Confronting COVID-19: Surging critical care capacity in Italy

  1. Jose M Rodriguez-Llanes
  2. Rafael Castro Delgado
  3. Morten Gram Pedersen
  4. Pedro Arcos González
  5. Matteo Meneghini

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Abstract

The current spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in Europe threats Italian’s capacity and that of other national health systems to effectively respond to the needs of patients who require intensive care, mostly due to pneumonia and derived complications from concomitant disease and age. Predicting the surge in capacity has proved difficult due to the requirement of a subtle combination of diverse expertise and difficult choices to be made on selecting robust measures of critical care utilization, and parsimonious epidemic modelling which account for changing government measures. We modelled the required surge capacity of ICU beds in Italy exclusively for COVID-19 patients at epidemic peak. Because new measures were imposed by the Italian government, suspending nearly all non-essential sectors of the economy, we included the potential impacts of these new measures. The modelling considered those hospitalized and home isolated as quarantined, mimicking conditions on the ground. The percentage of patients in intensive care (out of the daily active confirmed cases) required for our calculations were chosen based on clinical relevance and robustness, and this number was consistently on average 9·9% from February 24 to March 6, 2020. Five different scenarios were produced (two positive and three negative). Under most positive scenarios, in which R 0 is reduced below 1 (i.e., 0 ·71), the number of daily active confirmed cases will peak at nearly 89 000 by the early days of April and the total number of intensive care beds exclusively dedicated to COVID-19 patients required in Italy estimated at 8791. Worst scenarios produce unmanageable numbers. Our results suggest that the decisive moment for Italy has come. Jointly reinforcement by the government of the measures approved so far, including home confinement, but even more important the full commitment of the civil society in respecting home confinement, social distancing and hygiene will be key in the next days. Yet, even under the best circumstances, intensive care capacity will need to get closer to 9000 units in the country to avoid preventable mortality. So far, only strong measures were effective in Italy, as shown by our modelling, and this may offer an opportunity to European countries to accelerate their interventions.

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  1. ScreenIT

    SciScore for 10.1101/2020.04.01.20050237: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    Institutional Review Board Statementnot detected.
    Randomizationnot detected.
    Blindingnot detected.
    Power Analysisnot detected.
    Sex as a biological variablenot detected.

    Table 2: Resources

    No key resources detected.

    Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    Our study is not exempt of limitations. Our rate of daily ICU use is obviously affected by conditions such as changes in case definitions, testing capacity, changes in clinical early detection, and changes in disease severity. We were conscious that case definition and testing strategies to optimize resource use were redirected before the end of February in Italy. Most severe patients probably arrived first to hospitals and a majority of them were of advanced age and with varying levels of comorbidities (11, 14). Equally important, ICU admission criteria may have changed over the course of the emergency to deal with scarce ICU resources in particular locations, with difficult ethical choices to be made between providing ICU treatment versus palliative care in certain patients (26). To counteract these effects we chose a longer period to estimate our daily ICU rates and we corroborated the consistency of these values across days and periods defined. Additionally we chose the period at the beginning of the emergency where decisions were more likely made based on clinical realities and not on allocation of scarce resources. Our models, to a certain extent, depends on the quality of parametrization and its ability to predict future evolution of the epidemic. With this issue in mind, we tested its predictive ability on a six day window and we hope that this is enough to provide a range of good predictions from 25 March on and for at least 10 days, in a context where new drastic me...

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • No funding statement was detected.
    • No protocol registration statement was detected.

    About SciScore

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  2. Version published to 10.1101/2020.04.01.20050237v1 on medRxiv