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A dozen physicians at the epicenter of Italy’s Covid-19 outbreak issued a plea to the rest of the world on Saturday, going beyond the heartbreaking reports of overwhelmed health care workers there and a seemingly uncontrollable death toll to warn that medical practice during a pandemic may need to be turned on its head — with care delivered to many patients at home.

“Western health care systems have been built around the concept of patient-centered care,” physicians Mirco Nacoti, Luca Longhi, and their colleagues at Papa Giovanni XXIII Hospital in Bergamo urge in a paper published on Saturday in NEJM Catalyst, a new peer-reviewed journal from the New England Journal of Medicine. But a pandemic requires “community-centered care.”

The experience of the Bergamo doctors is crucial for U.S. physicians to understand “because some of the mistakes that happened in Italy can happen here,” said Maurizio Cereda, co-director of the surgical ICU at Penn Medicine and a co-author of the paper. The U.S. medical system is centralized, hospital-focused, and patient-centered, as in most western countries, “and the virus exploits this,” he told STAT.

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Although Papa Giovanni XXIII Hospital is a new state-of-the-art facility, its 48 intensive-care beds and other advanced treatment capacity have staggered under the Covid-19 caseload, which passed 4,305 this week.

“We are far beyond the tipping point,” Nacoti and his colleagues write. With 70% of ICU beds reserved for critically ill Covid-19 patients, those beds are being allocated only to those “with a reasonable chance to survive,” as physicians make wrenching triage choices to try to keep alive those who have a chance. “Older patients are not being resuscitated and die alone without appropriate palliative care, while the family is notified over the phone, often by a well-intentioned, exhausted, and emotionally depleted physician with no prior contact,” they report.

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Most nearby hospitals in the wealthy region are “nearing collapse while medications, mechanical ventilators, oxygen, and personal protective equipment are not available,” the physicians write.

Other health care in northern Italy has come to a near-halt, they report: The system “struggles to deliver regular services, even pregnancy care and child delivery, while cemeteries are overwhelmed … [V]accination programs are on standby.”

To have any hope of avoiding that disaster in the U.S., the health care system needs to decentralize and make the community a focus of interventions on a par with patients, said Cereda, a graduate of the medical school at the University of Milan who has been in touch with colleagues in Italy. The coronavirus has now killed more people there (the toll passed 4,000 this week) than in China (3,255).

One such step reflects the finding that hospitals might be “the main” source of Covid-19 transmission, the Bergamo doctors warned. The related coronavirus illness MERS also has high transmission rates within hospitals, as did SARS during its 2003 epidemic.

Major hospitals such as Bergamo’s “are themselves becoming sources of [coronavirus] infection,” Cereda said, with Covid-19 patients indirectly transmitting infections to non-Covid-19 patients. Ambulances and infected personnel, especially those without symptoms, carry the contagion both to other patients and back into the community.

“All my friends in Italy tell me the same thing,” Cereda said. “[Covid-19] patients started arriving and the rate of infection in other patients soared. That is one thing that probably led to the current disaster.”

Although doctor house calls seem as prehistoric as rotary phones, home-based care for Covid-19 patients may be necessary in order to protect the community even if, to an individual patient, hospital care might be more effective.

“Managing patients at home is a brilliant thing,” Cereda said, and one that could be augmented by mobile clinics and telemedicine. “Bring them nutrition, measure their oxygen levels, even bring them oxygen, and you can probably keep many of them at home. This is what we mean by moving from patient-centered medicine: Of course you still care for and care about the patient, but you also think about the population as a whole. That change would decrease transmission and protect other patients as well as health care workers.”

For patients who need more intensive care, dedicated Covid-19 medical centers, akin to the “fever hospitals” that London set aside for smallpox, cholera, and typhus patients 200 years ago, would be a safer way to deliver care than the current system, Cereda said.

Another needed move from patient- to community-centered care: Assume everyone who develops a fever and other symptoms has the coronavirus, Cereda said. (A positive identification usually isn’t necessary and doesn’t change treatment, since there is no known Covid-19-specific therapy yet.) Then, at least until the U.S. has adequate testing capacity, reserve those tests for nursing homes, schools, and other possible hot spots in the community in order to identify people who are infected with virus but who do not have symptoms.

“Don’t let them spread it,” Cereda said. “If we had done this in January, the U.S. wouldn’t be in this situation,” with an exploding number of cases (poised to blow past 20,000 on Saturday) and overwhelmed hospitals.

Health officials in some hard-hit areas in the U.S., including in California and Washington, are already moving to reserve testing for high-risk populations, including health workers, the Washington Post reported.

Correction: An earlier version of this article misspelled the name of Maurizio Cereda of Penn Medicine.

  • I strogly agree and since our president has allotted so much money for this Pandemic ibelievemobile hospitals would save thousands of lives (thanks for the article)YOU ROCK!

  • Italy should be prescribing chloroquine or hydroxychloroquine as widely as possible, as early as possible in the disease progression. Early usage likely reduces the chance someone needs the ICU in the first place, and these drugs can be taken at home.

    • You don’t know that! The efficacy ( and safety) of these drugs against coronavirus has not been proven and the risk of side effects or complications may outweigh any positive effect of the drug. People are already overwhelming doctors with requests for these drugs. Please don’t play doctor when the data is still not available.

  • You’ve misspelled Dr. Maurizio Cereda as Maurizo.

    “Dr. Maurizio Cereda is an anesthesiologist in Philadelphia, Pennsylvania and is affiliated with multiple hospitals in the area, including UPMC Presbyterian Shadyside and Pennsylvania Hospital. He received his medical degree from University of Milan Faculty of Medicine and has been in practice for more than 20 years.”

  • Anyone who holds hope in relying on a supernatural being (a god) to intervene in this terrible epidemic is a total idiot. It will not be a god that saves lives but it will be the efforts of tens, if not hundreds of thousands of people throught the world – the doctors, nurses, scientists, care workers, support staff, pharmacists, ambulance drivers etc, etc, etc, It is these HUMANS, these PEOPLE who will help you and your loved ones. Do not waste your time on praying to a supernatural being – use your time and energy to help others, or help yourselves. You are being totally disengenous to all of the other people on the planet. WAKE UP !! WWe no longer live in the middle ages when we could not explain what a rainbow was – it had to be ‘God sent’ did’nt it ?? Or why the earth shook – surely God was angry ?? Well, we now have dismissed this ignorance – and it’s about time this ignorance was dismissed entirely. There is no such thing as a god – it’s only your imagination.

  • This makes great sense. Why are we counting beds at hospitals when people can be treated and contained at home. They will have no choice but to stay home if or when the hospitals fill up. Decentralize. I believe there should be a protocol developed for family/housemates as far as how to handle someone who gets sick at home, avoiding going to the hospital if possible and home treatment if there is any.

  • @zena
    The point is that we don’t know if they were going to die from something else. We have to find out. We can do this if authorities would release daily death number and compare it to current death numbers.

  • Exactly!! You have to go back to the drawing board when dealing with problems of this magnitude. As with do things, not only medical, you have to make sure that your solution isn’t part of the problem.

  • It seems like many think we cannot know the percentage who have had the virus, how many are in early stages etc.
    It is actually not difficult at all, and it it strange that it has not been done. We use the technique all the time in political polls, we test a representative sample. In polls, people may lie, but if we test randomly 100 persons and 50 come up as Corona infected, we know that the rate is around 50%. If we test 1000 randomly, we will know it even more acccurately.
    If we test 100 randomly every day, we could track the progression very closely and actually see if our social distancing has any effect.
    NIMH research indicates that hand washing and hygiene has a very good effect , but that social distancing, which is what wrecks the economy, does not have any proven positive effect.
    Another number that is easy to find and doesn’t require any extra testing is the difference of daily normal death rate and how much the daily dearth rate is increased with Corona.
    1700 persons die in Italy pr day in non Corona times, most of them very old, as expected. If 50 extra die now, but 300 are counted as Corona deaths, we know that we don’t have to be so alarmed. 250 died with Corona, not from Corona, they would have died anyway. This could be computed on a daily basis, and we would see trends easily.

    • Do you think that 647 persons yesterday and 793 persons today died because they were “already going”? Probably another number of persons died in their homes but are not in the official numbers, in a second time we will know when a sort of analysis of the tragedy will be drawn and studied.

    • That is an excellent question. I too would like to know the answers.
      Both the prevalence of disease in the total population, and the average death rates for regions by month.

    • It would be tremendous to have actual, factual solid information. CDC or someone needs to TAP into local population to transmit real time info. Military uses system of regional joint operations command and control centers to gather, up channel & disseminate real time info to make real time decisions. Why… we need to make immediate adjustments to save those infected, combat further spread and develop an aggressive plan to safely return Americans to work (equal effort across all three fronts). Each county needs a crisis ACTION team in place coordinating these three efforts. We cannot sit back and wait at home afraid… get your communities energized to figure out how we can safely get back to work. Give everyone a mask… make it mandatory for ninety days… develop procedures work in a high threat contagion work environ. What if the virus doesn’t slow down for three months. Is our stay at home course of action sustainable. It is unacceptable to sit home & await further instructions while the country falls into depression or recession. Brainstorm this thing and get people back out there working. Stay at home/distancing good first step… what is next. Where is action and sustainment plan? Can’t shut down forever… aid packages good.. people need something other than China stats, politician talk and newspaper doom/gloom. This will happen again. Let’s build a blueprint to keep working under these conditions. We need to shelter at home and at work.

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