Japanese ICUs understaffed and overlooked as coronavirus influx looms

Intensive care is expected to play a critical role as the coronavirus spreads in Japan, but finite resources and a shortage of specially trained staff in intensive care units have cast doubt upon the country’s ability to withstand a surge in patients.

The nation's health care system may be world class but fully staffed ICUs in the country are few and far between, said Satoru Hashimoto, the director of intensive care medicine at the hospital of the Kyoto Prefectural University of Medicine.

“Intensive care requires endurance and an extremely high level of skill that few people have,” Hashimoto said, adding that ICUs are a burden for hospitals because they’re not profitable and tend to have high employee turnover.

“To put it bluntly, we don’t have enough people.”

The health ministry estimates that Tokyo could see up to 700 patients in need of intensive care every day once the epidemic reaches its peak.

An intensive care unit is a specialized ward that provides treatment and close monitoring for seriously ill patients that can’t be cared for in other parts of the hospital.

In Japan, a single ICU nurse is expected to take care of two patients at all times in accordance with the Medical Care Act, which sets the standard for hospital staffing in the country, putting it behind other Group of Seven nations.

The standard in Germany, for example, is for one nurse to attend to one patient while two nurses are required for every three patients in the U.S. and Canada.

The ICU at Hashimoto’s hospital has 12 beds — six of which are reserved for children — and is well-staffed with each one continuously monitored by one doctor and four nurses.

While nearly all Japanese hospitals have ICUs, Hashimoto said few are staffed well enough to be constantly monitored.

The World Health Organization says about 5 percent of coronavirus patients require intensive care, a small fraction of whom are treated using extracorporeal membrane oxygenation, or ECMO, a resource-intensive but cutting-edge technology used occasionally to remedy serious lung and heart problems.

There are 1,412 ECMO machines in Japan, according to a joint survey released in March by the Japanese Society of Respiratory Care Medicine and the Japan Association of Clinical Engineers. But only about 300 of these machines are available for COVID-19 treatment, Hashimoto said.

The Tokyo Metropolitan Government, meanwhile, said more than 3,000 ventilators are available for coronavirus patients in the capital.

“That’s probably more than enough ventilators but the real question is, how many people know how to use them?” Hashimoto said, explaining that using a ventilator or an ECMO machine is “equal parts science and art” and generally requires a team of doctors to operate.

In some cases, a coronavirus patient with shortness of breath can enter critical condition in the span of a few hours. Radiographic imagery and lung capacity tests produce varied results, making it difficult for doctors or nurses to determine the patient’s condition and therefore what treatment is most appropriate.

Echoing Hashimoto’s concerns, the Japanese Society of Intensive Care Medicine and the Japanese Society of Anesthesiologists issued a joint statement last week, sounding the alarm that a further spread of the virus could trigger a sharp rise in fatalities the likes of which are being witnessed in several countries abroad.

The health ministry is adapting to the situation and plans to increase the number of available ECMO machines in the country to 800. The ministry has called on experts like Hashimoto to provide training for doctors so they can better administer intensive care.

The low number of ICU beds may become a problem if the number of critical coronavirus patients surges in Japan.

According to the JSICM, there are about 29 ICU beds for every 100,000 individuals in Germany and about 12 for the same number of people in Italy. In Japan, there are about five.

Italy had suffered more than 105,000 cases of COVID-19 and an 11.7 percent death rate by the end of March. Germany, on the other hand, saw nearly 72,000 cases but a death rate of just 1.1 percent.

“That disparity comes down to the quality of the intensive care system in each country,” JSICM President Osamu Nishida said in the statement. “The Japanese intensive care system is particularly vulnerable to pandemics.”

The Tokyo Metropolitan Government allocated ¥23.2 billion in the supplementary budget on Monday night, more than ¥19 billion of which will be spent on strengthening the capital’s health care system by providing funding for additional hospital beds, medical staff and the operation of ECMO machines, among other things.

Gov. Yuriko Koike said the capital aims to secure 4,000 hospital beds — 700 for severe patients and 3,300 for mild patients — by the end of June.

The Tokyo Medical Association declared a medical emergency on Monday, just a day before Prime Minister Shinzo Abe declared a monthlong national emergency and Koike asked Tokyo residents to isolate themselves until May 6.

“Ideally the country would have been prepared for this situation but it’s far too late for that discussion,” said Haruo Ozaki, president of the Tokyo Medical Association.

“We’re in a contingency now,” he said. “We have nothing left to do but work together and fight back.”