INTRODUCTION
In December 2019, coronavirus disease 2019 (COVID-19) was first reported in Wuhan, China [1]. This disease was caused by a new coronavirus, called Severe Acute Respiratory Syndrome-Coronavirus-2 (SARS-CoV-2) [2]. In contrast to past epidemics, which took years to spread around the world, the new virus reached Europe in a few months [3], with the first official case identified in Northern Italy on February 18 [4] and leading to the Italian outbreak. COVID-19 is a systemic disease [5], presenting with interstitial pneumonia (computed tomographic scan is the gold standard for diagnosis) [6–8], but it can also have a paucisymptomatic course [9]. The rate of newly infected patients increased daily on a logarithmic scale, especially in Lombardy, the most populated region in Italy (about 10 million inhabitants), forcing the Italian government to take extraordinary measures to contain the infection. Quarantine and the closure of non-essential activities were enforced.
The National Health Care System, in accordance with Italy’s universal welfare principles, was put under extreme pressure. Almost every hospital was completely reorganized in order to meet the needs of the COVID-19 patients. New areas and new intensive care units (ICUs) dedicated to patients with COVID-19 were set up. As a result, all elective activities were postponed or cancelled.
A dedicated pathway had to be created to guarantee access to the best possible health care treatment, i.e. for emergency, urgent or non-deferrable (ND) cases. To ensure such a system, the Health Care Lombardy Regional System promoted the hub-and-spoke organization system on March 8 [10]. This system had been used successfully in the past [11–13]. On March 8, 7375 Italian patients were infected with SARS-CoV-19, 650 of whom were in critical condition. In Lombardy, there were 3372 and 399 cases, respectively [14]. In this scenario, heart and vascular surgical activities had to be reorganized. Four reference and enrolment hub hospitals were identified. Other hospitals, the spokes, which treating almost entirely COVID-19 patients, became peripheral referral centres. Hubs had to identify different dedicated pathways for COVID-19-positive and -negative patients. The main tasks of the hubs were to admit and treat patients (24/7) coming from the cardiovascular spokes [15]. Our goal was to analyse our flow charts and examine the pathways designed for COVID-19-positive and -negative patients.