COVID-19

Code ST-Elevation Myocardial Infarction-COVID-19: A Detailed Management Protocol

Tawfiq R. Choudhury, MRCP, Andrew Wiper, MRCP, Gillian Burnett, BSc, Billal Patel, PhD, Hesham K. Abdelaziz, MD, PhD

Tawfiq R. Choudhury, MRCP, Andrew Wiper, MRCP, Gillian Burnett, BSc, Billal Patel, PhD, Hesham K. Abdelaziz, MD, PhD

Authors’ note to readers: Recommendations from national societies regarding ST-elevation myocardial infarction (STEMI) patient care and protocols regarding COVID-19 and STEMI patients are not identical around the world. In the United States, the American College of Cardiology, American College of Emergency Physicians, and Society for Cardiovascular Angiography and Interventions have put forward a systematic approach for the care of patients with an acute myocardial infarction (AMI) during the COVID-19 pandemic.1 In the United Kingdom (UK), guidance has been published by the National Health Service (NHS) on STEMI management during the COVID-19 outbreak.2 In this article, we present a UK center’s detailed management protocol for STEMI patients presenting during COVID-19.

The COVID-19 pandemic is creating a huge burden on global healthcare systems. The cardiovascular community, along with other specialties, is facing unprecedented pressure. The task of delivering effective care to patients while ensuring personal safety is a key challenge for physicians and allied health professionals involved in patient care. One such challenge is the management of ST-elevation myocardial infarction patients presenting via the primary percutaneous coronary intervention (PCI) pathway who are suspected to be COVID-19 positive. Proposed protocols for the management of such patients have recently been published by our group and others.1,3 While these papers outline the management of potential STEMI patients from a decision-making point of view, a paper looking at the granular details of the logistical setup when dealing with such patients during the COVID-19 pandemic (eg, cath lab setup, personal protective equipment [PPE]) is lacking. This article details the proposed management pathway for patients presenting to a primary PCI center with a suspected STEMI during the COVID-19 pandemic. 

STEMI and Suspected COVID-19 Pathway: Pitfalls, Tips, and Tricks

The pathway described below is based on an institution-approved protocol that we designed for STEMI in suspected/confirmed COVID-19 patient at a tertiary cardiac center in northwest England (Figure 1A). 

Step 1. Primary contact. The initial STEMI referral call to the primary PCI phone is the first triage point for the PCI center. The ambulance service will have already assessed the COVID-19 risk based on their criteria, as follows. If patients meet the following criteria, they are classified as a possible COVID-19 case: acute respiratory distress syndrome or high temperature (of 37.8°C/100°F or higher), and at least one of the following, which must be of acute onset: persistent cough (with or without sputum), hoarseness, nasal discharge or congestion, shortness of breath, sore throat, wheezing or sneezing.4 

If the patient is COVID-19 positive or suspected COVID-19, this has to be relayed to the primary PCI team members, meaning the STEMI call has to be sent out as “Code STEMI-COVID”. 

Step 2. The arrival. The patient will remain in the ambulance parked in the STEMI bay of the hospital. The person receiving the ambulance crew will need to be in PPE (at least level 2 [Table 1]). The electrocardiogram (EKG) and history from the paramedic crew will usually be sufficient to make the decision as to whether to take the patient to the cath lab. In cases where a preliminary assessment is necessary in close proximity to the patient (ie, a physical exam), a clinician from the primary PCI team will “don” personal protective equipment (level 3) and assess the patient in the ambulance. A focused echo using a handheld device might be useful in ambiguous cases (eg, to assess for regional wall motion abnormality). When an echo is used, a disposable cover for the echo setup is essential. If the patient arrests in the ambulance, cardiopulmonary resuscitation will be commenced once members of the team are in level 3 PPE. Alternative options to the above approach, adopted in some centers, include transferring all suspected COVID-19 STEMI patients to the emergency department (ED) and then assessing them first in the ED. We feel this approach could delay the treatment received by the patients with genuine STEMI.  

Step 3. Preliminary decision. If the patient needs further assessment or is a STEMI, the patient is a “yes” for the cath lab. If a “no” for the cath lab, the patient is repatriated back to their local hospital and does not disembark at the PCI center (unless the center is also their local hospital, in which case they will be transferred over to the ED for further assessment). This allows the following, in our opinion: (1) reduces hospitalization of patients away from their local area and (2) each hospital looks after their own catchment population. Constant communication is maintained throughout between the cath lab and the receiving staff member by means of walkie-talkies. 

Step 4. Donning. All remaining members of the team will have donned PPE by now and should all be inside the cath lab. The details of the donning process and the PPE are complex and detailed in Table 1. Due to the shortage of PPE globally, our institutional policy stipulates that the consultant (attending), fellow, and one nurse will be in level 3 PPE. The other members will be in level 2 PPE. If applicable, the anaesthetist will confirm what airway equipment and drugs are required, and will discuss the anaesthetic plan should they be required prior to procedure commencement. The team will now be ready to receive the patient. 

Step 5. The patient. Once the team is ready, they will communicate to the “runner” (see below) to alert the ambulance crew to bring in the patient to the lab. When the patient arrives in the cath lab, any further assessment can be undertaken. Consent for the primary PCI should be verbal. The Lucas (Stryker Medical) or similar cardiopulmonary resuscitation device should be set up from the start. Where possible, manual chest compressions should be avoided. Mechanically ventilated patients will need the full anaesthetic team in PPE as well, ready to receive the patient. The member in charge of the airway should be in level 3 PPE. 

Step 6. The procedure. The primary PCI will be performed by the operator in full PPE. All labs should be well stocked so that all equipment is available within the lab and members of the team do not have to request the sixth person to supply equipment unless absolutely necessary. 

Step 7. Post procedure. Once the patient has left the lab, the receiving team or transfer team, who will be donned, will then transfer the patient to the designated isolation bay on the coronary care unit.

Step 8. Doffing. The cath lab team will then doff as detailed in Table 1. 

Step 9. Deep cleaning. The deep cleaning team will then prepare the lab for the next patient. In the event of multiple patients arriving in quick succession, a designated second lab will have to be on standby. 

Logistics

The team consists of the attending, the fellow, the cardiac physiologist, the radiographer (in the UK, this is standard practice in most centers), and two nurses. All the members must be inside the lab once donned. There will be an extra person: the runner. He/she will be able to enter patient details outside the lab on the system. He/she will also be able to receive blood samples to pod as well as deliver any equipment that is not inside the lab (although this should be a very infrequent occurrence).

The cath lab arrangement is key (Figure 1B). The lab should be adapted with the following features:

  • There should be separate donning and doffing areas, with clear demarcations on the floor separating these areas from the main lab area. It is a one-way route, ie, donning area>>cath lab>>doffing area>>exit. 
  • A 6-foot radius should be marked on the floor with the patient’s head as the center. This is an area of high risk and staff not directly involved in the procedure should step outside this area when possible. 
  • The lab should be fully equipped so that external request for equipment to the runner is not made.
  • Should equipment be required, a drop-off trolley should have been set up at the border between the donning area and the lab area. At the location of this setup, equipment can be dropped off or blood collected via a “drop into pod” method where the cath lab staff drop the blood into an open pod held by the runner. 
  • The cath lab should be equipped with an echocardiogram machine and stethoscopes. 
  • A communication system has to be on between the cath lab team and the runner. Walkie-talkies could be used for this purpose. 
  • Communication between cath lab team members might be difficult with face masks on. Alternative strategies could include a sterile pen and board, or sign language. However, loud vocal communication should usually suffice. 

Personal Protective Equipment (PPE)

The PPE required among personnel performing primary PCI is a matter for discussion and varies between centers. Furthermore, resource constraints in terms of supply of PPE mean that rational use of such equipment is essential, but at the same time, not at the expense of safety. The World Health Organization (WHO) document and our own consensus agreement on PPE forms the basis for our recommendations.5 Details of the recommended PPE from our center are shown in Table 1. 

Conclusion

The mainstay of delivering good care in COVID-19 suspected or confirmed patients with STEMI is adequate preparation. This will involve a thorough protocol that is well rehearsed by means of drills including all members of the primary PCI team, along with members of the anaesthetic teams, so that it becomes second nature. The goal is to deliver seamless care while maintaining staff safety at all times. 

Lancashire Cardiac Centre, Blackpool Teaching Hospitals, Blackpool, United Kingdom  

Disclosure: The authors report no conflicts of interest regarding the content herein.

Dr. Tawfiq Choudhury can be contacted at tawfiqc@hotmail.com.  

References
  1. Mahmud E, Dauerman HL, Welt FGP, et al. Management of acute myocardial infarction during the COVID-19 pandemic: A Consensus Statement from the Society for Cardiovascular Angiography and Interventions (SCAI), the American College of Cardiology (ACC), and the American College of Emergency Physicians (ACEP) [published online ahead of print, 2020 Apr 20]. Catheter Cardiovasc Interv. 2020;10.1002/ccd.28946. doi:10.1002/ccd.28946.
  2. NHS England and NHS Improvement. Clinical guide for the management of cardiology patients during the coronavirus pandemic. March 20th 2020. Available online at https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/03/specialty-guide-cardiolgy-coronavirus-v1-20-march.pdf. Accessed May 26, 2020.
  3. Abdelaziz HK, Patel B, Chalil S, Choudhury T. COVID-19 Pandemic and acute myocardial infarction: management protocol from a British cardiac centre. Crit Pathw Cardiol. 2020;19(2):55-57. doi:10.1097/HPC.0000000000000222
  4. COVID-19: guidance for ambulance trusts. UK Government. Updated May 18, 2020. Available online at https://www.gov.uk/government/publications/covid-19-guidance-for-ambulance-trusts/covid-19-guidance-for-ambulance-trusts. Accessed May 19, 2020.
  5. Rational use of personal protective equipment for coronavirus disease 2019 (COVID-19). World Health Organization. February 27, 2020. Available online at https://apps.who.int/iris/bitstream/handle/10665/331215/WHO-2019-nCov-IPCPPE_use-2020.1-eng.pdf. Accessed May 19, 2020.