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.

  • Due to the shortage of masks, some US hospitals are only allowing staff to wear masks if a patient is a confirmed COV19 patient or a PUI. The nurses and other providers are not using the masks at all times as should be required to stop the spread of this virus to all the patients they are caring for, to their colleagues and to everyone’s family and the general public. I understand the hospitals management team to “ conserve” what masks /PPE they have but if they don’t have enough better they close down then become a source of breeding the Virus. “ Due no harm” Partners is now requiring all of their staff throughout their large system , to wear masks at all times. Let’s us hope no pray that the others hospitals follow suit because otherwise when this is over it will be really sad to find out that the staff that were so committed to providing care to patients actually became the source for others to become infected with COV19.

  • So basically, Italy did it to themselves. And rather than just having those with severe symptoms go to hospital, everyone goes due to the fear of it.
    Hospitals get hemorrhaged, and they let the most sick die.
    This knee-jerk, fear driven response is killing people. And will for years to come from the healthcare shortfall this is going to cause.

  • So if I have it . I have controllable symptoms at present .It’s best to stay at home , unless it is unmanageable or too severe? I am 62 with high blood pressure and history of SVT . Ran 1oo.2 temp on Fri but quickly came down and no fever since then.. this morning I woke up with a wet cough but it goes away

  • Please keep this important advice from professionals in the “hot zone” of Italy on the front page, as I have not seen it in any other source over the last several days. In addition to Gord P’s excellent comments below on augmented spread, home care of patients reduces or eliminates exposure to Covid-19 to first responders and family members transporting patients to hospitals. It prevents patients awaiting triage, who are actually suffering from influenza or other problems, from exposure to Covid-19. It reduces exposure for hospital workers who do not provide direct care, while conserving PPE. Telemedicine reduces Covid-19 exposure and conserves PPE for providers and mobile care units are certainly feasible. Most people are more comfortable in their own homes than among overextended, burnt-out strangers, and one designated caregiver can be closely responsive to the needs of a patient, and far more comforting.
    Mind and body are not distinct, and lying alone for extended periods in a stark and strange hospital among the fearful, delirious, suffering, dying and dead, attended by worn, stressed attendants perhaps too exhausted or busy to offer comfort, does not encourage the will to live.
    Anecdotally, my grandmother, who was a nurse in the 1918 influenza pandemic in 1918, cared for soldiers at Fort Stevens, close to her home near the Oregon coast. Certainly, the young were particularly vulnerable to that flu, but the soldiers crammed together with strangers in barracks-wards, many of them away from home and family for the first time, suffered a tragic and appalling mortality rate, which my grandmother compared to a forest fire. The influenza quickly hit town and my grandmother was soon nursing fellow citizens. Isolated except for one or two family caregivers, the town doctor and my grandmother, most of these influenza patients did become desperately ill, but were lovingly nursed in their own beds. My grandmother often sat through the night with patients, reassuring them through their delirium and fevers. According to my grandmother’s detailed journal (1918-1919) and the oral history I recorded with her, she didn’t lost a patient nursed in their own home.
    My grandmother’s information accords well with my own more recent experiences working on an NIH project in equatorial Africa, when a respiratory illness swept through the village where I was based, and the different outcomes for those taken to the sub-prefecture hospital (and the deaths and illnesses of the family members who took them) as opposed to those I took care of in their compounds in the village.
    In considering the optimum place to nurse those not critically ill, I would not discount psychological factors, including the stress of hospitalization, nor the debilitating effects of despair.
    May you and yours all do well through Covid-19.

  • This sound advice is so very predictable. Of course, a concentration of virulent germ causes augmented spread. This resembles bacterial brother / “hospital bug” Methicillin-resistant Staphylococcus Aureus (MRSA). And certainly when all protective supplies run low and there is no drug, it gets worse yet. The logistics of non-clinical care must be stepped up to support this very valuable endeavour, urgently advised by professionals working in one of the worst-hit covid-19 chaos-centres in the world.
    On another note: there is zero room for the biased favoritism / blaming utterations by many responders to this article. All of humanity needs to band together to not get wiped out by a powerful bug.

  • What tests are you talking about for healthcare workers?! Is this a joke? I’m a nurse and they’re telling us to come back to work in as little as 7 days if we get symptoms. Looked it up on the CDC website and that’s what it says. We were also told that nurses won’t be able to get tested even if we have symptoms. CDC is lowering the standards of PPE requirements to the point that we’re told we don’t even need airborne precaution for anyone anymore. We all know we’re going to get it at some point but the scary part is how many patients we’re going to spread it to.

  • This selfish bigoted nurse gave the nurse looking after the screaming demented patient one of her precious stash of n95 mask. Even though the nurse was a visible minority. Even though the hospital refuse to/can’t supply nurses with n95 masks as part of PPE. You can stick your bigoted comments about white nationalists where the sun don’t shine because you’re just a judgemental wishy-washy Democrat.

  • TJ if I had a family member with the Chinese virus, I wouldn’t expect others to nurse him/her. I’d take my relative home and look after him/her myself. That’s just the kind of selfish person I am.

  • Treating a patient at home is patient-centred care if done well. When people are sick and feeling vulnerable, most prefer to be in a familiar environment where they have some control over their situation, what they do and when they do it. They can be where they want to be in their own homes, with views that suit them, rather than surrounded by strangers. They won’t need to work around hospital schedules and neither will their families who may provide much of the care with appropriate medical support. If patients deteriorate and die, most would prefer to be with family at home, than in an impersonal sterile place like a hospital or clinic. It is better for families to care for and have access to their loved ones, as long as they’re well supported in doing so. This combines the best of both worlds, patient and community centred care.

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