One important step to avoid Italy’s fate
Analysis: Italian doctors say hospitals can serve as a major vector for Covid-19 transmission. Here's what New Zealand is doing to stop that from happening here
"The situation here is dismal as we operate well below our normal standard of care," a group of doctors from Papa Giovanni XXIII Hospital in Bergamo, Italy wrote.
"Wait times for an intensive care bed are hours long. Older patients are not being resuscitated and die alone without appropriate palliative care, while the family is notified over the phone, often by a well-intentioned, exhausted, and emotionally depleted physician with no prior contact."
"But the situation in the surrounding area is even worse. Most hospitals are overcrowded, nearing collapse while medications, mechanical ventilators, oxygen, and personal protective equipment are not available. Patients lay on floor mattresses."
How did it get this bad? The Bergamo doctors point to transmission of Covid-19 within hospitals as the turning point for the region, which has seen at least 1,878 deaths - more in the one city than any country other than China, Iran, France, Spain or the United States. The New York Times says the actual death toll may be four times higher.
Hospital transmission to blame
At the time the Bergamo doctors wrote their letter to the New England Journal of Medicine, Bergamo had more cases of Covid-19 than any other province in Lombardy, the northern region of Italy that has been hardest hit by the virus.
"If we have to identify a spark, it was the hospital," Bergamo mayor Giorgio Gori told the New York Times.
The Times continued: "While those suspected of infection are taken to hospitals, the hospitals themselves are not safe. Bergamo officials first detected the coronavirus at the Pesenti Fenaroli di Alzano Lombardo hospital.
"By then, officials say, it had already been present for some time, masked as ordinary pneumonia, infecting other patients, doctors, and nurses. People carried it out of the hospital and into the city, out of the city and into the province. Young people passed it to their parents and grandparents. It spread around bingo halls and over coffee cups."
The Bergamo doctors, in their letter, have identified hospitals as a particular risk with Covid-19.
"We are learning that hospitals might be the main Covid-19 carriers, as they are rapidly populated by infected patients, facilitating transmission to uninfected patients," they wrote.
"Patients are transported by our regional system, which also contributes to spreading the disease as its ambulances and personnel rapidly become vectors. Health workers are asymptomatic carriers or sick without surveillance; some might die, including young people, which increases the stress of those on the front line."
David Murdoch, an expert in infectious diseases and dean of the University of Otago, Christchurch, told Newsroom a similar pattern was observed with Sars. "I suppose Sars was a good example where there was a lot of transmission in healthcare settings. That was a real lesson in terms of appreciating that as a risk," he said.
"I think we're learning from that sort of experience that it's really important just to make sure that - obviously there's a concentration of people with the virus in healthcare settings - that it is contained. We learned from particularly Sars that that was eventually a big issue."
"We're just starting to hear the details from Italy, but it is the main concern. Even just using basic principles, the idea that you're getting together a mix of people with the virus, plus a vulnerable population of people that may not have it at the time, plus a whole lot of busy healthcare workers who are obviously coming in contact and we need to protect. It's just a potential mix for ongoing transmission. It's a big deal but it's just that simple concept."
Stopping transmission in NZ hospitals
This is the reason why fathers are increasingly banned from the delivery room, why visitation in hospitals has been all but eliminated, why elective surgeries are being postponed or cancelled. Hospitals are now operating at around 50 percent capacity, Director-General of Health Ashley Bloomfield said Sunday - normally they operate at 90 to 100 percent, sometimes even more.
Keeping beds open means that hospitals are ready for any surge in severe Covid-19 cases, but it also means there's less risk of the virus spreading. By keeping all but the most urgent patients out of hospitals, New Zealand is seeking to keep hospitals clear of any infection.
Bloomfield also highlighted other measures hospitals are using to rein in the threat of Covid-19 transmission. "I know that they've got measures at the front door to make sure anyone coming in through the ED is being screened, first of all, to see if they're symptomatic. And if they're coming in for a respiratory-type illness, they go down a different pathway," he said.
"Of course, a key part of this is to make sure that anyone coming into the hospital, whether they are staff or visitors or couriers or so on are not symptomatic. We need to really keep our healthcare facilities Covid-19-free if we're going to protect them to be able to do the work they need to do."
DHBs are also gearing up to deal with the virus.
"We need to be ready for more patients with respiratory illness, more patients who need to be isolated from other patients and more people that might need a higher level of care with severe respiratory illness," Northland DHB's Dr. Lucille Wilkinson said. There is one patient with Covid-19 being treated in Whangarei Hospital.
In a statement, Taranaki DHB - where another Covid-19 patient is being treated - said it had banned all visitors with the following three caveats: one parent or guardian is permitted in the Neonatal Unit and paediatrics, one significant other in labour and maternity wards and one person is permitted to support a terminal patient through end-of-life care.
"In all exceptions where a visitor is allowed to access any TDHB facility, appropriate screening will take place before they are allowed to enter the care environment to ensure they are well, have clean hands and are using appropriate PPE," a spokesperson said.
Hidden transmission scares
The country had its first scare on Sunday, when Bloomfield revealed the first person in New Zealand to die of Covid-19 was admitted to hospital as a suspected influenza case, complicated by underlying health conditions. The patient, a woman in her 70s on the West Coast, was treated for influenza for several days before being diagnosed with Covid-19.
Now, 21 staff from Grey Base Hospital are in self-isolation because they didn't wear visors while treating the patient. Murdoch doesn't think this was a major oversight, since they were wearing other protective equipment.
"Not to say that the visor is not needed but there is a lot of extra precaution put on. I would've thought the added risk is probably fairly low in that setting," Murdoch said.
On Monday, Bloomfield said hospitals were now changing their policies and would treat all respiratory infections as potential Covid-19 cases.
"There were good precautions taken for if that person had had influenza," he said.
"Now, we have suggested to District Health Boards and, in fact, there is a common approach to this: Anyone coming into ED who has what we would call a lower respiratory tract infection - cough, fever - whether that's pneumonia or bronchitis, is being treated as if they are Covid-19 until proven otherwise. Therefore the appropriate measures are taken in terms of personal protection."
However, the same day, a new scare arose: a Queenstown nurse who hadn't been in contact with any of the Covid-19 cases in her hospital contracted the virus. The Otago Daily Times reported that the Lakes District Hospital was closed Monday evening and disinfected top to bottom as close contacts self-isolated and 36 staff received Covid-19 tests.
"While there have been two COVID-19 patients cared for at Lakes District Hospital, the nurse did not provide care directly to either of these patients," the Southern DHB said in a statement.
"The Public Health team is investigating to find out how the nurse contracted the virus. We are aware of a number of cases in the Queenstown likely due to community transmission and are exploring all possible ways of exposure for this nurse."
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