Management of COVID micro-areas for asymtomatic or paucisymptomatic patients hospitalized in Azienda Ospedaliera Universitaria Pisana (AOUP, Italy)

To face the challenges posed by the coronavirus disease 2019 (COVID-19) pandemic, mainly treatment of affected patients as well as implementing safety measures for the protection of patients and personnel, hospitals had to adapt their operational workflows in the Azienda Ospedaliera Universitaria Pisana (AOUP), a 1,165 bed specialistic Italian teaching hospital the first pandemic wave (first half of 2020) (1) required a scaling down of the ordinary medical and surgical activities, to face the needs for treatment of COVID patients, as well as the activation of ad hoc units of low and intermediate care dedicated to these patients in the second and third pandemic waves (second half of 2020 and first half of 2021) to avoid hospital overcrowding (2). In the first phase of the emergency, dedicated COVID areas were established, including intensive care units (ICUs), operating rooms and medical wards.

Following the transition of the COVID epidemiology from pandemic to endemic (3), an increasing number of patients admitted to the hospital for reasons other than COVID, but positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) and either asymptomatic or paucisymptomatic was observed; considering the clinical requirements related to their diagnosis, admission to a dedicated COVID ward was no longer appropriate, furthermore transfer of these patients to a COVID ward would have resulted in an overcrowding of the latter.

In July 2022, the mean percentage of COVID positive patient in AOUP was 15%, but only 11% of them are symptomatic for the presence of pneumonia or respiratory failure and were admitted in hospital for these pathologies. All symptomatic patients were located in dedicated ICUs.

The aim of this letter is to describe the management of a new model of hospitalized positive patients without severe respiratory symptoms.

There are some criteria chosen by others hospitals for calculate the required percentage of COVID beds to their facilities, such as the number of nursing staff and the ward areas. Overall, each hospital may calculate a synthetic indicator (installed capacity index) assessing hospital capacity (4).

The Tuscany Directive Degree n. 581/2022 (5) describes the guidelines for the management of positive asymptomatic or paucisymptomatic COVID-19 cases. It directs every healthcare facility to define distinct care pathways of those patients, within the specialist ward, providing for the isolation of patients in single rooms, and compliance with care precautions even in the absence of airborne systems ensuring negative pressure (normal ventilation). Rooms occupied by SARS-CoV2 positive patients were required to be appropriately marked as such. Health care workers (HCWs) should receive additional training in the use of personal protective equipment (PPE) and designated location for donning and doffing of PPE by the HCWs were established (6).

The abovementioned Tuscany directive was implemented in AOUP by establishing a COVID dedicated micro-area in many wards, allowing thus to admit and treat patients positive for SARS-CoV2 but asymptomatic, for diagnoses other than COVID.

These micro-areas are small part of medical, surgical or ICU, functionally isolated to prevent further transmission of SARS-CoV2 to other patients and HCWs.

This setup allowed AOUP to set up a total of 273 COVID beds, organized in 8 micro-areas of medical setting (135 beds); 8 micro-areas of specialized clinical setting (84 beds); 3 micro-areas of ICUs (16 beds) and 2 micro-areas of surgical setting (38 beds) (Table 1). Overall, 273/1,165 (23.4%) of total beds number were dedicated to COVID patients.

This new organization requires any patient of one of these micro-areas developing new symptoms related to infection and respiratory or systemic involvement, to be transferred to COVID-19 specific areas (medical units or ICUs).

The safety of other patients in the same ward is guaranteed by routine monitoring, with nasopharyngeal swab at admission, every 7 days of stay and at the discharge. Positive patients are submitted to nasopharyngeal swab at the admission and every 4 days as described elsewhere (7,8).

The establishment of COVID micro-areas creates logistical and organizational challenges, in terms of adequate staffing, HCWs training and PPE supply to name a few.

Acknowledgments

We thank the whole team of the Azienda Ospedaliera Universitaria Pisana.

Funding: None.

Footnote

Provenance and Peer Review: This article was a standard submission to the journal. The article has undergone external peer review.

Peer Review File: Available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-22-82/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-22-82/coif). The authors have no conflicts of interest to declare.

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References

1. Baggiani A, Briani S, Luchini G, et al. Management of healthcare areas for the prevention of COVID-19 emergency in an Italian teaching hospital in Pisa, Tuscany: A hospital renovation plan. Infect Control Hosp Epidemiol 2020;41:1368-9. [Crossref] [PubMed]
2. Baggiani A, Luchini G, Cristofano M, et al. Management of hospital overcrowding during the second wave of COVID-19 pandemic in Pisa (Italy) before vaccination campaign: from medical stays to low and intermediate cares. 2022. Available online: https://arpi.unipi.it/handle/11568/1141087
3. Biancolella M, Colona VL, Mehrian-Shai R, et al. COVID-19 2022 update: transition of the pandemic to the endemic phase. Hum Genomics 2022;16:19. [Crossref] [PubMed]
4. Pereira CCA, Soares FRG, Machado CJ, et al. Development of an Index to Assess COVID-19 Hospital Care Installed Capacity in the 450 Brazilian Health Regions. Disaster Med Public Health Prep 2022; [Crossref]
5. Regione Toscana. Delibera n.581 del 23 maggio 2022. Linee di indirizzo per la gestione dei casi positivi da Covid-19 asintomatici o paucisintomatici. 2022. Available online: https://www.regione.toscana.it/
6. World Health Organization. Rational use of personal protective equipment for coronavirus disease (COVID-19) and considerations during severe shortages. 2020. Available online: https://www.who.int/publications/i/item/rational-use-of-personal-protective-equipment-for-coronavirus-disease-(covid-19)-and-considerations-during-severe-shortages
7. Hsu JY, Liu PY, Tseng CH, et al. COVID-19 Screening for Hospitalized Patients: The Role of Expanded Hospital Surveillance in a Low Prevalence Setting. J Multidiscip Healthc 2021;14:3027-34. [Crossref] [PubMed]
8. Ambretti S, Bassetti M, Clerici P, et al. Screening for carriage of carbapenem-resistant Enterobacteriaceae in settings of high endemicity: a position paper from an Italian working group on CRE infections. Antimicrob Resist Infect Control 2019;8:136. [Crossref] [PubMed]