key: cord-0889920-x5zwhkkj
authors: Katz, Jason N.; Sinha, Shashank S.; Alviar, Carlos L.; Dudzinski, David M.; Gage, Ann; Brusca, Samuel B.; Flanagan, M. Casey; Welch, Timothy; Geller, Bram J.; Miller, P. Elliott; Leonardi, Sergio; Bohula, Erin A.; Price, Susanna; Chaudhry, Sunit-Preet; Metkus, Thomas S.; O’Brien, Connor G.; Sionis, Alessandro; Barnett, Christopher F.; Jentzer, Jacob C.; Solomon, Michael A.; Morrow, David A.; van Diepen, Sean
title: Disruptive Modifications to Cardiac Critical Care Delivery During the Covid-19 Pandemic: An International Perspective
date: 2020-04-16
journal: J Am Coll Cardiol
DOI: 10.1016/j.jacc.2020.04.029
sha: b67a65a16c722262f376a3320469a5e044dabf0f
doc_id: 889920
cord_uid: x5zwhkkj

Abstract The COVID-19 pandemic has presented a major unanticipated stress on our workforce, organizational structure, systems of care, and critical resource supply. In order to ensure provider safety, maximize efficiency, and optimize patient outcomes, health systems need to be agile. Critical care cardiologists may be uniquely positioned to treat the numerous respiratory and cardiovascular complications of the SARS-CoV-2 virus and support clinicians without critical care training who may be suddenly asked to care for critically ill patients. This manuscript draws upon the experiences of colleagues from heavily impacted regions of the United States and Europe as well as lessons learned from military mass casualty medicine. We offer pragmatic suggestions on how to implement scalable models for critical care delivery, cultivate educational tools for team training, and embrace technologies such as telemedicine to enable effective collaboration despite social distancing imperatives.

Coronavirus disease-2019 SARS-CoV-2

Severe The Critical Care Cardiology community may be uniquely positioned to help establish, test, and disseminate novel solutions for the current crisis. Straddling the overlapping specialties of critical care and cardiovascular medicine, many critical care cardiologists have already been called upon and deployed to COVID-19-specific intensive care settings. Here we offer our international perspectives on necessary modifications to existing care delivery platforms and potentially impactful collaborations that might optimize the critical care response and patient outcomes in the COVID-19 era.

As of April 12, 2020, more than 1.6 million COVID-19 cases were reported globally resulting in nearly 100,000 deaths.(5) While much of the morbidity and mortality associated with COVID-19

has been due to respiratory failure, cardiovascular complications of the SARS-CoV-2 virus, as well as primary cardiovascular presentations of COVID-19, have become increasingly reported. (4, 6, 7) This infectious illness may provoke a multitude of cardiovascular events including acute coronary syndromes, arrhythmias, thromboembolism, myocarditis, sudden cardiac death, heart failure, cardiogenic and mixed shock states. (8, 9) The primary mechanism(s) underlying the development of each of these pathologies is unknown but is likely multifactorial, possibly involving vascular insufficiency, direct viral injury, tissue hypoxemia, systemic inflammation, and cytokine release. (8, 10) Pre-existing cardiac disease appears to be a significant risk factor for the development of severe lung injury and subsequent mortality among infected patient cohorts. These same comorbidities have also been associated with an increased burden of acute cardiac injury.

Cardiac injury has been described in up to 28% of hospitalized COVID-19 patients. In two studies out of China, its development was associated with a significant risk of death. (1, 10) Worldwide, hospitals have mobilized resources to combat an influx of critically ill patients, while a more agile critical care workforce has emerged and continues to adapt to rapidly changing priorities. For perspective, Table 1 highlights key clinical observations, unique modifications to cardiac critical care delivery platforms, novel educational initiatives, and solutions to workforce limitations shared by authors from high-impact pandemic regions.

Critical care cardiology, as a discipline, developed in large part out of necessity, to meet the demands of an evolving patient population with evolving clinical needs.(11) Substantial changes in demographics, medical comorbidity, and resource requirements of patients with cardiovascular disease requiring critical care were described in a series of initial reports. (11) (12) (13) (14) As the prevalence of respiratory insufficiency, heart failure, structural heart disease, and multisystem organ dysfunction in Cardiac Intensive Care Units (CICUs) surpassed the number of patients with complicated acute myocardial infarction, (13, 14) providers in the CICU found an increased demand for proficiency in general critical care medicine and leadership of collaborative multidisciplinary teams. This evolution of care toward greater medical and operational complexity necessitated changes to both the structure and organization of cardiovascular ICUs, and the training and skills of critical care cardiologists. (11, 15) In this manner, the field of critical care cardiology and the contemporary structure of advanced CICUs arose from a responsive redesign of clinical care. While this evolution in cardiac critical care has better prepared us for the challenges that we now face, the COVID-19 pandemic necessitates that we again take action to adapt to the changing needs of our patients amidst this new crisis.

Pandemic and disaster planning is a subspecialty that comprehensively encompasses hospital capacity, staffing, medical supply and distribution chains, training/simulation, and adaptive leadership response structures (i.e. challenge-driven leadership skills). It is important to identify any bottlenecks throughout the system. Although a comprehensive review is well beyond the scope of this manuscript, resources are publicly available. (16, 17) Herein, we describe potential adaptive CICU staffing, organizational structure, medical treatment, and regional care pathways. Recognizing that they frequently practice in tertiary-care CICUs and routinely care for patients with primary cardiovascular diagnoses complicated by multi-system organ injury, (18) critical care cardiologists are arguably well-positioned to take a leading role in hospital-and Similarly, hospitals that have historically admitted non-ST-segment elevation acute coronary syndromes (NSTE-ACS) to a CICU or ICU will need to transition stable patients to telemetryenabled wards in keeping with more contemporary guideline recommendations. (27) Opening more CICU beds to COVID-19-afflicted patients will necessitate additional changes to operational workflow, including daily care rounds and diagnostic testing. (9) The traditional CICU philosophy is to concentrate intense resources, simultaneously addressing all active issues of a critically ill patient. During the COVID-19 crisis, however, a more utilitarian approach must be utilized, evaluating operations on the basis of efficiency, equity, and justice for patients and the hospital system as a whole. Routine laboratory studies and daily chest radiographs, for instance, that may offer low clinical value relative to the costs associated with health care worker and patient exposure should be re-considered and potentially eliminated. (28) Analogously, the use of comprehensive echocardiography should be limited to those situations where full imaging is essential, replaced instead by more focused study protocols using handheld devices performed by physicians already examining their patients. (29) Indeed, the very nature of CICU team-based, bedside rounds may need to change in order to facilitate social distancing. We suggest that physician-patient contact be minimized and that rounds be re-engineered with technological links to facilitate distanced discussions between the care team whenever possible.(9) Furthermore, to prevent patient-to-patient spread, it may be reasonable to structure rounds temporally so that providers can examine individuals without COVID-19 before approaching those with suspected or confirmed illness.

In order to meet ICU surge capacity, new ICU environments will need to be created in some institutions. (30) In the event of a regional stage 4 pandemic disaster, hospital systems must be prepared to expand ICU capacity by utilizing other regional facilities such as ambulatory and surgical centers, hotels, and even public spaces for non-critical care needs. In Barcelona and Madrid, for instance, hotels have been re-purposed as medical facilities for lower-risk patients, and have also been used to accommodate health care workers who do not have the means to safely isolate themselves at home. Additionally, modifications to existing ICU spaces may be required. Within some centers, single-occupancy critical care rooms are being converted to double-occupancy and procedural suites have become ICU-ready.

Anticipated hospital-level challenges to these adaptations will include engineering problems (such as when and where to create these new ICUs, whether creation of airborne isolation rooms is possible, and how to equip new ICU spaces with industry-standard features like medical gas, vacuum systems, and electrical outlets attached to back-up emergency power sources), optimal staffing of nurses (including the need to retrain or reinstate out-of-scope nurses to meet new clinical demands), and how best to facilitate physician re-activation or recruitment from non-critical care environments. Perhaps moving forward, all ICU beds should have the ability to easily switch between both negative and positive pressure capabilities, and include high-efficiency particulate air (HEPA) filtration systems. Institutional leadership will have to embrace a flexible approach to implementation based upon local staffing demands, physical capacity, expertise, and resource availability.

In recent years, many CICUs have moved to "airline type" hub-and-spoke models of critical care delivery. Tertiary and quaternary care centers serve as regional hubs, providing the highest level of subspecialty intensive care. This has become the standard for managing patients with STEMI, cardiogenic shock, pulmonary embolism, and acute aortopathies. 

Pandemic

The escalation in the COVID-19 pandemic has required medical professionals to take on Table 2 illustrates some of the major tenets of military medicine and their potential utility in influencing a CICU pandemic response.

If a surge in the number of patients becomes overwhelming, bottlenecks will need to be quickly identified and care plans may require alterations in order to better allocate essential resources.

There are established military and disaster medicine tenets that may help to improve patient care and aid in difficult triage decisions. In times of war and mass casualty, military physicians have often operationalized the North Atlantic Treaty Organization (NATO) triage system -a system which classifies patients into 4 categories: 1) immediate, requiring lifesaving intervention, 2)

delayed, requiring intervention that can wait hours to days, 3) minimal, injured but ambulatory, and 4) expectant, too injured to save or already deceased ( Table 2) . (36) The aim of this triage system is to rationally allocate available resources to those in need 

While clinically actionable COVID-19 data is rapidly emerging, ongoing knowledge deficits preclude any medical systems from complete preparedness. This uncertainty has motivated medical professionals to propose and adapt novel care strategies. As previously described, staffing has been enhanced through the hiring of new nurses and re-engagement of former nurses with previous critical care experience. PPE procedures have been significantly refined, and patient transportation and necessary isolation processes have been implemented. Teams throughout the hospital, both at unit and system levels, must collaborate for the common good to benefit each other and their patients. The largest threat to health care workers during this pandemic may not be the virus itself, but rather the fear and anxiety invoked by either not knowing a policy or having differing policies across care settings. Empowering team members to offer suggestions to leadership and providing mental health support to colleagues will be important measures to enhance patient care and protect the workforce. Rather than expecting readiness for every possible scenario, teams must be agile and ready to respond to change. (39) Institutional leaders should also be prepared to augment critical care physician pools with non-traditional providers. Flexible call schedules and additional levels of "back-up" clinicians may be required to fill in when work-related exposures and infections de-stabilize the workforce.

Finally, we must be proactive in safely re-introducing care providers back into the workplace once they have recovered from illness.

Many centers have developed extensive regional networks to facilitate uniform and timely multidisciplinary interventions for cardiogenic shock patients. These shock teams focus on early In other words, mechanical circulatory support (MCS) decisions can be shifted from the bedside to a phone call with referring institution practitioners who can provide detailed patient information, hemodynamic, and metabolic data. This process ensures the transfer of only those cardiogenic shock patients with a clearly delineated plan for temporary MCS and/or clear exit strategies in line with available resources, multidisciplinary consensus, and patient and caregiver expectations.

Over the preceding weeks, reports from Europe have described overwhelmed ICUs and the need to mobilize healthcare professions who do not typically care for critically ill patients. (30, 40) The being learned "on the fly." Communication will also need to be streamlined and, if possible, centralized to prevent the sharing of inconsistent information from a myriad of sources. Finally, we will need to transfer knowledge from regions with more experience treating these patients to regions just beginning to treat these patients, and we need to do it globally. As an example, critical care providers in Singapore conducted simulation training exercises to address a myriad of resuscitation scenarios. Reports of these experiences have helped to improve provider communication, and have also led us to a better understanding of where and when advanced mechanical support strategies are most useful. (46) Clinical "boot camps," didactic sessions, and on-line training methods have similarly been employed in Europe and New York (Table 1) .

Additionally, educational imperatives are likely to evolve across various pandemic stages (Table   2 ), and will need to include facile research collaborations. Important lessons will be learned from prospective registries that define risk factors, patterns of presentation, and variables associated with specific cardiac and respiratory outcomes. Pragmatic and adaptable trials will be required to determine optimal care pathways, staffing models, and methods for efficient and equitable resource allocation. Undoubtedly, operational aspects of clinical research have and will continue to be impacted by the pandemic. While beyond the scope of this paper, decisions regarding optimal trial management will need to be fluid in response to evolving demands.

The COVID-19 pandemic has already impacted both ambulatory and inpatient cardiac consultative practices, with many institutions now transitioning to a telemedicine approach either universally or on a case-by-case basis. Telemedicine is not a new addition to the cardiovascular armamentarium, as it has been previously leveraged to improve access to patients in rural health environments and to augment home monitoring programs. (47, 48) Over the past decade, telemedicine has also expanded into the intensive care realm, allowing critical care physicians to treat patients across geographically-and resource-diverse hospital settings using advanced audiovisual interfaces. (47, 48) COVID-19 has also presented us with new and unusual barriers to effective patientphysician, physician-family, and patient-family communication. As family members are now frequently prohibited from hospital visitation, it would be advisable to consider novel telecommunication and video options for patients to speak with loved ones, review treatment choices, and even discuss goals of care. Particularly in the event that a patient is unable to communicate directly, these telemedicine platforms could then be used to assist physicians in providing daily family updates in lieu of traditional face-to-face discussions.

The COVID-19 pandemic has and will continue to stress our workforce, healthcare systems, and critical resource supply and distribution chains. In response, we need to be committed, cohesive, and innovative in order to optimize care efficiency, ensure provider safety, and improve patient outcomes. Critical care cardiologists must familiarize themselves with the SARS-CoV-2 virus and its numerous clinical manifestations. Its unique cardiovascular presentations and devastating cardiac sequelae will likely lead many patients into CICU beds. Furthermore, critical care cardiologists may find themselves leaving their CICUs in order to staff non-cardiac and COVID-19-specific ICU settings (Figure 2) . It is important for us to learn from the experiences of our colleagues in heavily impacted regions of the United States, Europe, and Asia so that we can proactively develop efficient and scalable models for healthcare delivery, cultivate practical educational tools for team training, and embrace technologies such as telemedicine which will enable us to collaborate effectively despite social distancing imperatives. Finally, this pandemic should serve as a clarion call to our healthcare systems that we should continue to develop a nimble workforce that can adapt to change quickly during a crisis. We believe critical care cardiologists are well positioned to help serve society in this capacity.

Paulo Coelho once wrote, "Life waits for some crisis to occur before revealing itself at its most brilliant." Although these are unusually challenging times, we have the unique opportunity to craft and employ novel strategies that focus on clinical agility and multidisciplinary collaboration -adaptations to care practices that, before this pandemic, may have been dismissed in favor of the status quo. 

Host susceptibility to severe COVID-19 and establishment of a host risk score: findings of 487 cases outside Wuhan

Characteristics and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72314 cases from the Chines Center for Disease Control and Prevention

Review of clinical characteristics of coronavirus disease 2019 (COVID-19)

Cardiac involvement in a patient with coronavirus disease 2019 (COVID-19)

Coronavirus disease 2019 and cardiovascular disease

Coronaviruses and the cardiovascular system: acute and long-term implications

Potential effects of coronaviruses on the cardiovascular system: a review

Cardiovascular considerations for patients, health care workers, and health systems during the coronavirus disease 2019 (COVID-19) pandemic

Cardiovascular implications of fatal outcomes of patients with coronavirus disease 2019 (COVID-19)

Evolution of critical care cardiology: transformation of the cardiovascular intensive care unit and the emerging need for new medical staffing and training models: a scientific statement from the American Heart Association

Evolution of the coronary care unit: clinical characteristics and temporal trends in healthcare delivery and outcomes

Changes in primary noncardiac diagnoses over time among elderly cardiac intensive care unit patients in the United States

Demographics, care patterns, and outcomes of patients admitted to cardiac intensive care units: the Critical Care Cardiology Trials Network Prospective North American multicenter registry of cardiac critical illness

Role of critical care medicine training in the cardiovascular intensive care unit: survey responses from dual certified critical care cardiologists

Triage: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement

United-States-Resource-Availability-for-COVID-19/United-States-Resource-Availability-for-COVID-19.pdf?lang=en-US

Development of a triage protocol for critical care during an influenza pandemic

Definitive care for the critically ill during a disaster: a framework for allocation of scarce resources in mass critical care: from a Task Force for Mass Critical Care summit meeting

Predictive value of the sequential organ failure assessment score for mortality in a contemporary cardiac intensive care unit population

Catheterization laboratory considerations during the coronavirus (COVID-19) pandemic: From ACC's Interventional Council and SCAI

Intensive care utilization in stable patients with ST-segment elevation myocardial infarction treated with rapid reperfusion

Will cardiac intensive care unit admissions warrant appropriate use criteria in the future?

Prognostic assessment of patients with acute myocardial infarction treated with primary angioplasty: implications for early discharge

Impact of coronavirus disease 2019 (COVID-19) outbreak on ST-segment elevation myocardial infarction care in Hong Kong, China. Circ:Cardiovasc Qual Outcomes

CSC expert consensus on principles of clinical management of patients with severe emergent cardiovascular diseases during the COVID-19 epidemic

guidelines for the management of patients with unstable angina/non ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients with Unstable Angina/Non ST-Elevation Myocardial Infarction): developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons: endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine

Routine chest xrays in intensive care units: a systematic review and meta-analysis

The application of appropriate use criteria for transthoracic echocardiography in a cardiac intensive care unit

Critical care utilization for the COVID-19 outbreak in Lombardy, Italy: early experience and forecast during an emergency response

Development of systems of care for ST-elevation myocardial infarction patients

Contemporary management of cardiogenic shock: a scientific statement from the American Heart Association

Multidisciplinary standardized care for acute aortic dissection

MOD=AJPERES&CONVERT_TO=url&CACHEID=ROOTWORKSP ACE.Z18_M1HGGIK0N0JO00QO9DDDDM3000-5e89f600-3775-4bbd-9274-77163f36ba70-n4OvUkA. Accessed

Mass Casualty Preparedness and Response

Mass Casualties and Triage. In: Otolaryngology / Head and Neck Combat Casualty Care. Army Medical Department (AMEDD) and Borden Institute

Flugtag-88 (Ramstein Air Show Disaster): An Army response to a MASCAL

A framework for rationing ventilators and critical care beds during the COVID-19 pandemic

US Army split forward surgical team management of mass casualty events in Afghanistan: surgeon performed triage results in excellent outcomes

COVID-19 and Italy: what next? Lancet

At the epicenter of the Covid-19 pandemic and humanitarian crises in Italy: changing perspectives on preparation and mitigation

SARS-CoV-2 and COVID-19: facing the pandemic together as citizens and cardiovascular practitioners

Simulation training in the ICU

Struggling for a feasible tool -the process of implementing a clinical pathway in intensive care: a grounded theory study

An intervention to decrease catheterrelated bloodstream infections in the ICU

Preparing for COVID-19: early experience from an intensive care unit in Singapore

Call to action: rural health: a presidential advisory from the American Heart Association and American Stroke Association

Telemedicine helps cardiologists extend their reach