Management of COVID micro-areas for asymtomatic or paucisymptomatic patients hospitalized in Azienda Ospedaliera Universitaria Pisana (AOUP, Italy)
Letter to the Editor

Management of COVID micro-areas for asymtomatic or paucisymptomatic patients hospitalized in Azienda Ospedaliera Universitaria Pisana (AOUP, Italy)

Angelo Baggiani1,2, Michele Cristofano2, Andrea Porretta1,2, Michele Totaro1, Nunzio Zotti1, Chiara Terrenzio1, Sara Civitelli1, Giulia Geminale1, David Rocchi1, Francesca Di Serafino1, Elena Lucaccini2, Giulia Gemignani2, Caterina Rizzo1,2, Federico Gelli3, Grazia Luchini2, Silvia Briani2

1Department of Translational Research and the New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy; 2Azienda Ospedaliera Universitaria Pisana, Pisa, Italy; 3Regione Toscana, Firenze, Italy

Correspondence to: Prof. Angelo Baggiani. Department of Translational Research and the New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy. Email:

Keywords: Coronavirus disease micro-areas (COVID micro-areas); asymptomatic/paucisymptomatic patients; coronavirus disease epidemic phase (COVID epidemic phase)

Received: 20 July 2022; Accepted: 06 December 2022; Published: 25 December 2022.

doi: 10.21037/jhmhp-22-82

To face the challenges posed by the coronavirus disease 2019 (COVID-19) pandemic, mainly treatment of affected patients as well as implementing safety measures for the protection of patients and personnel, hospitals had to adapt their operational workflows in the Azienda Ospedaliera Universitaria Pisana (AOUP), a 1,165 bed specialistic Italian teaching hospital the first pandemic wave (first half of 2020) (1) required a scaling down of the ordinary medical and surgical activities, to face the needs for treatment of COVID patients, as well as the activation of ad hoc units of low and intermediate care dedicated to these patients in the second and third pandemic waves (second half of 2020 and first half of 2021) to avoid hospital overcrowding (2). In the first phase of the emergency, dedicated COVID areas were established, including intensive care units (ICUs), operating rooms and medical wards.

Following the transition of the COVID epidemiology from pandemic to endemic (3), an increasing number of patients admitted to the hospital for reasons other than COVID, but positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) and either asymptomatic or paucisymptomatic was observed; considering the clinical requirements related to their diagnosis, admission to a dedicated COVID ward was no longer appropriate, furthermore transfer of these patients to a COVID ward would have resulted in an overcrowding of the latter.

In July 2022, the mean percentage of COVID positive patient in AOUP was 15%, but only 11% of them are symptomatic for the presence of pneumonia or respiratory failure and were admitted in hospital for these pathologies. All symptomatic patients were located in dedicated ICUs.

The aim of this letter is to describe the management of a new model of hospitalized positive patients without severe respiratory symptoms.

There are some criteria chosen by others hospitals for calculate the required percentage of COVID beds to their facilities, such as the number of nursing staff and the ward areas. Overall, each hospital may calculate a synthetic indicator (installed capacity index) assessing hospital capacity (4).

The Tuscany Directive Degree n. 581/2022 (5) describes the guidelines for the management of positive asymptomatic or paucisymptomatic COVID-19 cases. It directs every healthcare facility to define distinct care pathways of those patients, within the specialist ward, providing for the isolation of patients in single rooms, and compliance with care precautions even in the absence of airborne systems ensuring negative pressure (normal ventilation). Rooms occupied by SARS-CoV2 positive patients were required to be appropriately marked as such. Health care workers (HCWs) should receive additional training in the use of personal protective equipment (PPE) and designated location for donning and doffing of PPE by the HCWs were established (6).

The abovementioned Tuscany directive was implemented in AOUP by establishing a COVID dedicated micro-area in many wards, allowing thus to admit and treat patients positive for SARS-CoV2 but asymptomatic, for diagnoses other than COVID.

These micro-areas are small part of medical, surgical or ICU, functionally isolated to prevent further transmission of SARS-CoV2 to other patients and HCWs.

This setup allowed AOUP to set up a total of 273 COVID beds, organized in 8 micro-areas of medical setting (135 beds); 8 micro-areas of specialized clinical setting (84 beds); 3 micro-areas of ICUs (16 beds) and 2 micro-areas of surgical setting (38 beds) (Table 1). Overall, 273/1,165 (23.4%) of total beds number were dedicated to COVID patients.

Table 1

COVID and total beds numbers located in each ward of different medical and specialized clinic setting, ICUs, and surgical settings of AOUP

Ward COVID beds Total beds
Medical setting
   General medicine unit 1 10 45
   General medicine unit 2 7 32
   General medicine unit 3 35 96
   General medicine unit 4 20 88
   Emergency medicine 16 46
   Geriatrics 36 30
   Internal medicine 4 10
   Other 7 94
Specialized clinical setting
   Nephrology 8 16
   Pneumology 12 21
   Infectious diseases 14 24
   Gastroenterology 8 28
   Diabetology-endocrinology 7 26
   Immunology 3 12
   Rheumatology 12 27
   Cardiology 20 59
Intensive care units
   Pneumology 10 12
   Cardiothoracic 2 12
   COVID hospital 4 4
Surgical setting
   Traumatology 20 69
   Emergency surgery 18 46
Other settings (no COVID) 0 368
Total 273 1,165

COVID, coronavirus disease; ICU, intensive care unit; AOUP, Azienda Ospedaliera Universitaria Pisana.

This new organization requires any patient of one of these micro-areas developing new symptoms related to infection and respiratory or systemic involvement, to be transferred to COVID-19 specific areas (medical units or ICUs).

The safety of other patients in the same ward is guaranteed by routine monitoring, with nasopharyngeal swab at admission, every 7 days of stay and at the discharge. Positive patients are submitted to nasopharyngeal swab at the admission and every 4 days as described elsewhere (7,8).

The establishment of COVID micro-areas creates logistical and organizational challenges, in terms of adequate staffing, HCWs training and PPE supply to name a few.


We thank the whole team of the Azienda Ospedaliera Universitaria Pisana.

Funding: None.


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Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at The authors have no conflicts of interest to declare.

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doi: 10.21037/jhmhp-22-82
Cite this article as: Baggiani A, Cristofano M, Porretta A, Totaro M, Zotti N, Terrenzio C, Civitelli S, Geminale G, Rocchi D, Di Serafino F, Lucaccini E, Gemignani G, Rizzo C, Gelli F, Luchini G, Briani S. Management of COVID micro-areas for asymtomatic or paucisymptomatic patients hospitalized in Azienda Ospedaliera Universitaria Pisana (AOUP, Italy). J Hosp Manag Health Policy 2022;6:40.

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