key: cord-330492-kbob8z48 authors: Vervoort, Dominique; Luc, Jessica G.Y.; Percy, Edward; Hirji, Sameer; Lee, Richard title: Assessing the Collateral Damage of the Novel Coronavirus: A Call to Action for the Post-COVID-19 Era date: 2020-04-30 journal: Ann Thorac Surg DOI: 10.1016/j.athoracsur.2020.04.015 sha: doc_id: 330492 cord_uid: kbob8z48 nan As of April 20th, 2020, the coronavirus disease 2019 (COVID-19), caused by SARS-CoV-2, has killed over 170,000 people worldwide and mortality projections for the United States have been as high as 200,000. 1 Health systems have been pressed with an uncomfortable reality to rapidly adapt to the growing burden of COVID-19 patients requiring critical care. This comes at the expense of elective surgeries, which are increasingly being cancelled across the world. This paper explores the contemporary issues impacting healthcare resources during the pandemic and makes recommendations for identifying an appropriate balance of their use to optimize patient care. Whilst necessary precautions must be taken to optimize patient care and the paucity of available resources in equipment, personnel, and infrastructure, collateral damage is inevitable (Figure 1) . The following is anticipated in different time-frames or waves: First Wave: Infections and Burden on the Healthcare System CVD as a poor prognostic factor. CVD is associated with a higher death rate in patients with COVID-19 (13.2%) compared to other comorbidities, including diabetes (9.2%), chronic respiratory disease (8.0%), hypertension (8.4%), and cancer (7.6%). 2 As such, the ethical obligation of physicians to prioritize the well-being of individual patients may be overridden by a delicate balance of policies that aim to prioritize the greatest good for the greatest number of patients: premature withdrawal or cessation of care in cardiovascular patients or 'Do not resuscitate'/'Do not intubate' in elderly with COVID-19 and perceived limited life expectancy, in order to reallocate resources to those with a better prognosis. 7 Conversely, by delaying patients with underlying CVD, they may be faced with a worse prognosis if they become infected with COVID-19. A reduction in healthcare personnel, limiting access to care. Healthcare workers themselves are at substantial risk for SARS-CoV-2 infection due to 3 increased exposure to high viral loads. 2 Additionally, increased rates of burnout among health workers, and cases of post-traumatic stress disorder as a result of frontline experiences can lead to a shortage of professionals trained to care for patients. 3 Blood bank shortages. Social distancing and lack of COVID-19 test kits for blood donors has led to a substantial decline in the availability of blood products. Although elective procedures requiring blood products are cancelled at most institutions, surgical emergencies may still necessitate blood reserves to optimize outcomes. Delayed routine screening. Recommended screening for malignancies (e.g., colorectal cancer), predisposed conditions (e.g., diabetes), and preexisting comorbidities (e.g., cardiac stress tests) may be partially postponed for an indefinite time until hospitals can reasonably manage existing patient loads. This will likely negatively impact their prognosis and lifespan. Delayed presentations of patients with progressive disease. For example, the recommendations for 'lockdown' to 'flatten the curve' may deter some patients (e.g., patients with chest pain, node positive lung cancer) from seeking time-sensitive care, out of fear or lack of access to transportation. They may be forced to or otherwise elect to "wait out their symptoms", which could pose substantial risk. Declines in transplant procedures. Given the risks associated with procurement team travel, combined with increased infection risk in recipients who will be immunosuppressed post-operatively, non-urgent transplantations may be delayed. Reduction in preventive medicine. The acute measures to stay at home and social distancing may lead to a myriad of negative effects in mental health, 4 physical wellbeing, and other lifestyle behaviours. Additionally, the shift in priority of primary care to triage suspected COVID-19 patients may limit the time available for routine visits (e.g., tracking CVD risk factors, such as hypertension, cholesterol, and diabetes -which have previously demonstrated survival benefit), supporting smoking cessation, and providing psychosocial support, despite the emergence of telehealth visits. As we move forward in this physical and emotional war, we propose the following for all healthcare professionals alike: 1. Real-time outcomes tracking will better inform the development of disease-specific guidelines for specialty care during pandemics, as well as the interaction between COVID-19 and pre-existing surgical conditions. Rightfully so, there is focused attention on outcomes tracking of patients who develop COVID-19. However, we urge the medical community that the tracking of outcomes of non-COVID-19 patients is equally important to better inform us of not only the mortality rates of COVID-19 but also its collateral damage because of patients' reluctance to seek care, or the absence of otherwise routine care. The use of digital-health technologies should be employed to longitudinally track patients initially scheduled for elective surgery. For example, the inclusion of real-time tracking for cardiac mortality would result in a realtime impact of decision making: i.e., if mortality from CVD dramatically increases, a corrective course may be developed in real-time. We must remain comitted to, and available for, all patients--COVID-19 or not-as a way of ensuring population health. This strategy may also assist in keeping 6 comorbidities under control, especially as their propensity complicates the potential COVID-19 disease severity course. Decentralization of care and the use of telemedicine to consult patients from their own homes is necessary to maintain an optimal patient-doctor relationship, whilst providing preventive care, triaging of new conditions, and comprehensive health counseling. These aspects may be supplemented by the use of emerging telemonitoring and cardiac-wearables which can also track patients' vital signs as well as serve as portable point-of-care testing. Additionally, dedicated multidisciplinary virtual triage rounds, if feasible, may be initiated to convene healthcare professionals to discuss the care of patients whose procedures have been cancelled or whose health status has changed. 3. Patient and community education is critical to flatten the epidemiological curve, whilst ensuring that patients understand when to seek care, led by example by physician leaders. Establishing virtual emergency care triage is essential, and can allow for timely patient evaluation without subjecting them to unnecessary travel to the emergency department. Empowering patients to self-access information via their electronic medical record and digitization of patient support groups via chat groups, smartphone applications, and real-time video-conferencing, and remote rehabilitation can help to improve patient engagement and health literacy. guidelines to centralize and streamline urgent cardiovascular care in this rapidly changing era. These include ensuring that a separate emergency team remains active and able to accept cases, minimizing crossover infections among patients and health workers, dedicating select hospitals, catheterization labs, operating rooms, and wards to non-COVID-19 patients, and allowing other healthcare personnel to become available when COVID-19 patients surge. Furthermore, it may include the need to have dedicated hospitals caring for COVID-19 patients only, whilst other hospitals outside heavily-hit areas take care of non-COVID-19 patients. Lastly, 7 attention should be paid to preparing patients for post-acute care and rehabilitation to reduce care fragmentation and offload the burden from acute-care centers. 8 procedures, and the reallocation of surgical patients to non-guideline-directed therapies (e.g., thrombolytics versus revascularization for acute coronary syndromes). Likewise, early-stage malignancies, small aneurysms, and asymptomatic congenital heart defects may be postponed to prioritize urgent interventions and COVID-19 critical care. However, this must be weighed against timely intervention for patients with potentially life-threatening illnesses. The importance of the multidisciplinary heart-team approach, in close collaboration with the hospital ethics and palliative care committee, cannot be overstated. Furthermore, it is important to recognize that competency is not determined by case numbers. 10 Maintaining a rigorous standard for surgical competency during a pandemic calls for a thoughtful and coordinated national approach. This may highlight the need for development and integration of advanced simulation in present day training. As the COVID-19 pandemic continues, clinicians and policymakers must be weary of the potential collateral damage on non-COVID-19 patients, health workers, and health systems. The decisions we make now will have important longitudinal implications on patient care as well as healthcare worker wellbeing. The surgical workforce should continue to take the necessary steps to protect oneself, COVID-19 patients, and, importantly, also non-COVID-19 patients. Cardiovascular surgical emergencies, traumatic injuries, obstetric complications, and congenital malformations will continue to occur, and will likely expose the weaknesses of the already burdened health system. However, sound judgement and calculated responses--proactive rather than reactive--are vital to ensure the robustness of our health system and to promote population health. We providers have the responsibility to all our patients to make sure our resource allocation does more good than harm. An interactive web-based dashboard to track COVID-19 in real time Report of the WHO-China Joint Mission on Coronavirus Disease Cardiothoracic Surgeons in Pandemics: Ethical Considerations The International Society for Heart & Lung Transplantation. 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