Surgery catch-up hamstrung by shortage of ICU nurses

Hospitals in SA have been put under immense strain over the past two years as beds were filled with Covid-19 patients and elective surgeries had to be put on hold.

To make things worse, pre-existing shortages of intensive care trained nurses and other critical staff were exacerbated by healthcare workers contracting Covid-19 and falling ill or having to isolate themselves.

We explore surgery catch-up plans in Gauteng and the Western Cape and ask what is being done to address the underlying problem of not having enough ICU nurses.

Western Cape

Mark van der Heever, spokesperson for the Western Cape department of health, said by mid-January they had 758 active cases of healthcare workers who tested positive for Covid-19.

“Although the numbers remain significantly high, staff are returning to work as they come out of isolation and there is an overall easing of pressure on the health platform. The Omicron wave did not have the impact on health services the way the first three waves had. For example, at Tygerberg Hospital we did not de-escalate our normal operations during the fourth wave,” he said.

Looking back, Yolanda Walsh, a registered nurse specialising in critical care, said the second and third waves were horrendous.

“ All hell was breaking loose. There was a triaging system and critical decisions had to be made on whether you continue giving a patient in the ICU more time or you give the one outside a chance. The workload was something else. Remember ICU beds have always been a problem, even before Covid-19,” she told Spotlight.

“We were running up and down, the sweat was flowing down to the legs. It was traumatising.”

Apart from the psychological trauma of those earlier waves, their impact is also felt in the ongoing backlog of elective surgeries.

“Nurses are not OK. We don’t have the numbers and we don’t have the quality for critical care,” said Walsh.

“We are dealing with very tired and short-staffed nurses and they have to go through thousands of surgeries. Many surgeries had to be postponed and repostponed and this had a major impact on people.”

‘Unlikely to ever catch up’

At Tygerberg Hospital 7,000 patients were waiting for surgeries by late January.

Head of the department of surgery, Prof Elmin Steyn, said they “are unlikely to ever catch up”.

However, acting spokesperson for Tygerberg Hospital Rozaun Botes said they did not de-escalate their normal operations during the fourth wave so waiting lists for emergency surgery were not out of the ordinary.

“We have 30 theatres all running at full capacity,” she said.

“We normally de-escalate services between Christmas and New Year where we basically only focus on emergency operations. Last year, we had to bring it forward by one week and that was due to staff testing positive. Qualitatively and quantitatively the impact was not as severe as with the first three waves.”

Botes said catching up is not easy “as over and above the normal activities, we have to create more services to catch up and that is not easy as it requires more human resources and theatre time, which costs money.”

She said they do not have a shortage of ICU nurses in general.

“There is a shortage of trained ICU specialist nurses, but we appoint and train general professional nurses to support the staffing complement. During the pandemic we appointed additional nurses on contract to support with the patient load.”

Groote Schuur surgical recovery project

At Groote Schuur Hospital (GSH), Prof Lydia Cairncross, head of general surgery, said like all other hospitals in the country, the pandemic had a significant impact.

“We had to prepare our hospital for the waves by decreasing out patient clinic visits and all non-urgent clinical services. This included surgical procedures. For large parts of 2020 and 2021, our theatre ran at 50% of its normal capacity. This meant while we were able to assist patients who required emergency operations, patients who were waiting for essential but not emergency surgery had to be postponed. During this time we did 10,000 fewer operations than in the 2018/2019 period.”

The hospital has more than 6,000 patients waiting for surgery. The operations on this list include surgery for cataracts, joint replacements, hernia and gall bladder surgery, prostate surgery, and gynaecological operations.

“While we tried our best to keep our cancer surgery service running, these backlogs do affect cancer waiting time to a certain extent too. We are planning a one-year surgical recovery project to decrease this backlog and waiting time for our patients. As the health system returns to relatively normal functioning, we are inundated with new patients into the system who also need our assistance, and often surgery as part of that. With a system running at capacity, it is almost impossible to add extra operating but that is what we need to do as Covid-19 added an extra burden of disease to the system as a whole,” said Cairncross.

The idea of the surgical recovery project is to run an additional 1,500 operations over one year as a theatre service parallel to their normal operation. There is a need for a core theatre team of nurses and anaesthetists and generalist surgeons to make this possible, hence they are fundraising for R15m towards employing this team for a year. The Gift of the Givers has committed R5m towards this project.

Cairncross noted that huge shortages in intensive care trained nursing were highlighted by the pandemic.

“This shortage was the main factor affecting our ability to expand ICU, not the lack of the ventilator machines. It is the people to look after the patients that became the limiting factor. This lack of sufficiently trained intensive care nurses is not limited to Groote Schuur but is a provincial and national phenomenon.

“To provide a service, we needed to use locum staff and our own staff members were stretched to their limits, doing extra overtime to meet the massive increased need during Covid-19. During the peak of the third wave, Groote Schuur’s ICU expanded to three times its normal capacity to treat patients with Covid-19 pneumonia,” she said

Walsch said there is a need to acknowledge there is a problem, invest and create more posts to be able to deal with the shortage of intensive care nurses.

“In SA, there is very little incentive for a critically qualified nurse and a registered nurse so there is no motivation to train as a critical care nurse,” she said.

“I don’t think there are nearly enough nurses especially for specialised care.”

Gauteng

Kwara Kekana, spokesperson for the Gauteng department of health, said by June last year there were 700 ICU-trained nurses in the province. The ideal number is 1,421. This meant the critical care trained nurse to patient ratio is 1:4, rather than the targeted 1:1.

“Many nurses went [into] isolation and quarantine and this exacerbated the shortage,” she said.

Kekana said the province entered into agreements with two nursing agencies to supply nurses, employed nurses on Covid-19 and used its nursing staff overtime budget to deal with the shortages.

“Professional nurses were trained in a 10-day ICU short course to equip them with critical care skills.”

Explaining the province’s training plans over the next three years, Kekana said the plan is to train 550 nurses in the 2022/23 financial year, 800 in 2023/24, and 800 in 2024/25.

Professional nurses (general) will also be trained in critical care nursing (adult). The plan is to train 76 by 2024, 90 by 2025, and 99 by 2026. She said the funding for this will come from the province’s budget for health sciences and training.

Dr Nthabiseng Makgana, acting CEO at Pholosong Hospital in Brakpan, said the hospital is running six theatres during normal working hours and all departments are recalling patients and performing elective operations in order of priority to reduce the backlog. The hospital had elective surgical backlogs of 146 patients for general surgery, 67 for gynaecology and 91 for orthopaedics. The hospital had no backlogs for ear, nose and throat ( and ophthalmology.

“Covid-19 contract personnel was injected to accommodate increased demand due to the pandemic, but there was a high need for highly specialised staff (ICU nurses, doctors, physiotherapists and so on) to cater for critically ill Covid-19 patients. This was not always possible due to the limitation of highly specialised staff,” said Makgana.

Not enough specialist nurses

Sibongiseni Delihlazo, national spokesperson for the Democratic Nursing Organisation of SA (Denosa), also said the country does not have enough ICU-trained nurses.

“We are very short of specialist nurses and pandemics like Covid-19 are seriously exposing this area. ICU nurses were burnt out and not sure if they will be able to withstand the test of time post the second wave. They were drained physically, emotionally and mentally with no intervention whatsoever from government in terms of support in the form of time off due to the shortage,” he said.

Noting the nurse-to-patient ratios, he said in the ICU there must be one nurse per patient but the increase in admission to ICU of patients, especially due to Covid-19, is stretching this to a point where, in some instances, general nurses report they are deployed into ICU without training.

“The situation is the same with maternity, where general nurses would be allocated to delivery rooms without training. This is how the shortage of staff and shortage of specialist nurses are compromising the quality of healthcare services.”

Delihlazo believes government is not doing enough to train more specialised staff.

“It is regressing terribly and South Africans should be concerned about that”.

He said they lose many patients in facilities as a result of the shortage of staff.

“Nurses are busy with critical patients and more patients get critical with no extra hand to look out for those.”

Cairncross also said not enough is being done to train more critical care nurses.

“From our perspective, this is a chronic problem which is not being adequately addressed at a systems level. The shortage is not only of intensive care trained nurses but nurses in general. We need more nurse training colleges and to graduate more registered nurses, enrolled nurses and enrolled nursing assistants. We need to be training more specialised nurses at accredited institutions across all disciplines. ICU and theatre are two major areas of shortfall.”

Juggling budgets and staff shortages

National department of health spokesperson Foster Mohale said the department recruited additional staff and employed them on a temporary basis to cope with the demand for care in the management of Covid-19. He said staff were recruited through additional resources allocated to departments for Covid-19 (Covid-19 grant), recruiting and deployment of a foreign health workforce (Cuban Brigade), use of personnel recruited through nursing agencies by some provinces as a temporal stop-gap measure, and using community service staff.

“There was an implementation of an ICU short course for nurses, including non-ICU nurses, as a short-term measure to increase capacity for management of Covid-19 patients. In the medium to long term, government will continue to grapple with staff shortages as a result of budget constraints that are public sector wide amid competing priorities.”

He said government’s personal and salary administration system by December 31 2021 showed there were 23,350 vacant posts for nurses in all categories.

Mohale said plans to increase nurse numbers depend on the availability of funded posts in provinces and “recruitment of staff in provinces is negatively affected by fiscal constraints”.

Toward the end of 2020, the health department approved a human resources for health strategy 2030 that is supposed to guide government’s efforts relating to the training and retention of healthcare workers.

Owing to anticipated human resources for health capacity and resource constraints, Mohale said “it was deemed critical to understanding the cost of implementing the strategy and government’s capacity to fund it. In this regard, a costing study aimed at identifying and generating cost estimates for the proposals in the strategic plan was commissioned and is being finalised”.

This article was first published by Spotlight