The authors introduced a table of considerations for the level at which to reinstitute cardiovascular (CV) Services. Levels of patient and personnel risk COVID Risk in conjunction with local health officials and hospital capabilities and availability of PPE and other hospital services.
Recommendations are based on 3 Response Levels:
Level 2 – Reintroduction of some services.
- STEMI – PCI for most patients unless diagnosis unclear and Patient’s COVID Status in question. Exception is lab that routinely treats with thrombolytics.
- ACS/NSTEMI – PCI for High Risk, Medium Risk – selective decisions and low risk initiate medical therapy.
- Stable Coronary Artery Disease (CAD): Focus on High Risk, Symptomatic Patients. Stable and moderate risk patients deferred.
Level 1 – Reintroduction of most services.
- STEMI – Same as Level 2.
- ACS/NSTEMI – Definite angiography for High-Risk patients and now inclusion of Medium Risk Patients. Low Risk patients – consider selective angiography.
- Stable CAD – Stable patients with moderate risk. Truly stable patients remain deferred.
Level 0 – Reintroduction of regular services.
- ACS/STEMI – Same as Level 1 & 2.
- NSTEMI – Routine management without restrictions.
- Stable CAD – Routine management
Note: These represent a composite of concepts gleaned from multiple sources, formal Society recommendations, webinars physician discussions aa well as a variety of social medical posts and discussions. These are meant to be considerations and not guidelines nor do they represent the views of any specific society.
- Important to minimize need for prolonged hospitalizations and/or ICU bed or ventilator use from complications delaying prompt discharge post an invasive procedure.
- Importance of minimizing hospital and ICU bed use from procedures as “insurance” against a sudden increase in COVID – 19 use. Maintaining a critical level of protected ICU beds is critical to continued reintroduction of procedures.
- Minimizing patient risk by scheduling procedures for physicians who are not covering COVID – 19 patients elsewhere and are COVID test negative.
- Screening patients for COVID – 19 to avoid procedure lab and staff contamination.
Maximizing Through-put considerations:
- Triage patients to perform procedures on the highest risk patients first.
- Communicate with further “delayed” patients so they recognize that if symptoms change they notify the Team promptly or seek medical attention promptly depending on the severity of symptoms. This concept seems critical to avoid greater delayed patients assuming they don’t have a problem because of the continued delay and ignoring a symptom change.
- For a given day’s schedule, arrange patients in the reverse order of the likely risk of a complication – doing the most complex last (I know it seems counter-intuitive) but the goal is to get as many patients done before a possible ICU admission might truncate the remainder of a day’s schedule.
Procedure Considerations to minimize hospital days:
Review patient’s clinical and procedure parameters carefully before proceeding. The goal is to development a plan to optimize outcomes while minimizing risk of complications. (Thus, minimizing use of hospital ICU and general beds). It is important to balance optimal outcomes with safety.
Important factors to assess:
- Bleeding risk
- Optimal access site(s) based on vascular disease, bleeding risk and operator and lab experience
- Consider a closure device if anatomically feasible and operator is experience. This is not the time for on-job training.
- Risk of acute kidney injury (AKI).
- Hydrate well and be sure hemodynamically stable with compensated heart failure.
- Extent of revascularization needed – while “staging” maybe seen as a simple way to reduce risk but staging adds to total procedures and additional hospital days. Complete revascularization is the standard for optimal outcomes and is optimally accomplished at a single setting – And reduces hospital days.
- A useful consideration is to use p-VAD (Impella) hemodynamic support for high-risk cases to increase the probability of ideal outcomes in terms of completeness of revascularization, optimal lesion results and potentially reducing the risk of AKI. Optimal results reduce initial hospital time but also reduce the need for repeat hospitalizations for complications such as acute stent closure.
- Post-procedure before discharge, optimize patient education and availability of needed medications – again to maintain a good outcome and lessen readmission.
- Insure family support and follow up including contact for questions.
A final thought:
- While all of these measures are important in the current reintroduction of cardiac procedures, all of them support sound practice principles so that optimizing through-put is not a “tainted” business concept but supports good practice.
George W. Vetrovec, MD, MACC,MSCAI