Pressure ulcers after prone positioning in patients undergoing extracorporeal membrane oxygenation: A cross-sectional study.

BACKGROUND: The combination of prone positioning and extracorporeal membrane oxygenation (ECMO) in patients with acute respiratory distress syndrome (ARDS) is recognized as safe but its use has been limited due to potential complications. AIM: To report the prevalence of pressure ulcers and other complications due to prone positioning in adult patients receiving veno-venous ECMO. STUDY DESIGN: This cross-sectional study was conducted in a tertiary level intensive care unit (ICU) in Milan (Italy), between January 2015 and December 2019. The study population was critically ill adult patients undergoing veno-venous ECMO. Statistical association between pressure ulcers and the type of body positioning (prone versus supine) was explored fitting a logistic model. RESULTS: In the study period, 114 patients were treated with veno-venous ECMO and 62 (54.4%) patients were placed prone for a total of 130 prone position cycles. ECMO cannulation was performed via femoro-femoral configuration in the majority of patients (82.4%, 94/114). Pressure ulcers developed in 57.0% of patients (95%CI: 44.0%-72.6%), most often arising on the face and the chin (37.1%, 23/62), particularly in those placed prone. The main reason of prone positioning interruption was the decrease of ECMO blood flow (8.1%, 5/62). The fitted model showed no association between body position during ECMO and occurrence of pressure ulcers (OR 1.3, 95%CI: 0.5-3.6, p = .532). CONCLUSIONS: Facial pressure ulcers were the most frequent complications of prone positioning. Nurses should plan and implement evidence-based care to prevent such pressure injuries in patients undergoing ECMO. RELEVANCE TO CLINICAL PRACTICE: The combination of prone positioning and ECMO shows few life-threating complications. This manoeuvre during ECMO is feasible and safe when performed by experienced ICU staff.

The starting temperature of high-flow nasal cannula and perceived comfort in critically ill patients: A pragmatic randomized controlled trial.

BACKGROUND: High-flow nasal cannula (HFNC) therapy is a non-invasive respiratory treatment characterized by high tolerability, which largely derives from the patient's comfort. AIMS: The primary aim of this study was to explore whether the patient's perceived comfort was the same regardless of different approaches used to reach the target humidification temperature. The secondary aim was to assess the patient's perceived nasal dryness and humidity. STUDY DESIGN: This single-centre, pragmatic, randomized trial was registered at clinicaltrials.gov (NCT05688189). Patients in the intensive care unit (ICU) in need of HFNC therapy were randomly assigned to one of three study arms: a two-step increase (31 to 34 to 37°C), a one-step increase in temperature (34-37°C) or no temperature increase (started and remained at 37°C). The patients were asked to rate their perceived comfort, as well as their perceived nasal dryness and humidity on a scale from 1 (lowest value) to 5 (highest value). RESULTS: We enrolled 21 patients, aged 34-85 years. The mean (±1 standard deviation) comfort level was 3.3 (1.3) for patients who received a one-step increase, 3.1 (1.3) for those who received no increase and 2.7 (1.7) for those who received a two-step increase (p = .714). There was also no difference in nasal dryness (p = .05) or humidity (p = .612) across the study arms. Greater comfort was fairly correlated with less nasal humidity (ρ = -0.34, 95% confidence interval -0.68 to 0.07) but not with nasal dryness (ρ = 0.01, p = .94). CONCLUSIONS: After 30 min of HFNC therapy at a target temperature of 37°C, overall comfort was rated similarly in the three study arms. Additional studies are needed to accumulate evidence corroborating the findings of this study. RELEVANCE TO CLINICAL PRACTICE: The temperature of the mixture of air and oxygen is a fundamental component of HFNC therapy. A pragmatic approach irrespective of the initial temperature setting seems to yield a similar comfort score in hospitalized patients with mild respiratory failure because of extrapulmonary causes.

The end of life of patients with COVID-19 in intensive care unit and the stress level on their family members: A cross-sectional study.

BACKGROUND: During the Coronavirus disease 2019 (COVID-19) pandemic, hospital visits were suspended and video calls were offered to connect patients with their family members, especially toward the end of life (EoL). AIM: The primary aim was to describe EoL care for COVID-19 patients dying in an intensive care unit (ICU). The secondary aim was to explore whether making video calls and allowing visits was associated with lower death-related stress in family members. DESIGN: Single centre cross-sectional study. The setting was the ICU of a COVID-19 center in northern Italy, during the first year of the pandemic. Data on patients who died in the ICU were collected; death-related stress on their family members was measured using the Impact of Event Scale-Revised (IES-R). The statistical association was tested by means of logistic regression. RESULTS: The study sample included 70 patients and 56 family members. All patients died with mechanical ventilation, hydration, nutrition, analgesia and sedation ongoing. Resuscitation procedures were performed in 5/70 patients (7.1%). Only 6/56 (10.7%) of the family members interviewed had visited their loved ones in the ICU and 28/56 (50%) had made a video call. EoL video calls were judged useful by 53/56 family members (94.6%) but all (56/56, 100%) wished they could have visited the patient. High-stress levels were found in 38/56 family members (67.9%), regardless of whether they were allowed ICU access or made a video call. Compared with other degrees of kinship, patients' offspring were less likely to show a positive IES-R score (odds ratio [OR] 0.22, 95% confidence interval [CI] 0.05 to 0.89). CONCLUSIONS: During the first year of the COVID-19 pandemic, patients died without their family members at the bedside while on life-sustaining treatment. Stress levels were high in most family members, especially in patients' spouses. Video calls or ICU visits were judged favourably by family members but insufficient to alleviate death-related stress. RELEVANCE FOR CLINICAL PRACTICE: During a pandemic, ICU access by patients' family members should be considered, particularly as the time of death approaches. Although generally appreciated by family members, EoL video calls should be arranged together with other measures to alleviate death-related stress, especially for the patient's spouse.

Prospective comparison of AMB, GAP AND START scores and triage nurse clinical judgement for predicting admission from an ED: a single-centre prospective study.

BACKGROUND: It is postulated that early determination of the need for admission can improve flow through EDs. There are several scoring systems which have been developed for predicting patient admission at triage, although they have not been directly compared. In addition, it is not known if these scoring systems perform better than clinical judgement. Therefore, the aim of this study was to validate existing tools in predicting hospital admission during triage and then compare them with the clinical judgement of triage nurses. METHODS: To conduct this prospective, single-centre observational study, we enrolled consecutive adult patients who presented between 30 September 2019 and 25 October 2019 at the ED of a large teaching hospital in Milan, Italy. For each patient, triage nurses recorded all of the variables needed to perform Ambulatory (AMB), Glasgow Admission Prediction (GAP) and Sydney Triage to Admission Risk Tool (START) scoring. The probability of admission was estimated by the triage nurses using clinical judgement and expressed as a percentage from 0 to 100 with intervals of 5. Nurse estimates were dichotomised for analysis, with ≥50% likelihood being a prediction of admission. Receiver operating characteristic curves were generated for accuracy of the predictions. Area under the curve (AUC) with 95% CI for each of the scores and for the nursing judgements was also calculated. RESULTS: A total of 1710 patients (844 men; median age, 54 years (IQR: 34-75)) and 35 nurses (15 men; median age, 37 years (IQR: 33-48)) were included in this study. Among these patients, 310 (18%) were admitted to hospital from the ED. AUC values for AMB, GAP and START scores were 0.77 (95% CI: 0.74 to 0.79), 0.72 (95% CI: 0.69 to 0.75) and 0.61 (95% CI: 0.58 to 0.64), respectively. The AUC for nurse clinical judgement was 0.86 (95% CI: 0.84 to 0.89). CONCLUSION: AMB, GAP and START scores provided moderate accuracy in predicting patient admission. However, all of the scores were significantly worse than the clinical judgement of the triage nurses.

Quality of dying in hospital general wards: a cross-sectional study about the end-of-life care.

BACKGROUND: In the last decade, access to national palliative care programs have improved, however a large proportion of patients continued to die in hospital, particularly within internal medicine wards. OBJECTIVES: To describe treatments, symptoms and clinical management of adult patients at the end of their life and explore whether these differ according to expectation of death. METHODS: Single-centre cross-sectional study performed in the medical and surgical wards of a large tertiary-level university teaching hospital in the north of Italy. Data on nursing interventions and diagnostic procedure in proximity of death were collected after interviewing the nurse and the physician responsible for the patient. Relationship between nursing treatments delivered and patients' characteristics, quality of dying and nurses' expectation about death was summarized by means of multiple correspondence analysis (MCA). RESULTS: Few treatments were found statistically associated with expectation of death in the 187 patients included. In the last 48 h, routine (70.6%) and biomarkers (41.7%) blood tests were performed, at higher extent on patients whose death was not expected. Many symptoms classified as severe were reported when death was highly expected, except for agitation and respiratory fatigue which were reported when death was moderately expected. A high Norton score and absence of anti-bedsore mattress were associated with unexpected death and poor quality of dying, as summarized by MCA. Quality of dying was perceived as good by nurses when death was moderately and highly expected. Physicians rated more frequently than nurses the quality of dying as good or very good, respectively 78.6 and 57.8%, denoting a fair agreement between the two professionals (k = 0.24, P <  0.001). The palliative care consultant was requested for only two patients. CONCLUSION: Staff in medical and surgical wards still deal inadequately with the needs of dying people. Presence of hospital-based specialist palliative care could lead to improvements in the patients' quality of life.

Self-Report and Biological Indexes of Work-Related Stress in Neonatal Healthcare Professionals: A Repeated-Measures Observational Study.

BACKGROUND: Healthcare providers working in neonatal intensive care units (NICUs) are considered at high risk for psychological work-related stress. PURPOSE: To evaluate both perceived and biological measures of work-related stress in neonatal healthcare professionals and to compare professionals working in the NICU with their colleagues working in less critical environments (ie, neonatal wards [NWs]). METHODS: The salivary cortisol level at the beginning (CORT-B) and at the end (CORT-E) of a daily work shift was collected once a week for 6 weeks and a psychological questionnaire was submitted to NW and NICU workers of a tertiary university center. RESULTS: No differences emerged in the overall cortisol secretion between professionals (NW 45 vs NICU 28), but the decrease in the mean cortisol values between CORT-B and CORT-E was less pronounced in NICU professionals (P < .001) who had greater psychological stress (P < .001). Lack of correlation between perceived and biological indexes was observed. IMPLICATIONS FOR PRACTICE: NICU professionals reported greater levels of self-perceived psychological stress, especially in terms of professional self-doubt and the complexity of interactions with infants and their parents.The disconnection between psychological and biological indexes raises the issue that work-related stress might be covert to the professionals themselves. Dedicated resources should be developed to address quality of life and the work environment of NICU professionals. IMPLICATIONS FOR RESEARCH: The absence of a correlation between perceived and biological indexes highlights the need to incorporate multidimensional physiological and biological measurements in evaluating burnout levels in neonatal healthcare providers.

What is the healing time of Stage II pressure ulcers? Findings from a secondary analysis.

UNLABELLED: Pressure ulcers (PrUs) remain a concern for clinicians, patients, caregivers, and researchers. Although data on prevalence and incidence are available, as well as evidence-based prevention and management intervention, PrU healing time is underreported. OBJECTIVE: The objective of this study was to evaluate the healing time of Stage II PrUs. METHODS: Secondary analysis of data collected from a multicenter randomized clinical trial was undertaken. Patients (a) with a Stage II PrU, (b) older than 18 years, and (c) who had given informed consent were included. The endpoints of the study were complete re-epithelialization of the PrU measured with the Pressure Ulcer Scale for Healing Tool 3.0 and the healing time. A network of 46 healthcare centers located in northern Italy participated in the study. RESULTS: Two hundred seventy patients with an average age of 83.9 years (95% confidence interval [CI], 82.71-85.10) were recruited. Among 270 Stage II PrUs included, 153 lesions healed (56.7%), whereas 74 (27.4%) were still present after 10 weeks of follow-up. For 43 lesions (15.9%), the follow-up evaluation was interrupted because of patient death or transfer to units not included in the study. The PrUs healed on an average of 22.9 days (95% CI, 20.47-25.37 days), with a median of 18 days. The average healing time for PrUs of less than 3.1 cm was significantly shorter (19.2 days; 95% CI, 16.6-21.8) compared with those 3.1 cm or greater (31.0 days; 95% CI, 26.4-35.6 days) (P = .000). CONCLUSIONS: To achieve complete re-epithelialization in Stage II PrUs, it takes approximately 23 days. This is quite a long time if we consider that pressures of only 60 to 70 mm Hg for between 30 and 240 minutes are needed to cause tissue damage. On average, a small ulcer heals 12 days faster compared with those with a surface of 3.1 cm or greater.

Short-term effects of positive expiratory pressure mask on ventilation inhomogeneity in children with cystic fibrosis: A randomized, sham-controlled crossover study.

BACKGROUND: Can physiotherapy with a positive expiratory pressure (PEP) mask improve peripheral ventilation inhomogeneity, a typical feature of children with cystic fibrosis (cwCF)? To answer this question, we used the nitrogen multiple-breath washout (N2MBW) test to measure diffusion-convection-dependent inhomogeneity arising within the intracinar compartment (Sacin*VT). METHODS: For this randomized, sham-controlled crossover trial, two N2MBW tests were performed near the hospital discharge date: one before and the other after PEP mask therapy (1 min of breathing through a flow-dependent PEP device attached to a face mask, followed by three huffs and one cough repeated 10 times) by either a standard (10-15 cmH20) or a sham (<5 cmH20) procedure on two consecutive mornings. Deception entailed misinforming the subjects about the nature of the study; also the N2MBW operators were blinded to treatment allocation. Study outcomes were assessed with mixed-effect models. RESULTS: The study sample was 19 cwCF (ten girls), aged 11.4 (2.7) years. The adjusted Sacin*VT mean difference between the standard and the sham procedure was -0.015 (90% confidence interval [CI]: -∞ to 0.025) L-1. There was no statistically significant difference in Scond*VT and lung clearance index between the two procedures: -0.005 (95% CI: -0.019 to 0.01) L-1 and 0.49 (95% CI: -0.05 to 1.03) turnovers, respectively. CONCLUSION: Our findings do not support evidence for an immediate effect of PEP mask physiotherapy on Sacin*VT with pressure range 10-15 cmH20. Measurement with the N2MBW and the crossover design were found to be time-consuming and unsuitable for a short-term study of airway clearance techniques.

Perceived burden of respiratory physiotherapy in people with cystic fibrosis taking elexacaftor-tezacaftor-ivacaftor combination: a 1-year observational study.

BACKGROUND: To limit the progression of disease, people with cystic fibrosis (pwCF) perform daily respiratory physiotherapy, which is perceived as the most burdensome routine in managing their condition. The elexacaftor-tezacaftor-ivacaftor (ETI) combination has changed respiratory management. OBJECTIVE: To investigate how the perceived treatment burden changed in 1 year of treatment with ETI. DESIGN: Prospective observational study. METHODS: Ad hoc questionnaires for the pwCF and for the caregivers of pwCF < 18 years were administered before the initiation of ETI therapy and then at 6-12 months. The Cystic Fibrosis Questionnaire-Revised (CFQ-R) and the Sinonasal Outcome Test (SNOT-22) were administered to explore disease-related symptoms and social limitations. The International Physical Activity Questionnaire was used to determine levels of physical activity. Mixed-effect models were fitted to explore whether the time engaged in respiratory physiotherapy changed during 1 year. RESULTS: The study included 47/184 pwCF aged 21.4 (5.7) years, who completed 1 year of ETI therapy. At 6 months, time on aerosol therapy was decreased by 2.5 (95% CI -32.9 to 27.8) min/day, time on airway clearance therapies (ACTs) was decreased by 8.8 (95% CI -25.9 to 8.3) min/day, and time for cleaning and disinfecting respiratory equipment was decreased by 10.6 (95% CI -26.5 to 5.3) min/day. At 1 year, gains in time saved were nearly 15 min/day on average. At 1 year, 5/47 (10.6%) pwCF reported that they had discontinued positive expiratory pressure mask. CONCLUSION: PwCF on ETI may note less time engaged in their daily respiratory physiotherapy routine. Nonetheless, aerosol therapy, ACTs and maintaining respiratory equipment were still perceived as time-consuming daily activities.

Understanding the challenges of respiratory physiotherapy in individuals with cystic fibrosis using triple therapy: a one-year study.In order to slow down the progression of their disease, people with cystic fibrosis typically do daily respiratory physiotherapy, which they find to be the most challenging part of managing their condition. The elexacaftor-tezacaftor-ivacaftor combination has changed how they manage their respiratory health. We wanted to see how the perceived difficulty of the treatment changed over one year of using elexacaftor-tezacaftor-ivacaftor. We gave questionnaires to people with cystic fibrosis and to their caregivers before they started the triple therapy and again at 6-12 months. We also used two international questionnaires to learn about symptoms and social limitations related to the disease. The International Physical Activity Questionnaire helped us understand their physical activity levels. We used statistical models to see if the time spent on respiratory physiotherapy changed over the year. Our study involved 47 individuals with cystic fibrosis, with an average age of 21 years, who completed one year of elexacaftor-tezacaftor-ivacaftor therapy. After 6 months, time spent on aerosol therapy decreased by 2.5 minutes per day, time on airway clearance therapies decreased by 8.8 minutes per day, and time for cleaning respiratory equipment decreased by 10.6 minutes per day. By the end of the year, they were saving almost 15 minutes per day on average. At one year, 5 out of 47 said they had stopped using the positive expiratory pressure mask. People with cystic fibrosis using elexacaftor-tezacaftor-ivacaftor may find that they spend less time on their daily respiratory physiotherapy routine. However, activities like aerosol therapy, airway clearance therapies, and maintaining respiratory equipment were still seen as time-consuming.

Medical occurrence and safety of SARS-CoV-2 vaccination outside of the hospital setting.

During COVID-19 pandemic, vaccination has been strongly recommended and advocated to prevent COVID-19 infection and adverse outcomes, particularly among at-risk populations. The vaccination against SARS-CoV-2 (COVAC) occurred at off-site locations capable of accommodating large crowds, distinct from the hospital setting, where a team of intensivists, emergency physicians, and nurses, ensuring prompt medical attention (medical occurrences, MO) in cases of adverse event following immunization. Our aims were to estimate the incidence of MO, and to assess its association with demographics, and vaccine characteristics. Our retrospective cohort study included all subject aged 12 years and older who received vaccinations at two large out-of-hospital vaccination hubs (Fiera Milano City, Palazzo delle Scintille), between April 12th and August 31st, 2021. Nine hundred and ninety-five thousand and twenty-eight vaccinations were administrated. MOs incidence rate was 278/100,000 doses (95% confidence interval (CI) 268-289). Most MOs were mild (86.27%) and mainly observed in subjects who received the Comirnaty vaccine; 92 MOs (3.32%) were severe and mostly occurred in recipients of the Vaxzeria vaccine. The incidence rate for hospital transfers following vaccination was 4.7/100,000 doses (95% CI 3.5-6.2) and any level of anaphylaxis occurred in 0.4 cases per 100,000 administrated doses (95% CI 0.3.-0.7). Sex, age, type of vaccine and first dose were associated with incidence of MO. Our results showed a low incidence rate in MOs after COVAC, mainly mild and support the feasibility, effectiveness and safety of vaccinations administered in hubs with a dedicated SEU located outside of the hospital setting.

Thematic analysis of intensive care unit diaries kept by staff: insights for caring.

OBJECTIVE: To explore recurrent themes in diaries kept by intensive care unit (ICU) staff during the coronavirus disease 2019 (COVID-19) pandemic. DESIGN: Qualitative study. SETTING: Two ICUs in a tertiary level hospital (Milan, Italy) from January to December 2021. METHODS: ICU staff members wrote a digital diary while caring for adult patients hospitalized in the intensive care unit for >48 hours. A thematic analysis was performed. FINDINGS: Diary entries described what happened and expressed emotions. Thematic analysis of 518 entries gleaned from 48 diaries identified four themes (plus ten subthemes): Presenting (Places and people; Diary project), Intensive Care Unit Stay (Clinical events; What the patient does; Patient support), Outside the Hospital (Family and topical events; The weather), Feelings and Thoughts (Encouragement and wishes; Farewell; Considerations). CONCLUSION: The themes were similar to published findings. They offer insight into care in an intensive care unit during a pandemic, with scarce resources and no family visitors permitted, reflecting on the patient as a person and on daily care. The staff wrote farewell entries to dying patients even though no one would read them. IMPLICATIONS FOR CLINICAL PRACTICE: The implementation of digital diaries kept by intensive care unit staff is feasible even during the COVID-19 pandemic. Diaries kept by staff can provide a tool to humanize critical care. Staff can improve their work by reflecting on diary records.

[Preparedness for emergencies: strategies to increase the supply of beds and advanced intensive skills]. / Prepararsi alle emergenze: strategie per aumentare l'offerta di posti letto e di competenze intensive avanzate.

. Preparedness for emergencies: strategies to increase the supply of beds and advanced intensive skills. INTRODUCTION: The recent pandemic has highlighted the importance of emergency preparedness plans. In addition to technological and structural resources, it is essential to have professionals with skills that allow them to safely work in intensive care areas. AIM: The aim of the contribution is to propose an intervention model to develop the skills of nurses of operatory theatres or intensive care to enable them to work safely in critical care settings. METHODS: A plan was devised, involving a multiprofessional group to increase the number of beds in the intensive and semi-intensive care areas, as well as to train staff, hypothesising the activities to be reduced by moving staff to different areas. RESULTS: The proposed organisational model could be implemented in other hospitals; it guarantees emergency preparedness and the expansion of the skills of the staff involved. CONCLUSIONS: Nursing staff with advanced skills should be readily available to safely guarantee the expansion of intensive care beds. The current division between intensive and semi-intensive settings could be revised in favour of a single critical care area.

Association of Oxygen Therapy with the Natural Disease Progression of Cystic Fibrosis: A Multi-State Model of the European Cystic Fibrosis Society Patient Registry.

Background: Association between dependence on oxygen therapy (OT) and natural disease progression in people with cystic fibrosis (pwCF) has not been estimated yet. The aim of this study is to understand the prognosis for pwCF on OT, evaluating how the transition probabilities from being alive without lung transplantation (LTx) to LTx and to death, and from being alive after LTx to death change in pwCF with and without OT. Methods: We used 2008-2017 data from the 35-country European CF Society Patient Registry. A multi-state model was fitted to assess the effects of individual risk factors on transition probabilities. Results: We considered 48,343 pwCF aged from 6 to 50 years. OT (HR 5.78, 95% CI: 5.32-6.29) and abnormal FEV1 (HR 6.41, 95% CI: 5.28-7.79) were strongly associated with the probability of having LTx; chronic infection with Burkholderia cepacia complex (HR 3.19, 95% CI: 2.78-3.67), abnormal FEV1 (HR 5.00, 95% CI: 4.11-6.08) and the need for OT (HR 4.32, 95% CI: 3.93-4.76) showed the greatest association with the probability of dying without LTx. Once pwCF received LTx, OT (HR 1.75, 95% CI: 1.41-2.16) and abnormal FEV1 (HR 1.63, 95% CI: 1.18-2.25) were the main factors associated with the probability of dying. An association of gross national income with the probability of receiving LTx and with the probability of dying without LTx was also found. Conclusion: Oxygen therapy is associated with poor survival in pwCF with and without LTx; harmonization of CF care throughout European countries and minimization of the onset of pulmonary gas exchange abnormalities using all available means remains of paramount importance.

Setting up and managing the largest COVID-19 mass vaccination center in Lombardy, Italy.

Background: The rapid global spread of severe acute respiratory syndrome coronavirus (SARS-CoV-2) was met with the rollout of vaccination campaigns at mass vaccination centers. The Palazzo delle Scintille, Milan, was designated by the Lombardy regional administration as a vaccination site with the target of processing about 9,000 users daily. Methods: For this observational study, we compared data on vaccinations delivered at the Palazzo delle Scintille with coronavirus disease (COVID-19)-related regional data. Results: Between 25 April 2021 and 28 February 2023, a total of 1,885,822 COVID-19 doses were administered; the mean hourly rate was 289 (247.2), the mean daily rate was 3185.5 (3104.5), the mean user age was 49.5 years (10.7). The Comirnaty vaccine (Pfizer-BioNTech) was most often given (1,072,030/1,885,822; 56.8%). Between 4 December 2021 and 15 January 2022, the daily dose rate was above the maximum daily capacity set by the regional administration. Conclusion: The trend for daily dose rates administered at the Palazzo delle Scintille center was in line with COVID-19-related regional data. The center played a major role in the regional mass vaccination campaign.

Anti-Sars-CoV-2 vaccination campaign in children aged 5-11 years: the experience of a mass vaccination center in the city of Milan.

BACKGROUND AND AIM: After the approval of the anti-Sars-CoV-2 vaccines for the pediatric population, it is necessary to encourage the immunization of children aged 5-11 years, as this can reduce intergenerational transmission. Therefore, this goal has become a priority for the COVID 19 vaccination campaign in Italy. In the city of Milan, the mass vaccination center (MVC) Fiera Milano City, previously settled for general population, became the main site to host pediatric vaccinations. The center was consequently remodeled to ensure a suitable space for children. This paper provides an overview on the organization strategy implemented by Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico. The modular structure and the wide surface available in the center allowed the administration of hundreds of vaccines per day, especially in the first opening phase. METHODS: All the data for the entire period of activity of Fiera MCV, from December 16th 2021 to February 20th 2022, were analyzed using descriptive statistics. RESULTS: During the entire period of activity, from 16 December 2021 to 20 February 2022, 23% of the population in the province of Milan aged 5-11 years has been reached and vaccinated with at least one shot of vaccine in this center. CONCLUSIONS: Despite an enthusiastic response in the first weeks of the campaign, a progressive reduction in vaccination adherence was observed, maybe due to the absence of restrictive measures for unvaccinated children in Italy.

[At least a thanks: reflections on the new employment contract for nurses]. / Almeno un grazie.Riflessioni sul nuovo contratto di lavoro per gli infermieri.

. At least a thanks: reflections on the new employment contract for nurses. The signing of the new work contract is an opportunity to take stock of what has been given, promised and actually received. The nurses' salary increase is limited, late, and is almost completely cancelled out by inflation. Though the current contract also offers some recognitions such as the institution of the so-called 'deputy manager', the payment for new and advanced responsibilities a salary increase for those who work in emergency services, it is not enough. There remains the problem of a nursing profession with a severe shortage, in which we need to invest not only from an economic perspective. The effort for the new contract must start now.

Sensitivity and specificity of the new Geriatric Dehydration Screening Tool: An observational diagnostic study.

OBJECTIVES: The aim of this study was to evaluate the diagnostic accuracy of the Geriatric Dehydration Screening Tool-Modified (GDST-M) in detecting dehydration in older people and, if possible, to simplify the tool and make it easier to use. METHODS: This was a monocentric diagnostic accuracy study. We involved people ≥65 y of age with a Mini Mental State Evaluation (MMSE) score >24 and who were hospitalized in five medical wards of a large teaching hospital in Milan (Italy). We administered the GDST-M to hospitalized older people who met the inclusion criteria and compared outcomes with the values of serum osmolarity to evaluate their dehydration status and the accuracy of the tool. RESULTS: A total of 299 older people were recruited, of which 202 were dehydrated and 97 were hydrated. The GDST-M, with a cutoff value of 6, showed a sensitivity of 61.9% and a specificity of 47.2%. Multiple correspondence analysis and cluster analysis enabled extraction of 9 items from the 23 items present in the GDST-M. The new tool had a moderate diagnostic accuracy in detecting dehydration in older people aged over 75 y, with a sensitivity of 63.4% and a specificity of 69.6%. CONCLUSIONS: The short form of the tool is simple and contains minimally invasive assessments of low fluid intake dehydration in older people. The new GDST could also be easily used by lay people after a short training session.

Intensive care unit diaries to help bereaved family members in their grieving process: a systematic review.

BACKGROUND: Intensive care unit diaries are often used to support patients during their psychological recovery. The intensive care unit stay can be upsetting, disturbing and traumatic for both patients and their families especially when the patient does not survive. AIM: To investigate the connection between intensive care unit diaries and the grieving process experienced by family members of adult patients deceased in the intensive care unit. METHODS: Systematic literature review according to PRISMA guidelines: PubMed, CINAHL and Cochrane Library were consulted. The Caldwell's framework was used for the quality appraisal. RESULTS: Only six studies examine this topic. The potential benefits of intensive care unit diaries in family members' bereavement process may be an aid to realise how extremely ill their loved one was, may provide comfort and may help relatives to cope with their loss. CONCLUSION: The use of intensive care unit diaries to help family members' bereavement process may be a useful tool but further research is necessary to better understand their role and benefits.

Italy's rollout of COVID-19 vaccinations: The crucial contribution of the first experimental mass vaccination site in Lombardy.

BACKGROUND: In occurrence of the coronavirusdisease 19 (COVID-19) pandemic, carrying out an efficient large-scale vaccination campaign is vital in order to control the virus. Especially in high prevalence areas of COVID - 19, it is crucial to implement an effective vaccination strategy. In Italy, programming an efficient COVID-19 mass vaccination campaign has been the main target of the Ministry of Health. AIMS: This paper gives a comprehensive overview of how the mass vaccination campaign is performed in Milan, one of the cities that has been mostly affected by the COVID-19 pandemic in Italy. We analyze the vaccination strategy implemented by Fondazione Ca' Granda - Ospedale Maggiore Policlinico located in Milan. Furthermore, we compare the organization of this campaign in regards of those carried out across EU and UK. MATERIALS AND METHODS: The data derive from an analysis of the different vaccination plans implemented across EU and UK from the 27/12/2020 to the 15/06/2020. In addition, we discuss the data collected from the internal data server of IRCCS Fondazione Ca' Granda - Ospedale Maggiore Policlinico from the 15/02/2021 to the 15/06/2021.The collected data are examined by means of descriptive statistics. RESULTS: From the analysis of the internal data server, we observe that the modular organization of Fiera Milano City guarantees up to 5000 vaccinations/day. Moreover, the precise flow organization of users and a series of strategies adopted to avoid identification errors or vaccine type administration errors are crucial to reach the aforementioned target. CONCLUSIONS: The institution of mass vaccination centers thanks to the optimization of all the involved processes and the meticulous organization of these structures, allows to avoid crowds and guarantees the administration of elevated amounts of vaccines. All these elements assure a rapid vaccination coverage of the population in Lombardy, with a meaningful increase in daily administration doses.