3. Providing health services effectively
The section on PROVIDING HEALTH SERVICES EFFECTIVELY describes approaches for service delivery planning and patient pathways for suspected COVID-19 cases. It also considers efforts by countries to maintain other essential services during periods of excessive demand for health services.
3.1 Planning services
At the very beginning of the outbreak in Belgium, two hospitals were designated as referral centres for the treatment of COVID-19 patients (St Pierre Hospital in Brussels and UZ Antwerpen). When the epidemic increased, all hospitals started admitting COVID-19 patients and, from March 14th measures were taken to create additional beds.
Increase hospital capacity: act first at hospital level
From March 14th all hospitals (general and university, psychiatric and rehabilitation settings) were required to activate their emergency plan (see section 2 on Ensuring sufficient physical infrastructure/Hospitals). They had to cancel all non-urgent consultations, investigations and elective interventions (with special focus on those potentially impacting intensive care capacities). Urgent consultations, investigations and interventions could be maintained as well as necessary treatments (i.e. chemotherapy, dialysis, etc.) and rehabilitation.
On March 17th, hospitals were further asked to do their utmost to create additional critical care capacity for both ventilated and non-ventilated patients. Empty units, medium care facilities and post-anaesthesia care units could be used for this purpose. Hospitals undertook an inventory of the capacity of CPAP devices and they had to be made fully operational, as well as equipment used for demonstrations, simulations or training. A maximum number of inpatient beds had to be immediately released, at a ratio of 3 to 4 inpatient beds per intensive care bed in order to be able to admit patients to non-critical units as much as possible in order to save the intensive care beds.
It was also stressed that patients who no longer required hospital care should leave the hospital as soon as possible. Residential facilities for older people and other residential care facilities had to reintegrate their residents after hospitalisation as much as possible.
When saturation is reached: Hospital & Transport Surge Capacity Plan (federal level)
All hospitals have to organise proactive agreements, at least at the local-regional level, regarding possible transfers when a hospital's maximum capacity is exceeded. As soon as 50% of the COVID-bed capacity is reached, partner hospitals in the same loco-regional network have to be notified. At 75% of capacity, transfers must be initiated. At this level of saturation at loco-regional level, the federal authorities take the necessary decisions regarding referrals in accordance with the agreements reached within the Hospital & Transport Surge Capacity Committee (subgroup of the federal Risk Management Group - see section 5 Governance).
In order to keep COVID-19 patients out of regular ambulances as much as possible, and to keep the availability of the regular system as high as possible, additional COVID-19 hotlines have been set up in each province. The inter-hospital transport of COVID-19 patients had to be organised by the hospitals themselves (at their own cost) with non-emergency (non-112) services, in consultation between the sending and receiving hospitals.
From early April, transition centres have been opened (or are in progress of being open) for patients who are no longer ill enough to stay in hospital but cannot yet go home following hospitalisation (e.g. in some empty, rapidly refurnished, hospitals). By mid-April there were four such centres in Flanders, two in Wallonia and one soon to open in Brussels.
Emergency medical services
Within the Emergency Medical services several (EMS) measures were taken to face the crisis:
• In the dispatch centres, a new ‘COVID-telephonic-triage-protocol’ was initiated. This was created in order to determine if a 112-call is COVID-related or not;
• A dedicated COVID ambulance-capacity was created (36 ambulances). COVID-related calls are preferably managed by these dedicated ambulances;
• To maintain business continuity in EMS, an online ‘temp-office’ was created to fill in the gaps in EMS-schedules throughout the country (https://112support.belgambu.be/).
General practitioners (GPs) are to be contacted by phone by patients suspecting COVID-19 for a telephone triage (remunerated by the NIHDI since April 1st). The GP has to evaluate the severity of symptoms and to decide whether the patient should stay home or go to the hospital. Detailed procedures are available on the Sciensano website (how to take a nasopharyngeal sample, how to manage relatives, prudent use of antibiotics in case of bacterial superinfection, etc.) (https://epidemio.wiv-isp.be/ID/Pages/2019-nCoV_procedures.aspx). If symptoms are relevant and the GP wishes to make a clinical examination, he/she may carry it out himself if he has the protective equipment (surgical mask, gown, goggles and gloves) preferably at the patient's home. If he/she does not have the necessary protective equipment, he/she refers the patient to a triage site/to the hospital. During the peak of the epidemic, there were up to 152 triage centres on the Belgian territory (some local initiatives of mobile teams for less mobile patients and residential care have also been set up).
If symptoms are severe, the GP has to make contact with the ambulance service and with the hospital for admittance. The GP's role is not to diagnose COVID-19, but to assess whether or not the patient's condition is deteriorating and, therefore, whether or not the patient should be hospitalised.
Pharmacists received detailed recommendations commonly issued by their professional associations (on March 11th) to help them maintain a safe place, while they continue serving the population (https://epidemio.wiv-isp.be/ID/Documents/Covid19/COVID-19_SOP%20recommandations%20pharmacie-pharmacien_FR.pdf).
Dentists, home care nurses, physiotherapists, and some other primary care professionals have received specific recommendations, the essence of which is that they must judge the importance of their care and apply it accordingly to maintain the continuity of care to the population without exposing their patients to unreasonable risks.
Another subgroup of the federal Risk Management Group, namely the Primary and Outpatient Care Surge Capacity Committee was created (on March 13th) to streamline and harmonise the organisation and availability of care outside the hospital, both before and after admission, in the different federated entities. This Committee gathered representatives from federated entities, hospital federations, GPs, the scientific COVID committee and the FPS Public Health.
Alternatives to face-to-face consultations
On March 16th, it was decided that physicians would be paid a fee for telephone consultations taking place in connection with the COVID-19 crisis (telephone triage and telephone consultations with other patients as part of the continuity of care).
Since April 1st, phone or video consultations are remunerated and totally reimbursed by the NIHDI for the following other health care professionals: psychiatrists, psychologists, dentists, speech therapists, physiotherapists, midwives, dieticians, occupational therapists and diabetes educators.
The older people care sector
After an initial focus on hospitals and their intensive care units, it became clear that nursing homes and homes for older people were also being particularly affected by the epidemic. Approximately half of the recorded deaths have occurred in these facilities (but this may be a possible overestimation, see section 1.4 on Monitoring and Surveillance).
On April 15th, the Interministerial Public Health Conference approved a framework for possible support from the hospital sector to the older care sector. This framework foresees that hospitals can give support to institutions caring for older people by providing expertise (e.g. geriatric liaison, hygiene and control of infectious diseases, etc.), by making staff available (in addition to other possibilities for staff reinforcement), by helping them to procure equipment or products (e.g. supply of oxygen or certain medicines), and by supporting them in the screening process or by providing infrastructure (as long as their own basic hospital missions are not compromised). Similar requests arising from other communities (e.g. institutions for disabled people) will be dealt with the same way as for care facilities for older people.
In preparation for transition towards the post-lockdown phase, great attention has been put on the testing of residents and staff in nursing homes and homes for older people. Testing began in mid-April but has progressed slowly because of logistical problems.
• FPS Public Health (2020). Coronavirus Covid-19. Brussels: Federal Public Service Health, Food chain safety and Environment (www.info-coronavirus.be, Accessed April 2020);
• Sciensano (2020). Coronavirus. Brussels: Sciensano (https://epidemio.wiv-isp.be/ID/Pages/default.aspx, Accessed April 2020);
• Flemish Agency for Care and Health (2020). Uitbraak coronavirus COVID-19. Brussels: Flemish Agency for Care and Health – Agentschap Zorg en Gezondheid (https://www.zorg-en-gezondheid.be/covid-19, Accessed April 2020);
• Flemish Agency for Care and Health (2020). Schakelzorgcentra. Brussels: Flemish Agency for Care and Health – Agentschap Zorg en Gezondheid (https://www.zorg-en-gezondheid.be/schakelzorgcentra, Accessed April 2020);
• AVIQ (2020). Coronavirus 2019. Charleroi : Agency for a Quality Life-Agence pour une vie de Qualité (https://www.aviq.be/coronavirus.html, Accessed April 2020) ;
• Iriscare (2020). COVID-19. Brussels: Iriscare (http://www.iriscare.brussels/fr/professionnels/, Accessed April 2020);
• Ostbelgienlive (2020). Coronavirus: Fragen und Antworten. Eupen: Ostbelgienlive (http://www.ostbelgienlive.be/desktopdefault.aspx/tabid-6711/, Accessed April 2020);
• Personal communication with the FPS Public Health: Van der Auwera Marcel;
• Personal communication with the German Community: Lena Pankert;
• Press release of the Interministerial Public Health Conference on April 15th
From May 4th, hospitals progressively stared to reopen non-urgent consultations (see 3.3 maintaining essential services).