Table 2 main challenges in the outbreak and response

Lack of PPE, misuse and theft

Increased order, closed stock and counted distribution to personnel according to their shifts.

Patients with clinical suspect of COVID19 with a negative swab test

CT scan and double swab test in high clinical suspicion, if still negative swab on bronchoaspirate or bronchoalveolar lavage.

Lack of isolation rooms

Early adaptation of a department floor (24 rooms) in ED isolation area with the possibility to transform into double rooms.

Food delivery

Pre-ordered closed meals to distribute to each single patient

Laundry and scrubs for staff

Single-use paper scrubs and new unnamed scrubs with daily change in dedicated stock, special biocontainment bags for used scrubs with dedicated laundry system.

Cleaning and sanitizing

Implemented a 24 h/24 cleaning staff inside COVID-19 area.

Lack of oxygen nozzles

Oxygen nozzle splitters can double each nozzle, flow-meter up to 30 Lit/min.

Lack of CPAP devices

Increased order of masks and Venturi device, use of resin 3Dprinted Venturi device that can be used with standard oxygen nozzles.

Understaffing

Training to other specialists and staff to be assigned to walk-in patients or low-intensity departments with clear and shared protocols to assess COVID-19 patients and senior ED physician supervision.

Information and contact with families

Implementation of a daily routine call system with VoIP or other communication devices. Systematic routine phone calls daily by the physician in charge. Dedicated phone number for families overseen by Medical Students to provide information.