Triage in the Aarau Hospital: The triages have started in Switzerland

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Switzerland reports 20 percent more occupancy in intensive care units every week.

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Two weeks ago, Taskforce President Tanja Stadler warned of triages.

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“The nurses have to look after the triaged patients and their relatives,” says Yvonne Ribi, managing director of the Swiss Nursing Association.

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“The current measures are not enough,” says epidemiologist Olivia Keizer.

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With over 10,500 new infections, Switzerland recorded a sad pandemic record last Monday. Nevertheless, the Federal Council decided on Friday against the obligation to work from home and mass tests at all schools. The widespread introduction of the 2G rule was not even up for debate.

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This is also due to the resistance from the cantons and from business circles, who prefer not to want any restrictions at all. Ultimately, according to the Swiss Trade Association, no measures are needed “as long as the risk of overloading the health system is not acute”.

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But what does acute mean? Switzerland reports a weekly increase in new infections of 50 percent, 40 percent more hospitalizations and 20 percent more occupancy in intensive care units. They are already overloaded: There are no more vacant intensive care places in the entire canton of Zurich. “Code Red” was proclaimed in Bern, a state of emergency, and Geneva is in crisis mode. So-called elective interventions are postponed, patients relocated in an emergency.

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“It doesn’t work without a vaccination.”

“Half of our intensive care beds are occupied by Covid patients,” says Christian Frey, deputy head of the intensive care unit at the Hirslanden Klinik Aarau. “They’re all not vaccinated.” He has trouble with that, says Frey: “Because we have to put other patients on hold because of them.” For Frey it is clear: “It doesn’t work without a vaccination.”

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The experienced intensive care doctor is particularly concerned about the increasing number of Covid patients because they have to be looked after for a very long time. “They stay in the intensive care unit for an average of one month.” The more the number of cases increases, the bigger the problem becomes.

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At the end of the cascade, there is triage in intensive care units, which Task Force President Tanja Stadler warned about in November. Exactly this extreme situation occurred this week at the Hirslanden Klinik Aarau: “We have already triaged patients with concomitant diseases,” says intensive care doctor Frey. For example, a cancer patient was not admitted to the intensive care unit with his consent, but was not invasively ventilated in a normal ward. “If the number of cases continues to rise, the triages will also increase,” says Frey.

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Massive burden for everyone involved

Triage means sorting out: if, in the event of a war or disaster, the medical resources are no longer sufficient for all patients, the medical professionals have to make a selection. In Switzerland you can orientate yourself on the guidelines of the Swiss Academy of Medical Sciences (SAMS) and the Swiss Society for Intensive Care Medicine (SGI). They state that if all capacities are exhausted, priority will be given to those patients who will benefit most from intensive care when admitted to the intensive care unit. “In the case of a so-called rationing decision, i.e. a hard triage, those patients who have the greatest chance of surviving are cared for in intensive care”, explains Miodrag Filipovic, Head of Intensive Care Medicine at the St. Gallen Cantonal Hospital and SGI board member.

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The triage is a massive burden for everyone involved – also for nurses: “You have to look after the triaged patients and their relatives,” says Yvonne Ribi, managing director of the Swiss Nursing Association. In any case, they have been under constant pressure for almost two years. The consequences are layoffs and workload reductions, which has led to a loss of personnel resources in intensive care units of around 15 percent since the beginning of the pandemic – Covid diseases of the nursing staff, who are exposed on the front line, also contribute.

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There is a lack of skilled workers

“This staff shortage is the reason why the situation is now so acute,” says Ribi. There were significantly more hospitalizations in the last major corona wave a year ago. “But due to a lack of skilled workers, there are now fewer intensive care places.” In fact, last autumn Switzerland had 1,100 such beds – today there are 860. The percentage occupancy is now higher than in the second wave.

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And it should rise even further – not only in the centers, but also in winter sports destinations where the season is just beginning. Ski accidents are programmed. During a normal winter season, the intensive care places are on average 80 to 100 percent full, says Thomas Fehr, chief physician for internal medicine and medical director of the Cantonal Hospital of Graubünden in Chur. In addition, there are now the corona patients, who in November alone occupied an average of 40 to 60 percent of the intensive care places in Chur. “So it is clear that overcrowding can occur on peak days,” says Fehr.

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For Olivia Keizer, epidemiologist at the University of Geneva, one thing is certain: “The current measures are not enough.” The situation in the hospitals is now the only target for politics. “Now these are heavily overloaded, and yet far too little happens!”

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Too late and too little

From an epidemiological point of view, it is clear what is useful: “Above all, mass tests, CO2 measuring devices and filters, but also good FFP2 masks, the ban on large events, temporary closings and compensation for high-risk locations.” Keizer also emphasizes: “We have to boost and introduce child vaccinations as quickly as possible.” The example of Austria shows that a large-scale introduction of 2G would also have a strong effect.

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“Too late and too few,” says SP National Councilor and doctor Angelo Barrile about the current measures. Health politicians are dismayed that triages are now being carried out in Switzerland. After suffering from cancer, Barrile cannot build up immune protection despite the vaccination and booster. “So it could happen to me too that in an emergency I won’t get an intensive care place.” Politicians now have to wake up: “The back and forth between the federal government and the cantons has consequences. Obviously not everyone involved is aware that it is a matter of life and death. ” For Barrile it is clear: “Stricter measures must come.”

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Until then, the situation in the hospitals will worsen – and further triages will follow. It will also be about unvaccinated people. According to SGI board member Filipovic, they make up 90 percent of the treated Covid patients in the intensive care units. But the vaccination status should not play a role in the triage decision, explains Felix Uhlmann, constitutional lawyer at the University of Zurich. «That would be discriminatory. The only decisive factor is the patient’s short-term chance of survival. “

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Corona deniers alien to reality

Could triage patients or their relatives sue the doctors? Uhlmann: “This cannot be ruled out in the case of wrong triage decisions, but it is probably difficult in practice. Complex forecasts have to be made under great time pressure. I assume that only clear wrong decisions trigger civil or criminal liability. ”

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It is worrying that Switzerland is now having to discuss such issues. All the more disturbing in this precarious situation are voices who still dismiss an overload of the health system as “not acute”.

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