Registration of hospital capacity and use

g An organigram of the HTSC committee can be found at

https://www.health.belgium.be/sites/default/files/uploads/fields/fpshealth_the me_file/organigram_htsc_nl.pdf and

2.5 Issues discussed

The HTSC committee discussed many issues related to the organisation of the hospital activities in the COVID-19 crisis, varying from stopping and resuming of regular hospital activities, testing of personnel and patients on COVID-19, availability and use of personal protective equipment (PPE), regulation of hospital visitors, transport of patients to/from/between hospitals, cooperation with and support to nursing homes, intermediate care structures, case definitions, international cooperation, and many others.

One issue, directly related to the HTSC committee’s main mission, was discussed in each meeting: the availability/occupancy of hospital (ICU) beds, and the number of (new) patients admitted and discharged.

Hereafter, we discuss in more depth the issues that were discussed in the HTSC committee meetings and were reflected in the letters of the committee to the acute hospitals (see Chapter 3).

2.5.1 Registration of hospital capacity and use Bed availability and bed occupancy

Since the main focus of the HTSC committee is to monitor hospital capacity to treat COVID-19 patients, figures on available capacity and on the number of admissions of COVID-19 patients were discussed in each meeting; these figures were discussed at the national and provincial level.

Hereto, the HTSC committee used data from two surveys that hospitals had to fill out daily: the “Incident Crisis Management System” (ICMS)^h and the

“hospital surge capacity” (HSC) survey of Sciensano.

https://www.health.belgium.be/sites/default/files/uploads/fields/fpshealth_the me_file/organigram_htsc_fr.pdf.

h ICMS is a software platform, developed as part of the federal hospital emergency plan, and each Belgian hospital has access to it. The manual of

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

In the letter of 04/03 hospitals were asked to register daily their hospital capacity data into ICMS and send these daily before 11am to the federal authorities. Next to this ICMS registration, hospitals were required in the letter of 10/03 to fill out daily a questionnaire from Sciensano with information about hospital bed occupation. This became legally obliged on 30/04 after publication in the Belgian Official Journal (“Belgisch Staatsblad”/”Moniteur belge”)⁹.

According to the text in the Belgian Official Journal, the following data had to be filled out daily:

• in ICMS, per hospital site:

o available capacity of beds, on which patients with COVID-19 could be admitted

o available capacity of ICU-beds, on which patients with COVID-19 could be admitted

o number of available ventilators

o number of available extracorporeal membrane oxygenation (ECMO) machines

• in the Sciensano HSC survey, per hospital, and split by confirmed and suspected COVID-19 cases:

o total number of hospitalised patients with COVID-19

o number of newly (since previous survey) admitted patients with COVID-19 (split by patients that were directly admitted to the hospital and patients that were referred form another hospital) o number of patients with COVID-19 on the ICU

o number of patients with COVID-19 that are mechanically ventilated o number of patients with COVID-19 receiving extracorporeal

membrane oxygenation (ECMO).

Both surveys asked for aggregated data. An example on how these data (27/03) were discussed in the HTSC committee is shown in Box 1.

This scheme was discussed in each meeting; the new daily numbers were compared to the numbers of the day before and in each meeting the committee formulated lessons learned from the numbers (e.g. increasing pressure of COVID-19 patients in some hospitals or regions and if transfers to other hospitals or regions are required; total pressure on hospital (ICU) beds and if additional capacity should be created).

Numbers were mostly only compared to the day before and only the minutes of the meeting (MM) of 18/05 contained a chart (Figure 2) in which numbers over a longer period were presented.

the ICMS can be found at https://sites.google.com/view/icms-elearning/home?authuser=0.

KCE Report 335 Hospital surge capacity in Belgium during the first wave of the COVID-19 pandemic 21

Box 1 – Daily data available to the HTSC committee, example of 27/03/2020 Sciensano

• Response 97% (12:00h)

• Hospitalised

o Confirmed: 3637 (yesterday: 3042) o Suspected: 1358 (yesterday: 1369)

• In ICU

o Confirmed: 770 (yesterday: 690) o Suspected: 87 (yesterday: 103)

• New patients – not referred

o Confirmed: 548 (yesterday: 490) o Suspected: 775 (yesterday: 749)

• New patients – not referred o Confirmed: 13 (yesterday: 11) o Suspected: 9 (yesterday: 9)

• Discharged – not referred

o Confirmed: 201 (yesterday: 183) o Suspected: 205 (yesterday: 162)

• Discharged – not referred

o Confirmed: 15 (yesterday: 11) o Suspected: 11 (yesterday: 4)

• Ventilated

o Confirmed: 566 (yesterday: 498) o Suspected: 33 (yesterday: 47)

• ECMO

o Confirmed: 16 (yesterday: 11) o Suspected: 1 (yesterday: 0)

• Deceased

o Confirmed: 57 (yesterday: 74) – total 386 o Suspected: 17 (yesterday: 15) – total 152

• Number on provincial level (17:00h) o Antwerpen: 627

o Brabant Wallon: 56 o Brussel-Bruxelles: 579 o Hainaut: 451

o Liège: 388 o Limburg: 353 o Luxembourg: 84

ICMS

• 119 of the 128 hospital sites shared their data by 11h08:

o Currently, there are in total, regardless of specialism (ICU or COVID-19) 11 803 beds available.

o There are 2 973 beds on hospital units foreseen for COVID-19 patients.

o The hospital sites have foreseen a complementary capacity of 869 beds on ICU.

o Currently there are 806 beds on ICU available for admission of COVID-19 patients.

o 547 beds on ICU remain available for admission of non-COVID patients.

o A total of 610 ventilators are available on 119 hospital sites.

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

o Namur: 79

o Oost-Vlaanderen: 393 o Vlaams-Brabant: 217 o West-Vlaanderen: 409 o Military hospital

Figure 2 – ICU availability and occupancy between 20 March and 17 May 2020

Source: HTSC committee meeting minutes 18/05/20

KCE Report 335 Hospital surge capacity in Belgium during the first wave of the COVID-19 pandemic 23

During the meeting of 11/05, it was decided to add a new parameter to the data discussion: the acceleration rate. This was defined in the MM as the number of new patients with COVID-19 (confirmed and suspected) admitted on a given day in percentage of the number for the day before as well as in percentage of the average number of the seven previous days (“Het aantal nieuwe patiënten (nieuwe gevallen bevestigd en verdacht) in percentage afgezet tegen het gemiddelde van 1 dag en het gemiddelde van 7 dagen ervoor op ziekenhuisniveau.”). This was calculated per hospital. In this way the HTSC committee could better detect and estimate an increase/decrease in pressure to the hospitals and locate regional problems and take appropriate actions (e.g. transfer to other hospitals / regions).

Additionally, the MMs of 25/03, 26/03 and 27/03 mention a data-visualisation tool from DNalytics made available for HTSC committee members, but it is not clear to what extent this was used and which data were visualised by the tool.

Also some MMs mention the use of a prediction model(s) by the HTSC committee (MM of 07/04: “Predictiemodel van Lise R en PWC wordt door ons gebruikt om de trends in opnames te volgen”), but it did not came clear from the minutes how this tool/model was applied or used to inform decisions and if eventual other models were also used.

By discussion of all above numbers, the HTSC committee could see if available (ICU) bed capacity was in balance with bed occupancy and new admissions of COVID-19 patients. In this way it could decide if additional capacity had to be created or if hospitals in some regions were saturated and if inter-hospital transport was needed (regulation).

However, it appeared from several HTSC committee minutes that there were often and recurrent data problems: hospitals not reporting daily, missing data, mismatches between the HSC survey and ICMS numbers, changes in

i This was recognised by the HTSC committee and therefore an external consultancy group (KPMG) was invited to the meeting of 28/03 to hear if they could develop a tool on human resource availability. However, it is not clear from the MM what happened with the KPMG proposal.

data definitions, wrong data input, unclear operationalisations of variables, and other. At several times it was mentioned in the MM that the HTSC committee lacked a good view on available (ICU) beds and available number of ventilators and ECMO equipment and there was a kind of mismatch between licensed and extra created beds and de facto available operational beds (so including personnel to care for a patient on a ICU bed);

the same applied to ventilators and ECMO equipment. The HTSC committee lacked view on available human resourcesⁱ.

All this made the interpretation of capacity and occupancy difficult and it required changes to the surveys and communication to the hospitals. Also from reactions of the hospitals to the HTSC committee, it became clear that there were interpretation difficulties on how to fill out both questionnaires.

During the crisis, the HTSC committee also decided (MM 18/04, 24/04) to organise additional single surveys to hospitals on top of the Sciensano and ICMS daily surveys, e.g. on the number of ventilators and ECMO equipment.

The discussions in the HTSC committee on availability and occupancy of hospital (ICU) beds led to several letters to the acute hospitals in which instructions were given on registration of data.

MM 31/03 “Omwille van blijvende onduidelijkheid zou ik graag binnen ICMS volgende wijzingen in de omschrijvingen laten uitvoeren.”

MM 04/04 “Minder ICU bedden in ICMS dan dat wij menen te weten.”

MM 17/04 “Cijfers m.b.t. capaciteit die gegeven worden door Sciensano lijken niet overeen te komen met onze gegevens.”

MM 04/05 “Discordantie tussen de gegevensverwerking van capaciteit volgens Sciensano en volgens ICMS.”

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

MM 19/05 “De case definition van Sciensano zorgt voor blijvende onduidelijkheid. De ziekenhuizen hebben elk hun interpretatie, waardoor dit mogelijks van invloed is op de totale cijfers die we krijgen van Sciensano.”

MM 28/05 “Er is een verkeerde inschatting voor de beddencapaciteit.

De cijfers uit ICMS stemmen niet overeen met de realiteit.”

Length of (ICU) stay

Next to the Sciensano HSC and ICMS data described above, it appeared from the meeting minutes that length of stay (LOS) in hospital and ICU was felt as a central factor that influenced largely availability of beds and in consequence the number of needed extra beds. However, neither the Sciensano HSC survey nor the ICMS provided data on that.

The problem of missing information on (ICU) length of stay was first signalled in the MM of 04/04 and it was decided to send a specific survey to the hospitals concerning LOS that should be returned by 06/04. This survey had many limitations according to the MM of 07/04, but it showed that between 67-73% of the ICU-admitted COVID-19 patients required ventilation therapy on ICU and that the minimal length of ICU stay should be estimated at minimally 10 to 15 days and that mean length of ICU stay might be approximately 21 days (La durée minimum d’une personne (hors décès devrait être au minimum de 10 à 15 jours) et il est probable que la valeur moyenne soit plus proche de 21 jours) when used as input variables for the prediction models.

In the MM of 08/04 it is signalled that Sciensano is also gathering data about LOS and that the committee would ask Sciensano for further information.

Length of stay could be derived from the voluntary individual patient clinical

j Detailed information on the variables in the clinical survey can be found in Appendix 2 of Van Goethem et al. 2020.¹¹

k On 02/07 Sciensano published a report¹² that stated that the median LOS of the confirmed COVID-19 patients was 8 days (P25=4; P75=14) and for

survey that was initiated by Sciensano. Hospitals were asked (but it was not obligatory) to fill out a survey for each (confirmed) COVID-19 patient at admission and at discharge.¹⁰ The survey contained questions on clinical parameters^j, ICU use, ICU LOS and of course an admission and discharge date, from which LOS could be calculated.¹¹ However, this clinical survey did not cover all patients (for 76% of admitted COVID-19 patients admission and discharge data were filled out) and was not filled out by all hospitals (n=97).

In the MM of 28/04 it was again signalled that the HTSC committee missed important information about LOS and that a new survey to hospitals should be organised and that it was of utmost importance to receive information from Sciensano on what they gathered on LOS data. On 30/04 the HTSC committee discussed the dispersion of COVID-19 patients across regular units and ICUs and differences in this between hospitals, but this raised even more questions and showed lack of essential information.

Nevertheless, it was decided to put the intended new survey on LOS on hold until more information was received from Sciensano.

On 04/05 Sciensano joined the HTSC committee and informed the committee about the individual patient clinical survey it was doing and what type of results could be expected (however, without presenting actual results). In this meeting of 04/05 it was also questioned whether these individual patient clinical survey should be mandatory. On 07/05 Sciensano joined again the HTSC committee and its clinical survey was again discussed. On 14/05 and 28/05 Sciensano came to the HTSC committee and presented preliminary data from the clinical survey, but nothing specific about LOS^k. No further mentions were made in the HTSC committee minutes neither on new LOS data nor on the intended new survey to the hospitals (unclear if it has been sent or not).

patients that required ICU the median ICU LOS was 8 (P25=4; P75=17); later on (21/07) an article concerning LOS was published on behalf of The Belgian Collaborative Group on COVID-19 Hospital Surveillance, based on the Sciensano individual patient data admission/discharge survey and presenting the same results concerning LOS.¹³

KCE Report 335 Hospital surge capacity in Belgium during the first wave of the COVID-19 pandemic 25

Conclusion on data discussions in the HTSC committee

In conclusion, the HTSC committee discussed the availability and occupancy of hospital / ICU beds in every meeting to its best ability based on the available aggregated data from the Sciensano HSC survey and ICMS.

However, the discussions were compromised due to the suboptimal data quality and due to the lack of data. As a consequence the surveys needed several adaptations and extensions during the COVID-19 crisis and this had to be communicated to the hospitals.

The HTSC committee lacked important information to fulfil its mission. For example, number of infected persons in the general population, number of infected patients in residential care settings, number of deaths, length of stay, number of (available and appropriate) healthcare professionals, number of non-COVID-19 patients requiring hospital care, evolution over time of the parameters, and other. In this way it was difficult for the HTSC committee to have a clear view on the (expected) pressure on the hospitals and to anticipate adequately in organising (extra) hospital capacity.