The second surge: an honest picture
Posted on 25 Jan 2021
Mediclinic’s clinical data gives crucial insight into the challenge we all face in managing the second surge of COVID-19.
“The main difference between these two surges? A more infectious variant. More patients. And yes, a greater number of deaths,” says Dr Kim Faure, Clinical Performance Manager, Clinical Services: Mediclinic Southern Africa, who’s been helping to guide Mediclinic’s in-hospital response to the COVID-19 outbreak as it’s evolved into a full-blown public health crisis.
How is Dr Faure doing this? By carefully collecting, tracking and analysing the data around treatments, best practices and their outcomes. This has placed her in the eye of an ongoing storm: putting in place strategies and structures that help hospitals cope with rising number of positive patients.
It’s a job that has recently become a whole lot harder, she says. “If you look back to mid-July, when we were deep in the first wave, we saw a sharp, sustained rise in cases all over South Africa. It was alarming, but steady. What we’re looking at today is a different kind of crisis. We have a spike that shows exponential spread. Exponential admissions. And it’s a spike that shows no sign of slowing.”
A more infectious variant
Data shows the new variant of COVID-19 is remarkably more infectious than that which first presented in March 2020. It also shows that this new variant affects the body in much the same way, causing a clinical response that can be difficult to manage and challenging to predict.
At the height of the first wave, Mediclinic hospitals faced an influx of around 5 400 new COVID-19 patients over a month. This was a slow and steady increase over 4 months until the peak in July. Now, the same number of admissions has already been reached within the first few weeks of the second surge, which is extremely alarming.
Speed matters, Dr Faure explains. “A slow and steady increase can be predicted and planned for. But this new increase has escalated in a matter of weeks. We’re looking at average occupancy of hospitals going into the 80-99%. When volumes go through the roof like that, it can overwhelm your staff, resources, and equipment. It can overwhelm a whole hospital and impact on patient care.”
Some reassuring news: Dr Faure’s data shows Mediclinic has not yet seen an increase in the mortality rate (deaths as a percentage of admissions) of COVID-19 patients who present to hospital. “There are far more cases, and as a result, more people are dying,” she says. “The impact on the elderly remains significant with more admissions but so far, we can see the mortality rate is unchanged from the first wave.”
In the first wave, the mortality rate of patients admitted to a general ward was at 10%, while just over half of those who were treated in intensive care were discharged after a full recovery. Those ratios are almost unchanged or slightly better for those receiving the most intensive care, according to the latest data, which is updated weekly.
This may mean the doctors and nurses understanding the disease progressive better and adapting their clinical treatment and care protocols for a disease that, to date, has no definitive cure.
It also means that while Mediclinic hospitals face extreme numbers of positive cases, the quality of care remains of a clinically high standard, and that the new variant of the virus – while more infectious – does not seem at this early stage to be deadlier than that which first emerged almost a year ago.
Major strain on resources
“We are seeing extreme volumes,” Dr Faure warns. “What does that mean? It means strain. Strain on staff, resources, and space. Think about that: ventilators, oxygen, nurses. Beds. These are finite. Our hospitals can absorb and accommodate a lot. They can scale up. But there is a limit.”
During the first wave, Mediclinic hospitals had more than sufficient ICU capacity for those already-high numbers of COVID-19 patients who showed signs of severe disease. Now, it is a more fluid process, as staff look to manage growing constraints on the resources available.
Under this unfamiliar strain, Mediclinic hospitals are adjusting triage processes to allocate critical care resources for those patients who may benefit the most from them. In other words, where the triage process may usually indicate a patient is moved from the Emergency Centre directly to intensive care, now, doctors decide on the basis of other prognostic aspects that may indicate their chances of recovery.
“Hypertension, obesity, diabetes – these prevalent comorbidities continue to affect how well people manage or recover from COVID-19, new variant or not,” says Dr Faure. “At the triage stage, we must now take the full clinical presentation of the patient into consideration. We must ask, ‘Is a ventilator going to make a difference here?’” These ethical dilemmas are an unfamiliar situation for the private sector and are causing significant staff and doctor psychological harm and distress with the patient’s family.
Data shows that as a result of considering these prognostic indicators, the patients admitted to high care and ICU are younger, respond faster to the care.
Facing the second surge together: your actions matter
“A prepared healthcare system that is ready and equipped is essential to fighting a pandemic effectively,” says Dr Faure. “If we overburden our hospitals, we compromise our capacity to provide expert care. We run the risk of not being able to receive care.”
The public should understand that their behaviours impact directly on the hospitals ability to provide lifesaving care. Practicing the precautionary protocols designed to mitigate against the spread of COVID-19 – such as wearing a face mask in public spaces, avoiding social gatherings, and practicing rigorous hand hygiene – are more crucial than ever.
“The data gives us a very real picture of not only where we are now but where we are going, if we don’t act. If the situation continues to escalate it can get to a tipping point: with extreme volumes come extreme strain on resources, extreme burnout and fatigue in our staff. Our hospitals might not be able to achieve or guarantee the outcomes we expect and desire.”
The lesson: manage your exposure. Social gatherings over the festive season played a clear and direct role in increasing the number of positive patients currently presenting to hospitals.
Remember these 7 simple steps to prevent the transmission of COVID-19:
1. Wash your hands regularly with soap or an alcohol-based hand sanitiser.
2. Avoid touching your eyes, nose, and mouth with unwashed hands.
3. Avoid close contact with people who are sick.
4. Avoid closed or poorly ventilated areas.
5. Cover your cough or sneeze with a flexed elbow or a tissue, then throw the tissue in the bin.
6. Clean and disinfect frequently touched objects and surfaces.
7. Always wear a face mask when in public spaces, as indicated by regulations.
A data-driven future
Responding to the pandemic has been a learning curve, for both frontline staff in Mediclinic hospitals across Southern Africa and the team of clinical governance specialists who guide them. Data is central to that process, helping Dr Faure and her team to define and disseminate effective, accurate protocols and strategies.
“We collect this data in order to give our patients the best, most up-to-date and effective care,” she explains. “The numbers also contextualise how we are managing these cases. We can see how the virus is being transmitted, and how it affects the body. It is a meticulous process; it is a comprehensive picture. But it’s by no means a complete picture.”
We know more about what treatments have been shown to work for COVID-19 and which are unproven – but we still don’t have a cure.
Mediclinic’s culture of learning has helped nurses and doctors on the frontline adapt to treating waves of patients who present with a new and, in many cases, clinically unpredictable disease. This rapidly evolving learning process has seen doctors and nurses collaborating on care and treatment protocols and working in teams to provide round the clock quality care to all patients, whilst allowing staff to get rest in-between.
This means that patients are cared for by teams of healthcare professionals and not individual doctors. Treatment in some hospitals is being standardized to only those interventions that have shown a proven benefit.
Data is also crucial for governance. “The nurses and doctors are doing everything they can. They’re working their fingers to the bone here. But they need the tools to work smart as well,” says Dr Faure. “As we progress, day to day and from surge to another, we are building a body of knowledge. Using that data to define strategies is how we can help our staff to save lives on the frontline.”