Issues to increase hospital capacity

Major problems with equipment (including drugs and personal protective equipment) and staff were reported during the first wave For a list of actions, we asked the hospitals to evaluate how the implementation of the hospital emergency plan went, on a four-point scale, from very difficult to very easy. Respondents who answered that the implementation of a given action was difficult or very difficult were invited to provide further explanation. Although this question was part of the hospital emergency plan section of the survey (see Table A. 7 in Appendix 2.2), it provides a good insight on the general difficulties faced by hospitals during the crisis.

Overall, nothing was easy during the first wave but all staff and departments did a lot of efforts to deal with the crisis. Several respondents stated that they had to install working groups around certain themes because there were not enough national guidelines (e.g. testing staff, visitor regulations, screening ambulatory patients).

As shown in Figure 6, finding personal protective equipment (PPE) was the most difficult action (evaluated as very difficult by 60% of the respondents and as difficult by 33%). Most hospitals also found that the management of drug stock levels was very difficult (17%) or difficult (52%). It was also difficult to find staff (evaluated as difficult or very difficult by 56% of the responding hospitals) and equipment such as ventilators (50%). Regarding the increase of length or frequency of staff shifts: 53% of the responding hospitals found it difficult or very difficult but it must be noted that 10 hospitals (all located in Flanders) said this situation did not apply to them.

Due to the global spread of the COVID-19 pandemic, there was a general shortage of ICU medication (e.g. sedation), ventilators, PPE, etc. In addition, the lockdown measures also caused practical problems (e.g. contractors in lockdown and not available for construction works required to make

architectonical changes). These shortages also caused excessive prices for PPE, ventilators, etc.

On the contrary, actions related to patients were evaluated as easy or very easy by a majority of the respondents: the triage of patients was evaluated as easy or very easy by 80%; cohorting patients by 72% and cancelling elective procedures by 66%. However, regional differences were found for the latter: among the 20 hospitals that reported difficulties in cancelling elective procedures, 11 of them are located in Wallonia (61% of the Walloon responding hospitals) and 5 in Brussels (all responding hospitals in that region). Among the 36 responding Flemish hospitals, only 5 (14%) stated that the cancellation of elective procedures was difficult. Respondents encountered the following difficulties when cancelling elective and unnecessary care. First, many discussions were needed within hospitals to agree on which medical interventions could be postponed. Next, the annulation of so many appointments on such a short notice required a huge logistic/administrative operation.

Actions concerning hospital beds did not seem to pose major problems either: 66% stated that it was easy or very easy to increase or reallocate beds or services and 61% to make architectural adaptations. Nevertheless, it was more difficult in Wallonia than in Flanders: 11 of 18 Walloon respondents (61%) found it was difficult to increase or reallocate beds or services and the same proportion found it was difficult to make architectural adaptations. In Flanders, only 8 out of 36 responding hospitals (22%) reported difficulties to increase or reallocate beds or services and 6 out of 32 (19%) to make architectural adaptations. In Brussels, the proportions are respectively 100% and 50% (out of four respondents).

The reallocation of units to COVID-units resulted in discussions within the hospital. First, in some hospitals there were discussions with the medical staff because they wanted to preserve the regular medical care. It also caused difficulties with staff having to change discipline (expertise, culture, etc.). Re-allocating staff was not easy because of competency problems (i.e.

ICU competencies), staff being anxious, shortage of staff, concertation with social partners, and the lack of PPE did not help to motivate them to work on a COVID-unit. Although a large proportion of staff showed willingness to

KCE Report 335 Hospital surge capacity in Belgium during the first wave of the COVID-19 pandemic 111

work overtime or work more than the regular contract time, it was mentioned that working on COVID-units is physically (i.e. because of PPE) and mentally exhausting. Given the long duration of the crisis, it was mentioned that this is not the most appropriate strategy. Also some hospitals reported an increasing rate of absenteeism.

To separate (cohorting) COVID from non-COVID patients there were some practical infrastructural changes that caused problems (e.g. creating a separate entrance at the emergency department). Another problem was the lack of testing capacity and the period of uncertainty (awaiting test results).

Figure 6 – Perception of the ease to implement actions within the hospital emergency plan

112 Hospital surge capacity in Belgium during the first wave of the COVID-19 pandemic KCE Report 335

Lack of nurses with ICU expertise, space and PPE were major issues to increase hospital capacity

When asked to what extent they experienced problems to increase their ICU capacity during the period going form 1 March 2020 to 30 April 2020 (Figure 7), 82% of the respondents found that they had to deal with PPE availability issues. Several respondents emphasized that finding PPE was the major issue for them, certainly at the beginning of the crisis. For smaller hospitals (in terms of beds) it was more difficult than for larger ones.

Also, 64% of the respondents stated that the lack of nurses with ICU expertise was an issue, while this was not the case for physicians with such expertise (mentioned as a problem by only 17% of the respondents).

Availability of sufficient space and the possibility to separate the ICU for COVID and non-COVID patients were judged as (definitely or rather) problematic by respectively 49% and 43% of the respondents. Two respondents mentioned that the cancellation of elective activity was a key reason explaining why they did not face space availability issues they would have faced otherwise. Cohorting was more difficult in hospitals with few ICU beds: among the nine respondents stating it was definitely problematic to separate ICU for COVID and non-COVID patients, the average number of licensed ICU beds is 14 (median is 9) while it is 24 (median is 14) for the 15 hospitals reporting it was definitely not problematic.

Staff absenteeism (physicians and nurses) appeared to be less a problem when ICU capacity had to be increased (evaluated as definitely or rather problematic by respectively 2% and 21% of the respondents). However, in the Brussels region, four out of the five responding hospitals stated that nursing staff absenteeism was rather problematic. The problem is also more pronounced in small hospitals: half of the responding hospitals with less than 200 beds marked nursing staff absenteeism as rather or definitely problematic.

Also equipment availability (ventilators and ECMO) did not appear as a major problem, as respectively 28% and 13% of the respondents evaluated this as definitely or rather problematic. In particular, the availability of ventilators was not an issue for university hospitals: all four responding hospitals stated it was rather or definitely not problematic. Note that only 32 hospitals answered the question regarding ECMO devices. Indeed, only 35 hospitals in Belgium dispose of such devices, 21 of them took part in the survey and they all answered to that particular question. Note that five hospitals without ECMO devices also answered the question.

KCE Report 335 Hospital surge capacity in Belgium during the first wave of the COVID-19 pandemic 113 Figure 7 – Problems experienced to increase ICU capacity during the period 1 March – 30 April 2020

The actual increase in ICU capacity is related to the problem experienced

From 4 March onward, hospitals were asked to register daily their hospital capacity data into the ICMS and from 17 March they were asked to do everything they could to create extra ICU capacity (see also Chapter 3).

Using ICMS data from 1 April, we calculated the increase in ICU capacity as the ratio between newly created ICU beds and licensed ICU beds. The 62 hospitals that responded to the survey created extra ICU beds amounting to 66% of their number of licensed ICU beds (numbers on 1 April 2020;

median is 59%, minimum is 0% and maximum is 250%).

As shown in Table 5, for each of possible difficulties to increase the number of ICU beds, hospitals that experienced problems created less extra capacity than those that for whom the establishment of extra ICU beds posed no problems. For instance, hospitals that stated that space availability was definitely problematic created on average 36% extra ICU capacity, while those reporting that space was definitely not problematic created on average 80% extra ICU capacity.

114 Hospital surge capacity in Belgium during the first wave of the COVID-19 pandemic KCE Report 335

Table 5 – Extra ICU beds actually created on 1 April 2020, by problems experienced to increase ICU beds Problems to increase ICU beds Definitely yes Rather yes Rather no Definitely no

Average percentage of extra ICU beds created (median) Cohort ICU COVID-unit 38% (40%) 50% (63%) 79% (83%) 66% (77%) Nurses with ICU expertise 53% (50%) 75% (59%) 66% (63%) 66% (77%) Physicians with ICU expertise 46% (46%) 55% (48%) 62% (60%) 75% (79%) Nursing staff absenteeism 38% (50%) 65% (59%) 61% (58%) 73% (77%)

Physician absenteeism 42% (42%) 67% (60%) 64% (58%)

Space availability 36% (38%) 64% (59%) 63% (55%) 80% (83%) Appropriate ventilators availability 59% (41%) 62% (50%) 65% (63%) 67% (50%) ECMO availability 35% (35%) 84% (84%) 60% (50%) 63% (50%) PPE availability 57% (54%) 64% (50%) 68% (77%) 116% (83%)

The number of respondents in each category is given in Figure 7. Source of data for extra capacity created on 1 April: FPS Public Health.

5.2.4 Strategies related to staff to ensure sufficient ICU capacity