Secondary Logo

Journal Logo

Scholarly Perspectives

Just-in-Time Training in a Tertiary Referral Hospital During the COVID-19 Pandemic in Italy

Ragazzoni, Luca MD, PhD; Barco, Ambra MD; Echeverri, Lina MD, MScDM; Conti, Andrea MD; Linty, Monica MA; Caviglia, Marta MD; Merlo, Federico MD; Martini, Daniela MA; Pirisi, Alessandro MSc; Weinstein, Eric MD, MScDM; Barone-Adesi, Francesco MD, PhD; Della Corte, Francesco MD

Author Information
doi: 10.1097/ACM.0000000000003575
  • Free


The coronavirus disease 2019 (COVID-19) pandemic is threatening health systems around the world, requiring an extraordinary international response to contain and control the virus. This response includes effective education and training of health care workers in several operational-level public health skills that are beyond the experience and knowledge base of most practitioners, who are not familiar with public health emergencies arising from outbreaks of infectious diseases.1

Italy has been one of the most affected countries, where hospitals were struggling from February to May 2020 to deal with the surge of patients with COVID-19.2 Patients are being treated in hospital corridors, and hospital departments have been converted to treat COVID-19 patients only. Many physicians and nurses are working outside of their fields of expertise, feeling uneasy managing and treating a highly transmissible infection for which there is no specific therapy or vaccine.3 Moreover, the risk of secondary infections among health care workers is extremely high. This reality highlights the inadequate infection control practices and protections in many Italian treatment centers and primary health care services.4

In this context, we believe that implementation of just-in-time training focused on population-based medicine and management skills is of paramount importance to equip health care workers with basic competencies to proficiently and safely work in any hospital and prehospital services during the COVID-19 pandemic. Population-based medicine and management focus on the aggregation of patient and systems requirements into one highly integrated clinical approach. Just-in-time training is a well-established concept among disaster and humanitarian responders and is intended to rapidly address “disaster-specific information, tasks, skills, and knowledge” just before deployment to a disaster-stricken area “to prepare providers for the deployment experience and to maximize the effectiveness of disaster response.”5

In this brief Perspective, we describe the just-in-time training implemented in the Maggiore della Carità University Hospital (MCUH) in Novara, Italy, during the COVID-19 pandemic.

Training Needs

The MCUH is the second largest tertiary referral hospital in the Piedmont region, one of the most affected regions in Northwest Italy. Before the admission of the first COVID-19–positive patients, we designed and delivered an initial just-in-time training for emergency and intensive care staff to improve their technical skills in the use of appropriate personal protective equipment (PPE). While COVID-19 was rapidly spreading in the region, the activation of the hospital contingency plan for a massive influx of patients resulted in the progressive transformation of hospital wards into intensive and non–intensive care units for COVID-19–positive patients, each with their own cohorts. At the peak of admissions, the emergency department and the intensive care unit expanded their operational capacity,6 and more than 200 COVID-19 beds were made available by converting orthopedic and cardiac surgery, internal medicine, cardiology, neurology, and otorhinolaryngology wards into COVID-19 treatment units. More than 300 health care workers were asked to change roles and tasks to staff these newly opened hospital units. Moreover, since the MCUH is a tertiary referral center, emergency procedures, nondeferrable oncological interventions, and maternal and child health services were maintained and the staff involved in managing non–COVID-19 patients were required to apply the same basic infection prevention and control (IPC) principles as those working with COVID-19 patients to prevent the dissemination of the disease.

In this scenario, we recognized that a more comprehensive COVID-19 just-in-time training was essential to enable the entire MCUH staff to rapidly attain competencies in areas in which most had no experience. Furthermore, we strongly believed that the unexpected magnitude of the crisis generated by the pandemic required not only teaching our staff IPC and public health skills that are the core of population-based health management but also familiarizing them with disaster medicine principles, such as surge capacity, and allocation of scarce resources, triage, and the ethical dilemmas of rationing medical care.

Learning Objectives and Training Program

We designed the COVID-19 just-in-time training to provide the entire hospital staff with a common background, the competencies, and the proper attitude needed to (1) proficiently and safely work inside the MCUH during the COVID-19 pandemic, (2) understand the working principles and the standard operating procedures in place at the MCUH, (3) accurately apply and safely remove PPE, and (4) understand basic principles of disaster medicine and public health emergencies applied to the COVID-19 pandemic. At the end of the training, participants met the needs of the MCUH for qualified hospital-based health care personnel: They had basic IPC competencies, an awareness of disaster medicine, and were ready to respond to the COVID-19 pandemic.

The most important learning objective was to deliver practical information to improve the trainees’ awareness of public health management, their technical performance, and their attitude with respect to working safely and effectively in a public health emergency, rather than to deliver mere theoretical knowledge on the subject matter.

In Chart 1, we report the curriculum for the COVID-19 just-in-time training delivered at the MCUH. We ran this 4-hour training every afternoon for 3 weeks starting on March 9, 2020, and we trained approximately 200 hospital staff. Every training session was open to a maximum of 30 participants and took place in the main hospital conference hall (around 100 seats) to ensure social distancing.

Lessons Learned

Just-in-time training has already proved to be an efficient technique during sudden-onset disasters, when it is essential that information, instructions, and guidelines specific to the event be provided exactly when needed, in other words immediately before the deployment of first responders.5 This technique also serves to refresh and update responders’ capability and to address specific training needs relevant to the operational context. Weiner and Rosman have emphasized that just-in-time training is particularly effective in enhancing responders’ situational awareness and personal preparation and resiliency.5 In our previous experience during the response to the 2014 Ebola outbreak in West Africa, we applied an innovative just-in-time training methodology using virtual reality simulation.7 We demonstrated that virtual reality simulation was effective in increasing the safety of staff before they took on the risk of working in an Ebola treatment center.7 Unfortunately, the rapid spread of COVID-19 in Northern Italy meant we had to train the MCUH health care workers in a matter of days; in light of the urgent need to respond, we could not devote time to developing a virtual reality scenario at that point. However, at the time of this writing, we are working on creating an online virtual reality simulation module to train health care staff virtually, especially those in low-resource settings.

At the beginning of the COVID-19 outbreak in Northern Italy, records from China showed a high risk of secondary infections among health care workers.8 Therefore, we immediately recognized the need to rapidly train the health care workers at our hospital in basic operational public health skills to ensure that they followed safety procedures and used PPE correctly. This training was also designed to instill confidence in any health care workers who felt uneasy about treating a highly transmissible infectious disease for which there is no vaccine or specific therapy. On May 29, 2020, 3 months after the beginning of the outbreak in Italy, nearly 28,000 Italian health care workers had contracted COVID-194 and 167 had died.9 These numbers reinforce the importance of implementing training to address competencies that we knew were beyond the experience of most of our colleagues. Moreover, our idea to address disaster medicine and population-based health management concepts was also crucial given that the rapid spread of COVID-19 had pushed the MCUH contingency plan to the limit, creating a crisis management condition that was leading to the collapse of all the major public health protections that society depends on daily. This was the first time that the majority of the MCUH’s health care workers had responded to a large-scale public health emergency or a disaster. Regrettably, most of them never studied disaster medicine or global health in medical or nursing schools, apart from those medical doctors who graduated after 2004 in Novara, where they attended our mandatory disaster medicine course during their final year of medical school.

Despite the increasing risk of disasters and health crises worldwide, Italy is not alone in failing to equip the new generation of health care workers with basic education in disaster medicine and global health and specifically global public health.10 Unfortunately, the teaching of disaster medicine is underrepresented in several countries worldwide.10 The COVID-19 pandemic should stimulate the academic community to consider introducing at least some basic disaster medicine and global health teaching in medical and nursing school programs.

Given the strong, traditional public health measures in place during the COVID-19 pandemic, e-learning has been the favorite training methodology worldwide. However, taking the proper precautions and safety measures, we decided to use a classroom-based approach to ensure that participants could practice donning and doffing PPE and could discuss any doubts directly with us. For those unable to be present or who wanted a review, we also offered an e-learning version of the training on the official MCUH e-learning platform together with the online courses provided by the World Health Organization11 and the Italian Higher Institute of Health.12 As in any good operations-level training, we trained health care staff following specific standard operating procedures, which we—members of the hospital crisis unit—had authored. This approach maximized the impact of the training and significantly reduced the risk of incomplete or unevenly distributed education among the hospital health care workers. In Chart 1, we report lessons learned during the implementation of each training module, which could facilitate the delivery of such COVID-19 just-in-time training elsewhere or the use of a similar curriculum for future public health emergencies. Even though we were not able to assess outcomes or evaluate the quality of the training, we strongly believe that this is a useful example of how to create a just-in-time training in a large hospital during a crisis of an unprecedented scale.


An effective response to the COVID-19 pandemic includes appropriate education and training of health care workers so that they will learn operational public health skills essential for infection control and management of disease treatment while reducing their risk of exposure. Just-in-time training has been recognized by disaster responders as a valid solution for rapidly acquiring new information and competencies just before deployment. In this Perspective, we reported an example of just-in-time training delivered in a tertiary referral hospital during the COVID-19 pandemic in Italy. The curriculum included not only disease epidemiology, IPC protocols, and application of PPE but also basic principles of disaster medicine and public health emergencies. Since Northern Italy was one of the worst-stricken places in the world at the time of this writing, we strongly believe that sharing our experience is key to supporting other countries in their advance preparations.


The authors would like to thank the medical personnel at the Maggiore della Carità University Hospital who have worked relentlessly during the COVID-19 pandemic. They acknowledge the contribution of the rest of the team at the Research Center in Emergency and Disaster Medicine (CRIMEDIM) who assisted in carrying out the activities described in this Perspective despite the logistical difficulties arising from the Italian national lockdown.


1. Errett NA, Barnett DJ, Thompson CB, et al. Assessment of medical reserve corps volunteers’ emergency response willingness using a threat- and efficacy-based model. Biosecur Bioterror. 2013;11:29–40
2. Tuite AR, Ng V, Rees E, Fisman D. Estimation of COVID-19 outbreak size in Italy. Lancet Infect Dis. 2020;20:537
3. Lai J, Ma S, Wang Y, et al. Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Netw Open. 2020;3:e203976
4. Istituto Superiore di Sanità. Sorveglianza Integrata COVID-19 in Italia. Published May 29, 2020. Accessed June 1, 2020.
5. Weiner DL, Rosman SL. Just-in-time training for disaster response in the austere environment. Clin. Pediatr. Emerg. Med. 2019;20:95–110
6. Paganini M, Conti A, Weinstein E, Della Corte F, Ragazzoni L. Translating COVID-19 pandemic surge theory to practice in the emergency department: How to expand structure [published online ahead of print March 27, 2020]. Disaster Med Public Health Prep. doi:10.1017/dmp.2020.57.
7. Ragazzoni L, Ingrassia PL, Echeverri L, et al. Virtual reality simulation training for Ebola deployment. Disaster Med Public Health Prep. 2015;9:543–546
8. Mingkun Zhan, Yaxun Qin, Xiang Xue, Shuaijun Zhu. Death from COVID-19 of 23 health care workers in China. N Engl J Med. 2020;382:2267–2268
9. Elenco dei medici caduti nel corso dell’epidemia di Covid-19. Federazione Nazionale degli Ordini dei Medici Chirurghi e degli Odontoiatri. Published June 1, 2020. Accessed June 1, 2020.
10. Ragazzoni L, Conti A, Dell’Aringa M, Caviglia M, Maccapani F, Della Corte F. A nationwide peer-assisted learning program in disaster medicine for medical students Eur J Emerg Med. 2020;27:290–297
11. Emerging respiratory viruses, including COVID-19: Methods for detection, prevention, response and control. OpenWHO. Published April 9, 2020. Accessed April 17, 2020.
12. Corso di formazione a distanza, prevenzione e controllo delle infezioni nel contesto dell’emergenza COVID-19. EDUISS–Formazione a distanza dell’Istituto Superiore di Sanità. Published March 30, 2020. Accessed April 17, 2020.

Chart 1 Overview of a COVID-19 Just-in-Time Training Curriculum for Health Care Workers Used in an Italian Tertiary Referral Hospital During the COVID-19 Pandemic, March 2020a

Copyright © 2020 by the Association of American Medical Colleges