Role of public authorities to increase hospital capacity

We asked hospitals how they see the role of public authorities so that sufficient hospital capacity can be provided in case of a future crisis such as the COVID-19 crisis. Almost all responding hospitals totally agreed with at least one of the suggested areas of involvement. In case they did not agree, they were invited to explain why. As shown in Figure 14, in general, public authorities’ involvement in various areas of action is demanded by a large majority of hospitals.

124 Hospital surge capacity in Belgium during the first wave of the COVID-19 pandemic KCE Report 335 Figure 14 – Perceived role of public authorities to ensure sufficient hospital capacity in case of a crisis such as the COVID-19 crisis

Involvement of public authorities is requested in various areas

All responding hospitals agreed (totally agree or rather agree) that public authorities must keep a strategic (rotating) stock of personal protective equipment and increase the attractiveness of the nursing profession (see Figure 14). This attractiveness should be ensured through an improvement of the staffing norms rather than by an increase in remuneration (although still 48 respondents (84%) rather agree or totally agree with that option). The respondents that do not agree with “increasing attractiveness of the nursing profession via remuneration” indicated that salary is only a temporary motivator. They stressed that higher priority should be given to a change in

working conditions by adapting staffing standards (i.e. less patients assigned to one nurse) and the content of the work (i.e. task substitution).

Almost all responding hospitals (rather or totally) agreed that public authorities should organise an external liaison with nursing homes (98%) and with general practitioners (GPs) (96%).

Most respondents also believed that public authorities should pay for having buffer capacity, at the hospital level (93%) more than at the loco-regional network level (74%). Financing buffer capacity is not regarded as an efficient or priority solution by all. Some respondents argued that financial means are limited and should not be used to finance empty beds. The respondents that were not in favour of financing buffer capacity at the network level referred

KCE Report 335 Hospital surge capacity in Belgium during the first wave of the COVID-19 pandemic 125

to the problems currently encountered with organising services at the network level. They consider the loco-regional networks as dysfunctional or too immature and therefore preferred to have buffer capacity at the level of individual hospitals. One respondent indicated that a more pragmatic approach than financing buffer capacity is to downscale elective and postpone non-necessary care in case of capacity needs.

For 87% of the respondents (47 hospitals), public authorities should guarantee the development of digital healthcare applications, although the terminology has been considered as too vague.

The creation of a care programme for infectious diseases is also something that public authorities should ensure, according to 43 respondents (80%). It is less the case for a care programme for respiratory diseases (selected by 32 respondents – 60%). The respondents that did not agree with a respiratory care programme as a potential solution for the future argued that in future crises respiratory problems might not be the main problem. In addition, a respondent indicated that infection prevention and control is already well structured in hospitals.

Forty-seven respondents (82%) stated that public authorities should ensure that the role of loco-regional networks is defined. Those who did not agree indicated that the crisis demands a supra-regional approach, that hospitals are professional enough to make arrangements at the most appropriate level when required, and that loco-regional networks do not work well.

Opinions were more divided regarding the role of public authorities in maintaining the knowledge and expertise of former ICU staff members, for example via additional training (71% agree for nursing staff, and 63% for medical staff). Maintaining expertise of former ICU nurses and physicians can be very difficult for several reasons. First, people who left the field have their reasons. Opponents argued that it will be difficult to motivate them to return to ICU care or to keep this specific expertise up to date when not involved in daily ICU practice. Several respondents indicated that it is important to improve working conditions such that retention rates improve.

Moreover, for nurses the importance of improving staffing standards was emphasized as an important element to increase retention rates.

Only few additional suggestions were given. A recurrent theme was the reinforcement of primary care services (e.g. role of primary care zones, external liaison function of hospitals). Yet, respondents also stated that when these additional roles become structurally embedded, an appropriate payment is an essential precondition.

5.2.9 Hospital emergency plans

A hospital emergency plan (HEP) defines what needs to be done in case of a disaster inside (e.g. blackout, chemical accident, hospital bacteria, etc.) or outside (e.g. chain collision, flood, attack, etc.) the hospital. Each hospital must have such plan. We refer to Chapter 1 for a description of the procedure for approval and the content of a HEP.

Most plans were ready but not approved yet

One of the steps in the procedure of approval is the advice of the municipal authorities. This advice can be favourable, favourable with conditions or unfavourable.

As shown by Table 6, 92% of the responding hospitals submitted their HEP to the municipal authorities for approval but most of them (64% of the respondents) had not received a response on 1 March 2020. Most of the hospitals that received a response (for a large part between November 2019 and January 2020), the advice was favourable without conditions (25% of the respondents). None of the respondents had an unfavourable answer.

One respondent (not accounted for in Table 6) mentioned that the status differed depending on the considered site of the hospital. Indeed, the HEP (and its approval) is made for each hospital site, while the survey has been carried out at the hospital level.

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

Table 6 – Status of the hospital emergency plan on 1 March 2020 Flanders

(n=32) Wallonia

(n=17) Brussels

(n=4) All

respondents (n=53) Submitted but no

response yet 20 (63%) 12 (71%) 2 (50%) 34 (64%) Favourable 8 (25%) 4 (24%) 1 (25%) 13 (25%) Subject to

conditions 2 (6%) 0 (0%) 0 (0%) 2 (4%)

Unfavourable 0 (0%) 0 (0%) 0 (0%) 0 (0%)

Not submitted yet 2 (6%) 1 (6%) 1 (25%) 4 (8%)

Hospitals activated the HEP action phase before it was required by the committee

Hospitals were asked to provide the date at which they activated the information phase, action phase 1 and, if they did so, action phase 2 of their HEP. Thirty-nine hospitals provided data about the three phases. On Figure 15, each line represents one of these hospitals. Twenty-four of them activated action phase 1 of their HEP before it was made mandatory on 14 March. For most hospitals this happened in the week before 14 March, but in some hospitals, action phase 1 was already activated at the end of February or early in March. These are mostly very large non-university hospitals: five of the nine hospitals who activated action phase 1 before 5 March have more than 450 beds.

Some hospitals activated action phase 1 after 14 March, but not long after (the last one on 19 March). From Figure 15, it can also be seen that some hospitals activated the information phase of the HEP quite early (the first one already in January). These are also mainly very large hospitals: among the 12 non-university hospitals who activated the information phase before March, eight have more than 450 beds.

Out of the 39 hospitals considered here, 22 activated action phase 2 (before 30 April). Most of them did it very shortly after 14 March, some of them even switched directly form information phase to action phase 2. A few hospitals activated the second phase later on.

KCE Report 335 Hospital surge capacity in Belgium during the first wave of the COVID-19 pandemic 127 Figure 15 – Date of activation of the HEP phases per hospital

Each horizontal bar represents one hospital (n=39).14 March 2020 is the date at which all hospitals were asked by the HTSC committee to activate the action phase of their HEP (see Chapter 1).

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

From 17 June, hospitals were authorized to scale down to the information phase provided that all hospitals of a loco-regional network do so at the same time. This is only possible if the entire network has a COVID-19 load (confirmed and suspected) of less than 15% of the licensed ICU beds.

Between 19 June and 1 July, at least 19 of the 25 loco-regional networks in the country have confirmed scaling down to information phase (data FOD – SPF).

Hospitals are in favour of adding a pandemic plan to the hospital emergency plan

In half of the responding hospitals (27 out of 52), the current HEP already contains a pandemic plan (defined as a specific part of the HEP related to the occurrence of a large-scale infectious disease in the general population).

The vast majority of the respondents (49 out of 53 – 92%) believed such a pandemic plan should be included in the HEP. However, one respondent stipulated that such a pandemic part could not provide an answer to all problems hospitals were faced with during the first wave (e.g. lack of PPE).

All except one of the hospitals already having a pandemic part in their plan stated such part should be included.

Recurrent elements that should be included in such a pandemic plan are:

identification outbreak infectious diseases (intern and extern) and activation of the plan, specification of different phases and thresholds, up- and downscaling of regular care, upscaling staff and (ICU) beds, composition of the hospital coordination cell, communication, isolation and cohorting of patients, PPE and medication stock management, collaboration within the loco-regional network and with primary care, visitor rules and instructions, instructions for ambulatory patients, education of staff, data collection and analysis, transition from acute phase towards a situation of long duration.

According to the minority that did not support the idea of adding a specific pandemic plan, the HEP has the objective to have processes in place in hospitals that enable them to react quickly in acute crisis situations. Although the acute onset of the COVID-19 pandemic created an acute crisis, the duration of the pandemic requires a different approach. A respondent stated that the pandemic preparedness (e.g. early warning systems, stock

management) is more a role of the public authorities than that of individual hospitals. Another argument against a specific pandemic plan given by respondents is that the type of pandemic can differ.

Hospital coordination cell: core members supplemented by crisis-dependent participants

When the HEP is activated, the hospital coordination cell (HCC) takes over the coordination and command and makes subsequent decisions for the hospital. The mode of activation of the HCC and its nominative composition are mentioned in the HEP. However, additional members can be called upon depending on the emergency. Respondents to the survey had to list the persons who took part in the HCC in the period from 1 March to 30 April 2020. Some possible members were suggested, but respondents had the possibility to add more. As shown in Table 7, in all 57 responding hospitals, the CMO and the CNO took part in the HCC. In all but two Flemish hospitals, the CEO took part in the HCC and in two other ones there was no HEP coordinator in the HCC. In most hospitals, also a hospital physician or nurse hygienist and the head physician of ICU were member of the HCC. In addition to these suggested members, 22 hospitals added the head physician or nurse of the emergency department and 17 added someone from the communication department. These functions are among the ones that usually are a member of the HCC, whatever the type of crisis.

Apart from the usual members, pharmacists, infectiologists, pulmonologists and the logistic department were each cited as members of the HCC by nine hospitals. Many other participants were cited (those cited by 5 hospitals or less are not shown in Table 7) coming from diverse hospital departments:

purchasing, technical, facility, clinical biology or labs, care management, ICT, administrative and financial, medical board, internal medicine, surgery and anaesthesia, prevention, biosafety, bed management, geriatrics, liaison with nursing homes, etc.

It is worth noting that several hospitals explained that at least part of the added members were not present at all meetings, but were invited when needed. In addition, one respondent stated that it is important to keep the HCC as flexible as possible, i.e. not increasing the list of mandatory

KCE Report 335 Hospital surge capacity in Belgium during the first wave of the COVID-19 pandemic 129

members, but let the opportunity to invite additional participants when needed, also depending on the type of crisis. For instance, although the involvement of infectiologists and labs was relevant in the COVID-19 crisis, it may not be in other cases. One hospital created two cells: a medical one and an organisational one. One large hospital with several sites mentioned the HCC was supplemented by a central working group and a hospital command post as decision-making body in each individual site.

Table 7 – Participants in the hospital coordination cell in the period 1 March – 30 April 2020

Number of

hospitals % of responding hospitals (n=57)

Chief medical officer 57 100%

Chief nursing officer 57 100%

Chief executive officer 55 96%

Coordinator HEP 55 96%

Hospital physician hygienist 52 91%

Hospital nurse hygienist 42 74%

Head physician ICU 45 79%

Head (physician or nurse)

emergency department* 23 40%

Communication department* 17 30%

Pharmacist* 9 16%

Logistic department* 9 16%

Infectiologist* 9 16%

Pulmonologist* 9 16%

Human resources department* 9 16%

Purchasing department* 6 11%

Technical department* 6 11%

Facility department* 6 11%

Clinical biology departments – labs* 6 11%

Members with a * were not suggested in the survey but were added by the respondents. Members cited by 5 or less respondents are not shown in the table.

The hospital coordination cell held daily meetings in most hospitals As shown in Table 8, the HCC had daily meetings in 71% of the hospitals and three to six times a week in 26% of them. Four hospitals (from which two answered “daily” and two answered “three to six times a week”) specified that the HCC met daily at the beginning or at the peak of the crisis, then decreased the frequency to three to six times a week. Four hospitals even reported that the HCC had more than one meeting per day at the peak of the crisis.

Table 8 – Frequency of HCC meetings during the period 1 March – 30 April 2020

Letters from the HTSC committee were discussed within the hospital coordination cell

In almost all hospitals (57 out of the 58 responding hospitals) most, or even all, of the letters from the HTSC committee were discussed within the HCC:

55% discussed all of them and 43% most of them. The only hospital in which the letters were not discussed in the HCC pointed out that the letters were not comprehensible enough and contained irrelevant information. This hospital indeed ranked four of the nine measures in Table 3 as (rather or definitely) not clear (see Figure 4).

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

The HCC appealed to several existing or new committees for support In an open-ended question, respondents were asked to describe the advisory committees that were set up by the HCC or existing committees it appealed to for support. Several committees were reported by the respondents. The most commonly reported was the hospital infection prevention and control committee, yet a plethora of other committees was reported such a nursing home support committee, HR committee, laboratory committee, PPE committee, etc.

Hospitals are engaged in internal evaluation processes

Most hospitals carried out an internal evaluation of their HCC (54 out of the 58 responding hospitals – 93%) and/or their HEP (44 hospitals – 76%).

Hospitals plead for simplification, automatisation and centralisation of capacity data

The HEP also defines data registrations on the available hospital capacity in the “Incident Crisis Management System” (ICMS) platform. In the letter of 4 March, the HTSC asked hospitals to register daily their hospital capacity data in ICMS and send these before 11am to the federal authorities.

In an open-ended question, respondents were asked to describe the main potential areas of improvement for the ICMS data in the context of a pandemic compared to the current registration (September 2020). Several respondents gave suggestions to improve the ICMS registration.

Respondents stated that it is important to make the ICMS platform more user-friendly and evolve towards an automatic extraction from hospital information systems which match other data collection systems. They proposed to use one central data platform. Given the labour intensity of a manual coding system it was suggested to simplify the system (e.g. less variables, one data submission per hospital and not for each hospital site) and to avoid redundant data requests (e.g. ECMO data via ad-hoc survey and ICMS).

Other suggestions were to make the coding instructions simple and clear.

Also, to enhance the motivation of hospitals to register the necessary data there should be a benefit in return (e.g. data transparency, feedback reports, dashboard at regional level). Although some respondents stated that the ICMS registration is too detailed, others suggested to register additional variables such as type of isolation rooms (negative and positive pressure), the total capacity of the ICU including the maximal number of additional capacity (not only the available beds). The frequent and fast changes in terminology and definitions were considered as a burden and a source of frustration for hospitals. Several respondents stated that this should be avoided in the future.

Another comment was that the ICMS data only give a static view on hospital capacity (one moment in a day) which can rapidly change. Nevertheless, several respondents questioned the appropriateness/usefulness of a daily ICMS data registration.