









































31 J Global Clinical Engineering, Special Issue 3, 2020 

Date of publication April 15, 2020

ITALIAN CLINICAL ENGINEER EXPERIENCE DURING 
COVID-19  
Transcript of March 24, 2020 Webinar (on behalf of AIIC & IFMBE/CED)

Health Technology Alliance TownHall (HIMSS, AAMI and ACCE)

By Umberto Nocco,  
Vice-president of AIIC and Director of the Clinical Engineering Department, in charge of evaluation, acquisition 
and maintenance of medical equipment. A.S.S.T. dei Sette Laghi, Varese, Italy
Copyright © 2021. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY): Creative Commons - Attribution 4.0 International 
- CC BY 4.0. The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original 
publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

Umberto Nocco: It's a pleasure to be here and to share 
with you some of the things we've been dealing with for 
the past month, actually, because it hasn't been longer 
than that. Lombardy is the region in the northern part 
of Italy where I live in. It's been one of the most struck 
from the virus inside our state. Basically, data shown 
today shows that we have some 30,000 cases among the 
70,000 gross numbers throughout Italy. This happened 
basically in three weeks. Patient one, as we call him, was 
found positive on February 21st. Since then, we add an 
exponential incremental ratio of known patients basically 
based in kind of a defined area throughout the region. But 
later on, the outbreak expanded over the entire nation.

The point is that the rest of Italy aside Lombardy see-
ing cases after two weeks from the start in our region, so 
that at least they had the time to get ready to some extent 
before the outbreak reaches them. Of course, we all wish 
it doesn't happen, but it's an option, of course, that this 
might end up having quite a number of cases.

Just to give you an idea, the difference between Lom-
bardy and Rome, for example, although I'm saying they did 
a great job, they had the time one week, not very much, 

to remodel a closed hospital to accept COVID-19–positive 
patients only. While in our region due to the birth and the 
continuous flow of patients to the hospitals, we had to 
work day by day and try to find out the solution to have 
them inside our hospitals.

From an HTM point of view, I would like to outline 
three major problems:

1. Machine availability plus space inside the hospitals 
(e.g., ICU beds).

2. Organizational issues.
3. Acquisition problems for devices.

One of the main problems we had to cope with was 
that the need for ventilated beds, not only did we use ICU 
beds which were more or less full because of standard 
patients. We were just running normal routine, and we 
are normally running at 95% better in Lombardy and I 
think that more or less the same number throughout Italy, 
but we had to define new areas where positive patients 
were to be placed.

The more patients, the more ICU beds were needed. 
Those that could create new ICU beds out of nowhere 

This document is posted with permission from Italian Clinical Engineers Association (AIIC)

http://www.globalce.org
http://globalce.org
http://globalce.org


PATIENT SAFETY RECOMMENDATIONS FOR COVID-19 EPIDEMIC OUTBREAK: Lessons from the Italian Experience

J Global Clinical Engineering, Special Issue 3, 2020  32

did so, while other suffered the way even and they had 
to figure out a place where to put them, whether it be a 
normal ward, or some hospitals are starting to put tents 
outside the hospital at least to do the first screening when 
a patient comes in with the ambulance or with their car 
or however they get to the hospital.

This means that the major issue about acquiring tech-
nology is basically on four to five types of assets. I'm talk-
ing about continuous positive airway pressure systems, 
ventilators, monitors, infusion systems, and beds being 
the last and the easier to describe and with difficulties 
to be found on the market and to be acquired. Although, 
in the end, we ended up using normal ward beds even 
if we are to handle intensive care patients because, in 
some places throughout our region, we are basically a 
war zone. It's really whatever you have available, that's 
fine for the patient. 

ITALY: THE MOST IMPORTANT DEVICES NEEDED
Umberto Nocco: The point is that if you get the continu-
ous positive airway pressure system, they are the first 
line because patients come in with some sort of breath-
ing problems. You might use noninvasive ventilation but 
usually requires a mechanical ventilator which is precious 
because we don't have a lot of them. We immediately 
swapped to continuous positive airway pressure systems.

These can be used outside the ICU, especially if you 
already have training personnel like in lung department 
or other specialties or medical departments. But you 
have to be aware that you are risking a lot more aerosol 
spreading outside the system rather than with the inva-
sive ventilators. We have come to the point where we are 
making basically our own gas blenders because vendors 
can't keep up with the need we have.

When it comes to ventilators, if you ask an anesthesi-
ologist, he will ask for the top quality of the product. The 
point is that we had so many patients that we have become 
greedy rather than specific, if you see what I mean. We had 
to acquire devices really fast. The typical call we used to 
make a couple of weeks ago was calling the vendor and 
saying, "How many ventilators do you have in stock that 
can you bring me, say, tomorrow?"

What we had to consider especially devices that could 
run without compressed air since we don't usually have 

that in ward. If you end up installing ICU beds in what 
yesterday used to be normal wards, of course, you don't 
have all the facility you may have in an ICU as usually 
defined. Of course, I don't know how many of you are 
familiar with the Italian way of setting up at hospitals. We 
usually don't have a room for the patient regardless of his 
type of treatment that goes from the ICU to the general 
ward before he goes home. We have specific areas of the 
hospital dedicated to a different level of intensity of care 
we have to give to the patients.

The next kind of asset we need to acquire really fast 
and in good big numbers were monitors and monitoring 
systems. They are, of course, important for an ICU but 
also for patients who are taking care in normal wards. 
General conditions that we want to monitor are oxygen 
saturation, which is probably the best for a meter to look 
at, together with CO2, to figure out whether the lungs are 
working correctly. But they asked for monitors rather 
than simple telemetry systems because they want to be 
able to view the monitor without going too close to the 
patient. So they avoid getting dressed up with protection 
clothes and breathing all the aerosols, which is, of course, 
one of the major issues.

As far as I figured out in this past three weeks, you 
don't need a high-level monitoring. You don't need a lot 
of parameters. Basically, basic parameters: pressure, of 
course, invasive pressures because the more the patient 
becomes bad and more ill, the more you may need to have 
some invasive pressure, and plus CO2 monitoring unless 
you have it on the ventilator, of course, because you need 
to be really aware of the condition of the oxygen exchange 
in the lungs.

The point is that we needed a lot. In my hospital, we 
have in standard conditions, some 50 intensive care beds. 
We've come up to almost a hundred. We basically doubled 
the number of ICU beds in the hospital to handle this kind 
of patients and you have to be aware that the hospital I 
work in, it's not one of the most involved in the outbreak. 
We have a lot of cases but not as many as in other parts 
of the region.

The last thing is the infusion systems, both syringe 
and IV lines. The thing is you never know how many you 
need. At least, that's what happened to me. If you talk to 
different anesthesiologists, they may ask you for different 
numbers. I wouldn't be able to say the correct number, 



33 J Global Clinical Engineering, Special Issue 3, 2020 

PATIENT SAFETY RECOMMENDATIONS FOR COVID-19 EPIDEMIC OUTBREAK: Lessons from the Italian Experience

but probably a gross number is something around four 
pumps per patient, but the problem is always the same.

We're talking about 20, 30 beds at the time, so numbers 
go up real, real fast. In Italy, at least, we don't have a sort 
of organization where we have stocks of medical devices 
that can be used by hospitals without too much effort. I 
mean we had to buy all the devices to get them running 
inside the hospitals. Of course, the more you get into it, 
the more requests come up from clinicians because, then 
basically, you need to put up a COVID-positive, as we call 
it, patients and a non-COVID patients ICU.

There are really two different ICUs for different kinds 
of patients. Hopefully, once this empties, the COVID-
positive, while the other doesn't, but then everything is 
doubled up. So, you need two more ultrasound machines, 
more point-of-care diagnostics, and many other devices. 
For example, the emergency ward requires for extra ul-
trasound machine to do first screening of the patient's, 
portable x-rays because they're easy to handle. They give 
you a good shot at the beginning, and then, they're really 
easier to assess rather than CT scans.

ITALY: WHAT SUPPLIES ARE RUNNING OUT 
Umberto Nocco: One of the problems we are starting 
to face right now, and we are talking about right now and 
in the past two or three days, is the problem about spare 
parts. I don't have data on this, but one thing I must say 
is that probably ventilators run more steadily, if you see 
what I mean, because they're running on the same patient 
for a long time, so they suffer less failure if compared with 
the time when you have a higher patient turnover in the 
ICUs. So basically, technology is more stable, but then you 
need a lot more oxygen cells because they fail more often, 
probably it is due to the higher oxygen concentration used.

And also one of the other problems is the consumption 
of oxygen. I don't have calculations handy, but lump figures 
say that we kind of doubled up, or maybe more than that, 
the oxygen used in the hospital. And so you need to increase 
the capability of the tanks, of the oxygen tanks. And also 
you need to be sure that you give an extra boost to the 
oxygen in the flow because continuous pressure airways 
support system use very high flows. And when you have 
many of them connected to the same pipe, you might end 
up figuring out that you're not really giving the patient 

the wanted flow of oxygen because everybody's sucking 
up from the same reservoir. So basically that's what it is.

ITALY: TACKLING ORGANIZATIONAL ISSUES 
Umberto Nocco: At the beginning of the outbreak we had 
to divide production lines, especially in the ERs, sorry for 
my poor English, and I hope you understand what I mean. 
Basically you need to define which wards and which ICUs, 
if you have them, you want to put positive patients in and 
which wards you want to put non-positive patients in.

I know it's a stupid point of view, but the thing is that 
normal patients will show up anyway. So if you have a 
contagious disease ward, which is usually designed also 
with regard to air flux and isolation of the rooms, then 
you're quite ahead. But at least in Italy, those are really a 
few and usually they don't have so many beds as needed 
in this kind of an outbreak. So you need to use a general 
ward, which is usually not designed to handle this kind 
of situation.

You need to set it up with monitors, continuous pres-
sure airway support system, point of care diagnostics, 
personnel, which we're really running short of personnel, 
and protection devices. These can be set up in advance. Of 
course, if you know where to put patients, where you're 
really staying there.

And this process division has to, at least we experienced, 
you have to figure it out also in the emergency ward, 
especially if you need to have basis for clean patients be-
cause unfortunately, as I said before, strokes, trauma still 
happen. Although we experienced a significant decrease, 
especially after lockdown, it seems like patients don't have 
strokes anymore. We're kind of asking, “Why?” But there 
are fewer cases that have come up to the hospital, luckily.

Of course, you have to have completely different spaces 
for known or suspect positive patients and known posi-
tive patients. This basically is like having two emergency 
departments inside the same hospital. Also from an asset 
point of view, so you need to have the space, and you need 
to have the technology to make it run.

Another thing is about biomeds and biomedical equip-
ment technicians and as hospital technology management 
people who kind of walk around the hospital just to have 
everything set. We need to be alert. Of course, this is easy 
to say, but it's hard to handle. But one thing is that you 



PATIENT SAFETY RECOMMENDATIONS FOR COVID-19 EPIDEMIC OUTBREAK: Lessons from the Italian Experience

J Global Clinical Engineering, Special Issue 3, 2020  34

may need to define where to go and especially when it's 
worth or needed. By this, what I mean, this is mainly to 
prevent exposure to the virus, to the biomeds, and to your 
people in your organization, plus, to reduce the use of the 
protection clothing and devices, which are always short.

And so this might not be liked by the personnel, at least 
it is not liked in Italy, they don't like to attach cables, but 
sometimes some really easy basic line maintenance prob-
ably should be given out by nurses and people who can 
do that inside the ward without biomeds and people from 
the health technology department going inside a kind of 
positive area, which has all kind of problems.

ITALY: THE CHALLENGE OF ACQUIRING DEVICES 
Umberto Nocco: Last, but it's still a major problem, 
probably it's more local because it's probably it's more 
related to the way we acquire devices in Italy. I won't get 
into the details related to public tenders, which probably 
don't apply to the U.S. market, but to some extent we faced 
a kind of saturation of the capability to produce devices, 
which is probably typical of medical device market, which 
is not usually accustomed to producing by the hour in 
great numbers, if you see what I mean.

So, we were the first, and so we were able to use stocks, 
and we were able to acquire some numbers of devices at 
the beginning of the outbreak. But after a short time, we 
started experiencing a longer and longer time to hospital, 

as they call it, for ordered goods. Orders given today are 
scheduled to be given to the hospital by the mid of April. 
So that's way too long. We need the devices before that. 
And we also experience lower quality due to a certain, 
probably to the speed on the production line, details that 
are not present on the devices, things that are missing, 
things that probably are not assembled very well and 
stuff like that.

Last thing, is how many devices do I need? Basically, 
it's another way of putting the question I started with. 
We had hospitals where more was never enough, still 
today, and hospitals where you had the feeling that you 
were doing something wrong in acquiring all that kind 
of technology because it didn't seem like needing more 
devices and beds and somebody else might have a need 
rather than you.

The problem is that you never know. You never know 
what's going on tomorrow. Also, all these nice curves of 
patients that we see every day, we're not really sure they're 
correct. So we don't know what will be happening in the 
hospital tomorrow, how many cases we have at home, and 
they're are not even aware that they have COVID-19, and 
they might end up in a hospital in a couple of days. So it's 
really hard to find the balance when you have to decide 
how many devices, which type, what you want them to 
do, and how you want the thing run.


