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
The National Coordination Centre for Distribution of Patients will take on a steering role in the allocation of COVID-19 patients among the Dutch hospitals. The Centre announces one week in advance how many COVID-19 patients the hospital can expect and the hospital is obliged to accommodate these patients. To help hospitals, independent treatment centres (these are private clinics, often connected to a hospital, that provide uncomplicated treatments or day surgery interventions) can take over some part of the care, either by taking over regular care or by asking personnel to help out in hospitals.
In the past few months (up to October 2020), about 200 ICU beds and 600 hospital beds have been created for COVID-19 care. This required high numbers of personnel and a further surge of the capacity will not be possible, according to Kuipers, head of the National Coordination Centre. (https://nos.nl/artikel/2352271-spoedeisende-hulp-in-de-knel-door-groeiend-aantal-coronapatienten.html; https://www.nrc.nl/nieuws/2020/10/22/spoedoverleg-tussen-minister-en-ziekenhuizen-over-patientenspreiding-a4016992).
As limited lab tests were available, especially during the first wave and in the beginning of the second wave, mainly due to the shortages of supplies needed to perform the tests, tests are limited (for more details, please refer to Section 1.5 Testing).
In the Netherlands, there are 1150 ICU beds available, which normally have a 70% occupancy rate. As of 29 March 2020, there were 915 confirmed COVID-19 cases admitted to an ICU (https://www.stichting-nice.nl/). The aim is to scale up to 1600 beds, of which 1100 will be available for COVID-19 patients for the week of 30 March 2020. The week of 6 April is expected to have 2000 beds available, and the week thereafter 2500 beds to treat COVID-19 patients. To ensure optimal use of ICU beds, COVID-19 patients and other patients who need treatment that might require ICU care are redistributed over the Dutch hospitals. For instance, in the Groningen hospitals (north of the Netherlands) 32 of the 34 COVID-19 patients are coming from the south of the Netherlands (provinces of Noord-Brabant and Limburg) (https://www.ad.nl/binnenland/nu-meer-dan-900-patienten-op-ic-operatie-corona-is-race-tegen-de-klok~ab471cce/; https://nos.nl/artikel/2327537-corona-in-nederland-cijfers-van-28-maart.html).
To ensure optimal use of available beds, all hospitals in the Netherlands will be connected to a real-time computer system that shows bed availability. About half of the hospitals were connected already at the end of March 2020 and the rest will follow shortly. Connection to the system is compulsory, according to the National Coordination Centre for Patient Distribution. National coordination was urgently needed, because transferring the large numbers of patients led to chaotic situations (Landelijke Coördinatiecentrum Patiënten Spreiding; https://nos.nl/l/2328856). However, the Network of Medical Information Specialists criticized the chosen system, arguing that there are already alternatives in place (such as zorg-capaciteit.nl). The National Coordination Centre argued that their system is real-time and thus more accurate than the others that require manual updates (https://www.nrc.nl/nieuws/2020/03/31/landelijke-coordinatie-van-ic-bedden-is-nodig-om-chaos-te-bestrijden-a3995516).
Patients have been re-located with, among others, the help of the army and of a special ambulance bus that can transport 6 patients at a time. During one of the transports, the bus broke down and was taken on a tow truck with patients still in the bus. After an extra check on their condition halfway through the journey, the patients arrived safely in Groningen (https://jeugdjournaal.nl/artikel/2327857-leger-gaat-helpen-met-verdelen-corona-patienten.html). Since 23 March Erasmus Medical Centre is the central coordinator to match patients and available beds (https://nos.nl/artikel/2328037-verdeling-coronapatienten-over-nederland-nu-centraal-geregeld.html). ICU units all over the country are urgently requested to provide their ICU bed availability three times per day to the website www.zorg-capaciteit.nl to facilitate a good overview of availability (https://nvic.nl/sites/nvic.nl/files/20200317%20Bericht%20van%20de%20voorzitter%203.pdf). Many hospitals have cancelled all non-urgent operations to ensure capacity for COVID-19 patients.
There is an impeding shortage of ventilator equipment. Private hospitals (independent treatment centres) have provided equipment that can be used for treating COVID-19 patients. The Army has also provided ventilator equipment to hospitals. The Ministry of Health ordered 1000 extra machines, of which 100 have been delivered as of 29 March (https://nos.nl/artikel/2328651-apparatuur-voor-100-extra-ic-bedden-geleverd.html). The option to have two patients using one machine has been explored, but this has not yet been necessary. (https://nvic.nl/sites/nvic.nl/files/20200323%20Splitsen%20van%20Beademingsmachines%20NVIC%20v%20dd%2024032020%20final%20final.pdf). The Dutch government ordered 2000 extra ventilators from several manufacturers, but it is unsure whether these will (all) be delivered. Several initiatives to develop simple ventilators have been initiated, such as a company that already delivers parts of ventilators, now will deliver 500 ‘simple’ machines to the government (https://www.ad.nl/dossier-coronavirus/extra-ic-bedden-enschedees-bedrijf-gaat-500-beademingsapparaten-leveren~a0a5ade4/).
There are impending shortages in protective equipment, especially face masks. The guidelines for mask use were adjusted on 9 and 18 March. FFP2 masks are now only used when treatment may cause a lot of aerosols (as is the case with intubation and some other medical procedures). In all other cases, surgical masks are considered sufficient (https://lci.rivm.nl/sites/default/files/2020-03/Advies%20Ademhalingsbeschermingsmaskers%20voor%20COVID_19%20%20dd%20180320.pdf). Hospitals should keep used masks in order to disinfect and reuse them as soon as an approved method becomes available. A large order of face masks, that was already distributed to hospitals, appeared to be of insufficient quality and had to be recalled (https://nos.nl/artikel/2328673-honderdduizenden-chinese-mondmaskers-teruggeroepen-uit-nederlandse-ziekenhuizen.html). A central reporting point for shortages in protective materials, initiated by a professional association for nurses, has been created in order to have an overview of where shortages become problematic. The results will be presented to the Ministry of Health on 2 April (https://www.nu91-leden.nl/news/MELDPUNT_BESCHERMENDE_MIDDELEN&id=2038).
In the home care sector, there is a pressing shortage of protective garments. Only nurses who take care of identified cases have access to protective garments, while all others have to work without extra protection. According to the guidelines of the National Institute of Public Health and the Environment, protective garments are not necessary when there are no symptoms. However, there is a lot of discussion about this, because most of the people that receive home care are highly vulnerable to infection. This may also cause a workforce capacity problem, because home care personnel now call in sick with only very mild symptoms (as they are advised to do), leading to higher absenteeism than normal (https://www.nrc.nl/nieuws/2020/04/07/als-maanmannetje-of-juist-onbeschermd-op-huisbezoek-bij-een-kwetsbare-zieke-a3996098).
As a result of the shortage of protective garments, a central allocation model was developed to assess the availability of protective garments and manage distribution. The Regional consultative body acute care (Regionaal Overleg Acute Zorg) assesses the demand for these garments at the regional level, which are aggregated every day to create an overview at the national level. The National Consortium Assistive Devices (Landelijk Consortium Hulpmiddelen) manages the physical distribution of the available resources (https://www.rijksoverheid.nl/onderwerpen/coronavirus-covid-19/documenten/publicaties/2020/04/11/factsheet-verdeling-pbm). Initially, this model focused on supplying hospitals as a first priority. Since Monday 12 April, the distribution will be focused on the risk for care personnel of being infected by a patient as a result of the treatment. This implies that personnel at nursing homes and home care nurses will have better access to protective masks of high quality when treating COVID-19 patients. However, this does not solve the problem of scarcity (https://nos.nl/artikel/2330169-nieuwe-verdeelsleutel-voor-beschermingsmiddelen-in-zorg.html).
As of 5 June, the number of COVID-19 patients in the ICU dropped below 100 persons. The overall ICU bed occupancy is low, suggesting that regular care is still not at normal capacity (https://nos.nl/artikel/2336311-coronacijfers-van-5-juni-minder-dan-100-ic-patienten-dodental-naar-6000.html).
The Chair of the Association of Intensive Care Units warned that in the summer months the ICUs cannot process an increase in COVID-19 patients, since personnel is limited due to summer holidays (https://www.bnr.nl/nieuws/gezondheid/10417488/nu-geen-plek-voor-nieuwe-covid-patienten-op-ic).
In preparation for a second wave, the Minister of Health has commissioned the National Network of Acute Care to draft a plan that will take the following into account:
a. A plan to scale up ICU capacity to 1700 beds (normal capacity is around 1150 beds, actual capacity due to shortage of personnel is 1050 beds)
b. When there is a(n expected) peak pressure on ICU capacity, using ICU beds in Germany should be considered in an early stage
c. A plan to scale up care to more than 1700 beds in the case of peak pressure, while scaling down regular care.
The plan for managing the second wave was drafted in the typical Dutch way: all stakeholders were involved in the process (the professional association for nurses, the professional association for ICUs, the Federation of Medical Specialists, the National Association of Hospitals, the National Association of University Hospitals, the Association of Health Insurers, the Association of Ambulance Services, and the Dutch Healthcare Authority). To develop the plan, a core team was assembled from the stakeholders and several working groups consisting of professionals from the relevant disciplines contributed to parts of the plan. Experiences from the first wave were used to develop the surge capacity plan for the possible second wave.
A capacity of 550 beds is considered necessary for regular care, and as long as no vaccine is available in the years to come, an expected 650 beds are necessary for COVID-19 patients. This is based on the calculation that 60% of the population will contract COVID-19 and that 0.45% of these people will need an ICU admission. Furthermore, a buffer capacity of 150 beds will be needed to have beds available for unforeseen circumstances, adding up to 1700 beds. The plan also includes cooperation with German hospitals when capacity in the Netherlands is insufficient. (https://www.lnaz.nl/cms/files/opschalingsplan_covid-19_def.pdf). The Minister of Health approved the plan. The Minister is planning to provide as soon as possible clarity upon the financing of this plan and will assess options through consultations with hospitals and health insurers. (https://www.rijksoverheid.nl/binaries/rijksoverheid/documenten/kamerstukken/2020/06/30/kamerbrief-over-opschalingsplan-covid-19/kamerbrief-over-opschalingsplan-covid-19.pdf).
The availability of skilled personnel is still a problem. A survey by the nurses’ professional journal “Nursing” showed that many nurses have not recovered from the physical and emotional stress of the height of the pandemic. (https://www.nursing.nl/helft-verpleegkundigen-is-niet-klaar-voor-tweede-coronagolf/)
Another problem related to hospital capacity is the number of elderly that stay in the hospital because there is no room in nursing homes. Nursing home capacity has been limited already for a long time, but since the current lack of personnel due to COVID-19 and outbreaks in nursing homes, the problem has become more prominent. One hospital had to close the emergency department for 24 hours on Monday 24 October 2020, because of a lack of free beds due to patients who could not be transferred to nursing homes (https://nos.nl/nieuwsuur/artikel/2354561-geen-bed-voor-coronapatient-door-ouderen-die-op-verpleeghuiszorg-wachten.html).