key: cord-0744316-2ra85537 authors: Marrazzo, Francesco; Spina, Stefano; Pepe, Paul E.; D'Ambrosio, Annapaola; Bernasconi, Filippo; Manzoni, Paola; Graci, Carmela; Frigerio, Cristina; Sacchi, Marco; Stucchi, Riccardo; Teruzzi, Mario; Baraldi, Sara; Lovisari, Federica; Langer, Thomas; Sforza, Alessandra; Migliari, Maurizio; Sechi, Giuseppe; Sangalli, Fabio; Fumagalli, Roberto title: Rapid reorganization of the Milan metropolitan public safety answering point operations during the initial phase of the COVID‐19 outbreak in Italy date: 2020-09-27 journal: J Am Coll Emerg Physicians Open DOI: 10.1002/emp2.12245 sha: 560255f5c10948404ac9bb8944600b8d6426670f doc_id: 744316 cord_uid: 2ra85537 OBJECTIVE: To quantify how the first public announcement of confirmed coronavirus disease 2019 (COVID‐19) in Italy affected a metropolitan region's emergency medical services (EMS) call volume and how rapid introduction of alternative procedures at the public safety answering point (PSAP) managed system resources. METHODS: PSAP processes were modified over several days including (1) referral of non‐ill callers to public health information call centers; (2) algorithms for detection, isolation, or hospitalization of suspected COVID‐19 patients; and (3) specialized medical teams sent to the PSAP for triage and case management, including ambulance dispatches or alternative dispositions. Call volumes, ambulance dispatches, and response intervals for the 2 weeks after announcement were compared to 2017–2019 data and the week before. RESULTS: For 2 weeks following outbreak announcement, the primary‐level PSAP (police/fire/EMS) averaged 56% more daily calls compared to prior years and recorded 9281 (106% increase) on Day 4, averaging ∼400/hour. The secondary‐level (EMS) PSAP recorded an analogous 63% increase with 3863 calls (∼161/hour; 264% increase) on Day 3. The COVID‐19 response team processed the more complex cases (n = 5361), averaging 432 ± 110 daily (∼one‐fifth of EMS calls). Although community COVID‐19 cases increased exponentially, ambulance response intervals and dispatches (averaging 1120 ± 46 daily) were successfully contained, particularly compared with the week before (1174 ± 40; P = 0.02). CONCLUSION: With sudden escalating EMS call volumes, rapid reorganization of dispatch operations using tailored algorithms and specially assigned personnel can protect EMS system resources by optimizing patient dispositions, controlling ambulance allocations and mitigating hospital impact. Prudent population‐based disaster planning should strongly consider pre‐establishing similar highly coordinated medical taskforce contingencies. (n = 5361), averaging 432 ± 110 daily (∼one-fifth of EMS calls). Although community COVID-19 cases increased exponentially, ambulance response intervals and dispatches (averaging 1120 ± 46 daily) were successfully contained, particularly compared with the week before (1174 ± 40; P = 0.02). With sudden escalating EMS call volumes, rapid reorganization of dispatch operations using tailored algorithms and specially assigned personnel can protect EMS system resources by optimizing patient dispositions, controlling ambulance allocations and mitigating hospital impact. Prudent population-based disaster planning should strongly consider pre-establishing similar highly coordinated medical taskforce contingencies. ambulances, call centers, COVID-19 pandemic, disaster planning, emergency medical dispatch, emergency medical services, SARS-CoV-2 infection The first cases of a severe acute respiratory syndrome stemming from the novel coronavirus designated severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) were reported by China in December 2019. 1, 2 As the virus quickly spread to other countries, transmission was amplified by a large number of asymptomatic, yet highly contagious, carriers. 1,3 Despite early preventive measures to limit spread, the nation of Italy soon was challenged with the largest number of patients in Europe with this new and poorly understood disease, coronavirus disease 2019 (COVID- 19) . [4] [5] [6] [7] The first case in Italy was confirmed on February 21, 2020. Following widespread media coverage, an unprecedented increase in telephone calls to "1-1-2" (European equivalent to 9-1-1, 9-9-9, or 0-0-0 emergency call systems) began to escalate. Many callers were "worried-well" persons requesting information and guidance about the new illness. Many other callers were concerned about symptoms they or family members were experiencing. Escalating call volumes soon challenged the capacity of the Azienda Regionale Emergenza Urgenza (AREU), the regional emergency medical services (EMS) system of Milan and surrounding Lombardy. 8 Recognizing that call volumes were becoming overwhelming, a strategic plan was implemented immediately to protect ambulance resources and the healthcare system at large. In contrast to most public safety answering point (PSAP) systems worldwide, on a day-to-day basis, the Milan AREU dispatch call center already incorporates expert medical oversight with a rotating team of on-site physicians and nurses provided by the Niguarda Hospital and the School of Medicine and Surgery at the University of Milano-Bicocca and University of Milan. Therefore, the medical team members, including their supervising medical director (RF), are quite familiar with the 1-1-2 system and its operation and they already provide the medical care protocols for the dispatch center as well as real-time medical direction and counsel to ambulance crews on-scene with patients. They can also make disposition decisions related to hospital destinations and coordinate with those hospitals in real time. In that respect and in contrast to most other PSAP operations, they were well positioned and also prospectively authorized to rapidly modify alternative procedures and also to seamlessly assign additional personnel to the AREU PSAP. 9 Also, most of the physician members of the AREU were critical care specialists based at the one of the largest tertiary care facilities in Italy who possessed the most up-to-date knowledge about COVID-19. They also held close affiliations with local public health and infectious disease (ID) specialists who could join in this deployment to the PSAP. The multidisciplinary team's main task was to attempt identification of possible COVID-19 patients but also to help determine an appropriate disposition, including directives to remain in isolation, go to the most appropriate hospital, or make other referrals as indicated. The multilevel, interdisciplinary response plan would, it is hoped, enable a more comprehensive interaction between the emergency medical system and regional hospitals as well as public health authorities and the community at large. 10 Accordingly, the primary study purpose was (1) to quantitate the onset, timing, and magnitude of increased EMS call volumes in the largest metropolitan region in Northern Italy after announcement of the nation's first confirmed case of COVID-19; and (2) analyze how well rapid reorganization of the EMS dispatching system could control ambulance dispatches, response intervals, and other system resources by introducing tailored COVID-19 algorithms, increased staffing, and a specialized team of healthcare system-oriented call-takers. During the COVID19 pandemic the sudden profound escalation of emergency medical services (EMS) call volume can be mitigated by having an EMS physician specialist on-site at the public safety answering point thereby optimizing EMS system resources by rapidly reorganizing dispatch operations using tailored algorithms, specially assigned personnel, providing real-time patient dispositions, controlling ambulance allocations, and assigning of hospital destination. With escalating call volumes, several actions occurred ( Figure 1B ). 9 Staffing was adjusted and COVID-tailored algorithms were provided to both PSAP-1 and PSAP-2 staff to help better navigate and manage phone calls. 1. PSAP-1 Staffing: Staffing was rapidly augmented from 12 to 30 technicians on duty at any given time using extended work shifts, overtime activity, and recruitment of additional personnel. Staffing was progressively amplified over the next 3 days. 9 With concomitant suspension of elective surgeries and other hospital activities, additional members of the anesthesia department experienced in EMS and emergency medicine became immediately available to supplement and rotate with the original core group. The team also incorporated public health department physicians c. Ambulances were promptly dispatched for hospital transport when identifying severe symptoms (eg, fever refractory to antipyretics with productive cough and dyspnea). 11 Data were derived from a regionally developed and commercially avail- During the immediate 2 weeks following public announcement of the first COVID-19 case in Italy (February 21), the 1-1-2 primary call cen- Figure 4A ). The medical calls processed and triaged by PSAP-2 staff that did not result in an ambulance dispatch had an average daily volume of 408 ± 61 (26% of total PSAP-2 calls) the week before the outbreak, but that COVID-19 created unprecedented challenges for healthcare systems worldwide with death tolls continuing to rise. In Italy alone, over 34,000 deaths had occurred just within the first 120 days after announcing the nation's first case. Half of those deaths occurred within Lombardy. 17 COVID-19 was an unexpected, chimeric pandemic with a spectrum of presentations, variable severities, and many asymptomatic carriers. Unanswered questions still remain, not only for the public at large, but knowledgeable scientists as well. Understandably, many non-ill citizens immediately called 1-1-2 seeking guidance following the first confirmed case. The phenomenon of the "worried-well" seeking assurance is well known. For example, following the 1989 radiation contamination event in Goiânia, Brazil, 120,000 of 1.2 million residents flooded clinical sites seeking screening examinations whereas <250 may have been exposed. 18 Recognizing that such public reactions are predictable, the current study makes another compelling argument that future disaster planning, be it for another pandemic, a nuclear event, bioterrorism incident, or other similar challenges, should include response strategies such as those implemented in this report. 19 Even in an age of widespread social media, mass media, and the internet, 1-1-2 and counterpart systems on other continents remain universal safety nets for the public early on. The profound escalation in PSAP calls in those early days following Although more difficult to quantify, the efforts and processes taken for expert patient assessments, more optimal patient dispositions, and better coordination of the more complex cases with public health officials and hospitals were pivotal functions that also laid the foundations for optimal patient disposition strategies as the disease continued to spread and directly challenged the healthcare system with the truly sick patients. 21, 22 The specific screening algorithms for PSAP-1 developed by the team also contributed to more effective management of suspected COVID-19 cases by allowing PSAP-2 to better focus on the cases that needed their attention. PSAP-1 and 2 algorithm referrals to public health authorities added further protection until better public education could evolve through social and mass media. 23, 24 As exemplified here, demands on the system can suddenly appear overnight, requiring immediate, same-day implementation. Logistical, regulatory and training barriers to implementation need to be overcome well before the crisis presents itself. The initial overwhelming phase of the public response demonstrated that such contingencies need to be in place ahead of time and that additional qualified personnel should be knowledgeable, prepared, and readily available to constitute specific response teams. In addition, contingency algorithms should be developed with templates that can be easily tailored or updated for the specific event or threat. In terms of communicable diseases, these protocols should be aimed at detecting suspected cases, limiting contagion, assigning the right hospital destination or quarantine dispositions, and avoiding needless ambulance dispatches. As more is learned about any new threat, algorithms must be continuously modified to adapt to evolving epidemiological characteristics and any directives from public health authorities. In summary, utilizing disease-tailored algorithms and specially assigned personnel, rapid reorganization of PSAP operations protected Characteristics of and important lessons from the coronavirus disease 2019 (covid-19) outbreak in China First case of 2019 novel coronavirus in the United States Novel coronavirus (2019-nCoV) situation report 168. World Health Organization Ministero della salute. Nuovo coronavirus COVID-19). 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Coronavirus disease 2019 (COVID-19) COVID-19) deaths in Italy as of Community disaster recovery and resiliency: exploring global opportunities and challenges Clinical review: mass casualty triage -Pandemic influenza and critical care Priorities for the US health community responding to COVID-19 Feasibility of controlling 2019-nCoV outbreaks by isolation of cases and contacts Unique epidemiological and clinical features of the emerging 2019 novel coronavirus pneumonia (COVID-19) implicate special control measures Transmission of 2019-nCoV infection from an asymptomatic contact in Germany AUTHOR BIOGRAPHY Roberto Fumagalli, MD, is anesthetistin-chief, in the Department of Anesthesia and Critical Care at ASST Grande Ospedale Metropolitano Niguarda Rapid reorganization of the Milan metropolitan public safety answering point operations during the initial phase of the COVID-19 outbreak in Italy The authors are deeply grateful for the professionalism and dedicated, resilient work ethic of the participating public safety answering point (PSAP) technicians, nurses, and physicians serving the AREU 118 emergency medical system network in Lombardy (Italy) as well as fellow PSAP colleagues worldwide. None of the authors have any conflicts of interest to declare and the research is derived from the routine quality assurance functions of a public agencies. No human subjects were involved and personal medical information was not involved. There was also no specific funding for the research and no specific grants received from any funding agency in the public, commercial, or not-for-profit domains.