Hospitals prepared for Sars, but wary

By WARREN GAMBLE

Life has imitated health planning for New Zealand hospitals dealing with the Sars epidemic.

Just over a year ago the health system went through a month-long exercise with uncanny similarities to Sars (severe acute respiratory syndrome).

The scenario for the Ministry of Health's Operation Virex involved an outbreak of an influenza-like illness in a remote part of China and its spread to Hong Kong and other Asian countries, and on to Australia and New Zealand.

Public health officials and hospital managers say it provided an invaluable stocktake on New Zealand's ability to cope with a large-scale infectious disease.

It tested a chain of response, from the ministry to regional co-operation to individual hospitals, and showed up weaknesses in a health system already running at near capacity after years of economically driven change.

One of the key lessons was the need to protect front-line health staff from infection.

Operation Virex was staged after virologists internationally agreed that the world was overdue for an influenza epidemic and because of Government concerns after September 11 about New Zealand's ability to cope with a bioterrorism attack.

The exercise was a valuable dry run for Sars, which in turn, because of its small scale so far with only one confirmed case in Hawkes Bay, has been a valuable practical test.

Hospitals have boosted their ability to isolate infectious patients, stocked up on new protective suits and masks, and developed infection control plans. The three Auckland regional health boards met in the first week of the Sars crisis to share information, decide what equipment was needed and develop clinical guidelines.

But what if New Zealand hospitals were faced with hundreds or thousands of admissions from a rapidly spreading deadly strain of influenza?

The straight-talking director of public health, Dr Colin Tukuitonga, says NZ would struggle for the simple reason that there is a limit to every health system's resources.

If large numbers of intensive care beds were needed there would be a physical limit, but more particularly a limited number of highly skilled nurses to provide 24-hour care.

The 21 health boards have a total of 113 negative pressure rooms where airborne viruses can be contained - no air escapes outside when doors are opened. Only about 20 of those are in intensive care units.

Green Lane provides the main isolation ward in Auckland, although North Shore Hospital says Sars has underscored the need for permanent negative pressure rooms and these will be given priority.

The hospital hired two portable negative pressure Machines after the Sars alert. Other wards, including a floor in the soon to be old Auckland Hospital, could be used as isolation areas in a large-scale outbreak, but they would be less effective.

"In a worst-case scenario if the health system wasn't able to cope, people would be required to be cared for in corridors in less than ideal facilities," Dr Tukuitonga says. "But that would happen in the best resourced health systems around the world."

In Britain's Daily Telegraph, GP and writer Theodore Dalrymple says the UK is ill-placed to deal with a Sars outbreak because its hospitals perpetually run at, or even above, the limit of their capacity.

"Most British hospitals are already working as if there were a permanent epidemic of unprecedented proportions, though in fact they are merely dealing with normal day-to-day demand." .

He says a sudden additional load of patients, such as the winter influenza peak, causes almost unbearable stress among the staff.

"We operate our hospitals on the Japanese principle of car manufacture: the just-in-time system of supplying parts.

"No doubt this is economically sound, in the sense of being cheap, but the idea that present demand for hospital beds is stable, that there should be no slack in the system, that slack in the system means slack staff is to invite nemesis.

"If Sars doesn't get the National Health Service, something else will."

New Zealand hospitals aim to run at 85 per cent capacity, but all three Auckland boards acknowledge that they often run at well over 90 per cent, and in the winter peak sometimes exceed capacity, meaning some patients are treated in corridors.

Auckland is actually reducing the number of beds when the merged city hospital opens in October.

But chief medical officer Dr David Sage says a new assessment ward and declining lengths of hospital stays will allow it to cope better. Like any hospital, he says, if there is a sudden surge in patients room can be made by cancelling non-urgent surgery.

There are also regional initiatives, including a suggestion that one hospital could handle the winter peaks, freeing others to deal with elective surgery.

Dr Tukuitonga says New Zealand is fortunate that it could absorb key lessons from the spread of Sars overseas, particularly the need to train and protect healthcare staff who were most at risk in its early days.

Outbreak planning

The good news: A Sars dress rehearsal last year went well.

The bad news: A full-scale outbreak would probably overwhelm any health system, including New Zealand's.