A YEAR OF CARE: INTERVIEW WITH DR. MASSIMO CASTOLDI

Medical Director of Humanitas Gavazzeni e Castelli, Bergamo

EV: In light of the health emergency related to COVID-19 and how hard we know the area in which your facility operates was affected, what do you think were the aspects of health and lifestyles of professionals and social health workers that were most difficult to manage during the previous year?

MC: In terms of the health aspects, I want to focus primarily on what a hospital and a Chief Medical Officer has to do as health protection for health professionals and health care workers. This is because the paradigm, during the course of the Covid-19 outbreak, was completely changed. In the first phase, it was essential to change the tools to protect staff. Therefore, we introduced a higher level of protection in all departments with masks, gloves, use of sanitization systems, hydrogen alcohol for hand sanitization as frequently as possible in all departments and outpatient clinics. In addition, we introduced higher standards of protection in all the so-called “gray” wards, i.e., those wards where we were not sure whether the patient we had with us was a Covid-19 patient or not. A typical example is represented by the Outpatient Clinics where, not being able to perform diagnostic tests for Covid-19 at the daily access of each patient, we raised the level of protection. The most important was, in the Covid wards, the use of masks, coveralls, visors, double gloves, that is, all those procedures and individual protection devices that have even higher level of health protection. Obviously, all this was accompanied, throughout the year, by a campaign to sensitize people to the proper behaviour and use of personal protective equipment. For example, even in administrative offices, the use of special protective barriers in the canteen, the reduction of spontaneous gathering points such as those near the coffee machines, the introduction of dividers even at the bar to prevent the transfer of the virus by air. One of the problems with this awareness campaign is that, over the course of the year, the focus of our individual behaviour has risked fading several times, which is why this campaign needed to be renewed. It is one thing to manage the first wave, that is, the violent impact, and then we all became alert. One thing is to manage in the continuation of daily life the variants not of Covid-19, but to introduce the variants due to Covid, which imposed a paradigm shift. This has brought lifestyle change for professionals. This brought lifestyle change for some professionals within their own families: in the first wave, many isolated themselves in their homes, many sent their children to their in-laws, many sent their whole family to their second home, being able to do so.

EV: What strategies and methods have you adopted during the previous year to be able to protect and preserve the physical, psychological and social health of your professionals and social workers?

MC: Obviously, the impact has been the same for everyone, some more, some less. For example, we introduced smart working. Where not essential, for all the administrative offices, the control office, the purchasing office, the human resources office, smart working has contributed significantly to the modification of our processes. This is to preserve the physical health of our workers. We have transformed the hospital into red, grey, yellow areas, redone all protocols and made training to all staff, so that they could adapt to the new behaviours and tools, dressing and undressing to enter the department Covid-19, how to go to the cafeteria, check-points at the entrance, every morning measure the temperature, to erect a barrier of protection even at the entrance of the hospital. From the psychological point of view, we opened real spaces and agendas with psychologists for those among the staff who had a problem, a real complaint of their insecurity, fear, anxiety that was generated, so we opened a space for psychological consultation in order to relieve the stress generated by the pandemic. We have also done a climate analysis within the hospital in all services, both clinical and administrative, based on the analysis of the experience, the feelings that have been established and also the ability or not to form a group. Beyond our strategies, we found that there was a strengthening of relationships within the work group. The work network, from the point of view of attention to others has been greatly strengthened.

EV: How to preserve the health of professionals and social and health workers in this particular period, still very much affected by the pandemic? What projects and strategies do you have in mind for the coming months in order to sustain and support your professionals and social and health workers?

MC: First of all, we have heavily modified our surveillance plan. This is, of course, still in the containment phase of the virus. We have selected and analysed the data of about 450 people, we considered that they work in services particularly exposed to risk such as emergency rooms, intensive care or in particularly fragile departments such as radiotherapy and oncology, inserting them in a surveillance plan with swabs every 14 days. This is because, on the one hand, we need to secure the so-called fragile wards and, on the other hand, to make our operators understand how much we care about their health: even if you are asymptomatic, we monitor you, so that even if you who work in a particularly exposed ward receive more attention. We have done an internal vaccination campaign, obviously supported by the National Health System, which we are continuing and thanks to which we will get to vaccinate between 80 and 85% of our professionals and health workers. And that’s certainly important. We keep these systems of communication and psychological counselling open for operators who need it or manifest real burnout.

EV: Burnout was already a major problem during the pre-pandemic period. In your opinion, what can be strategies to mitigate its financial consequences as well?

MC: This is a particularly important topic because really, in my opinion, there are two phenomena to note. Burnout due to facing the pandemic in its most violent phase, a real physical fatigue, such as increased shifts, use of devices that yes, protect, but having to wear for 7 hours an airtight suit, visors, masks, double gloves, the heat that develops the human body, is a situation, a prevalent impact of the first wave … this is added to the psychological impact: the numerous deaths, the tampons, the many patients who have absorbed virtually the entire hospital. We’re a 220-bed hospital and we had, during the peak period, 250 people with Covid admitted. There is this aspect of burnout risk, that of the violence of the impact. Now, in the second wave, at this stage, even with vaccination, the risk is to have trench attrition. That is, always having to be on the lookout not because I have a tide, but because I have a trickle of cases. Every two or three days there is a case, or the patient becomes positive, the protocol does not hold, and people, just as they are tired of not being able to go skiing, are also tired of having to keep “staying tuned”, always connected to the theme of the pandemic.Just the paradigm shift of ordinariness. Right now, the ordinariness has changed to the ordinariness of all the everyday patients that was the one before, with heart attack, cancer, the femur fracture and on these I have to surmount more attention. So, it’s the change of the work in profound terms. In the first phase, everyone was treating Covid. Now, everyone is back to treating other pathologies as well. In addiction, there’s the Covid to keep at bay. So now burnout is about attrition rather than violent impact. Attitudes change and financial and economic needs change as well. We’ve realized that we have to try to increase our staffing, their numbers not because I have the 250 active beds, but because the staff that yesterday was enough for me to cover the 220 patients is no longer enough, because I have this variability, this accordion-like opening and closing of services and departments. I turn a department into “Covid” or “no-Covid.” It’s a phenomenon that wears operators down. Up until 15 days ago, my department was orthopedics, and now I transform it because a new wave is coming in. Then, I go back and this fluidity of the moment leads to different attrition. One of the organizational systems is also to increase the tightness of the system with an increase in human resources to be made available. Which is not easy and everyone has noticed that. Trivially, even the declarations of the political world that makes available billions of euros for the health personnel. But in reality, there is no healthcare personnel who are at home right now, except for those over 70 who are retired. Everyone else is already employed, so putting the most money into the system doesn’t mean increasing its responsiveness. It doesn’t. Unless I get it from other weights of the world, but it’s a chase after the same dynamic because the need has increased everywhere. If there were 10,000 more doctors and 20,000 more nurses it would be different. The other strategy is communicative because we realize that attrition causes us to risk relaxation of behaviour. Lastly, we have to try, without distracting, to soothe, without pretending. It is not a stable situation, nor overcome. We are very confident that the national vaccination campaign will lead to a turnaround, but it will take a few more months. Between now and then we need to do more. We have made a book that tells more than numbers with the feeling, a book interview of the experiences of our professionals, nurses, technicians and operators. It is a narrative, which we will publish shortly, of our Covid-19 year. We are making it available to everyone in order not to forget, because no one will forget anyway, to make us reflect on what this year has been, to make us think and renew the feelings that have been there. It is a collective story that will become a book that we will publish shortly for all our operators, for the city and for those who want to listen to us. In the story, a very personal note, in the story of the stories someone told about the function that our works of art have had, those that we have in the wards….from a certain point of view, to accompany the most difficult periods. During this time, one of our anesthesiologists even wrote his own book about this year.

EV: Insights and other things you feel are important to highlight on the topic?

MC: During the course of the year, we had an editorial initiative that was already planned, called “Opere in parole” (Works in words), within which, besides having important external authors such as Lella Costa, Marco Bagliani, Dora Albanese, Michela Murgia… many of them wrote, we also had a sort of internal competition, but calling it a competition is perhaps not correct. Twenty-five of us wrote a story that referred to the paintings and to Covid. It was maieutic to get the feelings out. It’s an initiative that ended last summer and so the Covid story connected to the artwork on our wards and to Narrative Medicine and so there was a confluence of the two needs. It was particularly good. This new book is on that wavelength, it’s a narrative of the experience of those who have lived the Covid in here.

All year long I’ve been trying to say that this year was not a year of war. The metaphor of war has been used a lot and it has been said that this is the battle against Covid and that we are heroes. I don’t really like this metaphor of war and the hero myth. Rather than a year of war, I prefer to talk about 2020 and even now as a year of care. We took care of ourselves, of the sick, of those who came with Covid or without Covid. And that completely changes the perspective, because it’s not that of the hero, but of the caregiver. The thinking also comes better with respect to the future. We cared and took care and got better. Not only did we resist Covid, but we took care. We improved as people and as hospitals because we took care. Rarely in real wars there are winners and losers. Even those who win come out with so many wounds and they better take care of themselves too.

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