Opinion Critical Care Utilization for the COVID-19 Outbreak VIEWPOINT in Lombardy, Italy Early Experience and Forecast During an Emergency Response Giacomo Grasselli, MD On February 20, 2020, apatientinhis30sadmitted it would not have been feasible to allocate all critically Department of to the intensive care unit (ICU) in Codogno Hospital ill patients to a single COVID-19 ICU. The decision was to Pathophysiology and (Lodi, Lombardy, Italy) tested positive for a new coro- cohort patients in 15 first-responder hub hospitals, cho- Transplantation, navirus, severe acute respiratory syndrome coronavi- sen because they either had expertise in infectious dis- University of Milan, Italy; and Dipartimento rus 2 (SARS-CoV-2), the virus that causes coronavirus ease or were part of the Venous-Venous ECMO Respi- di Anestesia, disease 2019 (COVID-19). He had a history of atypical ratory Failure Network (RESPIRA).3 Rianimazione ed pneumonia that was not responding to treatment, but The identified hospitals were requested to do the Emergenza-Urgenza, 1 Fondazione IRCCS Ca’ he was not considered at risk for COVID-19 infection. following. Granda Ospedale The positive result was immediately reported to the 1. CreatecohortICUsforCOVID-19patients(areassepa- Maggiore Policlinico, Lombardy health care system and governmental rated from the rest of the ICU beds to minimize risk Milan, Italy. offices. During the next 24 hours, the number of of in-hospital transmission). reported positive cases increased to 36. This situation 2. Organize a triage area where patients could receive Antonio Pesenti, MD Department of was considered a serious development for several rea- mechanical ventilation if necessary in every hospital Pathophysiology and sons: the patient (“patient 1”) was healthy and young; in to support critically ill patients with suspected Transplantation, less than 24 hours, 36 additional cases were identified, COVID-19 infection, pending the final result of diag- University of Milan, without links to patient 1 or previously identified posi- nostic tests. Italy; and Dipartimento di Anestesia, tive cases already in the country; it was not possible to 3. Establishlocalprotocolsfortriageofpatientswithre- Rianimazione ed identify with certainty the source of transmission to spiratory symptoms, to test them rapidly, and, de- Emergenza-Urgenza, patient 1 at the time; and, because patient 1 was in the pending on the diagnosis, to allocate them to the ap- Fondazione IRCCS Ca’ Granda Ospedale ICU and there were already 36 cases by day 2, chances propriate cohort. Maggiore Policlinico, were that a cluster of unknown magnitude was present 4. Ensure that adequate personal protective equip- Milan, Italy. and additional spread was likely. ment (PPE) for health personnel is available, with the OnFebruary21,anemergencytaskforcewasformed organization of adequate supply and distribution Maurizio Cecconi, MD bytheGovernmentofLombardyandlocalhealthauthori- along with adequate training of all personnel at risk Dipartimento Anestesia e Terapie Intensive, ties to lead the response to the outbreak. This Viewpoint of contagion. Humanitas Rozzano, provides a summary of the response of the COVID-19 5. Report every positive or suspected critically ill Milan, Italy. Lombardy ICU network and a forecast of estimated COVID-19 patient to the regional coordinating center. ICU demand over the coming weeks (projected to In addition, to quickly make available ICU beds March 20, 2020). and available personnel, nonurgent procedures were canceled and another 200 ICU beds were made avail- Supplemental Setting the Priorities and the Initial Response able and staffed in the following 10 days. In total, over content In Lombardy, the precrisis total ICU capacity was ap- the first 18 days, the network created 482 ICU beds proximately 720 beds (2.9% of total hospital beds at a ready for patients. total of 74 hospitals); these ICUs usually have 85% to 90% occupancy during the winter months. Containment Measures The mission of the COVID-19 Lombardy ICU Net- Local health authorities established strong containment work was to coordinate the critical care response to the measures in the initial cluster by quarantine of several outbreak. Two top priorities were identified: increasing townsinanattempttoslowvirustransmission.Inthesec- surge ICU capacity and implementing measures for ond week, other clusters emerged. During this time, the containment. ICU network advised the government to put in place ev- ery measure, such as reinforcing public health measures Increasing ICU Surge Capacity of quarantine and self-isolation, to contain the virus. The recognition that this outbreak likely occurred via Corresponding community spread suggested that a large number of ICU Admissions Over the First 2 Weeks Author: Antonio COVID-19–positive patients were already present in the There was an immediate sharp increase in ICU admis- Pesenti, MD, region. This prediction proved correct in the following sions from day 1 to day 14. The increase was steady and Fondazione IRCCS Ca’ Granda Ospedale days. Based on the assumption that secondary trans- consistent. Publicly available data indicate that ICU ad- Maggiore Policlinico, mission was already occurring, and even with contain- missions (n = 556) represented 16% of all patients Università degli studi di ment measures that health authorities were establish- (n = 3420)whotestedpositiveforCOVID-19.AsofMarch Milano, Via F. Sforza 35, ing, it was assumed that many new cases of COVID-19 7, the current total number of patients with COVID-19 20122 Milan, Italy (antonio.pesenti@ would occur, possibly in the hundreds or thousands of occupying an ICU bed (n = 359) represents 16% of cur- unimi.it). individuals. Thus, assuming a 5% ICU admission rate,2 rently hospitalized patients with COVID-19 (n = 2217). jama.com (Reprinted) JAMA Published online March 13, 2020 E1 © 2020 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by Livio Carnevale on 03/14/2020 Opinion Viewpoint All patients who appeared to have severe illness were admitted for higher than what was reported from China, where only 5% of pa- hypoxic respiratory failure to the COVID-19 dedicated ICUs. tients who tested positive for COVID-19 required ICU admission.2,4 There could be different explanations. It is possible that criteria for Surge ICU Capacity ICU admission were different between the countries, but this seems Within 48 hours, ICU cohorts were formed in 15 hub hospitals to- unlikely. Another explanation is that the Italian population is differ- taling 130 COVID-19 ICU beds. By March 7,the total number of dedi- ent from the Chinese population, with predisposing factors such as cated cohorted COVID-19 ICU beds was 482 (about 60% of the total race, age, and comorbidities.5 preoutbreak ICU bed capacity), distributed among 55 hospitals. As On March 8 and 9, planning for the next response, which in- of March 8, critically ill patients (initially COVID-19–negative pa- cludes defining a new hub and spoke system for time-dependent pa- tients) have been transferred to receptive ICUs outside the region thology,increasingICUcapacityfurther,andreinforcingstrongercon- via a national coordinating emergency office. tainment measurement in the community, has begun, as well as discussions of what could have been done differently. Forecasting ICU Demand Over the Next 2 Weeks First, laboratory capacity to test for SARS-CoV-2 should have been During the first 3 days of the outbreak, starting from February 22, increased immediately.Laboratory capacity reached saturation very the ICU admissions were 11, 15, and 20 in the COVID-19 Lombardy early.Thiscanaddextrastresstoasystemandaffecttheabilitytomake ICU Network. ICU admissions have increased continuously and accurate diagnoses and allocate patients appropriately. exponentially over the first 2 weeks. Based on data to March 7, Second, in parallel to the surge ICU capacity response, a large, when 556 COVID-19–positive ICU patients had been admitted to dedicated COVID-19 facility could have been converted more quickly. hospitals over the previous 15 days, linear and exponential mod- On day 1 of the crisis, it was not possible to predict the speed and els were created to estimate further ICU demand (eFigure in the extent of the contagion. Importantly, the forecasts show that in- Supplement). creasing ICU capacity is simply not enough. More resources should The linear model forecasts that approximately 869 ICU admis- be invested to contain the epidemic. sionscouldoccurbyMarch20,2020,whereastheexponentialmodel As of March 8, Lombardy was quarantined and strict self- growth projects that approximately 14 542 ICU admissions could oc- isolation measures were instituted. This may be the only possible cur by then. Even though these projections are hypothetical and in- waytocontainthespreadofinfectionandallowresourcestobede- volve various assumptions, any substantial increase in the number veloped for the time-dependent disease. of critically ill patients would rapidly exceed total ICU capacity,with- As of March 10, Italy has been quarantined and the govern- out even considering other critical admissions, such as for trauma, ment has instituted stronger containment measures, including strict stroke, and other emergencies. self-isolation measures. These containment measures and indi- In practice, the health care system cannot sustain an uncon- vidual citizen responsibility could slow down virus transmission. trolled outbreak, and stronger containment