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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.

  • This is valuable insight. My 71 years old friend in Florida has been suffering from discomfort for the past few days in her throat that now moved to her chest. But she does not have fever, neither shortness of breathe. So he is refraining from visiting clinic or hospital. She is sipping in a lot of warm water and trying yo recover at home. Maybe this is all we should do.

  • MODERATOR NEEDED on Aisle Two

    Sabine Cohen – Your comments suggesting tinfoil hat theories about the development and spread of SARS viruses and your insistence on racist language are out of line with the policies against racism and conspiracy theories on StatNews, and I hope will be removed ASAP by a MODERATOR.

    “Spanish flu” did not originate in Spain. And the term “Spanish flu” does not arise from “bigot[ry] against Europeans,” as you incorrectly imagine. The influenza pandemic occurred during World War I, and since Spain was a neutral country, reporters from the U.S. and in Europe could use the phrase as shorthand for influenza in Europe without having their stories censored by various governments which did not want to broadcast the extent of illness in their countries. “Spanish flu” is a misnomer, but since that influenza pandemic occurred over 100 years ago, and those involved are long dead, it’s hard to understand why this is an issue for you or why you are imagining bigotry against Europeans. Europeans are not being attacked in the streets in America, despite what toxic white nationalists might want people to believe.

    Unfortunately, across America, people who appear to be of any Asian descent – Japanese, Laotian, Malaysian, Korean and others, as well as Chinese, ARE being attacked in the streets. They are being beaten, their families stabbed, their homes vandalized, because of the racist and ignorant use of terms like “China virus.” I hope that you do not want anyone harmed because you’ve failed to use the term Covid-19, as real medical professionals do, and that you will never use such racist terms again.

    Thanks, Mariana, for reminding Ms. Cohen that all people deserve respect, kindness and care, no matter what languages they speak or don’t speak. Compassion is the universal language. You are a credit to nursing.

  • It amazes me how great is incited and people panic. they operate on incomplete information and use things such as this virus as an excuse when their true colors come out. The fact people are already making comments about who shouldn’t be allowed in hospitals, deserve treatment and that they should be put down because somehow their lives are worth less than others, is totally mind blowing and absolutely disgusting.

    We are all people, we are all members of the human race. And if in this insane time of fear mongering, and partial information you’re so hateful and selfish you feel the right to say people should be left to die and that certain people shouldn’t be given the same care makes me sick.

    It’s not this virus that makes you decide to say such terrible things, they are already in you, this virus is just your justification to say your hateful things out loud. I pray anyone who does this has a wake up call and they do some soul searching, and most of all at least are convicted enough to keep their selfish, unkind and uncaring words to themselves. If all you have to say is self centered and shows how you thinks you have right to play God or at least ok deciding who should die or go untreated then keep your small minded crap to yourself by keeping your mouth shut. Not only will it help with all of us getting through this together, but it will keep any stupid hatred from causing things to be worse. There’s nothing worse than those who divide and then look down on people but to think you have the right to say someone shouldn’t be saved makes you a human being that isn’t further us as humans but holding back the growth of every person on Earth.

    Just for curiositys sake I wonder how many of these with the opinions of let them die and not all then in hospitals go to church, or identify with a religion, consider themselves godly or Christian….

    If it was your family member would you be so filled with hate?

  • No Marianna, the patient was not in respiratory distress. And she frightened the healthcare staff severely because her behavior was potentially exposing them and their family to a severe disease. And no one complains about calling the Spanish flu, the Spanish flu, so why the double standard of not calling it the Chinese Virus? I guess its just OK to be bigot against Europeans. We hadvSARS 1, now SARS 2. And it is questionable how both SARS got released into the population. I am not calling it the Asian virus. If we continue to ignore certain issues, we’re going to have a SARS 3.

  • I’m a nurse in a hospital and we just had our first presumptive Chinese virus patient: A demented 92 year old obese woman who spoke no English. She spent 90 percent of the time shrieking at the top of her lungs, pulled out all her lines, and attempted to crawel out of bed and fall on the floor. Daughter called and said how sorry she was, but she could not look come and help look after mom. These types of patients should be DNR and not allowed admission to hospital. She only required a small amount ofvextra oxygen. This should have been supplied to her long term care facility.

    • Hi, as a colleague nurse I’d like to encourage people and especially nurses not to label the Coronavirus as the “Chinese virus. ” I think it sounds wrong and it might inflame bigotry in some people.
      If this patient was “shrieking”, she was obviously in some distress and probably respiratory, which requires prompt intervention or this poor woman will continue to be in distress. The nurse should be culturally sensitive and aware to all patients and even if there is a language barrier either due to dementia or poor English, the nurse should not fail to provide care with empathy.
      Stay healthy everyone!

  • Sounds like excellent advice from ppl who know from experience. The US would do good to take heed.

  • Readable, interesting and relevant. The general public are poorly informed in the UK and many are scared.
    The current UK policy of ‘making availability of intensive for all who will need and demand it by slowing the spread of the virus down’ the main aim, is questionable, It will damage the economy far more than uncontrolled spread.
    A controlled spread that could be rapid yet manageable is asking for volunteers to be infected, infesting them with the virus on condition they stay home for ten days, and pay them for their time off work. Once the results of the first batch were made public, provided few had major problems, there would be no shortage of volunteers which might eventually total half of the population

    • This is not a good strategy. 40% of patients hospitalized in the US are from 20-54, no one is immune to the disease. There is no such thing as a “controlled spread”, there are already community transmission that can’t be controlled, otherwise why do you see the positive numbers keep growing despite containment or mitigation effort? 20% of all patients will need hospital care, 6-8% will be in critical condition, without medical resources they’ll all die, tell that to the volunteers. If millions of people will die, why do you still worry about the economy?

  • How many patients with Covid 19 on ventilators have survived? I read yesterday that in Italy no one has recovered from being on a ventilator, please let me know if anyone has any figures on this.

    • My understanding is that people in the critical stage of the disease process have ARDS (acute respiratory distress syndrome). Look this up and you should get an answer to your question. My father had ARDS when H1N1 came around. He survived without being put on a ventilator. This is rare. Looking at medical journals for ARDS without COVID-19 suggests anywhere from 40-70%.

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