Use of critical care resources during the first 2 weeks (February 24-March 8, 2020) of the Covid-19 outbreak in Italy.

BACKGROUND: A Covid-19 outbreak developed in Lombardy, Veneto and Emilia-Romagna (Italy) at the end of February 2020. Fear of an imminent saturation of available ICU beds generated the notion that rationing of intensive care resources could have been necessary. RESULTS: In order to evaluate the impact of Covid-19 on the ICU capacity to manage critically ill patients, we performed a retrospective analysis of the first 2 weeks of the outbreak (February 24-March 8). Data were collected from regional registries and from a case report form sent to participating sites. ICU beds increased from 1545 to 1989 (28.7%), and patients receiving respiratory support outside the ICU increased from 4 (0.6%) to 260 (37.0%). Patients receiving respiratory support outside the ICU were significantly older [65 vs. 77 years], had more cerebrovascular (5.8 vs. 13.1%) and renal (5.3 vs. 10.0%) comorbidities and less obesity (31.4 vs. 15.5%) than patients admitted to the ICU. PaO2/FiO2 ratio, respiratory rate and arterial pH were higher [165 vs. 244; 20 vs. 24 breath/min; 7.40 vs. 7.46] and PaCO2 and base excess were lower [34 vs. 42 mmHg; 0.60 vs. 1.30] in patients receiving respiratory support outside the ICU than in patients admitted to the ICU, respectively. CONCLUSIONS: Increase in ICU beds and use of out-of-ICU respiratory support allowed effective management of the first 14 days of the Covid-19 outbreak, avoiding resource rationing.

University of Modena Experience With Liver Grafts From Donation After Circulatory Death: What Really Matters in Organ Selection?

INTRODUCTION: The use of grafts from donation after circulatory death (DCD) is an important additional source to implement within the donor pool. We herein report the outcomes of our early experience with DCD grafts for liver transplantation (LT). METHODS: Ten patients successfully underwent LT with grafts from DCD donors between August 2017 and January 2019 at the Hepato-Pancreato-Biliary Surgery and Liver Transplant Unit of University of Modena and Reggio Emilia. All donors underwent normothermic regional perfusion after death declaration and, after the procurement, all the suitable grafts underwent ex situ hypothermic perfusion prior to transplantation. RESULTS: Mean postoperative hospital stay after transplant was 12.7 days (range, 5-26), and in 5 cases we placed a biliary drainage (Kehr tube) during surgery. Primary graft nonfunction did not occur after LT in this cohort, although, we registered one case of biliary anastomosis stricture that was managed endoscopically by endoscopic retrograde cholangiopancreatography. All patients are alive and none required retransplantation. CONCLUSIONS: In our experience with controlled DCD donors, the demonstration of: (1) a negative trend of lactate during normothermic regional perfusion; (2) an aspartate aminotransferase and alanine aminotransferase level lower than 2000 mU/dL; and (3) less than 1 hour of functional warm ischemia time along with no signs of microscopic or macroscopic ischemia of the grafts, are related to positive outcomes in the first year after transplant. A DCD risk score based on Italian population characteristics and regulations on death observation may improve donor-recipient match and avoid futile transplants.

The PIRP project (Prevenzione Insufficienza Renale Progressiva): how to integrate hospital and community maintenance treatment for chronic kidney disease.

Chronic kidney disease (CKD) represents a global health burden with great economic impact on healthcare and therefore it requires appropriate interventions by Health Care Systems. The PIRP (Prevenzione Insufficienza Renale Progressiva) project is endorsed and funded by the Emilia-Romagna Regional Health Board and involves all the Nephrology Units of the Emilia-Romagna Region (Italy). The project has a predominantly clinical purpose and is expected to bring about a continuous quality improvement in the treatment of patients with CKD. Its aims are to intercept patients in an early phase of CKD, to delay their illness progression and to prevent cardiovascular complications. An integrated care pathway involving nephrologists, general practitioners (GPs) and other specialists has been created to identify patients to whom ambulatory care targeted on effective, efficient pharmaceutical and dietary treatment as well as on lifestyle modifications is subsequently provided. With the cooperation of GPs, in its 13 years of activity the project identified and followed up more than 25,000 CKD patients, who attended the Nephrology units with more than 100,000 visits. The effects of a closer and joint monitoring of CKD patients by GPs and nephrologists can be quantified by the reduction of the mean annual GFR decline (average annual CKD-EPI change: - 0.34 ml/min), and by the decrease in the overall incidence of patients who annually started dialysis in the Emilia-Romagna Region, that dropped from 218.6 (× million) in 2006 to 197.5 (× million) in 2016, corresponding to about 100 cases.

[Challenges and results of the PIRP project (Prevenzione della Insufficienza Renale Progressiva) of the Emilia-Romagna Region].

The PIRP project was conceived in 2004; with the aim to face the increased prevalence of chronic kidney disease (CKD) associated with the aging and increased survival of the population. The first phase of the project consisted of training primary care physicians to identify people at risk of CKD and to implement intervention strategies that proved to be effective in preventing CKD it or delaying its progression once it is established. In the second phase of the project, dedicated ambulatories were opened in the nephrology units of Emilia-Romagna hospitals to provide an in-depth assessment and personalized care to CKD patients, following them up until renal failure or death or referring them back to general practitioners, according to the study protocol. A web-based registry was implemented to collect demographic and clinical data on PIRP patients. As of 30 June 2018, the registry included 26.211 CKD patients, with a median follow-up of 24.5 months. Over the 14 years of the PIRP the mean age of incident patients increased from 71.0 years to 74.2 years and the mean eGFR increased from 30.56 to 36.52 mL/min/1.73 m ², proving that the project was successful in recruiting older patients with a better renal function. At 5 years, the percentage of patients still active in the project was =45%.The implementation of the project has seen a reduction in the number of patients arriving every year to the dialysis treatment in E-R (about 100 units less from 2006 to 2016). The PIRP cohort is the largest in Italy and in Europe, which makes it ideal for research based on international comparisons and as a model for national registries.

Effect of cardiologist care on 6-month outcomes in patients discharged with heart failure: results from an observational study based on administrative data.

OBJECTIVES: To evaluate the effect of cardiologist care on adherence to evidence-based secondary prevention medications, mortality and readmission within 6 months of discharge in patients with heart failure (HF). DESIGN: Retrospective observational study based on administrative data. SETTING: Local Healthcare Authority (LHA) of Bologna, one of the largest LHAs of Italy with ~870 000 inhabitants. PARTICIPANTS: All patients residing in the LHA of Bologna discharged from hospital with a diagnosis of HF between 1 January 2015 and 31 December 2015. PRIMARY AND SECONDARY OUTCOME MEASURES: Multivariable regression analysis was used to assess the association of inpatient and outpatient cardiologist care with adherence to evidence-based medications, all-cause mortality and hospital readmission (including emergency room visits) within 6 months of discharge. RESULTS: The study population included 2650 patients (mean age 82.3 years). 340 (12.8%) patients were discharged from cardiology wards, while 635 (24.0%) were seen by a cardiologist during follow-up. Inpatient and outpatient cardiologist care was associated with an increased likelihood of adherence to ACE inhibitors/angiotensin receptor blockers (ACEIs/ARBs), ß-blockers and aldosterone antagonists after discharge. The risk of mortality was significantly lower among patients adherent to ACEIs/ARBs and/or ß-blockers (-53% and -28%, respectively); the risk of hospital readmission was significantly lower among patients adherent to ACEIs/ARBs (-28%). CONCLUSIONS: Compared with non-specialist care, cardiologist care improves patient adherence to evidence-based medications and might thus favourably affect mortality and readmission following HF.

[OssERvare Project: direct observation of use of the Safety Surgery CheckList in the operating room.] / Progetto OssERvare: osservazione diretta dell'uso della Safety Surgery Checklist in sala operatoria.

INTRODUCTION: Safety Surgery CheckList (SSCL) is a support tool for operating teams, used to carry out safety checks while also encouraging compliance with the implementation of recommended quality and safety standards. In Emilia-Romagna it was deemed appropriate to check actual surgical team compliance with correct checklist application in the operating theatre, through a project called "OssERvare". METHODS: Direct observation was identified as the preferred inspection method. With the use of special report sheets, observers proceeded with the guided observation of behaviour in the operating room, recording any inconsistencies with correct SSCL use methods. The project began in January 2017 and all observations were carried out from 1st January-15th April 2017. RESULTS: In 43% of observed operation sign in, all three team members were not present, whereas in 7% of observed cases, sign out was not carried out. All three team members were present in 88% of observed operation time out. There are two evidently critical phases: sign in and sign out. Results obtained for time out were better. DISCUSSION AND CONCLUSION: Compliance data collected from observations differed markedly from reported compliance in administrative flow records. The results of the observational study indicate that the SSCL is not properly filled in many times; there is also a great possibility to improve the correct use of this tool. In conclusion, we think that the combined approach of use of administrative data and assessing compliance appeared to be a useful instrument to investigate the implementation and to promote the real utilization of safety tools such as the SSCL.

Heat wave in Italy and hyperthermia syndrome.

In the city of Modena, Italy, daily temperatures registered during the year 2003 showed a higher mean increase of 3 degrees C compared with the previous three years, with average temperature of 26.1 degrees C, compared with 22.8 degrees C. The reported ambient temperature was higher than 32.3 degrees C in 84% of the recorded days, and daily values exceeded 35.1 degrees C in 62% of the days. During the summer, four heat waves occurred (June 11-15, July 21-23, August 3-15 and August 17-24). Nine patients affected by hyperthermia syndrome with a mean body temperature of 41.4 +/- 1.3 degrees C were admitted to the Intensive Care Unit (ICU) of the Modena Teaching Hospital. Another patient with similar clinical features was not admitted to ICU, but to a general ward, and eventually died a few hours later. Mortality reached 80% and the mean survival time was 4.2 days with median values of one day. All patients except for one were admitted during one of the four above-mentioned heat waves, and in particular, 7 patients were admitted during the period from August 3rd to 15th. A common feature among 8 of the 10 patients was the chronic consumption of psychoactive drugs. According to these observations, it is important to identify a population at risk in case of bioclimatological alarm, to find prevention strategies. It is extremely important in patients with hyperthermia to lower body temperature levels in the early hours to influence the malignant evolution of this severe pathologic process.