key: cord-0982309-hfe077rm
authors: Annane, Djillali; Federici, Laura; Chagnon, Jean-Luc; Diehl, Jean Luc; Dreyfuss, Didier; Guiot, Philippe; Javouhey, Etienne; Joram, Nicolas; Lesieur, Olivier; Rigaud, Jean Philippe; Outin, Hervé; Sement, Arnaud; Sevens, Chantal; Thévenin, Didier; Touati, Samia; Terzi, Nicolas
title: Intensive care units, the Achilles heel of France in the COVID-19 battle
date: 2021-01-29
journal: The Lancet regional health. Europe
DOI: 10.1016/j.lanepe.2021.100046
sha: 3c6532bac53185652f191fbc79ef3c8f17172e5a
doc_id: 982309
cord_uid: hfe077rm

nan

From January 3 to January 13, 2020, France reported 2,760,259 cases of COVID-19 with 68419 deaths 1 and ranked the sixth country. After Ebola and Zika crises, France promoted universal health coverage to achieve global health security. 2 COVID-19 pandemic demonstrates that French initiative was mothballed after the 2017 presidential election. The Defence Council takes decisions during closed meetings without involvement of civil society, local stakeholders or affected populations, and without transparency. There were insufficient mechanisms for surveillance, alert, diagnosis and plans for crises responses. As a result, France failed foreseeing the insufficient hospital capacity to handle massive surge of critical cases, and securing universal access to healthcare. In 2006, there were 10.7 beds per 100,000

inhabitants. In January 2020, the number of ICU beds per capita was eight per 100,000 (about 5400). It was lower than the average capacity of 185 countries. 3 France has lower availability and accessibility of ICU beds, and more regional disparities than Germany, Luxembourg and Austria. 4 Differences in ICU resources were associated with differences in COVID-19 related case fatality ratio. 4 Most of these temporary units could not meet regulatory requirements for setting/equipment and staff resources. 6 They were mostly run by doctors and nurses without critical care experience. By end of May, while the number of hospitalized cases returned to levels equivalent to those observed in February 5 temporary ICUs were dismantled. Albeit the high likelihood of a second wave after the summer, France strategy continued to rely on temporary 4 units not on increasing permanent ICUs capacity. 7 Of 296 surveyed ICU directors, 114 (39%) declared 1641 and 1663 permanent beds as of January 1 st and November 1 st , respectively, and 670 temporary beds. As of November 1 st , ICU overflow triggered long-distance (including to neighbouring countries) transfers of ICU patients, and a second general lockdown.

Approximately 30% of non-COVID-19 related care were suspended to mount temporary ICU beds. This reduced access to care for non-COVID patients may be associated with worse outcomes. 8 A recent study suggested increased in-hospital mortality associated to ICU overflow and temporary ICU beds. 9 There were significantly more COVID-19 related deaths between October 1 st and January 12 than between March 1 st and September 30. 5 The major drawback to increasing permanent ICU beds capacity was the shortage in staff resources.

French regulation set the nurses to ICU patients ratio at two for five. 6 Thirteen percent of ICU directors declared that they cannot meet this requirement on a 24/7 basis and the frequent use of overtime. Likewise, undersized medical teams, i.e. less than three full time attending physicians per 4 ICU beds, ran most ICUs. 10 

All authors have equally contributed to the design, conduct and interpretation of the survey, and to the writing of this manuscript. CS has taken responsibility of logistic support. DA, LF and NT have taken responsibility of collecting and analysing survey data, and of writing the first draft of the mansucript. DA as the president of the French Union of Intensive Care Physicians is responsible for the dissemination of this information and for submitting the manuscript to the Journal.

Authors have no conflict of interest to disclose.

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