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 Strategic Operative Plan (number 00-2/1; March 26th 2020) drawn up by the Healthcare Crisis Response Team designated hospitals to treat COVID-19 patients. The total number of “COVID-19” hospitals was seven:
1. Clinical Center of Montenegro
2. General hospital Bar
3. General hospital Berane
4. General hospital Niksic
5. General hospital Pljevlja
6. Special hospital for pulmonary disease “Jovan Bulajic” Brezovik (near Niksic)
7. Private healthcare institution – special hospital Codra
The remaining 6 hospitals (General hospital Kotor, General hospital Bijelo Polje, General hospital Cetinje, Special hospital for orthopaedics, neurosurgery and neurology “Vaso Cukovic” in Risan, Special psychiatric hospital in Dobrota (near Kotor), Private healthcare institution – general hospital Meljine) were designated to treat other patients.
The main hospital in the country (the Clinical Center of Montenegro, situated in the capital, Podgorica) is a tertiary care center, which was prepared for the outbreak by organizing the capacities of the Clinic for infectious diseases, the Clinic for internal medicine (and its Intensive care unit) and the Institute for children’s diseases, for a total of 163 beds empty and prepared for COVID-19 patients.
Three other hospitals in the country (General hospital Niksic, General hospital Berane and General hospital Bar) were designated as “respiratory centers”, providing treatment (and intensive care support, including mechanical ventilation) for eventual COVID-19 patients in the three regions of Montenegro: Berane for the north, Niksic for the middle, and Bar for the south region. Furthermore, two additional hospitals were designated for less severe cases (General hospital Pljevlja and Special hospital for pulmonary disease “Jovan Bulajic” in Brezovik near Niksic). The total number of COVID-19 designated beds was 583 in the entire country (in addition to those in the Clinical Center of Montenegro).
The private hospital “Codra” (Podgorica, Montenegro) was appointed for the obstetrics of all pregnant women with COVID-19, as well as for the labor and hospital care of all pregnant women from quarantine areas.
The remaining hospitals (general hospitals in Bijelo Polje, Cetinje, Kotor and Meljine) were designated to treat non-COVID-19 patients from their areas, as well as from the communities where COVID-19 hospitals are located. The Special hospital for orthopaedics, neurosurgery and neurology “Vaso Cukovic” in Risan was appointed for all patients requiring orthopaedic surgery or neurosurgery.
In total, the capacities of the entire country were:
- 583 COVID-19 beds (out of which 160 were ICU beds) plus circa 600 beds in five field hospitals
- 161 ventilators
- 2130 medical doctors (out of which: 48 anaesthesiologists and 20 specialists in infectious diseases) and 3323 nurses/technicians
- 462 beds for isolation of asymptomatic SARS-CoV-2 positive people who do not have the conditions for adequate self-isolation (e.g. living in small homes with family members who tested negative for SARS-CoV-2) in the institutional isolation facility in the student home in Podgorica, Montenegro (appointed by the Government of Montenegro; decree number 07-2405 on April 16th, 2020).
The institutional isolation facility in the student home in Podgorica ceased its activities in May, because the University of Montenegro restarted its activities. The institutional isolation facility was later referred to the Special hospital for pulmonary disease “Jovan Bulajic” Brezovik because of its structural organization (the hospital consists of several buildings and one of them is currently used as the isolation facility).
The decrease of the active number of cases in Montenegro (which occurred at the beginning of May) influenced the Healthcare crisis response team to reduce the number of COVID-19 beds in the hospitals, in order to enable other hospital services to be continued (e.g. deferred elective surgeries, diagnostics etc.). Initially, the total number of COVID-19 beds was reduced to 138 beds in the entire system (May 8th 2020); followed by 51 beds (May 25th, 2020). The end of the epidemic in Montenegro was formally declared on June 2nd, 2020.
The resurgence of the COVID-19 epidemic in mid-June yielded an increase in the number of COVID-19 beds to 146 (June 18th, 2020), followed by 297 beds (June 30th, 2020), 396 beds (July 3rd, 2020), and finally 486 beds (July 6th, 2020) as follows:
- 77 beds in the Clinical center of Montenegro (the entire Clinic for Infectious diseases; as well as a significant segment of the Clinic for Internal disease, the Intensive metabolic care unit as well as the Institute for Children’s Disease)
- 15 beds in the General hospital Pljevlja
- 85 beds in the General hospital Berane
- 79 beds in the General hospital Niksic (out of which 24 beds are located in the psychiatric ward and are designated for the treatment of SARS-CoV-2 positive psychiatric patients)
- 60 beds in Special hospital for pulmonary disease “Jovan Bulajic” Brezovik
- 100 beds in the General hospital Bar
- 40 beds in the Private hospital Codra (which was reinstated as the hospital for COVID obstetrics)
- 20 beds in the Primary health care center Rozaje (owing to the severity of the epidemiological situation in the municipality of Rozaje)
- 10 beds in the Private hospital Meljine
The previously designated “respiratory centers” (General hospitals Berane, Bar and Niksic, as well as the Clinical center of Montenegro) are once again active in accepting the most difficult cases in the north, mid and south regions. The Clinical center of Montenegro accepts the most challenging cases from the entire country.
As of 16 July 2020, all elective surgeries are once again deferred (besides malignant disease surgeries, which require that the patient has 1 negative PCR test for SARS-CoV-2). All hematologic and oncologic treatments are continued without any delays, as well as all outpatient examinations. All patients with emergency conditions (which are hospitalized on an urgent basis) are tested on admission and are dealt with as SARS-CoV-2 - positive (until the PCR results arrive).
The primary care centers (Institute for Emergency Medical Assistance as well as the general practice institutions) were included in the response to COVID-19 by their cooperative efforts in the triage of suspected patients, as well as the healthcare supervision over the people in self-isolation or quarantine. Their main focus is the early recognition of COVID-19 related symptoms and testing the suspected cases. Also, they perform regular visits to the COVID-19 confirmed cases who are at home, in order to keep their recovery in check and to recognize any signs or symptoms that would require hospital treatment.
Montenegro started enforcing the so-called dual track for service delivery for COVID patients, but also for persons with chronic conditions, through a specially designed helpline staffed by specialists from the Clinical Center of Montenegro (detailed description in Section 3.3 on “Maintaining essential services”).
The contact between primary care and hospitals is based on their cooperation when dealing with COVID-19 cases or other pathologies (routes of transport, admission boards for COVID-19 or other cases etc.). The primary care centers deal with a significant number of chronic non-COVID-19 patients by home visits in order to reduce the number of patients coming to hospitals for regular check-ups.
Five field hospitals (see Section 2.1 on “Physical infrastructure”) did not receive any patients by 19 May 2020. One of them was fully equipped and ready to receive patients, while the other field hospitals were prepared to be fully functional in a matter of a day (regarding medical equipment). The staff is put on standby to be mobilized from nearby hospitals should patients arrive at the field hospitals. See 2.1. (Temporary structures).
Telemedical support for all healthcare workers in the country is provided by experts from the Clinical Center of Montenegro. It builds on the type of communication that existed before the epidemic and was developed further, with more frequent contacts and a stronger connection in knowledge distribution.
Furthermore, psychiatrists and psychologists from the Clinical Center of Montenegro maintained a telephone helpline (which was open every day from 8am to 11pm) providing psychological support for all citizens in need. The helpline helped many citizens (nearly 1000) to cope with the negative feelings related to quarantine, self-isolation, fear of infection etc. The helpline was terminated in May, owing to the improvement of the epidemiological situation.