Strategies to convert hospital beds for COVID-19 patients to minimize emergency department overcrowding

Background: The shortage of hospital beds for COVID-19 patients has been one critical cause of Emergency Department (ED) overcrowding. Purpose: We aimed at elaborating a strategy of conversion of hospital beds, from non-COVID-19 to COVID-19 care, minimizing both ED overcrowding and the number of beds eventually converted. Research Design: Observational retrospective study. Study Sample: We considered the centralized database of all ED admissions in the Lombardy region of Italy during the second "COVID-19 wave" (October to December 2020). Data collection and Analysis: We analyzed all admissions to 82 EDs. We devised a family of Monte Carlo simulations to evaluate the performance of hospital beds' conversion strategies triggered by ED crowding of COVID-19 patients, determining a critical number of beds to be converted when passing an ED-specific crowding threshold. Results: Our results suggest that the maximum number of patients waiting for hospitalization could have been decreased by 70% with the proposed strategy. Such a reduction would have been achieved by converting 30% more hospital beds than the total number converted in the region. Conclusions: The disproportion between reduction in ED crowding and additionally converted beds suggests that a wide margin to improve the efficiency of the conversions exists. The proposed simulation apparatus can be easily generalized to study management policies synchronizing ED output and in-hospital bed availability

Intensive follo w-up after liver resection for colorectal liver metastases: results of combined serial tumour marker estimations and computed tomography of the chest and abdomen – a prospective study

The aim of the study was to prospectively evaluate an intensive follow-up programme using serial tumour marker estimations and contrast-enhanced computed tomography (CT) of the chest and abdomen in patients undergoing potentially curative resection of colorectal liver metastases. Seventy-six consecutive patients having undergone potentially curative resections of colorectal liver metastases in a single unit were followed up with a protocol of 3 monthly carcinoembryonic antigen and carbohydrate antigen 19-9 estimations and contrast-enhanced spiral CT of the chest, abdomen and pelvis for the first 2 years following surgery and 6 monthly thereafter. The median period of follow-up was 24 months (range 18–60). Recurrent tumour was classed as early if within 6 months of liver resection. Thirty-seven of the 76 patients (49%) developed recurrence on follow-up. Nineteen recurrences were in the liver alone (51%), 16 liver and extrahepatic (43%) and two extrahepatic alone (6%). Of the 19 patients with isolated liver recurrence, eight developed within 6 months of liver resection none of which were resectable. Of the 11 recurrences after 6 months, five (45%) were resectable. Of the 37 recurrences, CT indicated recurrence despite normal tumour markers in 19 patients. Tumour markers suggested recurrence before imaging in 12 and concurrently with imaging in 6. In the 12 patients who presented with elevated tumour markers before imaging, there was a median lag period of 3 months (range 1–21) in recurrence being detected on further serial imaging. Seventeen patients who developed recurrence had normal tumour markers before initial resection of their liver metastases. Of these 17, 10 (58%) had an elevation of tumour markers associated with recurrence. Over a median follow-up of 2 years following liver resection, the use of CT or tumour markers alone would have failed to demonstrate early recurrence in 12 and 18 patients respectively. A combination of tumour markers and CT detected significantly more (P<0.05) recurrence than either modality alone. Tumour markers and CT should be used in combination in the follow-up of patients with resected colorectal liver metatases, including patients whose markers are normal at the time of initial liver resection