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International Archives of Pediatrics & Neonatology
doi: 10.39127/2575-8253/IAPN:1000106
Research Article Centonze A, et al. In Arch Pedia Neon: IAPN-106
Dynamic Adaptation To COVID-19 In the Pediatric Emergency Departments
of Calabria (Italy): Evaluation of The Organizational Workflow
Antonella Centonze1*, Valentina Talarico1, Lucilla Sabetta1, Maria DeFilippo2, Luciano Pinto4, Benedetta
Rodio1, Domenico Sinopoli3, Stefania Zampogna1
1Pediatric
Department-Pugliese- Ciaccio Catanzaro Hospital- Italy
2Pediatric
Department-San Matteo Hospital, Pavia Italy
3Department of Haematology, Oncology and Transfusion Medicine
4Member of SIMEUP Italy
*Corresponding author: Antonella Centonze MD, Pediatric Department-Pugliese Ciaccio Hospital-Catanzaro-Italy.
(Address: Azienda Ospedaliera Pugliese-Ciaccio, viale Pio X, 88100, Catanzaro, Italy). Mobile number: +39 366.7242.376;
Email: antonellacentonze@hotmail.com; ORCID; Scopus
Citation: Centonze A, Talarico V, Sabetta L, DeFilippo M, Pinto L, et al. (2021) Dynamic Adaptation To COVID-19 In the
Pediatric Emergency Departments of Calabria. In Arch Pedia Neon: IAPN-106.
Received Date: 20 January 2021; Accepted Date: 25 January 2021; Published Date: 31 January 2021
Abstract
Objective: SIMEUP (Italian Society of Pediatric Emergency Medicine)-Calabria conducted an observational study to
evaluate the impact of containment strategies on the pediatric hospital network in the Calabria region at the onset of the
covid-19 pandemic.
Methods: The study was conducted through the administration of a questionnaire to all hospitals in Calabria where there
is a Pediatric Unit.
Results and Conclusions: From the analysis of the data found thanks to the research conducted by SIMEUP Calabria, some
interesting ideas emerge. The first observation is the very strong contraction that has been observed in accesses and
admissions to Pediatric Units. This certainly appears to be an effect of the general health indications expressed at the
regional level; however, other correlated and dependent effects should not be overlooked, such as those linked to the fear of
the spreading effects of the contagion in children and therefore in their families of origin and belonging. All this could lead
to further considerations regarding the more efficient and effective organization of pediatric care systems post-COVID19.
Another consideration concerns the absence of a prearranged and systemic action plan for the phenomenon of regional
COVID- 19 emergency. Our study shows that despite the lack of a prearranged action plan the responses in terms of
distribution of personal protective equipment, emergency management, and all other indications provided by the regional
ordinance were regularly implemented.
Keywords: organizational workflow, pediatric emergency, covid-19, observational study, preventive strategy.
Introduction was conducted through the administration of a
questionnaire to all Calabrian hospitals in which a pediatric
The pandemic in Italy is developed by some outbreaks unit was present.
located in the northern regions, which have therefore
represented an epidemiological and clinical "model" on The pandemic caused by COVID-19 had profound
which the government system has organized measures to consequences on the national health system, ending up
prevent the spread of the infection. The containment having an impact on the regional organization of hospital
measures were the social distances followed by the use of and territorial models on the organization itself. To
personal protective equipment(P.P.E.). understand its operational effects, however, it makes sense
to describe the situation in our country which with
SIMEUP of the Calabria region(Italy)conducted an 1,354,901 positive cases and 27,967 deaths shows a very
observational study to assess the impact of containment serious situation in the contingent panorama of the spread
strategies on the pediatric hospital network of the Calabria of COVID19 in Europe.
region at the beginning of the covid-19 pandemic. The study
In Arch Pedia Neon: 2021; Issue 1 Page: 1|7Citation: Centonze A, Talarico V, Sabetta L, DeFilippo M, Pinto L, et al. (2021) Dynamic Adaptation To COVID-19 In the
Pediatric Emergency Departments of Calabria. In Arch Pedia Neon: IAPN-106.
Compared to this national situation, the number of positive (Ciaccio Pugliese), Cosenza (SS. Annunziata) and
totals in Calabria compared to the other Italian regions Reggio Calabria (Bianchi Melacrino Morelli); total: 3
maintains a constant trend over time (Source of civil Central Hospital.
protection at May 15, 2020). The spread of the virus has • Emergency and Acceptance Department (DEA) in the
therefore put a strain on the emergency system of our "Spoke" General Hospital (Peripheral Hospital):
country, for the high percentage of patients who experience Cetraro (Iannelli), Corigliano (Compagna), Crotone (S.
respiratory failure, for the parallel use of intensive care for Giovanni di Dio), Lamezia Terme (Giovanni Paolo II),
survival. Locri and Polistena (Locri and Polistena), Vibo Valentia
(Iazzolino; total: 6 Peripheral Hospital.
Severe bilateral pneumonia occurs in 10% of cases, with the • Paediatric emergency room: Peripheral General
possible development of an Acute Respiratory Distress Hospital of Soverato
Syndrome (ARDS). Hence the growing demand for new
intensive care beds in healthcare facilities, appears to be These structures have applied the measures provided for
respected overall by most of the southern regions. by the Ordinance of the President of the Region of Calabria
no. 4 of 10 March 2020 and have set up a paediatric
Compared to the national situation, in the Calabria region, diagnostic course even though it was not included in the
the number of positive cases is stable. On this basis, it aforementioned Ordinance.
should be noted that Calabria had in particular an increase
of 10.58%, equal to 60 additional beds compared to the A pre-thoracoscopic facility was therefore set up in all
beds present before the pandemic. From the comparison emergency rooms, entrusted to a general nurse. Short-term
between emerging needs and availability, the following observation (S.T.O.) care was organised, in 6 hospitals, in an
table shows the saturation index of intensive care beds. environment created within the paediatric ward. Paediatric
Calabria compared to the other regions of Southern Italy intensive care (PIC) was provided only in the "Annunziata"
has the lowest percentage of 3.40%. Regarding to incidence hospital in Cosenza and to a very limited extent: 2 beds in
of positive cases for age group, in Calabria region, there is the neonatal intensive care unit, reserved for children over
an increasing trend with increase of age. 30 days old and weighing less than 10 kg.
Materials and Methods All the paediatric units involved answered our
questionnaire. We investigated in particular some aspects
Although there were far fewer paediatric cases than adults, 1) children arrived in the emergency department in March
the Calabrian section of SIMEUP assessed the current 2020, 2) adoption of covid-19 - for children diagnostic and
situation in paediatric emergencies. The survey was therapeutic pathway (PDTA) - 3) logistic organisation, 4)
compiled by doctors in order to gain experience in use of personal protective equipment.
paediatric emergencies.
Our paediatric units consist of: Results
• Emergency and Acceptance Department (DEA) at the The measures provided for by the Regional Ordinance were
General Hospital "HUB" (Central Hospital): Catanzaro applied in the pediatricians of 8 hospitals: Table. 1
Measures COVID-19 N° Hospitals
Use of PPE 8
Nasal swab 8
Nasopharyngeal swab 8
Aspirated swab 1
broncho-alveolar- lavage 1
Admission/Isolation 7
Transfer to another hospital 7
Healthcare personnel management with
suspected COVID-19 3
Management of the birth of the mother
Covid-19 and the newborn 0
Table 1: Meseaures Covid-19 in Calabrian Hospital.
Specifically, according to the indication provided by the The distribution of consumable materials in the Pediatric
Civil Protection, in Calabria, the distribution of consumable wards before COVID-19 " and "After" COVID-19 is reported
goods was equal to 3,010,618 while the non-consumable in detail in tab. 2
ones amounted to 16,121, equal to 1.65% and 4.90%
respectively of the national average.
In Arch Pedia Neon: 2021; Issue 1 Page: 2|7Citation: Centonze A, Talarico V, Sabetta L, DeFilippo M, Pinto L, et al. (2021) Dynamic Adaptation To COVID-19 In the
Pediatric Emergency Departments of Calabria. In Arch Pedia Neon: IAPN-106.
Usual use of PPE before and after the onset of COVID-19
5-point Likert scale, from 1 (never) to 5 (always)
Table 2: Usual use of PE before and after the onset of Covid-19.
The use of PPE after COVID-19 has more than doubled; as pandemic. The average utilization index has in fact gone
shown in the graph, the use of PPE in the daily routine from 1.66 to 3.42 (+1.66).
before the covid-19 emergency and after the start of the
Usual use of PPE before and after the onset of COVID-19
5-point Likert scale, from 1 (never) to 5 (always)
Before COVID-19 After COVID-19
5.00
4.50
4.00
3.50
3.00
2.50
2.00
1.50
1.00
0.50
0.00
Figure 1: Usual use of PPE before and after the onset of Covid-19.
PPE use increased during COVID 19 disease. The same difficulty in finding), which allowed the representation that
availability of these devices has been detected, in order to follows with the temporal reference before and after the
verify their difficulty or not; therefore, the questionnaire advent of the virus.
used a ranking from 1(= very many difficulties) to 5 (= no
In Arch Pedia Neon: 2021; Issue 1 Page: 3|7Citation: Centonze A, Talarico V, Sabetta L, DeFilippo M, Pinto L, et al. (2021) Dynamic Adaptation To COVID-19 In the
Pediatric Emergency Departments of Calabria. In Arch Pedia Neon: IAPN-106.
Difficulty in supplying protective equipment
5-Points Likert scale, from 1 (very many) to 5 (none)
Table 3: Difficulty of supplying PPE
Figure 2: Difficulty in supplying protective equipment.
The survey also asked for PPE availability and rank 1 was 2020, it is noted that there was an overall reduction of 77%
established for not available and rank 5 for easily available, for accesses (-4,220) and 70% of admissions (-686), with a
as showed in figure 2. variation for each hospital between 96% and 70% for
admissions and between 81% and 25% for admissions.
From the comparison of admissions to the emergency room Table. 4.
and admissions between the months of March 2019 and
In Arch Pedia Neon: 2021; Issue 1 Page: 4|7Citation: Centonze A, Talarico V, Sabetta L, DeFilippo M, Pinto L, et al. (2021) Dynamic Adaptation To COVID-19 In the
Pediatric Emergency Departments of Calabria. In Arch Pedia Neon: IAPN-106.
Decrease/ Decrease/
Access/Emerge Access/Emerge Access Admission Admission admission
ncy ncy march march march march
Hospital City March 2019 march 2020 2020 % 2019 2020 2020 %
Pugliese-Ciaccio Catanzaro 642 103 539 84 110 30 80 73
Jannelli Cetraro 50 15 35 70 20 15 5 25
Compagna Corigliano 50 10 40 80 30 14 16 53
Annunziata Cosenza 768 150 618 80 180 48 132 73
S. Giovanni di
Dio Crotone 597 162 435 73 75 28 47 63
Giovanni Paolo II Lamezia 625 112 513 82 78 20 58 74
Locri 311 126 185 59 99 19 80 81
Locri e Polistena
Polistena 384 77 307 80 126 38 88 70
Reggio
1.135 240 895 79 140 37 103 74
G.O.M. Calabria
Soverato Soverato 376 88 288 77 80 28 52 65
Vibo
Iazzolino Valentia 512 147 365 71 47 22 25 53
Total 5.450 1.230 4.220 77% 985 299 686 70%
Table 4: Hospital admissions and hospitalizations comparison March 2019 - March 2020
From the analysis of the data found thanks to the research public health emergency of international concern (PHEIC).
conducted by SIMEUP Calabria, some interesting ideas Declaring a PHEIC is an urgent call, at the highest levels, for
emerge. the international community to initiate a coordinated
The first observation that derives from the comparison of global effort to stop the epidemic, which requires a strong
the last table is the very strong contraction observed in the response to public health, high-level political commitment
number of admissions and admissions to paediatric wards. and sufficient funding. Despite its worldwide spread, the
This is certainly an effect of the general health indications epidemiological and clinical models of COVID-19 remain
expressed at regional level; however, other correlated and largely unclear, particularly among children. Children of all
dependent effects should not be overlooked, such as those ages were sensitive to COVID-19 and there was no
linked to the fear of the contagion spreading to newborns significant sexual difference. The clinical manifestations of
and therefore to the families of origin and belonging. COVID-19 cases in children were less severe than in adult
patients. However, young children, especially infants, were
All this could lead to further considerations concerning the vulnerable to the 2019-nCoV infection. Children of all ages
more efficient and effective organisation of paediatric care were sensitive to COVID-19, but no significant sexual
systems post-COVID19. difference was detected. The clinical manifestations of
pediatric patients were generally less severe than those of
Another consideration concerns the absence of a adult patients. However, young children, especially infants,
prearranged and systemic action plan for the COVID19 were vulnerable to the new coronavirus infection of 2019
regional emergency phenomenon. Despite this, the [1].
responses in terms of emergency equipment and other
indications provided by the regional ordinance have been Many studies have simulated the dynamics of the Wuhan
regularly implemented. outbreak network using a susceptible-exposed-infected-
recovered (SEIR) deterministic model that classifies the
Conclusion population into four states: sensitive individuals (S),
asymptomatic individuals during the incubation period (E),
An increasing number of studies have focused on the 2019 confirmed infected individuals (I) and healed individuals
coronavirus novel (COVID-19) since its outbreak, although (R). In the first 75 days of the epidemic, a significant
initially there was very little data available on the amount of work has been published to understand the
epidemiological characteristics and transmission patterns novel coronavirus, as well as to develop prevention and
of Covid-19 in children. In early December 2019, numerous treatment strategies. Strict containment measures have
cases of pneumonia of unknown origin emerged in Wuhan, been established effectively implemented throughout
Hubei Province, China. The disease spread rapidly, China, particularly in infected areas, preventing the spread
nationally, to other parts of China and around the world to of the infection. Statistical studies have recorded that the
many countries on 6 continents. On January 7, 2020, the reproduction number has has had a downward trend,
World Health Organization (WHO) named it the novel indicating lower spread rates through containment and
coronavirus 2019 (2019-nCoV). On February 11, 2020, rigorous isolation measures [2]. The well-being of the
WHO named the 2019 coronavirus novel (COVID-19) as health workforce is the cornerstone of any well-functioning
2019-nCoV associated disease. The emergence of 2019- health system. As a result of the pandemic, medical health
nCoV drew global attention and WHO declared COVID-19 a care providers are under enormous pressure on the
In Arch Pedia Neon: 2021; Issue 1 Page: 5|7Citation: Centonze A, Talarico V, Sabetta L, DeFilippo M, Pinto L, et al. (2021) Dynamic Adaptation To COVID-19 In the
Pediatric Emergency Departments of Calabria. In Arch Pedia Neon: IAPN-106.
workload with an increase in total healthcare costs. The interstitial pneumonia) but instead the damage is driven by
overwhelming burden of COVID-19 disease could lead to vasculitis and small vessel thrombosis.
the caregiver Burnt. The overwhelming burden of COVID-
19 illness could lead to caregiver burnout. The major causes Indeed, cases of kawasaki disease associated with Covid19
of psychological distress among healthcare workers are are increasing. Another finding in the pediatric population
including long work hours, sleep disturbances, debilitating yet to be evaluated is the finding of negative swabs versus
fatigue, and the risk of getting infection and put their family positive serology.
at risk of a life-threatening condition. In times of epidemic,
emergency departments can become overwhelming chaotic From this first work it is possible to make some summary
places where a large number of patients arrive. The most considerations, with respect to which SIMEUP Calabria
important aspect is that everything must be prepared and intends to continue its work of awareness and stimulation;
established in advance. The concept of "forward triage" was in particular, from the analysis carried out, it seems
designed for respond to various types of crisis scenarios appropriate to seize the "opportunities" offered by the
such as epidemics and viruses Catastrophes. Forward specific situation of COVID-19 to strengthen the pediatric
triage is the process of determining patients condition emergency-urgency network with the creation of clearly
before they reach the emergency room [3]. defined Pediatric Emergency Room facilities.
A study on Emergency Departments (CONFIDENCE) To all operators, the invitation to use the "operational
involved a cohort of 100 Italian children younger than 18 pause" undergone, to devote themselves to updating and
years old with Covid-19 confirmed to nasal or rethinking the structures of the Emergency Departments
nasopharyngeal swab test. patients were evaluated and Pediatric Departments, adapting them to the new
between March 3 and March 27, 2020 in 17 pediatric emerging needs stimulated by the ongoing pandemic
emergency departments. This work reports the results of situation, which could lead to a new organization of the
the CONFIDENCE study and compared with those of three pediatric care system at the end of the COVID-19 pandemic.
groups previously published in analysis. According to the
categories described by Dong et al., 21% of patients were As we refine our understanding of COVID-19, a high degree
asymptomatic, 58% had mild disease, 19% had moderate of active surveillance in the community and a dynamic
disease, 1% had severe disease and 1% had critical reevaluation of Urgent and Emergency Department
conditions [4]. workflow processes, along with hospital and public health
response nationwide, could help us better manage this
Compared to adults, there have been fewer reported cases ongoing pandemic and prepare for the next one. 10.
of COVID-19 in the pediatric population, although the
incidence is increasing every day. The authors publish a SIMEUP's study, through this survey, was able to identify
review of specific epidemiological factors, symptoms, several characteristics of the regional pediatric care
laboratory analysis and imaging and other relevant metrics system. These preliminary findings may suggest that
derived from the limited published literature that are children, even when they present with mild symptoms or
specific to the pediatric population. This review is useful for are asymptomatic, could be a source of viral transmission.
the pediatric professional and partially guides the creation This underscores the importance of broad preventive
of a clinical algorithm for the management of COVID-19 in strategies.
the pediatric population that can be used by pediatric
institutions [5]. The development of investigation and Bibliography
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Pediatric Emergency Departments of Calabria. In Arch Pedia Neon: IAPN-106.
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Copyright: © 2021 Centonze A. This Open Access Article is licensed under a Creative Commons Attribution 4.0 International
(CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and
source are credited.
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