Understanding the impact of the COVID­19 pandemic on healthcare services for adults during three waves of COVID­19 infections: A South African private sector experience.

BACKGROUND: Since the onset of the COVID­19 pandemic, healthcare resources have been repurposed to focus on COVID­19. Resource reallocation and restrictions to movement that affected general access to care may have inadvertently resulted in undue disruptions in the continuum of care for patients requiring non-COVID­19 healthcare services. OBJECTIVES: To describe the change in pattern of health service use in the South African (SA) private sector. METHODS: We conducted a retrospective study of a nationwide cohort of privately insured individuals. An analysis of claims data was performed for non-COVID­19 related healthcare services provided from April 2020 to December 2020 (year 1 of COVID­19) and April 2021 to December 2021 (year 2 of COVID­19) relative to the same period in 2019 prior to the COVID­19 pandemic in SA. Over and above plotting the monthly trends, we tested for statistical significance of the changes using a Wilcoxon test given the non-normality of all the outcomes. RESULTS: Between April and December 2020, relative to the same period in 2021, and also relative to the same period in 2019, we found a 31.9% (p<0.01) and a 16.6% (p<0.01) reduction in emergency room visits, respectively; a 35.9% (p<0.01) and 20.5% (p<0.01) reduction in medical hospital admissions; a 27.4% (p=0.01) and 13.0% (p=0.03) reduction in surgical hospital admissions; a 14.5% (p<0.01) and 4.1% (p=0.16) reduction in face-to-face general practitioner consultations for chronic members; a 24.9% (p=0.06) and 5.2% (p=0.54) reduction in mammography for female members; a 23.4% (p=0.03) and 10.8% (p=0.09) reduction in Pap smear screenings for female members; a 16.5% (p=0.08) and 12.1% (p=0.27) reduction in colorectal cancer registrations and an 18.2% (p=0.08) and 8.9% (p=0.07) decrease in all oncology diagnoses. Uptake of telehealth services throughout the healthcare delivery system increased by 5 708% in 2020 compared with 2019, and 36.1% for 2021 compared with 2020. CONCLUSION: A significant reduction in emergency room visits, hospital admissions and utilisation of primary care services was observed since the start of the pandemic. Further research is required to understand if there are long-term consequences of delayed care. An increase in the use of digital consultations was observed. Research on their acceptability and effectiveness may open new modalities of care, which may have cost- and time-saving benefits.

Supraclavicular regional anaesthesia affecting bispectral index as level of consciousness monitor (SUPRABLOC): a pilot randomised controlled trial

Background: Renewed interest in regional anaesthesia during the recent COVID-19 pandemic has inspired application of neuraxial anaesthesia for previously unconventional indications, such as awake abdominal surgeries. These patients needed little sedation, since studies demonstrate that neuraxial anaesthesia causes sedation as measured by the bispectral index (BIS). In contrast, no published study has investigated the possible sedative effects of non-neuraxial regional anaesthesia. This pilot randomised controlled trial (RCT) was designed as a template for, and to test the feasibility of, performing a definitive RCT to establish if non-neuraxial regional anaesthesia has any sedative effect. Method(s): Forty participants presenting for forearm surgery were randomly allocated to two treatment groups (supraclavicular block and control). Their level of sedation was monitored with BIS prior to surgery for 60 minutes. Specific feasibility outcomes were planned and data were collected according to CONSORT 2010 recommendations. Result(s): Out of 48 patients screened, 41 (85.42%) were invited to participate. Forty patients (97.56%) consented and 100% of these completed the study. In four participants (10%), BIS electrodes needed replacement, while inadequate contact was shown in three participants (7.50%). Data collection and form completion were deemed "easy" and block success rate was 100%. Differences in mean BIS between groups were < 5 and a difference of 10% between groups in incidence of BIS < 80 (85% block group, 75% control group) was shown. Conclusion(s): We propose that progression to formal RCT is feasible only with specific modifications to the study design. The decrease in BIS value from baseline should be measured per patient and a clinically significant decrease should be estimated;emergency patients should be excluded;the sample size should be 500 patients;and multiple trial sites should be used. Further consideration should be given to whether such a trial would provide clinically useful information, and would justify the risks, patient discomfort and the considerable financial cost.Copyright © 2023, Medpharm Publications. All rights reserved.

SUPraclavicular Regional Anaesthesia affecting Bispectral Index as Level Of Consciousness monitor (SUPRABLOC): a pilot randomised controlled trial

Background: Recent renewed interest in regional anaesthesia during the COVID-19 pandemic has inspired the application of neuraxial anaesthesia for previously unconventional indications, such as awake abdominal surgeries. These patients needed little sedation, since studies demonstrate that neuraxial anaesthesia causes sedation as measured by Bispectral Index (BIS). In contrast, no studies have investigated the possible sedative effects of non-neuraxial regional anaesthesia. Aim: This pilot randomised controlled trial (RCT) was designed as a template for, and to test the feasibility of performing a definitive RCT to establish if non-neuraxial regional anaesthesia has any sedative effect. Methods: Forty patients presenting for forearm surgery were randomly allocated to two treatment arms (supraclavicular block and control). Their level of sedation was quantitatively monitored before surgery for 60 minutes. Specific feasibility outcomes were planned and data collected according to CONSORT 2010 recommendations. Results: Out of 48 patients screened, 41 (85.42%) were invited to participate, 40 (97.56%) consented and 100% completed the study. Four (10.00%) BIS electrodes needed replacement, inadequate contact was shown in three patients (7.50%), data collection and form completion were deemed “easy”, and block success rate was 100%. Differences in mean BIS between groups were < 5, and a difference of 10% between groups in the incidence of BIS < 80 (85% block group, 75% control group) was shown. Conclusion: We propose that progression to formal RCT is feasible with modifications. Decrease in BIS value from baseline should be measured per patient, and clinically significant decrease should be estimated (we suggest a decrease of 10 or more), exclusion of emergency patients (starved for longer, more anxious, may affect BIS), the sample size should be 500 patients and multi-site involvement implemented.

Use of high-flow nasal oxygenation outside COVID-19: a rural hospital experience

Background: Before the COVID-19 pandemic, there was an increasing interest in the use of high-flow nasal oxygenation (HFNO) due to the way it delivers oxygen and because of its impact on respiratory mechanics. Its use extends from the operating room, e.g. pre-oxygenation, apnoeic oxygenation in ENT surgery, electroconvulsive therapy, to the emergency room and intensive care unit, e.g. acute respiratory failure, cardiogenic shock in adults and paediatrics. It has also been advocated as a useful method to prevent reintubation. However, it has not always shown to be a superior approach to other oxygenation methods. Currently, the medical literature is inundated with the use of HFNO in the management of COVID-19. Yet, the picture may differ outside this ambit. Methods: We describe two complex cases in which this therapy was used and was decisive toward a positive outcome. Results: We describe two complex cases in which HFNO therapy was used and was decisive toward a positive outcome. In our first described case, it was an effective tool to bypass the need of endotracheal intubation in a high-risk OSA patient. In the second case the traditional epidural with invasive or noninvasive ventilation was challenged. The higher tolerability of HFNO, absence of sedation, better mobility and easier access to enteral nutrition resulted in the quick, successful recovery of the patient despite the combination of chronic restrictive pulmonary disease and severe thoracic-abdominal trauma. Conclusion: In our opinion, both cases may illustrate a significant potential for the use of HFNO in different clinical scenarios.

Governing a pandemic: A case study of South Africa?s coordination and management structures used to respond to the COVID-19 pandemic

During a public health emergency, coordination and management are essential for ensuring timeous, decisive, and harmonised leadership. In this paper, the governance structures utilised in South Africa (SA) during the COVID-19 pandemic are recorded and the key strengths and weaknesses of response in the country are discussed. A qualitative methodology is used for the case study and comprises insights from stakeholders who were at the forefront of SA???s response as well as from documentation that was used to guide the response. Structured, transparent, science-based and agile coordination and management systems are necessary to gain the public???s trust during a public health emergency. This case study contributes to the literature on governing a pandemic and shares lessons learned from the COVID-19 response. The lessons learned by the stakeholders within the SA governance structures can be leveraged in future public health emergencies within SA and other low-and middle-income countries.

Recovery and transforming the South African health system

The COVID-19 pandemic has devastated lives and livelihoods globally and in South Africa (SA). The SA government has been lauded for its swift response to the pandemic, in March 2020 and subsequently. Many routinely provided health services were severely disrupted and there is an urgent need to recover to 2019 levels at least. In this paper, the lessons from the COVID-19 response are discussed and proposals for transformation of the SA health system are considered.

Protecting the Unprotected – Occupational health and safety among informal workers in Southern Africa

The International Labour Organisation (ILO) estimates that approximately 2 billion people, about 61% of all globally employed people, are in the informal economy. This statistic is substantially higher for continental Africa (approximately 86%), and varies across the continent: 31.5% in South Africa, and exceeding 95% in Mozambique, Democratic Republic of Congo and Chad. The informal sector is characterised by vulnerabilities in income, job security, occupational risks and access to healthcare. The ILO, in addressing these challenges, developed Recommendation 204, the “Transition from the Informal to the Formal Economy Recommendation, 2015”. This provides a policy framework that requires a transition that provides adequate social and labour protection, extends legal coverage and protection and ensures compliance with laws. While this transition is necessary, its character particularly with regard to occupational health and safety, needs to be shaped in accordance with needs of workers, harnessing resources from the formal economy and structuring legal frameworks that prioritise health and social protection. Informal work environments vary from extractive, manufacturing, food preparation, commercial, social and retail. Hazardous exposures vary, with workers having little or no resources to introduce controls or to protect their health. Most lack the knowledge about the risks posed by their exposures. Access to medical surveillance is non-existent. While workplace exposures are important factors, social contexts further drive health outcomes: lack of health facilities close to working environments reduce primary health care access, lack of childcare facilities result in child exposures and precarious conditions increase gender and xenophobic violence. Numerous interventions have been piloted and proposed for protecting the health of workers in this sector, including the ILO initiatives such as Work Improvements in Small Enterprises (WISE). However, the success of any intervention is dependent on the multi-stakeholder context. The SARS-CoV-2 pandemic brought into sharp focus the vulnerability of the informal sector – both in terms of economic stability as well as health protection. In South Africa alone, approximately 1.5 million informal sector jobs were lost in the first quarter of 2020. The nature of work has meant that the risk for transmission of infection is extremely high, thus return to work is likely to have resulted in disproportionately higher rates of hospitalisation and death compared to formal workers – but few countries have collected data to better understand the epidemic-related risk of informal work. The growth in the informal economy is a direct result of neo-liberal economic policies championed by government and big-business. The policy infrastructure that encourages the growth in this sector excludes the protection of the health of these workers. All tiers of government should be obliged to commit to policy frameworks, local infrastructure for informal work activity and provision of resources for hazard control and medical surveillance. It is the responsibility of the state to ensure that these workers enjoy the rights to safe and healthy workplaces.