How coronavirus is affecting trauma systems in Italy

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Italy is the first Western nation to experience the full impact of coronavirus disease. The pandemic is stretching the country’s ability to care for older adults and patients with serious underlying medical conditions. But how is COVID-19 affecting systems of care for trauma patients?

To find out, I asked trauma professionals in Italy how the pandemic is impacting injury care. While healthcare providers across the country are working at full capacity, I was grateful to receive responses from three trauma specialists in Central Italy who are experiencing the impact of coronavirus. They described a broad range of consequences for trauma systems, trauma protocols and trauma teams.

Lower trauma volume, higher injury severity

All three trauma professionals report that COVID-19 quarantines have reduced the volume of trauma patients throughout the system.

The trauma program at Ospedali Riuniti in Ancona treats nearly 1,200 major trauma patients per year. But according to trauma medical director Dr. Mario Giusti, the volume of injured patients has fallen by half in recent weeks.

“The most evident effect is a significant decrease in the number of trauma cases,” Dr. Giusti said. “Compared to the same period last year, we are estimating a 50% reduction in hospitalized patients. This corresponds to an overall reduction in emergencies, especially the lower codes.”

Claudio Torbinio, trauma program coordinator and data analyst, said the recent fall-off is directly related to local quarantines and self-isolation.

“Our major traumas are typically caused by car crashes and work accidents,” Torbinio said. “Now, people cannot move, they cannot go to work, they aren’t playing sports — so we are seeing much fewer injured patients in the hospital. It’s a paradox, but as a trauma program we are working less now.”

“I must say, however, that injured patients who come to our hospital are worse now,” Torbinio said. “Previously, we received a lot of situational major trauma [trauma patients without compromised vital signs], but now these patients are very few. Now, the major trauma patients coming to the hospital are all clinical major trauma. This is probably due to the overtriage done in the last few years.”

Trauma staffing and resource challenges

A wide range of healthcare specialists in Italy have been recruited to care for COVID-19 patients. Trauma professionals are no exception.

“Many of the staff in our hospital have been reassigned to the coronavirus emergency,” Torbinio said. “Our trauma teams are also contributing to this effort.”

With trauma professionals diverted to the coronavirus response, trauma leaders are taking unique steps to ensure staffing.

“In this situation, the problem of human resources is a most delicate one,” Dr. Giusti said. “To make sure we have trauma teams available, we are increasing the use of very young doctors and nurses. This certainly entails a reduction in performance, but it is acceptable for now since this is an extraordinary situation.”

In addition, COVID-19 has impacted the availability of air transport for trauma patients. “Now we are treating all major trauma patients as potentially infected by coronavirus,” Torbinio said. “As a result, our helicopter needs to spend a lot of time in sanitization.”

Testing patients and trauma team members

All trauma patients at Ospedali Riuniti are being carefully monitored for body temperature. Some patients who were apparently healthy at the time of injury were later found to be infected with COVID-19.

“Based on these experiences, it would probably be useful to make early temperature measurement common within the primary survey,” Dr. Giusti said.

In addition, Torbinio emphasizes the importance of communicating with family members. “If any relatives of the trauma victim are available, it is very important to ask them if the patient had any symptoms of infection before the injury,” he said. “It may be the only way to get this information, because in an emergency there may be little time to assess for infection risk.”

When a trauma patient does have an elevated temperature, the team tests the patient for COVID-19.

“So far, we have had three major trauma patients who were COVID-positive,” Torbinio said. He added that all three of these patients had poor respiratory performance, with SO2 less than 90%.

“In addition, when a patient tests positive, the entire trauma team is then tested for the virus,” Torbinio said. “At this moment, we have two doctors and two nurses who are COVID-positive but without symptoms.”

As of the third week of March, all four healthcare professionals are still involved in patient care.

“They are still at work because we have a shortage of personnel,” Torbinio said. “The outbreak here in Ancona is relatively mild in comparison to regions like Lombardia and Veneto and Emilia-Romagna, but we have a staff shortage anyway.”

Separate streams for trauma and COVID-19 patients

Trauma professionals in Italy emphasize the need for extra precaution. “Our care protocols have not changed in our approach to patients,” Dr. Giusti said. “The most important thing right now is the need to use specific PPE to reduce the risk of contagion with all patients.”

A major priority is keeping trauma patients separate from patients infected with COVID-19.

“Obviously, the trauma path must be separate from that of infected patients in the hospital,” Dr. Giusti said. “But this is only accomplished with great effort and it calls for onerous logistical adjustments.”

According to Torbinio, the team has created separate pathways in several key units:

  • Operating rooms: 4 ORs are operational for emergencies, with 1 OR reserved for infected patients
  • Computed tomography: 1 CT suite has been designated for infected patients, and 1 CT suite has been designated for non-infected patients
  • Interventional radiology: The hospital has only 1 IR suite, so this unit is disinfected after every procedure

In addition, the hospital has created separate ICU areas for infected patients (who require pronation) and non-infected patients. Torbinio noted that 14 ORs were closed and converted to intensive care beds.

“All this was done in one week, and we now we have about 40 beds available in intensive care for infected patients and 10 beds for non-infected patients,” Torbinio said.

Disaster protocols and extra field precautions

According to Daniele Manno, an EMT paramedic in Teramo, the surge of COVID-19 patients has forced hospitals to adopt concepts from Major Incident Medical Management and Support (MIMMS).

“Most of those affected by COVID are elderly people and, as you can imagine, it took very little to saturate the ICUs,” Manno said. “After a few days, our professionals were driven to apply the same protocols that are used in MIMMS, changing/inverting the triage sequence and supporting those who have higher life expectancy.”

Manno specializes in remote, tactical and prehospital trauma, and he is certified in Tactical Combat Casualty Care (TCCC). He said that prehospital trauma providers have adopted several special protocols to guard against virus spread:

  • Team leaders are now instructed to stop 1 meter from trauma victims and first verify the absence of fever or respiratory problems.
  • If fever or symptoms exist, the team leader approaches the victim alone wearing an FFP3 mask (recommended) or an FFP2 mask (acceptable) and two pairs of gloves.
  • If evaluation shows that the patient is not critically ill, the team leader calls the Operation Center and requests instructions.
  • If the patient is critically ill, the team leader uses the minimum number of rescuers to provide care to the patient, with all rescuers appropriately masked and gloved.

In addition, Manno reported that the Italian Resuscitation Council has changed its recommended protocols for prehospital CPR.

  • Rescuers are now instructed to assess respiration visually (without getting too close to the patient’s face) and to assess level of consciousness by shaking the patient’s lower body
  • If infection is suspected and the patient is unconscious and breathless, rescuers are instructed to begin chest compressions only with no ventilation.
  • However, for children with suspected or confirmed contamination, rescuers are still instructed to perform complete CPR with compressions and ventilations.

“Ventilating the kid is risky for the rescuer, but it is also risky for the kid if the rescuer is infected but asymptomatic,” Manno said. “However, the risk of death for the kid is considered higher without ventilation because cardiac arrest in children is usually a consequence of a respiratory problem.”

Aside from any protocol changes, Manno emphasizes the importance of personal protection. “Everyone involved in prehospital trauma care — both professionals and volunteers — may act the very same way they always have IF they use adequate PPE and body substance isolation.”

Again, the positive news is that quarantine is reducing the incidence of injury.

“The good fact is that almost all our population is staying at home, and therefore there are much fewer emergency trauma calls,” Manno said.

“Appiattire la curva”

Like all healthcare providers, trauma professionals in Italy are focused on slowing the spread of COVID-19 so that all patients can receive optimal care.

“We are trying to flatten the curve of this pandemic as much as possible, because it is really important not to overload the capacity of our healthcare system,” Torbinio said. “Otherwise, you may need to choose who lives and who dies, and that’s a tough way to work.”

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