Hospitals all over the world are working to rapidly expand their capacity to treat critically ill patients with COVID-19. To find out how hospitals on the frontlines of the pandemic are coping —and the lessons learned that could help other hospitals prepare—FUJIFILM SonoSite’s Chief Medical Officer, Diku Mandavia, MD interviewed Enrico Storti, MD, the ICU Director/Unit Coordinator of the Emergency Department at Maggiore Hospital in Lodi, Italy, located near Milan and the epicenter of the Italian COVID-19 outbreak.

Dr. Storti’s ICU has treated what is believed to be Patient One of the Italian outbreak and hundreds of other COVID-19 patients. In this article, Dr. Storti discusses how his team rapidly transformed their hospital’s ICU to deal with an unprecedented “mass casualty event,” what clinicians can expect when the pandemic reaches their hospitals, and the role that point-of-care ultrasound has played in triaging patients and providing more efficient care.

Dr. Mandavia: How are the people of Italy doing throughout this crisis?
Dr. Storti: I've seen things that would have been absolutely unbelievable until three weeks ago. We have found ourselves in a mass casualty event. This is really the right definition because we were immediately forced to face a huge number of patients. Our emergency department [ED] on average has received 150, sometimes 200 patients per day. A large portion of these patients exhibited acute respiratory distress, and needed to be oxygenated. This has been a huge challenge for the ED and for the entire hospital.

We immediately understood that we couldn't cope with the situation like this in which there was a huge disproportion between resources and the number of patients and the intensity of their illness. We were forced to change our hospital rules and reshape our hospital staffing from the emergency department, passing through the stepdown unit, and reaching into the ICU—without the option of transporting these patients because all the nearby hospitals were completely overwhelmed.

Dr. Mandavia: How were you able to surge your ICU capability?
Dr. Storti: In the beginning, syringe pumps and other ICU items were insufficient because we only had instruments and ventilators for seven beds. We were forced to collect every ventilator inside the hospital. We used the OR [operating room] ventilators, and brought patients to the OR in order to give them the opportunity to be properly ventilated in a sort of ICU setting. Now the situation is a little more stable. Our Lombardy region welfare department managed to collect a large number of ventilators: We now have 24 ICU beds and 26 ventilators.

Dr. Mandavia: Yes, tell us a little bit about that.
Dr. Storti: We immediately understood that this was a war scenario. We had so many patients at the same time that we couldn't cope by using the gold standard. What I mean by gold standard is that every ICU physician knows perfectly how to handle and treat an acute respiratory distress syndrome (ARDS) patient. The problem is that you have to treat 15 ARDS patient at once and your team is decreased in terms of people able to work the shifts. It was immediately clear that we first had to reinvent our way of approaching this patient.

On day one, we were completely overwhelmed and astonished about what was going on. But immediately we tried to react and have a different approach. For example, we had too many patients with ARDS to refer them to the CT scanner. The patients were presenting with a severe respiratory distress, PO2/FiO2 very low, and a fever and a flu in the few days before. So, the diagnosis was not so complicated.

What was really challenging was to triage these people with something which was very quick, very simple, very effective, addressing clinical decisions. Otherwise we couldn't cope. So we managed these patients only with blood gas analysis, chest X-ray, and ultrasound evaluation. And, of course, their previous medical history. Those have been our pillars to have the final diagnosis.

Deciding when you have to distribute your resources in the proper manner became very important: where to refer the patient, who could stay in emergency department for 24 or 48 hours, who should be intubated immediately, and who to refer to the stepdown unit. We have redefined the wards in our hospital and created from scratch a stepdown unit from zero to 18 beds. We have erased neurology and the neurology ward, and moved in ventilated patients to be treated by a multidisciplinary staff, including a pulmonologist and an intensivist, to enlarge our ICU capacity.

When coronavirus infects people, you create a ratio which is roughly like this: You create one ICU patient, you create five to 10 stepdown unit patients, and you have 10 to 20 patients who simply need to be oxygenated. For these number of patients, it has been so important the oxygen sockets and the total amount of oxygen supply in our hospital increases fivefold. So we had to ask the factory that brings our oxygen to refill our oxygen reservoir once per day.

Dr. Mandavia: Besides the oxygen, what other areas do you have constraints on? What else should physicians anticipate?
Dr. Storti: We were the first ICU in Italy to have the first coronavirus diagnosis, whom we call Patient One. Of course, we know now that the virus was already circulating here in Italy for sure 15 days before. And this is important because [since the day of the first diagnosis], we received a number of patients where we had to use 15 liters [of oxygen] per minute. When you have 80-100 patients, you have to apply 15 liters per minute, your oxygen delivery in your pipelines are not sufficient. So we were forced also to rebuild the different oxygen sockets inside the hospital and to empower our oxygen pipelines in order not to have a crash in our oxygen system.

So my message is, if you are in the middle of an outbreak or where the virus is spreading actively, you have to be prepared to reshape your hospital, and to use techniques that are following the pace that this virus has imposed on your hospital. Don’t try to cope with what you are accustomed to doing, such as a CT scan for every patient, immediate ICU recovery, prone supine strategy from the very beginning. You can't cope because you have not enough nurses to supine 18 patients at the same time. So it's a sort of different triage.

And let me say that this kind of triage, which is absolutely not common for Italy, is something that is not easy to do. It has not been so easy to convince people that we were in a sort of war scenario, and the only solution was to completely change our way of treating patients. Now we have teams that weren't present until a few weeks ago because we now have different patients in different locations in our hospital with different needs, and a disproportion between those needs and our ability to catch them.

Dr. Mandavia: How do you protect your staff?
Dr. Storti: This is absolutely a crucial issue. Luckily, we had enough PPE (personal protective equipment) to wear. We immediately briefed people how to wear it and protection strategies. We still had physicians and nurses [who tested positive for COVID-19]. However, I do believe that the larger portion of them were infected when our patient one hadn’t been identified yet.

Dr. Mandavia: What is the role of your lung ultrasounds? Anything unique to COVID-19?
Dr. Storti: Our hospital has a high competence in ultrasound because we did a very extensive job in training people in the last ten years. Every single floor of this hospital has an ultrasound machine, or more than one, and all the physicians—pediatricians, neurologists, surgeons, intensivists, whoever is working here—are able to perform point-of-care ultrasound. Because we were so confident with point-of-care ultrasound, we decide to use it at the very beginning: the triage, to assess coronavirus lung involvement and decide where to bring the patient. Sometimes we received young people with only lung involvement, ranging from pneumonitis to ARDS. We also see elderly [patients] with other pathologies or comorbidities. Ultrasound is very useful to better assess the patient in the ED.

Around this area, under this “tsunami of patients,” many other hospitals were overwhelmed and sort of collapsed just because they were referring patients to a CT scan, waiting for a CT scan report, and waiting for the scanner to be available for the next examination. That made EDs very slow in addressing a large number of patients. Bringing ultrasound into the middle of the decision tree has been really, really effective.

Again, for us, it was a blood gas analysis, chest X-ray and lung ultrasound. The chest X-ray is very important: When it is very white, it's a clear positive result [for COVID-19]. When it seems to be negative, ultrasound has a huge capacity to better discriminate if lung involvement is present and to perfectly match the findings with the clinical approach to determine if the patient needs to go the stepdown unit or ICU. This has also been a huge solution to decide which patient we could discharge.

Dr. Mandavia: Any other advice to physicians?
Dr. Storti: The real answer is to be flexible, reinvent your daily practice and use whatever tools you have. Because you’ll have disproportion between ICU beds, ventilators, nurses, physicians, and the number of patients, you have to keep patients alive until you are able to give them the right standard of care (ICU, stepdown unit, normal ward). For example, we use CPAP and non-invasive mask ventilation extensively. You have to properly balance patients’ needs, priorities and try to free ICU beds, and then bring up the other ones who are waiting in the emergency department or in the stepdown unit. Otherwise, if you are too rigid in your protocols, you can't cope. Because we were first, unfortunately, we had to reinvent things without stopping hospital functionality. We managed to do that, but it's not simple. So whoever has one week ahead, think and forecast your needs. This is a very, very precious time.