LAUSR

During the night of 20–21 February 2020, the first case of domestic SARS–CoV-2 (severe acute respiratory syndrome coronavirus 2) was diagnosed in Northern Italy, in the Lombardy region. Later, the coronavirus outbreak spread throughout the entire region [1]. Hospitals involved in the epidemic needed to change their internal organization and “modus operandi” in order to accommodate the growing number of affected patients. We would like to report and share our experience, which involved the Emergency and the Internal Medicine Departments, particularly addressing the setting of medium-intensity care wards for hospitalized Covid patients. Luigi Sacco Hospital is a medium sized (600 beds), University-Affiliated Hospital in northwest Milan. It handles almost all the main medical/surgical specialties (except for Neurosurgery), but due to the presence of a huge Infectious Diseases Department it has always been a specialty-referral center for northern Italy. For this reason, other hospitals referred the first diagnosed Covid-19 patients to our Infectious Diseases and Intensive Care Unit (ICU), as they were adequately prepared for bio-emergencies. This allowed other sectors of the hospital time to organize in case of an epidemic increase, which unfortunately occurred. The number of infected patients needing hospitalization grew rapidly. On 11 March 2020, close collaboration between the Emergency and the Internal Medicine Departments began. The Emergency Department staff set-up repeated 3-h training sessions on the use of continuous Positive Airway Pressure (CPAP) helmets [2], while the Department of Infectious Diseases provided multiple daily training sessions regarding the correct use of Personal Protective Equipment (PPE) [3]. Moreover, since all Internal and Emergency Medicine specialists and residents had already been adequately trained in bedside chest ultrasound, a standardized reporting protocol was shared, in order to monitor lung disease efficaciously. We decided to create a shared staff, including consultants and residents from the Internal Medicine and the Emergency Departments, in order to facilitate the transfer of different skills between them (to allow for role flexibility in case of staff shortage) and to learn as much as possible from this rare situation. Internists completely changed their shift habits, from a model of care where they usually looked after patients from admission to discharge, to an intensive care model which assured 24 h intensive patients’ surveillance over three major shifts. In the medical area, on 11 March, a 30-bed medium-intensity Care Unit was opened for COVID patients. The Pneumology ward was transformed into a 20-bed sub-intensive unit for the most critical patients. After a few days, since the epidemic spread continued growing, another 30-bed Unit was opened. The Internal Medicine and Emergency medicine staff was further implemented by Rheumatologists, Cardiac Surgeons, Cardiologists, and multidisciplinary teams for each shift were set. Patients were admitted to our wards either from other hospitals—in particular from Bergamo, Brescia, and east-Milano districts, the most impacted area in the Italian Covid-19 epidemicand from our ED. Illness severity ranged from the need for oxygen support to CPAP support. Later, on 20 March, a 30-bed low-intensity care unit was opened for recovering patients with low oxygen needs or already weaned. They were transferred from the other hospital wards in order to guarantee increased bed availability for acute patients. Colleagues from the surgical area (general surgeons, orthopedists, * Elisa Ceriani [email protected]