Northern Italy was the world’s second most impacted area by COVID-19 after central China, until regions of the United States and other countries surpassed them. One of 24×7 Magazine’s editorial board members, Dr. Binseng Wang, exchanged emails with the operations manager of an independent service organization (ISO) that supports public hospitals in Northern Italy to learn firsthand how the pandemic affected the people and CE/HTM professionals there.

Here’s a snippet of the conversation.

Binseng Wang: Please introduce yourself and your organization.

Alberto Lanzani: I have been working for Technologie Sanitarie Spa for 16 years, starting as a site manager. [Currently], I am responsible for Northern Italy. We provide installation, testing, maintenance, upgrade, and technical advice of medical equipment. My team is comprised of about 300 persons and we support about 70 hospitals (all of which are over 400 beds; many of them are over 1,000 beds, and some are even over 2,000 beds). We are located in the worst areas affected by COVID-19: Codogno, Lodi, Cremona, Brescia, Bergamo, and Milano. I live in the province of Cremona, where more than 10% of its 100,000 inhabitants were infected.

Wang: When did your local or national government discover the first cases of COVID-19?

Lanzani: The first case in Italy was diagnosed on Feb. 20, 2020, at one of the hospitals we manage, the Codogno hospital, which is part of the ASST di Lodi (the public service corporation of Lodi—the administrative center of Codogno county).

Wang: Have the Italian authorities managed to discover how COVID-19 got started (or found the “patient one”)?

Lanzani: In Italy, in the first period of this epidemic, there was a big concern on who was “patient one.” Initially, we thought the Codogno patient was “patient one,” but we were not able to confirm it. The entire area around Codogno was locked down three days after this patient was diagnosed because the virus was spreading very quickly. Just to give you an idea: My father who lived 10 km from Codogno contracted COVID-19 on February 24, four days after the first case was announced. On February 25, only five days after the announcement of “patient one,” there were already more than 500 confirmed cases of COVID-19 in the same area. There are many theories on where and how the pandemic started—each with plausible reasons, but none have been confirmed.

Wang: The percentage of deaths among the infected seems to be higher in Italy than other countries, especially among older man. Are you aware of why?

Lanzani: There are multiple possible reasons for this high fatality rate. First, the Italian government was only testing people with clear symptoms (fever and oropharyngeal infection). People without symptoms were not tested. Now we know that many have contracted the virus but are asymptomatic and able to transmit it to others. Second, Italy has a population that is older than most other countries (e.g., Korea). After Japan, we have the oldest population in the world. The elderlies are the ones most stricken by this virus. Finally, Italy has been honestly communicating its data, but we are not sure if other countries have been doing the same.

Wang: Here in the U.S., up to 10% of those infected have been healthcare workers. We have heard that more than 50 Italian clinicians have died. What is the fraction in Italy and why it is so high?

Lanzani: In Italy, the fraction of healthcare workers infected by COVID-19 is also approximately 10%, according to the authorities. However, this fraction may not be reliable, due to the policy of testing only symptomatic persons. We believe most of [the healthcare workers] got infected in the hospitals, probably by persons who were asymptomatic.

Wang: Are you aware of Italian clinical engineering professionals infected by COVID-19, due to work-related contamination (instead of through family and friends)?

Lanzani: There are definitely cases of clinical engineers, technicians, and administrative staff who contracted COVID-19. However, I am not in a condition to say that they got infected within the work environment or elsewhere.

Wang: Besides the shortage of PPE and ventilators, what other medical equipment and devices became scarce in Italy?

Lanzani: All the ventilator accessories, (e.g., oxygen flowmeters, patient circuits, etc.) infusion/syringe pumps, and pulse oximeters are in short supply. Otherwise, we have sufficient quantity of most other devices. However, this is because the most affected area is currently Lombardia, which is the richest and most developed region of Italy and, thus, has the most healthcare resources. If the Italians do not follow the government’s “stay-at-home” recommendation, COVID-19 could spread to the Southern part of Italy, where hospitals have fewer resources. This would be a real disaster.

Wang: During the crisis, did the Italian government allow CE professionals to postpone scheduled maintenance (aka: PM) so they could focus on keeping the critical equipment running?

Lanzani: As the result of a coordinated action from CE/HTM professionals, the Italian government issued a specific Legislative Decree on March 18, stating that “non urgent and essential [maintenance] activities must be suspended.”

Wang: What were the most common services needed for medical equipment during the crisis?

Lanzani: In addition to maintaining ventilators and infusion pumps, most of the efforts were in preparing patient wards to receive COVID-19 patients—for instance, uninstalling and shipping equipment from other locations and re-installing it at the new locations, as well as inspecting and testing new equipment.

Wang: Were the Italian CE professionals able to get support (field service professionals, parts, PM kits, service manuals/instructions, etc.) from manufacturers during this crisis?

Lanzani: Not at the level that I thought they would.

Wang: Have Italian CEs/BMETs serviced (e.g., troubleshot) a ventilator or a patient monitor while it’s been connected to a confirmed or unconfirmed COVID-19 patient?

Lanzani: Whenever possible and authorized, we try to perform service outside of the COVID-19 area. However, we often have to service equipment inside of it. We never service equipment when it is connected to a patient, except in the extreme situation of life-or-death.

Wang: What other challenges have you and your Italian colleagues faced with regards to medical equipment?

Lanzani: Due to many donations made without coordination, Italian hospitals are receiving many devices (especially ventilators and infusion/syringes pumps) without a CE mark (especially from China). We, the CE/HTM professionals, are very concerned about putting them to use. Obviously, we test them, but we can only perform some limited tests. The laws need to be respected, but the patients cannot wait for a full, thorough investigation.

Wang: You work for an ISO that supports several hospitals. How differently did the COVID-19 pandemic impact ISOs versus in-house CE teams?

Lanzani: Where I work in Italy, most hospitals are supported by ISOs (and mine is the biggest in the area), although there are some in-house CE teams. In the current crisis, they often ask us for help since we have more resources and expertise.