==== Front Infect Control Hosp Epidemiol Infect Control Hosp Epidemiol ICE Infection Control and Hospital Epidemiology 0899-823X 1559-6834 Cambridge University Press New York, USA S0899823X20013112 10.1017/ice.2020.1311 Letter to the Editor Analysis of costs for pandemic management in a tertiary-care hospital in Italy: An investment for a more resilient structure Baggiani Angelo MD 12 Briani Silvia MD 1 Luchini Grazia MD 1 Giraldi Mauro MD 1 Fernandez Jacopo MD 1 Collecchi Carla MD 1 Filippi Matteo MD 1 Trillini Lucia MD 1 Mamone Domenica MD 1 Martino Maria Carola MD 1 Ciucci Antonella MD 1 Cristofano Michele MD 1 De Vito Antonella MD 1 Pellegrini Gabriella MD 1 Valori Grazia MD 1 Arzilli Guglielmo BS 2 Sironi Daniele BS 2 Mariotti Tommaso BS 2 Papini Francesca BS 2 Casigliani Virginia BS 2 Scardina Giuditta BS 2 Visi Giacomo BS 2 Casini Beatrice MD 12 Porretta Andrea MD 12 Totaro Michele BS 2 Privitera Gaetano MD 12 Milli Carlo MD 1 1 The Azienda Ospedaliero Universitaria Pisana, Pisa, Italy 2 Department of Translational Research and the New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy Author for correspondence: Prof Angelo Baggiani, E-mail: angelo.baggiani@med.unipi.it 04 11 2020 13 23 10 2020 26 10 2020 27 10 2020 © The Society for Healthcare Epidemiology of America 2020 2020 The Society for Healthcare Epidemiology of America This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited. ==== Body To the Editor—The tertiary-care teaching hospital of Pisa (Azienda Ospedaliera Universitaria Pisana, AOUP) received its first coronavirus disease 2019 (COVID-19) patient on March 4. During the outbreak, this hospital setting underwent major reorganization to respond to the situation. Hospital wards and patient management protocols were modified to quickly adapt to the clinical needs of the patients as well as to ensure patient safety and healthcare worker (HCW) protection from infection.1,2 The execution of this strategy to deal with the epidemic imposed significant costs on our hospital. Currently, many expenditure models have been published, as data concerning national health insurance and losses in terms of investments in the various economic sectors.3-5 We quantified economic costs incurred by the AOUP from March to July 2020 for the management of the COVID-19 pandemic, focusing on the structural costs for the implementation of the present structure and for the realization of a new COVID-19 hospital. AOUP is organized into 2 main facilities for a total of 1,082 beds. For pandemic management, the Cisanello facility was reorganized and 160 bed places were dedicated to COVID-19 patients in medical wards, 39 beds in intensive care units, and 24 bed for C-PAP therapy.1 Santa Chiara facility is an old pavilion hospital that has been gradually disused. A building that used to accommodate the old emergency room has been renovated as the city’s COVID-19 center. For the purpose of this analysis, we considered 3 phases: phase 1 (March 4–May 4); phase 2 (May 4–July 4), and phase 3 (March 15–July 4). In the first phase, the emergency was addressed by increasing response to COVID-19 patients. Ordinary wards were progressively closed to dedicate these areas to COVID-19 patients. Therapeutic pathways were reorganized, and COVID-19 cases were stratified into patients requiring low-, medium-, and high-intensity care. Construction of negative pressure chambers in operating theatres and the extension of intensive care wards were carried out. In the second phase, the objectives were the radical sanitization of the areas dedicated to COVID-19 patients, the reconversion to their original use, and the gradual resumption of outpatient activities by eliminating the waiting lists created and of visits to patients. The objective of the third phase was to create a hospital for COVID-19 patients in the Santa Chiara facility to prepare for future outbreaks. For each phase, we analyzed costs directly related to the preparedness and the management of the epidemic (Table 1). Table 1. Costs Directly Related to the Preparedness and the Management of the COVID-19 Epidemic in Azienda Ospedaliera Universitaria Pisana Phase Description Costs Euros US$a Phase 1 Technical area (COVID hospital rearrangement) 338,444.51 395,239.17 Technical area (site safety charges) 4,000.00 4,671.24 Ventilation system adaption (from positive to negative pressure) 70,000.00 81,755.40 Health management units (cleaning setting improvement) 154,648.22 180,618.96 Health management units (biological materials transport) 20,000.00 23,358.69 Health management units (security services) 65,268.00 76,228.74 Health management units (special waste disposal) 20,000.00 23,358.69 Medical devices (including FFP2/FFP3 masks) 1,586,505.57 1,852,829.24 Health furnishing 633,000.00 739,260.50 Pharmaceutical spending for COVID patients) 446,666.67 521,647.75 Pharmaceutical spending for medical gases 233,333.33 272,502.55 Hydroalcoholic gel 40,000.00 46,714.72 SARS COV-2 screening test 1,466,666.67 1,712,824.47 Administrative burden expense (notebook) 20,000.00 23,358.69 New healthcare workers recruitment 585,136.49 683,342.79 Accommodation services for employees 10,000.00 11,678.35 Phase 2 Technical areas (aeraulic facilities reconversion and cleaning) 740,000.00 864,197.80 Health Management Units (wards cleaning and sanitizing) 560,000.00 653,984.76 Environmental monitoring and microbiological analysis 13,672.00 15,966.57 Phase 3 New COVID hospital reconstruction (structural costs and health furnishing) 3,817,882.00 4,458,636.85 Environmental monitoring and microbiological analysis 6,882.00 8,037.01 Note. FFP, filtering face piece. a Exchange rate: 1 euro = 1.1678 USD. In phase 1, the final cost accrued was €342,444.91 (US$399,952.17) for the technical area. Furthermore, €70,000.00 (US$81,755.20) was attributed to the adaptation of the ventilation system of the wards from positive pressure to negative pressure. For the costs sustained by the health management unit (HMU), we estimated the total expenditure to be €2,479,421.79 (US$2,895,794.65). In total, €1,586,505.57 (US$1,852,929.72) was attributed to medical devices. For pharmaceuticals, €680,000.00 (US$794,119.19) was spent, and €40,000.00 (US$46,712.89) was spent to purchase hydroalcoholic gel for the entire hospital. Screening of patients and HCWs for severe acute respiratory coronavirus virus 2 (SARS-CoV-2) cost €1,466,666.67 (US$1,712,806.10). In addition, €585,136.49 (US$683,346.90) was spent to recruit healthcare workers, and €10,000.00 (US$11,678.42) was spent in accommodation services for employees. In phase 2, €740,000.00 (US$864,202.99) was spent on the technical area for cleaning and reconversion of the aeraulic facilities. In addition, €560,000.00 (US$653,991.45) was spent by the HMU for cleaning and sanitizing COVID-19 wards. Costs related to environmental monitoring and microbiological analyses performed before the reopening of the departments and restart of ordinary activities amounted to €13,672.00 (US$15,972.23). In phase 3, €3,817,882.00 (US$4,460,216.00) was spent for the construction of the new COVID-19 patients hospital. Most of this expense was for structural costs and health furnishings. In addition, €6,882.00 (US$8,039.85) was spent for environmental microbiological analyses. In total, €13,556,355.43 (US$15,837,124.73) was spent globally for the 3 phases: €8,417,919.43 (US$9,837,164.61) was spent in phase 1, €1,313,672.00 (US$1,535,154.60) was spent in phase 2, and €3,824,764.00 (US$4,469,611.93) was spent in phase 3. Healthcare facilities had to quickly adapt; they underwent huge changes to protect HCWs, to manage COVID-19 patients, and to limit the risk of infection for other inpatients. The way health services are delivered has been greatly modified at our institution during the pandemic.6 Meeting these challenges has entailed significant expenditure in economic terms. Even if many reports on the costs that health systems had to face because of the COVID-19 emergency have already been published, it is difficult to quantify the real expenditure, and the estimates are most likely underrepresented. In Italy, according to the ALTEMS report,7 the total impact on hospital expenditures has been €1,586,858,655 (US$1,854,400,002). In our study, the entire process of conversion (the reconversion of Cisanello and requalification of Santa Chiara) cost a total of €13,556,355.43 (US$15,840,470.55). These resources were deployed by making decisions toward significant benefits. Furthermore, we set up adequate infrastructures to meet possible future waves. The placement of these funds is in accordance with the WHO guidelines, which affirm that expenditures for COVID-19 should lead to longer-term, wider benefits in line with national needs for sustainable capacities.8 Our hospital has made efforts and incurred costs to adapt in a short time to the emerging crisis. We used this opportunity to increase the hospital’s resilience and preparedness. The strategies adopted, with the related costs, have allowed us not only to overcome the acute phase but also to prepare the necessary resources for future crises. Acknowledgments We acknowledge the efforts of healthcare workers and essential workers during the COVID-19 pandemic. Conflicts of interest All authors report no conflicts of interest relevant to this article. Financial support No financial support was provided relevant to this article. ==== Refs References 1. Baggiani A , Briani S , Luchini G , et al. Management of healthcare areas for the prevention of COVID-19 emergency in an Italian teaching hospital (Pisa, Tuscany): a hospital renovation plan. Infect Control Hosp Epidemiol 2020;41 :1368–1369.32336306 2. Baggiani A , Briani S , Luchini G , et al. Preparedness and response to the COVID-19 emergency: experience from the teaching hospital of Pisa, Italy. Int J Environ Res Public Health 2020;17 . doi: 10.3390/ijerph17207376. 3. Nicola M , Alsafi Z , Sohrabi C , et al. The socio-economic implications of the coronavirus pandemic (COVID-19): a review. Int J Surg 2020;78 :185–193.32305533 4. Bartsch SM , Ferguson MC , McKinnell JA , et al. The Potential Health Care Costs And Resource Use Associated With COVID-19 In The United States. Health Aff (Millwood) 2020;39 :927–935.32324428 5. Coronini-Cronberg S , John Maile E , Majeed AA-O. Health inequalities: the hidden cost of COVID-19 in NHS hospital trusts? J R Soc Med 2020;115 :179–184. 6. Strengthening health systems resilience: key concepts and strategies. European Observatory on Health Systems and Policies website. https://www.euro.who.int/en/about-us/partners/observatory/publications/policy-briefs-and-summaries/strengthening-health-systems-resilience-key-concepts-and-strategies-2020. Published 2020. Accessed October 29, 2020. 7. Postgraduate School of Health Economics and Management. Analisi dei modelli organizzativi di risposta al COVID-19: Instant REPORT 15. Rome; 2020. 8. World Health Organization. Investing In and Building Longer-Term Health Emergency Preparedness During the COVID-19 Pandemic. Geneva: WHO; 2020.