3 ANALYSIS OF THE LETTERS TO THE HOSPITALS
3.3 RESULTS
3.3.3 Topics of the letters
t We refer to these hospitals as acute hospitals throughout the report.
3.3.3 Topics of the letters
Thirteen letters concerned hospital surge capacity as the main theme and three letters concerned patient transport only. Other topics of the letters were data registration, testing of patients and personnel, hospital emergency plans, reference hospitals, cooperation within hospital networks, elective non-urgent procedures, hospital visitors, PPE, involvement of hospital infection control team, nursing homes, discharge of patients, intermediate care structures, financing, restart normal care, preparation for a second wave of COVID-19, etc. Below the topics that relate most to surge capacity are further discussed.
3.3.3.1 Registration of hospital capacity and use Daily registrations
The HTSC committee considered as one of their essential tasks to have an overview of hospital (ICU) bed availability and occupancy and to adequately monitor these. Hereto, hospitals were asked to register these parameters and to share these with the public authorities. In the letter of 04/03 hospitals were asked to register daily their hospital capacity data into the “Incident Crisis Management System” (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. Both registrations became legally obliged on 30/04 after publication in the Belgian Official Journal (“Belgisch Staatsblad”/”Moniteur belge”).9
In subsequent letters of the HTSC committee (03/04, 30/04, 20/05, 17/06), the request for registration of data in ICMS and the Sciensano questionnaire was repeated and further specified and clarified. The exact text in the letters from the HTSC committee on data to register evolved across the pandemic and sometimes differed from the text in the Belgian Official Journal and also
36 Hospital surge capacity in Belgium during the first wave of the COVID-19 pandemic KCE Report 335
from texts that are available on the Sciensano websiteu. Besides letters from the HTSC committee, hospitals received also lettersv from the Department of Urgent Medical Care of the FPS Public Health with further details and specification on the data gathering in ICMS. So, instructions for the hospitals concerning data registration were sent by the HTSC committee, the FPS Public Health and Sciensano.
Ad hoc surveys
Next to the above-mentioned daily surveys, hospitals were asked in the letter of 10/03 to fill out a questionnaire regarding the number of available ventilators that are suited for treatment of COVID-19 patients and the number of available ECMO devices. These parameters on available number of ventilators and ECMO devices were later integrated into the ICMS and required to be filled out daily from 24/03 (ventilators) and 30/04 (ECMO) on.
In the letter of 20/05 the HTSC committee asked hospitals to fill out two questionnaires: one regarding test strategy and the other regarding laboratory capacity.
u For example, according to this text https://covid-19.sciensano.be/sites/default/files/Covid19/COVID-19_FAQ_NL_final.pdf (page 12) hospitals were also supposed to send data about number of casualties.
v Letters of the FPS Public Health concerning ICMS:
• 14/03 (https://gibbis.be/images/documents/2020/
coronavirus/0327/Begeleidende_Brief_ICMS_Ziekenhuizen.pdf)
• 14/03 (https://gibbis.be/images/documents/2020/
coronavirus/0327/Basisinfo_ICMS_Ziekenhuizen.pdf
• 19/03 (https://gibbis.be/images/documents/2020/coronavirus/0327/19-03-2020_Brief_ICMS_Ziekenhuizen.pdf)
Individual patient data
Hospitals were invited in the letter of 20/05 to fill out voluntarily individual patient data of each patient infected with COVID-19 through an online surveyw of Sciensano: for each patient a form had to be filled out at admission and again one at discharge.
In the same letter hospital were also invited to cooperate with an intended survey of the Belgian Society of Intensive Care Medicine in cooperation with Sciensano.
3.3.3.2 Hospital / ICU capacity measures
Concerning hospital capacity, three phases in the measures could be distinguished: creating extra capacity in the rise of the pandemic, phasing out / reducing capacity after the pandemic peak and perpetuating capacity for eventual future pandemic outbreaks.
Creating extra capacity
At the start of the COVID-19 crisis, two hospitals were appointed as reference hospitals to admit COVID-19 patients, but this was rapidly extended to nine (mainly university and two highly specialised) hospitals that were asked to reserve bed capacity for the admission of COVID-19 patients.
• 24/03 (https://gibbis.be/images/20200324_Brief_ICMS_
Ziekenhuizen_NL_SIGN.pdf),
• 31/03 (https://www.zorg-en-gezondheid.be/sites/default/files/atoms/
files/20200331_Brief_ICMS_Ziekenhuizen_NL_SIGN.pdf)
• 06/05 (https://gibbis.be/images/20200508_Brief_ICMS_
2de_GOLF_NL_SIGN.pdf)
w More details of this survey can be found at https://covid-19.sciensano.be/sites/default/files/Covid19/COVID-19_FAQ_NL_final.pdf, p10.
KCE Report 335 Hospital surge capacity in Belgium during the first wave of the COVID-19 pandemic 37
However, it soon became clear that also other hospitals had to prepare for admission of COVID-19 patients.
All acute hospitals were urged to create extra capacity in the letters of 10/03, 13/03, 17/03, 25/03. The instructions in the letters evolved from kind vague requests to clear commands, accompanied with numbers of extra beds to realise.
On 10/03, hospitals were asked to take all necessary measures (without further specifying) to admit COVID-19 patients as much as their capacity allows.
In Dutch
"Elk ziekenhuis draagt daarbij solidair en verantwoordelijk maximaal bij volgens zijn capaciteit en expertise."
In French
"Chaque hôpital contribue autant que possible de manière solidaire et responsable en fonction de ses capacités et de son expertise."
On 13/03, hospitals were required to stop from 14/03 onwards with all elective procedures in order to render these beds available for admission of COVID-19 patients.
In Dutch
“Vanaf 14/03 moeten alle algemene en universitaire ziekenhuizen, revalidatieziekenhuizen, alsook de privé-klinieken, alle electieve consultaties, onderzoeken en ingrepen annuleren. Bijzondere aandacht moet er zijn voor ingrepen met impact op de capaciteit van het ziekenhuis inzake intensieve zorgen. Vanzelfsprekend kunnen alle dringende en noodzakelijk consultaties, onderzoeken en ingrepen wel blijven gebeuren. Ook alle lopende levensnoodzakelijke therapieën (bv.
chemotherapie, dialyse, etc.) of noodzakelijke dagelijkse revalidatie worden voortgezet.”
In French
"À partir du 14/03, tous les hôpitaux généraux et universitaires, les hôpitaux de réadaptation ainsi que les cliniques privées doivent annuler toutes les consultations, examens et interventions électives. Une attention particulière doit être accordée aux interventions qui ont un impact sur la capacité de l'hôpital en matière de soins intensifs. Toutes les consultations, examens et interventions urgentes et nécessaires peuvent continuer à être mis en œuvre. En outre, toutes les thérapies nécessaires à la vie courante (par exemple, chimiothérapie, dialyse, etc.) ou la rééducation quotidienne nécessaire seront poursuivies."
In the same letter of 13/03 the hospitals were also asked to make plans to increase ventilator capacity, e.g. by freeing up operating theatre and recovery rooms.
On 17/03, measures were scaled up and hospitals were required to create extra ICU beds (for ventilated and non-ventilated patients) and to free up non-ICU beds at a rate of 3 to 4 beds per ICU bed for COVID-19 patients and to discharge patients as soon as possible in order to have possibilities for new patients. Further specifications and measures followed in the letter of 25/03, in which hospitals were urged to reserve 60% of their licensed ICU beds for COVID-19 patients only and to reserve 4 non-ICU beds per licensed ICU bed for COVID-19 patients (and if possible a same ratio per extra created ICU bed).
Moreover, in the same letter of 25/03 hospitals were asked to give training to non-ICU personnel in such a way that they are able to work on an ICU.
Phasing out /exit strategy
Based on the observed decreasing number of COVID-19 patients in hospital/ICU, measures were launched in the letter of 24/04 for downscaling of extra created capacity. Hospitals were allowed to slightly decrease the extra created bed capacity but still required to reserve 25% of their licensed ICU beds for treatment of COVID-19 patients (A) and to keep permanently an additional 25% extra number of ICU beds on top of the number of their licensed ICU beds that needed to be operational within 48 hours (B) and to
38 Hospital surge capacity in Belgium during the first wave of the COVID-19 pandemic KCE Report 335
permanently reserve non-ICU beds equal to minimally 4 times the sum of the number of the permanent reserved ICU beds (A) and the number of the additional ICU beds (B). Additionally hospitals were asked to ensure in a second phase they could double the aforementioned capacity within 7 days when considered necessary by the HTSC committee.
The letter of 30/04 further specified above measures and added that in a third phase hospitals must be able to triple the capacity.
Perpetuating capacity
As was already mentioned in the letters of 24/04 and 30/04, the HTSC committee required hospitals to be prepared for an eventual second wave of COVID-19 outbreak and to keep permanently a reserve extra bed capacity.
In the letter of 20/05, the HTSC committee sent an overview of planned/realised extra capacity per hospital for the second wave and explained that staffing of the extra ICU beds needs to be the same as the staffing of the regular ICU beds.
In Dutch
“Wat de bestaffing van de bijkomende bedden (25% in de eerste fase tot 50% in de tweede fase van de “tweede golf”) bovenop de erkende ICU-capaciteit betreft, dient deze te voldoen aan de bestaffing die voorzien is voor erkende ICU-bedden.”
In French
"L'encadrement (staffing) des lits supplémentaires créés en plus de la capacité USI agréée (25 % dans la première phase jusqu'à 50 % dans la deuxième phase de la "deuxième vague") doit être identique à celui des lits USI agréés."
The extra staff could be either new extra staff or reallocated staff from other units. The letter also mentioned that these efforts would be taken into account in the calculation of the financial compensation.
The letter of 17/06 contained an update of the planned extra capacity per hospital for an eventual second COVID-19 wave and stated that hospitals need to permanently reserve minimally four times the sum of the permanently reserved licensed ICU beds and the number of additionally created ICU beds for the non-intensive treatment of COVID-19 patients. An attachment to this letter explained what this exactly meant for each hospital and contained exact numbers of beds to reserve per hospital. Another attachment to the letter presented a figure in which all phases and needed extra capacity are schematised (see Figure 3).
KCE Report 335 Hospital surge capacity in Belgium during the first wave of the COVID-19 pandemic 39 Figure 3 – Surge capacity plan for the second wave
Source: Letter of the HTSC committee to hospitals dd 17/06.
40 Hospital surge capacity in Belgium during the first wave of the COVID-19 pandemic KCE Report 335
In recapitulation, all above measures along the time are summarised in Table 2.
Table 2 – Overview of surge capacity measures in the letters from the HTSC committee to the hospitals
Phase Date of letter Measures
Creating extra capacity 10/03 • Take all necessary measures to admit COVID-19 patients as much as possible 13/03 • Stop all elective procedures by 14/03
• Enlarge ventilator capacity
• Free up rooms
17/03 • Create extra ICU beds
• Free up non-ICU beds at a rate of 3-4 to 1 ICU bed
• Discharge patients asap
25/03 • Reserve 60% of licensed ICU beds for COVID-19 only
• Reserve 4 non-ICU beds per 1 ICU bed for COVID-19 only
• Start ICU training for non-ICU personnel Phasing out /exit strategy /
preparation for a second wave 24/04 Phase 1
• Reserve 25% of licensed ICU beds for COVID-19 (A)
• Keep permanently an additional 25% extra number of ICU beds on top of the number of licensed ICU beds that need to be operational within 48 hours (B)
• Reserve permanently minimally 4 times the sum of the number of the permanently reserved ICU beds (A) and the number of the additional ICU beds (B)
Phase 2
• Ensure to be able to double the aforementioned capacity within 7 days when considered necessary by the HTSC committee
30/04 Phase 1 Permanent reflex capacity:
• Reserve 25% of licensed ICU beds for COVID-19 (A)
• Keep permanently an additional 25% extra number of ICU beds on top of the number of licensed ICU beds that need to be operational within 48 hours (B)
KCE Report 335 Hospital surge capacity in Belgium during the first wave of the COVID-19 pandemic 41
• Reserve permanently minimally 4 times the sum of the number of the permanently reserved ICU beds (A) and the number of the additional ICU beds (B)
Phase 2 Additional reflex capacity:
• Ensure to be able to double the aforementioned capacity of phase 1 within 7 days when considered necessary by the HTSC committee
Phase 3
• Ensure to be able to triple the aforementioned capacity of phase 1
Perpetuating capacity 17/06 Reserve minimally four times the sum of the permanently reserved licensed ICU beds and the number of additionally created ICU beds for the non-intensive treatment of COVID-19 patients
All measures regarding bed capacity in the letters of the HTSC committee used the concept of “licensed hospital beds” and depart from the number of
“licensed ICU beds” to calculate extra ICU and non-ICU bed capacity. From 25/03 the measures were illustrated by exact numbers of extra capacity per hospital.
The communication of the HTSC committee regarding surge capacity mainly related to surge / scaling up of (ICU) bed capacity and to a much smaller extent to surge in equipment (ventilators, ECMO), surge in PPE (masks, gloves, etc.) or infrastructure (e.g. closing operating rooms) or to surge of personnel (how much extra personnel is needed, how much training does new personnel need, strategies to find extra personnel, etc.).
Surge capacity within networks
The proposed measures regarding extra capacity were initially addressed to individual hospitals, but from 26/04 the letters explained that it was allowed that hospitals within a loco-regional network could create this in a combined way with the other hospitals from that network. Later surge capacity targets for an eventual second wave were formulated at the network level. More details are described in section 3.3.3.6.
Financing of surge capacity
The letters of 24/04, 30/04 and 17/06 explained that the federal authorities would take care of financial compensation of the hospitals regarding the reserved and extra capacity for admission of COVID-19 patients in the first wave and for the permanent reflex capacity for an eventual second wave.
The letters also mention that his financial compensation will be discussed with the Federal Council of Hospital Facilities (“Federale Raad voor Ziekenhuisvoorzieningen”/”Conseil fédéral des Etablissements hospitaliers”).
In Dutch
24/04: “De federale overheid zal voorzien in een systeem van financiële compensatie van de permanent gereserveerde capaciteit (eerste fase), alsook voor wat de eventueel te activeren tweede fase betreft.”
30/04: “De federale overheid zal binnen haar bevoegdheden voor de
“tweede golf” voorzien in een systeem van financiële compensatie van de permanent gereserveerde capaciteit (eerste fase), alsook voor wat de eventueel te activeren tweede (en later ook derde) fase betreft. Deze compensatie zal zowel betrekking hebben op het ter beschikking houden van de capaciteit zelf, als op het gebruik ervan voor de zorg van COVID-patiënten. Voor wat de “eerste golf” betreft, wordt in het kader
42 Hospital surge capacity in Belgium during the first wave of the COVID-19 pandemic KCE Report 335
van de daartoe reeds opgerichte werkgroep binnen de Federale Raad voor Ziekenhuisvoorzieningen, een oplijsting worden gemaakt van de meerkosten en minderopbrengsten ten gevolge van de behandeling van COVID-patiënten; een systeem moet worden ontwikkeld dat verhindert dat zwaar belaste ziekenhuizen in hun globale financiering benadeeld zouden worden ten opzichte van minder belaste ziekenhuizen.”
17/06: “Binnen de werkgroep van de Federale Raad voor Ziekenhuisvoorzieningen zal met beide scenario’s (waakcapaciteit en reflexcapaciteit) rekening worden gehouden bij het voorzien van een compenserende financiering. We houden hierbij rekening dat deze capaciteiten niet noodzakelijkerwijs bezet zullen zijn en de extra aanvullende kosten (extra personeel, structurele werkzaamheden, gespecialiseerde medische apparatuur, verlies van honoraria, …) zullen hierbij in rekening worden gebracht.”
In French
24/04: “Le gouvernement fédéral prévoira un système de compensation financière pour la capacité réservée en permanence (première phase), ainsi qu’en ce qui concerne l'activation de la deuxième phase si nécessaire.”
30/04: “Le gouvernement fédéral prévoira, dans le cadre de ses compétences pour la "deuxième vague", un système de compensation financière pour la capacité réservée en permanence (première phase), ainsi que pour toute deuxième (et plus tard troisième) phase à activer.
Cette compensation couvrira à la fois le maintien de la capacité elle-même et son utilisation pour la prise en charge des patients COVID. En ce qui concerne la "première vague", le groupe de travail déjà constitué à cet effet au sein du Conseil fédéral des Etablissements hospitaliers établira une liste des coûts supplémentaires et des recettes réduites résultant du traitement des patients COVID ; un système doit être mis au point pour éviter que les hôpitaux fortement sollicités ne soient désavantagés par rapport aux hôpitaux moins sollicités en termes de financement global.”
17/06: “Au sein du groupe de travail du Conseil Fédéral des Etablissements Hospitaliers, les deux scénarios (capacité de veille et capacité réflexe) seront pris en compte lors de l'octroi du financement compensatoire. Nous tiendrons compte du fait que ces capacités ne seront pas nécessairement occupées et que les coûts supplémentaires (personnel supplémentaire, activités structurelles, équipement médical spécialisé, perte d'honoraires, ...) seront pris en compte.”
3.3.3.3 Regular hospital care
As mentioned in paragraph 3.3.3.2 the letter of 13/03 stipulated that the hospitals had to stop all elective consultations, investigations and procedures by 14/03. The letter stipulated further that all urgent and necessary consultations, investigations and treatments could be maintained, and that all current vital treatments (e.g. chemotherapy, dialysis, etc.) or necessary daily rehabilitation could be continued.
The letter of 16/04 further specified what essential care is that could be continued, such as treatment of chronic conditions in cases that postponing would lead to irreversible or unacceptable deterioration, treatment of acute mental health problems and preventative activities such as vaccinations and neonatal screening. And as far regular care activities were continued, these could only take place under the condition that this can happen in a safe way, on which Sciensano developed specific guidelines. This letter also stated that the HTSC committee understood that there might be discussion on what exactly is meant by urgent and necessary care and that the stop of all elective activities might have severe consequences for the hospital functioning. Therefore the HTSC committee announced to carefully monitor this and to counsel health professional organisations on how to start regular activities again.
In the letter of 24/04 the hospitals were informed that an advice of the High Council of Medical Specialists and General Practitioners (“Hoge Raad van Artsen-specialisten en van Huisartsen”/”Conseil supérieur des médecins
KCE Report 335 Hospital surge capacity in Belgium during the first wave of the COVID-19 pandemic 43
spécialistes et des médecins généralistes”x) concerning resuming regular care was received and a discussion meeting was held between the Directorate-General Healthcare of the FPS Public Health, RIZIV – INAMI, the Union of Professional Organisations of Medical Specialists (“Verbond der Belgische beroepsverenigingen van artsen-specialisten”/”Groupement des unions professionnelles belges de médecins spécialistes” (VBS – GBS))y and the associations of CMOs. In that meeting it was agreed to develop practical guidelinesz on how types of regular hospital care could be restarted taking into consideration the eventual impact on ICU capacity,
spécialistes et des médecins généralistes”x) concerning resuming regular care was received and a discussion meeting was held between the Directorate-General Healthcare of the FPS Public Health, RIZIV – INAMI, the Union of Professional Organisations of Medical Specialists (“Verbond der Belgische beroepsverenigingen van artsen-specialisten”/”Groupement des unions professionnelles belges de médecins spécialistes” (VBS – GBS))y and the associations of CMOs. In that meeting it was agreed to develop practical guidelinesz on how types of regular hospital care could be restarted taking into consideration the eventual impact on ICU capacity,