HUB-AND-SPOKE MODEL
On 8 March 2020, in order to deal with the COVID-19 outbreak, the Lombardy regional government revised the entire regional healthcare system by introducing a temporary ‘hub and spoke’ model [8].
The hub-and-spoke system is an organizational model comprising a network of primary anchor centres (hubs), able to provide a wide spectrum of services, and secondary satellite establishments (spokes), which offer more limited assistance [9]. Patients in the spokes needing more intensive care are routed to their hubs. This model provides a highly efficient organization and enhanced quality of care. It has been used in several countries (i.e. Willis-Knighton Health System’s hub-and-spoke network, Shreveport, LA, USA) and even in rural areas with beneficial results (i.e. catheterization laboratories in the Tamil Nadu region of India). However, some disadvantages include hub congestion and transportation challenges.
As defined by the Lombardy ordinance, hub centres should: Guarantee patient access/hospitalization by providing multiple available medical teams (with at least 1 team on active duty 24/7).
Activate a ‘fast track’ for non-COVID emergency/urgent patients, thereby avoiding COVID-19 emergency room transit.
Welcome spoke teams in their respective hubs and encourage collaboration.
Ensure that patient transport is managed by the forwarding hospital.
A decision was made to apply this model to major trauma, stroke, emergencies/urgencies in neurosurgery, cardiovascular surgery and interventional cardiology (in particular for acute myocardial infarction and electrophysiological procedures). An ordinary extracorporeal membrane oxygenation network was maintained as well.
A mean of 150–200 adult and 50 paediatric cardiac surgical procedures have been estimated per month in Lombardy, a region with almost 10 million inhabitants. In contrast to our usual practice, patients from other regions are now treated in their own district because of transfer limitations.
Four adult and 1 paediatric cardiac surgery hubs have been identified (Fig. 1). In the decision-making process, the following criteria were considered for the choice of the hub centres: the presence of dedicated 24/7 operating rooms (at least 3 simultaneously) and the presence of a COVID-free postoperative cardiovascular ICU.
Figure 1:  Lombardy emergency cardiac surgery hub-and-spoke system during the coronavirus disease 2019 epidemic. This map shows the reorganization of the cardiac surgery system for emergency and urgent situations during the coronavirus disease-2019 outbreak in Lombardy: 4 adult (A–D) hubs and 1 paediatric (E) hub have been identified; satellite spoke centres (in numbers) are asked to transfer patients needing emergency/urgent surgery to their respective hubs.