key: cord-329350-qrxl5o1e
authors: Pan, Angelo; Matteo, Giorgi-Pierfranceschi; Giancarlo, Bosio; Lorenzo, Cammelli; Laura, Romanini
title: Suggestions from Cremona, Italy - two months into the pandemic at the frontline of COVID-19 in Europe
date: 2020-06-09
journal: Clin Microbiol Infect
DOI: 10.1016/j.cmi.2020.05.038
sha: 
doc_id: 329350
cord_uid: qrxl5o1e

nan

The COVID-19 pandemic is hitting hard even the most advanced health care (1). We have had to care for high numbers of severely ill patients with limited resources, i.e. ventilators and specialists in respiratory failure management, often with a lack of health-care workers (HCW): a terrible situation. The hospital of Cremona, Italy, is a 500-bed facility and was the second hospital hit with this tsunami-like disease in Europe, on February 21st. Rapidly the number of patients with COVID-19 induced pneumonia reached 540. During the first eight weeks of pandemic the emergency room evaluated 1706 patients, with 1542 admissions; 242 patients were intubated, 419 underwent noninvasive ventilation (NIV), and 342 died. Home care was activated in 58 cases. At two months into the pandemic and in the phase of descent, we are offering advice -useful tips derived from real life experience -to our colleagues facing this disease. Indications regarding preparedness are available, but a view from the "battlefield" may help in everyday practice (see factual summary) (2,3).

The indications here described should be managed by a group of clinicians and management experts, in charge of the organization of the hospital in this war-like setting, this being point zero.

1. Education first: it is difficult to organize continuing HCW education in an emergency setting, but it is necessary to implement courses on infection control and prevention (ICP) and on COVID-19 management. Three main points need to addressed (4-7):

A. correct use of personal protective equipment (PPE): many HCW will be displaced from their routine work to a new task, the treatment of a transmissible infection. HCW need to be rapidly updated on necessary competencies required to manage highly infectious patients with respiratory failure. Rapid and thorough courses on the correct use of PPE is the first thing that should be done to protect both HCW and patients. Doffing procedures are critical, due to a high risk of contamination (4, 8) . While HCW are often placing stress on the use of face masks, meticulous hand hygiene (HH) is probably the most important prevention strategy, and adherence to this is instrumental (8, 9) . B. Proper nasopharyngeal swab taking is fundamental to obtain the best sensitivity/specificity of this test.

C. COVID-19 management: "fast and dirty" courses on should be organized on general principles of respiratory insufficiency, blood gas analysis, oxygen therapy, venous thromboembolism prevention, antivirals and anti-inflammatory drugs use (7) . Intensive care patients management retraining for HCW should be performed.

Since indications evolve rapidly, courses should be repeated regularly.

2. Implement home care: collaborating with GPs to correctly manage patients at home, limiting access to the hospital only to patients with possible pneumonia, is of paramount importance. Webinars on COVID-19 ICP strategies and management should be implemented: one hour courses on one-two items are very appreciated.

3. Re-organize the Emergency Room (ER): we saw up to 70 COVID-19 patients per day: a reorganization of the ER will be necessary. Consider: how and where to perform triage, and to receive patients into the ER -clean and COVID-19 triage areas may be necessary. You may rapidly be struggling for beds and even for oxygen therapy points, since most COVID-19 patients have respiratory failure. 5. Extend intensive care unit and ventilation capacity: we had to increase our intubation capacity from 10 to 52 beds in three weeks. Early intubation is recommended to manage COVID-19 patients (7) and very rapidly you may run out ventilators. Since ventilation weaning takes often over two weeks, a rapid saturation of ICU is easily foreseeable, and early intubation may become a difficult problem to solve. You should program in advance when to convert areas with ventilators (i.e. operating theaters) to COVID-19 intensive and semi-intensive care units. Consider to prone patients to improve respiratory function. A re-organization of the staff is also fundamental since high level skills are needed to manage these patients.

6. Re-organize diagnostic services: organize high throughput nasopharyngeal SARS-CoV-2 swabs and define which exams have to be performed to manage these patients, including D-dimer, ferritin, and IL-6 determination.

The need for high resolution computed tomography (HRTC), the best diagnostic exam for interstitial pneumonia will rapidly grow. (10, 11) We performed over 2400 pulmonary HRTC in March, as compared to a standard of 200. A dedicated CT service has to be organized.

Antithrombotic prophylaxis should not be overlooked due to increased risk of venous thromboembolism. To improve knowledge all efforts should go to treat all patients within randomized controlled trials. Patients are so numerous that almost any utilized drug will rapidly go out of stock.

8. Program work with shortage of HCW: it is likely that a certain number of HCW, will already be infected at the beginning of the epidemic, thus others will become infected. An emergency plan on how to reorganize services and how to re-allocate HCW to continue to offer high level services, is of primary importance. Infected HCW should be visited through dedicated internal services and treated following standard procedures. 9 . Check facility needs: ensure that all you need for patients with respiratory failure is in place.

Oxygen consumption will rapidly increase and it may become insufficient: in our hospital oxygen use skyrocketed from 3 to over 80 m3/day. Drug use will increase similarly: norepinephrine and midazolam passed from 2,500 and 800 vials/month to 21,000 and 7,000, respectively. Blood gas analysis syringe use will increase: in our hospital consumption passed from 1,900 in January 2020 to 12,900 in March. PPE use will be critical: mask use, i.e. surgical masks and FFP2/FFP3 respirators, increased from 5,000 to 41,000/week, impermeable gowns from 1,300 to 11,700/week, goggles/face shields from 30 to 1200/week. Adequate supplies have to be organized. 10 . Take into account the needs and stress of patients and HCW: patients are scared of the disease and visits, at least in our country, are forbidden. Time individually spent with patients is not enough, and the whole team -doctors, nurses, nurses aids -should try to stay as close to them as possible. In our experience this is exactly what every HCW is willing to do, limiting the sense of anxiety and fear that is common during COVID-19. On the HCWs' side, working with COVID-19 patients is an incredible stressful duty since it is a highly transmittable disease. Furthermore, the level of uncertainty in management is high, the mortality is dreadful, and patients' social life within the hospital is extremely difficult. Additionally, bringing home the stresses from work and worrying about the risk of transmitting SARS-CoV-2 infection to family members is a source of anxiety to the extent that normal marital relationship may be altered. Psychological support from the very beginning of the outbreak would be very useful both for patients and HCW.

The latin motto estote parati -be prepared -is what we learnt from this terrible pandemic:

while waiting for possible new waves, we are working on education on PPE, HH, and ventilation, and programming how to dedicate general ward and ICU to manage new COVID-19 patients.

Finally, once the tsunami is passed you will need to have re-habilitation services to manage patients discharged after long ICU stays: be prepared (12) . To conclude, we have rapidly proposed what we think could be of help to our colleagues facing COVID-19 pandemic (see table 1 ). This experience has so far taught us that even in these extremely difficult situations you have to struggle for collaboration and discussion. We think that aid to coordinate such a strenuous situation could be sourced form experts in medicine of catastrophe or war medicine: the needs of the hospital, its patients and HCW undergo a rapid and dramatical change over only a few days, similar to what is observed during war. 

An interactive web-based dashboard to track COVID-19 in real time

European Centre for Disease Prevention and Control. Checklist for hospitals preparing for the reception and care of coronavirus 2019 (COVID-19) patients. ECDC: Stockholm

World Health Organization. Critical preparedness, readiness and response actions for COVID-19. Interim guidance

European Centre for Disease Prevention and Control. Infection prevention and control for COVID-19 in healthcare settings -Third update

How to Obtain a Nasopharyngeal Swab Specimen

Interim Clinical Guidance for Management of Patients with Confirmed Coronavirus Disease (COVID-19)

Infectious Diseases Society of America Guidelines on the Treatment and Management of Patients with COVID-19

Personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff. Cochrane Database Syst Rev

Air, surface environmental, and personal protective equipment contamination by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) from a symptomatic patient

Coronavirus Disease (COVID-19): Spectrum of CT Findings and Temporal Progression of the Disease

High-resolution Chest CT Features and Clinical Characteristics of Patients Infected with COVID-19 in Jiangsu

Postacute Care Preparedness for COVID-19. Thinking ahead

Transparency declaration • Conflict of interest disclosure: that should be identical to the content of the COI form that is submitted

• Funding: no external funding was received

Acknowledgments: we want to thank Pantelis Tsoulfas for his thoughtful review and Allegra Della Ragione for the language review

Access to data: not applicable. • Contribution: 1. All authors gave substantial contributions to the conception of the work, literature search and analysis and discussion and interpretation of data

All authors revised it critically for important intellectual content

All authors gave final approval of the version to be published

All authors agreed to be accountable for all aspects of the work. All authors ensure that all questions related to the accuracy or integrity of any part of the work have been appropriately investigated and resolved

All authors have nothing to disclose.The study did not receive any external.
