Resuscitation beds have emerged during the pandemic as the alpha and the omega: their occupancy rate determines overheating of the hospital system, economic and social life and even public freedoms.
Much has been said about the backwardness of France, which according to the OECD would only have 16.3 critical care beds per 100,000 inhabitants, against 33.9 for Germany.
A criticism swept aside by the Court of Auditors in its activity report for whom "
the differences between the two models make comparisons difficult
», These figures do not count the same things.
In reality, France had on December 31, 2010, before the outbreak of the pandemic, 5,433 "sheave" beds, to which must be added 8,192 continuous surveillance beds and 5,955 intensive care beds.
That is a total of 19,580 critical care beds, bringing together nearly 54,000 full-time equivalents of medical and paramedical personnel.
These beds represent an expenditure of nearly 7.2 billion euros (against 6.6 billion in 2014), including 3.3 billion devoted to pure resuscitation.
However, the Court makes two criticisms.
First of all, to cope with the sudden influx of patients at the heart of the crisis, the services have reorganized themselves by transforming hospital beds - sufficiently equipped with medical equipment and fluids - into so-called “ephemeral” resuscitation beds.
This mobilization made it possible to rapidly increase from 5,080 beds installed on January 1 to 10,502 beds on April 8, and 10,707 beds on April 15.
But this reconfiguration came at the cost of massive deprogramming, resulting in a loss of chances for non-covid patients whose impact "
today unknown and potentially considerable
" will have to be measured, considers the Court.
Read also: Coronavirus: caregivers alert on the ethical issues of deprogramming
On the other hand, the private sector was too late involved in the health response, observes the Court.
Hospitalized patients in the public fell from 80% at the start of April to 67% by the end of the month.
At the same time, the non-profit private sector saw its share drop from 10% to 19% and the lucrative private sector from 9% to 14%.
Public-private coordination took a long time to set up, sometimes leading patients to be accommodated in degraded mode in overcrowded public hospitals, or transferred, when places were available in clinics and private hospitals.
In the future, it will be necessary to build "
a model of organization and coordination of critical care and its mode of governance, which is able to include public and private structures
" recommends the Court.
Read also: Covid-19: private hospitals could take care of more than 2,000 intensive care patients, according to their federation
Faced with this observation, the wise men of rue Cambon identify three priorities.
First of all, it will be necessary in the future in the future to take better account of the needs.
Public service unions have strongly criticized bed closures in the past, which were believed to be responsible for the overcrowding during the pandemic.
However, while it is true that inpatient beds were closed (-5.6% between 2013 and 2019) to take into account the development of outpatient care, critical care beds increased by 7%. over the same period.
This growth has mainly benefited continuous monitoring beds.
For intensive care, “
the increase of 0.17% per year is ten times lower than that of the number of elderly people (+ 1.7% per year), who nevertheless constitute nearly two-thirds of patients hospitalized in this area. sector
”, regrets the Court.
In fact, the rate of equipment in resuscitation beds was only 37 per 100,000 inhabitants over 65 years of age on the eve of the health crisis, while it was 44 per 100,000 inhabitants in 2013. The Court therefore advocates “
to assess the impact of the aging of the population on long-term critical care hospitalization needs and to increase the supply accordingly
”.
Read also: Covid-19: patients in intensive care at their highest since November
The second priority will be to reduce the strain on human resources, which has been found to be the main bottleneck.
Because the work in intensive care is tiring and psychologically heavy - one in five patients admitted to “sheaves” dies during their stay - nurses quickly seek to change departments.
"
A significant turnover of nurses reflects the difficulty in retaining these staff and occasionally leads to the closure of beds
", underlines the Court.
And this, especially since the 28,000 nurses working in critical care are 95% non-specialized.
The magistrates therefore recommend reviewing the initial training of nurses and above all setting up qualifying and recognized training for intensive care nurses.
In addition, the Court also recommends increasing the number of doctors, both anesthetists-resuscitators (MAR) and intensivist-resuscitators (MIR).
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Finally, the third course of action, it will be necessary
"to determine a new funding model for critical care"
, recommends the Court.
Indeed, with the current pricing system, hospitals are not encouraged to open new beds, because each currently generates an average deficit estimated by the Court at 115,000 € per year.
And this, knowing that a stay in intensive care represents an average charge of € 1,848 per day of hospitalization in 2018.