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Three Months of COVID-19 in a Pediatric Setting in the Center of Milan

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Three Months of COVID-19 in a Pediatric Setting in the Center of Milan www.nature.com/pr INSIGHTS Three months of COVID-19 in a pediatric setting in the center of Milan Carlo Agostoni1,2, Giuseppe Bertolozzi1, Barbara Cantoni1,3, Carla Colombo1,2, Giovanni Montini1,2 and Paola Marchisio1,2 The second epicenter of the global COVID-19 epidemic following Wuhan, and the first in the Western world, occurred unexpectedly in the Lombardy region of Italy, whose capital city is Milan. The aggressive nature of the outbreak in the region was dramatic, leading to a 2-month period of lockdown. Within the Policlinico, the historic hospital in the center of Milan, many units were rapidly converted into intensive care units or semi-intensive units for adult patients. During lockdown, the pediatric inpatient units had to face daily reorganization caused by the necessary logistic and structural transformations, thus restricting routine care pathways for chronic patients, while the Pediatric Emergency Unit had to develop a system able to effectively separate the children and caregivers infected with COVID-19 from those who were not affected. These 2 months enhanced resilience among both doctors and nurses, and facilitated the transversal transmission of data aimed at helping colleagues and patients in any way possible, in spite of the restrictive measures limiting the rate of activity in pediatric care. The reorganization of the current phase of decreasing epidemic activity still leaves us with unanswered questions regarding the further possible changes to implement in the event of a potential reoccurrence of epidemic peaks. Pediatric Research (2021) 89:1572–1577; https://doi.org/10.1038/s41390-020-01108-8 1234567890();,: INTRODUCTION: FOCUS ON THE CONTEXT cold and deserted during those days. Figure 1 contains a series of At the end of February 2020, the COVID-19 pandemic took firm photos taken at 3 p.m. on March 30, which show a deserted hold in the north of Italy, and from there it seemed that the Duomo Square in Milan’s Old Town and empty streets in the ongoing global spread of the virus spiralled out of control. Among famous Brera Fashion District. the eight regions of Northern Italy, Lombardy (10 million In our hospital, IRCCS Policlinico, the oldest and largest hospital inhabitants) currently has the highest number of COVID diagnoses, in the center of Milan, and one of the of the most important in the accounting for one in three of all nationwide infections and one in region, the pediatric building (The De Marchi Clinic) was literally two deaths. With ~16,000 deaths recorded by the end of May, the surrounded by adult units, which were being rapidly converted Lombardy region ranked sixth among the countries of the world for into either intensive care units (ICUs) for critical patients or clinical COVID-19-related deaths, yet in spite of this period of under- units for the less severe cases, all COVID-19 positive. Fortunately standably negative growth rates (website www.truenumbers.it for us, the core of the clinical emergency did not involve children, updated May 26), it is still responsible for >20% of the Italian even those who were theoretically more at risk, such as, for gross domestic product. Milan is the capital city of Lombardy and instance, primary and secondary immunosuppressed patients the largest in terms of population density, and it is widely (kidney transplant recipients, rheumatological cases, primary recognized as the economic center of Italy. Although Milan was immunodeficiencies, autoimmune liver disorders, and some initially indirectly affected by the pandemic, as the most affected inborn errors of metabolism) or especially fragile groups of towns were situated to the south and east of the city (the Italian patients, such as those with cystic fibrosis (CF). At the same time, patient zero was from Codogno, to the south, while Bergamo and our good friend Lorenzo D’Antiga, Director of the Pediatric Unit at Brescia lie to the east), this soon changed for the worse. the Giovanni XXIII Hospital in Bergamo, one of the worst affected At the end of March, when I (C.A.) was first asked by the Editors cities, was asked to provide voluntary support to the COVID-19 of Pediatric Research to report on the COVID situation in Milan, we adult units due to the limitation of resources caused by this felt like the Israelites fleeing Egypt, crossing the Red Sea, with unprecedented, unexpected, and tragic situation.1 We hereby towering walls of seawater on either side of us, the Egyptian army report the changes in clinical activity, the unanswered questions, and the Pharaoh behind, and the Promised Land lying somewhere and the pragmatic solutions, as well as the changes in the didactic over the horizon, out of sight. What was unfolding and which and scientific activities, that the Directors of each individual direction it would take seemed to be in the hands of the Fates. Pediatric Unit in the Pediatric Area of the IRCCS Policlinico of Milan “Andrà tutto bene,”“Everything will be OK,” were the words of had to deal with. Of note, the few of us who contracted COVID-19 hope we could read on every corner of a deserted, locked-down went into mandatory quarantine, while those with milder forms Milan; and for what felt like an eternity, we lived in hope of finally continued to work since swab testing was compulsory only in the finding a Promised Land that nobody could envisage. Milan was case of ascertained fever. 1Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, De Marchi Clinic, 20122 Milan, Italy; 2University of Milan, 20122 Milan, Italy and 3Healthcare Professional Department, 20122 Milan, Italy Correspondence: Carlo Agostoni ([email protected]) Received: 20 July 2020 Accepted: 26 July 2020 Published online: 27 August 2020 © International Pediatric Research Foundation, Inc. 2020 Three months of COVID-19 in a pediatric setting in the center of Milan C Agostoni et al. 1573 Fig. 1 The empty center of Milan, March 30, 2020, 3 p.m. Panels (clockwise) represent the “Milano Brera fashion district” (1,2,3,4,5) and Duomo Square (6), respectively. 22,737 23,740 5212 942935 281 381 982 Total no. accesses Non-Italians Foreign address Extra-urban address Fig. 2 Number of accesses to the Pediatric Emergency Unit, IRCCS Policlinico, Milan, for the years 2018 (blue bar) and 2019 (red bar). PEDIATRIC EMERGENCY UNIT (PEU): THE MIXED AREA important, and a staff of nurses with advanced triage training The PEU of the hospital is considered to be a major referral center and long-standing experience was promptly established. for pediatric emergencies by the citizens of Milan, as illustrated in The potential overcrowding of the unit was avoided because of Fig. 2, which reports the total number of accesses recorded for the the significant decrease in admissions immediately following the years 2018 and 2019. The PEU has two exam rooms, a beginning of the lockdown phase. The mean number of cases resuscitation room for the initial stabilization of critically ill presenting daily at the PEU during lockdown was ~28% of those patients, and four beds for short-stay observation. At the onset presenting during the same period of the previous year (on average of the pandemic, the unit was subjected to some extremely 69 vs. 20 patients per day, between March 1 and May 4, in 2019 and stressful changes that were necessary for the real-time, mandatory 2020, respectively), with no significant difference seen in the planning of a system for the identification of two structurally well- distribution of patients according to gravity assessed at triage (Fig. 3). differentiated pathways for suspected and non-suspected cases, All patients accessing the PEU were interviewed upon arrival, respectively, with the aim of preventing any contact between using an anamnestic questionnaire drafted according to the most these two groups of patients and thus the possible spread of the recent data available in the literature (homemade, de facto). The infection. It must be said that during the days of mourning that main assessment criteria were: (1) recent travel to local epidemic followed, it became very difficult for all of us to separate areas, and (2) the presence of pyrexia (≥37.5 °C) and/or cough potentially infected patients from those for whom infection and/or shortness of breath. Following the legislative decree from seemed unlikely. Indeed, on the basis of the data available, two the Italian government dated March 3, and the World Health dedicated areas were initially identified. These were quickly Organization declaration of global pandemic issued 7 days later increased to four, due to the rising difficulty we experienced in on March 11, the area of residence became irrelevant in terms of separating suspected from non-suspected cases because of the the classification of patients, while triage assessment criteria were rapid spread of COVID-19, and the concept, although not expanded to include any contact the caregiver may have had with evidence-based, of a possible asymptomatic status in children. a suspected or proven case of COVID-19, together with flu-like Within this context, the triage process became increasingly symptoms in the caregiver. Pediatric Research (2021) 89:1572 – 1577 Three months of COVID-19 in a pediatric setting in the center of Milan C Agostoni et al. 1574 1% 1% 4536 10% 11% 20% 13% 1310 69% 75% 2019 2020 Fig. 3 Total number of accesses (blue bars) to the PEU for the period March 1 to May 4 for 2019 and 2020, according to priority codes at triage: white, green, yellow, and red, as percentages of total accesses. Table 1. Decision-making algorithm at PEU triage. First assessment of Emergency → Attribution of a Code Red based on vital signs or PAT → To be managed in Resuscitation Room • Treat patient and caregiver as if they were positive for COVID-19 • Use of DPI for every team member • Communicate unavailable Resuscitation Room to the Regional Coordinating Center • Complete decontamination after the patient has been treated post-op recovery areas.
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