and August 2021).

Altogether there must be 1,300 to 1,370 people in ICUs at the moment. Based on this methodology (which is a simplified one and, as such, not the most accurate one), Hungary has reached 78 to 82% of its maximum healthcare capacity, which is not far from what we calculated by the first methodology.

We have pointed out in one of our previous articles that 1,500 to 1,600 ICU beds (the top capacity) can be managed by human resources, as well.

Outlook

We have no way of knowing what epidemic curve and hospital load the cabinet projects for the ‘fourth wave’ of the coronavirus pandemic. Experts have been trying to sound the alarm for some time now, though. Gábor Vattay, head of the Department of Complex Physics at ELTE, warned some 8,000 COVID patients could flood Hungarian hospitals in a few weeks’ time, and daily fatalities could go as high as 150-180 by late November.

Calculating with the current ratios, that situation would imply around 800 COVID-19 patients on ventilator (some 350 more than currently), i.e. there would be more than 1,000 ventilated patients (the assumed top capacity), and there would be more patients in ICUs (1,650 to 1,720). With this the top capacity of the health care system (in terms of ICU beds and personnel) would already be exhausted.

In view of the situation policy makers have several choices if hospital statistics keep deteriorating and the forecasted rate. (The autumn break in schools and the compulsory mask-wearing in public transport as of 1 November might dampen the worsening to some extent, though, but this may be a pipedream from our part.)

One way to go is to expand Covid capacities in hospitals. This is what started a couple of weeks ago. Reassignment of health care staff needs to go hand in hand with this measure. A kind of a last resort tool is the postponement of elective surgeries.

The gravity of the situation is attested unambiguously by the fact that official government portal (koronavirus.gov.hu) has announced on Tuesday that hospitals have added more beds to the treatment of Covid patients, and in order to ease the load on the health care system some hospitals may need to put off elective procedures.

Cover photo: MTI/ Tamás Vasvári