Strategies for prevention of SARS-CoV-2 infection in a rural Emergency Department

Dear Editor,

We would like to address to your attention our letter about the development of an effective management emergency protocol of COVID-19 infection that we called ‘the Assisi Protocol’, as this clinical approach algorithm has been efficiently applied in the Emergency Department of the local hospital in the Italian city of Assisi with remarkably satisfying outcomes.

The healthcare workers (HCWs) are on the frontline of COVID-19 pandemic battlefield, and the risk of overloading and possible collapse of intensive care units (ICUs) and the potential burden on the availability of HCWs represents the two main concrete threats for public health. ¹ The rapid spread of this new and little-known coronavirus, the huge Emergency Room admission flow of patients at a frenetic pace, and the widespread shortage of personal protective equipment throughout Italy are all factors that expose frontline HCWs to great risk of infection. The protection of healthcare staff is as crucial as ever, because they represent the frontline in the fight against the virus. ²

In response to the COVID-19 national outbreak, Assisi Hospital is a clinically led national healthcare public facility providing joined up care by bridging the gap between hospital and community services that activated a restructure plan to isolate patients affected by COVID-19 from other patients and hospital staff. The hospital has modified the preset distribution of beds to create a sort of bigger ward composed of 40 beds in order to isolate the patients with respiratory symptoms. Moreover, the management of this kind of patients has been quite simple due to the great cultural and clinical background of the physicians and nurses trained to deal with patients in respiratory disease. In case of direct access to Accident & Emergency Department, the patients are properly screened in a specific environment built up aside the main entrance of the Department, in a sort of properly managed and equipped ‘filtered-area’ where the patient are priorly be asked for specific medical condition questions. The COVID-19 Assisi Hospital management protocol is summarized in Figure 1. In case of a rarely occurring event of a severely ill patient spontaneously accessing the ‘pre-triage’ area and coming to the healthcare facility by himself, all the personal protective equipment (PPE) and isolation protocols are immediately activated directly from pre-triage area, followed by a quick transfer of the patient to the dedicated isolation containment area. This isolation area has been built into an operating room with negative air pressure inside to establish a space separated from other areas in the hospital, where staff providing care are equipped with full PPE.

Figure 1.

Management algorithm of the ‘suspicious COVID-19 case’ at Assisi Hospital.

All the environment has been provided with specific and visible, widespread signs and posters explaining the procedure and the following step by step further incoming screening path.

The whole emergency working area is scheduled to be deeply cleaned and sanitized three times per day. All healthcare professionals are regularly invited to take part in instructional meetings, providing specific rules for the management of any COVID-19 ‘suspicious case’.

Moreover, considering the pivotal role of air conditioning in spreading previous epidemic diseases such as severe acute respiratory syndrome (SARS) and middle-east respiratory syndrome (MERS), the whole air conditioning system of the facility has been temporarily shut down. ³ Until July 2020, 3200 overall accesses in the Accident & Emergency Department were recorded and 560 patients with respiratory signs and symptoms treated via direct access with dedicated biosafety above-mentioned protocol. Moreover, 137 suspicious patients were directly picked up from home and transferred to dedicated COVID-19 hospital in the same period: of the latter, 17 patients were actually confirmed affected by COVID-19 infection. To date, all HCWs of Assisi Hospital underwent COVID-19 diagnostic swab and no one proved to be infected and no admitted patient was accidentally affected by COVID-19 infection as well. The importance of timely education and training of hospital staff are pivotal in order to contain the spread of COVID-19.

After the beginning of COVID-19 epidemic outbreak in Italy, all HCWs operating in our Emergency Department began to use advanced PPEs for the management of any ‘suspected case’ and complied with the biosafety rules established by the Crisis Unit. ³

The measures adopted inside Assisi hospital permitted to manage high clinically demanding patients ensuring the safety for the other admitted patients and all healthcare staff as well. The measures that we managed within the Assisi hospital have allowed, to date, to manage patients even in need of high intensity care, while preserving the biosafety of patients and all hospital staff.

Further healthcare insights and improvements are needed to reduce the risk of infection of SAR-CoV-2 virus among healthcare professionals, but sharing experiences about efficiently applied measures of biosafety is crucial for the network of Emergency Departments to reduce the number of infections among their HCWs. The procedures adopted in our hospital could be very useful for all the hospital Staff especially for the ones working in small hospitals.