Lessons from Milan: Spine care and COVID-19

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Currently with Europe’s highest number of confirmed cases of the novel coronavirus COVID-19, Italy’s healthcare services have been forced to adopt drastic and wide-ranging measures to cope with the epidemic. Speaking to Spinal News International, Pedro Berjano, an orthopaedic spine surgeon at IRCCS Istituto Ortopedico Galeazzi in Milan, shares his experience of how services in a specialist orthopaedic centre have adapted to the outbreak.

Pedro Berjano

I’m not a professional in the field of epidemiology, thus my comments have to be read as those of a person who lives in the middle of the problem and has clinical background, but expertise in other fields. That said, in the current state of things in the occidental world, with thousands or tens of thousands of identified cases per country, and a large proportion of virus carriers who are unidentified—asymptomatic, with minor symptoms or untested—the entire population must be considered at risk of being a vector for the virus.

In this situation, the early measures of identifying the cases and isolating them are likely not useful alone, and general and strong isolation measures—such as those undertaken in Wuhan first and then in Italy—seem to be necessary for society as a whole. Only by allowing enough time for carriers of the virus to recover and lose their contagious status—at least three to four weeks, but probably more—the number of cases can be reduced sufficiently to return to a situation in which tracing the cases and their contacts and isolating them is enough. After the strong isolation measures will be relaxed, this should probably be combined with some new social etiquette—regular cleaning of hands and use of sanitisers, sanitisation of spaces, avoidance of crowds, and the universal use of face masks.

To contribute to social isolation and during this phase, we have chosen to avoid all clinical services that can be procrastinated. This is because one visit to the doctor causes a multitude of interpersonal contacts by the patient and probably by relatives, which should be avoided to keep the diffusion of the disease low.

As an orthopaedic hospital, Istituto Ortopedico Galeazzi has undertaken the following actions:

  • Participating in mandatory coordination with the regional health system authorities and strictly following their guidelines.
  • Elective activity has been cancelled. This has happened in steps, first with a week of half volume, then a week of surgery for non-intensive care unit (ICU) candidates, no surgeries needing transfusions, no patients with expected prolonged hospital stay, no patients with risk of complications, and, finally, suppression of all elective activity. For institutions that have had the time to observe the outbreak behaviour in other countries, a faster process of activity reduction might be more appropriate, as unnecessary hospital activity may act as source of spread of the infection.
  • A programme of facilitated home discharge was introduced at the outbreak of the epidemic, aiming to avoid any unnecessary days of hospital stay. The goals were to free space for the emergency and to reduce potential exposure to COVID-19 among our patients. This included the preference in favour of discharge at home rather than at closed institutions whenever possible.
  • A programme of training for doctors and health professions has been started including practical exercises to learn how to properly use protective equipment at work.
  • A filter area with temperature control and symptoms questionnaires has been initiated at the entrance of the hospital.
  • The cafeteria at the hospital has been closed.
  • All the non-indispensable personnel have been set to remote working from home.
  • COVID-19 free and specific areas and pathways have been established.
  • Following the regional authorities’ requirements, the hospital organisation has been changed, in order to dedicate the necessary resources to COVID-19 infections—today one out of three hospital beds and virtually all the ICU beds in the region are occupied by COVID-19 patients­—and to continue to provide care to patients who do not have COVID-19. Thus, specific hospitals have been designated as “hubs” for the care of specific disease areas. Consequently, the Galeazzi Institute has become one of the two hubs in the city for fractures.
  • Currently one in three of the hospital’s beds are dedicated to the treatment of COVID-19 patients —including all of the ICU beds). Orthopaedic and spine specialists are volunteering to cover ward shifts and have been trained to do so.

As a spine specialist these are a number of changes in activity that I have undertaken. All patients with office visits scheduled have been contacted. Those with problems for which there is no option to delay have been confirmed (about 5%). All the rest have been offered to replace the visit with a telemedicine consultation. Currently the office is closed seven days a week.

Additionally, all of the protocols in the office have been revised. Patients are asked to come without accompanying relatives, only one patient is admitted into the office at a time (this includes the waiting room), safety distances have been increased, hand disinfection protocols have been revised and enforced, and patients with fever or respiratory symptoms are invited to stay at home. Phone calls with patients have been increased in order to provide support to those needing spinal care.

Regarding behaviour in OR, for suspected or confirmed COVID-19 patients we have modified the surgical wear in order to combine protection of the patient and of the team. This means that the surgeon has to wear three strata of gloves, one gown with liquid barrier and one sterile gown, antibacterial mask and face screen. Such changes imply that the comfort of the surgical team is reduced and that surgery requiring more than two hours can be really challenging to perform. Also, in order to maintain the safety of the personnel—having a last pair of virus free gloves at the end of the removal of the protective equipment—the usual standards of scrubbing cannot be 100% respected. But this seems to be an unavoidable compromise with the equipment currently available.

The main lesson that we have learned in Italy is that early lockdown is essential to reduce cases and deaths. At the speed of growth of contagion in most of the occidental countries, every three to four days of delay in starting lockdown might double the number of dead. Soft lockdowns seem to be unhelpful. This is the sad maths of the epidemics.


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