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Background The aim of this study is to quantify the hospital burden of COVID-19 during the first wave and how it changed over calendar time; to interpret the results in light of the emergency measures introduced to manage the strain on secondary healthcare. Methods This is a cohort study of hospitalised confirmed cases of COVID-19 admitted from February–June 2020 and followed up till 17th July 2020, analysed using a mixture multi-state model. All hospital patients with confirmed COVID-19 disease in Regione Lombardia were involved, admitted from February–June 2020, with non-missing hospital of admission and non-missing admission date. Results The cohort consists of 40,550 patients hospitalised during the first wave. These patients had a median age of 69 (interquartile range 56–80) and were more likely to be men (60%) than women (40%). The hospital-fatality risk, averaged over all pathways through hospital, was 27.5% (95% CI 27.1–28.0%); and steadily decreased from 34.6% (32.5–36.6%) in February to 7.6% (6.3–10.6%) in June. Among surviving patients, median length of stay in hospital was 11.8 (11.6–12.3) days, compared to 8.1 (7.8–8.5) days in non-survivors. Averaged over final outcomes, median length of stay in hospital decreased from 21.4 (20.5–22.8) days in February to 5.2 (4.7–5.8) days in June. Conclusions The hospital burden, in terms of both risks of poor outcomes and lengths of stay in hospital, has been demonstrated to have decreased over the months of the first wave, perhaps reflecting improved treatment and management of COVID-19 cases, as well as reduced burden as the first wave waned. The quantified burden allows for planning of hospital beds needed for current and future waves of SARS-CoV-2 i.

Background: Understanding the risk factors associated with hospital burden of COVID-19 is crucial for healthcare planning for any future waves of infection. Methods: An observational cohort study is performed, using data on all RT-PCR confirmed cases of COVID-19 in Regione Lombardia, Italy, during the first wave of infection from February-June 2020. A multi-state modelling approach is used to simultaneously estimate risks of progression through hospital to final outcomes of either death or discharge, by pathway (via critical care or not) and the times to final events (lengths of stay). Logistic and time-to-event regressions are used to quantify the association of patient and population characteristics with the risks of hospital outcomes and lengths of stay respectively. Findings: Risks of severe outcomes such as ICU admission and mortality have decreased with month of admission and increased with age. Care home residents aged 65+ are at increased risk of hospital mortality and decreased risk of ICU admission. Being a healthcare worker appears to have a protective effect on mortality risk and length of stay. Lengths of stay decrease with month of admission for survivors, but do not appear to vary with month for non-survivors. Interpretation: Improvements in clinical knowledge, treatment, patient and hospital management and public health surveillance, together with the waning of the first wave after the first lockdown, are hypothesised to have contributed to the reduced risks and lengths of stay over time. Funding: This work has been funded by the Medical Research Council (De Angelis, Jackson, Presanis: Unit programme number MC UU 00002/11; Kunzmann: Unit programme number MC_UU_00002/10); and the UKRI-MRC COVID-19 Rapid Call (Presanis, De Angelis, grant no MC_PC_19074). Declaration of Interests: None to declare.

Health Care Organizations are properly considered the most complex ones and there is a growing attention at a complexity perspective in health policy. Leading complex organizations is a crucial task, moving away from a trait and personality background towards the relevance of leadership styles and behaviours. Based on this assumption, we planned the development of an effective model for leading groups or organizations in health care in order to achieve better outcomes, that arises from a structured observation of Health Care CEOs working in their context. The main clue was the importance of specific behaviour patterns that can be elicited through modeling processes. Modeling process enables people in the groups and learning organizations to cope through scheduled intervision to verify improvements and to produce continuous feedback. Different techniques based on the so-called ‘sleight of mouth’ procedure were selected to elicit specific leadership patterns, through an observational study, and comparing main indicators of performance, included in Regione Lombardia and Sant’Anna of Pisa networks. Among the set of behavior patterns investigated through the lens of ‘sleight of might’ technique were: not knowing, active listening, relationships, giving answers immediately, seeking feedback, values bridging, easiness, reframing, sense making, utilizing ‘strange’ attractors, interpersonal management tactics. The conclusive results of the benchmarking analysis and the patterns are ongoing. Impact is valued through the awareness of different levels of learning, recognizing specific patterns of performance, modeling and acting strategies for change. Learning groups and organizations are powerful setting of improvement, particularly in health care where many variables are at stake. The analysis of the patterns to be elicited related to performance represents a platform for coping and reproducing successful strategies in the realm of leadership.

The present chapter highlights the importance of PAD projects by emphasizing the path that led to their widespread diffusion through the initial introduction of the AEDs into clinical practice. Presently the AEDs use a biphasic waveform technology but most of the devices have different features in terms of energy and current delivered as well as different waveforms duration depending on whether they deploy a biphasic truncated or a rectilinear waveform. However, the effects of these technical differences on the success of defibrillation and on outcome are as yet largely unknown. Current studies on technology are now investigating the optimal defibrillation time according to the ventricular fibrillation waves. Cardiac perfusion guaranteed by an optimal chest compression is of paramount importance to maintain the heart vital to subsequently allow successful defibrillation. PAD projects are developed differently according to the legislation or to the rules existing in each country. Only few European countries have specific laws which define the modality of use and describe the requirements to achieve a certification for using the AEDs. Scientific data report that the highest effectiveness occur when the PAD (and consequently the AEDs) are linked to the local Emergency Service. This offers a potential quicker activation in case of a cardiac arrest occurred nearby an AED location. Isolated AEDs are often useless due to lack of equipment control and to the expiration of pads and batteries. Overall, the use of Public AEDs in the clinical setting accounts for approximately 2% of the total cardiac arrest interventions which are thus mostly performed by the EMS personnel. However, survival from VF in the groups of patients treated by lay people with the deployment of a public AED is higher than 55% raises up to 65%.

a b s t r a c t Aim: Assessment and comparison of the electrical parameters (energy, current, first and second phase waveform duration) among eighteen AEDs. Method: Engineering bench tests for a descriptive systematic evaluation in commercially available AEDs. AEDs were tested through an ECG simulator, an impedance simulator, an oscilloscope and a measuring device detecting energy delivered, peak and average current, and duration of first and second phase of the biphasic waveforms. All tests were performed at the engineering facility of the Lombardia Regional Emergency Service (AREU). Results: Large variations in the energy delivered at the first shock were observed. The trend of current highlighted a progressive decline concurrent with the increases of impedance. First and second phase duration varied substantially among the AEDs using the exponential biphasic waveform, unlike rectilinear waveform AEDs in which phase duration remained relatively constant. Conclusions: There is a large variability in the electrical features of the AEDs tested. Energy is likely not to be the best indicator for strength dose selection. Current and shock duration should be both considered when approaching the technical features of AEDs. These findings may prompt further investigations to define the optimal current and duration of the shock waves to increase the success rate in the clinical setting.