The coronavirus disease 2019 (COVID-19) is a highly transmissible viral infection of the respiratory system, which in later stages appears to have cardiovascular effects together leading to multi-organ failure and death in some patients. Accordingly, symptoms can vary and range from mild to severe, in which patients progress to acute respiratory distress syndrome (ARDS), requiring critical care and prolonged mechanical ventilation. In early March 2020, the World Health Organization declared COVID-19 a global pandemic, which resulted in a monumental re-prioritization of all health care to focus on flattening the curve, preserving and reallocating resources in order to combat this illness, and preserve the integrity of the United States healthcare system before it becomes overwhelmed.
Optimal treatment strategies are far from understood in this patient population. Studies are extremely limited, with most based on single-center observational data and case reports. In the field of interventional cardiology, new therapies, medications, and medical devices go through stringent trials before receiving widespread acceptance and dissemination. However, we have now entered a new era in which we are forced to change our mindsets regarding the delivery of cardiovascular care amid a situation where guidelines and protocols simply do not exist. Overall, the United States healthcare system was woefully unprepared and ill-equipped to manage a viral pandemic. With no finite timeline for when things can return to business as usual, we have found ourselves in uncharted territory. This leaves many nurses and specialty technologists working in the cath lab in an uncertain and daunting position.
Cardiovascular Disease and COVID-19
Studies show a high prevalence of cardiovascular diseases in patients with COVID-19, especially patients with the most severe manifestations.1 The most prevalent and deadly comorbidities appear to be advanced age, hypertension, diabetes, and cardiovascular and cerebrovascular diseases, all of which are common in the patients that fill our labs on a daily basis.1,2 As these patients become ill from infection, their likelihood of needing to come to the cath lab for emergency or urgent procedures is increased.
Common cardiovascular manifestations, either related to underlying pre-existent cardiovascular disease or due to the direct and primary result of infection, include arrhythmias, myocarditis, acute coronary syndrome, cardiomyopathy, venous thromboembolism, pulmonary embolism, heart failure, and cardiogenic shock.3 Elevated troponin levels and abnormal electrocardiograms are a common finding in COVID-19 patients, as there are many mechanisms of the illness which induce demand ischemia and make it hard to differentiate between type I and type II myocardial infarction. In addition, myocarditis, vasospasm, and stress cardiomyopathy have all been reported in these patients, leading to elevated troponins. Although type I myocardial infarction and acute coronary syndromes have not been well identified in this patient population, it is clear that both ST-elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) occur in these patients and may be difficult to discern from the above non-coronary etiologies.4 Due to the profound inflammatory process seen in severe cases, we can be sure that these patients are at increased risk for plaque rupture as we have seen in patients with influenza.4 New information is being discovered daily that validates or makes inappropriate current methods of treatment, making it difficult for health care workers to keep up to date. Nonetheless, staff will need to be ready to handle these patients in the cath lab, understanding that a significant portion will not have intervenable disease, but may require advanced hemodynamic assessment or mechanical circulatory support.
COVID-19 Cases in the Cath Lab
The ultimate aim of the cath lab should be to provide necessary cardiac procedures in a timely fashion without compromising the safety of the patient or staff. Interventional cardiologists, managers, and staff should be working closely with administration to establish protocols on how to protect employees and treat patients who are COVID-19 positive or under investigation. We must maintain a mindset that COVID-19 patients are going to come through the lab, so it is best to treat all patients as potentially positive and protect staff accordingly. The American College of Cardiology (ACC) and Society of Cardiac Angiography and Intervention (SCAI) have compiled COVID-19 resources on their websites with the latest research and consensus statements for treating cardiovascular patients, with cath lab recommendations.3, 5
Patients should be assessed and screened prior to coming to the cath lab, and if there is a risk of decompensation and intubation, this should be performed prior to arrival to minimize aerosolization and risk to the staff. Primary percutaneous coronary intervention (PCI) for STEMI has been an area of controversy, as risks to the staff are significant, false positives are not uncommon, and it is unclear whether the risk to benefit ratio is as robust as STEMI patients without COVID-19. ACC and SCAI maintain that PCI remains the recommended standard of care, though the consideration and administration of fibrinolytics should be weighed heavily, especially in patients with COVD-19 and severe bilateral pneumonia. Patients presenting with unstable angina or NSTEMI allow for more time for diagnostic testing and the ability to make more informed decisions regarding infection control. In general, most NSTEMI patients can await testing for COVID-19 and then undergo catheterization and PCI within the next 24 to 72 hours. Given the infectious risk of transporting patients from wards to the catheterization lab, some procedures routinely done in the catheterization laboratory should be considered for bedside performance. Examples include pulmonary artery catheter placement, pericardiocentesis, transvenous pacemaker placement, and intra-aortic balloon pump insertion.
Staff Health and Safety
For all COVID-19 positive and suspect patients, proper personal protective equipment (PPE) should be readily available to all staff members, including N95 respirator, gown, face shield and/or goggles, and gloves. Protecting employees should be of utmost importance. If not, it can lead to staff exposure and quarantining, which may result in understaffing. In hard-hit states, many healthcare workers have become ill with COVID-19 and some have died. Therefore, it is imperative to protect staff both to maintain their availability to cover the cath lab, and to protect them and their families. Proper education on donning and doffing PPE should not be taken lightly or foregone. Staff members should undergo training and know the proper procedure for PPE use. The procedure for donning and doffing can be found from the Centers for Disease Control (CDC) and SCAI.5 Effort should be taken to identify high-risk cases for transmission prior to arrival to the cath lab so that proper precautions can be taken by staff members. Furthermore, staff should be educated regarding procedures that place them at the highest risk for transmission by causing increased aerosolization, including cardiopulmonary resuscitation, bagging, and intubation. When possible, automated cardiopulmonary resuscitation (CPR) machines and use of anesthesiologists for intubation should be instituted. Close coordination with critical care and anesthesia teams in airway management is extremely important to avoid emergency intubation in the cath lab as much as possible.
Currently, cath labs are only performing emergent procedures, as all elective cases have been halted to preserve and reallocate resources to areas of need. It is pertinent to keep in mind that there is a wide regional variation of COVID-19 intensity. In the U.S., southern states remain several weeks from reaching their predicted peak infection rate. As quarantine restrictions begin to loosen in certain areas of the nation and elective procedures restart, staff should continue to take measures to protect themselves, keeping in mind that a significant amount of the population is positive and potentially contagious, but asymptomatic. Furthermore, with unknown rates of re-infection and the possibility of a second surge of infection with loosening of quarantine measures, it is extremely important to continue these safety measures for the cath lab staff.
COVID-19 has caused disarray and uncertainty in cath labs across the nation. Due to the regional variation in the volume of cases, staff are dealing with reallocation/cross training to work in areas of need (or high risk) in the hospital on the one hand, and pay decreases, furloughs, and layoffs on the other. Though the timing is uncertain, restrictions will loosen and the case volumes will rise, requiring the return of staff to run at full capacity. It can be expected that lab volumes may be exceptionally high in the months after the peak of infection, as we manage the backlog of patients who were unable to have procedures during the outbreak. Bringing back staff who have been transferred to areas of need may pose a challenge. This should be done strategically, based on the needs of the hospital, and may occur as a process over a period of weeks.
As important as maintaining our physical health and safety is during this time, mental health is just as crucial. This pandemic has forced us to change our perspectives of healthcare from patient-centered care to public-centered health, which seems to push us further into the already muddied ethical waters of healthcare. For the first time for many of us, we must consider what is best for the patient versus what is best for the community, country, and even ourselves as health care providers. Furthermore, we are facing difficult circumstances where we may be needed to directly work on the front lines caring for COVID-19 patients or we may be relieved from our duties completely. As we have learned from other pandemics, the mental health impact of COVID-19 on health care workers is projected to be immense. During this time, healthcare workers are more prone to experience higher levels of stress, depression, anxiety, and feelings of inadequacy.6 Staff should be encouraged to utilize in-house resources and programs set up by hospitals to help with mental stress as national resources. Many medical and nursing societies, as well as the CDC, provide a list of resources on their websites.
The short- and long-term effect that COVID-19 poses on both patients and healthcare workers alike remains unknown. As infection rates vary in different areas of the nation, staff should remain vigilant and not grow complacent in upholding assessment and screening protocols, and safety measures with proper PPE, for all COVID-19 positive and suspect patients. The mental and physical safety of staff during this time remain of great importance, as we are dealing with constant change and uncertainty. The role of the cath lab during COVID-19 remains vital, because this patient population holds a high prevalence of cardiovascular diseases and manifestations requiring the activation of the cath lab staff in order to provide timely interventions.
Bailey Ann Estes, BSN, RN-BC, RNFA, CNOR, RCIS, can be contacted via Twitter at @baileyannRN or via email at firstname.lastname@example.org.
- Li B, Yang J, Zhao F, et al. Prevalence and impact of cardiovascular metabolic diseases on COVID-19 in China. Clin Res Cardiol. 2020:1-8.
- Yang J, Zheng Y, Gou X, et al. Prevalence of comorbidities in the novel Wuhan coronavirus (COVID-19) infection: a systematic review and meta-analysis. Int J Infect Dis. 2020. pii: S1201-9712(20)30136-3. doi: 10.1016/j.ijid.2020.03.017. [Epub ahead of print]
- Driggin E, Madhavan MV, Bikdeli B, et al. Cardiovascular considerations for patients, health care workers, and health systems during the coronavirus disease 2019 (COVID-19) pandemic. J Am Coll Cardiol. 2020 Mar 18. pii: S0735-1097(20)34637-4. doi: 10.1016/j.jacc.2020.03.031. [Epub ahead of print]
- Zhou F, Yu T, Du R, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020;395:1054-1062.
- Szerlip M, Anwaruddin S, Aronow HD, et al. Considerations for cardiac catheterization laboratory procedures during the COVID-19 pandemic. Perspectives from the Society for Cardiovascular Angiography and Interventions Emerging Leader Mentorship (SCAI ELM) Members and Graduates. Catheter Cardiovasc Interv. 2020 Mar 25. doi: 10.1002/ccd.28887. [Epub ahead of print]
- 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.