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Places of care Interviews

Designing the hospital network of the future

Those necessary changes to make models coincide with reality

Interview with Francesco Enrichens

Advisory board National System of Guidelines,National Institute of Health Public Investment Evaluation and Assessment Unit, Ministry of Health

By May 2020July 17th, 2020No Comments
Photo by Lorenzo De Simone

Covid-19 put a strain on the healthcare system and particularly on regions. What went wrong?

Our colleagues from the ‘20s certainly would have known how to manage better the current situation we’re in, as they were more used to dealing with epidemics and pandemics. When you’re caught unprepared you seek for a solution with any tools available, including cultural ones. Many blamed Balduzzi’s 2015 Ministerial Decree – DM no. 70 – which led to the conversion of hospitals towards a “hub and spoke” model, with a distribution of bed spaces based on the parameter of 3.7 per 1,000 inhabitants, out of which 0.7 are dedicated to post-acute care. Some believe that this parameter caused a drastic cut to bed spaces but that’s not really the case because many Italian regions had a much lower number of beds even before the reform. In fact, intensive care beds actually increased from the 4679 in 2010 to the current 5179 thus it certainly can’t be claimed that the DM no. 70 caused the reduction of intensive care beds. The reality is that the initial impact of Covid-19 caused a massive hospitalisation of vulnerable groups and elderly patients suffering from acute respiratory conditions, and this required a sudden increase of intensive care beds, reaching roughly 9,000 bed spaces. The hospital network in its pre-reform structure would have been certainly much more inefficient and would have sustained the impact of the emergency even less than the current one. The DM no. 70, whenever applied, guaranteed the presence of specialisms for ordinary emergency services that continued to weigh on the hospital system in parallel with the pandemic. The only true flaw in the plan was not arranging the simultaneous rearrangement of the local networks in the area. Any change to one of the networks is bound to affect the other ones. As a matter of fact, it’s been more challenging to contain the assault on hospitals, and its known consequences, whenever the corresponding provision of local services proved to be weaker.

How was the hospital network restructured with the DM no. 70?

We used a “hub and spoke” structure defining different layers of complexity based on the catchment area and the volume of activities. The hub has a catchment area ranging from 600,000 to 1,2 millions of inhabitants and should be the point of reference for all specialist services required for an all-round response. The “spokes” have a catchment area of 150,000-300,000 inhabitants and guarantee basic services. Medical centres with catchment areas between 300,000 and 600,000 inhabitants have an intermediate level of complexity so they can manage time-dependent cases such infarction with ST elevation, stroke and multiple traumas. The emergency system, including the local (118 and 112 emergency numbers) and hospital networks, allows to manage patients at risk of death in a timely manner and to transport them to the closest and most appropriate medical facility. This redesign introduced a historic cultural change in the organisation of healthcare services, based on appropriateness, efficiency and financial sustainability. The system, optimal to manage the ordinary influx of patients with injuries (the scenario for the internal contingency plan being a heavy influx of patients with injuries), was not ready for a biological emergency like the Covid-19 pandemic. Additionally, our hospital network is dated and the facilities and services are rather rigid so don’t allow rapid transformations. For this reason the new emergency measures for hospitals also include the increase of bed spaces in intensive care units as well as an important rearrangement of sub-intensive care with the addition of 6,000 beds, and the provision of another 6,000 beds for ordinary inpatient units.

This way we will not be unprepared when facing the next peak…

The goal is to restructure the spaces, the support pathways and the logistics. The hospital of the future must be more flexible and offer inpatient rooms designed to convert into a single space and increase the ward capacity when needed. Compressed air, vacuum and oxygen systems, air conditioning and all the other required technologies must be guaranteed. It is crucial to subdivide the routes inside the hospital to avoid contaminations. A&E departments must provide pre-triage and waiting areas for diagnostics in order to separate infected subjects, or the potentially infected ones, from the rest of the patients.
The hospitals providing support services for pathologies other than Covid-19 will have to be identified and connected to the network of Covid-19 hospitals. There will also be dedicated centres with infectious disease specialists, pulmonologists and other specialist consultants, available to the Covid-19 network for consultations, local activities and home-based services. The hospital and emergency networks must work even more in synergy with the local network now. That’s because the battle can be won with the help of local services, through early tracking of infected patients, self-isolation at home, and even home-based healthcare services, until these are feasible and appropriate, so that hospital overcrowding and the resulting increased rates of infection and mortality can be prevented.

The hospital of the future should be more flexible. It is crucial to subdivide the routes inside the hospital.

What are the next steps?

The conversion of the existing bed spaces in isolatable areas, following better technological and qualitative standards, will allow to improve the level of support provided even during normal times. The specialists will have to step out of corporate thinking and aim to create multidisciplinary training, sharing technologies, communication and organisation tools, like the local operations centres (the 116117 helpline) and telemedicine: a more elastic construction activity on one end and a more modern and collaborative culture on the other. The opportunity for this could lie in the emergency addition of healthcare staff, like nurses, that, once made permanent in their role, would allow us to rebuild connections between the various networks (emergency, hospital and local networks). They could provide training and help create multiple disciplines and professions, divided based on the intensity level of the care required. The other indispensible requirements for greater planning and management are data transparency and the identification of standards for staffing – for local services as well as hospitals – based on the volume of activities and the demand of services. This will allow us to identify promptly the percentage of elderly and vulnerable groups that suffer from multiple conditions and to manage their care proactively.

A more elastic construction activity on one end and a more modern and collaborative culture on the other.

The interview took place on 11 April 2020