**3.2 COVID-free hospital organization**

Phase 2, therefore, began after having guaranteed the status of COVID-free Hospital to the Monastier Hospital and the safety of the subjects who up to now have passed through it.

In this new phase, the difficulty in eliminating the risk of contagion (which, however, will increase) has led to further restrictive decisions, in order to maintain a closer and therefore more effective control network.

The management of the Nursing Home has therefore decided to create a "lean" structure to direct these operations coordinated by a COVID manager.

This structure will make use of all the best technical-scientific and specialist skills in order to further safeguard the integrity of the Hospital's COVID-free status and to make access to it still safe for patients, staff (and therefore their families) and all those who want to take advantage of the excellences that are available to a territory and a population that at this moment needs "Safe Care".

To this end, it was decided to reorganize the resumption of services as follows:



**Table 1.** *Filter areas A-B-C-D-E.* Waiting room with entrance gate

Seats with a minimum distance of one and a half metres

Turnstiles with fever measurement and PPE control

Entrance gates and infrared thermo-scanner

Diversified path for symptomatic or febrile (sub-febrile) patients through filter area A

Check-in for booked patients

It is desirable to reach 100% of online or telephone bookings (CUP) as soon as possible

Check-in for unbooked patients

(It is desirable to reach 0% of accesses without booking as soon as possible)

Presence of a room assistant

Water-drink-coffee dispenser

Mask and gloves dispenser

#### **Table 2.**

*Gate features.*

Seats with a minimum distance of 1-m

Certain tensile structure at Gate A, no tensile structure at Gate B, no tensile structure at Gate C, tunnel already present at Gate D, hot room of the accident and emergency department already present at Gate E

Summer air conditioning with a negative air pressure circuit in the tensile structure or natural air recycling

Doors/windows that can be opened to allow air to be recycled in the tensile structure or in the waiting rooms

Seating with fixed chairs spaced one and a half metres apart

Monitor skip queue (Filter Zone B-C)

TV monitor (Zone B-C)

Totem for booking at Gates A and B

Disinfectant dispenser

The turnstiles with fever measurement and device control allow control of access and exit flows (with data centralization and remote access control) for patient access at presentation time with a thermo-scanner and alarm if:

• TC ≥ 37°C

• no PPE (Mask)

**Table 3.**

*Management of outpatient areas – waiting room with entrance gate.*

If the patient is febrile (TC ≥ 37.5°C), he/she is sent to the entrance to the Emergency Department (ramp side) upon communication of the room assistant from the Gate sending the room assistant of Gate E

If a patient with 37°C ≤ TC <37.5°C, re-evaluation of the temperature by the Room Assistant with the tympanic or axillary thermometer. If confirmed, sent as in the previous point

If a patient is without PPE (mask and gloves), he/she is asked to purchase them

The Room Assistant must provide for patients who are unable to purchase surgical masks and gloves

The patient must enter and exit (if possible) the Nursing Home through the same turnstile

Each turnstile must be "controlled and governed" by the Room Assistant

The Room Assistants must be equipped with manual thermo-scanners (even in the case of turnstiles with thermo-scanners)

The filter area E can be controlled by a volumetric thermo-scanner

Infrared thermo-scanners are turnstile devices

The temperature check is guaranteed by the Room Assistant

The Gate and waiting area for symptomatic or febrile (sub-febrile) patients are located in the waiting room of the emergency department

**Table 4.** *Various events.*

> If the reason for accessing the Nursing Home is the symptom or fever he/she presents, the procedure already established at the time of booking will be followed

If the reason for access is different and there is no urgent need for access to the Nursing Home, he/she will be sent to the care provider for territorial care

If the reason for access is different and there is an urgent need for access to the Nursing Home, the referral specialist will be contacted

If the referral specialist is not reachable or is unable to define the problem or urgent management, the patient will be placed in safety and sent to the referral emergency room with 118

If the symptomatic or febrile (sub-febrile) subject is the carer, he/she will be sent to the care provider for territorial care

Surveillance protocol applications already in place

#### **Table 5.**

*Diversified path for symptomatic or febrile (sub-febrile) patient through Gate A – the symptomatic or febrile (sub-febrile) patient, sent to the waiting room of the emergency department, is taken in charge by the assistant of Gate E and accommodated there.*


#### **Table 6.**

*Check-in for booked patients - it is desirable to reach 100% of online or telephone bookings as soon as possible.*

Such patients should be referred to Gate A

Non-booked patients must ask the Room Assistant for a manual booking

These patients will be able to book their examination by entering with a report, one for every five patients already booked (1/5) at check-in

#### **Table 7.**

*Check-in for non-booked patients – it is desirable to reach 0% of accesses without booking as soon as possible.*

The presence of a Room Assistant is foreseen, positioned at each gate

This person will refer to the user

He/she will act as an intermediary with the check-in

He/she will control the body temperature or provide PPE if not available

He/she (at Gate A-E) will be the liaison with the switchboard for the search for the specialist

He/she (at Gate A) must deliver the information form for registration at check-in to patients who show up without registration

He/she will verify the regularity of the procedures, will give information on the path to follow, will verify that all the safety protocols are adopted: maintaining distance between people, correct use of PPE, avoiding assemblies

He/she will have to use gentle, appropriate manners, avoiding any conflicts that can arise in waiting situations

He/she will end his/her function with the Gate closed

He/she will write a report of the most significant events that emerged during his/her function

#### **Table 8.**

*Presence of a waiting room.*

Patients (and carers) who will pass through filter zones A and B can access the parking in front of the Nursing Home (PARK A-B)

Patients (and carers) who cross the filter area C can access the rear parking (access to physiotherapy) at the Nursing Home (PARK C)

Patients (and carers) who will cross the filter area E can access the rear-lateral parking (after the roundabout) at the Nursing Home (PARK E).

At the rear and side parking (after the roundabout) at the Nursing Home (PARK D) all the personnel (medical, technical and support) will be able to access the filter area D

#### **Table 9.**

*Parking - the distribution and indications for the parking areas will be given by the civil protection volunteers.*

This paper information form will be delivered to the patient who shows up without a booking and delivered to the assistant in Gate A (who will access him with a 1/5 ratio)

Questions to ask when booking:


#### **Table 10.**

*Booking information form - it is desirable to reach 100% of online or telephone bookings as soon as possible.*

After check-in, the patient must follow the path indicated at the time of booking and confirmed at check-in

The patient will arrive at the waiting room at the appointed time and he/she will receive the examination or service booked

Along the routes there will be stewards/hostesses who will check the regularity of the procedures, give information on the path to follow and verify that all safety protocols are adopted (maintaining distance between people, correct use of PPE also by personnel, avoiding assemblies)

Once the examination has been completed, the patient can go to the cashier, the bar and try to limit the stay in the Nursing Home to a maximum of 15 minutes

elf-sufficient patients must have individual access to the visiting areas

In any case, the access of a companion of non-self-sufficient patients or minors is allowed

The exit from the facility will take place through the entry gate (if possible)

Surveillance protocol application already in place

In the clinic, the operator must present himself with the following PPE:


if invasive maneuvers on the airways or other invasive maneuvers are foreseen:


#### **Table 11.**

*Outpatient clinics – service areas to be provided.*

After check-in, the patient must follow the path indicated in the instructions given for admission and confirmed at check-in

The patient will arrive at the waiting room of the reference ward at the established time where he/she will prepare for admission

In this circumstance, the temperature will be re-measured and the Head of the Department informed by the reception nurse

Along the routes there will be stewards/hostesses who will verify the regularity of the procedures, give information on the path to follow and verify that all safety protocols are adopted (maintaining distance between people, correct use of PPE also by personnel, avoiding assemblies)

Self-sufficient patients will have to access the admission areas individually

In any case, the access of a companion of non-self-sufficient patients or minors is allowed

In all cases, a device (tablet for video calls) will be made available during the hospital stay for communication with the family

Surveillance protocol applications already in place

#### **Table 12.**

*Departments – hospital areas.*


#### **Table 13**

*Connections.*


The strategic combination of operating procedures (as represented by the tables) and sequencing of Reverse Transcriptase-Polymerase Chain Reaction (RT-PCR) tests have proved successful, allowing uninterrupted system operativity.

All patients admitted to our hospital (DH-DS included) will be subjected to RT-PCR tests (T0) performed the day before hospitalization at Gate F – COVID Point (7.00– 9.00), in order to promptly intercept any positive cases before hospitalization. Patients will continue with molecular swabs from hospitalization, following the scheme:



#### **Table 14.** *Sequential swabs.*

The surveillance with sequential molecular swabs for the health and non-health personnel operating at the facility has also made it possible to avoid the formation of clusters within the structure and propagate the infections. The temporal variability of these swabs for staff will change depending on the course of the epidemic outside the hospital and will diversify into active or passive surveillance [12, 13]. These RT-PCR tests were performed on hospital staff up to once per day.

During the First Pandemic Phase of Coronavirus in Veneto in Spring 2020, we can distinguish three periods of activity at our hospital. An initial block Phase from 22 February to 9 March, a Phase 1 (total block) from 10 March to 3 May and a Phase 2 from 4 May to today (data collection deadline 18 June 2020).

The admissions activity at our hospital was referable only to urgent patients with admissions to the Departments of Orthopedics, Physiotherapy and Medicine. The outpatient activity was only possible on patients of various specialties of an urgent nature or with priority evaluation within 7 days.

In the initial phase, 85% of outpatient visits were carried out and 98.5% of patients were seen compared to the same period in 2019, and there were 102% admissions compared to 2019.

In Phase 1, 21% of outpatient visits were made and 18% of patients were seen compared to the same period in 2019 and there were 26.4% of admissions compared to 2019.

In Phase 2, 94.7% of outpatient visits were carried out and 101.6% of patients were seen compared to the same period in 2019 and there were 81.3% of admissions compared to 2019.

During the Initial Phase and Phase 2, the recovery of activity highlighted by the numbers above led to an optimization of the Health Organization according to the still present and important external circulation of SARS-CoV-2.

All while continuing to maintain the structure of a COVID-free hospital.
