The heartbreaking reports from Italy come as a sobering reality check: Italy is not the worst-case scenario, it is the scenario most countries will have to face. We need to change our perspective to avoid a disaster, Italian doctors warn.
A dozen physicians in the city of Bergamo in Lombardia, Italy, have published a plea for the rest of the world: patient-centered care is inadequate in a global pandemic and must be complemented by community-centered care.
The report starts off with a heartbreaking recollection of the situation in Bergamo.
“The situation here is dismal as we operate well below our normal standard of care. Wait times for an intensive care bed are hours long. Older patients are not being resuscitated,” they add.
Faced with limited resources, doctors in Italy (and already in other countries) must make dramatic decisions. They decide who gets one of the limited ICU beds, and who does not — a decision no doctor should ever have to make.
The experience of Bergamo doctors can also be very useful for physicians in other parts of the world to better prepare for the situation. “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. Cereda and colleagues hope that physicians and policymakers will heed the warnings.
The US medical system, like that in Europe and most parts of the world, is centralized and hospital-focused. This makes an excellent environment for the virus to spread inside the hospital, and putting other patients at risk of infection is something that must be avoided.
“We need dedicated Covid-19 hospital pavilions and operators, separated from virus-free areas,” the Italian medics continue. “In hospitals, protection of medical personnel should be prioritized. No compromise should be made on protocols; equipment must be available. Measures to prevent infection must be implemented massively, in all locations and including vehicles.”
The change they are referring to in particular is home treatment. Home care and mobile clinics can avoid unnecessary movements and release pressure from hospitals, offering a much-needed breath of air.
“This approach would limit hospitalization to a focused target of disease severity, thereby decreasing contagion, protecting patients and health care workers, and minimizing consumption of protective equipment,” the researchers explain.
This would require the deployment of mobile clinics, as well as home visits. Some treatment and monitoring could be delivered to the homes of patients with non-severe symptoms, setting up a broad surveillance system, leveraging innovative telemedicine instruments, researchers say.
Medical home visits might seem like an idea from a long-gone era, but it’s this type of solution we must look towards to stave off the damage coming from the novel coronavirus.
It requires a shift in perspective, and it requires an understanding that this crisis will require community solutions.
“This outbreak is more than an intensive care phenomenon, rather it is a public health and humanitarian crisis. We urgently need humanitarian agencies who recognize the importance of local engagement,” the researchers add.
As hospitals are “nearing collapse” in resource-rich Lombardy, solutions such as these are not only worth considering — they might be paramount in the upcoming battle with the outbreak.
The researchers also draw attention to the fact that this will be a drawn-out challenge, and no country is free of problems just yet — suppression is merely the first step.
“Lockdown is paramount: social distancing reduced transmission by about 60% in China. But a further peak will likely occur when restrictive measures are relaxed to avoid major economic impact.”
