How to improve access to appropriate therapy and outcome of the acute ischemic stroke: a 24-month survey of a specific pre-hospital planning in Northern Italy.

Few patients with acute cerebral infarction are medicated with thrombolysis as yet. Thus, a specific plan was created in the area of Bergamo in Northern Italy to increase the number of procedures. The plan, started in 2010, consisted of: (1) subdivision of the area of Bergamo into three zones, each one served by a single Stroke-Unit (SU) licensed to thrombolysis; (2) information to population via newspapers and local broadcasting; and (3) teachings both to personnel of Emergency Medical Service and General Practitioners. Here, we have compared the results of the SU of Policlinico San Marco in the years 2008-2009 versus those in the years 2010-2011. During 2008 and 2009, SU admitted 376 acute ischemic strokes, 60 of whom (16 %) within 3 h of the event. Of those patients, 8 (2 %) were treated with thrombolysis. At 3 months of stroke, 61 patients (16 %) were alive and self-independent. During 2010 and 2011, SU admitted 401 acute ischemic strokes, 91 of whom (22 %) within 3 h of stroke. Of those patients, 23 (6 %) were treated with thrombolysis. At 3 months of stroke, 100 patients were alive and self-independent (25 %). The increases of thrombolytic procedures (p = 0.0171), of self-independent patients (p = 0.0036), and of patients arriving within 3 h of stroke (p = 0.0226) were statistically significant. In conclusion, our study shows that a specific plan increases the numbers of thrombolysis and of self-independent patients at 3 months of stroke.

Stroke-Unit and emergency medical service: a 48-month experience in northern Italy.

Since the therapeutic window for acute ischaemic stroke is very short, early arrival at emergency care rooms is mandatory. Emergency medical service (EMS), assuring fast patients transportations, plays a fundamental role in the management of stroke. We have prospectively analysed the utilisation of EMS in the management of stroke patients in a countryside area of northern Italy. Among patients presenting with an acute stroke during the period January 2007-December 2010, those with an ascertained time of onset and documented ongoing brain ischaemia at neuroimaging were included in the study. For all of those patients, the personal data, means of arrival, nature of stroke, whether first stroke or recurrence, severity of stroke and the in-hospital outcome were recorded. Of 1,188 patients hospitalised with a definite diagnosis of stroke, 757 patients were included in the study. Of those, 285 patients (37.6 %) were transported by EMS. EMS allowed earlier admissions (75 % within 3 h of stroke onset), but also transportation of patients of an older age (75 vs. 71 years, p < 0.001), and with more severe strokes (62 % of total anterior circulation infarctions). Our study confirms that EMS is essential in delivering the earliest therapy to patients with acute cerebral infarction living in an extra-urban area of northern Italy. However, work is needed in optimising EMS, since transported patients are often not prone to therapy.

Identifying Trauma Patients in Need for Emergency Surgery in the Prehospital Setting: The Prehospital Prediction of In-Hospital Emergency Treatment (PROPHET) Study.

Prehospital field triage often fails to accurately identify the need for emergent surgical or non-surgical procedures, resulting in inefficient resource utilization and increased costs. This study aimed to analyze prehospital factors associated with the need for emergent procedures (such as surgery or interventional angiography) within 6 h of hospital admission. Additionally, our goal was to develop a prehospital triage tool capable of estimating the likelihood of requiring an emergent procedure following hospital admission. We conducted a retrospective observational study, analyzing both prehospital and in-hospital data obtained from the Lombardy Trauma Registry. We conducted a multivariable logistic regression analysis to identify independent predictors of emergency procedures within the first 6 h from admission. Subsequently, we developed and internally validated a triage score composed of factors associated with the probability of requiring an emergency procedure. The study included a total of 3985 patients, among whom 295 (7.4%) required an emergent procedure within 6 h. Age, penetrating injury, downfall, cardiac arrest, poor neurological status, endotracheal intubation, systolic pressure, diastolic pressure, shock index, respiratory rate and tachycardia were identified as predictors of requiring an emergency procedure. A triage score generated from these predictors showed a good predictive power (AUC of the ROC curve: 0.81) to identify patients requiring an emergent surgical or non-surgical procedure within 6 h from hospital admission. The proposed triage score might contribute to predicting the need for immediate resource availability in trauma patients.

Bergamo Field Hospital Confronting COVID-19: Operating Instructions.

The coronavirus disease (COVID-19) pandemic represented an unprecedented challenge for health care facilities, and innovative solutions were urgently required to overcome the high volume of critically ill infectious patients, limit in-hospital outbreaks, and limit the risk of occupational infection for health care workers (HCWs). Bergamo was the hardest-hit Italian province by COVID-19, and the local health care system had to undergo a profound and prompt reorganization. A COVID-19-only field hospital was rapidly set up meeting the standards for severe acute respiratory infection (SARI) treatment centers (https://apps.who.int/iris/handle/10665/331603). A zones partition, dedicated in-hospital pathways for HCWs, strict infection prevention and control (IPC) measures, and constant staff supervision were key components of our strategy to limit the risk of occupational infection for HCWs. Herein, we present the Bergamo field hospital layout enlightening fundamental IPC measures adopted as a valuable example of a SARI treatment center confronting COVID-19.

A Community-Based Model to the COVID-19 Humanitarian Crisis.

A multidisciplinary group, mainly from Bergamo region - the epicenter of the COVID-19 pandemic crisis in Italy on march 2020- has developed concept of creating intermediate care facilities and proposes a three-tier model of community-based care, with the goal of reducing hospital admissions, contagion and mortality related to hospital overloading and optimizing human resources.

Impact of the COVID-19 outbreak on severe trauma trends and healthcare system reassessment in Lombardia, Italy: an analysis from the regional trauma registry.

BACKGROUNDS: The COVID-19 pandemic drastically strained the health systems worldwide, obligating the reassessment of how healthcare is delivered. In Lombardia, Italy, a Regional Emergency Committee (REC) was established and the regional health system reorganized, with only three hospitals designated as hubs for trauma care. The aim of this study was to evaluate the effects of this reorganization of regional care, comparing the distribution of patients before and during the COVID-19 outbreak and to describe changes in the epidemiology of severe trauma among the two periods. METHODS: A cohort study was conducted using retrospectively collected data from the Regional Trauma Registry of Lombardia (LTR). We compared the data of trauma patients admitted to three hub hospitals before the COVID-19 outbreak (September 1 to November 19, 2019) with those recorded during the pandemic (February 21 to May 10, 2020) in the same hospitals. Demographic data, level of pre-hospital care (Advanced Life Support-ALS, Basic Life Support-BLS), type of transportation, mechanism of injury (MOI), abbreviated injury score (AIS, 1998 version), injury severity score (ISS), revised trauma score (RTS), and ICU admission and survival outcome of all the patients admitted to the three trauma centers designed as hubs, were reviewed. Screening for COVID-19 was performed with nasopharyngeal swabs, chest ultrasound, and/or computed tomography. RESULTS: During the COVID-19 pandemic, trauma patients admitted to the hubs increased (46.4% vs 28.3%, p < 0.001) with an increase in pre-hospital time (71.8 vs 61.3 min, p < 0.01), while observed in hospital mortality was unaffected. TRISS, ISS, AIS, and ICU admission were similar in both periods. During the COVID-19 outbreak, we observed substantial changes in MOI of severe trauma patients admitted to three hubs, with increases of unintentional (31.9% vs 18.5%, p < 0.05) and intentional falls (8.4% vs 1.2%, p < 0.05), whereas the pandemic restrictions reduced road- related injuries (35.6% vs 60%, p < 0.05). Deaths on scene were significantly increased (17.7% vs 6.8%, p < 0.001). CONCLUSIONS: The COVID-19 outbreak affected the epidemiology of severe trauma patients. An increase in trauma patient admissions to a few designated facilities with high level of care obtained satisfactory results, while COVID-19 patients overwhelmed resources of most other hospitals.