The memo to stop care that hospitals wanted but did not get

March 20, 2020. Hospitals in Brabant sound the alarm: We are going down and need help. They are not prepared for so many corona patients to come. Now research from NOS shows that as early as the beginning of February 2020, RIVM knew that a coronavirus outbreak would completely paralyze Dutch hospitals. Only that information never reached the hospital administrators.

For unclear reasons, the Ministry of Health, Welfare and Sport (VWS) never shared this information. What do we know about the time that hospitals could have spent preparing for a corona crisis? A reconstruction.

First, the note that the institute’s model builders sent to the RIVM management on 9 February 2020. The text is crystal clear: “There are approximately 37,000 hospital beds in the Netherlands, including 1,208 operational IC beds. This capacity is insufficient,” the model builders write. “For the whole range of estimates [de] possible seriousness (…) we calculate that the demand for care exceeds this available capacity. “

The model companies warn in the note that the number of corona patients will double every five days, which quickly increases the pressure on care. “Due to the rapidly increasing demand for care, hospitals, nursing homes, primary care and home care have a very short time to take action after a first case of nCoV infection has been admitted,” reads the note in which nCoV stands for “the new coronavirus. “

The risk analysis also indicates that the number of hospital beds in the Netherlands is “significantly less” than in neighboring countries. The Netherlands could therefore prepare earlier than other countries “for what can be done so that the demand for care does not exceed capacity”.

Dutch approach already cracked in the note

Barely three weeks after the memo, the first corona patient in the Netherlands was identified on 27 February 2020. At that time, the government’s approach was still aimed at quickly detecting and isolating infected people, but that approach has already been cracked by RIVM in the memo.

The modelers estimate that 38 percent of all infected people must be found before they become contagious. “We [berekenen] that this percentage cannot be obtained if contact tracking only registers direct contacts in a case; it helps slow down an outbreak, not stop it. “

The note of 9 February shows that RIVM was not surprised by the serious consequences of a coronavirus outbreak for Dutch society. Earlier, a NOS reconstruction also showed that RIVM expected the virus to come to the Netherlands and that this would have “serious to catastrophic” consequences. This expectation has never been made public.

Room never informed

According to a spokesman for RIVM, it was up to the department to provide and interpret information for the cabinet. But it was up to the Ministry of Health, Welfare and Sports to ultimately make decisions on whether to inform, for example, hospitals or society.

But it is striking that RIVM also did not inform the House of Representatives about the alarming calculations during one of the first technical briefings on the corona virus. During such a briefing on 20 February 2020, Jaap van Dissel, director of the Center for Infection Control at RIVM, said nothing at all about the expected pressure on healthcare or hospitals.

Not just any script

The question remains as to why the Ministry of Health, Welfare and Sport did not explicitly inform the House of Representatives in February 2020 about the alarming risk analysis in the RIVM memorandum. According to a spokesman for VWS, this is because the memo was seen as one of several scenarios.

This is a remarkable statement, because the memorandum is not just a scenario, but a risk analysis which states that in any case there is insufficient hospital capacity as soon as the corona virus hits the Netherlands.

Questions about the views in the note in VWS are not answered. “We see no reason to extend the route for this specific note because it can be assumed that this is one of the scenarios being discussed at the time,” a ministry spokesman said. “Communication between VWS and RIVM has been transparent and open throughout the pandemic.”

“Calls immediately”

According to Diederik Gommers, chairman of the then Dutch Association for Intensive Care, the risk analysis was not discussed at the OMT meeting on 27 February (also the day of the first official corona infection in the Netherlands), in which RIVM also participated.

“If even part of this had been discussed, I would have called the alarm immediately. The national coordination of patient distribution could have been established earlier. We could have arranged more fans in advance. I finally called only at 8 o’clock. March when I got a call from the European IC Association. “

Gommers stresses that the note would not have made any difference in the number of IC beds that the Netherlands would have had available. “But if we had known, we could have scaled up much earlier, it would have saved a lot of stress.”

What was the route for the note?

In memory of Amsterdam UMC director Mark Kramer, as chairman of the Regional Consultation Acute Care Noord Holland / Flevoland, intensively involved in the crisis approach from the beginning of the pandemic, the alarm bells had already started ringing about the virus in February. In any case, the note of 9 February shows the opposite with regard to RIVM’s model builders.

“For me, the big question, therefore, is which office in RIVM or the Ministry of Health, Welfare and Sports has stopped the formal progress of this memo, and why it happened,” says Kramer. “This knowledge should have been introduced to the security regions and GGD GHOR. They could then have involved care partners, such as hospitals in their region, in the preparations well in advance.”

Jan Kluytmans (now UMC Utrecht, formerly Amphia in Breda) says he is “very surprised” by the note. In early March, he made his own calculations about the expected pressure on the hospitals in Brabant.

‘They fell off the chairs’

“When we showed those calculations to the ministry, they fell off the chairs,” Kluytmans says. “They would only believe it if the first model builder Jacco Wallinga from RIVM would calculate it again. Now it turns out that RIVM came to a similar conclusion a month earlier. I am very much looking forward to that.”

Bart Berden from Elisabeth-Tweesteden Hospital is also unpleasantly surprised. “Nota bene, we had a meeting in March with all the hospital administrators in Brabant and Jaap van Dissel from RIVM. He called our scenario ‘not unlikely’ at the time.”

According to Berden, the LCPS patient distribution system could also have been started earlier. “I would love to have known this before,” Berden says. “Then we would have been able to scale up, and if the health care institutions had visited each other much earlier. I would have immediately purchased more personal protective equipment. Now the planes went full of mouth holes to China in February.”

Kluytmans is a little less firm. “The idea that was still very much divided at the time, no matter how naive it was, was that Holland would get away with it. I do not know if such a note alone would have changed this mentality.”

Lost time

The congestion of Dutch hospitals as a result of the corona outbreak started six weeks after the RIVM memo. On 21 March 2020, the National Coordination Center for Patient Distribution (LCPS) was established with steam and boiling water, under the leadership of Ernst Kuipers, who is now Minister of Health, Welfare and Sport. Through this organization, corona patients were then spread from the epicenter of the virus, North Brabant, to hospitals across the country.

This is to prevent the health care system in Brabant from collapsing. On March 29, the first patients were transferred to Germany due to major capacity problems in the Netherlands.

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