> How much room is left in intensive care units? That question not only determines the fate of our country with each corona wave, it also puts its finger on the sore spot in our healthcare system. What could be better?
>
> With each corona wave, hospitals present us with the worst-case scenario: if the beds in their intensive care units are full, there is nothing left to do but make choices between patients in a life-threatening condition. That moment is getting close, Margot Cloet, the top woman of the healthcare umbrella organization Zorgnet-Icuro, warned again this week.
>
> The pressure on care remains high. According to the latest statistics, there are an average of 318 admissions per day. That brings the total to 3,707 occupied hospital beds. At 821, we have long passed the alert threshold of 500 people in intensive care units.
>
> Because of these figures, hospitals were asked by the Hospital & Transport Surge Capacity Committee (HTSC), the consultative body of the government, hospitals and experts, to postpone all non-urgent care by two weeks. This includes not only procedures that require an intensive care admission, but also day hospitalizations. Think wisdom tooth extraction or eardrum tube placement. The staff thus freed up in operating theatres and recovery rooms can assist in intensive care.
>
> **Boosting capacity**
> The decision should help curb the corona crisis. But there is another side to it: such a postponement will further increase the care backlog. Many treatments that were put on hold during previous surges have not yet been caught up. This leads not only to frustration, but also to discussion about the future of our care. Shouldn’t we organize intensive care, which during this crisis proves time and again to be the major bottleneck, differently?
>
> The solution that is quickly put forward is: increase the number of intensive care beds. From 2,000 to 3,000, suggested entrepreneur Marc Coucke. Then we’ll have a bigger buffer if things go wrong again.
>
> It’s not as simple as that, says every expert.
>
> Our country already has a lot of intensive care beds. While OECD countries have an average of 12 intensive care beds per 100,000 inhabitants, our country has 17.4. That puts us in fourth place.
>
> Many doubt that an increase in capacity will do much to help. Whether you have 3,000, 4,000 or 5,000 beds: they fill up anyway. There will never be enough to unleash a virus. A system always has a limit,’ says Geert Meyfroidt (UZ Leuven), who was president of the Belgian Society for Intensive Care Medicine until June. He compares it to adding freeways. ‘That doesn’t solve the traffic jam problem either.’
>
> The question also arises: if we provide more intensive care beds, what do we do with them when the pandemic subsides? ‘Even if you don’t use such beds, they require money. Infrastructure needs to be maintained and equipment needs to be kept up to date. The bigger the buffer, the less cost-effective,’ says Marcel Van der Auwera, head of the HTSC.
>
> Nurses and doctors can, however, be deployed flexibly in a scenario of increased capacity. At busy times, when a lot of virus is circulating, they can work in intensive care, in quieter periods on ordinary nursing wards. But even in that case there are limitations. Van der Auwera: “We are in any case faced with a major shortage of healthcare workers. For intensive care you need people who have had specialized training. Even if the influx of nursing students increases, it takes years before they are on the work floor. And the question remains: how many of them are prepared to change departments not just once, but continuously?’
>
> It is certain that a reorganization of intensive care should not focus only on covid. The future may also bring health crises of an entirely different nature. Think of a major chemical or biological incident, or a pandemic that mainly affects children. ‘In such cases you need a very different capacity,’ says corona commissioner Pedro Facon.
>
> The one receiving the most acclaim is the one where the 2,000 available beds are used more intelligently. Now, many note that all intensive care beds are being made equal. The same amount of funding and staffing is provided. But one intensive care bed is not another. Caring for a young person with multi-organ failure and sepsis is very different from caring for an elderly patient after standard heart surgery.
>
> Quality differences are pointed out. Take the extra intensive care beds created through the Surge Capacity Plan or hospital emergency plan. ‘There is staff there with little expertise in intensive care. Those people have received additional training, but they lack the experience of seasoned teams. Something like that can affect patients’ chances of survival. The same applies to the post-admission pathway: rehabilitation can also be more difficult if you haven’t received the highest quality intensive care,’ says Facon.
>
> In hospitals that were forced to provide additional beds during the first wave, seriously ill patients had a 27 percent risk of dying. In hospitals that did not have to scale up, it was 21 percent, the health institute Sciensano and intensivist Meyfroidt calculated in the journal The Lancet Regional Health. It also found large and unexplained differences between hospitals for patient outcomes, even after adjusting for severity of illness and overload. This suggests that there was a difference in quality of care.
>
> Anonymized but uncorrected data obtained by Chamber member Frieda Gijbels (N-VA) from the federal public health service also showed differences, albeit regional. Between March 2020 and mid-June 2021, fewer corona patients died in Flemish hospitals than in Brussels or Walloon ones.
>
> **Financing according to expertise**
> Experts in hospital financing and organization believe that it is wise to move away from the system in which all intensive care beds are put on an equal footing. They believe it would be better, as in the Netherlands or some Anglo-Saxon countries, to differentiate intensive care and install different levels of beds that are then financed and funded to a greater or lesser extent depending on their expertise. They make the comparison with complex stroke care: for that, a few centers have been designated that work at the very highest level. This is not to say that other hospitals can no longer help people after a stroke, but they are intended for more basic care.
>
> Facon says that a reorganization of this kind would make it possible to achieve gains in intensive care, perhaps without having to add beds. It’s the expertise that makes the difference. A doctor who performs certain actions on critical patients more often is a better doctor. The same applies to a nurse. Facon: “For corona, too, we saw big differences in practice. In some departments they put patients on a heart lung machine relatively quickly, while in others they don’t do that at all, because they know from experience that it has no added value for that patient.’
>
> What exactly might that level distribution look like? And how do you divide the beds? No one has an answer to that yet. Heart transplants will be classified differently from heart attacks, that goes without saying. But exactly how many beds you provide in which level is a complex exercise,’ says Van der Auwera. Next year, the Federal Knowledge Centre for Health Care (KCE) will start a study into the possibility of setting up an intermediate level in intensive care.
>
> In an ideal scenario, intensive care reform is part of hospital reform. This has been on the agenda for a long time, but due to corona, hardly any steps are being taken forward. The fragmentation of powers in the area of welfare and health makes unity of command difficult and led to all sorts of delays during the pandemic. Hospital networks, in which institutions collaborate more efficiently and redistribute expertise, are also only at the beginning. Hospital financing remains an old sore: it still lacks transparency and is not sufficiently results-oriented. Many institutions continue to run at a loss.
>
> The question, then, is whether intensive care will be reformed soon. On paper, that can be quickly drawn out. But then the institutional machinery follows. Some aspects, such as financing, must be decided at the federal level, others, such as recognition, by the states. In any case, the practical implementation must be the subject of a whole series of compulsory opinions.
>
> Many are apprehensive to have the discussions on this already. The sector is fully engaged in warding off a fourth wave. Not everyone thinks this is the right time to discuss in the field what needs to be done differently and better.
>
> That we remain stuck in that acute worry mode is one of Facon’s biggest frustrations. ‘But we can’t keep putting off the problems in healthcare. Today we are already paying the price for the adjustments that were not made in the past.’
Can people now stop spamming “just scale up healthcare!!!!!!!!!” as if it’s a solution to this crisis?
TL;DR;
It’s not possible to scale ICU on a short term because of infrastructure and personnel.
In the long term it would cost a shitload of money.
3 comments
> How much room is left in intensive care units? That question not only determines the fate of our country with each corona wave, it also puts its finger on the sore spot in our healthcare system. What could be better?
>
> With each corona wave, hospitals present us with the worst-case scenario: if the beds in their intensive care units are full, there is nothing left to do but make choices between patients in a life-threatening condition. That moment is getting close, Margot Cloet, the top woman of the healthcare umbrella organization Zorgnet-Icuro, warned again this week.
>
> The pressure on care remains high. According to the latest statistics, there are an average of 318 admissions per day. That brings the total to 3,707 occupied hospital beds. At 821, we have long passed the alert threshold of 500 people in intensive care units.
>
> Because of these figures, hospitals were asked by the Hospital & Transport Surge Capacity Committee (HTSC), the consultative body of the government, hospitals and experts, to postpone all non-urgent care by two weeks. This includes not only procedures that require an intensive care admission, but also day hospitalizations. Think wisdom tooth extraction or eardrum tube placement. The staff thus freed up in operating theatres and recovery rooms can assist in intensive care.
>
> **Boosting capacity**
> The decision should help curb the corona crisis. But there is another side to it: such a postponement will further increase the care backlog. Many treatments that were put on hold during previous surges have not yet been caught up. This leads not only to frustration, but also to discussion about the future of our care. Shouldn’t we organize intensive care, which during this crisis proves time and again to be the major bottleneck, differently?
>
> The solution that is quickly put forward is: increase the number of intensive care beds. From 2,000 to 3,000, suggested entrepreneur Marc Coucke. Then we’ll have a bigger buffer if things go wrong again.
>
> It’s not as simple as that, says every expert.
>
> Our country already has a lot of intensive care beds. While OECD countries have an average of 12 intensive care beds per 100,000 inhabitants, our country has 17.4. That puts us in fourth place.
>
> Many doubt that an increase in capacity will do much to help. Whether you have 3,000, 4,000 or 5,000 beds: they fill up anyway. There will never be enough to unleash a virus. A system always has a limit,’ says Geert Meyfroidt (UZ Leuven), who was president of the Belgian Society for Intensive Care Medicine until June. He compares it to adding freeways. ‘That doesn’t solve the traffic jam problem either.’
>
> The question also arises: if we provide more intensive care beds, what do we do with them when the pandemic subsides? ‘Even if you don’t use such beds, they require money. Infrastructure needs to be maintained and equipment needs to be kept up to date. The bigger the buffer, the less cost-effective,’ says Marcel Van der Auwera, head of the HTSC.
>
> Nurses and doctors can, however, be deployed flexibly in a scenario of increased capacity. At busy times, when a lot of virus is circulating, they can work in intensive care, in quieter periods on ordinary nursing wards. But even in that case there are limitations. Van der Auwera: “We are in any case faced with a major shortage of healthcare workers. For intensive care you need people who have had specialized training. Even if the influx of nursing students increases, it takes years before they are on the work floor. And the question remains: how many of them are prepared to change departments not just once, but continuously?’
>
> It is certain that a reorganization of intensive care should not focus only on covid. The future may also bring health crises of an entirely different nature. Think of a major chemical or biological incident, or a pandemic that mainly affects children. ‘In such cases you need a very different capacity,’ says corona commissioner Pedro Facon.
>
> The one receiving the most acclaim is the one where the 2,000 available beds are used more intelligently. Now, many note that all intensive care beds are being made equal. The same amount of funding and staffing is provided. But one intensive care bed is not another. Caring for a young person with multi-organ failure and sepsis is very different from caring for an elderly patient after standard heart surgery.
>
> Quality differences are pointed out. Take the extra intensive care beds created through the Surge Capacity Plan or hospital emergency plan. ‘There is staff there with little expertise in intensive care. Those people have received additional training, but they lack the experience of seasoned teams. Something like that can affect patients’ chances of survival. The same applies to the post-admission pathway: rehabilitation can also be more difficult if you haven’t received the highest quality intensive care,’ says Facon.
>
> In hospitals that were forced to provide additional beds during the first wave, seriously ill patients had a 27 percent risk of dying. In hospitals that did not have to scale up, it was 21 percent, the health institute Sciensano and intensivist Meyfroidt calculated in the journal The Lancet Regional Health. It also found large and unexplained differences between hospitals for patient outcomes, even after adjusting for severity of illness and overload. This suggests that there was a difference in quality of care.
>
> Anonymized but uncorrected data obtained by Chamber member Frieda Gijbels (N-VA) from the federal public health service also showed differences, albeit regional. Between March 2020 and mid-June 2021, fewer corona patients died in Flemish hospitals than in Brussels or Walloon ones.
>
> **Financing according to expertise**
> Experts in hospital financing and organization believe that it is wise to move away from the system in which all intensive care beds are put on an equal footing. They believe it would be better, as in the Netherlands or some Anglo-Saxon countries, to differentiate intensive care and install different levels of beds that are then financed and funded to a greater or lesser extent depending on their expertise. They make the comparison with complex stroke care: for that, a few centers have been designated that work at the very highest level. This is not to say that other hospitals can no longer help people after a stroke, but they are intended for more basic care.
>
> Facon says that a reorganization of this kind would make it possible to achieve gains in intensive care, perhaps without having to add beds. It’s the expertise that makes the difference. A doctor who performs certain actions on critical patients more often is a better doctor. The same applies to a nurse. Facon: “For corona, too, we saw big differences in practice. In some departments they put patients on a heart lung machine relatively quickly, while in others they don’t do that at all, because they know from experience that it has no added value for that patient.’
>
> What exactly might that level distribution look like? And how do you divide the beds? No one has an answer to that yet. Heart transplants will be classified differently from heart attacks, that goes without saying. But exactly how many beds you provide in which level is a complex exercise,’ says Van der Auwera. Next year, the Federal Knowledge Centre for Health Care (KCE) will start a study into the possibility of setting up an intermediate level in intensive care.
>
> In an ideal scenario, intensive care reform is part of hospital reform. This has been on the agenda for a long time, but due to corona, hardly any steps are being taken forward. The fragmentation of powers in the area of welfare and health makes unity of command difficult and led to all sorts of delays during the pandemic. Hospital networks, in which institutions collaborate more efficiently and redistribute expertise, are also only at the beginning. Hospital financing remains an old sore: it still lacks transparency and is not sufficiently results-oriented. Many institutions continue to run at a loss.
>
> The question, then, is whether intensive care will be reformed soon. On paper, that can be quickly drawn out. But then the institutional machinery follows. Some aspects, such as financing, must be decided at the federal level, others, such as recognition, by the states. In any case, the practical implementation must be the subject of a whole series of compulsory opinions.
>
> Many are apprehensive to have the discussions on this already. The sector is fully engaged in warding off a fourth wave. Not everyone thinks this is the right time to discuss in the field what needs to be done differently and better.
>
> That we remain stuck in that acute worry mode is one of Facon’s biggest frustrations. ‘But we can’t keep putting off the problems in healthcare. Today we are already paying the price for the adjustments that were not made in the past.’
Can people now stop spamming “just scale up healthcare!!!!!!!!!” as if it’s a solution to this crisis?
TL;DR;
It’s not possible to scale ICU on a short term because of infrastructure and personnel.
In the long term it would cost a shitload of money.