Development of a Critical Care Response - Experiences from Italy During the Coronavirus Disease 2019 Pandemic

Abstract

Italy was the first western country facing an outbreak of coronavirus disease 2019 (COVID-19). The first Italian patient diagnosed with COVID-19 was admitted, on Feb. 20, 2020, to the intensive care unit (ICU) in Codogno (Lodi, Lombardy, Italy), and the number of reported positive cases increased to 36 in the next 24 hours, and then exponentially for 18 days. This triggered a response that resulted in a massive surge in ICU bed capacity. The COVID19 Lombardy Network organized a structured logistic response and provided scientific evidence to highlight information on COVID-19 associated respiratory failure.

Keywords: Awake proning; COVID19 Lombardy Network; Coronavirus disease 19; Critical care; Helmet continuous positive airway pressure; Organizational response; Pandemic.

Fig. 1

Representation of the area dedicated to the management of COVID-19 patients at the Fair Milan Covid-19 Intensive Care Hospital covering more than 25,000 square meters of area Portello Pavilions 1 and 2 at Fieramilanocity, Milan, Italy. The image represents the empty space before Fair Milan Covid-19 Intensive Care Hospital was yet staged (permission obtained to reproduce the image by Fondazione Fiera – All Rights reserved – https://www.ospedalefieramilano.it/it/l-progetto.html).

Fig. 2

Number of daily hospital versus ICU admissions (A, C) and hospital admissions versus hospital mortality (B, D) during the Italian first and second wave of SARS-CoV2 outbreak in Lombardy (top panels) and in Italy (bottom panels) from Feb. 24 to Dec. 13, 2020 (original data reports from the public source of “Presidenza del Consiglio dei Ministri - Dipartimento della Protezione Civile” https://github.com/pcm-dpc/COVID-19/blob/master/dati-regioni/dpc-covid19-ita-regioni.csv). (D) The peak of mortality reported on Aug. 15 was explained by internal verification of mortality data of Azienda Unità Sanitaria Locale of Parma (Emilia Romagna) that reported 154 deaths over March, April, and May that were not previously included. The distribution of hospitalized patients, ICU admissions, and deaths was different during the 2 peaks of the Italian SARS-CoV2 pandemic. In Lombardy, while the highest number of deaths during the first wave (ie, 546 deaths) was reported approximately 10 days before (ie, on March 20) the highest number of hospitalized patients (ie, 13,328 on April 4) and ICU admissions (ie, 1381 on April 3), during the second coronavirus peak, the highest capacitance in terms of hospital and ICU beds (ie, 9340 and 949, respectively) was reached earlier (ie, on Nov. 22), and contrary to the first wave,10 days in advance compared with the highest number of deaths (ie, 347 on Dec. 3). Accordingly, in the whole country, a similar date was observed. During the first SARS-CoV2 wave, the highest number of deaths (ie, 969 deaths) was reported about 10 days before (ie, onMarch 26) compared with the highest request of hospital (ie, 33,004 on April 4) and ICU beds (ie, 4068 on April 3). In contrast, during the second peak of the pandemic, the highest numbers of hospital and ICU admissions (ie, 38,507 and 3848, respectively) were recorded on Nov. 23 and 25, respectively, about 10 days before the peak of COVID-19 deaths (ie, 993 on Dec. 3).

Fig. 3

Exemplary image of continuous positive pressure ventilation delivered by a helmet c-PAP during prone positioning in a healthy volunteer as per the authors’ practice at San Gerardo Hospital, Monza and Policlinico Maggiore Hospital, Milano.

Fig. 4

Humanitarian Program Hope Onlus “#Covid-19 con Hope” #Covid-19@storiedisperanza. On the first stand, Prof. Antonio Pesenti, on the left, and Prof. Giacomo Grasselli, on the right – Clinical Director and Clinical Lead of the Intensive Care Unit of Policlinico Maggiore Hospital, Milano – the 2 main actors who led the Lombardy Crisis Unit and coordinated the COVID-19 Lombardy ICU network.