To be or not to beintensive: Internal Medicine unit role during and after CoViD-19 pandemic

Background and Aim: CoViD-19 causes major changes in daily hospital activity, both in clinician and organizational aspects. Aim of this research is investigated a new model of Internal Medicine Unit. ASL Roma 6 is a local health facilities where hospital, territorial medicine and low-care facilities are integrated. Materials and Methods: Initially, Delphi method (by six experts with clinician, statistic, health economic and public health expertise) allowed to analyze bad outcome causes in Ospedale dei Castelli's CoViD wards cohort (Lazio, Italy) via Ishikawa diagram and to create a SWOT analysis table. At the least, a Barber-Johnson's nomogram has been made with performances of MC (Medicine- CoViD) and MCF (Medicine-CoViD-free) units considering: length of the stay, bed occupation ratio, turn over interval and bed rotation index. CoViD-three-waves have been considered alone and overall. Results: MCF hospitalized 790 patients (-23,90% compared to 2019 Internal Medicine admission), MC hospitalized 350 patients (M 199/F151). Main risk factor for mortality: patients admitted from local facilities (+7%, 57,14% of overall CoViD deaths) and presence of comorbidities (>3: 100%, =5: 24,7%). 197 (25%) patients have been treated with non-invasive ventilation (NIV). Conclusions: CoViD Medicine wards show higher complexity and demand compared to non-CoViD ones, comparable to Sub-Intensive Therapy units;it is necessary to promote the NIV usage in such setting and to use CoViD expertise to build a new hospital model, where Internal Medicine is the core of care, integrated with territorial medicine.

Is COVID 19 introducing a new model of internal medicine ward?

Background Covid 19 has recently been defined as a syndemia, because it combines the epidemic emergency of Sars Cov 2 with that of non-communicable diseases. This aspect is particularly known in internal medicine wards (IM), which have had to split up to support these new criticalities. Methods Delphi method has been used to make the Ishikawa's diagram to analyze the reasons of the death in COVID ward. Each item was attributed a score according to a pros/cons and opportunities/threats system, derived from evidence in the literature. Scores were presented in a Cartesian graph showing the positioning according to the potential value and the perceived risk associated with the items. In the end, the performances of MC (Covid ward, split in I wave, II wave and overall) and MCF (internal medicine Covid-free ward) have been compared through the Barber's nomogram. Results MCF hospitalized 790 patients (-23,90% compared to 2019), Overall-MC patients: 50% of the 2019 MCF. Main cause of mortality-risk: patients originating from local facilities (+7%) and comorbidities (58% Chronic renal failure, 41% cancer, 90% age, 70% COVID 19 WHO stage 3. >3 comorbidities: 100%, ≥5: 24,7%). Length of stay: 8-60 days (mean value, MV: 17) for MC, 2-12 (MV 8) for MCF. Turnover Index: 10 day for MC II, 8 MC I, 1 for MCF. 25% of patients in MC have been treated with Non Invasive Ventilation (NIV), with high cost hospitalization-related. Conclusions Internal-Medicine ward model is a ward strictly tied to the community both before and after hospitalization. COVID 19 proposes a new model of IM, nearly subintensive ward, with NIV and continuous monitoring of vital signs, long length of stay and low turnover index. Is this the internal medicine ward for the future? Key messages COVID 19 proposes a new model of Internal Medicine ward, nearly subintensive ward, with Non Invasive Ventilation and continuous monitoring of vital signs, long length of stay and low turnover index. Covid 19 mortality is strictly connected with the origin from territorial health-assisted residences.

The novel Mechanical Ventilator Milano for the COVID-19 pandemic.

This paper presents the Mechanical Ventilator Milano (MVM), a novel intensive therapy mechanical ventilator designed for rapid, large-scale, low-cost production for the COVID-19 pandemic. Free of moving mechanical parts and requiring only a source of compressed oxygen and medical air to operate, the MVM is designed to support the long-term invasive ventilation often required for COVID-19 patients and operates in pressure-regulated ventilation modes, which minimize the risk of furthering lung trauma. The MVM was extensively tested against ISO standards in the laboratory using a breathing simulator, with good agreement between input and measured breathing parameters and performing correctly in response to fault conditions and stability tests. The MVM has obtained Emergency Use Authorization by U.S. Food and Drug Administration (FDA) for use in healthcare settings during the COVID-19 pandemic and Health Canada Medical Device Authorization for Importation or Sale, under Interim Order for Use in Relation to COVID-19. Following these certifications, mass production is ongoing and distribution is under way in several countries. The MVM was designed, tested, prepared for certification, and mass produced in the space of a few months by a unique collaboration of respiratory healthcare professionals and experimental physicists, working with industrial partners, and is an excellent ventilator candidate for this pandemic anywhere in the world.

The metamorphosis of the field facilities organizationalmodel for vulnerable population protection in COVID-19infection: Mortality risk factors and management solutions

Background: Asl Roma 6 (population served 531,177 inhabitants) is a healthcare company characterized by strong hospitalfield integration due to the presence of 4 hospitals, 6 districts andover 36 low-intensity field facilities for frail elderly. Equipped withCovid Hospital within an active field surveillance system.Materials and Methods: Retrospective evaluation of the mortalityof patients admitted to Covid Medicine with identification of riskfactors and proposal of innovative risk reduction models. Results: 85 patients admitted (49F, 36M);average age 77 years;68% with>3 comorbidities;deaths 28% with average age 86.8years. Main risk factors: transferred from low intensity field facilities(100%), old age and comorbidities>3 (100%), followed by Covid-19 WHO Stage 3 (70%);IRC (58%);neoplasm (41%), D-Dimerat the entrance>500 (50%). Conclusions: To effectively carry out emergency preparednessactions it is necessary to introduce new organizational modelsaimed at the reorganization of activities specifically within thefield facilities for the elderly currently implemented in Asl Roma6: 1. acceptance only after 2 negative swabs;2. isolation withquarantine inside the structure and subsequently accomodationwith other patients;3. monitoring by periodic swabs;4. socialdistancing and PPE (Personal Protective Equipment) use. Prevention with selective isolation of vulnerable patients is the bestoption to reduce mortality as intensive care was not effective inavoiding deaths (10% of patients undergoing NIV- Non InvasiveVentilation with little benefit).