Detailing the Steps Italy Took to Mitigate their Coronavirus Crisis

Health care systems need to be prepared for collaborative emergency medicine in light of the novel coronavirus pandemic, according to a viewpoint published in JAMA based on the Italian COVID-19 outbreak. The government in Italy essentially locked down the country early last week, allowing only grocery stores, pharmacies and banks to operate.

On Feb. 20, a male patient in his 30s was admitted to the intensive care unit (ICU) with a history of atypical pneumonia. He was not considered at-risk for novel coronavirus infection, but he was not responding to treatment. He tested positive for COVID-19 and 24 hours later the number of reported positive cases jumped to 36. Those new cases did not have any links to the young, male patient or any other positive cases already reported in the country.

On Feb. 21, the Government of Lombardy formed a task force, prioritizing increasing the ICU capacity and implementing containment measures. Before the epidemic, the ICU capacity was about 720 beds (about 3% of the total hospital beds across 74 hospitals), the study authors said. During winter months, those ICU beds hover between 85-90% occupancy.

Study authors from Milan, Italy summarized the response from the COVID-19 Lombardy ICU network and forecasted the estimated demands on ICUs in the area through March 20. Noting that the positive coronavirus patient number jumped from 1 to 36 in 24 hours, the investigators and task force were led to believe that a large number of patients were already present in the region. They assumed many new cases would occur—many even hundreds or thousands, the study authors said.

The task force decided to designate 15 first-responder hub hospitals. They were chosen because they either had infectious disease expertise or were part of the Venous-Venous ECMO Respiratory Failure Network (RESPIRA), the study authors said. The hospitals were asked to take the following steps:

1. Create separate coronavirus areas in the ICU, to reduce in-hospital transmission to other patients.
2. Organize a triage area so patients could receive ventilation if necessary, until their diagnostic results came back.
3. Establish triage steps for patients presenting with respiratory symptoms and allocate them to the appropriate ICU area if necessary, depending on diagnoses.
4. Make personal protective equipment for health care personnel available and train those at-risk workers.
5. Report every positive or suspected coronavirus case to the appropriate channels.
6. Cancel non-urgent procedures to make more ICU beds available.

In the first 18 days of these implementations, 482 ICU beds were created, the study authors said. From day 1 to day 14, hospitals saw a sharp increase in ICU admissions. According to publicly available data, there were 556 ICU admissions (representing 16% of all patients) who tested positive for coronavirus. Data through March 7 showed that the current total number of patients with coronavirus occupying an ICU bed represented 16% of currently hospitalized coronavirus patients, the study authors wrote.

“The linear model forecasts that approximately 869 ICU admissions could occur by March 20, 2020, whereas the exponential model growth projects that approximately 14,542 ICU admissions could occur by then,” the study authors wrote, noting that these are hypothetical projections and involve making various assumptions. The numbers are increasing continuously and exponentially, they added.

“Any substantial increase in the number of critically ill patients would rapidly exceed total ICU capacity, without even considering other critical admissions, such as for trauma, stroke, and other emergencies,” they continued.

The health care system cannot sustain such an uncontrolled outbreak, the study authors said. These stronger containment measures in the region are the “only realistic option to avoid the total collapse of the ICU system,” they wrote.

The authors recommend increasing the laboratory capacity for coronavirus testing immediately and creating a dedicated coronavirus facility.

“While regional resources are currently at capacity, the central Italian government is providing additional resources, such as transfers of critically ill patients to other regions, emergency funding, personnel, and ICU equipment,” the study authors concluded. “The goal is to ensure that an ICU bed is available for every patient who requires one. Other health care systems should prepare for a massive increase in ICU demand during an uncontained outbreak of COVID-19… Health care systems not organized in collaborative emergency networks should work toward one now.”