Clinical Editor's Corner: Kern

Cath and COVID-19: What Should We Do?

Morton J. Kern, with contributions from:

Drs. Herb Aronow, Brown University, Providence, Rhode Island;

Arnold Seto, Long Beach VA Medical Center, Long Beach, California;

Prashant Kaul, Piedmont Heart Institute, Atlanta, Georgia;

Kirk Garrett, ChristianaCare, Wilmington, Delaware;

Steve Bailey, LSU Shreveport School of Medicine, Shreveport, Louisiana;

Ajay Kirtane, Columbia University, New York City, New York;

James Blankenship, Geisinger Cardiovascular Center for Clinical Research, Harrisburg, Pennsylvania;

Bonnie Weiner, University of Massachusetts, Worcester, Massachusetts;

James McCabe, University of Washington, Seattle, Washington;

Guri Sandhu, Mayo Clinic, Rochester, Minnesota

Habib Samady, Emory University, Atlanta, Georgia.

Morton J. Kern, with contributions from:

Drs. Herb Aronow, Brown University, Providence, Rhode Island;

Arnold Seto, Long Beach VA Medical Center, Long Beach, California;

Prashant Kaul, Piedmont Heart Institute, Atlanta, Georgia;

Kirk Garrett, ChristianaCare, Wilmington, Delaware;

Steve Bailey, LSU Shreveport School of Medicine, Shreveport, Louisiana;

Ajay Kirtane, Columbia University, New York City, New York;

James Blankenship, Geisinger Cardiovascular Center for Clinical Research, Harrisburg, Pennsylvania;

Bonnie Weiner, University of Massachusetts, Worcester, Massachusetts;

James McCabe, University of Washington, Seattle, Washington;

Guri Sandhu, Mayo Clinic, Rochester, Minnesota

Habib Samady, Emory University, Atlanta, Georgia.

One of my colleagues asked this critical question, “How are cath labs around the USA and the globe managing [ST-elevation myocardial infarction] STEMI and other cardiac emergencies in patients with suspected COVID-19 that would normally have resulted in a trip to the lab? Are you adopting an approach similar to that employed in Sichuan, China1 where STEMI is largely relegated to lytic therapy? Is it business as usual with added preventive measures in place for health care providers, or something in-between?”

There is no doubt we have moved into a new era of world health.2 Catching COVID-19 is not the same as catching a cold or influenza, because of the higher mortality. Lessons from the 1918 Influenza pandemic and the 2014 SARS epidemic, and affected nations’ preventative measures demonstrated the effectiveness of isolating the exposed and ill individuals, reducing social gatherings, increasing the social distance between people, frequent hand washing, and ultimately, vaccinations.3 

At this time, the full effects of the COVID-19 pandemic have only begun to be felt (Figure 1).  Universities, businesses, schools, and entertainment venues have all canceled, closed, or postponed large meetings and concentrations of participants. Hospital systems have already curtailed industry representative visits to the cath lab, limiting them to those absolutely necessary for safe patient care.  Quarantines, both enforced and voluntary, are a good first step and hopefully not too late to mitigate the illness (Figure 2).  

 

Some Open Questions About What We Should Do to Protect the Cath Lab Staff and Patients

 

Many questions are still unanswered but many have proposed some practical and hopefully effective approaches. 

 

Question

Opinion: M. Kern

Opinion: A. Seto

Are we at the point of canceling elective cases?

Not yet

Soon

Are health care professionals (technologists/nurses) allowed to decline participation in cases with a known or suspected COVID-19 patient?

They can, just as they can decline any activity if they are concerned about their safety.

Not in this time of crisis. Health care professionals have an obligation to patients when there are reasonably effective safeguards (gown, masks, shields).

If taking on a COVID-19 patient leads to quarantine of all participating personnel x2 weeks, what is the loss in capacity to other patients?

Huge

Huge

What precautions are needed to minimize exposure to staff and other patients?

Full personal protective equipment (PPE)

Some discussions of negative pressure room, airborne precautions vs droplet+mask.

Minimize staff in the room.  Terminal clean and possibly longer 4-6 hour clean.

Does it ever make sense to do a cath procedure on a COVID-19 patient, especially with a demand-related non-STEMI? 

Not immediately, unless they are unstable.

No, see Zheng et al.1

Should we only do STEMIs or none at all?

Maybe we should think about thrombolytics

Strongly consider thrombolytics to avoid exposure to staff.

Is a cath lab a critical operation of a hospital at this time or should critical care RNs and physicians be diverted to ICU care?

 

With elective volumes reduced, sharing workloads makes sense, but we should not risk losing specially trained cath lab staff to the ICU.

Depends on number of staff available, but should reserve at least one-two 24-hour teams to maintain care of cardiac emergencies. Given unique skills, cath lab staff should preferably be diverted to non-COVID-19 patients only.

 

 

What Did They Do in China?

Jie Zeng, Huang, and Pan1 reported in a letter to Intensive Care Medicine, describing how to balance acute myocardial infarction and COVID19. They published the protocols from Sichuan Provincial People’s Hospital, a large medical center massively affected by the epidemic. I have paraphrased some of the most important points here:

  1. Patients should choose the nearest center that can complete primary PCI.
  2. Avoid recommending public transportation.
  3. Adopt the principle of maximum protection. Patients with acute MI accompanied by fever, especially respiratory symptoms, should first go to a fever outpatient clinic. Combined with epidemiological history and body temperature screening, if SARS-CoV-2 infection is suspected, patients will be admitted to the hospital isolation ward for rapid nucleic acid test. The nucleic acid test can significantly delay the time of STEMI emergency reperfusion.
  4. Patients suspected or diagnosed with SARS-CoV-2 infection should be isolated and begin thrombolytic therapy immediately, if within reperfusion time.
  5. High-risk patients with contraindications for thrombolysis need to assess the risk of infection and the benefit of percutaneous coronary intervention (PCI). Perform PCI only for the culprit vessel.


For STEMI patients:

  1. Stable patients when the onset time is within 12 hours: use thrombolytics. For stable patients when the onset time is more than 12h, evaluate risk of PCI vs infection. Obtain echocardiogram 24-48h. Follow-up should be performed through an internet outpatient clinic.
  2. For unstable patients with severe pneumonia, admit to isolation ward. Unstable patients with mild to moderate pneumonia assess the onset time of STEMI. See #1.
  3. For non-STEMI, the door-to-balloon time in non-STEMI patients is not critical in most patients. Therefore, first exclude the SARS-CoV-2 infection. Any confirmed case should be transferred to the isolation ward until patient recovery and then assessed for further invasive interventions as needed.

 

What Should We Do in the USA Now?

Certainly, no one can speak for the whole country on cath lab protocols at this point, but here are several comments from our interventional colleagues:

 

Prashant Kaul, Piedmont Heart Institute, Atlanta, Georgia: We are proposing a similar protocol based on the Sichuan experience both for high risk or confirmed COVID cases that present with STEMI. Similarly, patients who are confirmed positive (or at high risk) with some other "urgent" need to come to the cath lab (hemodynamically or electrically unstable, tamponade) will be evaluated on a case-by-case basis with attempts made to avoid coming to the lab. If possible, we will consider bedside [intra-aortic balloon pump] IABP placement or bedside pericardiocentesis as appropriate. There are multiple implications to bringing a COVID positive patient to the lab for the rest of the staff, lab flow (room will be offline for several hours to clean), and in the situation where the COVID positive patient needs to be emergently intubated during the procedure.

 

Kirk Garrett, ChristianaCare, Wilmington, Delaware: We haven’t had any discussion about this at all among ourselves [Yet. -MK], but our first confirmed case of COVID-19 in the state was just yesterday. I will open the conversation with our [emergency department] ED and clinical operations teams today. My take on this issue: Primary PCI PCI still preferred for those with presumed or confirmed diagnosis if able to provide personal protective equipment to team members. Isolation and ‘lysis may be an option for those with uncontrolled cough and confirmed infection or febrile respiratory illness, if not lytic contraindications. The lab will need a terminal clean after each confirmed/suspected case, but right now the prevalence of the disease is still low in our community. Of course, that is certainly subject to change.

 

What About In-Person Meetings With COVID-19 Concerns?

Steve Bailey, LSU Shreveport School of Medicine, Shreveport, Louisiana, asks, “We have seen larger international and national meetings canceled. What decisions have our institutions made regarding the duration of any cancellations and size of allowed events? Specifically, what is being done regarding institutional educational events, grand rounds, other gatherings? Is there a protocol you have seen used that has been effective beyond isolating those at risk? Has anyone instituted any active screening for asymptomatic individuals?”

 

Mort Kern, Long Beach, California: Steve, as is occurring with most all other University/VAs, all extraneous or unnecessary travel is restricted. All large meetings are canceled. Grand rounds are now transmitted for online viewing. Telework is recommended for all those who can do it. Reduction in elective procedures is now being discussed as well. Our policies are developing daily and changing according to new incoming information and exposures/confirmed cases. During the COVID-19 crisis, we are making changes to our schedules, meetings, and gatherings to reduce exposure among attending physicians, residents, students, and other team members. We also requested that each rounding team enforce good hygiene regarding overall cleanliness of the surfaces, extraneous materials lying around, and frequent handwashing. 

 

Herb Aronow, Brown University, Providence, Rhode Island: At Brown University and Lifespan Hospitals, Match Day gathering is cancelled. Most educational events/grand rounds/gatherings are cancelled. No medical students are allowed to scrub into procedures to conserve personal protective equipment (PPE). No visitors are permitted except in extreme circumstances. COVID-19 testing is occurring outside of the hospital in a tent.

I can’t stress enough how important social distancing is to flatten the transmission curve (Figure 2). Absent a vaccine, it is one of the only tools we have to lower ‘R’, the reproduction number. There is no magic number below which it is ‘safe’ to gather; the fewer social interactions we all have and the longer we keep this approach in place, the slower the disease spreads and the better equipped we are to manage it.

 

Ajay Kirtane, Columbia University, New York City, New York: I fully agree with the above with one additional point which I only understood last week. Because of lack of testing, if a bunch of us are together in a room for conference and there is an exposure, the ENTIRE SERVICE may be out of commission due to quarantine. This is another reason we have cancelled conferences — to prevent a shortage of people to deal with what may be a large influx of patients on top of a stressed system.

 

James Blankenship, Geisinger Cardiovascular Center for Clinical Research, Harrisburg, Pennsylvania: Our system is asking that all meetings that are not essential to daily work or patient care be cancelled or postponed until after April 30, 2020. Additionally, if an essential meeting must occur, limit it to fewer than 50 in-person participants. Examples of non-essential meetings include grand rounds (unfortunately including one featuring Dr. Kern! Ouch. -MK), education events, and support group meetings, among others. For community events in which employees are participating, it is advised that you follow the same guidelines as above. Symptomatic visitors are asked to stay home and if they must come, then wear masks (they are not giving out N-95s.) Pretty much every meeting within our hospitals has been cancelled or converted to Skype, including meetings with only a few people. Employer-paid trips are cancelled and we are warned that if we return from personal travel we may be quarantined. Fellows have been told they should stay home if they are on rotations such as echo, cath, and research where their absence is not a direct threat to patient care. That way, if the fellows on service get sick, a healthy replacement team can come in from home to keep the services running.

 

Kirk Garrett, ChristianaCare, Wilmington, Delaware: ChristianaCare moved yesterday from limited restrictions (eg, advised no travel and home quarantine for 14 days after travel to certain area) to a broader restriction that cancels all non-essential business travel until June 30. In-person meetings on campus with external guests (vendors, consultants, students, speakers) are cancelled. Everything on your list, Steve, is off until summer.   

I walked out of the hospital yesterday with our Chief Virtual Health Officer (at a safe inter-personal distance). She believes patients will gravitate toward virtual care systems in the coming months, potentially accelerating establishment of those tools. I’m guessing everybody on this list is in a system that’s investing in virtual care delivery. COVID-19 could change health care permanently.

 

Bonnie Weiner, University of Massachusetts, Worcester, Massachusetts: I agree with Kirk’s comment about remote/telemedicine. Technology is there, but I’m not sure the security or payment systems currently support widespread use. Telework will definitely be part of the future healthcare systems.

                                                            

Guri Sandhu, Mayo Clinic, Rochester, Minnesota: We have cancelled all CMEs, grand rounds, large internal gatherings, and all travel at Mayo. Robust planning and implementation of COVID-19 response is ongoing.

 

James McCabe, University of Washington, Seattle, Washington: Seattle has obviously been a real hotspot for COVID thus far. At UW, we’ve currently moved cardiology grand rounds to Zoom for remote viewing. All other regularly held weekly meetings for fellows or cardiology section meetings have been cancelled for the indefinite future. Many staff are asked to work from home and the cath labs are closed to all non-essential sales representatives (define that as you will, but essentially everyone but certain CRM and valve/clip representatives). The hospital and Washington State Department of Health have suggested that any pregnant employees or employees over 60 years of age consider not coming to work based on best judgement. The hospital instituted a restriction yesterday that patient family members are not allowed to visit (with some exceptions). Elective interventional or operative cases haven’t been cancelled.  We’re still very busy in the lab with outpatient work, but clinics are slowing down some and routine clinic visits are all being rescheduled.

We’re in the midst of trying to put together an anticipatory cardiovascular COVID response plan based on what little anecdotal evidence exists about the cardiac manifestations of the virus. It’s our understanding from China and Kirkland (two places not often said in the same sentence….) that there have been cases of a myocarditis-like / [left ventricular] LV-dysfunction phenotype associated with this disease, which is what we’re trying to plan around.

 

Bonnie Weiner, University of Massachusetts, Worcester, Massachusetts: All internal meetings and educational programs are proceeding as planned. Patient screening is occurring outside the ED and patients with fever/[upper respiratory infection] URI symptoms are being tested and masked if they need admission. Otherwise they are being sent home. No visitors under 18 are being allowed and only 1 visitor per patient unless it is a critically ill patient that may be dying. Things could all change tomorrow.

 

Habib Samady, Emory University, Atlanta, Georgia: We postponed EPIC SEC from April to Aug 27-29, hoping that we will all be in a better place by then. We have also moved all our internal educational, quality, and operational meetings to a digital platform. We are currently reviewing operational aspects of postponing elective outpatients and cases. This pandemic is clearly forcing us all to expedite transformation of many aspects of our operations into the digital world with telehealth and teleconferencing. 

 

Guidance for Non-Essential Meetings and Events

(Provided by Dr. J. Tobis from UCLA Health Updates at https://www.uclahealth.org/coronavirus)

    • Meetings with >100 participants should be postponed if the event is not essential to maintain patient safety, clinical/regulatory competency, process improvement, or business/mission continuity.
    • Non-essential meetings with <100 participants should be reviewed and reconsidered.
    • Meetings related to the education of students and trainees should transition to remote learning.
    • Any request for modifications to clinical services offerings must be approved through your senior leadership.
    • Limit patient contact to essential personnel. Present circumstances require us to preserve personal protective equipment (PPE) to the greatest extent possible.
    • When providing direct clinical care to patients in isolation, including contact, droplet, and airborne isolation, the health care team using PPE should limit the interaction to the smallest number of care team members possible.
    • Please also minimize personnel who require PPE in the perioperative and procedural areas.
    • Determination of which health care team members are essential to a patient’s care should be made by the attending physician.

 

The Bottom Line

For the time being and until better COVID-19 testing kits and treatments become available to identify potential carriers of the virus, a general consensus opinion supports limiting your exposure by avoiding large meetings and unnecessary travel. Wash hands frequently, avoid touching your face, and increase interpersonal distance (3-6 feet).

For cath lab staff and patients, consider what will be essential, lifesaving procedures, and if you are treating a patient with suspected or confirmed COVID-19, all staff must use maximal personal protective equipment and reestablish a safe environment when the case is over. Lastly, be sure to get your N-95 mask fitted. 

In the end, I am confident we will meet this challenge with the professionalism that defines the cath lab life.  

 

References

1.         Zeng J, Huang J, Pan L. How to balance acute myocardial infarction and COVID‑19: the protocols from Sichuan Provincial People’s Hospital. Intensive Care Med. 2020 Mar 11. doi: 10.1007/s00134-020-05993-9. [Epub ahead of print]

2.           Huang CL, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020 Feb 15;395(10223):497-506. doi: 10.1016/S0140-6736(20)30183-5. Epub 2020 Jan 24.

3.    Pueyo T.  Coronavirus: why you must act now. Politicians, community leaders and business leaders: what should you do and when?  March 10, 2020. Available online at https://medium.com/@tomaspueyo/coronavirus-act-today-or-people-will-die-f4d3d9cd99ca  Accessed March 14, 2020.

 

Further Reading

1. Tabarrok A. What worked in 1918-1919? Marginal Revolution. March 7, 2020. Available online at https://marginalrevolution.com/marginalrevolution/2020/03/what-worked-in-1918-1919.html. Accessed March 14, 2020.

2. Hatchett RJ, Mecher CE, Lipsitch M. Public health interventions and epidemic intensity during the 1918 influenza pandemic. Proc Natl Acad Sci U S A. 2007 May 1; 104(18): 7582-7587.