Response by Twin Italian Hub Hospitals in a Double Seismic Event: A Retrospective Observational Investigation

Figures & data

Figure 1. A map of the Province of Modena (Italy). The area marked in red was more severely damaged by the seismic sequence of 2012. Arrows show the reorganization of the hospital system during the catastrophe. © Alberto Barbieri. Reproduced by permission of Alberto Barbieri. Permission to reuse must be obtained from the rightsholder.

Figure 2. Enrollment flow chart: Inclusion and exclusion criteria.

Figure 3. Temporal succession of phases and stages of the study. Phases: Pre-earthquake – from January 1, 2011 to May 19, 2012 – (phase 0), Earthquake – May 20 – May 29, 2012 – (phase 1), Immediate aftermath – June and July 2012 – (phase 2), Early reorganization – from August to October 2012 – (phase 3), Normalization – from November 2012 to December 2013 (phase 4); Stages: Pre-earthquake (0) – from January 1, 2011 to May 19, 2012 – (it includes phase 0), Earthquake (1) – from May 20 to November 3, 2012, when the Italian Red Cross declared the earthquake emergency over (it includes phase 1, 2 and 3), Post-earthquake (2) – from November 4, 2012, to December 31, 2013 (it includes phase 4).

Table 1. Referral rates for status codes 2 and 3 to Nuovo Ospedale S. Agostino Estense (NOCSAE) and Policlinico hub hospitals from January 2011 to December 2013.

Phase	Duration (Days)	Total Events	NOCSAE Events	Events/day Nocsae	Percentage	Policlinico Events	Events/day Policlinico	Percentage
0	505	1073	630	1.25	58.71	443	0.88	41.29
1	9	22	10	1.11	45.45	12	1.33	54.55
2	62	133	83	1.34	62.41	50	0.81	37.59
3	97	179	120	1.24	67.04	59	0.61	32.96
4	422	871,00	558	1.32	64.06	313	0.74	35.94

The studied period was subdivided into 5 consecutive time phases: 0, before the earthquake; 1, during the earthquake; 2, in the immediate aftermath; 3, in the late summer early autumn of 2012; and 4, from November 2012 to December 2013.

Table 2. Case mix of admissions by stage: before the earthquake 0, during the earthquake 1, after the earthquake 2.

Pathologies	Stage 0	Percentage	Stage 1	Percentage	Stage 2	Percentage	total	Percentage
Cardiac arrest	107	9.97	40	12.01	102	11.70	249	10.93
Polytrauma	132	12.30	48	14.41	107	12.27	287	12.60
Traumatic brain injury	137	12.77	40	12.01	106	12.16	283	12.42
Myocardial infarction	40	3.73	10	3.00	38	4.36	88	3.86
Cardiac failure	226	21.06	71	21.32	193	22.13	490	21.51
Respiratory failure	450	41.94	139	41.74	412	47.25	1001	43.94
Stroke	77	7.18	19	5.71	64	7.34	160	7.02
Septic shock	58	5.41	18	5.41	57	6.54	133	5.84
Other	202	18.83	73	21.92	195	22.36	470	20.63

Figure 4. Kaplan–Meier survival estimate curves for survival before, during, and after the earthquake emergency (stages 0, 1, and 2, respectively). Figure reports hazard ratios and p-values.

Table 3. Percentages of code 2 and 3 patients taken to each hospital before and after the earthquake.

Stage	Policlinico	NOCSAE	Total
0	453 (51.65%)	638 (45.54%)	1091 (47.89%)
1 and 2	424 (48.35%)	763 (54.46%)	1187 (52.11%)
Total	877	1401	2,278
	p-value 0.004

Analysis performed using chi-squared test.

Table 4. Ambulance referral times (ES) and emergency department treatment times (ED) in each hub hospital during the phases of the earthquake emergency including first line life-saving treatments and diagnostic procedures.

Stage	Policlinico obs	Mean time ES	St.er	NOCSAE obs	Mean time ES	St.er
0	415	46.78	4.90	608		4.14
1	114	37.92	4.59	201	43.27	5.87
2	297	47.14	6.55	528	45.80	4.73
p-value			0.6693			0.9376
Stage	Policlinico obs	Mean time ED	St.er	NOCSAE obs	Mean time ED	St. er
0	280	293.18	17.80	413	334.12	14.19
1	65	414.80	40.40	121	411.48	27.26
2	159	412.77	24.16	317	443.77	24.16
p-value			0.0001^*			0.0000^*

Policlinico obs and NOCSAE obs refer to the number of patients admitted to/treated by Policlinico and NOCSAE with codes 2 and 3. St.er - Standard error.