SURVEY ABOUT STRENGTHS AND WEAKNESSES OF THE HOSPITAL EMERGENCY

The HTSC committee invited hospitals on 22 June to participate in a survey to provide input for an initial evaluation of the form, structure and operation of the hospital emergency plan (HEP). One of the aims of the survey was “to optimise the operation and communication of the committee”, but the answers to the questions were also meant “to serve as a first step of a broader evaluation of the risk cycle”.

Hospitals were asked to discuss a list of questions within the hospital coordination cell and to provide a concise, structured summary of up to 2 000 characters per question by completing an online form. The deadline for the survey was 13 July 2020.

Two experts of the Federal Public Service (FPS) Public Health (Service:

emergency medical care), processed the answers following the structure of the questions and subquestions. This resulted in a document of 19 pages in Dutch, with a detailed list of answers, mainly presented in the form of (sub)bullet points. The selection of answers or the way they were described (or translated for the French-speaking hospitals) was based on the insights of the two experts. This document is not publicly available, but was made available to the KCE team for this study. Here, we only discuss the main findings, and give some examples to illustrate them.

6.2.1 Preparation phase of the hospital emergency plan

Hospitals were asked which measures they had taken before the activation of the HEP, related to the organisation, logistics, purchase, and update of the plan.

From the HTSC-survey it appears that hospitals already put in operation their HEP, either in the “information phase” or in the “action phase” (see Chapter 1), before this was imposed by the HTSC committee. According to the hospitals, the HEP was very helpful:

• to define the respective roles within the HEP

• for the internal and external (e.g. with other healthcare settings or with the municipality) consultation or communication

• for the organisation of specific groups related to the hospital coordination cell (e.g. outbreak control cell)

• to take measures concerning human resources (e.g. extra recruitment, flexible working hours, emotional support)

• to take measures concerning stocks (e.g. inventory or purchase of PPE or material)

• to take measures concerning separate patient and visitor flows

• to refine and write new procedures

• to provide training (e.g. on the use of PPE)

• to make architectural adjustments (e.g. extra walls).

Several hospitals reported that they had stopped the elective medical activities already before the directive of the HTSC committee was communicated (see Chapter 3).

Hospitals reported that the process of revising the HEPs and the experience of the hospital coordination cells (by experience or exercises) contributed to the successful response during the first wave.

KCE Report 335 Hospital surge capacity in Belgium during the first wave of the COVID-19 pandemic 149

6.2.2 The benefits of the hospital emergency plan during the first wave of COVID-19

Most hospitals reported that a clear benefit of the HEP is the activation of the hospital coordination cell. This process created a sense of urgency within the entire organisation and has several advantages:

• focus on the problem and take the necessary measures (e.g. translate influenza- and Ebola-plans into COVID-19 plan)

• a governance structure for crisis situations with a multidisciplinary composition and clear definitions, roles, task distribution and unity of command

• a frame to deal with processes in a structured manner

• the opportunity to act fast and take the necessary operational decisions at short notice

• the possibility to take decisions with a compulsory character (e.g. stop elective care, change rosters of staff)

• a model to communicate (internal and external).

6.2.3 Required adjustments to the hospital emergency plan in the context of a pandemic

Several suggestions were made to improve the current HEP. This included:

• Adding a generic pandemic section. Some hospitals stated that the current HEP was too generic, only targeting short-term crisis situations and insufficient to deal with the challenges caused by the COVID-19 pandemic. They advocated for adding a generic pandemic section to the HEP including: a roadmap with phased up- and down-scaling of the pandemic plan, phasing of outbreak plan, checklists, monitoring and dashboard system, use of prediction modelling, task distribution in case of a long-lasting crisis, architectonic guidance for cohort units, collaboration with other actors (e.g. primary care, schools, other hospitals of the loco-regional network), information gathering (e.g.

about the virus, guidelines), etc.

• Strategic stock monitoring. The severe logistic problems (e.g. shortage of medication and PPE) stressed the importance of a performant monitoring system of a strategic stock.

• Improve the financing of the HEP coordinator role. Since the coordinator of the HEP is judged to be insufficiently financed via the hospital budget, insufficient time was allocated to this role prior to the crisis.

• Increase training of the HEP processes (e.g. training sessions about HEP processes, simulations) and communication about its content (e.g.

role and tasks of the coordination cell).

• Include psychological support for staff but also psychological expertise to maintain human aspects of patient care.

6.2.4 Functioning of the HTSC committee Measures

The hospitals made several comments about the measures taken by the HTSC committee. These concerned:

• The nature of the measures (e.g. make them more compulsory:

enforcement by law; procedures to check compliance, unity of command and one clear point of contact for hospitals; more practical instead of theoretical measures).

• Measures regarding upscaling ICU were judged unrealistic because staff with this expertise was not available.

• Stopping elective care was a clear measure but the restart was too much left to the initiative of each hospital.

• No guidance about staffing issues was provided.

• The field should be more involved in drafting up the measures (e.g.

representation of the networks, CNOs, a platform of HEP coordinators).

• The measures could be linked with other initiatives such as intermediate care and primary care.

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

• Different communication channels (mail, letters, WhatsApp) should be used and the information should be addressed to other actors besides directors (such as the HEP coordinators).

• More practical support should be provided (e.g. PPE shortage, logistic support, payment system for crisis situations).

• The distribution key to transfer patients in case of local outbreaks should be provided.

• Manual registration systems should be limited and feedback about submitted data should be provided.

• There were no measures regarding psychosocial support of staff.

• Collaboration between hospitals (network) should be made compulsory.

Communication about the data

General remarks on the communication included: the use of unclear or inconsistent terminology, lack of one central point of contact, no direct feedback on questions, high registration burden, lack of transparency about data and no feedback to hospitals, and too many ad hoc surveys.

The way ICMS and Sciensano-registration guidelines were perceived differs across hospitals. Some hospitals were positive (e.g. very clear after a difficult start with many changes, examples were helpful for the understanding, online sessions were very supportive) while others were negative (e.g. unclear and ambiguous instructions, lack of definitions for key concepts, too frequent changes which were not always communicated).

ICMS was perceived as: having a user unfriendly interface (e.g. hospitals with different sites have to submit site by site) and should evolve to a system with automatic extraction of data, being used for purposes other than for what it was designed (e.g. static tool while bed management is dynamic), cannot be used for internal purposes of bed management.

Hospitals commented on the frequent changes to the Sciensano data requirements (e.g. variables, definitions at the start of the pandemic). In addition, an informed consent was not requested from patients and therefore some hospitals indicated that these data cannot be used for research.

Communication from the HTSC committee

Communication by the public authorities and content of the measures.

Hospitals indicated several issues regarding the guidelines from the HTSC committee: inappropriate timing of communication (late evening before weekend), insufficient time between communication of measures to hospitals and media (no time to inform hospital staff), rapidly changing nature of the measures, insufficient consultation of the field, measures insufficiently tailored to the local level and the long duration of HEP active phase (no formal end communicated by the authorities), need to adapt the HEPs to the particular context of psychiatric hospitals.

The responses were on several issues contradicting as they included positive (e.g. clear and well communicated content of the measures, communication via one channel, guidelines that combined efforts from federated and federal authorities, schematic figures explaining the measures) and negative comments (e.g. policy to upscale ICU was unclear in early period, rapidly changing instructions, bad timing of communication, communication perceived as lack of trust in hospitals, insufficient transparency about occupancy rates within the hospital network and beyond, disproportional measures: too much surge ICU capacity had to be provided in small hospitals) or pointed out that the composition and role of the HTSC committee was not clear.

KCE Report 335 Hospital surge capacity in Belgium during the first wave of the COVID-19 pandemic 151

6.2.5 Good practices & points for improvement Hospital level

Several good practices were named by the hospitals. These included in the first place the flexibility, motivation and professionalism of healthcare staff.

Several hospitals took initiatives to support staff (e.g. psychological support team, relaxation rooms, etc.), patients and family (e.g. skype connections, social media, practical support), the collaboration with primary care (e.g.

support of nursing homes with training and expertise, GPs working together with emergency departments on site).

Hospitals stated that work needs to be done to better support staff (e.g.

psychosocial burden of a crisis with a long duration), patients (e.g.

information that supports patients to continue to consult medical care, contact centres for patients and families). In addition several other points for improvement were listed such as clarification of the legal responsibility of the coordination cell, collaboration with other actors and internal communication flow.

Macro-level

Hospitals stated that the role of the federal health inspectors was crucial to support hospitals that faced problems that transcended the level of their hospital. In addition, the involvement of umbrella organisations in the HTSC committee was praised as a good point.

Several points of improvement were suggested such as an increased involvement of clinicians in the HTSC committee, the creation of clear guidelines to up- and downscale medical care and more (online) education about data registration requirements. Other suggestions concerned the measures (e.g. more tailored to local incidence rates, better tuning of measures with other actors, take into account the consequences such as loneliness and collateral damage on non-COVID pathologies). The HEPs should have a generic part and specific parts including pandemics, terrorist attacks, CBRNe, ICT.