Dr Tony Behrman, Medicolegal Business Consultant for Medical Protection, writes on the challenges of load shedding for South African healthcare professionals

By now the experience of power outages, or load shedding, will be very familiar to members. So, too, is the experience of having to put contingency plans in place immediately to ensure treatment continues and patient safety is not compromised.

While measures are in place to increase supply, the ever-present challenge of the power outage will not be going away any time soon.

In the first half of 2021 alone, South Africa experienced 650 hours of load shedding, which equated to 76% of the load shedding experienced throughout the previous year.

Power outages are challenging enough for any business or household. For healthcare professionals – who have a clear duty of care – the challenges are compounded.

I have written over the past two years about the guidance that healthcare practitioners should refer to when facing power outages. Given the continued prevalence of load shedding and the concurrent demands of winter temperatures and continuing spread of COVID-19, it is timely to revisit the issue.

The law and power outages

The Occupational Health and Safety Act 85 of 1993 and regulations forms the basis of risk assessments regarding power outages, among other risks. Under the Act and regulations, the 16.1 and 16.2 appointee (the CEO and their designated appointee) with their risk control staff have the final decision as to whether a hospital is safe to proceed with surgical cases, provided the risk can be mitigated.

The employer must provide a work environment which is safe. Such an obligation includes routine maintenance to eliminate, mitigate, and reduce the risk of danger to external healthcare providers, employees and patients.

The SA National Standards Electrical guidelines 10142 SANS is the only appropriate guideline to follow and contains a section on minimum power requirements for medical facilities. The guideline refers to a power supply from a “safe source” such as a generator, which shall be energised if the usual source of power fails.

Minimum response times for replacement power

There are three response times specified in the SANS 10142 regulations:

1) Uninterrupted Power Supply (UPS): The response time for an alternative power source in the event of a power failure needs to be faster than 0.5 seconds for all medical equipment in ICUs, theatres and recovery areas where there are high risk patients. This requirement can only be met using an Uninterrupted Power Supply (UPS). Unfortunately most UPSs only function for a limited time before they need re-energising, and as a result, hospitals are required to invest in UPS battery back-up equipment, which each must deliver power for a regulated 20 minutes as per SANS 10142. This power source is only a temporary bridge that ensures enough time for an alternative source of power from a generator, to supply the hospital.

2) Critical Generator Supply: A response within 30 seconds is required of the critical emergency generators that supply critical elements in the hospital for the continuation of critical services like emergency lights, life support equipment in theatres, ICUs and wards, medical gas compressors, pharmacy fridges, certain lifts, support to recharge drained UPSs etc. These generators must be able to function for at least 24 hours OR for a minimum of three hours to complete surgery and evacuate the building, and the day theatres, if required. The recent huge increase in the need for ventilators during the COVID-19 pandemic has placed hospital back-up power again firmly in the spotlight and resulted in considerable extra strain on already overstretched hospital resources.

This will affect the types of cases surgeons will be able to perform in that facility, as there is no legal requirement for an alternative power source over the requirement for a critical emergency generator. It is important that practitioners working in such a facility are aware of which generator back-up system or systems is in place, to understand their and the patient’s risk exposure in the event of a power failure or load shedding.

Due to the 30-second start-up time of critical generators to accept the load, a UPS is deployed to supply the equipment within 0.5 second and carry it through the 30 second power break until the critical generator takes over.

Based on this supply of power, a surgeon may need to cancel further operations after completion of the current case until the full risk is mitigated. For this reason, many large hospitals have dual redundancies on generators, such as two or more separate generators supplying power to the hospital if required, the essential and the ‘non-essential’ generators, inclusive of a UPS bridge.

When power outages are threatened or deemed likely, surgeons are encouraged to find out whether there are additional mobile generators, and whether there is sufficient fuel on site before starting surgery.

3) Base load generator supply:
These will supply a response after an interruption longer than 30 seconds. They are for non-essential supplies, and are only needed when a hospital provides a replacement ongoing base load supply as back up.

When such a generator is present, the surgeon may carry on with activities as if the normal power supply is present and until this fails, resulting in only the critical load generator being functional. At this point the surgeons should finish their cases as described above, and not consider starting any new cases. The decision to install and utilise these baseload generators is ultimately one that balances clinical and commercial factors. Managers will consider the cost of total downtime to a hospital versus the return on investment of keeping the hospital up and running. With these facilities, doctors are safe to do new cases as long as all systems remain functional.

While many private hospitals have voluntarily invested in large base load generators, which can run for many days, it’s important to remember that in times of severe power outages there may be severe rationing of diesel, which may result in fuel being diverted to other facilities, according to the state’s priorities.

Final advice for clinicians

Clinical teams who are working in a facility where power outages are likely to occur should have a contingency plan in place. They are encouraged to confer with the general manager of the facility and carefully consider their advice and explanation of the risks of losing back-up power supply. Should facility managers advise not to proceed with new cases, this advice should be taken extremely seriously. A doctor who ignores this advice could put a patient’s safety at risk and in doing so, could leave themselves vulnerable to claims of clinical negligence, an inquest, and even a possible criminal charge.

If you are in doubt about clinical decision-making in the face of potential power outages, contact Medical Protection for advice.

This article was originally published in Medical Brief and is republished with permission.