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Papa Giovanni XXIII Bergamo Hospital at the time of the COVID‐19 outbreak: Letter from the warfront…

2020; Wiley; Volume: 42; Issue: S1 Linguagem: Inglês

10.1111/ijlh.13207

1751-553X

Sabrina Buoro, Fabiano Di Marco, Marco Rizzi, Fabrizio Fabretti, Ferdinando Luca Lorini, Simonetta Cesa, S. Fagiuoli,

COVID-19 diagnosis using AI

In early December 2019, the 2019 novel coronavirus (COVID-19) was identified as the agent responsible for the first pneumonia cases of unknown origin in Wuhan, the capital of the Hubei region in China. The virus has been identified as a novel enveloped RNA betacoronavirus 2, that has been promptly named SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2). The World Health Organization (WHO), on January 12, 2020, declared the COVID-19 a public health emergency of international concern. On March 11, the WHO made the assessment that COVID-19 can be characterized as a pandemic. The COVID-19 infection, documented both in hospitals and in home settings, has spread diffusely worldwide with local minor differences, totaling over 234 073 laboratory-confirmed cases as of March 19, 2020.1 The first documented case in Italy was identified in a 38-year-old manager in the province of Lodi, Lombardy, in the north of Italy. The first documented case in our hospital (Bergamo Province, of over 1.1 million inhabitants) was identified on Friday, February 21, 2020. In this report, we describe the call for action activated to tackle the epidemic. The rapid increase of positive cases has caused, on the one hand, widespread panic among the people and on the other hand, the need for profound structural and logistical reorganizations of the Papa Giovanni XXIII Hospital. In this context, we describe the role of the laboratory. Starting from Saturday February 22, half of the infectious disease ward was dedicated to COVID-19 patients, moving 24 non-COVID-19 patients to other medical units of the same hospital or discharging them. On February 23, it became clear that this conversion was not enough and by Friday February 28, all of the 48 beds of the infectious disease unit were occupied. From that day on, every 48 hours, a new 48-bed unit was prepared, transferring out of the hospital the non-COVID-19 patients. In a rapid and tremendously organized fashion, several medical and surgical units were dismantled to create dedicated COVID-19 units, rapidly occupied by patients undergoing respiratory support (mainly continuous positive airway pressure, CPAP), up to 140 devices working simultaneously and some bi-level noninvasive ventilation, (NIV). As of March 10, 2020, five COVID-19-dedicated units (48 beds each) were progressively activated moving non-COVID-19-related patients to either other departments, external hospitals, or discharged. More than 35% of the medical personnel (approximately 400 physicians of any discipline), together with over 900 nurses, have been recruited and specifically formed to be fully dedicated to the newly born COVID-19 units. As of today, we are activating the sixth 48-bed unit. An additional 45 beds were prepared in San Giovanni Bianco Hospital (a section of our hospital, a few miles away from the main location). Simultaneously, the hospital increased the number of insensitive care unit (ICU) beds from the initially dedicated 8-bed unit to the current number of 88 ICU beds plus 12 respiratory semi-intensive unit beds. The rapid spread of the infection has led to a progressive increase in the number patients of accessing to the ER. In this context, the hematology laboratory has seen a progressive reduction of tests required for outpatients versus inpatients due to COVID-19. The laboratory plays an essential role in the diagnosis, even early, in the management, follow-up, and in the prognosis of many diseases.2 The diagnosis and the management of patients with COVID-19 are no exception to this paradigm; indeed, the molecular diagnostics testing allows for the direct identification of RNA virus, while the detection of specific antibodies for COVID-19 is the cornerstone for serological surveillance. The increase of critically ill patients has put the ICUs to the test. Therefore, there is an urgent need to identify the clinical and laboratory predictors which allow for risk assessment, the most appropriate clinical pathways, and the optimization of resource allocation. Currently, the clinical characteristics of patients with COVID-19 are well described,3-5 while few and contradictory information are available on the laboratory tests6 such as the complete blood count (CBC) parameters.7-10 Data on the most innovative parameters of the CBC profile (CBC extended) (ie, immature granulocytes, reactive lymphocytes and the nucleated red cells automatic counts, the platelet fraction or reticulated platelets, the erythrocyte and reticulocyte indices), are not currently available in literature. The only published and studied data on CBC parameters are focused on small case series which often do not exceed more than 100 subjects and are able to show that absolute lymphopenia is predictive of an increased risk of complications in ICU patients.8, 9 As a matter of fact, the evidence on all other CBC parameters shows contradictory results, perhaps due to timing in which the test is performed with respect to the development of the disease and factors such as ethnicity, gender, age, comorbidity, and possible therapeutic treatments. A puzzling factor lies adequate, but different multivariate statistical analyses that have been used in published articles. Nevertheless, we have no choice but to use whatever information is available. On a cohort of 300 COVID-19 patients randomly selected from those evaluated in the ER in the first week of the Bergamo outbreak, the lymphopenia was observed, but not anemia or thrombocytopenia. The leukocyte counts were normal, and only about 1% of subjects was observed to have the presence of circulating erythroblasts (ie, 0.02 × 109/L). Manual microscopy review showed the presence of reactive lymphocytes of which a subset appeared lymphoplasmacytoid according to Fan et al9 These are, of course, preliminary data of a timely observation from which no conclusions or indications can be drawn. These data must be supplemented with clinical information for the correct multivariate statistical analyses to be done. With regard to the safety of laboratory staff manipulating peripheral blood samples, a recent study by Wang et al11 showed that a small percentage of blood samples had positive reverse transcriptase-polymerase chain reaction (RT-PCR) test results (ie, 1%), suggesting that infection sometimes may be systemic, this study does not address the viability of the virus. The presence of viral RNA in the peripheral blood does not imply that infection may be transmitted by the parenteral route. Aerial transmission is considered the major exposure risk for coronaviruses such as SARS-CoV-2. The WHO released documents to provide interim guideline for the management of samples that might contain SARS-CoV-2.12 Iwen et al13 in a recent article points out that MERS-CoV and SARS-CoV cases as a laboratory-acquired infections are very rare and caused by incorrect safety behaviors of laboratory staff. The level of biosafety for virology labs depends on the type of activity performed. Biosafety level 2 or level 3 hoods are used for nonpropagative and propagative work of diagnostic laboratory, respectively.12 While a precise indication for all other laboratories at the moment is not available, the hematology laboratory staff must follow the rules of the biosafety and regulatory standards provided, according to the local risk assessment.13 Despite the emergency and limited time availability, more information is needed about the actual CBC pattern of COVID-19-positive subjects at different stages of disease development, for proper risk stratification, appropriateness of hospitalization and monitoring. Only this way, will it be possible to identify which, among the many parameters of the CBC extended profile, may have a real predictive value for the clinical progression and risk of complications of acute lung damage/acute respiratory distress syndrome. Only the proper production of strong scientific evidence can avoid the risk of interpretative errors, leading to potential delays in identifying the best therapeutic strategies. It should also be considered that the preparation of Papa Giovanni XXIII Hospital as the COVID-19 Hospital in Bergamo, with the total closure of health care, except for emergencies and oncological patients, will eventually lead to a delayed diagnosis of a great number of pathologic conditions, especially in hematology and oncology patients. There will be a progressive complexity of the cases which will gradually be diagnosed and require more attention and care from clinicians and many other resources to prevent worse outcomes. In the claim of great technological development and rapid sharing of information, it is necessary to enhance national and international cooperation and networks for sharing data and big data technologies from a multidisciplinary perspective. In these days, humanity is facing a long fraught road with obstacles, with an unknown destination. In this situation, time factor is the key factor in order to save as many lives as possible. Time is critical. In times of globalization, when the critical phase of this emergency is overcome, a deep reflection on global risk assessment strategies, economic, social development priorities, and development policies will be needed. It is also necessary to define and ensure a global health care and hygiene is essential at all levels, to warrant a health system which is necessarily barrier-free between states. If humanity is able to analyze this global crisis in the right perspective, maybe we can discover new horizons and new opportunities for a better future. We thank the following Crisis Unit of Papa Giovanni XXIII Hospital: Bombardieri Giulia (MD healthcare coordination), Cacciabue Eleonora (Head Healthcare coordination), Caldara Cristina (nurse in charge health and community), Canini Silvia (MD healthcare coordination), Cannistraro Valeria (MD healthcare coordination), Capelli Cinzia (bed manager), Casati Monica (Research, Education and Development), Colledan Michele (Director of the transplant department), Cosentini Roberto (Head emergency unit), D'Antiga Lorenzo (Head pediatric unit), Daleffe Luigi (nurse in charge risk management), Daminelli Marinella (nurse in charge pharmacy), Farina Claudio (Head microbiology unit), Ferrari Maddalena (nurse in charge operating rooms), Frattini Sabrina (assistant Chief Executive Officer), Fumagalli Monica (Chief Financial Officer), Ghilardi Patrizia (nurse in charge maternal child and pediatric department), Limonta Fabrizio (Health and community Chief), Pagani Gabriele (MD healthcare coordination), Pezzoli Fabio (Medical Director), Piccichè Antonio (MD healthcare coordination), Rota Lauretta (nurse in charge urgency and emergency department), Scetti Silvia (MD healthcare coordination), Spada Chiara (nurse in charge medicine and oncology department), Stasi Beatrice (Chief Executive Officer), Tomasoni Laura (nurse in charge surgery and cardiovascular department), Zanotti Anna (nurse in charge logistics and patient transport), Franca Averara (Infection Control Nurse). Laboratory staff Paola Dominoni, Michela Seghezzi, Giulia Previtali, Maria Grazia Alessio, Giovanni Guerra and to all the staff of the ASST Hospital Giovanni Paolo XXIII who today are doing everything possible to fight this pandemic.