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
In 2018, there were 2,9 hospital beds per 1 000 inhabitants of which 2,8 were acute care beds. The by far largest number of these beds are in Landspitali National University Hospital in Reykjavik with 631 hospital beds by the end of year 2018 and Akureyri Regional Hospital in the North coming up second with 110 hospital beds by end of year 2018. Fewer hospital beds are distributed in Regional hospitals around the country. Landspitali University Hospital and Akureyri hospital are the only hospitals in the country providing intensive care and providing inpatient care for COVID-19 patients. The centre of labs and testing during epidemics is at Landspitali National University Hospital, but tests were also made by a private lab at deCODE genetics (see below).
Iceland started preparing its physical infrastructure for the pandemics early. The Department of Civil Protection and Emergency Management declared an “uncertainty phase” in late January, 2020. In accordance with the Icelandic Pandemic and Influenza Preparedness Plan (IPIPPP) the first measures involved taking stock and upgrading nationwide supplies of food, pharmaceutical drugs, protective equipment, medical supplies and other resources necessary to respond to pandemics and provide all the necessary services, along with securing testing kits and infrastructure for SARS-CoV-2. The preparedness plan also requested testing communication channels and operating procedures, working processes and check-lists, as well as rehearsing the civil protection response plans. This stock taking exercise took place in early February and supplies were upgraded and the various supply-chains tested and secured. The entire community was activated, all institutions and firms in the economy, public and private, were advised to update their response plans and be prepared if the virus reaches Iceland. Regional and district epidemiologists in cooperation with the regional police officers were responsible for the preparation of responses in each district, in accordance with the IPIPP. Regional and district epidemiologists attend regular meetings with the CE.
On February 28th when the state of Alert phase was declared, this monitoring of supplies and capacities to respond to the imminent pandemic was intensified including consultation and co-operation with involved parties both domestically and internationally, distribution of information to the public and to all health care institution. Medical supplies were under continuous consideration as well as assessment of available isolation/quarantine facilities for foreigners, health care workers and other frontline workers which needed special protection to minimize the risk of becoming infected by family members (such as, experts and managers leading the nationwide co-ordination of the IPIPP).
On March 22nd 2020, health care services were restructured, prioritizing care for COVID-19 patients, but at the same time secure necessary health care for other patients in need. The Minister of Health, advised by the Medical Director of Health, announced that all elective treatments that could wait for more the 8 weeks were postponed until May 31st. In addition, in order to increase capacity in preparation for the growing number of COVID-19 patients, some operating theatres at Landspitali hospital were converted into intensive care units. Reserve beds were prepared in other health care institution in the Capital Region to admit patients from Landspitali hospital in case of need. A specialised COVID-19 ambulatory care unit was prepared at Landspitali hospital to meet the needs of all people who have tested positive for the virus.
In March 6th the state of emergency was declared. In mid-March the CE reported concerns over shortages of sampling swabs to carry on testing, yet this problem was resolved within days. On April 9th, when the CE announced that all figures indicated that the peak of the pandemic in Iceland had been reached, the CEO of Landspitali Hospital announced that the hospital had just received 17 new ventilators, protective equipment including masks and 140.000 swabs of testing. The 17 new ventilators adds to the 26 ventilators the hospital had prior to the outbreak. On April 10th, The CEO of the Landspitali hospital, which is also responsible for maintaining the supply chain and procurement of medical supplies including all protective equipment, announced that more supplies had arrived to the country ensuring supplies for several weeks to come, but more was underway.
As of April 10th 2020, there were 36 COVID inpatients at the Landspitali University Hospital, and 846 out-patients under a monitoring scheme at the ambulatory care units. There were 9 inpatients in intensive care, of which 6 were connected to ventilators. As per April 11, a total of 92 COVID-19 patients were hospitalized, 25 patients received intensive care and 13 were connected to respiratory ventilators. No shortages of hospital beds, tests or protective equipment have been reported.
As of April 15th 2020, there were 32 COVID-19 inpatients at the Landspitali University Hospital, and 617 outpatients under a monitoring scheme at the ambulatory care units. There were 7 inpatients in intensive care, of which 3 were connected to ventilators. As per April 15, a total of 109 COVID-19 patients had been hospitalized, 28 patients had received intensive care and 16 had been connected to respiratory ventilators. No shortages of hospital beds, tests or protective equipment have been reported.
- Efforts to build up public health capacity in preparation for the post-lockdown phase
In order to build up public health capacity in the ‘post-social restriction phase’, medical supplies have been restocked in April (after the first stocking during the uncertainty phase in February). At the beginning of the pandemic, the country was relatively well placed with medical supplies such as tests, personal protective equipment and ventilators. The preparation phase was based on scenarios and models which estimated higher pressure on the healthcare system than actually occurred. Based on these estimates, in April the country stockpiled medical supplies to restock and enlarge supplies, the same time the COVID-19 pandemic had reached its peak in Iceland. Shortages of equipment did never hamper the system´s response to COVID-19 with the exception of a few days in March while swaps for testing were temporarily in short supply.
Stockpiling and allocation of necessary equipment is centralized and under the responsibility of Landspitali University Hospital, supervised by the Chief Epidemiologist. The contact tracing ability was improved by massive adoption of a mobile app, which is now widely used. As of April 27th, the app had been downloaded to 138,000 mobile phones in the country (Directorate of Health. April 27th 2020. COVID-19 Status report at https://www.landlaeknir.is/servlet/file/store93/item41433/_COVID19_Stoduskyrsla_27042020.pdf).
The Medical Director of Health´s preliminary assessment of the COVID-19 response in Iceland is that the emergency team responsible for the responses to the pandemic in Iceland had always been a little bit ahead of the actual development of the outbreak and thus had been able to, so far, flatten the curve in order to maintain the capacity of the health care system to handle the COVID-19 crisis.
OECD Data 2018. Iceland https://data.oecd.org/healtheqt/hospital-beds.htm
Directorate of Health, 2020. the Icelandic Pandemic and Influenza Preparedness Plan https://www.landlaeknir.is/utgefid-efni/skjal/item29596/
Directorate of Health. Status Report. DCPEM and CE. February 2nd 2020. https://www.landlaeknir.is/servlet/file/store93/item38982/Koronaveira_StatusReport_04022020.pdf
Directorate of Health. Status Report. DCPEM and CE. February 4th 2020 https://www.landlaeknir.is/servlet/file/store93/item38982/Koronaveira_StatusReport_04022020.pdf
National Broadcasting Service, News February 29th https://www.ruv.is/frett/hoteli-breytt-i-sottkvi-gestir-fengu-uppfaerslu
Icelandic Health Insurance March 29th 2020, An agreement with Icelandair Hotels. https://www.sjukra.is/um-okkur/frettir/sjukratryggingar-islands-hafa-gert-samkomulag-vid-icelandair-hotels
National Broadcasting Services, News March 21st 2020, https://www.ruv.is/frett/serstok-gongudeild-sem-sinnir-covid-sjuklingum
DoH. Status Report, DCPEM and CE. March 24th 2020 https://www.landlaeknir.is/servlet/file/store93/item40626/COVID19_Stoduskyrsla_24032020.pdf
National Broadcasting Service, News March 26th,https://www.ruv.is/frett/fundu-lager-med-6000-synatokupinnum
The National Broadcasting Service. News April 9th 2020 https://www.ruv.is/frett/2020/04/09/mjog-vel-sett-med-thessari-hofdinglegu-gjof
National Broadcasting Service, Civil Protection Live information meeting, https://www.ruv.is/frett/2020/04/10/upplysingafundur-almannavarna
National University Hospital Statistics on COVID-19 https://www.landspitali.is/um-landspitala/spitalinn-i-tolum/-covid-19-a-landspitala-tolulegar-upplysingar/