Elena Marcon1, Francesca Scotton2, Elena Marcante2, Alberto Rigo1, Jacopo Monticelli1, Maria Emanuela Buggio3, Claudio Pilerci4, Domenico Montemurro1 and Patrizia Benini5
1 Direzione Medica di Presidio, Ospedale di Schiavonia, Azienda ULSS n. 6 Euganea, Monselice, Padua, Italy
2 Dipartimento di Scienze Cardio-Toraco-Vascolari e Sanità Pubblica, Università degli Studi di Padova, Padua, Italy
3 Servizio Professioni Sanitarie, Ospedale di Schiavonia, Azienda ULSS n. 6 Euganea, Monselice, Padua, Italy
4 Direzione Medica di Presidio, Ospedale di Piove di Sacco, Azienda ULSS n. 6 Euganea, Padua, Italy 5Direzione Sanitaria, Azienda ULSS n. 6 Euganea, Padua, Italy
Introduction. On 21 February 2020, Schiavonia Hospital (SH) detected the first 2 cases of COVID-19 in Veneto Region. As a result of the underlying concomitant spread of infection, SH had to rearrange the clinical services in terms of structural changes to the building, management of spaces, human resources and supplies, in order to continue providing optimal care to the patients and staff safety. The aim of this article is to de- scribe how SH was able to adjust its services coping with the epidemiological stages of the pandemic.
Material and methods. Three periods can be identified; in each one the most important organizational modifications are analyzed (hospital activities, logistical changes, com- munication, surveillance on HCW).
Results. The first period, after initial cases’ identification, was characterized by the hos- pital isolation. In the second period the hospital reopened and it was divided into two completely separated areas, named COVID-19 and COVID-free, to prevent intra-hospi- tal contamination. The last period was characterized by the re-organization of the facility as the largest COVID Hospital in Veneto, catching exclusively COVID-19 patients from the surrounding areas.
Conclusions. SH changed its organization three times in less than two months. From the point of view of the Medical Direction of the Hospital the challenges had been many but it allowed to consolidate an organizational model which could answer to health needs during the emergency situation.
Italy has been one of the most impacted country in the European Union by the SARS-CoV-2 pandemic. Such disease represented a challenge to the Italian NHS, in terms of remodeling services, coping with the increased hospitalization rate and growing demand of intensive care unit (ICU) beds [1-3]. In Veneto Region, on 31st March, there were 9625 confirmed COVID-19 cases, and of these 2368 (25%) were in the local health unit (ULSS) 6 Euganea healthcare authority area . The ULSS 6 Euganea is one of the most populous ULSS of the Region consisting of 101 municipalities covering an area of over 2127 sq km. On 1 January 2019, it counted 931 582 inhabitants. It is composed of five districts. In this context four Network Hospitals, two Subacute Hospital Nodes and one Hub University Hospital operate. The first cluster of the SARS-CoV-2 epidemic in Veneto occurred in Vo’ Euganeo, a town of approxi- mately 3300 inhabitants, in the Southern Padua Dis- trict. This Health District covers 46 municipalities for approximately 180 000 inhabitants. The Schiavonia Hospital is the major Hospital Presid- ium of the Southern Padua District. It was built in 2014 and it has been carried out in project financing. In the same area there are also two Subacute Hospital Nodes principally dedicated to post-acute care. The Clinical Laboratory of Schiavonia Hospital is the microbiology reference center for the whole ULSS 6.
On 20 February 2020, the Hospital Infectious Dis- eases specialist identified two patients, both residing in Vo’ Euganeo and admitted (on 16 and 19 February, respectively) with fever, type 1 respiratory failure and interstitial pneumonia, preceded by mild diarrhea. The patients were tested for common pneumotropic patho- gens (common bacterial respiratory pathogens, influ- enza A/B viruses, parainfluenza 1-2-3-4 viruses, RSV, adenovirus, coronaviruses 229E-HKU1-OC43-NL63, human metapneumovirus, rhinovirus/enterovirus, Bor- detella pertussis, Chlamydophila pneumoniae, Mycoplasma pneumoniae, Legionella spp.), for less frequent patho- gens (acid-fast bacteria, HSV, VZV, CMV, Pneumocys- tis jiroveci, Leptospira spp., Coxiella spp.) and fungal biomarkers (galactomannan, serum (1,3)-β-D-glucan). All tests resulted inconclusive. After a careful medical history, it appeared that the two patients used to at- tend the same local bar frequented by Chinese people. Although patients had no history of recent travel to endemic areas, it was considered appropriate to pro- ceed with performing nasopharyngeal swabs for SARS- CoV-2. On the next day, Schiavonia Hospital confirmed the first 2 cases of COVID-19 in Veneto.
This article aims to describe the measures taken by Schiavonia Hospital to manage the current evolving challenges, including identification of risks, strategies to prevent the transmission of COVID-19 in health- care setting, maintaining an efficient response for all patients with urgent conditions and an adequate staff support [5-8].
MATERIAL AND METHODS
Since 21st February three different periods can be identified.
The first period (21 February – 7 March 2020) started with the identification of the first two cases at Schiavo- nia Hospital and of the outbreak in Vò Euganeo town. In this phase the hospital was completely closed to out- patient, except for saving-life therapies.
The second period (8 – 15 March 2020) was charac- terized by the hospital reopening. This could happen because all the nasopharyngeal swabs for SARS-CoV-2 carried out in health-care workers (HCW) tested nega- tive, the trend of the epidemic was not yet known and external stakeholders and local mayors made pression for a return to routine activities. The facility was di- vided into two treatment areas, named COVID-19 and COVID-free, according to the regional programming, which identified Schiavonia Hospital as the only ULSS 6 facility that had to reserve an area to treat COVID-19 patients . In this phase it was also established the national lockdown following the surge of the pandemic.
In the third period (16 March 2020 – 3 May 2020) Schiavonia Hospital was identified as a completely dedicated COVID-19 Hospital . It was designated COVID-19 Hospital because it is newly built, organized in separate modules and with technologies and systems suitable for supporting high volumes of medical gas (oxygen). This involved important structural and orga- nizational changes also because before the COVID-19 emergency Schiavonia Hospital was not a hospital for treatment of infectious diseases.
On 21 February 2020 three Task Forces of different decisional levels were set up:
• a Regional Task Force (RTF), composed by the Gov-
ernment of Veneto Region, a regional scientific com- mittee and Civil Protection that coordinated the re- gional emergency;
• an ULSS 6 Emergency Task Force (ETF), formed by ULSS 6 General Manager, Chief Medical Officer and local health authorities that coordinated both the hospital response and the Prevention Department’s activities;
• an in-hospital Crisis Unit (HCU), composed by the Director and all staff of the Hospital Medical Direc- tion, the Directors of Medical, Surgical and Diagnos- tic Departments, the Occupational Physician, the Director of Healthcare Professions and the Project Financing Manager.
In the next paragraphs each period is described in de- tails, analyzing the following items:
• short description of beds disposition;
• hospital activities;
• logistical changes;
• surveillance on HCW.
First period: Veneto outbreak and hospital’s isolation (21 February – 7 March 2020)
Immediately after the identification of the first cases the RTF ordered the isolation of Vo’ Euganeo town.
The ETF, according to the decision of the Italian Ministry of Health, ordered the closure of the hospital facility giving indications on the measures that had to be taken to manage the emergency :
• nobody was allowed to enter or leave the facility;
• as a precautionary measure, access to the wards was
prohibited for non-healthcare workers;
• nasopharyngeal swabs for SARS-CoV-2 were per-
formed to all people present in the hospital at the time of closure, giving priority to patients’ relatives to allow them to leave the facility in presence of a nega- tive result. The HCU decided to test outpatients, fol- lowed by HCW and then hospitalized patients;
• swabs to inpatients were scheduled for the following day;
• Personal Protective Equipment (PPE) were provided to everybody;
• a cordon sanitaire was established to secure the area, keep order and speed up swabs transport to the Vene- to reference laboratory, located in Padua;
• six special field tents were arranged outside the hospi- tal, to be used in case of need.
At the time of closure there were 47 patients in the
Emergency Room: 15 with triage yellow code, 9 with triage green code and 23 with triage white code. The Director of the Emergency Room invited patients in the waiting area, not yet taken in charge, to move towards other ULSS 6 hospital facilities in order to be evaluated and taken in charge as soon as possible.
The HCU immediately established a quick form to screen all present people, in particular revealing presence/ absence of respiratory symptoms and body temperature.
Over 600 swabs were performed during the first night. The next day the total amount rose to 1231 swabs (Table 1). Laboratory capacity reached saturation very early, therefore, in order to have the response that al- lowed the subject to leave the hospital, the waiting time progressively increased to on average of 18 h.
No HCW tested positive, while two other patients had positive swabs (also these patients came from Vo’ Euganeo).
The total number of people resident in Vo’ Euganeo at the moment of the closure of the hospital was 16 (in- cluding relatives, patients and HCW), of whom 6 tested positive: 4 patients and 2 relatives of one of them. The four patients were hospitalized in three different Units: internal medicine, ICU and orthopedics; the one re- covered in ICU died on the night of February 21. His death was the first one in Italy due to COVID-19; none of the positive patients had significant comorbidities.
The three positive patients were transferred to Pad- ua University Hospital, where the Infectious Diseases Unit was ready for the isolation of confirmed cases.
The HCU therefore defined four “transit wards” where COVID-19 patients had stayed: ER, internal medicine, ICU and orthopedics (Figure 1). The ETF decided that patients admitted in non-transit wards who tested negative, could be discharged, instead those admitted in transit wards had to remain quarantined in hospital even if dischargeable.
Surveillance on HCW
In the early phase of the outbreak, the situation was rapidly evolving so hospital guidelines were modified frequently. Due to excessive increasing of laboratory response times it was established that:
- all HCW entering shifts had to undergo nasopharyn- geal swabs for SARS-CoV-2;
- HCW could leave the hospital without having to wait for swab result if asymptomatic at the end of the shift;
- if the swab tested negative HCW could continue nor-mal work shifts;
- if the swab tested positive or they were symptomaticthey had to stay home, quarantined;
- all HCW were provided with appropriate PPE.
Although the hospital was closed, HCU and ETF as- sessed the clinical activities that had to remain guar- anteed: clinical laboratory and intra-hospital surgical emergencies for inpatients, dialysis and chemotherapy, as life-saving therapies, both for inpatients and outpa- tients.
Dialysis and chemotherapy services could remain open for outpatients because the areas dedicated to these activities had independent entrance gates.
According to ETF priority lists, surgery and outpa- tient clinics had to be re-evaluated in order to define urgent cases that needed to be moved to other ULSS 6 hospitals or to outpatient settings.
The ER was closed, so the Emergency Service of Transports, coordinated at provincial level, diverted all requests to other hospitals of ULSS 6 (Table 2).
These events required a rapid reorganization of the hospital as a whole.
Access control was essential to reduce the risk of viral transmission to other patients or HCW. For this reason, specific active gates were created:
• gates for the entrance of HCW and other hospital staff:
entry times were scheduled to avoid overcrowding (6.30-8.00 for HCW, 8.00-8.30 for administrative staff): moreover, relatives could give personal belong- ings to dedicated staff who provided to deliver them to hospitalized patients;
• gate for dialysis and oncology: independent access where outpatients were identified and registered;
• gate for pharmaceutical assistance: independent access through which medical supplies were distributed on appointment to outpatients.
At each gate: people had to fill in a form with their
personal details; body temperature was measured us- ing infrared thermometers to recognize any person with fever; surgical masks were distributed to protect against droplet transmission. Relatives’ visits were suspended. In exceptional cases (end-of-life stage) only one person was allowed to enter, wearing proper PPE, after Medical Direction authori- zation. As the HCU ordered the closure of the hospital can- teen and inner bar to avoid crowding, the catering was reorganized through distribution of meals in disposable trays both for HCW and inpatients, maintaining the possibility to order differentiated meals according to patients’ nutritional needs.
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