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Chieregato A, Veronese G, Curto F, Zaniboni M, Fossi F, Zumbo F, Scattolini C, Compagnone C, Alberti BM, Baciu C, Bergesio L, Carenini SM, Cipolla C, Formentano AC, Guidi A, Massimo F, Galluccio I, Pagani S, Paparone R, Pozzi F, Pressato L, Pugnetti E, Riganti M, Ruggieri F, Tagliaferri F, Trinchero G, Vassena E, Bassi G, Giudici R, Sacchi M, Chiara O, Agostoni EC, Grasselli G, Fumagalli R. Emergently planned exclusive hub-and-spoke system in the epicenter of the first wave of COVID-19 pandemic in Italy: the experience of the largest COVID-19-free ICU hub for time-dependent diseases. Minerva Anestesiol 2021; 87:1091-1099. [PMID: 34102806 DOI: 10.23736/s0375-9393.21.15455-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Lombardy was the epicenter in Italy of the first wave of COVID-19 pandemic. To face the contagion growth, from March 8 to May 8 2020, a regional law re-designed the hub-and-spoke system for time-dependent diseases to better allocate resources for COVID-19 patients. METHODS We report the reorganization of the major hospital in Lombardy during COVID-19 pandemic, including the rearrangement of its ICU beds to face COVID-19 pandemic and fulfill its role as extended hub for time-dependent diseases while preserving transplant activity. To highlight the impact of the emergently planned hub-and-spoke system, all patients admitted to a COVID-19-free ICU hub for trauma, neurosurgical emergencies and stroke during the two-month period were retrospectively collected and compared to 2019 cohort. Regional data on organ procurement was retrieved. Observed-to-expected (OE) in-ICU mortality ratios were computed to test the impact of the pandemic on patients affected by time-dependent diseases. RESULTS Dynamic changes in ICU resource allocation occurred according to local COVID-19 epidemiology/trends of patients referred for time-dependent diseases. The absolute increase of admissions for trauma, neurosurgical emergencies and stroke was roughly two-fold. Patients referred to the hub were older and characterized by more severe conditions. An increase in crude mortality was observed, though OE ratios for in-ICU mortality were not statistically different when comparing 2020 vs. 2019. An increase in local organ procurement was observed, limiting the debacle of regional transplant activity. CONCLUSIONS We described the effects of a regional emergently planned hub-and-spoke system for time-dependent diseases settled in the epicenter of COVID-19 pandemic in Italy.
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Affiliation(s)
- Arturo Chieregato
- Neurointensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy -
| | - Giacomo Veronese
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Francesco Curto
- Neurointensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Matteo Zaniboni
- Neurointensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Francesca Fossi
- Neurointensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Fabrizio Zumbo
- Neurointensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Carla Scattolini
- Neurointensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Christian Compagnone
- Neurointensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Beatrice M Alberti
- Neurointensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Camelia Baciu
- Neurointensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Lavinia Bergesio
- Neurointensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Stefano M Carenini
- Neurointensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Cristiana Cipolla
- Neurointensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | | | - Alessandro Guidi
- Neurointensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Francesco Massimo
- Neurointensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Irene Galluccio
- Neurointensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Silvano Pagani
- Neurointensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Rosaria Paparone
- Neurointensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Federico Pozzi
- Neurointensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Lorenzo Pressato
- Neurointensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Enrica Pugnetti
- Neurointensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Mauro Riganti
- Neurointensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Francesco Ruggieri
- Neurointensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Fernanda Tagliaferri
- Neurointensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Gabriele Trinchero
- Neurointensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Emanuele Vassena
- Neurointensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Gabriele Bassi
- Department of Anesthesia and Intensive Care 1, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Riccardo Giudici
- Department of Anesthesia and Intensive Care 1, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Marco Sacchi
- SOREU, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.,Local Organ Procurement Organization, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Osvaldo Chiara
- School of Medicine and Surgery, University of Milan, Milan, Italy.,Trauma Team, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Elio C Agostoni
- Stroke Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Giacomo Grasselli
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.,Department of Anesthesia and Intensive Care, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Roberto Fumagalli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,Department of Anesthesia and Intensive Care 1, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
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Figini MA, Paredes-Zapata D, Juan EO, Chiumello DA. Mobile Extracorporeal Membrane Oxygenation Teams for Organ Donation After Circulatory Death. Transplant Proc 2020; 52:1528-1535. [PMID: 32327262 DOI: 10.1016/j.transproceed.2020.02.045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 02/05/2020] [Indexed: 01/25/2023]
Abstract
The shortage of available organ donors is a significant problem worldwide, and various efforts have been carried out to avoid the loss of potential organ donors. Among them, organ donation from cardiocirculatory deceased donors (DCD), in which withdrawal of life-sustaining therapies is ongoing (Maastricht type III donors), is one emerging strategy. Thanks to the latest advances in transplantation and organ preservation, such as normothermic regional perfusion (NRP), ex vivo perfusion techniques, and good organization and communication among prehospital care providers, emergency departments, intensive care units, and transplantation units, DCD is rapidly increasing; it's estimated that it will increase the number of donations of lungs and splanchnic organs by more than 40%. Although Maastricht type II DCD requires a 24/7 available experienced extra corporeal membrane oxygenation (ECMO) team in the institution, Maastricht DCD type III could be organized in secondary care and spoke hospitals without in loco ECMO facilities for NRP. This article analyses a potential mobile team organization based on the hub-and-spoke model, which already exists and functions in Italy, by estimating the dimension of the controlled DCD phenomenon in Italy, coordination requirements, costs, personnel training, and education, and reporting a single center experience in Milan, Italy.
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Affiliation(s)
- Maria Adele Figini
- Department of Anesthesia and Intensive Care Unit, ASST Santi Paolo e Carlo, Milano, Italy.
| | - David Paredes-Zapata
- Donation and Transplantation Coordination Unit, Hospital Clinic, Barcelona, Spain
| | - Eva Oliver Juan
- Transplantation Unit, Hospital de Bellvitge, Barcelona, Spain
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Chieregato A, Volpi A, Gordini G, Ventura C, Barozzi M, Caspani MLR, Fabbri A, Ferrari AM, Ferri E, Giugni A, Marino M, Martino C, Pizzamiglio M, Ravaldini M, Russo E, Trabucco L, Trombetti S, De Palma R. How health service delivery guides the allocation of major trauma patients in the intensive care units of the inclusive (hub and spoke) trauma system of the Emilia Romagna Region (Italy). A cross-sectional study. BMJ Open 2017; 7:e016415. [PMID: 28965094 PMCID: PMC5640142 DOI: 10.1136/bmjopen-2017-016415] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE To evaluate cross-sectional patient distribution and standardised 30-day mortality in the intensive care units (ICU) of an inclusive hub and spoke trauma system. SETTING ICUs of the Integrated System for Trauma Patient Care (SIAT) of Emilia-Romagna, an Italian region with a population of approximately 4.5 million. PARTICIPANTS 5300 patients with an Injury Severity Score (ISS) >15 were admitted to the regional ICUs and recorded in the Regional Severe Trauma Registry between 2007 and 2012. Patients were classified by the Abbreviated Injury Score as follows: (1) traumatic brain injury (2) multiple injuriesand (3) extracranial lesions. The SIATs were divided into those with at least one neurosurgical level II trauma centre (TC) and those with a neurosurgical unit in the level I TC only. RESULTS A higher proportion of patients (out of all SIAT patients) were admitted to the level I TC at the head of the SIAT with no additional neurosurgical facilities (1083/1472, 73.6%) compared with the level I TCs heading SIATs with neurosurgical level II TCs (1905/3815; 49.9%). A similar percentage of patients were admitted to level I TCs (1905/3815; 49.9%) and neurosurgical level II TCs (1702/3815, 44.6%) in the SIATs with neurosurgical level II TCs. Observed versus expected mortality (OE) was not statistically different among the three types of centre with a neurosurgical unit; however, the best mean OE values were observed in the level I TC in the SIAT with no neurosurgical unit. CONCLUSION The Hub and Spoke concept was fully applied in the SIAT in which neurosurgical facilities were available in the level I TC only. The performance of this system suggests that competition among level I and level II TCs in the same Trauma System reduces performance in both. The density of neurosurgical centres must be considered by public health system governors before implementing trauma systems.
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Affiliation(s)
- Arturo Chieregato
- Neurorianimazione, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Annalisa Volpi
- 1a Anestesia e Rianimazione, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Giovanni Gordini
- Rianimazione ed Emergenza Territoriale 118, Ospedale Maggiore, AUSL Bologna, Bologna, Italy
| | - Chiara Ventura
- Servizio Strutture, Tecnologie e Sistemi Informativi, Direzione Generale Cura della persona, Salute, Welfare - Assessorato alla Sanità - Regione Emilia-Romagna, Bologna, Italy
- Area Governo Clinico, Agenzia Sanitaria e Sociale - Regione Emilia Romagna, Bologna, Italy
| | - Marco Barozzi
- Pronto Soccorso e Coordinamento emergenze traumatologiche, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
| | | | - Andrea Fabbri
- Pronto Soccorso e Medicina d ’Urgenza, Ospedale di Forlì, Azienda AUSL di Romagna, Forlì, Italy
| | - Anna Maria Ferrari
- Pronto Soccorso e Medicina d’Urgenza, Azienda Ospedaliera Arcispedale Santa Maria Nuova–IRCCS, Reggio Emilia, Italy
| | - Enrico Ferri
- Rianimazione ed Emergenza Territoriale 118, Ospedale Maggiore, AUSL Bologna, Bologna, Italy
| | - Aimone Giugni
- Rianimazione ed Emergenza Territoriale 118, Ospedale Maggiore, AUSL Bologna, Bologna, Italy
| | - Massimiliano Marino
- Governo Clinico - Direzione Sanitaria, Azienda USL Reggio Emilia, Reggio Emilia, Italy
| | - Costanza Martino
- Anestesia e Rianimazione, Ospedale di Cesena, AUSL di Romagna, Emilia-Romagna, Italy
| | | | - Maurizio Ravaldini
- Anestesia e Rianimazione, Ospedale di Cesena, AUSL di Romagna, Emilia-Romagna, Italy
| | - Emanuele Russo
- Anestesia e Rianimazione, Ospedale di Cesena, AUSL di Romagna, Emilia-Romagna, Italy
| | - Laura Trabucco
- Pronto Soccorso e Medicina d’Urgenza, Azienda Ospedaliera Arcispedale Santa Maria Nuova–IRCCS, Reggio Emilia, Italy
| | - Susanna Trombetti
- Area Governo Clinico, Agenzia Sanitaria e Sociale - Regione Emilia Romagna, Bologna, Italy
- UOC Cure Primarie e Specialistica S. Lazzaro-Dipartimento Cure Primarie, AUSL di Bologna, Bologna, Italy
| | - Rossana De Palma
- Area Governo Clinico, Agenzia Sanitaria e Sociale - Regione Emilia Romagna, Bologna, Italy
- Servizio Assistenza Ospedaliera, Direzione Generale Cura della Persona, Salute e Welfare - Assessorato alla Sanità - Regione Emilia Romagna, Bologna, Italy
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Chieregato A, Venditto A, Russo E, Martino C, Bini G. Aggressive medical management of acute traumatic subdural hematomas before emergency craniotomy in patients presenting with bilateral unreactive pupils. A cohort study. Acta Neurochir (Wien) 2017; 159:1553-1559. [PMID: 28435989 DOI: 10.1007/s00701-017-3190-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 04/13/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND The outcome of patients with severe traumatic brain injury (TBI) and acute traumatic subdural hematoma (aSDH) admitted to the emergency room with bilaterally dilated, unreactive pupils (bilateral mydriasis) is notoriously poor. METHODS Of 2074 TBI patients consecutively admitted to our facility between 1997 and 2012, 115 had a first CT scan with aSDH, unreactive bilateral mydriasis, and a Glasgow Coma Score of 3 or 4. Sixty-two patients were unoperated and died within hours or a few days. The remaining 53 patients (2.5% of the 2074 consecutive patients) were scheduled for emergent evacuation of the aSDH. We compared three different dosages of mannitol to landmark different comprehensive levels of treatment: (1) a "basic" level of treatment characterized by a single conventional dose (18 to 36 g), (2) "reinforced" treatment landmarked by a single high dose (54 to 72 g), and (3) "aggressive" treatment landmarked by a single high dose (90 to 106 g). Doses above 36 g were administered intravenously over a period of 5 min. RESULTS Of the 53 selected patients, 7 were aggressively managed (13.2%) and 24 (45.3%) received reinforced treatment. Rates of hyperventilation and barbiturate bolus administration were appropriately associated with increasing doses of mannitol. After adjustment for age, aggressive management was significantly associated with a lower risk of death and persistent vegetative state [adjusted OR 0.016 (95% 0.001-0.405)]. Patients surviving after aggressive management suffered more severe disability at 1 year. CONCLUSION The study shows an association between reduced mortality and persistent vegetative state, albeit at the cost of increased long-term severe disability in survivors, and aggressive medical preoperative management of mydriatic patients with aSDH following TBI.
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Affiliation(s)
- Arturo Chieregato
- Neurorianimazione, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy.
| | - Alessandra Venditto
- Ospedale "M Bufalini", Anestesia e Rianimazione, Area Vasta Romagna, Cesena, Italy
| | - Emanuele Russo
- Ospedale "M Bufalini", Anestesia e Rianimazione, Area Vasta Romagna, Cesena, Italy
| | - Costanza Martino
- Ospedale "M Bufalini", Anestesia e Rianimazione, Area Vasta Romagna, Cesena, Italy
| | - Giovanni Bini
- Ospedale "M Bufalini", Anestesia e Rianimazione, Area Vasta Romagna, Cesena, Italy
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