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
The Government Emergency Committee supported the proposal of health authorities to start gradually reopening elective care. As long as the transmission does not escalate over the weekend of 18 April, the Health Board will make the decision the following week about which elective specialist care, primary care, dental care and services provided by private providers for non-urgent care can be reopened. The prerequisite for expanding the treatment volumes will be to reduce risks for infection transmission to a minimum. The Health Board will provide the conditions in the guidance, which is currently in development.
In view of the current trend in the number of people diagnosed with COVID-19 and receiving inpatient care in Estonia, as well as the availability of personal protective equipment (PPE), the restrictions on scheduled treatment due to the emergency situation will be gradually abolished starting from 21 April. The restrictions for private providers and dental care will be lifted from 26 April. The Health Board has provided instructions and minimum requirements for health care providers for restarting the provision of elective care under COVID-19 circumstances. These instructions were developed by the emergency medical directors and the Estonian Society of Infectious Diseases and consulted with all parties.
The instructions set the basic requirements among others: (i) availability of infection prevention and control guidelines (hand hygiene, use of PPE, cleaning and disinfection of the facilities, waste management); (ii) employees must be trained in the above guidelines; (iii) adequate supply of infection control equipment; (iv) ability to treat COVID-19 positive patients, including conducting COVID-19 testing.
Due to low demand, the University Clinic of Tartu reinstated its emergency medical department for COVID-19 patients on 8 May, as it was temporarily used for day care of hematology-oncology patients. Although all patients needing emergency care will use the same entrance, the COVID-19 patients will be separated from the rest. Specifically, emergency departments will conduct two levels of triage: first for COVID-19 and then for emergency care.
The opening of elective care continues in hospitals and starting from 18 May, the most affected hospital in the epicenter of Estonia’s COVID-19 outbreak – Kuressaare hospital – will also begin providing elective care.
Health care providers started to increase their preparedness after the health system preparedness level was raised to level 2 (of 3 levels) on 13 March.
Ambulance care providers have activated additional teams to only interact with COVID-19 patients. The functions of these teams includes taking tests, as well as providing transport for patients referred from local level hospitals to higher levels. Ambulance care providers prioritize urgent patients with life-threatening conditions, and refer other patients to primary health care (PHC).
Hospitals have been increasing their capacity by repurposing wards to accommodate COVID-19 patients and expanding intensive care units by reassigning staff and opening additional beds.
Elective inpatient and outpatient care was stopped on 17 March until 30 April 2020 and only continues for those patients whose health situation does not allow for postponement of the treatment. The decision about continuation of the treatment is made by the treating doctor. As of 26 March, dental care and private clinics can only provide emergency services.
PHC providers have postponed elective care to increase capacity for urgent patients. PHC and outpatient specialist care providers have increased consultations via telephone, email or alternative digital channels and Estonian Health Insurance Fund have introduced online-consultations as a new service. Also, sick leave notices are possible to open at PHC digitally.
All health care providers are ready to relocate and start to operate in another location.
Despite the emergency situation and regulation to postpone elective and non-emergency care, the North Estonian Medical Center, one of the two biggest hospitals in Estonia, has continued to provide some elective and non-COVID-19 services. The hospital reports that due to the rapid response to COVID-19 at the beginning of the emergency, the hospital was able to collaborate well with patients and partly rearrange their service provision to remote appointments. This has ensured a similar level of service provision in March 2020 as compared to earlier years. The East-Tallinn Central Hospital has announced that more outpatient (virtual) appointments in urology will be available. There may be other similar experiences from other service providers, but these have not been reported.