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.
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.
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.