Reinventing the ICU for COVID-19

March 23, 2020

Enrico Storti is the Anesthesia and ICU Director/Unit Coordinator of the Emergency Department at Maggiore Hospital in Lodi, Italy. Lodi is located near Milan and the epicenter of the COVID-19 outbreak in Italy. Lodi was hit very hard by the pandemic, and Dr. Storti is on the frontlines treating patients and helping to contain the outbreak.

Dr. Fujifilm Sonosite Chief Medical Officer Diku Mandavia, M.D. interviewed Dr. Storti to gain a better understanding of the clinical situation in Italy. Storti discussed how his hospital has coped with the sudden surge of patients. He describes how his team transformed the ICU to deal with an unprecedented “mass casualty event,” and what clinicians can expect when the coronavirus reaches their hospitals. He also talked about the key role point-of-care ultrasound plays in making the ICU far more efficient when dealing with a huge number of patients at the same time. You can view a video of the interview on Sonosite's COVID-19 resource page. We also conducted a follow-up interview of Dr. Storti, where he gives advice on how the community can support its local hospitals.

Dr. Mandavia:

Thank you for joining us today. I'm Diku Mandavia, Chief Medical Officer for Fujifilm Sonosite. As all of you know, we're in the middle of a global public health crisis with the COVID-19 outbreak. We have areas that are endemic, and certainly Italy seems to be an epicenter at the current moment. And Italy is living through this crisis. I think it's important for us to learn from the physicians on the front line in Italy so that other physicians can better prepare as we receive these critically ill patients. So with me today is my friend and colleague Dr. Enrico Storti, ICU Director in Milan, Italy. He's is the coordinator for pre-hospital emergency and ICU care there. He's also a pioneer in point-of-care ultrasound and the founder of the WINFOCUS Organization. And he's been instrumental in promoting lung ultrasound as well as many other applications for point-of-care ultrasound. So with that as a preamble, thank you, Enrico. I see you're with us from the ICU. Thank you for sparing some time. I think it's really important to get this critical information out. So maybe you can tell our listeners a little bit of, maybe a little bit more of who you are, where you're working, things like this.

Dr. Storti:

Thank you for inviting me, and it's my privilege to share the experience because here, our situation is tough, let me say. Yes, I'm a critical care physician as you mentioned. I've been working in Milan for the last 17 years in Niguarda Hospital, which is the largest trauma center in the north part in Italy. Also I've been working the burn units section. And since the last four years, I became responsible for the ICU and anesthesia department in Lodi, which is more or less 40 kilometers from Milan. I am responsible for general ICU with seven beds. As you mentioned, I am one of the founders of the World Interactive WINFOCUS, so as you know ultrasound is part of my life. I couldn’t see how to run ICU without a probe in my hands. So this is also, you know, another part of my career, and part of my expertise.

Dr. Mandavia:

We've been reading from the media what's happening in Italy. So tell us in your own words the current conditions in Italy, and then more into the hospital conditions.

Dr. Storti:

As you mentioned before, my ICU, and my hospital has been in the media a lot for this coronavirus epidemic. This story have been developing for the last three weeks. I've seen things that would have been absolutely unbelievable until three weeks ago. We have found ourselves in mass casualty event. This is really the right definition because we immediately forced to face a huge number of patients. Our emergency department on average has received 150, sometimes 200 patient per day, in a 24 hour period. We received 150 red codes and yellow codes with a wave of patients, and all these patients had severe respiratory distress, ARDS alike. And there were no green or white codes. I mean, the minor codes completely disappeared.

So we were dealing with a huge number of patient at the same time, coming to the emergency department or being referred to the emergency department at the same time. A large portion of these patients exhibited severe respiratory distress, and needed to be oxygenated. This has been a huge challenge for the emergency department, and for the entire hospital. We immediately understood that we couldn't cope with the situation like this where there was a huge disproportion between resources and the number of patients and the intensity, the standard of care that these patient need to improve their condition.

And so we were forced to change our hospital rules and reshape our hospital staffing from the emergency department passing through the step down unit, and reach into the ICUs. And also we have been forced to do this also without having the chance of medical transportation of these patients out of the hospital because all the nearby hospitals in this area were completely overwhelmed by the same number of patient, and even more. And so we treat this as a mass casualty event.

Dr. Mandavia:

So it sounds like you, as far as your patient load, had a disproportionate high acuity group. Meaning a lot of patients that needed admission. Can you tell me more about that group? The ages that you're seeing?

Dr. Storti:

Yeah, in the very beginning, the larger portion of these patient was elderly. So, 75, 80, 85 years old. And let me say that that's the age the mortality is in this cluster of patient has been really high. Because they had true ARDS (Acute respiratory distress syndrome) with severe BO2/FiO2 ratio reduction, and they needed of course to be ventilated, and to use prone supine strategies, nitric oxide, and so on. But the mortality was really high. Now, after the last 10 days, 15 days, we see that the average age of our patient is also a little bit lower. So we see patient with ARDS who are 40, 45, 50 years old. And this is also another issue just because you know that treating ARDS in ICU requires a long stay.

So here the problem is not only to create and to enlarge the ICU capability, but also to have in mind that whatever the number of new beds that you manage to collect, you still have in front of you a very long ICU stay. But unfortunately, this virus has the power to infect people that's very high, and it's very consistent. So there's always a large buffer of patient distributed inside the hospital, in the emergency department, the other floors, and in the other areas of the hospital completely dedicated to coronavirus positive patients, which is pressing you. It's very difficult to imagine how to manage with such a large number of patients with an ICU dependency.

Dr. Mandavia:

So speaking specifically to that, how were you able to surge your ICU capability? Did you have enough supplies such as ventilators, monitors, and so forth?

Dr. Storiti:

In the very beginning, we had a shortage of ventilators. But our Lombardy region welfare department managed to collect and to centralize a large number of ventilators. So finally we managed to have a large number of ventilators. But in the very beginning, I promise you, we were forced to collect every ventilator inside the hospital. We used the OR ventilators, and brought patients to the OR in order to give them the opportunity to be properly ventilated in a sort of ICU setting. And again, this has been really challenging in the very beginning. Now the situation is a little bit more stable. I mean, stable means that we have 24 ICU beds, and we have 26 ventilators. So we have the chance to manage this situation. Also in the beginning, syringe pumps and other ICU items were completely insufficient because we only had instruments and ventilators for seven beds.

And if you think it's important, we can also talk about how we have reshaped the hospital. It wasn’t just the ICU and emergency department that was changed to face this situation.

Dr. Mandavia:

Yes, tell us a little bit about that.

Dr. Storti:

Yeah, this has been a winning tool in this epidemic because you know, we immediately understood that this was a sort of worst-case scenarios. We had so many patients at the same time that we couldn't cope by using, let me say, the gold standard. What I mean by gold standard is that everybody, every ICU physician knows perfectly how to handle and treat an ARDS patient.

The problem is you have to treat 15 ARDS patient at the same time, and your team is decreased in terms of people able to work the shifts. You cannot use the same tools, you cannot refer to the same guidelines. It was immediately clear that we first had to reinvent our way of approaching this patient. And not only our way of approaching the patient, but also how the hospital could assist us in doing this.

On day one, we were completely overwhelmed and astonished about what was going on. But immediately we tried to react and have a different approach. Our experience with WINFOCUS has been important in this experience. In WINFOCUS, we got accustomed to go into critical scenarios. Ultrasound does an amazing job in countries where the healthcare systems are very weak with a large disproportion between resources and number of patient. Our experience in those countries was important. We are using more or less the same tools.

For example, by not using the gold standard of referring every ARDS patients for a CT scan. We just had too many patients to refer them to the CT scan. Rather, we immediately chose how to treat these patient that were absolutely the same. So, we have patients presenting with a severe respiratory distress, BO2/FiO2 very low, and a fever and a flu in the few days before. So, the diagnosis was not so complicated. What was really challenging was to triage these people in the very beginning with something which was very quick, very simple to be done, very effective, using a bedside point-of-care philosophy test. Otherwise we couldn't cope. So we managed these patient only with blood gas analysis, chest X-ray, and ultrasound evaluation. And, of course, their previous medical history. Those have been our pillars to have the final diagnosis.

Deciding when you have to distribute your resources in the proper manner became very important: Where to refer the patient, who could stay in emergency department for 24 or 48 hours, who should be intubated immediately, and what patients to refer to the step down unit. Of course, we have reengaged people and redefined the wards in our hospital. So we have created from scratch a step down unit from zero to 18 beds. We have erased neurology and the neurology ward, and moved in ventilated patients to be treated by a multidisciplinary staff: a pulmonologist, intensivist, and everybody who had the chance to intubate or to control and set up a ventilator. So, we enlarged our ICU capacity.

This is also very important because when coronavirus infects people, you create a ratio which is roughly like this…you create one ICU patient, you create more or less a five to 10 step down unit patients, and then you have 10 to 20 patients who simply need to be oxygenated. For these number of patients, it has been so important the oxygen sockets and the total amount of oxygen supply in our hospital increases fivefold. So we had to ask the factory who brings our oxygen to refill our oxygen reservoir more than once per day. This is only to give you a rough idea about what is the dependency on oxygen for so many patient at the same time.

Dr. Mandavia:

Wow. Now tell me, besides the oxygen, what other areas do you have constraints on? What other things should physicians anticipate?

Dr. Storti:

We were the first ICU to have the first coronavirus diagnosis, who we call patient one. Of course, we know now that this patient for sure is not the actual patient one, and probably the virus was already circulating here in Italy or wherever, for sure 15 days before or something like that. I'm not an epidemiologist, that’s not my task, but now we have enough findings to say this. And this is important because [since the day of the first diagnosis], we received a number of patients where we had to use 15 liters [of oxygen] per minute. And when you have 40 patients, you have to apply 15 liters per minute, your oxygen delivery in your pipelines are not sufficient. So we were forced also to rebuild the different oxygen sockets inside the hospital and to empower our oxygen pipelines in order not to have a crash in our oxygen system with the consequences that you can simply imagine.

So my message is, if you are in the middle of an outbreak or where the virus you know is spreading actively, you have to be prepared to reshape your hospital, and to use techniques that are following the pace that this virus has imposed on your hospital. Don’t try to cope with what you are accustomed to do. For example, CT scan for every patient, immediate ICU recovery, prone supine strategy from the very beginning. You can't cope because you have not enough nurses to supine 18 patients at the same time. So it's a sort of different triage.

And let me say that this kind of triage, which is absolutely not common for Italy, for industrialized countries, is something that is not easy to do. And let me say that also in my team has not been so easy to convince people that we were in a sort of worst-case scenario, and the only solution was to completely change our way of treating patients, also to redistribute and to reinvent our team. Now we have teams that weren't present until a few weeks ago. Because now we have different patients in a different locations in our hospital with different needs, and with a disproportion between those needs and our ability to catch them.

Dr. Mandavia:

Okay, so just switching gears just slightly. Obviously there’s a tremendous strain on the physicians, the nurses, respiratory therapists, a host of other workers. How do you protect your staff? Have you had many infections within your staff?

Dr. Storti:

Yes, this is absolutely a crucial issue. Yes, you have to protect your staff. You have to protect your staff just because they are your people. But also because when you have an outbreak to face, you have to protect them to avoid having insufficient staff because they’re positive [for coronavirus].

So, luckily we had enough PPE (personal protective equipment) to wear. We immediately debriefed people in order how to wear, and what were the protection strategies for all the team. That's exactly what we did, and let me say we still had physicians and nurses [who tested positive for COVID-19]. However, I do believe that the larger portion of those infected doctors and nurses were infected when our patient one hadn’t been identified yet.

You know in Italy we are adopting a social distancing measures, very important measures with a deep impact in our way of living and on the economic situation of our country. But these kind of restrictive measures are actually the only solution we have to avoid the spread of the virus. So we manage to protect ourselves. We have enough PPE, and we basically managed to do this.

Dr. Mandavia:

Okay, now I know a lot of our listeners will be very curious what you're seeing on your lung ultrasounds. Anything special or unique to COVID-19?

Dr. Storti:

Let me start from here. Our hospital has a high competence in ultrasound. Because we did a very long and very extensive job in training people in the last ten years. WINFOCUS did an amazing job here in Lodi. And now every single floor of this hospital has an ultrasound machine, or more than one, and all the physicians—pediatricians, neurologists, the surgeons, intensivists, whoever is working here—is able to handle a probe, and to perform the point-of-care ultrasound.

So point-of-care ultrasound means to bring the probe in a physician's hands and try to better asses and monitor the patients. Every physician brings his own experience in order to decide what is important for our patients. So let me say that this is the baseline where we have been starting. Because we were so confident with the point-of-care ultrasound, and because all the different teams were fully convinced that this is a real powerful tool, we decide to use ultrasound  at the very beginning, the triage, to assess coronavirus lung involvement, and to decide where to bring the patient, and to also treat the comorbidities.

Because sometimes we received young people with only ARDS, and only a lung involvement from the pneumonitis to bilateral pneumonitis, ranging from pneumonitis to ARDS. But also sometimes we see elderly with other pathologies, and other comorbidities. So ultrasound is also very useful to better assess the patient in the emergency department.

As I mentioned, these are at some extent is a sort of worst-case scenario. You know that ultrasound where just how critical the situation critical is. This is the message of WINFOCUS or ultrasound, a natural focus on critical ultrasound. Critical means when you have, or a critical situation just because the patient is very sick, or because we have a very sick patient also in a critical situation just like we are.

Because we have very sick patients, and we have also a huge disproportion between resources and number of patient. So ultrasound here is clearly the answer. And we need to compare what we did in this hospital because around this area, many other hospitals which sort of collapsed under this sort of tsunami, let's just say, sort of wave of patients, they have been overwhelmed, and they collapsed just because these hospitals referred patients to CT scan, waiting for a CT scan report, and waiting for the CT scan be available for the other examination. And this much slower, and made emergency departments very slow in addressing a large number of patients. And this is something that doesn't work at all.

So in our experience, exactly what we did is to bring ultrasound into the middle of the decision tree, and this has been really, really effective. So again, for us, it was a blood gas analysis, chest X-ray. The chest X-ray is very important when the chest X-ray is very, very white, it's a clear positive result [for COVID-19]. When the chest X-ray seems to be negative, ultrasound has a huge capacity to better discriminate if a lung involvement is present, to what extent the lung involvement is present, and to perfectly match this lung involvement, for example with the clinical approach.

For example, to decide if we won’t refer the patient to step down or the ICU, because the patient was not so sick, we use also the working test. We bring together blood gas analysis, chest X-ray, and lung ultrasound in this working test. The working test has been a huge solution to decide which patient we could discharge. This is also another issue. If you are not clear who to discharge, when to discharge the patient, and if the patient that you are discharging is going to the right place in order to stop the spread of the virus, this is a mess. Ultrasound has been really, really effective in doing such management.

Dr. Mandavia:

Well that's been really informative, Enrico. Any other final thoughts, or any other advice to physicians that'll be listening?

Dr. Storti:

Well let me say that here the real answer is to be flexible, and to imagine that you have to do something that is not in your background until the day you receive this kind of patient. Because what is incredible in coronavirus is its capacity to spread, and to create very, very important ARDS syndrome in patients at the same time. So what is unbelievable is that, for example, now I have 24 ICU beds, but in my step down unit I know that if you go and see what is there, for sure you’ll see another ten patients to immediately intubate.

And here again, what is important is to handle the time. It's because you have disproportion between ICU beds, ventilators, nurses, physicians, and the number of patients. You have to keep them alive until your resources are able to give them ICU access, an ICU chance. And whatever the tools that you have. For example, we use CPAP, and we use non-invasive mask ventilation extensively. Also if the BO2/FiO2 ratio is very low, and even if you know that this is not for sure the right way to go, let me say, in peaceful conditions. When you are at war, you have to keep your patients alive in order to create the right pathway. I mean, treat the sickest and try to free ICU beds, and then bring up the other ones who are waiting in the emergency department or in the step down unit.

So, you have to think and to imagine your way of treating patient, your daily practice, you have to reinvent your daily practice, and use tools that you are not accustomed using. Otherwise, if you are too rigid in your protocols, you can't cope. This is my message. You have to be flexible, you have to know your hospital very well.

Another great point is you have to talk with your administrators. You have to talk with your directors. Because you have to ask them for facilities, you have to ask them to provide stuff, and you have to keep in touch with them. You cannot deal with these physician issues. You have to talk with administrators, and you have to bring them and down and say, "Can you see the problem?"

I brought my CO to the emergency department and told them, "Okay, this is what we are facing. This is where we are starting from, and we have to cope with that. And we have to avoid being completely overwhelmed, so I need this. I am not asking for something which is not important now. I'm asking you only what is vital for my patients, and for our hospital to survive with our patients." And they understood.

And so let me say that also. This is important for Italy. Let me say that Italy has many problems, but here healthcare is a right, it is not a service, and what we did was an amazing job in providing care for everybody, no matter the financial support. We are struggling with something which is absolutely out of our forecast. But let me say that the government and our region healthcare system did an amazing job providing things, very concrete help, and also giving financial support for everything.


Dr. Mandavia:

Well thank you, this has been extremely informative. Sounds like you are doing an incredible job under extenuating circumstances. I think in modern medical history, none of us have been through anything like this. Thank you for spending the time with us. I know you're on shift at the hospital. On behalf of everyone at Fujifilm Sonosite, thank you. It's been, again, very valuable. I think our listeners will pick up a lot of pearls that will help save further lives. So thank you again, Enrico.


Dr. Storti:

Thank you so much, Diku, and thank you so much for the support. And as you mentioned, I think that yes, this is very important that our colleagues, wherever throughout the world knows exactly what may happen, and how to be prepared, how to get ready in time. Because we were first, unfortunately, had to reinvent things without stopping the hospital functionality. We managed to do that, but it's not simple. So whoever has one week ahead, have one week to dedicate to think and to forecast what are going be their needs. This is a very, very precious time. And I think that whatever we can do to share our knowledge, or to share simply what happened to us is more welcome. Thank you so much for your support, and for inviting me.