Management and personnel structure
The basic structures and principles for coordinating the hospitals were closely based on the german “disaster management manual 100” (DM100)2. The staff work is correspondingly divided into six subject areas (S1-S6): Personnel / Internal Service (S 1); - Situation (S 2); - Operations (S 3); Supply (S 4) press and media relations (S 5); - Information and communications (S 6). Also, care was taken to use already existing everyday structures. Using the usual division of the counties into command areas for major incidents, the counties of Donau-Ries and Dillingen were combined to form the coordination group north, and the counties of Augsburg, Aichach-Friedberg, and the city of Augsburg were combined to form the coordination group south (Figure 1). A pandemic officer (PO) was appointed by each hospital or hospital-association as a member of the respective coordination group. From the group of POs, one coordination group leader north and south was appointed respectively. These were directly subordinate to the MDHC. Also, a coordinator for intensive care transfers was appointed for each coordination group (Figure 2).
A district coordinator at the level of the administrative district of Swabia was appointed for the superordinate coordination of the three ambulance districts.
Close coordination of the MDHC, the ambulance dispatch center Augsburg and the medical director of ambulance service took place. The staff of MDHC was provided by anesthetists with disaster medical background from the University Hospital Augsburg, the Augsburg Fire Department, and last-year medical students from the University Hospital Augsburg.
The daily situation monitoring was mainly carried out via IVENA6. This web-based software is used in some regions of Germany in the regular ambulance service for the distribution of pre-hospital emergency patients. Herein all hospitals report at least once a day their current occupancy with COVID-19 patients, non-COVID-19 patients, as well as the available capacities separated into regular ward, IMC, and ICU. In urgent emergencies, the situation was queried by telephone. For the longer-term assessment of the situation development, reports from the State Office for Health and the Government of Swabia were used. Also, the 14-day case rates of the assigned counties were continuously monitored and included in long-term planning. A bed utilization forecasting tool was developed by our group during the first COVID wave7 and was incorporated into the situation assessment and action planning.
The operational structure described above served as the basic framework for the operational tactics. The communication and command paths were directed along with this structure. Each hospital in the ambulance district had to treat COVID-19 patients if necessary. As far as the situation permitted, a COVID-19 focal hospital was designated within each hospital association. These were primarily responsible for treating COVID-19 patients. This enabled the CEOs of the hospital associations to concentrate resources and expertise in one of their hospitals. If the capacities of individual hospitals were fully occupied, transfer options were first sought within the coordination group. If there were no options, the search would continue within the second coordination group, then the neighboring ambulance districts Donau-Iller and Allgaeu, and then outside the administrative district of Swabia (Figure 3). If no intensive care bed within Bavaria could have been provided, the transfer would have been coordinated between clusters of several federal states 8. However, this situation never occurred.
Also, approximately four COVID-19 ICU beds were always kept available at the University Hospital Augsburg for acute shortages of capacities. During the phase of maximum load from the beginning of December, all hospitals were required to maintain emergency ventilation capacities. In the event of an acute shortage of intensive care beds, these were intended to provide a fallback level for a few hours, so that the staff MDHC was able to organize transfers.
Two transfer ambulances were kept ready by the dispatch center for the increased volume of transfers.
Weekly conference calls were held with the coordination groups for general situation briefings. Video conferences were held twice a week with the district coordinator and the MDHCs of the neighboring ambulance districts Allgaeu and Donau-Iller.
Each subordinate hospital provided a 24-hour contact number to the staff of MDHC. The staff itself also set up a telephone number that could be reached 24/7. However, the primary communication channel was a designated e-mail address of the staff. Also, a fax connection was provided. The e-mail address, as well as the fax, was controlled Mon-Fri from 07:15 to 16:00. Time-critical matters were communicated via the central phone number of the staff.
Press releases from the MDHC were made in consultation with the acting mayor of Augsburg.
Determination of additional beds required
To determine the impact of transfers on bed occupancy, the number of additional beds required in the absence of transfers to external hospitals was examined retrospectively. Here, the transferred patients were given an additional length of stay (LOS) drawn from a stochastic distribution function and thus further listed in the system. After drawing a length of stay from this distribution function 10,000 times for each non-displaced patient, a confidence interval of additional bed occupancy per day could be obtained.