Assessing Hospital Adaptive Resource Allocation Strategies in Responding to Mass Casualty Incidents.

BACKGROUND: Hospitals are expected to operate at a high performance level even under exceptional conditions of peak demand and resource disruptions. This understanding is not mature yet and there are wide areas of possible improvement. In particular, the fast mobilization and reconfiguration of resources frequently result into the severe disruption of elective activities, worsening the quality of care. This becomes particularly evident during the on-going coronavirus disease 2019 (COVID-19) pandemic. More resilient resource allocation strategies, that is, which adapt to the dynamics of the prevailing circumstance, are needed to maximize the effectiveness of health-care delivery. In this study, a simulation approach was adopted to assess and compare different hospital's adaptive resource allocation strategies in responding to a sudden onset disaster mass casualty incident (MCI). METHODS: A specific set of performance metrics was developed to take into consideration multiple objectives and priorities and holistically assess the effectiveness of health-care delivery when coping with an MCI event. Discrete event simulation (DES) and system dynamics (SD) were used to model the key hospital processes and the MCI plan. RESULTS: In the daytime scenario, during the recovery phase of the disaster, a gradual disengagement of resources from the emergency department (ED) to restart ordinary activities in operating rooms and wards returned the best performance. In the night scenario, the absorption capacity of the ED was evaluated by identifying the current bottleneck and assessment of the benefit of different resource mobilization strategies. CONCLUSIONS: The present study offers a robust approach, effective strategies and new insights to design more resilient plans to cope with MCIs. It becomes particularly relevant when considering the risk of indirect damage of emergencies, where all the available resources are shifted from the care of the ordinary to the "disaster" patients, like during the on-going COVID-19 pandemic. Future research is needed to widen the scope of the analysis and take into consideration additional resilience capacities such as operational coordination mechanisms among multiple hospitals in the same geographic area.

Stranger Months: How SARS-CoV-2, Fear of Contagion, and Lockdown Measures Impacted Attendance and Clinical Activity During February and March 2020 at an Urban Emergency Department in Milan.

OBJECTIVES: An unprecedented wave of patients with acute respiratory failure due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) disease 2019 (COVID-19) hit emergency departments (EDs) in Lombardy, starting in the second half of February 2020. This study describes the direct and indirect impacts of the SARS-CoV-2 outbreak on an urban major-hospital ED. METHODS: Data regarding all patients diagnosed with COVID-19 presenting from February 1 to March 31, 2020, were prospectively collected, while data regarding non-COVID patients presenting within the same period in 2019 were retrospectively retrieved. RESULTS: ED attendance dropped by 37% in 2020. Two-thirds of this reduction occurred early after the identification of the first autochthonous COVID-19 case in Lombardy, before lockdown measures were enforced. Hospital admissions of non-COVID patients fell by 26%. During the peak of COVID-19 attendance, the ED faced an extraordinary increase in: patients needing oxygen (+239%) or noninvasive ventilation (+725%), transfers to the intensive care unit (+57%), and in-hospital mortality (+309%), compared with the same period in 2019. CONCLUSIONS: The COVID-19 outbreak determined an unprecedented upsurge in respiratory failure cases and mortality. Fear of contagion triggered a spontaneous, marked reduction of ED attendance, and, presumably, some as yet unknown quantity of missed or delayed diagnoses for conditions other than COVID-19.

Impact of the COVID-19 outbreak on severe trauma trends and healthcare system reassessment in Lombardia, Italy: an analysis from the regional trauma registry.

BACKGROUNDS: The COVID-19 pandemic drastically strained the health systems worldwide, obligating the reassessment of how healthcare is delivered. In Lombardia, Italy, a Regional Emergency Committee (REC) was established and the regional health system reorganized, with only three hospitals designated as hubs for trauma care. The aim of this study was to evaluate the effects of this reorganization of regional care, comparing the distribution of patients before and during the COVID-19 outbreak and to describe changes in the epidemiology of severe trauma among the two periods. METHODS: A cohort study was conducted using retrospectively collected data from the Regional Trauma Registry of Lombardia (LTR). We compared the data of trauma patients admitted to three hub hospitals before the COVID-19 outbreak (September 1 to November 19, 2019) with those recorded during the pandemic (February 21 to May 10, 2020) in the same hospitals. Demographic data, level of pre-hospital care (Advanced Life Support-ALS, Basic Life Support-BLS), type of transportation, mechanism of injury (MOI), abbreviated injury score (AIS, 1998 version), injury severity score (ISS), revised trauma score (RTS), and ICU admission and survival outcome of all the patients admitted to the three trauma centers designed as hubs, were reviewed. Screening for COVID-19 was performed with nasopharyngeal swabs, chest ultrasound, and/or computed tomography. RESULTS: During the COVID-19 pandemic, trauma patients admitted to the hubs increased (46.4% vs 28.3%, p < 0.001) with an increase in pre-hospital time (71.8 vs 61.3 min, p < 0.01), while observed in hospital mortality was unaffected. TRISS, ISS, AIS, and ICU admission were similar in both periods. During the COVID-19 outbreak, we observed substantial changes in MOI of severe trauma patients admitted to three hubs, with increases of unintentional (31.9% vs 18.5%, p < 0.05) and intentional falls (8.4% vs 1.2%, p < 0.05), whereas the pandemic restrictions reduced road- related injuries (35.6% vs 60%, p < 0.05). Deaths on scene were significantly increased (17.7% vs 6.8%, p < 0.001). CONCLUSIONS: The COVID-19 outbreak affected the epidemiology of severe trauma patients. An increase in trauma patient admissions to a few designated facilities with high level of care obtained satisfactory results, while COVID-19 patients overwhelmed resources of most other hospitals.

Impact of lockdown on emergency general surgery during first 2020 COVID-19 outbreak.

PURPOSE: To evaluate and analyze the impact of lockdown strategy due to coronavirus disease 2019 (COVID-19) on emergency general surgery (EGS) in the Milan area at the beginning of pandemic outbreak. METHODS: A survey was distributed to 14 different hospitals of the Milan area to analyze the variation of EGS procedures. Each hospital reported the number of EGS procedures in the same time frame comparing 2019 and 2020. The survey revealed that the number of patients during the COVID-19 pandemic outbreak in 2020 was reduced by 19% when compared with 2019. The decrease was statistically significant only for abdominal wall surgery. Interestingly, in 2020, there was an increase of three procedures: surgical intervention for acute mesenteric ischemia (p = 0.002), drainage of perianal abscesses (p = 0.000285), and cholecystostomy for acute cholecystitis (p = 0.08). CONCLUSIONS: During the first COVID-19 pandemic wave in the metropolitan area of Milan, the number of patients operated for emergency diseases decreased by around 19%. We believe that this decrease is related either to the fear of the population to ask for emergency department (ED) consultation and to a shift towards a more non-operative management in the surgeons 'decision making' process. The increase of acute mesenteric ischaemia and perianal abscess might be related to the modification of dietary habits and reduction of physical activity related to the lockdown.

How to Build the Plane While Flying: VTE/PE Thromboprophylaxis Clinical Guidelines for COVID-19 Patients.

Over the years, the practice of medicine has evolved from authority-based to experience-based to evidence-based with the introduction of the scientific process, clinical trials, and outcomes-based data analysis (Tebala GD. Int J Med Sci. 2018;15(12):1397-1405). The time required to perform the necessary randomized controlled trials, a systematic literature review, and meta-analysis of these trials to then create, accept, promulgate, and educate the practicing clinicians to use the evidence-based clinical guidelines is typically measured in years. When the severe acute respiratory syndrome novel coronavirus-2 (SARS-nCoV-2) pandemic commenced in Wuhan, China at the end of 2019, there were few available clinical guidelines to deploy, let alone adapt and adopt to treat the surge of coronavirus disease 2019 (COVID-19) patients. The aim of this study is to first explain how clinical guidelines, on which bedside clinicians have grown accustomed, can be created in the midst of a pandemic, with an evolving scientific understanding of the pathophysiology of the hypercoagulable state. The second is to adapt and adopt current venous thromboembolism diagnostic and treatment guidelines, while relying on the limited available observational reporting of COVID-19 patients to create a comprehensive clinical guideline to treat COVID-19 patients.

How to Surge to Face the SARS-CoV-2 Outbreak: Lessons Learned From Lombardy, Italy.

Italy is fighting against one of the worst medical emergency since the 1918 Spanish Flu. Pressure on the hospitals is tremendous. As for official data on March 14th: 8372 admitted in hospitals, 1518 in intensive care units, 1441 deaths (175 more than the day before). Unfortunately, hospitals are not prepared: even where a plan for massive influx of patients is present, it usually focuses on sudden onset disaster trauma victims (the most probable case scenario), and it has not been tested, validated, or propagated to the staff. Despite this, the All Hazards Approach for management of major incidents and disasters is still valid and the "4S" theory (staff, stuff, structure, systems) for surge capacity can be guidance to respond to this disaster.

European Society of Trauma and Emergency Surgery (ESTES) recommendations for trauma and emergency surgery preparation during times of COVID-19 infection.

A series of recommendations regarding hospital perioperative preparation for the COVID-19 pandemic were compiled to inform surgeons worldwide on how to provide emergency surgery and trauma care during enduring times.The recommendations are divided into eight domains: (1) General recommendation for surgical services; (2) Emergency Surgery for critically ill COVID-19 positive or suspected patients -Preoperative planning and case selection; (3) Operating Room setup; (4) patient transport to the OR; (5) Surgical staff preparation; (6) Anesthesia considerations; (7) Surgical approach; and (8) Case Completion.The European Society of Emergency Surgery board endorsed these recommendations.