Third wave puts Gauteng hospitals
Surpassing previous Covid-19 waves, the third is likely to hit harder, yet there have been no commensurate lockdown restrictions
The Covid-19 third wave has yet to peak as Gauteng takes the brunt of the surge, with some private hospitals nearing capacity and public sector hospitals at 72% bed occupancy — and climbing.
So far 73.6% of all South Africa’s Covid-19 patient admissions are to general wards, while 18.6% of patients are in intensive care units (ICUS) and 7.5% in high care beds, in both sectors.
As of Monday, 21 June, South Africa had 10 114 Covid-19 patients in 656 public and private hospitals, almost all of whom were infected during the third wave. The death toll stood at 59 966. The cold weather, less social distancing and less keeping rooms adequately ventilated, few restrictions on people’s movement and the slow vaccine roll-out have been cited as causes of the surge.
Most provinces are benefiting from the lessons learnt during the first and second waves, mostly regarding the use of bulk oxygen supplies, but also through public and private healthcare sector teamwork. However, this has hardly helped in Gauteng. The province is recording higher infection numbers than in both the first and second waves — and the upward trajectory shows no signs of slowing.
On Sunday, 20 June, Gauteng recorded 8 640 new cases — the highest daily provincial number yet.
Disaster management
Netcare chief executive Dr Richard Friedland said Netcare’s Gauteng hospitals were operating under disaster management protocols.
“Normally a mass casualty situation like a train accident or sports stadium collapse lasts a couple of hours or a day, but this scenario is ongoing. It’s not about preparedness, sufficient staff or enough equipment in either sector. We’ve learnt a huge amount from previous waves, but the sheer numbers now are just overwhelming,” he told the Mail & Guardian.
Friedland said the historic infection trend in Gauteng was broken last Wednesday (16 June) when positive cases accelerated way above the second wave, rising by an additional 63% by early this week. He believes Gauteng’s sheer population (of more than 16-million people) in a small land area and greater recorded mobility than during the first wave are responsible.
“Absent any regulations to curb mobility it’s very concerning,” Friedland said.
The fire at Charlotte Maxeke
Adding to Gauteng’s public sector woes was the decanting of all patients in the 1 066-bed Charlotte Maxeke Johannesburg Academic Hospital to other facilities after a recent fire. An anaesthetist who is usually based at the facility said that the province was failing to acknowledge the “crisis” aggravated by the hospital fire, which overloaded other hospitals — long before the Covid-19 surge.
“The problem at present is that the Johannesburg Fire Department keeps moving the goal posts with new minimum safety requirements like fire doors, and it won’t issue a compliance certificate,” he said.
Only the oncology department at Charlotte Maxeke was due to re-open this week, he said.
Heads of health departments in Gauteng and the lesser-affected Western Cape and Kwazulu-natal said private sector hospitals were taking more Covid-19 patient pressure than state facilities, which they said were currently “coping”.
An infectious diseases specialist at Chris Hani Baragwanath Academic Hospital, who declined to be identified, however, said she and her colleagues were “taking serious strain”.
“I’m on a Whatsapp group with my infectious disease colleagues and it’s true, the private sector guys are under more pressure — but we’re all really busy, everywhere,” the doctor added.
National helicopter view
Giving a national hospital overview, Ramphelane Morewane, the head of the national health department’s hospital and facility readiness sector, said total Covid-19 bed occupancy in public and private hospitals stood at an average of 10 114 people between 16 and 23 June.
Of these, 73.6% of patients were in general wards dedicated to Covid-19 and in no need of ventilators or emergency oxygen. A national dashboard snapshot taken on 19 June showed 1 761 Covid patients to be ICUS and 704 in high care beds nationally, Morewane said.
Staff fatigue fears mount
Gauteng’s health department chief, Dr Freddy Kgongwane, said on Tuesday 22 June that his province was at 72% public sector hospital bed occupancy while experiencing pressure “across all our hospitals”.
He said tertiary hospitals were under greater high care and ICU bed capacity pressure, while the loss of the Charlotte Maxeke Academic Hospital had been “a major discomfort, forcing us to think out of the box and adjust daily”.
Kgongwane described the third wave as a “major challenge due to staff fatigue and potential infections”. His staff was constantly monitoring bed occupancy with 1452 extra beds available in newly constructed field hospitals. Three of these were in Tshwane, he said, one on the West Rand and one in Johannesburg.
The total number of Covid-19 functional beds available in the state healthcare system was 3 496. Kgongwane did not provide their occupancy figures but said nobody had been turned away.
“We’ve adopted a risk-adjusted and demand-informed strategy to make this capacity functional for optimum patient-care outcomes,” he said.
The M&G understands that regular ad hoc meetings were held with private hospital groups to ensure a coordinated approach, especially when it came to patient transfers. Biweekly meetings were held with Afrox to monitor oxygen supplies while there were standing orders for hospitals to use bulk oxygen tanks, not cylinders, except as a last resort.
Kgongwane said if the current surge continued, critical care nurses and healthcare staff would soon be at a premium and pose the biggest potential overall challenge — despite the Sisonke healthcare worker vaccination campaign having reduced infection-related absences.
It’s widely speculated that Gauteng has less natural immunity against the disease because it was not as badly affected by the first and second waves as most other provinces.
KZN and Western Cape
The Western Cape health department head, Dr Keith Cloete, said his previously hard-hit province currently had just 9% of all public sector acute beds occupied by patients diagnosed with Covid-19 and patients under investigation. Excluding patients under investigation, the Western Cape had 558 Covid-19 patients in public hospitals and 778 in private hospitals.
“We’re at 1 000 new infections
per day currently [21 to 25 June], which is 200 more than where we were when the second surge was on the upswing in the second week of November last year,” he said.
The Western Cape’s Metro hospitals had an average occupancy rate of 94%, the George drainage area 69%; the Paarl drainage area 81%, and the Worcester drainage area’s occupancy rate was 70%, Cloete said.
His province had 10 000 active cases recorded by 21 June, with a reproductive number of 1.5 of every 10 cases producing 15 new cases — the highest day-on-day reproductive rate growth experienced in both the first and second infection waves.
The Western Cape’s Covid-19 supplementary amenities, which included separate facilities or repurposed hospital beds, were: Brackengate (55 of 338 beds occupied), Mitchells Plain (200 unoccupied beds) and Lentegeur (18 of 120 beds occupied), he said.
Cloete said it was “critical” to have viable oxygen points at every bedside. “You need massive tanks to ensure that. You can’t use cylinders.”
Working with Afrox and private sector hospitals, his department put a new system to the test between Christmas and New Year.
“We use a daily dashboard of bed occupancy and oxygen usage and know exactly how many tonnes are needed per day and where,” he said.
He said his colleagues in the private sector knew from their colleagues that this situation did not pertain in many other provinces. Every health district in the Western Cape had a joint operating agreement embracing all relevant role-players, with the head office monitoring a cyber-dashboard to ensure an equal patient load and that “no single hospital is incapacitated over another”.
Dr Wayne Smith, the Western Cape’s disaster management chief, warned that Eskom power outages posed a potential danger to patients on high-flow nasal oxygen machines, as these had to be reset manually whenever back-up generators kicked in. There had been no adverse incidents so far, mainly because his team worked intimately with both Eskom and City Power to prevent power cuts to hospitals.
The Western Cape has spearheaded an innovative patient transport
system using a fleet of specially risk-vetted so-called Red Dot taxis for use on an “Uber taxi” basis. The taxis transport patients between facilities or take healthcare workers to and from hospitals and clinics, dramatically freeing up provincial ambulances and buses.
Kwazulu-natal’s health department head Dr Sandile Tshabalala said just 4% of his province’s beds dedicated to Covid-19 were occupied on 21 June, but the fast rise in infections was cause for major concern. Early in June new infections were at “just double digits” per day but by 21 June they were at 500 new cases per day — and rising fast.
“We kept our temporary field hospitals going after the first two waves, and the five extra venues spread across the province gives us 556 extra beds,” he said.
Tshabalala said his biggest headache was getting people who were older than 60 to register for their vaccinations, with just 36 000 of 95 500 eligible elderly KZN residents registered on the electronic vaccine data system by Tuesday.
“I think that the vaccination thrombosis scare and attendant rollout pause really made people fearful — we’re doing our best to get celebrities, traditional leaders and political figures to model getting vaccinated.”
Echoing his colleagues in other provinces, Tshabalala said that most of those admitted to hospital for Covid-19 in his province were in the private sector, estimating this at 80% of all admissions in his province.
“I’m not sure what’s driving it — they might have a lower threshold for admission or different protocols, but I’m just speculating,” he added.
Friedland said he had not seen sector-comparative Covid-19 admission figures but scotched any suggestion that private hospital admission protocols were anything but clinically sound. The heads of health departments in other provinces were unavailable for comment by the deadline.