Global coronavirus pandemic (2019‐nCOV): implication for an Italian medium size dermatological clinic of a II level hospital

Abstract

Editor On 31 December 2019, from the Chinese city of Wuhan, Hubei, comes the first case of ‘atypical ARDS/interstitial pneumonia’. On 11 February 2020, the WHO officially announced the new name of the pathology associated with the coronavirus: Coronavirus Disease 2019 (COVID-19). On 13 February, 72 000 cases have been recorded in China, of which 15 000 in Hubei with 242 deaths in a single day. For this reason, China put in place drastic containment measures for the virus spreading.1 The epidemic has been spreading in Italy since 31 January 2020 when two Chinese tourists (female 65 y.o.; male 66 y.o.) tested positive for the virus in Rome. On 21 February, an epidemic outbreak was detected in Lombardy region with 16 cases of COVID-19 positive patients.2 The World Health Organization on 11 March 2020 declared the coronavirus outbreak a pandemic.3 To date, 16 March 2020 the pandemic in Italy has 27 980 total cases of contagion. To date, 16 March 2020, the pandemic in Italy has 27 980 total cases of contagion, of which 2749 have been resolved and 2158 have died.4 The dermatological clinic of United Hospital of Ancona City is a medium size Departmental Organizational Structure (S.O.D.) belonging to the department of clinical and molecular sciences of a II level hospital with a catchment area of 800 000 inhabitants. More than 15 000 annual day services are recorded in our clinic. As soon as the first cases of COVID-19 contagion occurred in Italy, and since even in China it has been found that dermatology departments could be at a relatively high risk for COVID-19 outbreaks,5 several measures to reduce the risk of contagion between patients and health professionals have been taken. First, we have arranged the reduction of outpatient services, in details Programmable or Deferred visits, coded as P and D priorities, respectively, according to the National Health Italian Institute, as procedures to be conducted within 90 and 30 days. Next, all the outpatient services, of any priority, first visits or control visits, have been temporary suspended according to the last Decree of the President of the Council of Ministers (DPCM) of 9 March 2020 (GU Serie Generale n.62 del 09-03-2020), reserving a route exclusively dedicated to urgent cases sent from the first aid. Dermatologic surgery and hospitalizations have been reorganized. It has been drastically reduced the number of patients in waiting rooms as required by DPCM of 1 March 2020 (GU Serie Generale n.52 del 01-03-2020) limiting to a maximum of one caregiver per patient. The following specialist outpatient services scheduled from 9 March 2020 to 3 April 2020 have been postponed indefinitely: General dermatological consultation, allergological dermatology, oncological dermatology, paediatric dermatology, digital dermoscopy, capillaroscopy, inflammatory and immunomodulated skin disease, sexual transmitted infections, integrated dermatology–rheumatology, gastroenterology, surgical and non-surgical medications, transplanted patients dermatological follow-up, trichology, melanoma and non-melanoma skin cancer screening visits, and physical therapy. Outpatients’ dermatology surgery activity (with an amount of 3400 annual surgeries in 2019) has been resized, reducing daily surgery procedures from 15 to 3, reserved only to patients with a clinically diagnosed neoplastic skin disease, in which surgery represented the only non postponable therapeutic resource. Patients previously scheduled from 9 March 2020 to 3 April 2020 have been contacted by phone, and the appointments have been postponed to be scheduled again, when new additional dedicated lists would have been available. Patients, who spontaneously gave up their visit, have taken care of their own recovery, taking contact to other dermatological service, signalled by the dermatologist who was treating the patient. It has been established the immediate suspension of ordinary hospitalizations (four beds) and day hospital admissions for the activities of the operating room (two beds), photodynamic therapy (20 admissions per week) and botulinum toxin (two admissions per month) (for a total of about 1000 admissions per year). Hospital availability was then reduced to two beds for patients with severe uncontrolled skin diseases, not responding to conventional therapy performed at home. The dermatological first aid service was maintained in action from the beginning, as the only access for external patients, according to the usual procedures. Patients who have took access to the general first aid were then sent to dermatological clinic, after triage, and upon acceptance with the attribution of a relative code of severity distinguished by colour. White codes (less serious dermatological diseases) were sent by fast track and discharged from the dermatological clinic after appropriate evaluation, unless otherwise indicated. Green and yellow codes (moderate and high severity dermatological pathologies) sent to dermatological consultation and then discharged from the general first aid. The dermatologist on duty remains available for consultation in other hospital departments. Immediately after these operative dispositions, a global reduction of the accesses in the emergency room was noted, moving from about 40 accesses per week to two accesses per week. Among few recorded accesses, no white codes were detected, as the service has been limited to conditions of real urgency. This evidence should make dermatologist aware how the access to the first aid for dermatological consultations is generally poorly managed, causing the well-known overloaded of useless medical consultations, for postponable clinical situations. Medical and nursing personnel have been equipped with appropriate Personal Protective Equipment (PPE) such as surgical masks, gloves and hand and environment sanitizers and instructed in their proper use. Medical staff has been available by telephone for patients already taken care by the clinic for appropriate clarification. In order to guarantee the therapeutic continuity of patients undergoing treatment with drugs whose prescription requires a therapeutic plan (e.g. biotechnological drugs), Italian Medicines Agency (AIFA, Agenzia Italiana del Farmaco), on 13 March 2020, ordered the automatic renewal of the therapeutic plan for a further 90 days if the therapeutic plan expires in the period between 1 March 2020 and 30 April 2020.6 All dermatologists followed strictly the Società Italiana di Dermatologia e Malattie Sessualmente Trasmesse measures for patient management during emergency.7 On 10 March, the attendance of medical and nursing students who were doing dermatological traineeship was suspended. The activity of clinicians on residency was reorganized: work shifts were defined to carry out the remaining activities, reducing the number of doctors to the strictly necessary; research and smart working activities were promoted where possible. Reduction of routine dermatological activities has made it possible to close the access to the outpatient clinic and make dermatological beds available for hospitalization of COVID-19 positive patients during the emergency. These preventive measures made it possible to use released departments to set up treatment areas dedicated exclusively to COVID-19 positive patients. Reducing ordinary activities, medical and nursing staff from dermatology departments became available to be relocated to above-mentioned areas of care for COVID positive patients, by assisting colleagues on anaesthesia and reanimation, pneumology and emergency medicine, after specific training. Owing to the lack of clear evidence on interhuman transmission, incubation period, infection control, vaccine or directed antiviral treatment, the most useful protective measure to control the diffusion into dermatological setting of infection seems to implement reorganization of clinicians and nursery activities, following specific, but also modulable, strategies. All the signing authors have contributed to the writing of the present manuscript.