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
Strategy to tackle rising COVID-19 infections in winter
On September 21, the Federal Minister of Health outlined a new strategy to combat COVID-19’s spread in the fall and winter seasons. The new strategy is expected to come into effect in mid-October and will feature:
- COVID-19 rapid tests, particularly to visitors at nursing homes and to those returning to Germany. This way, a result can come in 15-20 minutes to determine if a person is infected.
- New outpatient clinics for patients with symptoms to go directly to, rather than spending time in general waiting rooms where the virus can spread to other visitors. In the case where clinics cannot be located outside existing practices, special consultation hours will be offered.
As part of the federal government and states’ agreement from September 29, fever ambulances, special consultations and practices will provide relief to primary care providers and other health providers during winter season when the wave of influenza is expected and is added to the corona epidemic. Further, high-risk groups such as the elderly are advised to get vaccinated against flu as a precaution.
Reserving hospital beds for COVID-19 patients
On April 17, the Minister of Health announced that hospitals will return to regular operation step by step starting as of beginning of May. They will keep 25-30% of all ICU beds with ventilators for COVID-19 patients. On April 27, the Ministry of Health recommended a step-by-step procedure for re-planning hospital bed capacities in Germany. The ICU capacity for COVID-19 patients is set at 25% of available ICU beds (see also Section 5.3 Transition measures: Maintaining essential services).
Despite rising numbers of COVID-19 cases in Germany in August and September, German hospitals are keeping fewer and fewer beds in their ICUs available for COVID-19 patients. According to the newspaper Frankfurter Allgemeine Sonntagszeitung (FAS), only 10% of beds in hospitals in the state of Baden-Württemberg will be reserved for COVID-19 patients, instead of 35% of beds.This followed developments in states like Berlin, where only 10% of ICU beds have been reserved for COVID-19 patients since June, and Lower Saxony, which followed suit in mid-July. In the states of Bavaria and Brandenburg, hospitals have not had to keep any intensive care beds available for COVID-19 patients since the end of summer, and Hamburg abolished its requirement in August.
Reacting to rising new infections of COVID-19, hospitals in Germany have begun making preparations to postpone non-emergency operations and procedures in areas that may come under particular strain. As the number of COVID-19 patients in intensive care tripled in October (from 373 to 1,296), hospitals are also preparing to keep a certain number of beds free.
Reorganisation of hospital and ambulatory services
On March 12, the federal government urged all hospitals to postpone elective surgeries and treatments and recruit additional health professionals to prepare for the time when a growing number of people who are infected with COVID-19 and become seriously ill will need to be admitted into hospitals. The first specialized treatment centers for COVID-19 patients and patients with respiratory symptoms are set up by the Regional Association of SHI Physicians in North-Rhine Westphalia. Some diagnostic centers (see section 2.1) have been converted into specialized centers and are designated for suspected and confirmed cases. Patients are assessed whether ambulatory treatment is sufficient or inpatient treatment is necessary. The role of primary care providers so far is to provide testing possibilities and care for those with light or mild symptoms. Patients with severe symptoms are treated in hospitals. To manage patients and provide a tool for effective use of ICU capacities the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI), the RKI and the German Hospital Federation (DKG) launched an intensive care register to query free ventilation places, intensive care capacities and the COVID-10 cases treated in participating hospitals throughout Germany on a daily basis (see below): https://www.intensivregister.de/#/intensivregister
At the outbreak of the pandemic, the RKI released various documents providing guidance for prevention and management of COVID-19 cases for all relevant care areas (e.g. inpatient, ambulatory, elderly care), as well as updated case definitions which impacts on reconfiguration of services in care facilities (see also section 3.2).
On March 17, the federal government and the federal states approved a hospital emergency plan for German hospitals. The federal chancellery develop a rough concept for a hospital surge capacity plan. Also rehabilitation facilities, hotels or larger halls could become hospital wards. However, the federal states should develop capacity plans together with the respective hospitals with the objective to double ICU capacities. In Germany federal states are responsible for hospital planning and capital investment of hospitals.
During the outbreak of COVID-19 a number of federal states started a coordinated approaches in controlling the admission of patients across hospitals in their region. In Berlin for example there is the SAVE Berlin @COVID-19 action plan which steers patients across different types of hospitals (university hospitals, specialized hospitals etc.). The initiative aims to avoid admission of COVID-19 patients to hospitals that are not able to treat these patients (e.g. no availability of ventilators, trained staff). These non-COVID hospitals should be also kept free from COVID-19 patients to avoid infection of (non-COVID) patients. The SAVE Berlin concept was mainly developed by the Charité's Department of Anaesthesiology with focus on operative intensive medicine. The Charité as third-level hospital coordinates and advises the management of the intensive care capacities. The most serious cases are treated in the Charité. A further 16 specialized second-level hospitals are planned for the intensive medical care of COVID 19 patients. The 60 remaining Berlin emergency hospitals will initially provide the intensive care for patients who are not affected by COVID-19, as first-level hospitals. In addition, telemedical support for intensive care patients takes place in other hospitals in Berlin-Brandenburg. The Charité supports the treatment of ventilated COVID-19 patients by tele-visit with the help of a visit robot and exchanges information with the treating doctors via the video communication platform. The intensive medical network of the participating hospitals is constantly being expanded: All Berlin second-level hospitals have been equipped with telemedicine equipment and there are currently up to 60 visits per day. There are currently 25 visiting robots in use.
Intensive Care Registry (DIVI)
Since April 1, hospitals are legally required to report their intensive care capacities to the DIVI intensive care register on a daily basis. Following the ordinance of the federal government, they have to report the capacities of ICU beds with ventilators (ICU high care), without ventilators (ICU low care) and with extracorporeal membrane oxygenation (ECMO) machines. Capacity reporting involves the numbers of occupied beds, empty beds and an estimation of the maximum number of possible new admissions within the following 24 hours. Further, hospitals have to report the number of COVID-19 cases that are treated in ICU, on ventilators or that have been discharged from hospital since January 1.
As of April 2, in total 975 clinics or departments participated in the DIVI intensive care register (+63 change since previous day). A total of 29,290 intensive care beds were registered, of which 11,500 (39%) are occupied; 9,020 beds are currently not occupied. A total of 8,770 beds could be newly occupied within 24 hours.
As of April 16, 1,067 hospitals or departments reported to the DIVI registry. A total of 26,628 intensive care beds were registered, of which 15,316 (58%) are occupied and 11,312 beds are currently available.
As of April 26, 1,245 hospitals or departments reported to the DIVI registry. Overall, 32,067 intensive care beds were registered, of which 18,884 (59%) are occupied, and 13,183 beds (41%) are currently available.
As of May 4, 1,199 hospitals or departments reported to the DIVI registry. Overall, 31,334 intensive care beds were registered, of which 18,896 (59%) are occupied, and 12,738 beds (41%) are currently available.
As of May 13, 1,227 hospitals or departments reported to the DIVI registry. Overall, 32,310 intensive care beds were registered, of which 20,183 (62%) are occupied, and 12,127 beds (38%) are currently available.
Use of telemedicine
There are early signs for a growing number of tele- or video-consultations provided by physicians and psychotherapists. Restrictions on the volume of consultations that can be provided by a physician via video or telemedicine were relaxed. Also, the opening of a virtual hospital was brought forward to support other departments and practices. The Charité Berlin launched the “CovApp” (https://covapp.charite.de/), an web-based online tool to assess a patient’s medical condition, provide recommendations for action (doctor’s visit or testing) and inform about relevant contacts, health care services, access to hospitals or examination centres.
COVID-19 treatment centres
Following a decision of the federal state government of Berlin (March 19), a provisional COVID-19 treatment center will be set up to treat mild COVID-19 cases as well as emergency respiratory patients. The hospital will be built with the help of the German armed forces and will house up to 1,000 patients.
On May 11, the temporary Corona Treatment Center Jaffestrasse (CBZJ) was officially opened in Berlin. The CBZJ is an additional component to the well-positioned 50 emergency hospitals that work together as part of the [email protected] 19 concept for the care of COVID-19 patients. The first treatment area with initially around 500 beds was completed. A total of up to 1000 spare beds will be available.
Given the overall decline in COVID-19 cases, some of the assigned COVID-19 treatment centers throughout Germany are already designated to close down again in mid-May.