• Vanni Agnoletti, Emanuele Russo, Alessandro Circelli, Marco Benni, Giuliano Bolondi, Costanza Martino, Domenico P Santonastaso, Etrusca Brogi, Beniamino PraticÒ, Federico Coccolini, Paola Fugazzola, Luca Ansaloni, and Emiliano Gamberini.
• Department of Anesthesia and Intensive Care, M Bufalini Hospital, Viale Ghirotti 285, 47521, Cesena, Italy.
• Int J Qual Health Care. 2021 Feb 20; 33 (1).

Quality Problem Or IssueThe on-going COVID-19 pandemic may cause the collapse of healthcare systems because of unprecedented hospitalization rates.Initial AssessmentA total of 8.2 individuals per 1000 inhabitants have been diagnosed with COVID-19 in our province. The hospital predisposed 110 beds for COVID-19 patients: on the day of the local peak, 90% of them were occupied and intensive care unit (ICU) faced unprecedented admission rates, fearing system collapse.Choice Of SolutionInstead of increasing the number of ICU beds, the creation of a step-down unit (SDU) close to the ICU was preferred: the aim was to safely improve the transfer of patients and to relieve ICU from the risk of overload.ImplementationA nine-bed SDU was created next to the ICU, led by intensivists and ICU nurses, with adequate personal protective equipment, monitoring systems and ventilators for respiratory support when needed. A second six-bed SDU was also created.EvaluationPatients were clinically comparable to those of most reports from Western Countries now available in the literature. ICU never needed supernumerary beds, no patient died in the SDU, and there was no waiting time for ICU admission of critical patients. SDU has been affordable from human resources, safety and economic points of view.Lessons LearnedCOVID-19 is like an enduring mass casualty incident. Solutions tailored on local epidemiology and available resources should be implemented to preserve the efficiency and adaptability of our institutions and provide the adequate sanitary response.© The Author(s) 2020. Published by Oxford University Press on behalf of International Society for Quality in Health Care.

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