A load-shedding ‘must read’ for hospital CEOs

Just what’s in store for patients and those entrusted with their care – and how to mitigate the life-threatening scenario emerging from Eskom’s escalated load shedding, can be gleaned from similar global experiences. Here?Chris Bateman of AxessHealth, gives us a glimpse of what to expect should SA’s power supply continue to deteriorate and the figure of 18% of State hospitals currently exempt from load shedding does not rapidly increase within the current two-year plan to convert the most vulnerable among them to solar power. Doctors and hospital CEOs, still suffering from the moral injuries of the Covid pandemic, are slowly realising that it may once again be left up to them to handle an untenable situation, with privileged politicians seemingly immune from any social crisis and ever ready to lay the blame for patient deaths and suffering at their door.

A literature review of just how load shedding impacts healthcare in South Africa backed by dramatic global data on power-outage-induced deaths is almost certain to turbocharge efforts to mitigate the growing local crisis.

The sobering appraisal published in the SA Medical Journal, reports a 23% rise in both accidental and non-accidental deaths in New York during or shortly after mass power outages in 2003. In Ghana, for every day with a power outage lasting longer than two hours, hospital mortality was estimated to have increased by 43%.

In a 2017 survey of developed countries4 SA was ranked last on efficiency in healthcare-related expenditure, underscoring alarmed power outage-related comments made to Medbrief Africa by physicians in the context of woeful state healthcare, aggravated recently by Covid.

The reality of a total blackout

One leading Western Cape bariatric surgeon, Dr Wimpie Odendaal, (Blaauwberg Netcare), expressed concern at what a total blackout might mean for keeping patients alive.

“It was a revelation for me at a recent hospital meeting when they mentioned this blackout possibility. We’d run for three to five days, keeping people alive on ventilators, and then it would no longer be normal functioning, even with our four generators running all the time. The potential for doctors in the private sector unable to care for their patients and not able to generate an income is very real. Surely, somewhere people are going to say, how are we reimbursed for these losses in lives and income?”

Diesel costs, (excluding generator maintenance and repair), alone range from R1 million per annum for a single deep rural district hospital (Madwaleni in the Eastern Cape) to run two generators, to many millions per annum for a sophisticated private urban hospital.

Multiple, varied impacts

The SAMJ literature review predicts increased patient loads as people start using unsafe sources of energy (paraffin, gas, petrol, wood, and plastic), fast deteriorating hygiene and infection control (including through poorly maintained and flood-and power loss impacted sewage systems), an increase in foodborne diseases, plus compromised hospital temperature control, sterilisation of equipment and UV light sources. Also jeopardised would be the cold storage of products, medicines, and bodies, resulting in mortuary problems with burial delays, faulty critical devices and backup batteries, forced manual intervention, aggravating staff shortages, and compromising the mental health of hard-pressed healthcare workers.

Immobilized hospital elevators would restrict the movement of patients and staff while diagnostic services would be hard hit, including the complete loss of radiological and pathological amenities.

Communications and administrative services would be imperilled while hospital pharmacies using electronic scripting and dispensing would see increased backlogs in medical scripts.

Recommendations

The authors recommend widespread UPS installation, adequate non-perishable foods, a load shedding roster to activate additional clinical and administrative staff when required, and point-of-care ultrasound and lab testing as alternatives to formal radiology and lab services.

They advise hospitals to connect sensitive and life-sustaining devices to “red” electrical power outlets capable of automatically switching between municipal and emergency generator power circuits, plus ensuring adequate fuel reserves (within cost limitations and shelf life of six to 12 months).

Wind and solar power alternatives are strongly recommended as is the consideration of biomimicry architecture and multi-story ramps when designing new facilities.

Load shedding action plans and regular drills to test backup power sources are proposed as a priority, while extra oxygen cylinders with regulators, bag valve masks resuscitators, oxygen tubing, portable pulse oximeters, manual sphygmomanometers and extra blankets per high dependency bed are regarded as essential.

The authors recommend establishing community-based shelters where tech-dependent patients can access adequate power supply for continuation of medical care.

Devising crisis plans long after the fact

Dr Mvuyisi Mzukwa, Chairperson of the SA Medical Association, (SAMA) accused Health Minister Dr Joe Paahla of tardiness in addressing the hospital load shedding crisis.

“He says they’re still going to engage with Treasury and municipalities. At this point you should be telling us what’s already done, sharing your plan – not being futuristic about something so crucial.”

Mzukwa said extracting data on how many patients have already died or been affected by load-shedding would be difficult in such a secretive current political environment.

“Believe you me, people have died, but that information will be hidden, and nobody will be allowed to speak about this, even our members on the ground. We all saw what happened to Dr Tim de Maayer at Rahima Moosa Hospital when he blew the whistle on the state of public hospitals” he added.

Dr Caroline Corbett, President of the SA Anesthesiologists Association, SASA, said regardless of Eskom load shedding, rural areas suffered regular power outages due to cable theft and sub-station malfunction. This compromised patient care and resulted in patients overwhelming major hospitals.

‘The major hospitals like Rahima Moosa and Bara or Charlotte Maxeke are under-resourced and poorly maintained, so the power crisis has a massive knock-on effect. For us in private, we’re losing equipment and running batteries flat – a four-hour power loss with delayed cross-over is the absolute maximum our batteries can tolerate. The safety net is full of holes,” she asserted.

Continued resilience ‘expected’

Corbett said the mental wellness of healthcare workers was a major issue.

“It’s exhausting. Burnout is not a good word. It’s the expectation of continued resilience that’s so unfair. We’re tired of being thanked and rewarded, we want to see actual change, and impactful decision-making at grassroots level. Less gratitude and more action. Doctors have become the masters of frugal innovation, pulling together as a team to hold together failing systems – it’s what we’re bred to do.”

She said some staffers were forced to shower when they got to work because the water pumps on their peri-urban plots were without electricity, while others arrived late because of power outage-impacted traffic jams.

“There’s a continuous decay of every system and you’re not considered valuable enough as a health system to even come before a minister or cabinet member. There’s a hierarchy that should not exist. We’ve got our priorities back to front.”

Surgical case study

She cited the case of a semi-deaf young child she anaesthetised for the surgical implantation and testing of a hearing device. The operation was scheduled to fall between power outages, but load shedding suddenly escalated from Stage Three to Stage Six at the most delicate part of the operation, forcing them to abandon the procedure, revive the child and reschedule. The sensitive testing equipment was badly damaged.

“You cannot imagine the anxiety of a family or individual not knowing whether their surgery will take place safely or how long they’ll have to wait. To even consent to such surgery is devastating and deplorable. But they’re desperate and have been waiting so long that they’re prepared to risk it,’ she said.

Even before the currently ramped-up load-shedding, by October last year, there were 3 029 patients awaiting surgery at Sebokeng Hospital in Emfuleni alone. Statistics extracted during a Gauteng government legislative session last year reveal that 2 250 cataract patients waited for nine months for surgery, 544 patients waited three years for hip and knee-joint surgery, 133 urology patients waited for nine months for treatment, and 52 orthopaedics patients waited for two months for medical attention.

Health Minister Dr Joe Paahla recently admitted that generators could not meet increasing demands during loadshedding in health facilities, leaving some hospitals with no choice but to switch off some critical areas and compromising patient care

Paahla puts the backlog on elective surgeries in the public sector at between 170 000 and 180 000 cases.

He said the criteria for hospital load shedding exemption includes patient volumes, the nature of specialised services and the technological and medical equipment they have.

?Citations

A E Laher, B J van Aardt, A D Craythorne, M van Welie, D M Malinga, S Madi.?SA Med Journ; Vol 109, No 12 (2019); ‘Getting out of the dark’: Implications of load shedding on healthcare in South Africa and strategies to enhance preparedness, Department of Emergency Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.

?Anderson GB, Bell ML. Lights out: Impact of the August 2003 power outage on mortality in New York, NY.?Epidemiology 2012;23(2):189-193.?https://doi.org/10.1097/EDE.0b013e318245c61c

Apenteng BA, Opoku ST, Ansong D, Akowuah EA, Afriyie-Gyawu E. The effect of power outages on in-facility mortality in healthcare facilities: Evidence from Ghana.?Glob Public Health 2018;13(5):545-555.?https://doi.org/10.1080/17441692.2016.1217031

Groenewald Y. South Africa last in healthcare efficiency study.?Fin24, 9 June 2017.?https://www.fin24.com/Economy/south-africa-last-in-healthcare-efficiency-study-20170609.