South Africa: COVID-19 - Seven Lessons From the Western Cape

The COVID-19 epidemic in the Western Cape is at least a few weeks ahead of South Africa's other provinces. As a result, doctors in the province's COVID-19 wards have generally seen more COVID-19 patients over a longer period than their peers in other provinces. The province's designated COVID-19 hospitals have also had more experience in adapting to the unique challenges posed by the pandemic.

On Thursday afternoon, the South African Medical Research Council hosted a webinar on which some leading doctors in the province shared some key lessons from the last few months. We highlight seven that stood out.

1. Work in teams

Working together, both within hospitals, between facilities and across provinces is one of the most important pieces of advice for tackling COVID-19, according to Professor Ivan Joubert, who heads up Critical Care at Groote Schuur Hospital. "I can't state the importance of having teams... and this is not just healthcare workers, we need to make sure hospital and provincial management are actively engaged on those teams and are playing for the team," he said.

In a COVID-19 setting, effectively an emergency setting - rapidly changing and overwhelming, these teams need to make tough decisions around resources and patient care, and quickly.

Dr Helen van der Plas, who works at the private Life Vincent Pallotti Hospital, said that in her facility this need caused the very way health staff communicate to change.

"The key message is to get teams and to get organised. We hold regular outbreak meetings with teams and disseminate information via WhatsApp groups," she said.

While she said that this medium could hold a risk to patient confidentiality, the unprecedented circumstances presented by COVID-19 has meant that the need to change to rapid communication mediums, like WhatsApp, outweighs any potential risks.

She pointed out that social distancing recommendations apply to health staff too - making face-to-face meetings challenging, besides being time-wasting in an environment where there is increasingly little time to make life-saving clinical decisions.

Professor Marc Mendelson, also based at Groote Schuur, said that "teams are very powerful and the benefit of staying with teams is very strong". He said that the pandemic has brought about a sense of comradery amongst staff in facilities that is important to recognise as something positive to have come out of the otherwise disastrous pandemic.

2. Plan for everything you can plan for

Despite the province's high number of confirmed COVID-19 cases and deaths, Joubert describes the Western Cape's response as a "success".

"The biggest success is that we haven't had unfettered chaos in terms of the management of COVID-19. While all systems have been busy... we haven't had scenes like we've seen on the news in New York and Italy with patients laying everywhere and with staff trying to ventilate them in hospital hallways. Why did we achieve this success? We've got a strong provincial critical care network forum, and we spent a lot of time planning what the response would be," he said.

According to him, the results of this thorough planning was communicated incredibly effectively across the province, leading to many if not most facilities knowing exactly what the strategy was.

"This helped everyone on the ground to know... and made sure everyone was playing on the same page," he said.

However, according to Dr Usha Lalla, Tygerberg Hospital's head of ICU, "no matter how much we planned and planned and planned, we were never prepared for the actual onslaught of patients and the daily challenges we had to face and are still facing".

3. Don't ignore mental health - both of staff and of patients.

Joubert said another reason why thorough planning is important, is because it goes some way in alleviating staff anxiety - something which is a major challenge considering this is a new and unprecedented pandemic.

According to Lalla, psychological support for hospital staff is of utmost importance.

"ICU is a difficult place... there is a high rate of burnout [amongst ICU staff] normally... and COVID-19 seems to have intensified this by one thousand," she said.

She said many non-ICU experienced staff have had to be redeployed to ICU settings to manage the crisis, and that this has also created a lot of fear and anxiety for healthcare workers who do not feel confident in these settings.

She said that there "has been a massive impact of COVID-19-related leave... related to fear and anxiety" and not only due to the obvious impact of staff COVID-19 infection.

"It's very important that each ICU managing these patients have dedicated mental and psychological support for all staff - from the cleaners right through to the doctors and nurses. The past three or four months has been challenging and not a fun time," she said.

According to Professor Coenie Koegelenberg, based at Tygerberg Hospital, at any major hospital currently one can "expect up to 40% of nursing staff to be off sick".

Lalla said the mental health impacts of COVID-19 are not limited to healthcare workers - patients are experiencing trauma too.

She explained that the use of high-flow nasal oxygen (HFNO - a form of oxygen therapy that can in many cases be used instead of more invasive and more risky intubation) has led to an unexpected situation.

"Some of these patients are so awake and alert and conscious of what is going on around them. A big problem in ICU is patients are very sick," said Lalla. She said it has been "traumatising" for these patients to "actually see the deterioration of other patients in front of them" and to "witness the illness and constant death", so much so, that many of these unventilated patients have requested to be moved out of ICU and into other wards. "But, unfortunately, because of the limited beds we have, this becomes logistically impossible," she said.

4. Embrace innovation and new approaches

Several experts speaking on the webinar mentioned the benefits of HFNO. Apart from being less invasive and less risky, this form of oxygen therapy can also free up ICU beds as it can be delivered outside of ICU settings. (You can learn more about how HFNO works here.)

Another advantage is that, while ventilation and intubation require a high level of skill, training and experience, HFNO is very easy for staff to use and nurses can be easily trained to manage patients using this option, according to Dr Greg Calligaro, based at Groote Schuur Hospital.

"This is not something new in treating respiratory failure. But, in anticipation of ICU beds being full for months and being overcome by waves of patients needing respiratory support, we started looking at non-invasive means," he said.

However, he warned that this therapy requires an incredibly high volume of oxygen supply that is out of reach of many hospitals. Additionally, he said that while useful and showing increasing success, it is not a substitute for ventilation therapy - only an adjunct - as many patients, the most sick, will still require traditional invasive therapies.

5. Protect our most powerful prevention tool: personal protective equipment (PPE)

Shortages of PPE for staff, most notably face masks, has been a major challenge in the province, according to Lalla. There are supplier issues at play but she also suggested proper procurement planning is a factor as the expected need for these products has far outweighed what it turned out is required. She added that the impact of this is significant because staff need to be kept safe as a matter of priority.

"We underestimated just how much PPE we needed for our large medical staff (not including visiting staff)," she said.

Lalla said that all these staff members "all use PPE" and "because of the rapid turnover amongst registrars, nurses and doctors" a significant stockpile of such equipment should be a priority in any facility.

She added that there have been supplier-side shortages of masks which "has been a major problem", for example, one variant of face mask is completely unavailable in the province, while "there is a shortage of N95 masks currently".

Additional unforeseen issues around PPE have arisen as the pandemic has unfolded.

In one case, Lalla mentioned that her hospital received a sizeable donation of face masks - a welcome gift considering the shortages - but that, on closer inspection, the masks were found to be defunct and useless. She stressed the importance of ensuring the quality of PPE should other facilities receive similar donations.

Head of internal medicine at Tygerberg Hospital, Dr Neshaad Schrueder, mentioned another case where boxes of PPE began going missing in his facility necessitating stricter controls around guarding these stocks.

Lalla's hospital, after a "rigorous process to assess its feasibility", has tried an innovative way to solve mask shortages using a company that decontaminates masks rendering them re-usable.

6. Be ready to rethink how you do COVID/ non-COVID separation in hospitals

At the outset of the response, it was broadly agreed that, in facilities, there would be a distinct COVID-19/ non-COVID-19 divide, when it comes to physical spaces, services as well as health workers - one belonging to the COVID-19 section and the other to the non-COVID-19 area.

Recently, according to Schrueder, Groote Schuur Hospital has done away with this divide - the first of many facilities to do the same, he believes.

"What we are noticing as we go into the peak is more inadvertent COVID-19 cases popping up in non-COVID-19 parts of the system... and it has become increasingly difficult to maintain the split," he said.

He said that while Groote Schuur still maintains separate wards, the staff members are no longer separated into COVID and non-COVID teams. COVID-19 is so widespread every staff member needs to be a COVID-19 staff member.

"What made sense at the start is becoming increasingly irrelevant," he said.

An additional issue with this split is "people thinking they are safe in non-COVID-19 areas. We realised a while ago that this idea endangers people... and they tend to slack on [infection control] rules".

Joubert agreed: "This idea of COVID and non-COVID services is nonsense. There are huge numbers of staff and patients contracting COVID in non-COVID areas," he said.

Additionally, he said that "if you're a doctor and think that COVID won't affect your practice because you're not involved... in ICU or pulmonology, you're wrong," he said. In his facility, for example, even ophthalmologists have been redeployed to assist with COVID-19 patient management.

"The staff at Groote Schuur have been redeployed so dramatically. The vast majority of services are COVID services. The reality is that COVID has rolled through hospitals; there are more COVID areas by a long shot than non-COVID areas," he explained.

7. Compassion and kindness remains essential

While there is undoubtedly a pressing need for physical resources, according to Schrueder, the most important ingredient in this fight are our healthcare workers.

"People are key," he said.

And, as Van der Plas said, to protect people we need to show compassion. "Don't forget to be kind," she said.

Schrueder advised that key ways to protect include a focus on humility and gratitude.

"Humility is important. This is a new disease and we are all trying to get a handle on it. What makes a difference is how we do it. Show humility to juniors and don't be afraid to say you don't know. This will put them at ease as well. It's okay to be uncertain. It's okay to not know. Expressing this releases a lot of tension," he said.

Finally, he said, "express gratitude, say thank you". "We cannot do this without people and people need to feel they are appreciated and acknowledged."

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