2. Ensuring sufficient physical infrastructure and workforce capacity
ENSURING SUFFICIENT PHYSICAL INFRASTRUCTURE AND WORKFORCE CAPACITY is crucial for dealing with the COVID-19 outbreak, as there may be both a surge in demand and a decreased availability of health workers. The section considers the physical infrastructure available in a country and where there are shortages, it describes any measures being implemented or planned to address them. It also considers the health workforce, including what countries are doing to maintain or enhance capacity, the responsibilities and skill-mix of the workforce, and any initiatives to train or otherwise support health workers.
2.1 Physical infrastructure
Despite the inefficiency of international supply chains in delivering medical and pharmaceutical products, Greece has enhanced efficiency through the following measures:
• The Pharmaceutical Research and Technology Company (IFET S.A.), a publicly owned company acting on behalf of Greek Health authorities, has been ensuring imports and distribution of essential pharmaceutical products and medical supplies, including PPE, to the National Health System during the pandemic (subsequent to the necessary approvals from the National Organization for Medicines);
• The Ministry of Health (in coordination with the National Centralised Procurement Agency - EKAPY), in an attempt to allocate resources efficiently, has set up a Digital Registry which monitors in stock and utilization of all COVID-19-relevant equipment (gloves, masks, protective gear for medical personnel etc.), as well as hospital and ICU beds capacity and occupancy in real-time. The data are also utilized in econometric modelling forecasting future needs.
• Significant monetary and in-kind donations (mostly medical consumables, such as masks, ICU beds, monitors, respirators) have been directed to the Ministry of Health. On March 21, approximately eighteen tons of medical supplies were provided by the Chinese government to Greece, including 550,000 masks and sets of protective gear. Eleven tons of medical supplies donated by the United Arab Emirates to Greece arrived on March 26, 2020 in Athens. The supplies and equipment were redistributed to hospitals around the country. An accountability committee has been appointed by the Ministry of Health, to ensure rapid and transparent donations processing.
• Local tenders for personal protective equipment were initiated by the Regional Health Authorities, as well as by hospitals, covering a small supply segment.
• Licenses for domestic production of antiseptics were granted, increasing capacity from approximately 600.000 pieces/day to 1 million and the production of 3D-printed ventilators has been encouraged.
• The Greek government encouraged private investment towards domestic production of protective face masks, scheduled to begin in May 2020. Initial productive capacity was 400.000 pieces/day.
• Domestic pharmaceutical companies have commenced trials for chloroquine-based drug production as a further attempt to enhance the county’s approach in tackling the crisis with lower levels of reliance on the international market.
A number of restructuring measures were taken to ensure coverage for COVID-19 patients. A public hospital (Pammakaristos General Hospital of Athens) has been transformed into a COVID-19 hospital, along with a private hospital in the Attiki region which will also be used for COVID-19 patients only. In selected general hospitals, medical wards and ICU units were also dedicated to COVID-19 patients only.
By the onset of the current epidemic the Greek health system had a limited capacity for hospitalization of patients with highly infectious diseases, especially in isolation negative pressure chambers or single rooms, some of which were already occupied by existing cases requiring isolation (TBC, meningitis, immunosuppression, transplants, etc.).
Through co-ordinated actions and the cooperation of the Administrations of the Ministry of Health and the Nursing Units, 3,307 beds for the hospitalization of COVID-19 cases were secured by March 31. By April 16, 4,007 hospital beds had been amassed, of which 3,610 were available, including bed occupancy by highly suspected COVID-19 cases awaiting laboratory results.
First wave of the pandemic
On February 2020, there were a total of 565 ICU public beds in Greece with no availability for potential hospitalization of COVID-19 cases. By March 31st, the total number of ICU beds increased to 870, with the majority of them (n=703) being in public hospitals.
The initial increase in the total number of ICU beds came from:
a) The addition of 85 new ICU beds in public Hospitals.
b) Conversion of High Dependency Units (HDU), as well as negative pressure chambers or other spaces that had the necessary infrastructure for mechanical ventilation, to ICU.
c) Provision of 30 ICU beds by military hospitals.
d) Provision of 137 ICU beds by private Clinics.
The plan to increase ICU capacity in Greece in the spring 2020 was comprised of 3 phases:
• Phase 1 (completed). Objective: to make available at least 200 ICU beds exclusively for COVID-19 cases. Phase 1 has been completed in 4 weeks and is in place by 31st March (223 beds available).
• Phase 2 (completed). Objective: to allocate a total of 400 ICU beds (including the beds deemed available from the preceding phase) exclusively for COVID-19 cases. Implementation time: approximately 2-3 weeks. Some of these beds are planned to be made available by transferring non-COVID-19 patients to ICU beds in private clinics, alongside the development of 100 new ICU beds. In addition to medical, nursing and administrative staff, this phase will also require equipment (134 ventilators, 95 monitors, 81 beds). Part of this equipment is rendered absolutely necessary to ensure operability, while the remaining equipment is needed (a) to replace equipment temporarily transported from other units; b) to replace old equipment and (c) as a standby in the event of a failure. The cost of the additional equipment is expected to be covered either by either donations (grant is pending) or by tenders held by the Ministry of Health. Drug infusion pumps and special drug infusion syringes as well as large quantities of PPE specifically used in ICU will also be needed.
• Phase 3. Objective: To have a 1000 ICU beds capacity (including existing beds) exclusively available for the treatment of COVID-19 cases. Implementation time: 4 – 6 weeks These are planned to be made available from: a) Creation of ICU in ISO-BOXES in the main Reference Hospital in Athens (about 40-50 beds); b) The development of ICU beds in operating rooms, resuscitation rooms in cardiac surgery departments and neurosurgery clinics; c) Fill all private sector ICU beds with non-COVID-19 cases and convert most ICU beds available in the public sector into beds for COVID-19 cases (estimate for 50-100 extra ICU beds); d) The use of 40-50 ICU beds provided by military hospitals.
On April 13, 2020, the installation of 50 new ICU beds at Sotiria Hospital, one of 13 across the country designated to deal with serious coronavirus infections, financed by a Greece’s Parliament donation of 8,000,000 € was approved. By April 16, the total number of operational ICU beds had increased to 1000; 350 of which were designated for COVID-19 patients with 256 being available. By April 27, the total number of operational ICU beds had increased to 1017.
At the height of the first wave of the pandemic (in April 2020), 1,017 ICU beds were developed, of which 840 were in public hospitals, 32 in military hospitals for civilian treatment and 145 in private hospitals without any financial burden on citizens. The 840 beds of public hospitals also included 130 beds in High Dependency Units (HDU) or special ICUs for cardiac or respiratory diseases which were reinforced with special equipment and staff to function temporarily as ICU-COVID to meet the increased needs.
With the ease of the first wave of the pandemic, the additional COVID beds returned to their pre-pandemic use. Thus, in July 2020, there were 917 ICU beds (755 public, 32 military, 130 private). At the same time, the process of further increasing capacity was strengthened with the addition of new permanent ICU / HDU beds.
Second wave of the pandemic
By the beginning of November 2020, the National Health System has on its disposal 1006 ICU beds (of which 825 are in public hospitals, 32 beds in military hospitals and 149 beds in private hospitals), with a commitment by the Government to reach 1,200 ICU beds by the end of the year, reflecting the European average.