South Africa: Covid-19 - How Provinces Are Catching Up On Elective Procedures

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As South Africa prepared for the COVID-19 pandemic, hospitals had to come up with plans to deal with the expected influx of COVID-19 patients. Part of this plan was that hospitals would minimise or temporarily put elective procedures on hold to focus on the pandemic.

As hospital visits were limited during lockdown, this meant surgical procedures such as gallbladder removals, cataracts, elective removal of tonsils and elective knee replacements, among others, were put on hold.

Just over 680 000 cases of COVID-19 have been detected in South Africa. But, critically, the rate of new cases and hospitalisations has dropped dramatically from over 10 000 new cases a day a few months ago to about 1 000 a day - with hospitalisation rates having shown similarly dramatic declines. These dwindling numbers have enabled many hospitals to start the catch-up plans to deal with the backlog in surgical procedures.

Yet, many patients like Odette Gioio (61) from Plumstead in the Western Cape, remain anxious.

Gioio says she has an appointment for an endoscope in January 2021. She suffers from ulcers and worries if it will be done at that time.

"I'm so concerned. It is already difficult to wait this long for the surgery. With lockdown, everything slowed down. Now my worry is that there were other patients booked in before me who couldn't get their surgeries done because of the lockdown. This only means that everything has been pushed back for everyone."

Gioio says her condition may not be as serious, but the wait is painful and uncomfortable. "I just have to wait, but each day is a constant worry and my condition is getting worse," she says.

"Due to COVID, almost six months of work has been lost. How will they now prioritise patients? What criteria will be used?" Gioio asks. "In these six months, people's health deteriorated especially for us elderly, and maybe some of them will not be able to wait a little longer," she says.

Four provinces, Western Cape, Gauteng, Limpopo and KwaZulu-Natal shared some of their catch-up plans for elective surgeries with Spotlight.

Western Cape

In the Western Cape, elective procedures started and gradually increased since August. However, hospitals in the province are not back at pre-lockdown levels yet, and operations are still carefully scaled up to ensure continued vigilance to manage COVID-19 exposure.

Spotlight understands staff members who were doing COVID-19-related work, have now returned to their regular work duties at many health facilities.

Chief of operations for the Western Cape Department of Health, Dr Saadiq Kariem, says each department has its own plans depending on the need. "However, in general, surgeries are being slowly re-escalated with the more urgent cases being dealt with first. This will of course vary from department to department, as each department would deal with different types of cases. Departments are re-evaluating the cases needed for surgery and in some cases re-investigating cases as the pathology of the patient's condition might have changed," he says.

Tygerberg Hospital has an estimated backlog of 3 500 surgeries, says Kariem. Groote Schuur Hospital has an estimated backlog of 4 142 surgeries with about 6 948 surgical hours lost during a 20-week (between March and August) period.

To help save lives, Kariem says the most urgent operations will be prioritised and they will use specific criteria for this. "Life-saving surgeries such as cancer surgeries, urgent cardiac surgeries will be prioritised." Kariem says surgeries that improve debilitating conditions, for example, spinal surgery, restoring vision and any urgent surgery that cannot wait or will cause harm if it is postponed, will also be prioritised. Emergency surgeries such as trauma cases will also continue.

Kariem explains that all patients admitted for surgery will be tested for COVID-19 to ensure their safety and that of the staff.

According to Dr Gavin Reagon, chief director for emergency and clinical support services in the department, 4 708 people are on the waiting list to get either a hip or knee replacement. "We perform approximately 600 operations per year. Unfortunately, the need for hip and knee joint replacement operations is so great that every year we add more people to the waiting list than we are able to perform an operation for, and hence the waiting list keeps growing larger every year. We never stopped with the hip and knee joint replacement operations, however, as with other elective operations, we had to scale down significantly. We have performed 110 operations to date during this year," says Reagon.

"We attempt to do more operations but there is insufficient theatre time as available theatre time needs to be distributed to a range of other elective operations and emergency operations. Patients on average wait for three years," he says.

"The data-driven approach that had now been adopted during the COVID pandemic has been instrumental in driving the health platform response," says Kariem. "This approach will be continued while the comprehensive health services are re-introduced onto the clinical service platform. In considering which clinical services should be re-introduced onto the clinical service platform, a risk-based approach will be adopted. This could be in the form of an assessment of the risk of introducing a clinical service in a COVID environment versus the impact that the clinical service will have on health outcomes. A phased approach will be adopted to return the comprehensive health service platform back to a new normal."

Gauteng

In Gauteng, the Chris Hani Baragwanath Hospital has the same challenge of addressing backlogs in elective surgeries. The hospital started on its backlog towards the end of September when it gradually increased elective procedures.

The Gauteng Department of Health in a statement said Baragwanath Hospital, working together with Bheki Mlangeni Hospital, has carried out elective surgeries that were put on hold during the stricter levels of lockdown.

The department cancelled elective surgeries at the start of the national lockdown on 27 March as part of the COVID-19 response. Emergency surgery and essential surgery such as oncology, however, continued during this period.

According to Gauteng Acting MEC for Health, Jacob Mamabolo, facilities will depending on how the pandemic develops, gradually increase the number of surgeries, especially elective cases. "In the last two weeks, 517 surgeries ranging from surgical, urology, cataract to gynae cases have been successfully conducted," Mamabolo said in the statement.

A total of 7 541 elective surgeries were postponed at Baragwanath Hospital. This included 2 880 procedures in the department of Ophthalmology, 1 443 procedures in Orthopaedics, and 1 200 procedures in Paediatric Surgery. The rest of the postponed procedures are split among Neuro-surgery, Maxillofacial and others.

"Given the Alert Level that we are moving into, it becomes important that across our facilities we gradually resume those services that were negatively impacted at the height of the Coronavirus pandemic," Mamabolo said.

"Other facilities will also be catching up on elective surgeries," he said, cautioning that this will be done gradually because the fight against COVID-19 is far from over and they need to work within the parameters of a new normal.

Limpopo

Neil Shikwambana, the spokesperson for the Limpopo Department of Health, told Spotlight the province has already started with outreach to regional hospitals to deal with the surgical backlog for major surgeries which are mainly carried out at Pietersburg-Mankweng Hospital complex.

"We are currently using [a] manual system and we have 12 surgical disciplines. We are unable to quantify the number of operations deferred due to COVID," says Shikwambana. He explains the surgical disciplines with more patients awaiting procedures are Cardiothoracic, ENT (ear, nose and throat) and Ophthalmology. "Cardiothoracic patients [have been] waiting for six months, ENT [for] six months and Ophthalmology three months," he says.

"The hospital never stopped elective procedures during lockdown. We only reduced the numbers in April. The total number of elective procedures done from March to August in all surgical disciplines were 1 119."

Shikwambana explains the Orthopaedics department was operating throughout the COVID-19 pandemic and with the reduced number of trauma cases they could address some of their backlogs. "We have planned outreach programs to deal with the backlog," he says, adding that they have enough capacity to deal with the backlog.

KwaZulu-Natal

In KwaZulu-Natal, the provincial health spokesperson, Ntokozo Maphisa, says the provincial Department of Health is implementing its recovery plan.

All operations and procedures that were postponed as a result of COVID-19 are now gradually increased. "This process cannot be rushed but is being implemented gradually. All emergency operations and procedures have always been ongoing as they were never stopped even during the peak of the pandemic," says Maphisa.

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