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An italian hospital dedicated to covid 19 patients

Preparation of a radiology department in an Italian hospital dedicated
to COVID‑19 patients

Preparation of a radiology department in an Italian hospital dedicated to COVID‑19 patients

Anna Maria Ierardi1 · Bradford J. Wood2 · Antonio Arrichiello1 · Nicola Bottino3 · Laura Bracchi4 · Laura Forzenigo1 · Maria Carmela Andrisani1 · Valentina Vespro1 · Cristian Bonelli5 · Amel Amalou2 · Evrim B. Turkbey6 · Baris I. Turkbey7 · Giuseppe Granata1 · Antonio Pinto8 · Giacomo Grasselli3,10 · Nino Stocchetti9,10 · Gianpaolo Carrafello1,

Abstract

Preparedness for the ongoing coronavirus disease 2019 (COVID-19) and its spread in Italy called for setting up of adequately equipped and dedicated health facilities to manage sick patients while protecting healthcare workers, uninfected patients, and the community. In our country, in a short time span, the demand for critical care beds exceeded supply. A new sequestered hospital completely dedicated to intensive care (IC) for isolated COVID-19 patients needed to be designed, constructed, and deployed. Along with this new initiative, the new concept of “Pandemic Radiology Unit” was implemented as a practical solution to the emerging crisis, born out of a critical and urgent acute need. The present article describes logistics, planning, and practical design issues for such a pandemic radiology and critical care unit (e.g., space, infection control, safety of healthcare workers, etc.) adopted in the IC Hospital Unit for the care and management of COVID-19 patients.

Introduction

The Coronavirus Disease 2019 (COVID-19) pandemic began in Late 2019 in Wuhan, China. The outbreak is due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection [1]. Italy had precious little time to prepare any response to the COVID-19 pandemic. This response is led by the Italian national government in coordination and synchrony with local (or regional) governments and hospitals.

The major hot spot of COVID-19 patients have thus far been in the north of Italy, especially in the region of Lombardy. To date, the total of infections in Italy is > 215,000, of which 80,723 are in Lombardy [2]. Over 10 million people live in Lombardy region, forming more than one-sixth of Italy’s population, [3].

Within Lombardy, Milano’s metropolitan area is the largest in Italy, and the third most populated functional urban area in the entire European Union [2].

As it is now well known from the clinical course of COVID-19 available in the guidelines and the literature, the most severe cases develop acute respiratory conditions that require intensive care unit (ICU) admission. Although only a few of those infected require ICU, the need for ICU beds increases exponentially during the upward trajectory of the pandemic outbreak curve. In this scenario, the demand for critical care in the northern region of Italy exceeded supply, raising significant practical and ethical concerns in the process. To overcome this important issue, within 2 weeks from concept to opening, a new hospital was arranged. This is not a camp hospital or acute triage “fever clinic,” but a real “brick and mortar” hospital focused on intensive care and intensive triage of the critically ill cases. Two pavilions, located on two floors, of an exhibition area were made eligible to host all the equipment and staged care triage settings of the IC ward. All the services (laboratories, radiology, etc.) necessary to an independent functioning of over dedicated IC 200 beds were allocated in the same building with a strategic position. This location minimized cross-contamination and interactions with non-COVID-19 activities and staff. Procedural and staff sequestration that mimics the geographic sequestration of such an effort is requisite to successful nosocomial containment of pandemic COVID-19. Radiology is one of the frontline specialities in the clinical service, because of its role in diagnosis and follow-up of patients. A multidisciplinary symphony of coordinated policies, infrastructure, communications, flow, and staff awareness were harmonized to enable a successful mission to fight COVID-19. The present article describes the logistical setting, strategy, and organization for radiology services in a new dedicated Covid-19 critical care and critical triage hospital.

Hospital

A well-equipped dedicated hospital facility to deal with COVID-19 patients with adequate protective equipment and policies for healthcare workers is the key to successful delivery of safe and optimal public health care in the setting of a pandemic. The hospital was designed to be practically a self-contained and self-sufficient establishment that can meet most of its daily needs with only essential and limited contact with the outside world, via predetermined limited channels for such critical pipelines as nutritional services and other supply chains. Basic requirements that needed to be defined included: appropriate cleaning practices; adequate floor space for beds; adequate (ideally negative) one-pass ventilation for isolation rooms and procedure rooms; adequate isolation facilities for airborne, droplet, contact isolation and protective environment with well-defined and disseminated standard operating procedures (SOPs); and finally a regulated and rational traffic flow to minimize exposure or cross-contamination of high-risk patients and facilitate patient and clinical material transport.

The hospital, composed of 205 ICU beds includes 2 floors, is divided in red and green units or zones (Fig. 1). Red zones are completely dedicated to host beds for COVID-19 patients, ventilators and devices dedicated to IC management. Beds are contained in modules (from A to H as shown in the map (Fig. 2); in each module, 7 or 14 beds are located, depending on floor), with controlled access and unified connections to each other. Barrier nursing practices and protective isolation facilities are present to minimize risk of nosocomial infections. Beds are sequestered from each other as much as possible, to avoid cross-contamination, in case of different strains of COVID-19 or differing superinfections with more standard microorganisms. Part of the radiological services is also located in red zones (like CT, US, etc), laundry, access for patients, and patient triage is all located in the red zone also. Green zones include access for healthcare workers, changing rooms, offices and administrative area, and some support services. Such a staged space designation is analogous to the ante-room concept for staged doffing PPE, whereby the doffing occurs in staged locations, in very specific sequences, from very dirty to less dirty to more likely clean, in order to minimize human error and exposures. Doffing is done with a “Doffing Watcher” whose sole assignment is to watch the “doffers and donners” for human breaches in technique or sequence. Likewise it is wise to designate staff as “coordinators” for traffic control and communications of transport issues, and “educators” for dissemination of SOPs and new policies and practicing, and “runners” whose sole responsibility is to transfer equipment or supplies from a “clean” supply or storage space to a “dirty” procedure room, along predetermined and pre-practiced chains of transfer and chains of communication.

Green zones, as illustrated in the map (Fig. 1), are represented by an external perimeter, surrounding the red zones. Four entry points are present, equipped with protective personal equipment (PPE). Each red module is equipped with doffing points, from which it s possible to go out from the red zone. Attention to donning and doffing education, practicing, training, and standard SOPs is critical to safe operation of such a COVID-19 facility.

Radiology service

Radiology Unit is present in both red and green zones. In the red zones are located ultrasound (US) machines, one for each module; portable radiography is repeatable and easy to decontaminate and serves as the mainstay imaging tool for emergency departments and inpatient settings. Therefore, portable radiography equipment is present in predefined locations. A leaded glass barrier (similar to grocery store lines) may serve as an extra barrier for staff, especially in the field acute care or screening settings. Two CT machines are present, one for each floor: they are located in the red zone and closer to the triage to permit immediate access to the CT room, even for patients just admitted. A little room with a workstation is located closer to the CT room, but staffs are encouraged to do remote communications, remote interpretations, and remote consults whenever possible. In the green zone, a radiology office is present, in which 2 workstations are available to allow radiologists and residents to interpret images, do reconstructions, make a report, and be accessible via remote communications to the red zone staff. A workstation dedicated to artificial intelligence (AI) is also available to permit studies on chest X-rays and CT scans, for research purposes and point of care applications of novel approaches to multi-parametric data integration, all with regulatory clearances and a network of multinational partnerships.



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