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
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.
State of emergency declared in several federal states to distribute COVID-19 patients across hospitals
In light of increasing numbers of COVID-19 patients requiring intensive care and raising concerns about ICU bed capacity scarcity in December 2020, several federal states turn to central coordination of COVID-19 patients by declaring a ‘disaster situation’:
- On December 9, Bavaria enacted the disaster situation regulation similar to the period of March to June, which obligates hospitals to cooperate. Hospitals that do no treat COVID-19 patients must relieve other hospitals with all available means, e.g. in taking over other patients, sharing staff or other. The The regulation enables the involvement of the medical director of hospitals coordination in the structure of civil protection and thus the establishment of a streamlined organisational structure with clear chains of command as well as an expansion of the powers of the medical director. The latter may, for example, order the temporary assignment of staff from one facility to another, or prohibit hospitals from providing non-urgent treatments.
- On December 8, Brandenburg declared a mass causalty incident (MCI), which shall ensure coordinated cooperation between the rescue service, in particular with the fire brigades, the disaster control units and facilities, the hospitals and the aid organizations involved in civil and disaster control. The integrated regional control centers have more control options when transferring patients to a suitable hospital. The medical director rescue service decides, in cooperation with the central coordination office of the hospitals, about the utilization of the necessary hospital capacities. In addition, rehabilitation clinics might be used to treat non-severe non-COVID patients.
- Saxony, severely hit by the second wave of the pandemic, coordinates COVID-19 patients pathways and hospital capacities in three regional clusters. Three hospital control units have been set up at three large regional hospitals that monitor hospital capacities all day and coordinate with the rescue services. First, patients are redirected within one cluster. In case no capacities are available within one cluster, cross-cluster takeover takes place. Rehabilitation clinics in Saxony have been granted auxiliary hospital status by the Ministry of Health to take in and treat COVID-19 patients. The clinics have been assisting surrounding hospitals since December, with some clinics offering as many as 50 beds for COVID-19 patients. While 19 clinics have been designated to take in patients so far, not all may be able to due to lack of personnel and critical equipment (such as ventilators).
Inter-hospital transport: Cross-cluster takeover of COVID-19 patients in December 2020
Together with intensive care physicians, the Federal Government and the Länder have developed a concept through which they can transfer COVID-19 intensive care patients from regions heavily affected by the pandemic and scarce acute and intensive care capacities of hospitals to less severely affected regions.
In the event of lack of capacities for ICU and acute care in a region in which hospitals are not able to admit more patients, first a takeover of patients within a cluster/area takes place. If capacities are exceeded within that cluster a cross-cluster takeover of patients across regions takes place. The concept of cross-cluster takeover (“Kleeblattkonzept”, literally clover leaf concept) divides Germany into five areas/clusters: South (Bavaria), Southwest (Baden-Württemberg, Saarland, Rhineland-Palatinate, and Hesse), West (North Rhine-Westphalia), East (Thuringia, Saxony, Saxony-Anhalt, Brandenburg and Berlin), North (Lower Saxony, Bremen, Hamburg, Schleswig-Holstein and Mecklenburg-Western Pomerania).
All five regions are centrally coordinated at a single point of contact which are in regular exchange with their federal states and coordinate with each other. This organisation within and across regions regulates how to distribute COVID-19 patients throughout Germany – from regions heavily affected by the pandemic to less severely affected regions. Transfer of COVID-19 patients within the Eastern region have taken place mid-December 2020, namely with patients requiring acute and intensive care being transferred from Saxony and Southern Brandenburg to hospitals in Berlin and Saxony-Anhalt. COVID-19 patients are transported by helicopter or ambulance. There is also the possibility of transferring patients with trains by Deutsche Bahn. The latter has rescue trains that can be converted into rolling intensive care units.
The concept of cross-cluster takeover can be found here: https://cdn.aerzteblatt.de/pdf/117/48/a2321.pdf?ts=23%2E11%2E2020+19%3A52%3A49
Vaccination strategy and definition of three top priority groups
On December 15, a new ordinance regarding the entitlement for vaccination against the coronavirus SARS-CoV-2 came into force after being announced by the Prime Health Minister. Due to at least initial scarcity vaccination will follow of a hierarchical order with three priority stages.
First, the highest priority is given to persons above the age of 80; persons working in inpatient facilities or in medical facilities with a very high risk of exposure (e.g. intensive care units, in emergency rooms, in emergency services), in outpatient palliative care, in the vaccination centers; persons that are treated, cared for or are active in in-patient facilities for the treatment, care or nursing of elderly persons or persons in need of care; persons providing ambulatory long-term care services caring for elderly (e.g. in palliative care), providers of specialised, and persons working in treatment areas with a very high risk of serious or fatal disease course after being infected (e.g. oncology or transplant medicine).
Second, persons with higher vaccination priority include those over 70 years old; persons with a very high or high risk of serious or fatal disease course (trisomy 21, dementia or with an intellectual disability, patients after organ transplantation); persons with high or increased risk of exposure to the SARS-CoV-2 coronavirus (e.g. doctors and other staff with regular direct patient contact: staff from blood and plasma donation services and in SARS-CoV-2 test centers); those who live or work in close contact with people in care or pregnant women; those who work in residential facilities and ambulatory care for the treatment, care or nursing of mentally disabled persons; police and law enforcement officers who are exposed to a high risk of infection during (e.g. demonstrations); persons working at public health services or in a particularly relevant position to maintain the hospital infrastructure.
Third, persons with high priority comprise those above the age of 60; persons with an elevated risk of serious or fatal disease course (e.g. BMI>30, chronic kidney/ liver disease, immunodeficiency or HIV, COPD or bronchial asthma, diabetes, cancer, autoimmune or rheumatic disease, CAD, heart failure), persons who work in particularly relevant positions in state institutions (e.g. in the constitutional organs, in governments and administrations, in the armed forces, police, fire brigade, disaster management including the Federal Agency for Technical Relief (THW) and in the justice system) or relevant positions in other institutions and companies in the critical infrastructure (e.g. in the food industry, in the water and energy supply, in pharmaceutic industry and pharmacies, in wastewater disposal and waste management, in transport and traffic as well as in information technology and telecommunications); those working in medical facilities with a low risk of exposure to the SARS-CoV-2 coronavirus (medical laboratories); people who work in the food retail sector; persons who work as educators or teachers and people with precarious working or living conditions.
Changes to vaccine prioritisation
End of January 2021, Germany’s Standing Committee on Vaccinations (STIKO) has recommended that the AstraZeneca vaccine is only to be used on those between the ages of 18 and 64. The commission cited a lack of insufficient data to assess the efficacy of the vaccine for those older than 65. As a result, the Federal Ministry of Health implemented changes in the ordinance regarding the changes in entitlement for vaccination against the coronavirus SARS-CoV-2 (see above). In principle, prioritisation groups stay the same but in the group with high or higher priority Astrazenecas vaccine will be given only to persons under 65, others will get Biontech/Pfizer's vaccine. In addition, the possibility for individual decision was implemented. The federal states should create contact points that decide on individual cases. The opening for individual decisions should only take effect if this is not covered by the vaccination ordinance. The federal states are now also allowed to invite individual annual cohorts with a time delay. This would allow them to organise the vaccinations more flexibly. The regulation could also be changed again, for example if more vaccine is available.
The largest change in vaccine prioritizations of groups was decided on February 24. Teachers as well as Kita (daycare) staff will be able to get vaccinated against coronavirus. They are to be classified in the in priority group two instead of group three. The ordinance regarding the entitlement for vaccination against the coronavirus was modified accordingly. Some federal states started to schedule vaccinations for this group. Rationale of the changed vaccination prioritization is that there are numerous contacts between people from different households in day-care centers and schools and physical distancing with kids cannot always be maintained. However, e.g. the Standing Committee on Vaccination (STIKO) is sceptical, since the changed order is not in line with the recommendations and recent evidence.
Changes to vaccine prioritization
End of January 2021, Germany’s Standing Committee on Vaccinations (STIKO) has recommended that the AstraZeneca vaccine is only to be used on those between the ages of 18 and 64. The commission cited a lack of insufficient data to assess the efficacy of the vaccine for those older than 65. As a result, the Federal Ministry of Health implemented changes in the ordinance regarding the changes in entitlement for vaccination against the coronavirus SARS-CoV-2 (see above). In principle, prioritisation groups stay the same but in the group with high or higher priority Astrazenecas vaccine will be given only to persons under 65, others will get Biontech/Pfizer's vaccine. On March 4, the Standing Committee on Vaccinations revised its recommendation for the AstraZeneca vaccine given the broader evidence base from the UK for the age group of those above 65. As of March 5, the vaccine can also be given to those above 65 years.
Moreover, end of January the possibility for individual decision was implemented. The federal states should create contact points that decide on individual cases. The opening for individual decisions should only take effect if this is not covered by the vaccination ordinance. The federal states are now also allowed to invite individual annual cohorts with a time delay. This would allow them to organise the vaccinations more flexibly. The regulation could also be changed again, for example if more vaccine is available.
The largest change in vaccine prioritizations of groups was decided on February 24. Teachers as well as daycare staff will be able to get vaccinated against coronavirus. They are to be classified in the in priority group two instead of group three. The ordinance regarding the entitlement for vaccination against the coronavirus was modified accordingly. Some federal states started to schedule vaccinations for this group. Rationale of the changed vaccination prioritization is that there are numerous contacts between people from different households in day-care centers and schools and physical distancing with kids cannot always be maintained. However, e.g. the Standing Committee on Vaccination (STIKO) is sceptical, since the changed order is not in line with the recommendations and recent evidence.
Rollout of COVID-19 Vaccine Distribution
On December 23, Germany’s federal institute for vaccines and biomedicines (Paul Ehrlich Institute (PEI)) officially released 4.1 million doses of the COVID-19 vaccine from Pfizer/BioNTech in anticipation of beginning vaccinations in the country on December 27. This comes after the EU Commission approved the vaccine for member states in the past few days.Germany’s COVID-19 vaccination campaign for the workforce has begun with hospitals offering the shots for staff, first for those working in COVID-19 care units as well as those in the emergency room. Mobile teams have provided vaccinations to residents and workers in long-term care facilities. The roll-out began on December 27 and was met with strong support from medical staff.
Vaccination will be carried out in vaccination centers and by mobile vaccination teams that are affiliated with the vaccination centers (see also Section 1.1 Preventing transmission: Health communication). The vaccination centers are set up and operated by the federal states or on behalf of the federal states. Vaccination centres are usually set up by districts or independent cities and run by them or by medical-care and aid organisations such as the Red Cross, Malteser, Caritas and others (usually providing rescue services, civil protection). The recruiting of staff and management of vaccinations are often organised by or in collaboration with the Regional Association of SHI physicians and private suppliers (security, facility management etc.).The federal government can operate its own vaccination centers to carry out protective vaccinations for federal employees, in particular for people who work as functionaries in relevant positions. The costs of setting up and organising the vaccination centres are borne by the Länder (federal states) and the liquidity reserve of the Central Reallocation Pool as well as the private health insurances. Vaccinations are financed by the federal government.
At the end of March/beginning of April 2021, vaccinations are also offered by general practitioners and specialists in private practice. Medical practices, vaccination centres and mobile vaccination teams will then vaccinate in parallel. The vaccination centres will continue to allocate their appointments strictly according to the current vaccination prioritisation. In the doctors' surgeries, the decision on prioritisation will be made according to the doctor's assessment on site, in order to enable a more flexible implementation of the vaccinations. However, the vaccination ordinance remains the basis here as well. In addition, company doctors will be increasingly involved in the vaccination campaign in the course of the second quarter. In order to be able to offer vaccination to as many citizens as possible as soon as possible, the interval between the first and second vaccination, which is permissible according to the respective approval of the vaccines, should be exhausted as much as possible.
Operation of vaccination centres
The National Association of Statutory Health Insurance Physicians develops and operates a standardized module for telephone and digital arrangement of appointments in the vaccination centers, which enables the countries to organize appointments. A nationwide uniform telephone number, the 116117 non-emergency medical on-call service, is used for this. In most federal states letters are to be sent to people who are in the respective priority group for vaccination. The letter states the start date for vaccinations for the target group and explains the procedure from making an appointment via the hotline 116 117 or online portals, to how the second vaccination works. People who have not received a letter with an access code to book an appointment, can schedule an appointment via an online portal. Their eligibility for vaccination is verified in the vaccination center.
There are roughly 440 vaccination centers have been set up around the country and vaccinations there are being given by doctors and other trained personnel. In most vaccination centers, the process looks like this: the vaccination candidate registers and has their temperature taken. After that, the doctor gives the patient a briefing about the vaccination and associated risks. The patient signs the legal waiver and information sheet (see also Question 3). This is followed by the vaccination. Once the vaccination has taken place, the vaccinated person is asked to go to a separate waiting area with several seats, where he or she should stay for another 15 to 30 minutes.
Vaccination candidates bring their vaccination cards (Impfausweis) with them to the appointment and have it recorded in the card by the officials that administer the vaccine. If patients do not have this with them they will receive a certificate that says they have been vaccinated. The vaccination centers and their affiliated mobile teams transmit the following information to the Robert Koch Institute (RKI) on a daily basis:
Patient pseudonym, Month and year of birth, Gender, five-digit postal code / county of the person to be vaccinated, identification number and county of the vaccination center, Date of vaccination, Start or completion of vaccination series (first or subsequent vaccination), Vaccine-specific documentation number (vaccine product or trade name), Batch number vaccine, Basis of prioritization
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.
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.