Our data show the dependency of ICUs in Austria in particular on long transglobal supply chains of PPEs and essential pharmaceuticals and thus its non-insignificant vulnerability by reported shortages in times of COVID-19. As seen in our results, 90 percent of ICUs registered supply disruptions of PPE and 35% registered shortages of far more than 3 different pharmaceuticals. 78 percent of questioned ICUs feared or were already informed about further supply difficulties concerning PPE in near future. These results were also reflected in assessments of the heads of surveyed ICUs. A maximum duration of pandemic of 6 weeks without serious impact on health care system was estimated by most chief physicians mainly depending on availability of PPE and pharmaceuticals. Not only dependency on these factors was notably but also on commuting medical personnel from neighboring countries that made up on average 12% of medical personnel generally. Therefore, these three factors can be identified as the most pressing issues in times of pandemic.
Although Austria seems to be in a comparably favorable condition in times of COVID-19 crisis, this is mainly the result of preparation of high capacities (on average nearly 75%) that ICUs can provide especially for COVID-19 patients and lucky coincidences. As the first affected country inside the EU, Italy is one of the most affected countries in the EU. At that time, this virus was new, and not much was known about it, leading to plausible misjudgments and therefore Italy’s health care system got overwhelmed by suddenly high volumes of COVID-19 patients and limited hospital capacity during flu-season. Like in many other countries, hospitals tend to run close to full capacity, with up to 87% average occupancy (10).
From Italy’s experience Austria could draw attention to lessons learned from COVID-19 pandemic and has relatively early taken strict measures to avoid transmission, such as social distancing, school closures and event cancellations. With the aid of these restrictions time was gained to prepare hospitals as good as possible, expand testing capacity and thus keep death rates low. Additionally, the fact that people coming from regions of high population density such as Vienna or Lower Austria had holiday season a few weeks before outbreak of COVID-19 in Tyrol and thus could not visit these areas with high proportion of infected people resulting in moderately high infection rates in urban areas. Also, due to relatively early announced travel warnings majority of the Austrian population did not attend, for example, the carnival in Venice, which could have resulted in massive viral transmission.
Nonetheless in contrast to the positive findings of our survey we could elaborate on three major issues of Austria’s ICU in fighting COVID-19:
First, in our survey more than a half of responding heads of ICUs in Austria stated not getting enough high-class disposable PPE allocated for their employees and nearly all of them reported supply difficulties. About a maximal duration of pandemic of up to 6 weeks without serious negative impacts on our health system was speculated by responding heads of ICU (chief physicians), mainly arguing by stable supply chains of PPE.
In this context, we may underline that for adequate protection of medical personnel especially during the performance of aerosol generating procedures such as intubation bronchoscopy and suctioning a PPE is indispensable (9). Shortages result in inability of health care workers to protect themselves or their patients from being infected and thus will infect others (11). In most affected countries such as Italy as on 30 March 2020 9% of medical personnel got infected (10, 12), many of whom thereafter died. Since the outbreak of COVID-19 pandemic the demand on PPE increased exponentially, soon leading to depleted supplies. According to the WHO the industry must increase manufacturing by 40 per cent to meet rising global demand (11). Due to economic globalization of health care and decentralized production of disposables such as PPE to save costs, like many other countries in the EU, Austria buys masks, goggles, impervious gown and gloves mainly from Asia, resulting in high dependency of secure global supply chains. Closing of borders worldwide and ban of exports of Asia therefore aggravated the shortage of PPE. But also, within Europe, the crisis has piled stress onto intra-European supply chains with new border checks causing traffic jammed trucks. Recently also reported, transporters delivering PPE got confiscated on transportation route in transit countries. As a result, the Austrian government had to transport the equipment by air leading to enormous increase of purchasing costs. However, not only the availability but also the safety and efficacy of PPE is essential for health care workers. Recently published, a disproportional amount of masks, imported from China, failed in reliable safety testing. As a reaction to these developments Austria already started producing masks in local textile companies, especially in Vorarlberg.
Second, 35% of surveyed heads of ICUs reported shortages in more than 3 different pharmaceuticals for COVID-19 and non-COVID-19 patients.
Supply disruption of medications such as opioids, analgesics, antibiotics, and sedatives have been a global problem repeatedly during in the past decades and is increasingly affecting the EU causing widespread human misery (13). The Austrian generics producer’s association (OeGV/Österreichischer Generikaverbund) reported shortages in 230 pharmaceuticals already in November 2019 (14). As recently published by our group, supply shortages may significantly affect quality of care with e.g. lack of remifentanil causing significantly longer mechanical ventilation times and consecutively significantly prolonged ICU stay, even under normal circumstances (15).
While Europe is one of the world’s top manufacturers of drugs, the raw ingredients termed as Active pharmaceutical Ingredients (APIs) often are imported from China or India. According to the European Federation of Pharmaceutical Industries and Associations (EFPIA) as a result of rapid growth of the market and research environment in emerging economies such as China, India and Brazil during the last years, the production of APIs started to migrate from Europe to these fast-growing markets (16)(17, 18). This allows countries of the western world producing cheaper generic versions of pharmaceuticals and these normally outweigh costs of transportation and custom clearance by far.
APIs are responsible for the pharmaceutical effect of formulated pharmaceuticals and are mainly produced in China (60,5%), whereas only 27,9% of global needs of APIs are produced in western Europe (18)(17). The situation aggravated under COVID-19 due to temporary lockdowns of manufacturing sites, worker quarantines, travel restrictions impacting exports, export bans, increased demand for medicines used to treat COVID-19 patient and stockpiling by hospitals, by individual citizens or at Member State level in the EU (16). Additionally, the most affected countries in the COVID-19 crisis in the EU, Italy, and Spain, are the main producers of APIs in western Europe (18). The European Commission published guidelines to fight shortages in reaction to depleted supply in many hospitals, mainly located in Austria, Italy, Sweden, Finland, and France (18)(19).
Third, in more than the half of surveyed ICU wards nurses and 68% of doctors are employed commuting from neighboring countries – especially in boarder regions-, representing a mean rate of 11,5% generally. Difficulties in crossing boarders due to travel restrictions occurred in two-thirds of Austria’s critical care wards and as a result urgently needed specialized intensive care personnel is lacking.
As health care personnel is in the role of first responders in COVID-19 pandemic, countries try to compensate staff shortage by increasing the number of medical personnel by mobilizing inactive and retired health care professionals, even if they are at higher risk of severe infection (1, 20). Countries who spent a lot of Gross Domestic Product (GDP) on health expenditures, such as Switzerland, Norway and Germany have both relatively high numbers of doctors and nurses and are therefore in a more favorable situation in times of the COVID-19 pandemic. Austria has s relatively high number of doctors (approximately 5,3 per 1000 population) but low numbers of nurses (approximately 7 per 1000 population). In contrast the corresponding numbers for Germany are 4,3 doctors and 13 nurses per 1000 population respectively (20). A published study from the Austrian Ministry for Social Affairs in December 2019 reported an additional 13 000 nurses will be required in Austrian hospitals in 2030 (21). Especially staff working on ICU is extensively trained and specialized in caring for critically ill patients and operating with highly sophisticated equipment such as monitoring devices, ventilators, and extracorporeal organ support devices. Therefore, quick recruitment or training of staff from other departments or professional groups is not a viable option.