Doctors reveal what happened when Covid hit Groote Schuur

In the five months after Cape Town’s first two Covid-19 diagnoses, Groote Schuur Hospital became the epicentre of the national fight against the virus and admitted 1,781 patients who tested positive.

Teams were formed, clinical protocols developed, breakthroughs celebrated and processes streamlined. But with patient numbers now declining “the challenge continues”, said 32 front-line doctors who have recorded their experiences at the academic hospital attached to the University of Cape Town.

“The only certainty [is] that we still have much more to learn,” the doctors said in the South African Medical Journal.

They also posted the names of the hospital’s Covid-19 response team, and said: “We acknowledge with immense gratitude the tremendous contribution ... from our nurses, allied medical professionals, hospital and provincial managers, as well as every last porter, cleaner, caterer, volunteer and all other support staff.”

Key developments the doctors outlined include:

• The development of oxygen treatment through high-flow nasal cannulae, in combination with proning (placing patients on their stomachs), as a way of keeping people out of intensive care;
• The deployment of half of the hospital’s anaesthetists to an anaesthesia and airway team that treated more than 400 patients;
• A virtual ban on the use of antibiotics;
• A one-third reduction in deaths among ventilated patients after the introduction of treatment with the steroid dexamethasone;
• Large numbers of Covid-19 patients who either already had diabetes or who were diagnosed for the first time;
• The need to support health workers with counselling; and
• The development of new technology to speed up Covid-19 test results.

Anticipating “severe pressure” on intensive care beds, Groote Schuur dedicated medical wards to Covid-19 patients with pneumonia or severe respiratory failure, treating them with high-flow oxygen and proning.

“Despite the necessary compromises in offering this therapy in a less-monitored setting with a higher patient-to-nurse ratio as compared with ICU, we have found it to be a feasible strategy with lower overall intubation rates, less ICU resource utilisation, and cost savings,” said the doctors.

The anaesthesia and airway team developed a “highly protocolised” approach to safe intubation – a procedure in which a tube is inserted through the mouth into the airway.

“We undertook in situ simulation in theatres, emergency departments and wards, and actively encouraged cross-disciplinary participation of staff in interchangeable roles,” said the doctors. “This allowed systems testing and rapid improvement prior to the patient surge.”

The airway team also started using respirators with washable filters, saving approximately 50 disposable N95 respirators daily.

The doctors said the largest study of its type so far had found that only 7% of Covid-19 patients had laboratory-confirmed bacterial infections. The chance that patients had a bacterial infection when they were admitted to hospital was even lower.

Despite this, between 56% and 95% of patients in the study were given antibiotics, an approach which would not help them but would contribute to the “epidemic” of antibiotic-resistant bacterial infections.

The Groote Schuur team decided not to prescribe antiobiotics to Covid-19 patients, and to withdraw them from patients who had started taking them without proof that they had a bacterial infection.

“If antibiotics are to be given, blood and site-directed specimens should be sent for culture prior to starting antibiotics,” said the doctors.

Management of diabetics with Covid-19 had been challenging, and had been helped by the distribution of protocols and “rapid upskilling” of doctors and nurses who were inexperienced in managing diabetics. A helpline was set up so diabetic patients could speak to a doctor after being discharged.

A wellness team was formed to prioritisie the health of staff. The doctors said: “Working long hours in unfamiliar settings, and in personal protective equipment, fear of contracting SARS-CoV-2 and passing it on to their loved ones, seeing many patients die and breaking bad news to families are all having an impact on wellbeing.

“At the same time, the lockdown has meant that many have been unable to recharge their batteries. There is no socialising, and some have isolated themselves from their families to protect them.”

Early problems with Covid-19 test turnaround times in the Groote Schuur virology lab were resolved partly with an innovation that bypassed the time-consuming process of extracting nucleic acid from a sample.

This overcame shortages of test reagents and saved “precious processing time”, the doctors said.