Ministerial Statement by Dr Janil Puthucheary, Senior Minister of State, Ministry of Health, on Update on ICU and Hospital Capacity, 1 November 2021

1.     Mr Speaker, may I have your permission to deliver this Statement on behalf of the Minister for Health?
2.     Thank you, Sir. From today’s order paper I will address Oral Questions 1 through to 10 and Written Question 40, as well as questions filed by Ms He Ting Ru, Assoc Prof Jamus Lim, Mr Liang Eng Hwa, Mr Leong Mun Wai, Ms Mariam Jaafar, as well as Mr Murali Pillai for future sittings. Members may wish to withdraw the questions filed for future sittings if they have had their questions addressed.

3.     Sir, it has been five weeks since we entered the Stabilisation Phase. We had tightened restrictions to slow the growth in the number of cases, and to further expand and stabilise our healthcare system. I would like to explain to the House the current situation in the Intensive Care Units (ICUs) and Hospitals, and address questions about deaths and severe cases from COVID-19. I have been meeting the clinical teams that run the ICUs, visiting them on site to go through operational details, and speaking to their staff to understand the challenges they face. These discussions, and the insights shared, are vital in helping us plan ahead, should infection rates climb and severe cases increase.

4.     As of yesterday, we have 1,672 COVID-19 patients admitted into our acute hospitals, and they take up about 18% of hospital beds in our acute public hospitals. The occupancy rate of all our general ward beds is currently at 90%. For isolation beds it is now at 85%.

5.     Of the COVID-19 patients who are hospitalised, the more serious cases will need oxygen supplementation. This number of cases continues to increase, with 284 cases currently needing oxygen support in the general wards.

6.     The most serious cases need ICU care. The proportion of COVID-19 cases requiring ICU care is at about 0.3% today. Even though this is still only a small proportion, it translates into a large absolute number of ICU patients when the case numbers are high, and will place a serious strain on our ICU capacity.

7.     There are currently 130 patients who are critically ill, in the ICU. Some are intubated and require a mechanical ventilator. All of these patients require the continuous care of the ICU team. They occupy around 60% of the 219 ICU beds currently reserved for COVID-19 patients. These patients stay for an average of 11 to 15 days in the ICU, and some stay for up to a month in the ICU.

8.     Besides COVID-19 cases, there are also non-COVID-19 patients with life-threatening medical conditions who require ICU care, adding to the sustained load that our hospitals have to bear. Our public hospitals currently operate about 163 adult ICU beds for these patients, with an average occupancy of close to 80%.

9.     In comparison, in 2019, before COVID-19 struck, we had 298 adult ICU beds, and the average occupancy rate was 63%. So we have been reducing the non-COVID-19 ICU beds, in order to cope with more COVID-19 patients. This is one of the key trade-offs when we increase the number of COVID-19 ICU beds.

10.     We have had to increase the total number of ICU beds to 382 for both COVID-19 and non-COVID-19 patients over the past two months. The need to increase the capacity of our healthcare system is a heavy burden carried by the staff, our healthcare workers.

The State of our Healthcare Workers
11.     Already, our hospitals are feeling the manpower crunch. Signs of fatigue can be seen amongst our healthcare workers. It has been over 20 months of continuous daily battle against the pandemic. A large proportion of our healthcare workers have not had the opportunity to take leave since 2020, and over 90% of them will not be able to clear their accumulated leave for 2021. This is clearly a much higher proportion compared to the past two years. Our healthcare workers have gone and continue to go way beyond the call of duty to care for their patients. The hospitals are trying to minimise having staff work overtime. For the month of September, our nurses worked for an average of 160 to 175 hours per month.

12.     I received a WhatsApp message from a senior member of the clinical teams: “We are getting increasingly stretched, overworked and fatigued. We are armed up... We are uncertain how long we can keep this up. Morale is slipping.” Another colleague sent this: “It feels like what started as a 2.4k run became a marathon, and just as we are reaching the finishing line, we have to run a second marathon. Our people are exhausted physically, mentally, emotionally – whether they will admit it or not.” I know this person as a professional colleague. Their roles to look after ICU patients also extend to looking after their staff and managing their teams, making sure that people are in the position to perform to their best. So words like this, I take it very very seriously.

13.     It is therefore not surprising to find resignation rates going up this year. About 1,500 healthcare workers have resigned in the first half of 2021, compared to about 2,000 annually pre-pandemic. Foreign healthcare workers have also resigned in bigger numbers, especially when they are unable to travel to see their families back home. Close to 500 foreign doctors and nurses have resigned in the first half of 2021, as compared to around 500 in the whole of 2020 and around 600 in 2019. About double the usual rate. These resignations were mostly tendered for personal reasons, for migration, or moving back to their home countries.

14.     But it is also in such trying circumstances that we find stories of inspiration, stories of commitment to public service. On a recent visit to a COVID-19 ICU, I met a nurse who had been redeployed from her usual job in the Orthopaedic Department into the COVID-19 ICU. She had had a short training and orientation course, and then subsequently on-the-job training from her ICU colleagues. She is senior, a Nurse Clinician, and an Advanced Practice Nurse, with many decades in public service. Although it is a challenge to work in a new environment, with a new set of equipment, drugs and protocols, because of her excellent fundamentals and her experience and resolve, she demonstrated confidence and competence in delivering care that ICU patients need.

15.     On the day that I visited, she was looking after her first ever obstetric patient, after many years this is her first obstetric patient, a young lady who had to have her baby delivered prematurely because she had COVID19 and was now needing treatment in the ICU, not in the post-natal ward. An orthopaedic nurse, deployed to a COVID ICU, now looking after an obstetric patient. And there are many others like her, doctors, nurses, therapists, social workers - re-deployed to do what is urgently needed. And despite having to do difficult work in unfamiliar environments they have kept the clinical outcomes excellent, through hard work, professionalism, dedication and resilience.

16.     But this is taking a toll. They are getting tired. They are carrying a burden of care that is sometimes unimaginable. Having to hold a phone for a patient so their family can say their last goodbyes. Holding their patient’s hand, to keep them company, on behalf of the patient’s relatives. They need all the support we can give them.

17.     At MOH, we are redeploying manpower, to serve as healthcare or patient care assistants at our institutions. We are reaching out to more volunteers to join the SG Healthcare Corps and support this important work. We are collaborating with private hospitals to ease some of the load on healthcare workers in our public hospitals. We are stepping up the recruitment of healthcare workers from overseas.

18.     Our public healthcare institutions have also stepped up their outreach to staff to support them through measures to safeguard their well-being. This includes providing counselling services, staff helplines, and peer support programmes.

19.     To Dr Tan Wu Meng’s question about hospital departments factoring in sick leave as one of the indicators of work performance, there have previously been isolated incidents, but this practice has ceased. Healthcare workers who are concerned about the way sick leave affects their performance appraisals can approach their union, MOM or MOH for assistance.

Hospital and ICU Capacity
20.     Besides addressing the issues of manpower, we have also been working with public, community and private hospitals to set aside more beds for COVID-19 patients. We have also stood up COVID-19 Treatment Facilities (CTFs), which have close to 2,000 beds with an occupancy of 50% or less. We are continuing to add further capacity to our CTFs, with a view to reach around 4,000 beds in November.

21.     We will expand our ICU capacity further, in preparation for a potential rise in severe cases. We are currently working with our hospitals to ramp up from 219 to 280 ICU beds for COVID-19 patients. These can be ready this week. If needed, our next expansion will be to 350 beds. We have been repurposing existing hospital wards, such as single rooms and isolation rooms, into additional ICU beds. We have been augmenting ICU manpower by deploying previously trained ICU staff to help with patient care. Non-ICU staff have also been brought in as I described earlier, and they work under the supervision of ICU trained staff. The shift pattern of nurses may have to be adjusted in order to cater to these needs, and this has already started to happen in some hospitals. At the same time, we are also asking the private hospitals to set aside ICU beds to assist in managing both COVID-19 and non-COVID-19 patients who are critically ill.

22.     Increasing ICU beds takes time, and it affects regular hospital operations. 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.

23.     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 ICU duties. Any redeployed staff or new hires also have to undergo training to operate specialised equipment and medical devices in the ICU to care for their COVID-19 patients.

24.     Logistically, we can keep stepping up our ICU beds. We have ventilators, equipment, consumables, all the things that are needed. But not enough people. As a result, if we keep increasing beds, we stretch and stretch our healthcare workers. We will come to the point that they will no longer be able to provide that continuous excellent care. Our nurse-to-patient ratio will also be lower, which means each nurse will have to take care of more patients than they do today. In a normal ICU, peacetime, pre-COVID, one nurse looks after 1 or 2 patients. If she has to look after 4, she will not have enough hands or time, to provide the same level of care.

25.     There will come a point where even as the Healthcare professionals are doing their best, trying their hardest, more patients will die.

26.     And this will affect both COVID and non-COVID patients. As more healthcare resources are diverted to support COVID-19 services, our hospitals’ ability to sustain regular non-COVID-19 services will be reduced.

27.     So while we may have plans to step up to certain number of ICU beds, the real situation on the ground, the operational considerations, are not straight forward. We do not want to go anywhere near the theoretically possible number. If we do, the situation can easily get out of hand. It will affect the unvaccinated disproportionately, but it will also affect all the rest of us.

28.     MOH has strategies to restrict the number of cases, not only to try to shield our healthcare workers and hospitals from large surges, but also to protect all of us. We will continue to need care for heart disease, diabetes, cancer. We will have accidents and broken bones, and all of these patients, all of us, will need care, comfort and healing.

29.     Our ICU staff have been stretched to their limit in the last two weeks. At its peak, we had 171 COVID-19 cases in the ICU, but the situation has eased a little. Today this has come down to 130. The booster doses have helped in reducing severe illnesses among vaccinated seniors, but the unvaccinated continue to be at risk. This is why we continue to monitor the situation very closely, especially the number of unvaccinated seniors who get infected. Every day, there are about 60 of them, and 6 are likely to end up in the ICU. We need to keep this group as small as possible, to ensure everyone who needs care can receive it.

COVID-19 Deaths and Severe Cases
30.     Thankfully, because of our high vaccination coverage, almost all cases, about 99%, have had no or mild symptoms. We have also managed to keep our fatalities very low. But sadly, we have seen 407 deaths so far. Each death is a tragedy, and a loss felt by the family, the patient’s loved ones, and the care team. Of these, 395 of them passed away in a hospital, 8 at home and 4 at a care facility. The number of deaths has increased in the past two months as the overall number of cases increased.

31.     Seniors who are unvaccinated and have underlying medical conditions are at much greater risk of severe illness and death. Close to 95% of those who died in the last six months were seniors aged 60 and above. 72% of all deceased cases had not been fully vaccinated. Almost all of the remaining 28% who were fully vaccinated, suffered from underlying medical conditions such as high blood pressure, diabetes, cancer, and heart, lung or kidney diseases. Underlying conditions add risks, even if the conditions are well controlled before the patient encounters COVID19, especially if the patient is elderly.

32.     There is not yet conclusive information about the long-term health consequences of COVID-19. An NCID study found that one in ten COVID-19 patients who recovered after the initial infection continued to display symptoms such as coughing or breathlessness 6 months after recovering from the acute illness. A study conducted in the UK found that those who are vaccinated are half as likely to continue having symptoms about a month after COVID-19 infection as compared to those who are unvaccinated.

33.     While most of our cases recover fully from COVID-19, we do see instances of re-infection. Up to mid-August, we had detected 32 re-infected cases, and all of them were unvaccinated.

34.     The risks of being unvaccinated are high. Compared to the vaccinated, someone who is 60 years old and above and unvaccinated, is 6 times more likely to need oxygen, 8 times more likely to become critically ill and need the ICU, and 17 times more likely to die.

35.     So far, we have had one of the lowest fatality rates in the world. At the beginning it was because we had such tight restrictions, rapid contact tracing, and a low total number of cases in the community, but with cases rising fast, the case fatality rate remains low now because we have reached such a high vaccination rate, and because all those who have become sick have been able to receive the care that they need. Our healthcare system is stressed, but it has not been overwhelmed, unlike many countries last year, where patients had to be turned away and doctors had to choose amongst many patients whom to save.

36.     These other countries experienced what is known as excess mortality, as the pandemic spread rapidly through the population and hospitals were overwhelmed. Excess mortality is when a lot more people die in a year than you expect.

37.     We are trying very hard to avoid that. By keeping restrictions tight last year when our population was vulnerable to the disease, and then cautiously opening up after we vaccinated the vast majority of our population. Even then, we have to accept there will be some deaths. Our goal is to make sure that there are no significant excess deaths, as a result of an inability to provide adequate medical care. So far that is something that we have been able to do, and that we want to keep doing.

38.     Up until recently we kept the absolute number of deaths small by ensuring both that few people caught COVID-19 and also that those who were infected got good treatment and care. Now that we have to live with COVID-19, we will continue to protect people from getting infected through vaccination and Safe Management Measures, but this protection is not complete. And that is why much larger numbers will get infected. But we will continue to make sure that those who are infected get good treatment and care, and so keep the death rate from COVID-19 as low as possible. Hence we are doing everything we can to expand our ICU capacity and protect the healthcare system.

39.     These efforts have succeeded – our death rate is 0.2%, compared to 3% or more in countries that experienced a surge in cases before vaccination. This rate of 0.2% is comparable to catching pneumonia, pre-COVID. But it does mean that over time the absolute number of deaths from COVID-19 will rise despite the best possible medical care, and we could perhaps have 2,000 deaths per year from COVID-19. Most of these will be the elderly and those who are already unwell.

40.     In comparison every year, in peacetime, pre-covid, about 4,000 patients pass on as a result of influenza, viral pneumonias, and other respiratory diseases. These are also mostly the elderly and the unwell. That is why we keep emphasising the importance of vaccination and boosters. We must make sure that everyone who is infected with COVID-19 will receive proper medical care by our healthcare workers and hospital system, and be given the best chance to fight the disease.

Conclusion
41.     We have got to this point in our fight against COVID19 without excess mortality. We have managed to continue to provide excellent healthcare for all COVID-19 and non-COVID-19 patients. I am extremely proud of my colleagues, co-workers and friends who man the wards, clinics, and many other sites where they perform their duties. And we should place a high value on maintaining this standard.

42.     What we are trying to do has not yet been done by any other country. We are trying to get to the point where the combination of high vaccination rates, booster jabs and even more boosting from mild infections means that COVID 19 will no longer spread as an epidemic in Singapore. And we are trying to get there without excess mortality – in other words, though we will have fatalities as a result of COVID-19, we will not see more overall deaths that we would in a normal non-COVID year. Nearly every other country that has arrived at that destination has paid a high price, in lives.

43.     I hope my explanation has helped members understand why although we say we are living with COVID-19, we cannot just open up, and risk having the number of cases shoot up. Because more and more cases will translate into more and more ICU beds used, and beyond a certain point that will force us to accept a lower standard of care, and hence have more deaths that could have been prevented. Despite our best efforts events may overtake us, and we may have no choice in the matter. If despite our caution, ICU cases rise sharply, we will still do our very best to look after every patient. But at what level of care? I would strongly prefer if we can avoid that dreadful scenario. We need to continue to manage the overall number of cases in our population, even as we continue to increase our hospital capacity.

44.     In all of this there is hope. The main reason why we got to this point in the fight with COVID-19 with such low mortality rates is our people. Across all sectors, everyone has given their all, together with an ongoing commitment to excellence in service.

45.     MOH and the Healthcare teams will continue to train staff, increase beds and expand ICU capacity. My MOH colleagues and I will keep working directly with the ICU directors and clinical leads to help them. They know better than me how to manage their patients, to provide clinical care, but they need support, resources, and policies that allow them to optimise outcomes. We will help to look after them, and their staff.

46.     All of us can continue to play our part. Vaccination remains critical, every single extra person who gets vaccinated makes a difference, to themselves and for all of us. Getting your booster shot as soon as you are eligible makes a difference. Following the Safe Management Measures makes a difference. Regular testing makes a difference. Using the right healthcare resources appropriately makes a difference.

47.     The current situation will not last forever. We will eventually come out of this. Eventually enough of us will be vaccinated or will have been infected, that we will see the case numbers come down and the situation stabilise. But in getting there we should try to keep the number of deaths as low as possible.

48.     That we got to this point, where after nearly two years of fighting a pandemic I can explain our hope to maintain one of the lowest case fatality rates in the world is a small miracle. It did not happen by chance. It happened because Singaporeans stood together, looked out for each other, did their duty, and put the interests of others ahead of their own. And the healthcare workers of Singapore have done all this and much much more, caring for us all.

49.     I received another message from a colleague: “We are one of the few countries in the world where ICU teams don’t have to worry about resources and equipment – very grateful for that. Healthcare workers have given everything in the last two years, we have held ourselves up to the highest standards, we have the lowest mortality in the world. Our people are still pushing on.”

50.     The healthcare workers we are worried about, are also the same healthcare workers who are committed to doing what is needed to look after all their patients. They will do their duty, do their best and try their hardest. Words will never be enough, but I express our gratitude on behalf of this House. Thank you.