Policy responses for Italy - HSRM

Italy


Policy responses for Italy

3.2 Managing cases

In the last week of October 2020, Regions have mostly resorted to home isolation of new cases (95%).  Specifically, 156.5 people per 100,000 inhabitants have been isolated at home, 8.1 have been hospitalized in ordinary wards and 0.8 have been hospitalized in ICUs (ALTEMS, 29th October).

Guidelines released on 15th March 2021 by the National Health Institute (ISS) state that, given the impossibility of clinically identifying all patients with (or carriers of) new viral variants, cases are to be sought among:

- contacts of a confirmed COVID-19 case from a suspected/confirmed variant;
- those arriving from an area or country with known circulation of variants;
- those arriving from an area with a cluster of an initial case of COVID-19 and numerous secondary cases, suggesting increased viral transmission.

Although, at present, no scientific evidence calls for a single room isolation of patients with viral variants, in the presence of a suspected or ascertained diagnosis, the guidelines suggest to proceed with single-room isolation or grouping patients infected with the same variant, if known.

Tuscany
With Resolution 744/20 of 15th June, Tuscany launched a regional program for the reorganization of clinical pathways for residents with a Covid-19 related clinical situation; this program also includes the launch of studies targeted to better understand medium and long-term consequences of the disease. By the end of June, a surveillance program will be active for those who have contracted Covid-19 and are now clinically cured, in order to ensure that they are taken care of by the Regional Health System (SSR). Such surveillance allows identifying post-acute effects or medium and long-term complications that may, however, still require health interventions.

Cases may include either patients discharged from hospitals or individuals who were treated at home or in social or health facilities and organizational procedures have established that all Covid patients who have been hospitalized in Tuscany are contacted and engaged by the hospital itself which will work in close contact with the patients’ GP to share results and decisions-making on necessary interventions. On the other hand, non-hospitalized patients will be tracked and identified through regionally implemented platforms and contacted directly by their GP. Recruited patients will undergo a series of anamnestic investigations (mainly questionnaires and blood tests) and, at this stage, Special Units for Continuity of Care will be engaged. Consequently, they will be addressed to the most appropriate specialists (pulmonologists, neurologists, cardiologists, intensivists, nephrologists, psychiatrists, psychologists, otolaryngologists, ophthalmologists, diabetologists, physiatrists, geriatricians, physiotherapists, professional dietetics staff, etc.).
Furthermore, specialised Covid-19 surgeries will be activated in all healthcare facilities for multispecialistic day services and all costs will be borne by the SSR without out-of-pocket payments. The program also includes regional training for the involved professionals.

The figure of the GP will be crucial in the management of non-hospitalized patients and they will also be responsible for delivering clinical questionnaires, requesting blood tests and referral to specialists.

Sources:
- https://www.quotidianosanita.it/lettere-al-direttore/articolo.php?articolo_id=86319 
- http://www.quotidianosanita.it/lettere-al-direttore/articolo.php?articolo_id=86437
- ALTEMS, Instant REPORT#26: Analisi dei modelli organizzativi di risposta al Covid-19, 29th October 2020 [Available at: https://altems.unicatt.it/altems-executive%20summary%20instant%20report%2026.pdf]
- National Health Institute, Interim guidance on measures for the prevention and control of SARS-CoV-2 infections in terms of variants and vaccination against COVID-19. Version of March 13, 2021.
ISS Infection Prevention and Control Working Group 2021, 14 p. Rapporto ISS COVID-19 n. 4/2021 (in Italian) [Available at: https://www.iss.it/documents/20126/0/Rapporto+ISS+COVID-19+n.+4_2021d.pdf/5ece92de-7793-5f04-4edb-26762a55b47b?t=1615996998754] 

Patients who have symptoms but are not in a critical situation are asked to stay at home and contact their GPs (or a local number if the GP is unavailable). The GP makes the diagnosis either physically or virtually and, depending on the symptoms, s/he requests a nasopharyngeal swab that is generally taken at the patient’s home. Only patients who suffer from severe respiratory systems are told to go to the hospital. They generally reach the hospital by ambulance.

To our knowledge there are no official clinical protocols for patients with COVID-19. Nor are there specific therapies for the virus. Experts make suggestions and clinicians adopt their own strategy. The main strategies aim to alleviate symptoms (e.g., paracetamol to lower fever).
There are three ongoing studies on three different pharmaceutical regimens: a) Emapalumab + Anakinra; b) Sarilumab; c) Tociluzumab. They are phase 2/3 studies. More in info at:
http://www.salute.gov.it/portale/nuovocoronavirus/dettaglioNotizieNuovoCoronavirus.jsp?lingua=italiano&menu=notizie&p=dalministero&id=4344

Decree Law n° 14 released on 9th March 2020 requested the activation of one Special Unit for Continuity of Care every 50,000 inhabitants, for the management of home care to patients that do not require hospitalization (70,000 cases on the 12th April). Such newly dedicated structures are responsible for phone or video consultations and domiciliary visits and must be active seven days per week from 8.00 am to 8.00 p.m. Staff was recruited among volunteer medical doctors, nurses and administrative staff and serve as actual frontline gatekeepers of the health system, with a  remuneration of EUR 40 every hour.

Further, there are reports of “up and go” tests and 1-flight of stairs climbing tests being performed, followed by pulse oximeter reading to monitor oxygen saturation. Oxygen therapy is also offered, and a network of tanks replacements is organized through the producers, leveraging existing COPD services. The Lombardy region purchased 100 thousand pulse oximeters to do monitoring of oxygen saturation and do three follow-up calls a day to all of those who have been told to stay home rather than going to hospital.

There is no official reporting of rationing care for COVID-19 patients. However, it cannot be excluded that in certain situations, some patients would not have received the best standard of care due to the limits of hospital capacity.

The decentralization of the Italian healthcare system has led to different behaviours among regions with regard to the choice of care settings. Some examples are listed:

Lombardy
Lombardy has primarily managed cases by resorting to inpatient care (49% of positive cases are hospitalized – as of 8th April). Special Units for Continuity of Care (USCA) and dedicated nursing teams (ADI COVID) were instituted at the beginning of April to aid home care; moreover, intermediate care structures (cfr. residenze di sorveglianza) have been set up for those who are clinically stable but have not yet tested negative.

Emilia Romagna
Emilia Romagna has opted for a shared inpatient and outpatient management. Overall, 36% of positive cases have been hospitalized (as of 8th April), ranking among the lowest regions in Italy for the proportion of hospitalized patients. Several Local Health Units have already activated Special Units for Continuity of Care for homecare and, aside from intermediate structures, Emilia-Romagna is also activating Covid-19 dedicated practices.
Veneto
Veneto, with a very low hospitalization rate of 21% (as of 8th April), has been resorting mainly to outpatient care. Hospitalization has been almost entirely restricted to those requiring IC. It is currently working to institute Special Units for Continuity of Care for home-care and has set up 110 beds in intermediate care structures, known as community hospitals.

Lazio
Lazio has mainly responded with inpatient services by activating 5 Covid-19 centres and has hospitalized 44% of positive cases (as of 8th April). ICU capacity is not as saturated as the North of the country due to the lower number of infected cases. Monitoring of patients at home takes place through an app called LAZIODOCTOR, a tool that all citizens can use to find information and have online telemedicine consultations.   A total of 292 beds have been set up from the hospitality sector, for patients requiring low intensity care.
Order n° Z00034, issued by the President of the Lazio Region on 18th April 2020, has released further measures for the prevention, containment and management of the outbreak in local health and social and health care facilities. All healthcare professionals employed in these facilities must carry out their work exclusively within one single structure. Hospitals, local health and social and health care facilities must provide their staff adequate PPE and guarantee specific training to their employees on how to correctly utilize such equipment, resorting to distance learning platforms if necessary. Inadequately protected or untrained healthcare workers must limit movement and social interactions within the facility and must return to their home, avoiding all forms of contact along the way and with cohabitees. Should this not be possible, facilities must set up dedicated spaces for staff to stay overnight. Local health and social and health care facilities are required to check and record body temperature of employees twice a day, before entering the workplace and before returning home. For those with a temperature above 37.5 ° C, oxygen saturation must be measured.
Local Health Units are responsible for the continuous monitoring of all structures present in their territory by carrying out inspections and filling in checklists to assess the appropriateness of their conditions. They must also keep track of demand for PPE and, in case of an outbreak within one of the structures, they must alert the Regional Crisis Unit and to the Regional Service for Epidemiology, Surveillance and Control of Infectious Diseases (Servizio Regionale per l'Epidemiologia, Sorveglianza e controllo delle Malattie Infettive, SeReSMI) in order to activate the Regional Audit Groups  and the Special Regional Unit for Continuity of Care.

Piedmont
Initially, Piedmont resorted mainly to hospital care. However, by the end of March, it increasingly involved territorial care also due to the increase in the number of infected. As of 8th April, 43% of positive cases have been hospitalized. Starting from 27th March, they have instituted Special Units for Continuity of Care.

Sources:
- Cicchetti et al. Analisi dei modelli organizzativi di risposta al Covid-19 Focus su Lombardia, Veneto, Emilia-Romagna, Piemonte e Lazio Instant REPORT#2: 8 Aprile 2020, COVID19 – available at https://altems.unicatt.it/altems-ALTEMS-COVID19_IstantReport2-report.pdf
- https://www.quotidianosanita.it/studi-e-analisi/articolo.php?articolo_id=83945
- Lazio Region Order Z00034, 18th April 2020, available at http://www.regione.lazio.it/rl/coronavirus/wp-content/uploads/sites/72/Z00034-del-18_04_2020-Strutture-correzione.pdf