Pubblicazioni Scientifiche
In questa sezione sono disponibili gli articoli redatti negli anni dalle strutture dell'Agenzia Regionale Emergenza Urgenza della Lombardia e pubblicati sulle principali riviste scientifiche di settore.
2025_07 Implementation of Telemedicine for Patients Referred to Emergency Medical Services
Implementazione della Telemedicina per i Pazienti che si rivolgono al Sistema di Emergenza.
Francesca Cortellaro, Lucia Taurino, Marzia Delorenzo, Paolo Pausilli, Valeria Ilardo, Andrea Duca, Giuseppe Stirparo, Giorgio Costantino, Filippo Galbiati, Ernesto Contro, Guido Bertolini, Lorenzo Fenech, and Giuseppe Maria Sechi
Abstract
Background
The surge in the use of Pre-hospital Emergency Medical Systems (EMS) and Emergency Departments (ED) has become a pressing issue worldwide after the COVID-19 pandemic. To address this challenge, we developed an experimental and innovative care pathway supported by telemedicine. The aim of this study is to describe the activity of the Integrated Medical Center (CMI): a new telemedicine-based care model for patients referring to the Emergency Medical System.
Methods
A prospective observational study was conducted from January 2022 to December 2022. The CMI was established to manage patients referring to the Emergency Medical System.
Results
From January to December 2022, a total of 8680 calls were managed by CMI, with an average of 24 calls per day. 6243 patients (71.9%) were managed without ED access, of whom 4884 patients (78.2%) were managed through telemedicine evaluation only, and 1359 (21.8%) with telemedicine evaluation and dispatch of the Home Rapid Response Team (HRRT). The population treated by the HRRT exhibited a higher age. The mean satisfaction score was 9.1/10.
Conclusions
Telemedicine evaluation allowed for remote assessments, treatment prescriptions, and teleconsultation for HRRT and was associated with high patient satisfaction. This model could be useful in future pandemics for managing patients with non-urgent illnesses at home, preventing hospital admissions for potentially infectious patients, and thereby reducing in-hospital transmission.
2025_07 Prehospital management of supraventricular tachycardia: a multicentre study of current practices with a subgroup propensity score-based comparison of adenosine and electrical cardioversion in unstable patients
Gestione preospedaliera della tachicardia sopraventricolare: studio multicentrico sulle pratiche correnti con un confronto, basato sul propensity score, tra adenosina e cardioversione elettrica nei pazienti instabili
Lorenzo Gamberini, Valeria Carinci, Paolo Pallavicini, Matteo Rovera, Marco Tartaglione, Roberto Gioachin, Annapaola D’ambrosio, Riccardo Fiameni, Simone Baroncini, Davide Allegri, Carlo Coniglio, Federico Semeraro, Giuseppe Ristagno
Abstract
Background
Supraventricular tachycardia (SVT) is a common prehospital arrhythmia that can cause life-threatening instability. Adenosine is the first-line treatment for stable SVT, but guidelines differ for unstable cases with hypotension, syncope, myocardial ischaemia, or severe heart failure. The European Resuscitation Council recommends electrical cardioversion (ECV), while the American Heart Association allows for an adenosine trial. This multicentre observational retrospective study evaluated global prehospital management strategies for SVT, subsequently focusing on adenosine vs ECV in unstable patients.
Methods
Data from 2019 to 2024 were collected from three Italian physician-staffed Emergency Medical Services. Primary outcome was the rate of successful cardioversion; secondary outcomes included the presence of life-threatening complications following cardioversion. Finally, the diagnostic accuracy of available ECG traces was evaluated. Propensity score-weighted analysis was employed to control for potential cofounding variables.
Results
Among 1234 SVT events, 819 (66.3 %) underwent prehospital cardioversion. Of these, 763 (93.2 %) received adenosine and 56 (6.8 %) underwent ECV. Unweighted cardioversion success rates were 80.1 % for adenosine and 83.9 % for ECV. In unstable patients, ECV had a weighted odds ratio of 2.41 (95 % CI: 1.01–7.14) for successful conversion. ECV was associated with more frequent sedative use compared to adenosine. No complications were observed in either groups. ECG diagnostic accuracy was 90.7 %, with dangerous misdiagnosis, such as ventricular tachycardia, occurring in fewer than 2 % of available ECG readings.
Conclusions
In patients with prehospital SVT, adenosine is the preferred cardioversion strategy. In unstable cases, adenosine may be a safe first-line attempt before ECV, potentially reducing sedation-related risks.
2025_06 A Case Report of Prehospital Point-Of-Care Ultrasound in Acute Aortic Dissection: Reinforcing the Out-of-Hospital Chain of Survival
Descrizione dell’utilizzo di ecografia preospedaliera in un caso di dissezione aortica acuta: un rinforzo della catena di sopravvivenza preospedaliera.
Alba Ripoll-Gallardo, Maddalena Cabrini, Matteo Cairo, Alessandro Mori, Valeria Diana, Pietro Boschiroli, Annibale Navoni, Giacomo Balladore, Daniele Sozzani, Antonella De Pirro, Riccardo Stucchi
Abstract
This case report highlights the importance of prehospital point-of-care ultrasound (POCUS) when acute aortic dissection is suspected. At 2:09 pm the local emergency medical services (EMS) received a call from a small town in Lombardy, Italy, reporting that a 54-years-old man had collapsed while lifting weights in a fitness club. Response teams found him lying on the floor, fully responsive and very pale; he was a lean man, with no allergies, no home therapy and no significant past medical history. He had had a transient facial paralysis and complained of dizziness and mild chest discomfort. During physical examination he became suddenly hypotensive (60/30 mmHg). The electrocardiogram showed a sinus rhythm, 80 beats per minute (bpm) and unaltered T wave and ST segment. The POCUS showed a dilated aortic root with intimal flap and small pericardial effusion. A diagnosis of Type A acute aortic dissection was made on the spot. The EMS dispatch center identified the closest hospital with available cardiothoracic surgery and provided a full report of the patient’s condition, diagnosis and initial treatment. At 3:10 pm, the patient entered the emergency room and a rapid transthoracic ultrasound confirming the diagnosis was performed in the presence of the cardiac anesthetist and cardiothoracic surgeon. The patient was agitated, tachycardic (110 bpm) and hypotensive (50/30 mmHg). Upon stabilization with intravenous norepinephrine and fluids, a computed tomographic angiogram was performed demonstrating a Stanford Type A aortic dissection with intimal flap starting from the bulb/valvular plane and extending to the origin of supra-aortic trunks down to the left common iliac artery. At 4.00 pm the patient was ready for surgery; he underwent successful ascending aorta replacement with a regular postoperative course and no signs of neurological damage. On post-operative day eight he was referred to an inpatient cardiac rehabilitation facility and later discharged home. At prehospital level, POCUS is feasible and may provide key diagnostic findings in some threatening medical (non-trauma-related) conditions that are normally diagnosticated only once the patient has reached the hospital. In addition, this report highlights a perfect interaction between out-of-hospital medical personnel, dispatch center and in-hospital multidisciplinary health staff.
2025_03 Does Calm Always Follow the Storm? A Comprehensive Temporal Analysis of Emergency Department Visits in Northern Italy Before and After the COVID-19 Pandemic
Maria José De la Rosa, Andrea Duca, Lorenzo Querci, Francesca Cortellaro, Martina Calderaro, Paolo Pausilli, Annalisa Bodina, Andrea Albonico, Gabriele Perotti, Carlo Signorelli and Massimo Lombardo
Abstract
Background/Objectives
Emergency department (ED) crowding has become a pressing global concern exacerbated by the COVID-19 pandemic. No studies have addressed this issue in Europe during the post-pandemic period so far. This study examined ED visit volumes, patient acuity, hospital admission rates, emergency vehicle arrivals, and crowding metrics before, during, and after the pandemic.
Methods
We conducted a retrospective descriptive study including data on all ED visits in the Lombardy Region of Italy from January 2019 to December 2023. Furthermore, an inferential statistical analysis was performed to compare ED trends between 2019 and 2023.
Results
During the analyzed period, there were 15,515,128 visits across all Lombardy EDs. ED visits dropped from 3,514,426 in 2019 to 2,380,005 in 2020, then rebounded to 3,464,756 in 2023. In 2019, triage code distribution was 9.9% white, 68.7% green, 19.0% yellow, and 1.9% red. During the pandemic, the proportion of white and green codes decreased. By 2023, these comprised 80.7% of the total. The percentage of admitted patients was 11.9% in 2019, rose to 16.2% in 2020, and returned to 11.4% in 2023. The median ED length of stay (EDLOS) for admitted patients in 2023 was 5.2 h (IQR [2.1–17.4]), compared to 3.8 h (IQR [1.6–8.6]) in 2019 (p-value < 0.01). The median EDLOS for discharged patients in 2023 was 2.7 h (IQR [1.4–4.9]), compared to 2.4 h (IQR [1.3–4.4]) in 2019 (p-value < 0.01). The rate of patients leaving before completing treatment was 5.0% in 2019 and peaked at 6.8% in 2023 (p-value < 0.01).
Conclusions
In 2023, ED visits in Lombardy increased, compared to the pandemic period, but remained below 2019 levels. The proportion of high-acuity codes and hospital admissions was slightly lower than in 2019. However, ED crowding metrics worsened. The high levels of lower-acuity visits and the deterioration in crowding metrics highlight systemic challenges within the healthcare system.
Keywords: emergency service; hospital; emergency room visits; crowding; COVID-19
2025_02 Monitoring and Early Warning System: Regional Monitoring Strategy in Lombardy Region
Sarah Cataldi, Elena Maria Ticozzi, Federica Morani, Annalisa Bodina, Maurizio Migliari, Gabriele Perotti, Massimo Lombardo, Fabrizio Ernesto Pregliasco and Danilo Cereda
Abstract
Background
This article examines the infectious disease surveillance system in the Lombardy region of Italy, with a focus on its response mechanisms to respiratory syndromes. This study aims to describe the alert system and the organizational procedures in place, assessing their effectiveness in managing health crises.
Methods
This study is based on the analysis of Lombardy’s regional resolution No. 1125, developed by regional public health experts. Surveillance levels were categorized based on incidence thresholds and healthcare system impacts, establishing specific indicators and activation protocols. Information flows are managed through real-time data portals, enabling the real-time monitoring of COVID-19, influenza, and other infectious respiratory diseases.
Results
A multi-level response system was established, with levels ranging from ordinary regimes to critical epidemic activation. Each level includes specific actions, such as resource reallocation, emergency department support, and the suspension of elective procedures. The use of technological tools, such as electronic health records, streamlined reporting processes, and real-time data flow management, has strengthened the region’s response capabilities.
Conclusions
This study underscores the value of a structured, multi-level response system for infectious disease management, showing that a unified regional approach improves crisis response efficiency. It suggests that sharing activation indicators and protocols within the scientific community can help harmonize national and international responses to future pandemics. The system, while effective in its current context, may require adaptation for future health challenges.
Keywords: surveillance; infectious diseases; public health; influenza
2025 The leading “blended” civil medical evacuation operation (MEDEVAC) in unforeseen health emergency. From military use to civil development
Nazzareno Fagoni, Giuseppe Stirparo, Giuseppe Maria Sechi, Andrea Comelli, Gabriele Perotti, Guido Francesco Villa, Alberto Zoli, Marco Botteri
Abstract
Introduction
Medical evacuation has historically been rooted in military contexts. It involves the systematic transfer of sick or injured individuals from the battlefield to designated medical facilities. Medical evacuation has found application in civilian settings: the Ebola outbreak and the COVID-19 pandemic. This paper examines the medical evacuation that occurred during the COVID-19 pandemic in Lombardy, Italy (Operation “MEDEVAC”), where overloaded hospitals required the transfer of patients to other regions and even internationally.
Methods
MEDEVAC was implemented by the Regional Emergency and Urgency Agency (AREU). Data from MEDEVAC were analysed using the AREU register, detailing patient characteristics, transfer logistics, and outcomes.
Results
From March to April 2020, 121 intensive care patients were transferred via MEDEVAC, primarily by air. 65 % of patients were moved to other Italian regions. The Federal Republic of Germany received 35 % of patients, all transported by air. Outcome and mortality rates among transferred patients were comparable to those within regional intensive care units. One life-threatening event was reported during transport. The return of patient to Lombardy showed a 100 % survival rate.
Conclusion
This study emphasises the importance of standardised protocols, improved information exchange systems, and enhanced training for medical personnel involved in medical evacuation. MEDEVAC was found to be feasible and able to cope with demands that were excessive in relation to available resources. This study proposes the development of a shared protocol for air transport of patients and a model for international cooperation among emergency response agencies to optimise future medical evacuation activities in civil context.
2024_11 Management Of Psychiatric Emergencies and Associated Comfort Among EMS Physicians in Lombardy, Italy: A Cross-Sectional Study
Valutazione delle competenze e del livello di comfort relativi alla gestione delle emergenze psichiatriche da parte dei medici in servizio di emergenza preospedaliera: uno studio trasversale.
Alba Ripoll-Gallardo, Elisa Scarpolini, Giacomo Colzani, Roberto Biella, Ilaria Offredi, Roberto Di Silvestre, Claudia Giannotti, Giuseppe Maria Sechi, Roberto Fumagalli, Rita E Fioravanzo, Riccardo Stucchi
Abstract
Objectives
The aims of this study were to explore the knowledge of EMS physicians (EMSPs) on the legal aspects related to the management of prehospital psychiatric emergencies, assess their degree of comfort, and measure their perceived communication skills.
Methods
A survey was distributed to the 376 EMSPs working in the prehospital setting in Lombardy, Italy. Knowledge of medico-legal aspects was measured through multiple-choice questions; the Comfort Score (CS) and perceived Communication Skills Score (CSS) were calculated using Likert Scale questions. CS ranged from 11 points (lowest) to 44 (highest); CSS ranged from 8 points (lowest) to 32 (highest).
Results
A total of 272 EMSPs answered the survey (RR= 72.3%); 45.2% were women. Mean age was 45.76 years (SD 8.8). Mean percentage of correct knowledge test answers was 52.4 (SD 12.3); 81.3% believed to have little knowledge of the Italian legislation regarding this topic. Mean CS was 29.3 (SD 5.5); mean CSS was 19.1 (SD 3.9). A higher percentage of correct answers in the knowledge test was associated with lower CS (P = 0.019). Higher self-appraised knowledge of the Italian legislation was associated with higher CS (P < 0.001) and higher CSS (P < 0.001).
Conclusions
These findings should prompt policy makers to ensure proper training and support for EMSPs in the matter of prehospital psychiatric emergency management.
2024_07 Italy’s Post-COVID-19 Stroke Network: Has It Returned to Pre-Pandemic Standards?
Erika Kacerik, Francesca Bottega, Aida Andreassi, Giuseppe Sechi, Alberto Zoli, Marco Botteri, Carlo Signorelli and Nazzareno Fagoni
Abstract
The COVID-19 pandemic strongly transformed the healthcare system in the Lombardy region (Italy), forcing a rapid reorganization of hospital structures. The emergency medical service (EMS) system and emergency departments (EDs) were among the most affected departments. Several studies have shown a change in the epidemiology of time-dependent pathologies, such as stroke, during the pandemic’s peak. However, there is little scientific evidence regarding the interpandemic phase. The regional register for ED accesses (EUOL) was analyzed, taking into consideration all accesses for stroke and stroke-like syndromes during the years 2019, 2020, and 2021. The analysis shows a significant difference in the average number of diagnoses per month [2092 vs. 1815 vs. 2015, respectively (p < 0.05)] and an increase in the percentage of transports carried out by EMS vehicles to EDs [17% vs. 25% vs. 22%, respectively (p < 0.05)]. The length of stay (LOS) increased for both discharged patients (9.0 vs. 10.1 vs. 11.2 h, respectively; p < 0.005) and hospitalized patients (7.5 vs. 9.7 vs. 10.6 h, respectively; p < 0.005). During the COVID-19 pandemic, the overall number of stroke diagnoses decreased, while the percentage of patients transported to EDs by EMS vehicles increased. Furthermore, an increased processing time in EDs was highlighted.
Keywords: emergency department; COVID-19; stroke; Lombardy region
2024_07 Reshaping Emergency Care: Dynamics of OHCA and STEMI in a Three-Year Analysis
Francesca Bottega, Erika Kacerik, Gabriele Perotti, Carlo Signorelli and Giuseppe Ristagno
Abstract
The COVID-19 pandemic drastically reshaped healthcare in Lombardy, Italy, notably impacting EMS and emergency departments and altering the epidemiology of time-dependent pathologies such as STEMI and OHCA. While previous studies focused on modifications during the pandemic peak, with an increase in the number of OHCA diagnoses and a reduction in the number of STEMI, little evidence exists regarding the inter-pandemic phases. We analyzed OHCA and STEMI accesses to the ED in the regional emergency department access register (EUOL) for 2019–2021. The analysis revealed a significant difference in monthly diagnosis averages. For STEMI, the change was statistically significant (F(2, 33) = 4.45, p = 0.02), while it was not for OHCA (F(2, 33) = 0.18, p = 0.83). Despite the monthly decreases, the likelihood of receiving a STEMI diagnosis increased with total accesses, OR 1.40 [95% CI 1.25–1.58, p < 0.0001]. Additionally, there was a significant increase in March 2020 discharge diagnoses for OHCA compared to March 2019, OR 3.35 [95% CI 2.88–3.90, p < 0.0001], corresponding to the first pandemic wave. Therefore, our analysis indicates that the epidemiology of STEMI and OHCA was altered during the COVID-19 pandemic.
Keywords: emergency department; COVID-19; OHCA; STEMI; Lombardy region
2024_05 Out-of-Hospital Cardiac Arrest in the Paediatric Patient: An Observational Study in the Context of National Regulations
Roberta Pireddu, Giuseppe Ristagno, Lorenzo Gianquintieri, Rodolfo Bonora, Andrea Pagliosa, Aida Andreassi, Giuseppe Maria Sechi, Carlo Signorelli and Giuseppe Stirparo
Abstract
Introduction
Cardiac arrest results in a high death rate if cardiopulmonary resuscitation and early defibrillation are not performed. Mortality is strongly linked to regulations, in terms of prevention and emergency–urgency system organization. In Italy, training of lay rescuers and the presence of defibrillators were recently made mandatory in schools. Our analysis aims to analyze Outof-Hospital Cardiac Arrest (OHCA) events in pediatric patients (under 18 years old), to understand the epidemiology of this phenomenon and provide helpful evidence for policy-making.
Methods
A retrospective observational analysis was conducted on the emergency databases of Lombardy Region, considering all pediatric OHCAs managed between 1 January 2016, and 31 December 2019. The demographics of the patients and the logistics of the events were statistically analyzed.
Results
The incidence in pediatric subjects is 4.5 (95% CI 3.6–5.6) per 100,000 of the population. School buildings and sports facilities have relatively few events (1.9% and 4.4%, respectively), while 39.4% of OHCAs are preventable, being due to violent accidents or trauma, mainly occurring on the streets (23.2%).
Conclusions
Limiting violent events is necessary to reduce OHCA mortality in children. Raising awareness and giving practical training to citizens is a priority in general but specifically in schools.
Keywords: epidemiology; public health; policy; OHCA
2024_05 What If Nice Terrorist Attack Would Have Happened in Milan? Drawing a Disaster Plan for Mass Casualty Incidents Involving the Pediatric Population
Cosa sarebbe successo se l’attentato terroristico di Nizza fosse accaduto a Milano? Disegno di un piano d’emergenza per eventi di massa che coinvolgono la popolazione pediatrica
Margherita Difino, Riccardo Stucchi, Eric S. Weinstein, Maurizio De Pellegrin, Alberto Zoli, Giuseppe Maria Sechi, Roberto Faccincani
Abstract
Terrorist attacks involving children raised concern regarding the preparedness to treat pediatric trauma patients during mass casualty incidents (MCIs). The purpose of this project was to assess the resources available in Milan to respond to MCIs as the 2016 Bastille Day attack in Nice. Literature and guidelines were reviewed and minimal standard requirements of care of pediatric trauma patients in MCIs were identified. The hospitals that took part in the study were asked to answer a survey regarding their resource availability. An overall surge capability of 40-44 pediatric trauma patients was identified, distributed based on age and severity, hospital resources, and expertise. The findings showed that adult and pediatric hospitals should work in synergy with pediatric trauma centers, or offer an alternative if there is none, and should be included in disaster plans for MCIs. Simulations exercises need to be carried out to evaluate and validate the results.
2024_04 Acute Lung Injury after Cardiopulmonary Resuscitation: A Narrative Review
Giuseppe Marchese, Elisabetta Bungaro, Aurora Magliocca, Francesca Fumagalli, Giulia Merigo, Federico Semeraro, Elisa Mereto, Giovanni Babini, Erik Roman-Pognuz, Giuseppe Stirparo, Alberto Cucino and Giuseppe Ristagno
Abstract
Although cardiopulmonary resuscitation (CPR) includes lifesaving maneuvers, it might be associated with a wide spectrum of iatrogenic injuries. Among these, acute lung injury (ALI) is frequent and yields significant challenges to post-cardiac arrest recovery. Understanding the relationship between CPR and ALI is determinant for refining resuscitation techniques and improving patient outcomes. This review aims to analyze the existing literature on ALI following CPR, emphasizing prevalence, clinical implications, and contributing factors. The review seeks to elucidate the pathogenesis of ALI in the context of CPR, assess the efficacy of CPR techniques and ventilation strategies, and explore their impact on post-cardiac arrest outcomes. CPR-related injuries, ranging from skeletal fractures to severe internal organ damage, underscore the complexity of managing post-cardiac arrest patients. Chest compression, particularly when prolonged and vigorous, i.e., mechanical compression, appears to be a crucial factor contributing to ALI, with the concept of cardiopulmonary resuscitation-associated lung edema (CRALE) gaining prominence. Ventilation strategies during CPR and post-cardiac arrest syndrome also play pivotal roles in ALI development. The recognition of CPR-related lung injuries, especially CRALE and ALI, highlights the need for research on optimizing CPR techniques and tailoring ventilation strategies during and after resuscitation.
Keywords: cardiac arrest; cardiopulmonary resuscitation; lung injury; lung edema
2024 Cardiac arrest and medical technological innovations in the next decade: How about artificial intelligence-assisted tailored cardiopulmonary resuscitation?
Alberto Cucino, Francesco Palmisano, Giuseppe Stirparo, Giulia Merigo, Giuseppe Ristagno
2024 Changing the stroke network during pandemic scenarios does not affect the management of patients with a positive Cincinnati prehospital stroke scale
Nazzareno Fagoni, Lorenzo Bellini, Rodolfo Bonora, Marco Botteri, Maurizio Migliari, Andrea Pagliosa, Giuseppe Maria Sechi, Carlo Signorelli, Alberto Zoli, Giuseppe Stirparo
Abstract
Introduction
Time plays a crucial role in the management of stroke, and changing the prehospital emergency network, altering the HUB and spoke relationship in pandemic scenarios, might have an impact on time to fibrinolysis or thrombectomy. The aim of this study was to evaluate the time-dependent stroke emergency network in Lombardy region (Italy) by comparing 2019 with 2020 and early 2021. Three parameters were investigated: (i) time of arrival of the first vehicle at the scene, (ii) overall duration of missions, and (iii) number of patients transported by emergency vehicles.
Methods
Data analysis process conducted using the SAS-AREU portal (SAS Institute, USA).
Results
The number of patients with a positive CPSS was similar among the different pandemic waves. Mission duration increased from a mean time (SD) of 52.9 (16.1) min in 2019 to 64.1 (19.7) in 2020 and 55.0 (16.8) in 2021. Time to first vehicle on scene increased to 15.7 (8.4) min in 2020 and 16.0 (7.0) in 2021 compared to 2019, 13.6 (7.2) (P < 0.05). The number of hospital with available stroke units decreased from 46 in 2019 to 10 during the first pandemic wave.
Conclusions
The pandemic forced changes in the clinical mission of many hospitals by reducing the number of stroke units. Despite this, the organization of the emergency system allowed to identify strategic hospitals and thus avoid excessive transport time. The result was an adequate time for fibrinolysis/thrombectomy, in agreement with the guidelines. Coordinated management in emergency situations makes it possible to maintain service quality standards, despite the unfavorable scenario.
Keywords Prehospital · Emergency medical services · Cerebral ischemia
2024 Do different mechanical compressors provide equivalent hemodynamic support during cardiopulmonary resuscitation?
Ivan Silvestri, Giuseppe Stirparo, Claudia Bonetti, Beatrice Guerra Maria, Serena Ruberti, Anna Coppo, Maurizio Migliari, Giuseppe Ristagno
2024 Telephone calls to emergency medical service as a tool to predict influenza-like illness: A 10-year study
Rodolfo Bonora, Elena Maria Ticozzi, Fabrizio Ernesto Pregliasco, Andrea Pagliosa, Annalisa Bodina, Danilo Cereda, Gabriele Perotti, Massimo Lombardo, Giuseppe Stirparo
Abstract
Objectives
Influenza-like illness (ILI) refers to the set of symptoms associated with seasonal influenza infection. In Italy, the syndromic surveillance system RespiVirNet uses both epidemiological and virological data to monitor ILI incidence with a weekly cadence. To estimate ILI incidence in real time, several countries adopted surveillance systems which include data from the emergency-urgency (E-U) system. The aim of this study was to evaluate the relationship between the number of calls for respiratory symptoms to the E-U system and the regional incidence of ILI cases identified by the Italian syndromic surveillance system.
Study design
Retrospective observational cohort study
Methods
We analyzed data in the Lombardy region for the flu season from 2014 to 2024, excluding the COVID-19 pandemic period (from 2020 to 2022). We performed a linear regression analysis considering ILI incidence as the dependent variable and the percentage of respiratory calls to the E-U system as the independent variable.
Results
Statistical analysis showed a positive correlation (r = 0.70), with a statistically significant coefficient of 1.34 (p-value <0.001) and R2 of 0.50.
Conclusions
The observed correlation highlights the potential use of prehospital E-U system data in the surveillance systems of infectious diseases by using real-time data, encouraging future research to explore the limits and possibilities of an integrated surveillance system.
2024 Transthoracic impedance variability to assess quality of chest compression in out-of-hospital cardiac arrest
Aurora Magliocca, Valentina Castagna, Carla Fornari, Gabriele Zimei, Giulia Merigo, Alessio Penna, Jonas Carlson, Francesca Fumagalli, Giuseppe Stirparo, Maurizio Migliari, Anna Coppo, Giuseppe Maria Sechi, Giacomo Grasselli, Bjarne Madsen Hardig, Giuseppe Ristagno
Abstract
Background
Chest compression is a lifesaving intervention in out-of-hospital cardiac arrest (OHCA), but the optimal metrics to assess its quality have yet to be identified. The objective of this study was to investigate whether a new parameter, that is, the variability of the chest compression-generated transthoracic impedance (TTI), namely ImpCC, which measures the consistency of the chest compression maneuver, relates to resuscitation outcome.
Methods
This multicenter observational, retrospective study included OHCAs with shockable rhythm. ImpCC variability was evaluated with the power spectral density analysis of the TTI. Multivariate regression model was used to examine the impact of ImpCC variability on defibrillation success. Secondary outcome measures were return of spontaneous circulation and survival.
Results
Among 835 treated OHCAs, 680 met inclusion criteria and 565 matched long-term outcomes. ImpCC was significantly higher in patients with unsuccessful defibrillation compared to those with successful defibrillation (p = .0002). Lower ImpCC variability was associated with successful defibrillation with an odds ratio (OR) of 0.993 (95% confidence interval [95% CI], 0.989–0.998, p = .003), while the standard chest compression fraction (CCF) was not associated (OR 1.008 [95 % CI, 0.992–1.026, p = .33]). Neither ImpCC nor CCF was associated with long-term outcomes.
Conclusions
In this population, consistency of chest compression maneuver, measured by variability in TTI, was an independent predictor of defibrillation outcome. ImpCC may be a useful novel metrics for improving quality of care in OHCA.
Keywords: cardiopulmonary resuscitation, chest compression fraction, outcome, transthoracic impedance, variability
2023_12 Development and Validation of a New Tool to Improve the Accuracy of the Hospital Mass-Casualty Incident Response Plan Activation: The PEMAAF Score
Sviluppo e validazione di un nuovo strumento per migliorare l’accuratezza dell’attivazione del piano di risposta ospedaliera agli eventi di massa: il PEMAAF score
Claudia Ruffini, Monica Trentin, Alberto Corona, Marta Caviglia, Giuseppe Maria Sechi, Maurizio Migliari, Riccardo Stucchi, Luca Ragazzoni, Roberto Fumagalli
Abstract
Introduction
Effective response to a mass-casualty incident (MCI) entails the activation of hospital MCI plans. Unfortunately, there are no tools available in the literature to support hospital responders in predicting the proper level of MCI plan activation. This manuscript describes the scientific-based approach used to develop, test, and validate the PEMAAF score (Proximity, Event, Multitude, Overcrowding, Temporary Ward Reduction Capacity, Time Shift Slot [Prossimità, Evento, Moltitudine, Affollamento, Accorpamento, Fascia Oraria], a tool able to predict the required level of hospital MCI plan activation and to facilitate a coordinated activation of a multi-hospital network.
Methods
Three study phases were performed within the Metropolitan City of Milan, Italy: (1) retrospective analysis of past MCI after action reports (AARs); (2) PEMAAF score development; and (3) PEMAAF score validation. The validation phase entailed a multi-step process including two retrospective analyses of past MCIs using the score, a focus group discussion (FGD), and a prospective simulation-based study. Sensitivity and specificity of the score were analyzed using a regression model, Spearman’s Rho test, and receiver operating characteristic/ROC analysis curves.
Results
Results of the retrospective analysis and FGD were used to refine the PEMAAF score, which included six items–Proximity, Event, Multitude, Emergency Department (ED) Overcrowding, Temporary Ward Reduction Capacity, and Time Shift Slot–allowing for the identification of three priority levels (score of 5-6: green alert; score of 7-9: yellow alert; and score of 10-12: red alert). When prospectively analyzed, the PEMAAF score determined most frequent hospital MCI plan activation (>10) during night and holiday shifts, with a score of 11 being associated with a higher sensitivity system and a score of 12 with higher specificity.
Conclusions
The PEMAAF score allowed for a balanced and adequately distributed response in case of MCI, prompting hospital MCI plan activation according to real needs, taking into consideration the whole hospital response network.
2023_12 Prehospital Mass Casualty Incident Response to a Fire in a Nursing Home in Milan, Italy: Actions Taken and Shortcomings
Risposta preospedaliera ad un evento di massa in seguito ad un incendio in una casa di riposo a Milano, Italia: azioni intraprese e criticità
Alba Ripoll-Gallardo, Annapaola D’Ambrosio, Paola Manzoni, Vincenzo Grifone, Catia Pedrazzi, Giovanni De Luca, Davide Arghetti, Armando Stellini, Alessandro Zambelan, Ilaria Ruggiero, Riccardo Cusmà-Piccione, Gianluca Bacullo, Franco Lorito, Paolo Perbellini, Matteo Giacovelli, Massimo De Donno, Simone Pelà, Giacomo Colzani, Elena Brioschi, Gianluca Chiodini, Giuseppe Sechi, Alberto Zoli, Roberto Fumagalli, Riccardo Stucchi
Abstract
On July 7, 2023, at 1:21 am, a fire was declared in a retirement home in Milan, Italy. The number of casualties (n = 87) according to the Simple Triage and Rapid Treatment (START) triage system was categorized as 65 green, 14 yellow, 2 red, and 6 black; 75% were women, and the mean age was 85.1 years (± 9). Most patients were unable to walk. A total of 30 basic life support (BLS) ambulances, 3 advanced cardiac life support (ACLS) teams on fast cars, 2 buses, and 1 coordination team were deployed. A scoop and run approach was adopted with patients being transported to 15 health care facilities. The event was terminated at 5:43 am. Though the local mass casualty incident (MCI) response plan was correctly applied, the evacuation of the building was difficult due to the age and comorbidities of the patients. START failed to correctly identify patients categorized as minor. Communication problems arose on site that led to the late evacuation of critical patients.
2023_09 Severe Acute Respiratory Syndrome Coronavirus 2 and Medical Evacuation in Lombardy: Lessons Learned from an Unprecedented Pandemic
Sindrome respiratoria acuta severa da coronavirus di tipo 2 ed evacuazione sanitaria in Lombardia: insegnamenti acquisiti da una pandemia senza precedenti
Riccardo Stucchi, Alba Ripoll-Gallardo, Giuseppe Maria Sechi, Eric S. Weinstein, Guido Francesco Villa, Cristina Frigerio, Federico Federighi, Giacomo Grasselli, Alberto Zoli, Rodolfo Bonora, Roberto Fumagalli, AREU Crisis Unit
Abstract
The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerging infectious disease pandemic developed in Lombardy (northern Italy) during the last week of February 2020 with a progressive increase of patients presenting with serious clinical findings. Despite the efforts of the Central Italian Government, regional resources were rapidly at capacity. The solution was to plan the medical evacuation (MEDEVAC) of 119 critically ill patients (median age 61 years) to in-patient intensive care units in other Italian regions (77) and Germany (42). Once surviving patients were deemed suitable, the repatriation process concluded the assignment. The aim of this report is to underline the importance of a rapid organization and coordination process between different nodes of an effective national and international network during an emerging infectious disease outbreak and draw lessons learned from similar published reports.
2023_09 The impact of the Italian law mandating an automatic external defibrillator in all sports venues on sudden cardiac arrest resuscitation rates
Alessandro Gianni, Marco Botteri, Giuseppe Stirparo, Giulia Mattesi, Alessandro Zorzi, and Guido Francesco Villa
2023_07 How the Italian Formula 1 Grand Prix 2022 Mass Gathering Event Compares to the Arbon Model: A Descriptive Study
Il Gran Premio Italiano di Formula 1 2022 come raduno di massa a confronto con il modello di Arbon: uno studio descrittivo
Andrea Paleari, Stefano Spina, Francesco Marrazzo, Alba Ripoll, Fabio Volontè, Gianluca Greco, Alberto Zoli, Giuseppe Maria Sechi, Diego Saggiante, Gianluca Chiodini, Riccardo Stucchi, Roberto Fumagalli
Abstract
Objective
To describe the health-care resources implemented during the Italian Formula 1 Grand Prix (F1GP) and to calculate the patient presentation rate (PPR) based on both real data and a prediction model.
Methods
Observational and descriptive study conducted from September 9 to September 11, 2022, during the Italian F1GP hosted in Monza (Italy). Maurer’s formula was applied to decide the number and type of health resources to be allocated. Patient presentation rate (PPR) was computed based on real data (PPR_real) and based on the Arbon formula (PPR_est).
Results
Of 336,000 attendees, n = 263 requested medical assistance with most of them receiving treatment at the advanced medical post, and n = 16 needing transport to the hospital. The PPR_real was 51 for Friday, 78 for Saturday, 134 for Sunday, and 263 when considering the whole event as a single event. The PPR_est resulted in 85 for Friday, 93 for Saturday, 97 for Sunday, and 221 for the total population.
Conclusions
A careful organization of health-care resources could mitigate the impact of the Italian F1GP on local hospital facilities. The Arbon formula is an acceptable model to predict and estimate the number of patients requesting medical assistance, but further investigation needs to be conducted to implement the model and tailor it to broader categories of MGE.
2023_03 Out of hospital cardiac arrest in sporting facilities: an overview of rescue for sideline doctors
Arresto cardiocircolatorio extraospedaliero negli impianti sportivi, un’analisi del soccorso a supporto dei medici a bordo campo
Mario I. Sturla, Erika Kacerik, Aida Andreassi, Luca Pacciolla, Guido F. Villa, Giuseppe M. Sechi, Giuseppe Stirparo
Riassunto
Obiettivo
L’arresto cardiocircolatorio extraospedaliero (out-of-hospital cardiac arrest, OHCA) durante gli eventi sportivi è un evento raro ma comunque rilevante, che deve essere prontamente affrontato sia dai medici a bordo campo sia, in loro assenza, dai non addetti ai lavori presenti in loco. È stato dimostrato che l’uso di manovre di RCP (rianimazione cardiopolmonare) e dei PAD (defibrillatori ad accesso pubblico) aumenta la possibilità di ROSC e migliora l’esito dei pazienti. Lo scopo del nostro studio è quello di analizzare le caratteristiche dei pazienti soccorsi nelle strutture sportive della Lombardia, le manovre eseguite in loco e l’outcome dei pazienti.
Metodi
Studio osservazionale di coorte retrospettivo condotto nella regione Lombardia. I dati sono stati forniti dal registro sul sito di AREU. Sono state analizzate le registrazioni degli arresti cardiaci nel database EmMa dal 1° gennaio 2017 al 31 dicembre 2019.
Risultati
Il Sistema di Emergenza Urgenza di AREU ha soccorso 35.362 pazienti con OHCA, di cui lo 0,42% (N.=149) in impianti sportivi. Il tempo medio di arrivo del primo mezzo in posto è stato di 11,3±6,8 minuti, mentre il tempo medio di arrivo in ospedale è stato di 52,7±25,7 minuti. Il 76,0% dei pazienti ha ricevuto la RCP. I PAD sono stati utilizzati nel 43,0% degli eventi. In 32 casi (21,5%), i pazienti che hanno ricevuto CRP con PAD hanno raggiunto il ROSC.
Conclusioni
La formazione obbligatoria per dirigenti e allenatori potrebbe aumentare la possibilità di ROSC negli impianti sportivi e durante gli eventi sportivi, anche in caso di assenza dei medici a bordo campo. I medici a bordo campo dovrebbero avere familiarità con la formazione BLS-D e la formazione ACLS.
Parole chiave: Arresto cardiaco extraospedaliero; Medicina dello sport; Strutture per lo sport e il tempo libero.
2023_01 Social Illness Before and After the COVID-19 Pandemic: A Regional Study
Giuseppe Stirparo, Roberta Pireddu, Aida Andreassi, Giuseppe Maria Sechi, Carlo Signorelli
Abstract
Introduction
Coronavirus disease 2019 (COVID-19) has dramatically changed the epidemiology of several diseases.Much evidence on this has been published in the pandemic phase. In addition, many studies have shown that phenomena such as stress, substance abuse, and burnout increased in the general population during the lockdown. Unfortunately, few studies analyze the post-pandemic phase.
Study Objective
The study aimed to evaluate the trend of broad social problems, such as a diagnosis by the emergency department (ED), in the post-pandemic phase in the Lombardy (Italy) region.
Methods
The study is a retrospective observational cohort study. All admissions to emergency rooms in the Lombardy region registered in the Emergency Urgency OnLine (EUOL) portal made from January through June 2019 were analyzed, having as main causes: psychiatric disorders, self-harm, substance abuse, social disadvantage, and violence. All accesses in emergency rooms in the Lombardy region registered in the EUOL portal made from January 1, 2019 through June 30, 2019 were analyzed and compared with the same period in 2022.
Results
The study recorded an increase in the likelihood of events of self-harm (OR = 2.1; 95% CI, 1.8-2.6; P <.0001), substance abuse (OR = 1.2; 95% CI, 1.1-1.3; P <.0001), violence by others (OR = 1.3; 95% CI, 1.2-1.4; P <.0001), and social disadvantage (OR = 1.2; 95% CI, 1.1-1.4; P = .0045). The events are more concentrated in suburban areas (OR = 1.3; 95% CI, 1.2-1.4; P <.001).
Conclusion
The increase in diagnoses of these social problems in the ED is only the culmination of a phenomenon that hides an underlying rise in social illness. In the post-COVID-19 phase, there is a need to invest in community care and social illness prevention policies.
2023 Effectiveness of Cardiopulmonary Resuscitation at the Workplace
Lorenzo Bellini, Nazzareno Fagoni, Aida Andreassi, Giuseppe Maria Sechi, Rodolfo Bonora, Giuseppe Stirparo
Abstract
Background
Out-of-Hospital Cardiac Arrest (OHCA) is a medical emergency whose chances of survival can be increased by rapid Cardiopulmonary Resuscitation (CPR) and early use of Public Access Defibrillators (PAD). Basic Life Support (BLS) training became mandatory in Italy to spread knowledge of resuscitation maneuvers in the workplace. Basic Life Support (BLS) training became mandatory according to the DL 81/2008 law. To improve the level of cardioprotection in the workplace, the national law DL 116/2021 increased the number of places required to be provided with PADs. The study highlights the possibility of a Return to spontaneous circulation in OHCA in the workplace.
Methods
A multivariate logistic regression model was fitted to the data to extrapolate associations between ROSC and the dependent variables. The associations’ robustness was evaluated through sensitivity analysis.
Results
The chance to receive CPR (OR 2.3; 95% CI:1.8-2.9), PAD (OR 7.2; 95% CI:4.9-10.7), and achieve Return to spontaneous circulation (ROSC) (crude OR 2.2; 95% CI:1.7-3.0, adjusted OR 1.6; 95% CI:1.2-2.2) is higher in the workplace compared to all other places.
Conclusion
The workplace could be considered cardioprotective, although further research is necessary to understand the causes of missed CPRs and identify the best places to increase BLS and defibrillation training to help policymakers implement correct programming on the activation of PAD projects.
Keywords: Out-of-Hospital Cardiac Arrest; Workplace; Emergency Medical Services; Resuscitation
2023 Emergency department waiting-time in the post pandemic era: new organizational models, a challenge for the future
Giuseppe Stirparo, Erika Kacerik, Aida Andreassi, Paolo Pausilli, Francesca Cortellaro, Anna Coppo, Maurizio Migliari, Andrea Albonico, Giuseppe Maria Sechi, Alberto Zoli, Carlo Signorelli
Abstract
Background and aim
Covid-19 has profoundly changed the Emergency Department system in Lombardy, especially for the type of accesses and the number of diagnoses. Accordingly, the pre-hospital rescue system has undergone heavy changes, in particular regarding the times of rescue. Despite this, studies concerning the post-pandemic phase are lacking to understand whether the conditions of the emergency systems has resumed to the pre-pandemic period. The aim of the study is to evaluate the length of stay (LOS) phenomenon in the emergency departments (EDs) in the post-pandemic era.
Methods
A retrospective observational study was conducted, which analyzed the first six months of the years 2019, 2021 and 2022. The pandemic peak phase, corresponding to the first months of 2020, wasn’t included. The investigated area included the provinces of Milan and Monza, a metropolitan area with 4 million inhabitants.
Results
The average time spent by patients in the ED increased by +3.8 hours in 2022 and by +1.3 hours in 2021 compared to 2019. The average time from ED access to hospitalization also increased by +4.8 hours in 2022 and +5.0 hours in 2021 compared to 2019. The percentage of time in ED recorded in a National Emergency Department Overcrowding Study (NEDOCS) in black code in 2022 reached 5.4% against 1.7% in 2021 and 0.5 % in 2019.
Conclusions
Data show an increase in the time spent in the EDs and an increase in the overcrowding, according to the NEDOCS index. New management models and a reorganization of EDs are needed as the workload has increased significantly. (www.actabiomedica.it)
Key words: Length of Stay, Emergency Departments, Health system organization, Post pandemic era
2023 Management of possible stroke by laypeople in pre-hospital setting: Who should we train?
Giuseppe Stirparo, Erika Kacerik, Giuseppe Ristagno, Aida Andreassi, Anna Coppo, Maurizio Migliari, Andrea Albonico, Giuseppe Maria Sechi, Alberto Zoli, Carlo Signorelli
Abstract
Background and aim
The pre-hospital management of a possible stroke is fundamental for the transport of patients to the correct HUB facility; thus, they must be transported to the Emergency Department (ED) by EMS vehicles. Our study aims to analyze the factors correlated with a higher probability of accessing the ED through the EMS in this event.
Methods
This is a retrospective observational study. All accesses in the 120 EDs of the Lombardy region, with a diagnosis of discharge whose symptoms could resemble CPSS, were analyzed between 1 January 2019 and 31 December 2019.
Results
We identified an increased probability of using the EMS vehicles of 0,05% (I.C. 95%: 0.04% - 0.06%; p<0.0001) for each additional year of age, considering patients aged 20 to 100 years and the percentage was significantly higher in the female population (58% vs 49%; p<0.001). Moreover, we calculated that the incidence of stroke was approximately 140 cases per 100,000 inhabitants. Conclusions
Only half of the citizens in the Lombardy region use the EMS in case of suspicion of stroke; further information campaigns are essential to educate citizens. Information strategies should be directed especially at men between 30 and 59 years old. (www.actabiomedica.it)
Key words: emergency care pre-hospital, emergency medical services, Italy, stroke, training
2023 Spring, it’s time to ROSC
Giuseppe Stirparo, Aida Andreassi, Giuseppe Maria Sechi, Carlo Signorelli
Summary
Out‑hospital cardiac arrest (OHCA) is a multi‑factor disease. Many studies have correlated OHCA with a patient’s lifestyle; unfortunately, less evidence highlights the correlation with meteorological factors. Methods: Analysis of 23959 OHCA rescue performed by the emergency medical system (EMS) of Lombardy Region, the most Italian populated region, in 2018 and 2019, the pre‑pandemic era through a retrospective observational cohort study. The aim of the study consists on evaluating the probability of Return Of Spontaneous Circulation (ROSC) during months to highlight potential seasonal impact in ROSC achievement. In March and April, we highlight an increase of ROSC (OR: 1.20 95% CI 1.04‑1.31; p < 0.001) compared to other months. During March and April, we highlight an increase of public access defibrillation (PAD) (3.5% vs 2.5%; p < 0.001), and a reduction of overage time of first vehicle on scene (11.5 vs 11.8; p < 0.001) and age of patient (73.5 vs 74.2; p < 0.01). Finally, we highlight a slight reduction of cancer patient (1.6% vs 1.1%; p = 0.01). We didn’t register significant differences in the other variables analyzed as: onset place, sex, rescue team and the patient’s death before the rescue arrive. We highlight a difference in ROSC probability during the first month of spring. We register few differences in patient characteristics and EMS rescue, though just PAD use and age clinically impact OHCA patients. In this study, we are unable to fully understand the modification of the probability of ROSC in these months. Even though four variables have a statistically significant difference, they can’t fully explain this modification. Different variables like meteorological and seasonal factor must be considered. We propose more research on this item.
2022_12 Stroke and the need for immediate assistance at the place of onset: the future of mandatory training for lay people in Italy
G. Stirparo, R. Pireddu, E. Kacerik, T. Scognamiglio, A. Andreassi, G.M. Sechi, A. Zoli, C. Signorelli
Abstract
Introduction
Lay training is essential to manage emergencies properly, although patients or bystanders need increased recognition of medical urgencies such as strokes. In Italy, as defined by Legislative Decree 81/08, all companies must train employees responsible for correctly recognizing and managing medical emergencies. Our study aims to evaluate the characteristics of medical emergencies concerning patients with a possible stroke in the Lombardy Region.
Methods
A retrospective observational study was conducted. All missions performed by Regional Agency for Emergencies and Urgencies (Agenzia Regionale Emergenza Urgenza – AREU) in which the patient presented a possible stroke, recorded in the SAS-Areu database, were analyzed. The study period was from January 1, 2019, to December 31, 2019.
Results
10,201 patients with possible stroke were rescued, of whom only 540 (5.3%) occurred in workplaces. In workplaces, the percentage of males with a possible stroke was higher (62.2% vs 45.2%; p<0.01) and the mean age of rescued patients was lower (64.7 vs 77.5; p<0.01).
Conclusions
A stroke occurs less frequently in the workplace, while most events occur at home. Mandatory training on early stroke recognition should be extended to schools and conveyed through a media information campaign. Lay training is the first point in the chain of survival; redefining training is critical for the future.
2022_11 Changes to the Major Trauma Pre-Hospital Emergency Medical System Network before and during the 2019 COVID-19 Pandemic
Giuseppe Stirparo, Giuseppe Ristagno, Lorenzo Bellini, Rodolfo Bonora, Andrea Pagliosa, Maurizio Migliari, Aida Andreassi, Carlo Signorelli, Giuseppe Maria Sechi and Nazzareno Fagoni
Abstract
Objectives
During the coronavirus disease 2019 pandemic, emergency medical services (EMSs) were among the most affected; in fact, there were delays in rescue and changes in timedependent disease networks. The aim of the study is to understand the impact of COVID-19 on the time-dependent trauma network in the Lombardy region.
Methods
A retrospective analysis on major trauma was performed by analysing all records saved in the EmMa database from 1 January 2019 to 31 December 2019 and from 1 January 2020 to 31 December 2020. Age, gender, time to first Emergency vehicle on scene and mission duration were collected.
Results
In 2020, compared to 2019, there was a reduction in major trauma diagnoses in March and April, during the first lockdown, OR 0.59 (95% CI 0.49–0.70; p < 0.0001), and a reduction in road accidents and accidents at work, while injuries related to falls from height and violent events increased. There was no significant increase in the number of deaths in the prehospital setting, OR 1.09 (95% CI 0.73–1.30; p = 0.325).
Conclusions
The COVID-19 pandemic has changed the epidemiology of major trauma, but in the Lombardy region there was no significant change in mortality in the out-of-hospital setting.
Keywords: major trauma; coronavirus disease 2019; emergency medical service
2022_09 Smart‑working policies during COVID‑19 pandemic: a way to reduce work‑related traumas?
Giuseppe Stirparo, Aurea Oradini‑Alacreu, Carlo Signorelli, Giuseppe Maria Sechi, Alberto Zoli, Nazzareno Fagoni
Abstract
Eighth of March 2020, the Italian government introduced a national lockdown to counter the exponential increase in the number of COVID-19 cases; this decision avoided putting a strain on the health system. During the lockdown all non-essential services were stopped and a “stay at home” order was imposed. The purpose is to evaluate the impact of COVID-19 lockdown on Emergency Department (ED) visits due to work-related traumas in the Lombardy region. We performed a retrospective analysis on trauma admissions to the ED registered through the regional portal (EUOL), from 1st January 2019 to 31st December 2019 and from 1st January 2020 to 31st December 2020. The number of ED admissions for traumatic injury and work-related traumas dropped by 32% between 2019 and 2020. A remarkable reduction of work-related traumas was recorded during the two pandemic waves, from March to June and in October and November. The percentage of patient in critical condition in ED slightly raised. These results are probably a consequence of the unprecedented measures imposed by the Italian government to cope with the spread of COVID-19, with important implications for work contexts. This analysis should be considered to optimise the organisation of the emergency system in other critical scenarios. We speculate that the different epidemiology of occupational injuries during the lockdown period is a consequence of smart-working policies that can be held responsible for the drastic reduction of work-related traumas.
Keywords: Traumatic occupational injuries · Trauma · Lockdown · emergency Department
2022_09 The Impact of COVID-19 on Lombardy Region ST-Elevation Myocardial Infarction Emergency Medical System Network—A Three-Year Study
Giuseppe Stirparo, Lorenzo Bellini , Giuseppe Ristagno, Rodolfo Bonora, Andrea Pagliosa, Maurizio Migliari, Aida Andreassi, Carlo Signorelli, Giuseppe M. Sechi and Nazzareno Fagoni
Abstract
Objectives
The COVID-19 pandemic had a significant impact on emergency medical systems (EMS). Regarding the ST-elevation myocardial infarction (STEMI) dependent time network, however, there is little evidence linked to the post-pandemic phase regarding this issue. Such information could prove to be of pivotal importance regarding STEMI clinical management, especially pre-hospital clinical protocols such as fibrinolysis.
Methods
A retrospective observational cohort study of all STEMI rescues recorded in the Lombardy EMS registry from the 1st of January 2019 to the 30th of December 2021.
Results
Regarding the number of STEMI diagnoses, March 2020 (first pandemic wave in Italy) saw a reduction compared to March 2019 (OR 0.76 [0.60–0.93], p = 0.011). The average time of the entire mission increased to 63.1 min in 2021, reaching 64.7 min in 2020, compared with 57.7 min in 2019. The number of HUBs for STEMI patients saw a reduction, falling from 52 HUBs in the pre-pandemic phase to 13 HUBs during the first wave.
Conclusions
During the pandemic phase, there was an increase in the transportation times of STEMI patients from home to the hospital. Such changes did not alter the clinical approach in the out-of-hospital phase. Indeed, the implementation of fibrinolysis was not required.
Keywords: emergency care; COVID-19; STEMI; Lombardy region
2022_06 Cardiopulmonary resuscitation missed by bystanders: Collateral damage of coronavirus disease 2019
Giuseppe Stirparo, Nazzareno Fagoni, Lorenzo Bellini, Aurea Oradini-Alacreu, Maurizio Migliari, Guido Francesco Villa, Marco Botteri, Carlo Signorelli, Giuseppe Maria Sechi, Alberto Zoli
Abstract
Objective
The coronavirus disease 2019 (COVID-19) pandemic changed the timedependent cardiac arrest network. This study aims to understand whether the rescue standards of cardiopulmonary resuscitation (CPR) and out-of-hospital cardiac arrest (OHCA) were handled differently during pandemic compared to the previous year.
Methods
Data for the years 2019 and 2020 were provided by the records of the Lombardy office of the Regional Agency for Emergency and Urgency. We analysed where the cardiac arrest occurred, when CPR started and whether the bystanders used public access to defibrillation (PAD).
Results
During 2020, there was a reduction in CPRs performed by bystanders (odds ratio [OR] = 0.936 [95% confidence interval (CI95%) 0.882–0.993], p = .029) and in the return of spontaneous circulation (ROSC) (OR = 0.621 [CI95% 0.563–0.685], p < .0001), while there was no significant reduction in the use of PAD. Analysing only March, the period of the first wave in Lombardy, the comparison shows a reduction in bystanders CPRs (OR = 0.727 [CI95% 0.602–0.877], p = .0008), use of PAD (OR = 0.441 [CI95% 0.272–0.716], p = .0009) and in ROSC (OR = 0.179 [CI95% 0.124–0.257], p < .0001). These phenomena could be influenced by the different settings in which the OHCAs occurred; in fact, those that occurred in public places with a mandatory PAD were strongly reduced (OR = 0.49 [CI95%, 0.44–0.55], p < .0001).
Conclusions
COVID-19 had a profound impact on the time-dependant OHCA network. During the first pandemic wave, CPR and PAD used by bystanders decreased. The different contexts in which OHCAs occurred may partially explain these differences.
Keywords: cardiac arrest, COVID-19, defibrillators, resuscitation, return of spontaneous circulation
2022_04 Evaluation of Interaction Between Emergency Medical System and Hospital Network During a Train Derailment in Milano
Valutazione dell’interazione tra il sistema di emergenza medica e la rete ospedaliera durante il deragliamento di un treno a Milano
Roberto Faccincani, Riccardo Stucchi, Michele Carlucci, Riccardo Sannicandro, George Formenti-Ujlaki, Federico Pascucci, Carl Montan, Alberto Zoli, Carlo Picco, Roberto Fumagalli
Abstract
On January 25, 2018 a 5-car train derailed in Pioltello, 10 kilometers North-East of Milano City. A standardized post-hoc form was distributed to the hospitals involved in the management of the victims and allowed for an evaluation of the response to the incident.
The management of the incident by EMS (Emergency Medical System) was effective in terms of organization of the scene and distribution of the patients, although the time for the first severe patient to reach the closest appropriate hospital was very long (2 hours). This can be partially explained by the extrication time.
None of the alerted hospitals exceeded their capacity, as patients were distributed carefully among the hospitals. The overall outcome was quite satisfactory; no deaths were reported except for those on scene. Some responding hospitals reported that there was an over-activation based on the services ultimately needed. However this is common in MCIs, as an over-activation is preferable to an under-estimation. To address this concern, as more data are available, activation should be scaled down based on a plan established prior to it; this mechanism of scaling down seems to have failed in this event.
It is of note that the highest performing hospitals underwent recently to an educational program on MCI management.
2022_04 Impact of Point-of-Care Ultrasound on Secondary Triage: A Pilot Study
L’impatto dell’ecografia sul campo sul triage secondario: uno studio pilota
Riccardo Stucchi, Eric S. Weinstein, Alba Ripoll-Gallardo, Jeffrey M. Franc, Massimo Azzaretto, Giovanni Sesana, Francesco Della Corte, Luca Neri
Abstract
Objectives
In mass casualty scenarios, patients with apparent hemodynamic and respiratory stability might have occult life-threatening injuries. These patients could benefit from more accurate triage methods. This study assessed the impact of point-of-care ultrasound on the accuracy of secondary triage conducted at an advanced medical post to enhance the detection of patients who, despite their apparent clinically stable condition, could benefit from earlier evacuation to definitive care or immediate life-saving treatment.
Methods
A mass casualty simulated event consisting of a bomb blast in a remote area was conducted with 10 simulated casualties classified as YELLOW at the primary triage scene; patients were evaluated by 4 physicians at an advanced medical post. Three patients had, respectively, hemoperitoneum, pneumothorax, and hemothorax. Only 2 physicians had sonographic information.
Results
All 4 physicians were able to suspect hemoperitoneum as a possible critical condition to be managed first, but only physicians with additional sonographic information accurately detected pneumothorax and hemothorax, thus deciding to immediately evacuate or treat.
2022 Missed Training, Collateral Damage from COVID 19?
Giuseppe Stirparo, Lorenzo Bellini, Nazzareno Fagoni, Salvatore Compatti, Marco Botteri, Guido Francesco Villa, Stefano Sironi, Carlo Signorelli, Giuseppe Maria Sechi and Albero Zoli
Abstract
Background
During the COVID-19 pandemic, a total lockdown was enforced all over Italy starting on March 9, 2020. This resulted in the shrinking of economic activities. In addition, all formal occupational security-training courses were halted, among them the 81/08 law lectures and Basic Life Support-Defibrillation (BLS-D) laypersons training courses. The aim of this study was to evaluate the impact of the pandemic on BLS-D laypersons training courses in the Lombardy region.
Methods
BLS-D training courses records for the Lombardy region were analyzed. The analysis was conducted from 2016 to 2020 as part of the Hippo project.
Results
In the period between 2017 and 2019, BLS-D trained laypersons kept increasing, moving from 53500 trained individuals up to 74700. In 2020, a stark reduction was observed with only 22160 individuals trained. Formal courses were not halted completely during 2020. Still, in the months available for training, the number of individuals enrolled showed a sharp 50% reduction.
Conclusions
Laypersons training courses for emergency management are a fundamental component of primary prevention practice. The 81/08 and 158/12 Italian laws have decreed this practice mandatory in the workplace. Following the enforcement of the lockdown and the subsequent interruption of emergency management courses, efforts will be necessary to re-establish and guarantee the high quality training of the pre-pandemic period.
2021_09 Public health impact of the COVID-19 pandemic on the emergency healthcare system
G. Stirparo, A. Oradini-Alacreu, M. Migliori, G.F. Villa, M. Botteri, N. Fagoni, C. Signorelli, G.M. Sechi, A. Zoli
Abstract
Background
The Lombardy region has been the Italian region most affected by the coronavirus disease 2019 (COVID-19) pandemic in 2020.
The emergency healthcare system was under deep stress throughout the past year due to the admission of COVID-19 patients to the emergency department (ED) and had to be thoroughly reorganized.
Methods
We performed a retrospective descriptive analysis of patients admitted into the ED recorded in the Lombardy online regional portal called EUOL (Emergenza e Urgenza OnLine). We compared the data registered in the EUOL with the patients admitted to the EDs from 1 January 2019 to 31 December 2019 and from 1 January 2020 to 31 December 2020.
Results
The number of admissions to the ED decreased by 32.5% in 2020 compared with 2019, reaching the lowest number in March and April. However, the percentage of patients hospitalized after ED signicantly increased in 2020 compared with 2019 (P < 0.0001), reecting the management of patients with a more severe clinical condition. More patients arrived at the ED by ambulance in 2020 (21.7% in 2020 versus 15.1% in 2019; P < 0.0001), particularly during March and April.
Conclusions
This analysis showed the importance of monitoring the pandemic’s evolution in order to treat more critically ill patients, despite a lower number of patients.
Keywords: emergency care, health services, public health
2020_09 Rapid reorganization of the Milan metropolitan public safety answering point operations during the initial phase of the COVID‐19 outbreak in Italy
Riorganizzazione rapida delle operazioni del punto unico di risposta alle emergenze della Città metropolitana di Milano nella fase iniziale dell’epidemia di COVID-19 in Italia
Francesco Marrazzo, Stefano Spina, Paul E Pepe, Annapaola D'Ambrosio, Filippo Bernasconi, Paola Manzoni, Carmela Graci, Cristina Frigerio, Marco Sacchi, Riccardo Stucchi, Mario Teruzzi, Sara Baraldi, Federica Lovisari, Thomas Langer, Alessandra Sforza, Maurizio Migliari, Giuseppe Sechi, Fabio Sangalli, Roberto Fumagalli
Abstract
Objective
To quantify how the first public announcement of confirmed coronavirus disease 2019 (COVID‐19) in Italy affected a metropolitan region's emergency medical services (EMS) call volume and how rapid introduction of alternative procedures at the public safety answering point (PSAP) managed system resources.
Methods
PSAP processes were modified over several days including (1) referral of non‐ill callers to public health information call centers; (2) algorithms for detection, isolation, or hospitalization of suspected COVID‐19 patients; and (3) specialized medical teams sent to the PSAP for triage and case management, including ambulance dispatches or alternative dispositions. Call volumes, ambulance dispatches, and response intervals for the 2 weeks after announcement were compared to 2017–2019 data and the week before.
Results
For 2 weeks following outbreak announcement, the primary‐level PSAP (police/fire/EMS) averaged 56% more daily calls compared to prior years and recorded 9281 (106% increase) on Day 4, averaging ∼400/hour. The secondary‐level (EMS) PSAP recorded an analogous 63% increase with 3863 calls (∼161/hour; 264% increase) on Day 3. The COVID‐19 response team processed the more complex cases (n = 5361), averaging 432 ± 110 daily (∼one‐fifth of EMS calls). Although community COVID‐19 cases increased exponentially, ambulance response intervals and dispatches (averaging 1120 ± 46 daily) were successfully contained, particularly compared with the week before (1174 ± 40; P = 0.02).
Conclusion
With sudden escalating EMS call volumes, rapid reorganization of dispatch operations using tailored algorithms and specially assigned personnel can protect EMS system resources by optimizing patient dispositions, controlling ambulance allocations and mitigating hospital impact. Prudent population‐based disaster planning should strongly consider pre‐establishing similar highly coordinated medical taskforce contingencies.
2020_03 The response of Milan's Emergency Medical System to the COVID-19 outbreak in Italy
La risposta del servizio sanitario d’emergenza di Milano alla pandemia da COVID-19 in Italia
Stefano Spina, Francesco Marrazzo, Maurizio Migliari, Riccardo Stucchia, Alessandra Sforza, Roberto Fumagalli
The number of people infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus causing coronavirus disease 2019 (COVID-19), is dramatically increasing worldwide.1 The first person-to-person transmission in Italy was reported on Feb 21, 2020, and led to an infection chain that represents the largest COVID-19 outbreak outside Asia to date. Here we document the response of the Emergency Medical System (EMS) of the metropolitan area of Milan, Italy, to the COVID-19 outbreak.
On Jan 30, 2020, WHO declared the COVID-19 outbreak a public health emergency of international concern.2 Since then, the Italian Government has implemented extraordinary measures to restrict viral spread, including interruptions of air traffic from China, organised repatriation flights and quarantines for Italian travellers in China, and strict controls at international airports' arrival terminals. Local medical authorities adopted specific WHO recommendations to identify and isolate suspected cases of COVID-19.3,4 Such recommendations were addressed to patients presenting with respiratory symptoms and who had travelled to an endemic area in the previous 14 days or who had worked in the health-care sector, having been in close contact with patients with severe respiratory disease with unknown aetiology. Suspected cases were transferred to preselected hospital facilities where the SARS-CoV-2 test was available and infectious disease units were ready for isolation of confirmed cases.
Since the first case of SARS-CoV-2 local transmission was confirmed, the EMS in the Lombardy region (reached by dialling 112, the European emergency number) represented the first response to handling suspected symptomatic patients, to adopting containment measures, and to addressing population concerns. The EMS of the metropolitan area of Milan instituted a COVID-19 Response Team of dedicated and highly qualified personnel, with the ultimate goal of tackling the viral outbreak without burdening ordinary EMS activity. The team is active at all times and consists of ten health-care professionals supported by two technicians.
The COVID-19 Response Team collaborated with regional medical authorities to design a procedural algorithm for the detection of suspected cases of COVID-19 (figure). Patients were screened for: (1) domicile or prolonged stay in the hot zone (ie, where COVID-19 cases first appeared), or both; (2) close contact with suspected or confirmed cases of COVID-19; and (3) close contact with patients with respiratory symptoms from the hot zone or China. The COVID-19 Response Team assessed the clinical condition of screened individuals to determine the need for hospital admission or for home testing for SARS-CoV-2 and subsequent isolation. Finally, recommendations to limit viral spread were provided to the other family members, especially when isolation was indicated.4
The COVID-19 Response Team handles patient flow to local hospitals and addresses specific issues about bed resources, emergency department overcrowding, and the need for patient transfer to other specialised facilities. The algorithm is constantly updated to meet regional directives about hot zone extension and modalities for SARS-CoV-2 testing.
Recent literature suggests that viral spread is still expected to grow, and the preparedness of public health systems will be challenged worldwide.5 In this context, the EMS is inevitably involved in facing the consequences of the SARS-CoV-2 outbreak. Specific algorithms, detailed protocols, and specialised teams must be fostered within each EMS department to allocate the right resources to the right individuals when cases of COVID-19 present. The Italian EMS, along with public health authorities, has just started to fight a battle that must be won.