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Western Cape doctors make life-and-death decisions as Covid-19 cases soar

Public sector doctors have started to apply strict criteria that may mean some patients won’t be admitted to ICU

21 December 2020 - 18:24 By sipokazi fokazi
As Western Cape hospitals fill up with Covid-19 patients, provincial health authorities have established ethics committees to help doctors make clinical decisions about which patients should be admitted to ICU.
As Western Cape hospitals fill up with Covid-19 patients, provincial health authorities have established ethics committees to help doctors make clinical decisions about which patients should be admitted to ICU.
Image: Esa Alexander

As Covid-19 cases escalate in the Western Cape and hospital beds run out, public sector doctors are forced to make life-and-death decisions — and have started to apply strict criteria that may mean some Covid-19 patients will not be admitted to intensive care units (ICU).

On Sunday, the provincial health department said hospital admissions may be delayed and certain health services may be suspended as the pressure on its scarce health resources mounts. To assist doctors in making decisions about who is eligible for ICU, the department has established ethics committees to support the clinical decision-making.

Department spokesperson Mark van der Heever said factors such as the age of the patient and whether they have comorbidities would be looked at when making these decisions.

“We have a very clear and objective assessment triage tool in ICU where we use certain criteria to evaluate a patient’s condition and whether that patient would benefit being admitted to intensive are. This objective assessment allows clinicians to determine the best possible outcome for a patient,” said van der Heever.

“There are several criteria we look at, age being one of them, but also comorbidities and the condition of the patient. These, as a collective, will have an impact on the assessment and therefore the outcome of the patient for intensive care.

“Both clinical decision-making and access to certain care packages will, by necessity, be different to those experienced in normal day-to-day services — for both Covid-19 and non-Covid-19 patients.”

Van der Heever said Western Cape public hospitals are all taking strain. Metro hospitals are operating at 78% and rural hospitals at 89%. 

Some of the services that will be restricted and postponed include hospital visits, non-urgent outpatient appointments, elective surgery, outreaches from district and regional hospitals.

“Patients who are in hospital but are stable will be discharged for further management at home or at a step-down facility. Patients are urged to only access the emergency centres for emergencies, and non-emergencies are to access health-care services at the nearest clinics,” van der Heever said.

Emergencies that will continue include obstetric surgery, medical emergencies, fracture clinics and eye surgery, which will be available on a limited basis.

“These are unprecedented times globally and require us to take unprecedented actions to support the most vulnerable patients. Senior management fully supports clinicians in this difficult time as their decisions are guided by equity, fairness, dignity and engagement. To further support our teams and the demand for services, an additional 829 dedicated Covid beds have been made available,” said the department.

The department said it was seeing an increase its field hospitals, such as Brackengate, Sonstraal and Freesia ward at Lentegeur psychiatric hospital. Brackengate facility was nearing capacity with a total of 264 admissions by December 17. To lessen the pressure, more intermediate beds will be opened in December.

“To support these facilities, we will be creating an additional 263 beds at Lentegeur and Tygerberg hospitals. We have already started exploring/implementing certain plans to further expand our capacity to deal with the increased demand for hospitalisation. Each option is guided by the availability of suitable infrastructure and staff resources.”

“We have opened 10 additional acute care beds for Covid-19 patients at Tygerberg Hospital today [Monday] and are looking to have the full 263 of additional beds within Lentegeur and Tygerberg hospitals available at the end of December,” said van der Heever.

Meanwhile, Mediclinic said it has cancelled all its non-emergency surgery as its Covid-19 burden in the Western Cape has increased five-fold since the first wave.

Dr Gerrit de Villiers, Mediclinic’s general manager for clinical performance, said the second wave had resulted in a strong demand for care “starting in the Southern Cape and now evolving into the rest of the Western Cape, as well as other areas of the country”.

“Within the Western Cape, it has now become clear that the numbers of patients seeking care within our hospitals has exceeded previous numbers during the first peak, and that the demand in many of our ICU and high-care units has reached capacity. Within the last month, Mediclinic has noted an increase from less than 100 admitted Covid-19 patients, to more than 500 patients within its facilities across the Western Cape, including the Garden Route,” said De Villiers.

“This dramatic increase in numbers within the Western Cape has placed heavy strain on available health-care resources including staff, equipment and available beds to provide intensive treatment for seriously ill patients.”

To manage the growing demand, the private hospital group has increased the number of Covid-19 beds and has reallocated key resources to hotspots.

“We have provided additional training to upskill nursing staff from other units to assist in areas such as ICU and high care. All elective surgery has been cancelled or postponed within the region in an effort to create additional capacity within our facilities,” said De Villiers.