On February 20, 2020, a patient in his 30s admitted to the intensive care unit (ICU) at Codogno Hospital (Lodi, Lombardy, Italy) tested positive for a new coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS). -CoV-2), the virus that causes coronavirus disease 2019 (COVID-19). He had a history of atypical pneumonia that was not responding to treatment, but was not considered at risk for COVID-19 infection. The positive result was immediately reported to Lombardy’s healthcare system and government offices.
Over the next 24 hours, the number of reported positive cases increased to 36. This situation was considered a serious development for several reasons: the patient ("patient 1") was healthy and young; In less than 24 hours, 36 additional cases were identified, with no links to patient 1 or previously identified positive cases already in the country; it was not possible to identify with certainty the source of transmission to patient 1 at that time; and, since patient 1 was in the ICU and there were already 36 cases on day 2, it was likely that there was a cluster of unknown magnitude and further dissemination was likely.
On February 21, the Government of Lombardy and local health authorities formed an emergency task force to lead the response to the outbreak. This view provides a summary of the Lombardy ICU network COVID-19 response and a forecast of estimated ICU demand in the coming weeks (projected for March 20, 2020).
Establish priorities and initial response
In Lombardy, the total pre-crisis ICU capacity was approximately 720 beds (2.9% of total hospital beds in a total of 74 hospitals); These intensive care units typically have 85% to 90% occupancy during the winter months.
The mission of the COVID-19 Lombardy ICU network was to coordinate the critical care response to the outbreak. Two main priorities were identified :
- Increase ICU capacity.
- Implement containment measures.
Increase in ICU capacity
The recognition that this outbreak likely occurred through community spread suggested that a large number of COVID-19 positive patients were already present in the region. This prediction proved correct in the following days. Based on the assumption that secondary transmission was already occurring, and even with the containment measures that health authorities were putting in place, it was assumed that many new cases of COVID-19 would occur, possibly in hundreds or thousands of individuals.
Therefore, assuming a 5% ICU admission rate , it would not have been possible to assign all critically ill patients to a single COVID-19 ICU. The decision was to cohort the patients in 15 first response hospital centers, chosen because they had experience in infectious diseases or were part of the Venous-Venous ECMO Respiratory Failure Network (RESPIRA).3
Identified hospitals were asked to do the following:
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Containment measures
Local health authorities established strong containment measures on the initial group by quarantining several cities in an attempt to curb the transmission of the virus.
In the second week, other groups emerged. During this time, the UCI network advised the government to implement all measures, such as strengthening public health measures of quarantine and self-isolation, to contain the virus.
ICU admissions during the first 2 weeks
There was an immediate sharp increase in ICU admissions from day 1 to day 14. The increase was steady and permanent.
- Publicly available data indicate that ICU admissions (n = 556) represented 16% of all patients (n = 3420) who tested positive for COVID-19.
- As of March 7, the current total number of COVID-19 patients occupying an ICU bed (n = 359) represents 16% of currently hospitalized COVID-19 patients (n = 2,217).
- All patients who appeared to have severe illness were admitted for hypoxic respiratory failure to dedicated COVID-19 ICUs.
ICU capacity
Within 48 hours, ICU cohorts were formed at 15 central hospitals , with a total of 130 COVID-19 ICU beds.
As of March 7, the total number of dedicated cohorted COVID-19 ICU beds was 482 (approximately 60% of total ICU bed capacity before the outbreak), distributed among 55 hospitals.
As of March 8, critically ill patients (initially COVID-19 negative patients) have been transferred to receptive ICUs outside the region through a coordinating national emergency office.
Forecast ICU demand in the next 2 weeks
During the first 3 days of the outbreak, starting February 22, ICU admissions were 11, 15 and 20 in the Lombardy ICU COVID-19 Network.
ICU admissions have increased continuously and exponentially during the first 2 weeks.
Based on data through March 7, when 556 COVID-19 positive ICU patients had been admitted to hospitals over the previous 15 days, linear and exponential models were created to estimate additional ICU demand (Figure e in the Supplement). .
The linear model predicts that approximately 869 ICU admissions could occur by March 20, 2020, while the exponential growth model projects that approximately 14,542 ICU admissions could occur by then.
| Although these projections are hypothetical and involve several assumptions, any substantial increase in the number of critical patients would quickly exceed total ICU capacity , without even considering other critical admissions, such as trauma, stroke, and other emergencies. |
In practice, the healthcare system cannot withstand an uncontrolled outbreak, and stronger containment measures are now the only realistic option to avoid the total collapse of the ICU system.
For this reason, over the past 2 weeks, doctors have continually advised authorities to increase containment measures.
To our knowledge, this is the first report of the consequences of the COVID-19 outbreak on critical care capacity outside of China. Despite the prompt response of the local and regional ICU network, health authorities and the government to try to contain the initial cluster, the increase in patients requiring ICU admission has been overwhelming .
The proportion of ICU admissions represents 12% of all positive cases and 16% of all hospitalized patients. This rate is higher than what was reported from China, where only 5% of patients who tested positive for COVID-19 required ICU admission.
There could be different explanations.
- It is possible that ICU admission criteria were different between countries, but this seems unlikely.
- Another explanation is that the Italian population is different from the Chinese population, with predisposing factors such as race, age and comorbidities.
On March 8-9, planning for the next response began, including defining a new hub-and-spoke system for time-dependent pathology, further increasing ICU capacity, and reinforcing stronger containment measurement in the community, as well as discussions about what could have been done differently.
- First, laboratory capacity to detect SARS-CoV-2 should have been increased immediately. Laboratory capacity reached saturation very early. This can add additional stress to a system and impact the ability to make accurate diagnoses and assign patients appropriately.
- Second, in parallel to the surge ICU capacity response, a large, dedicated COVID-19 facility could have been converted more quickly. On day 1 of the crisis, it was not possible to predict the speed and extent of the contagion. Importantly, forecasts show that increasing ICU capacity is simply not enough . More resources must be invested to contain the epidemic.
As of March 8, Lombardy was placed under quarantine and strict self-isolation measures were instituted. This may be the only possible way to contain the spread of infection and allow time-dependent disease resources to develop.
As of March 10, Italy has been placed under quarantine and the government has instituted stronger containment measures, including strict self-isolation measures. These containment measures and the individual responsibility of citizens could slow the transmission of the virus.
While regional resources are currently at capacity, the Italian central government is providing additional resources, such as transfers of critical patients to other regions, emergency funds, ICU staff and equipment. The goal is to ensure that an ICU bed is available for every patient who needs one.
Other healthcare systems must prepare for a massive increase in ICU demand during an uncontrolled COVID-19 outbreak. This experience would suggest that only an ICU network can provide the immediate initial surge response to allow every patient who needs an ICU bed to receive one. Health care systems not organized into collaborative emergency networks should work to achieve one now.
