SUMMER made us catch our breath, but the real test has come with the reopening of the schools, the temperatures that drop making us spend more time indoors, and the infections that come back to surge. This time, however, the excuses are struggling to be acceptable: we know the enemy, the mistakes made in the past (perhaps inevitable) should have taught us how to act, and we have had more than six months to prepare for a second epidemic wave. With the relaunch decree, in May the government allocated three billion and 250 million euros to the reorganization of public health, of which about one billion and two aimed at territorial assistance, and almost one and a half billion for the reorganization of the hospital network. The ball was therefore in the hands of the Regions. Which after having dedicated most of the last decades to unhinging the medicine of the territory – by badly managing the relationship with general practitioners, abolishing doctors in schools and relegating prevention to the margins of health action – they should have retraced their steps. “The truth is that we should no longer think about the terms of the exchange as opposed to the local one, but in terms of service standards to guarantee – he says Antonio Gaudioso, president of Cittadinanzattiva. – Services to be guaranteed through a program that takes into account the characteristics of the territory and that includes emergency cases. So that everyone knows what they have to do. “It is precisely the chain of command, in fact, that was missing during the weeks of emergency and in fact not yet precisely delineated, throwing everyone into panic.
The tampon issue
What to do, for example, in case of symptoms that can be traced back to Covid? Who is the swab asked for? In recent weeks, citizens have tried to contact family doctors, but they are not able to do so: they must activate the territorial prevention department which will have to contact the patient again to proceed with the test. A waste of time, hours or perhaps days during which the patient would have to be in preventive isolation. That’s why everyone runs to the emergency rooms, which fill up just like they did in March, in full emergency. Therefore, especially in large cities, the points dedicated to tampons have been organized, in an outpatient or ‘drive in’ mode. But even here the queues are kilometric with waits for hours. In order to try to find a solution, on October 17, the Scientific Technical Committee recognized, among other things, “an absolute need for timely diagnosis, monitoring and effective contact tracing through the involvement of general practitioners and free pediatricians. choice, through active recruitment actions by enhancing diagnostic systems “.
Only one swab for Covid and flu. At the start of the surveillance of the Higher Institute of Health
October 15, 2020-
Family doctors
In recent days, the Lazio Region had promoted the voluntary membership of family doctors and pediatricians to perform rapid swabs. But the professionals protested: “We cannot commit ourselves without precise rules that protect us and the citizens,” he says Silvestro Scotti, general secretary of the Federation of General Practitioners. “First of all we must have personal protective equipment, we must act in safety”. Dozens of general practitioners have fallen on the battlefield of Covid-19, and unfortunately they continue to die even in these days. “And then it must be established which tampons, to whom, with what objective. Not to mention the fact that the studies must be reconfigured in order to guarantee the safety of citizens”, continues Scotti. Many have pointed the finger at general practitioners because they are unable to provide effective assistance or because they behave very differently from region to region. There are those who suggest that a solution would be to make general practitioners – who are now affiliated – dependent on the health system. “It is an old controversy. It would be enough to intervene on the contract by inserting additional notes for the services to be performed in the event of an emergency, thus ensuring uniformity and capillarity of the service”, says Scotti. For example, rapid tampons could enter the services of family doctors: this would establish a service to be provided at national level.
Coronavirus, Scotti: “The time between suspicion and diagnostic certainty must be shortened”
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There are no doctors
But even if all this happened – if general practitioners had the tools, protocols and obligations to act in the best possible way – we would run aground on one last high stumbling block: the lack of professionals. Already today the emergency is evident but in the coming months it will get worse: between 4 and 5 thousand doctors could retire, leaving 5-8 million Italians without a reference point. “In recent years, a rule has been introduced that allows you to become a MMG already during specialization in order to try to stem this problem – concludes Scotti. – However, we have been waiting for 6 months for the green light that depends on the Conference of Regions. Throughout Italy 2 thousand doctors would be ready to go to the office, in Lombardy there are 200 “. The truth, therefore, is that even if there were a plan to reorganize the services in the area, there would not be enough doctors to implement it. Especially in the north, experts say.
Covid, Ricciardi: “For the quarantine 10 days are enough, but a swab is needed”
by SIMONE VALESINI
09 October 2020-
The hospital network
As for the structures to be dedicated to the care of Covid patients, which will now have to guarantee strict separation from ordinary patients, each Region in recent months has had the freedom to organize itself in its own way, albeit with the obligation to submit a plan of reorganization approved by the Ministry of Health. “There are three strategies chosen: the use of Covid Hospital dedicated solely to the treatment of patients with Sars-Cov-2 infection, adopted only by Piedmont and Valle d’Aosta; a network model, chosen by Tuscany, in which the majority part of the hospitals also treat Covid patients; and the Hub and Spoke model suggested by the ministry and the Istituto Superiore di Sanità, with reference centers supported by a network of peripheral structures “, explains Americo Cicchetti, professor of the Faculty of Economics of the Catholic University of the Sacred Heart and director of the High School of Economics and Management of Health Systems, Altems.
Continuity care units
In addition to the reorganization of the hospitals, the Government’s strategy rests on two cornerstones: the strengthening of territorial assistance, with the creation of the Usca, or special assistance continuity units, dedicated to taking charge and monitoring of patients in home isolation, and the increase in beds in intensive care, which in all regions must reach 14 beds per 100 thousand inhabitants, considered sufficient to absorb the needs of a possible second wave which is expected to be less dramatic than the first, thanks to the logistical and therapeutic knowledge acquired in the past few months.
Coronavirus, a family locked in the house and the quarantine that never ends
of FIAMMETTA CUPELLARO
12 October 2020-
The Usca are a mirage in many regions and there is no monitoring system that tells exactly how many are actually in operation: with tens of thousands of Italians in isolation, the need for teams of doctors and nurses door to door is very evident. The latest available data speak of about 600 Usca in 15 Regions, just under half of what was considered necessary by the Government last March. Decree 14/2000 estimated the need for 1 team for every 50 thousand inhabitants – therefore about 1200 Usca – and for their creation, including the hiring of fixed-term doctors and nurses, it made available to the Regions 60 million euros. A new professional figure would then have had to knock on our doors: the family nurse. The decree made 330 million available for 2020 and 460 million for 2021 to hire 9,600. At the moment there are only a few hundred, in particular from Veneto, Emilia Romagna and Tuscany.
Coronavirus, Minister Speranza: “The key word is ‘proximity’ and the first place of care is the home”
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Who treats the sick in intensive care?
The second pillar is ICU beds. In recent days, Commissioner Arcuri and the Government have argued with the Regions for not having prepared beds for the most seriously ill in the face of the ventilators made available. On the other hand, it was replied that the call for the allocation of funds for intensive care was only opened on 2 October. But even when the Regions were able to guarantee a capacity for intensive care adequate to Covid standards, the people would be missing: who cares for the sick? And if in March doctors and nurses came to the fore because it was an emergency, now they rightly demand greater protection and organization. Also in this case, the Government has made funds available and the Regions have launched calls for tenders which, however, have resulted in a minimal increase in the percentage of professionals: the latest Altems Report clearly highlights how the vast majority of Regions have increased staff less than 10%. Only Molise, Piedmont and Valle D’Aosta exceed this threshold. “Almost two thousand anesthetists are needed to manage the new ICU beds alone, not to mention the nursing staff and specialists needed for the sub-intensive care enhancement plan,” he said. Carlo Palermo, secretary of the union Anaao Assomed. The increase, although not optimal, in intensive and sub-intensive beds, in fact, made the blanket even shorter. Still looking at the Altems analysis of October 15, it turns out that after the emergency the number of anesthetists per bed has decreased: if before Covid in Italy there were on average 2.5 anesthetists per bed today there are 1.6, with marked regional differences. Anesthetists, emergency doctors, pulmonologists, nurses, the teams that have to take care of a serious patient with Covid are made up of different professionals. “These are roles that must be regularized with fixed-term and permanent contracts, otherwise the shortage of medical personnel will only worsen in the coming years, and we will find ourselves again unprepared for the arrival of a new emergency”, concludes Palermo.
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