Strategies related to staff to ensure sufficient ICU capacity

Among all strategies to increase hospital capacity suggested in the survey (see questions C3 to C8 in Table A. 5 in Appendix), the ones related to staff (in particular nurses) were the most often pointed out by respondents.

Virtually all respondents selected at least one of these strategies (see Figure 8). Adjustments in working agreements (i.e. increasing labour time) had to be made for nursing staff (Figure 8) as well as for physicians (Figure 9).

Additional non-care staff was required, especially cleaning staff (Figure 10).

KCE Report 335 Hospital surge capacity in Belgium during the first wave of the COVID-19 pandemic 115 Figure 8 – Strategies related to nursing staff implemented by hospitals to ensure sufficient ICU capacity during the period 1 March – 30 April 2020

Mixed teams and training, but no increase in patient-to-nurse ratio As shown in Figure 8, almost all hospitals (52 out of the 62 respondents – 84%) deployed nurses at the ICU who were not originally affected there but had an expertise in intensive care (such as those working in emergency departments, recovery rooms, operating theatres, etc.). They also had to create mixed teams including nurses both with and without expertise in ICU:

47 hospitals (76%) implemented such a strategy. Thirty-two hospitals (52%) relied on former nurses with ICU expertise and 29 (47%) deployed nurses from general units to work at the ICU during the crisis. On the contrary, only 10 hospitals (16%) deployed students. To work in an ICU, small hospitals (less than 200 beds) relied more than others on nurses from general units

and much less on nurses from units with ICU expertise such as emergency departments or recovery rooms, on students and on former nurses.

Alongside, hospitals provided training to nurses from units related to ICU (39 hospitals – 69%) but to a lesser extent to nurses from general units (17 hospitals – 27%). Training to nurses from units related to ICU was much more common in Flanders than in the other regions (79% of the responding hospitals, compared to 40% in Brussels and 37% in Wallonia). Half of the respondents (32 hospitals – 52%) said they had to adapt working agreements (i.e. increase in labour time) of the nursing staff, but Flemish hospitals relied less on this solution than those in Brussels and Wallonia.

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

Among the other strategies related to staff that were implemented by the hospitals during the crisis, respondents cited the recruitment of temporary staff, the deployment of teachers in nursing or nurses working in other sectors as well as the transfer of some nursing tasks to available physicians.

Another possible strategy was to increase the patient-to-nurse ratio. This strategy was applied by 11 hospitals (18%), mainly located in the province of Limburg, Brussels and Vlaams-Brabant. It is, however, not possible to ascertain whether the above-mentioned strategies to increase the number of nurses has had an impact on the necessity to adapt the number of patients per nurse.

Availability of medical staff was less an issue, and solutions existed, at least for large hospitals

As previously shown (Figure 7), hospitals experienced less issues in finding physicians with ICU expertise than nurses with such expertise. Several large hospitals mentioned that they had sufficient intensivists and therefore did not have to put any strategy in place in order to find physicians with ICU expertise. As shown in Figure 9, 36 hospitals (58%) relied on physicians who were not originally affected at the ICU but had an expertise in intensive care (such as anaesthetists or physicians working in recovery rooms or emergency departments). Among the ten hospitals reporting that the

number of physicians with ICU expertise was problematic (Figure 7), eight relied on such strategy, and one small hospital transferred its COVID patients to another hospital. Sixteen hospitals (26%) reported deploying physicians from general units to work at the ICU. Globally, larger hospitals tended to rely more on physicians from units that are ICU-related, while small hospitals relied more on physicians from general units. When large hospitals deployed physicians from general units to work at the ICU, it was generally in addition to physicians from ICU-related units. Specialists in training were also deployed at the ICU in 23 hospitals (37%), mostly large or university ones. Only five hospitals relied on former ICU physicians.

As for nurses, training for physicians took place in some hospitals. Fifteen hospitals organised a fast-track training for physicians usually working in units related to intensive care, although only nine of them reported actually relying on such physicians to work in ICU during the crisis. In the same way fourteen hospitals (for a large part the same as the previous ones) organised a fast-track training for physicians working in general units, but only nine of them actually deployed them at the ICU. In addition, both kinds of training were much more common in Flanders than in the other regions. Only three hospitals in Wallonia (amongst the 19 responding hospitals) organised such fast-track training, and none in Brussels.

KCE Report 335 Hospital surge capacity in Belgium during the first wave of the COVID-19 pandemic 117 Figure 9 – Strategies related to medical staff implemented by hospitals to ensure sufficient ICU capacity during the period 1 March – 30 April 2020

Large involvement of non-caring staff and allied health professionals Alongside nurses and physicians, hospitals heavily relied on additional staff in other domains (see Figure 10) such as cleaning staff (48 hospitals – 77%), maintenance staff (31 hospitals – 50%), technical staff (22 hospitals – 35%), laboratory staff (20 hospitals – 32%) but also logistic staff, administrative staff, paramedical staff, physiotherapists, speech therapists, occupational therapists or staff to monitor dressing and undressing procedures. In addition, one hospital mentioned that even if no additional staff was deployed, the current staff had to work many additional hours.

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

Figure 10 – Strategies related to other staff implemented by hospitals to ensure sufficient ICU capacity during the period 1 March – 30 April 2020

5.2.5 Strategies related to beds to ensure sufficient ICU capacity