March 20, 2020

COVID-19: A Powerful Message from Italy

On Feb 21st, a patient by the name of Aldo, a 72-year-old male, came to our ED with fever and progressive dyspnea. In addition, his chest x-ray showed an interstitial pattern.

It was on this day that COVID19 had arrived in our emergency department…

In this post we will describe how we responded to the COVID19 challenge, the impressive number of patients seen in just a few days’ time and some suggestions to prepare your emergency department for the future.

Our Hospital System:

We are a level 1 trauma center, the only pediatric trauma center for 10 million people in our region. We are also the referral center for stroke, STEMI, ECMO, and have the only neurosurgery availability of the province. We see about 100,000 patients per year. The Bergamo province accounts for roughly 1.2 million people.

ED Organization Before the Epidemic:

  • 1 shock room (6 beds)
  • 1 intermediate acuity area (7 rooms for evaluation; 2 waiting rooms. Named BOX)
  • 1 low acuity area (1 room for evaluation; 1 waiting room. Named Vertical)
  • 1 isolation room (2 beds)
  • Observation unit (10 beds)
  • Acute medicine ward (11 + 6 beds)
  • 1 empty room dedicated to mass casualty events (named PEMAF, 24 oxygen sources)
  • Ortho ED (1 evaluation room, 1 waiting room)

Figure 1: Organization of the ED Before the Epidemic

ED Physician Shifts Before the Epidemic:

  • 26 total physicians
  • 9 physicians worked shifts from 8am – 2pm
  • 9 physicians worked shifts from 2pm – 8pm
  • 3 physicians worked shifts form 8pm – 8am

ED Organization After the Bergamo Outbreak:

On 02/21, following the Italian (Codogno) outbreak, we created 2 different pathways: a “clean” pathway and a “dirty” pathway. The “dirty” pathway initially started with patients complaining of respiratory symptoms and/or a body temperature of >37.5C coming from suspected areas (The Lodi Province or China).  The “clean” pathway was used for the evaluation of all other patients.  Initially, the “dirty” pathway used 1 low acuity room plus 1 waiting room. After about a week (from 02/21) the volume of patients with respiratory complaints increased so much that we had to change the organization of the ED to all patients presenting with any respiratory symptoms and/or a temperature of >37.5 being evaluated in the “dirty” area (regardless of travel from suspected areas) and this area was extended to most of the ED.

The emergency department was then organized according to the severity of acute respiratory failure following the model developed by our EM colleague Stefano Paglia in Lodi, the first Italian hospital that faced the outbreak.

  • 1 shock room (6 beds) converted to COVID Intubated room (Dedicated to intubated patients)
  • PEMAF 16 beds, 24 oxygen sources was converted to an intermediate area (Dedicated to patients requiring NIV)
  • 1 intermediate acuity area (7 rooms  for evaluation; 2 waiting rooms) converted to a COVID Horizontal room (Cohort isolation; Dedicated to the evaluation of new patients)
  • Observation unit (10 beds) & Acute medicine ward (11+6 beds) was converted to a COVID Horizontal area (Dedicated to patients needing oxygen and waiting for admission)
  • 1 low acuity (1 box; 1 waiting room) converted to COVID Vertical room (Dedicated to patients not requiring oxygen)
  • 1 isolation room (2 beds) was used for patients needing oxygen waiting for admission
  • Ortho Room converted to the “Clean” pathway (Dedicated to patients without respiratory symptoms)

Figure 2: Organization of the ED after the Bergamo Outbreak

We also changed our shift organization, adding 1 physician on night shift and 1 physician on call during the day. We also reduced the night shift length to 10 hours.

Physician Schedule Re-Organized:

  • 8 physicians 7am – 2pm
  • 8 physicians 2pm – 9pm
  • 4 physicians 9pm – 7am

Appropriate PPE is essential during this epidemic as evidenced by the fact on 02/24 we started to lose medical resources:

  • 02/24 1st physician in quarantine (Didn’t come back until 03/02 after a negative nasal swab)
  • 03/07 1st physician ill
  • 03/09 2nd physician ill
  • 03/10 3rd physician ill (Didn’t come back until 03/15)
  • 03/17 4th physician ill

Hospital Organization:

  • We work in an 880-bed hospital, with 80 intensive care beds
  • At the start of Chinese epidemic, the infectious disease ward was dedicated to suspected/confirmed cases by increasing its beds from 24 to 48.
  • On 02/21, following the Italian outbreak, we created the first 8 COVID beds for critically ill patients in the ICU
  • We gradually opened new wards and new intensive care beds dedicated to COVID positive patients
  • After the 02/29 Bergamo outbreak we now have 80 ICU beds dedicated to mechanically ventilated COVID patients, 12 beds dedicated to non-invasive ventilated patients managed by pulmonologists,  and about 400 regular ward beds dedicated to COVID patients needing oxygen or Helmet CPAP (coordinated by pulmonologists or anesthesiologists)

Patient Population:

We had a sudden increase in patients suspected of having COVID infection from 8 patients on 02/22 to a maximum of 80 patients on 03/06.

Graph 1: Number of Patients Presenting with Any Symptoms Suspected for COVID Infection

We observed 4 phases of ED presentation. The first patients presented with high airway symptoms, most of the time not needing admission, while in the next few days we started to see patients with persisting fever, followed by lower airway symptoms, needing oxygen and, in many cases, ventilatory support, while in the last days we are observing mainly pneumonia patients with a shift of age under 60 years of age.

Graph 2. Number of Patients Admitted and Discharged from the ED per Day

During the first peak of the COVID presentations (March 6) we ended up with 105 patients in the ED, most with high O2 demand, as the ICU’s were always full, but new beds were being created every day. We used helmet CPAP on all patients with a pO2 <60 mmHg or a respiratory rate >30/min on 15 L/min non-rebreather masks, then shifted to non-invasive ventilation in patients with persistent respiratory distress and finally intubated patients non-responsive to non-invasive ventilation.

Based on our data, from 02/29 to 03/10, 31% of the patients being admitted needed some form of ventilatory support (helmet CPAP 81%, NIV 7%, IMV 12%). Within them 18% had mild ARDS, 51% moderate ARDS and 31% with severe ARDS.

The last key factors are logistics and supply. The risk of running out of PPE, oxygen tanks and CPAP equipment is very high. For instance, the maximum O2 supply at our hospital is around  8,000 L/min Currently, we are using more than 7,000 L/min.

The impressive number of patients with pneumonia, the high proportion of severe cases and the long recovery phase poses a unique challenge to our health system.

Our experience suggests that with preparation, reorganization of both the ED and the hospital, the massive COVID19 outbreak is manageable, but the most important aspect is staff health, in terms of physical protection (PPE) but especially emotional assistance, since the burden is very high and prolonged.

If you remember nothing else from this post…

  • The COVID-19 epidemic led to a massive amount of severely ill patients presenting to the ED in a short period of time
  • The needs of the patients are disproportionate to the resources of any unprepared health system, thus, preparedness of health systems are fundamental
  • Continuous assessment of patient flow and the ability to quickly change the organization of the hospital/ED accordingly is a key element to face this epidemic surge

Guest Post By:

Andrea Duca
Attending Emergency Physician
Emergency Department, Ospedale papa Giovanni XXIII of Bergamo
Living in Milano
Twitter: @andreaduca00

Roberto Cosentini
Centro EAS Director – ASST Papa Giovanni XXIII – Bergamo, Italy
ASST Papa Giovanni XXIII – Bergamo, Italy
Milan, Italy
Twitter: @rob_cosentini

Additional REBEL EM Content – Critical Care Utilization for COVID-19 Outbreak in Lombardy, Italy [1]

Coronavirus in Italy – A Report from the Front Lines from March 13th, 2020 (Video Time 36:49)

On Feb 20th, 2020 the 1st patient with COVID-19 was admitted to the ICU in Lombardy Italy.  In the next 24 hours the number of reported positive cases increased to 36. This is important because this meant two things: the illness was present in the community and the number of patients requiring ICU level care was only going to increase. In Lombardy, the total ICU capacity was ≈720 ICU beds (2.9% of total hospital beds at a total of 74 hospitals).  Most of their ICUs function at 85 to 90% capacity in the winter months. They needed to increase their surge ICU capacity and achieved this by (Assuming a 5% ICU admission rate, it would not be feasible to care for all critically ill patients in the ICU) creating 15 first-responder hub hospitals that had infectious disease expertise or had ECMO available. These hospitals were tasked with:

  • Creating ICUs for COVID-19 patients (areas separated from the rest of the ICU beds to minimize risk of in-hospital transmission)
  • Having a triage area where patients could receive mechanical ventilation if necessary in every hospital with suspected COVID-19, pending the final result of diagnostic tests
  • Establishing local protocols for triage of patients with respiratory symptoms to have rapid testing
  • Ensure adequate PPE for health care personnel
  • All non-urgent/elective procedures were cancelled

Overall in the first 18 days the network created 482 additional ICU beds.  As predicted, there was an increase in ICU admissions from day 1 to 14 (ICU admissions with COVID-19 was 12% and 16% of all hospitalized patients with COVID-19). These rates of admission and ICU useage are far higher than what was seen in China (i.e. 5%). A forecast using a linear model predicted that 829 ICU admissions could occur by March 20th, 2020, which means there may potentially not be enough ICU beds.

The Numbers in Italy Up to March 15th, 2020

Lets Learn from the Tragedy in Lombardy:

  • Strong containment measures are the only realistic option to avoid the total collapse of health systems.  This includes social distancing including cancelling gatherings and travel. This is the only way to contain the spread of infection and allow resources to be developed for this time-dependent disease (Flattening the curve of infection)
  • Outbreaks can lead to significant increases in the need for ED/ICU beds and simultaneously reduce available beds in a hospital system.  Hospital administration should have a surge plan and the ability to augment ED/ICU bed capacity, which can be as simple as transforming general wards into ICUs
  • Increase laboratory capacity to test for SARS-CoV-2. In Italy the laboratory capacity reached saturation very early which can have other downstream effects in making timely accurate diagnoses and allocating patients appropriately
  • Protect healthcare personnel with education and having adequate personal protective equipment and training in DONning/DOFFing procedures through mandatory simulation training

Retrospective case series of 1591 consecutive patients with COVID-19 requiring ICU level of care in Lombardy region of Italy [2]

  • HTN most common comorbidity 509/1043 (49%)
  • 2nd most common comorbidity was cardiovascular dz 223/1063 (21%)
  • 1287/1300 (99%) of patients required respiratory support
    • 1150/1591 (88%) required endotracheal intubation
    • 137/1591 (11%) required NIV
  • ICU mortality = 405/1581 (26%)
  • Higher rate of intubation may be due to severity of hypoxia (Median PaO2/FiO2 = 160) requiring high levels PEEP
  • Many patients managed with NIV were able to be managed outside the ICU and were not included in this report

References:

  1. Grasselli G et al. Critical Care Utilization for the COVID-19 Outbreak in Lombardy, Italy: Early Experience and Forecast During an Emergency Response. JAMA 2020. [Epub Ahead of Print]
  2. Grasselli G et al. Baseline Characteristics of 1591 Patients Infected with SARS-CoV-2 Admitted to ICUs of the Lombardy Region, Italy. JAMA 2020. PMID: 32250385

For More on This Topic Checkout:

Post Peer Reviewed By: Anand Swaminathan, MD (Twitter: @EMSwami) and Mizuho Morrison, DO (Twitter: mizuhomorrison)

Cite this article as: Salim Rezaie, "COVID-19: A Powerful Message from Italy", REBEL EM blog, March 20, 2020. Available at: https://rebelem.com/covid-19-a-powerful-message-from-italy/.
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Salim Rezaie

Emergency Physician at Greater San Antonio Emergency Physicians (GSEP)
Creator & Founder of REBEL EM
21 Comments
  • Joshua Pit
    Posted at 11:30h, 21 March Reply

    Thanks so much for this information. What is the feeling around NIV and aerosolization risk? I imagine at a certain point the resources are so limited you have no choice, but many places in my area are intubating anyone not tolerating ventimask and this will quickly overwhelm us.

    • Salim Rezaie
      Posted at 17:48h, 21 March Reply

      Hey Josh,
      I think the big theoretical fear is aerosolization which is extrapolated from SARS/MERS infections. In Italy, it seems that 30% of patients had FiO2 requirements of >50%. They simply didn’t have enough ventilators, so they cohorted them into respiratory/COVID units and wore full PPE (N95/PAPR + eye protection + gloves + gown). I think the biggest thing limiting this in US EDs would be cohorting patients so that we don’t spread infection to others. I am all for avoiding intubation if we can, but have to plan for this ahead of time.

      Salim

  • Bassam nuseibeh
    Posted at 20:50h, 21 March Reply

    Hi Salim,

    From an infection risk the use of NIV is not ideal. I noticed that helmets were being used in Italy. Is this just local practice or is the risk of aerosolisation lower with a helmet complained to face-mask?

    stay safe

    Bassam

    • Salim Rezaie
      Posted at 20:57h, 21 March Reply

      Hey there Bassam,
      In my conversations with the Italians, they stated that they had no other choice…they didn’t have enough ventilators, so they created COVID-19 wards where they could do NIV with helmets/hoods in full PPE. I suspect, but don’t know 100%, that the risk of aerosolization is significantly less with the hoods/helmets vs masks that we traditionally use in the US. Sounds like they were between a rock and a hard place and had no other choice.

      Salim

    • Francesco Vetrone
      Posted at 06:05h, 22 March Reply

      Hi, there are some evidences about aerosolization with helmets versus facemask.
      This with a simulator:
      https://www.ncbi.nlm.nih.gov/pubmed/?term=Exhaled+air+dispersion+during+non-invasive+ventilation+via+helmet+masks

      Francesco

      • Salim Rezaie
        Posted at 10:09h, 22 March Reply

        TY for sharing…appreciate it. Will give this a look.

        Salim

  • Grant Price
    Posted at 03:57h, 22 March Reply

    Hi what are the outcomes for Helmet CPAP. I get the resources were outstripped by demand but what proportion of people only needed helmet CPAP and got better. We moved away from this mode years ago as most still ended up intubated. Clearly limited options in this pandemic.

    • Salim Rezaie
      Posted at 10:06h, 22 March Reply

      Hello Grant,
      I have emailed the physicians in Italy to get an answer to your question. Will let you know.

      Salim

    • Salim Rezaie
      Posted at 11:42h, 22 March Reply

      Hey Grant,
      Here is the answer from Roberto…

      Hi Salim,
      this is the key question we’re wondering about since the beginning
      we’re analysing the data, we dont’have the answer yet
      this upsets me; we cannot keep going if if we don’t know how it works …

      Dr Roberto Cosentini, MD

  • Mike Cornish
    Posted at 06:24h, 22 March Reply

    Does anyone know if nebulised Flolan (epoprostenol) has improved patient outcomes?

    • Salim Rezaie
      Posted at 10:12h, 22 March Reply

      Hey Mike,
      I am unaware of any robust evidence on nebulized Flolan. I know the society of critical care medicine argues agains inhaled NO accept under dire straits. There is also the issue of, if patient is not intubated, the potential for aerosolization. All that being said, I think this is a great question, but unfortunately I am unaware of the answer at this time.

      Salim

  • Mike Cornish
    Posted at 16:48h, 22 March Reply

    I saw it used to good effect on a ventilated patient who was deteriorating and just wondered if it had been tried on ventilated patients who were showing no improvement in Italy?

    • Salim Rezaie
      Posted at 18:14h, 22 March Reply

      Unsure, but will email the docs in Italy and see what they have to say.

  • COVID-19: The Novel Coronavirus 2019 - REBEL EM - Emergency Medicine Blog
    Posted at 19:52h, 22 March Reply

    […] REBEL EM Blog Post from Roberto Cosentini & Andrea Duca (2 EM Physicians in Bergamo, Italy) […]

  • COVID-19: uma mensagem poderosa da Itália – Emergência Rules
    Posted at 20:39h, 22 March Reply

    […] Original: Salim Rezaie, “COVID-19: A Powerful Message from Italy”, REBEL EM blog, March 20, 2020. Available at: https://rebelem.com/covid-19-a-powerful-message-from-italy/. […]

  • Tom Fox
    Posted at 15:03h, 29 March Reply

    Hey I’m an EM/IM resident physician in NOLA who will be on a new inpatient COVID step down team (non-icu pts) next month. Does Dr. Duca have any IM hospitalist friends he might be able to connect me with to help with strategies to minimize PPE use and risk of transmission to nurses, ancillary staff, etc? Eg videochatting patients with continuous pulse ox to avoid having to go in to take down vitals every 4 hours, teaching pts to use their own MDIs for albuterol, frequency of lab ordering, etc.

    Thanks!

    • Salim Rezaie
      Posted at 15:06h, 29 March Reply

      Hey Tom,
      Just sent an email with you attached.

      Salim

  • thomas fiero
    Posted at 06:58h, 04 April Reply

    Salim
    incredible job here. and thank you for allowing us to witness the experiences and thoughts and work of our friends in Italy.
    keep up the great work. stay well.

    tom
    merced, california

    • Salim Rezaie
      Posted at 07:04h, 04 April Reply

      Hey there Tom,
      All thanks to our colleagues in Italy. Really appreciate them taking the time to do this despite what they have going on there. Appreciate you reading and taking the time to leave a comment.

  • Natasha Nolan
    Posted at 15:08h, 05 April Reply

    NYC doctors are saying this presents more like HAPE and they need to be reducing PEEP pressures and increasing oxygen early. Does this match what you were seeing? https://twitter.com/cameronks/status/1246762772400148480?s=20

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