key: cord-0897938-l6l7bln0 authors: Hussain, Azhar; Balmforth, Damian; Yates, Martin; Lopez‐Marco, Ana; Rathwell, Claire; Lambourne, Jonathan; Roberts, Neil; Lall, Kulvinder; Edmondson, Stephen title: The Pan London Emergency Cardiac Surgery service: Coordinating a response to the COVID‐19 pandemic date: 2020-06-29 journal: J Card Surg DOI: 10.1111/jocs.14747 sha: 415e46c2024555c11893767b36cac3f983df4422 doc_id: 897938 cord_uid: l6l7bln0 Over the last 4 months, the novel coronavirus, SARS‐CoV‐2, has caused a significant economic, political, and public health impact on a global scale. The natural history of the disease and surge in the need for invasive ventilation has required the provision of intensive care beds in London to be reallocated. NHS England have proposed the formation of a Pan‐London Emergency Cardiac surgery (PLECS) service to provide urgent and emergency cardiac surgery for the whole of London. In this initial report, we outline our experience of setting up and delivering a pan‐regional service for the delivery of urgent and emergency cardiac surgery with a focus on maintaining a COVID‐free in‐hospital environment. In doing so, we hope that other regions can use this as a starting point in developing their own region‐specific pathways if the spread of coronavirus necessitates similar measures be put in place across the United Kingdom. There are seven NHS centers that provide cardiac surgical services in London, with an additional five independent hospitals covering a population of 8.5 million. Before the COVID-19 pandemic, approximately 7000 cardiac surgical procedures were performed on average in London every year, with the majority (90%) performed in NHS hospitals. The two centers chosen to deliver the PLECS service, Barts Heart Centre (BHC) and Harefield Hospital (HH), performed approximately 1800? and 900 procedures per year respectively. 3 Due to the impact of COVID-19, an initial pan-London conference call was set up on the 18 March 2020. At this point, almost all units had stopped elective cardiac surgery and were only operating on interhospital transfers for urgent cardiac surgery or emergencies. Some units had triaged "urgent from home" patients from the waiting list with life-threatening anatomy to be offered surgery if capacity allowed. From the details discussed in the conference call, it was apparent that a pan-London approach was not only sensible but necessary to maintain emergency cardiac surgery whilst maximizing resources for reallocation to the COVID-19 response. Two centers (BHC and HH) were chosen based on their capacity, geographical location, and the absence of an on-site A&E service, as it was felt that having to accommodate acute admissions via A&E would make maintaining a COVID-free environment challenging. There was a complete agreement from all units that the PLECS pathway was necessary, logical, and should be actioned as soon as possible. A steering committee was put in place to develop a protocol for the set up and delivery of the PLECS referral pathway, led by surgeons from Barts Heart Centre. It is important to note that due to the novel challenge of providing a cardiac surgical service in the midst of a global pandemic the PLECS pathway detailed in the subsequent sections was not implemented in its entirety from the outset. Some aspects were developed over time and modifications were made to the pathway, particularly in relation to how best to maintain a COVID-free environment. Outlined below is the final version of the pathway that incorporates these modifications. The first duty in developing the PLECS pathway was to define the cohort of patients that would be eligible for referral and treatment. Cardiac surgical patients can be considered in a few categories depending on clinical urgency. The initial referral pathway depends on the level of urgency at the time of referral/presentation and is schematically represented in Figure 1 . • Level 1 -Elective-patients who have indications for routine cardiac surgery who would normally be added to an elective waiting list. Such patients under the PLECS protocol would be treated by local centers as normal and be placed on waiting lists at the local center, with the knowledge that these waiting lists could be longer than usual. Level 1 patients will not receive surgery within the PLECS pathway. • Level 2 -Urgent from home-such patients are on the existing waiting lists or in the process of referral-but have critical/lifethreatening anatomy with worsening symptoms or the need for urgent prognostic intervention. Such patients will be triaged by the local centers and if appropriate passed through to the hub command center for consideration of surgical intervention should capacity allow. • Level 3 -Urgent interhospital transfers-such patients are in hospital with prognostic/critical anatomy or physiology or with unstable symptoms. They require cardiac surgery within this hospital admission (but not on the same day). The PLECS pathway dictates that such patients must all be discussed in a local multi- It is assumed that all nondelivery cardiac centers will have performed the basic preoperative investigations such as echocardiography and coronary imaging. Patients will not be transferred to a delivery center unless imaging has been transferred or is in the process of being transferred via the appropriate method. As such it is expected that referring centers and the delivery center will have adequate staff trained and able to facilitate the transfer of urgent image transfers. It is accepted that some of the additional investigations routinely used to assess cardiac patients preoperatively (such as carotid doppler ultrasonography, lung function tests) will be unlikely to take place. Detailed histories and clinical examination will be essential in documenting physiological reserve and suitability for cardiac surgery. As the local cardiac surgical center is triaging referrals for level 3 and 4 patients, it is important to have a named clinician responsible for the referral at the local center. This will allow the surgeon at the delivery center to communicate easily with the local center regarding the status of the patient. Close coordination between the command center and the nondelivering center will be essential. We expect continued dialog through the working day. However, two operational calls should be scheduled: 1. 8 AM-check theatre and bed availability and plans for the current day/review any emergency referrals overnight. for the next working day. It is anticipated there will be a weekly telephone conference with representation (clinical and managerial) from all participating sites. Daily feedback from the command center to the consultants on call at the delivery site will be expected to document a number of referrals and bed availability. The government has actively encouraged limiting unnecessary interactions in the workplace which includes certain staff in the healthcare system. The majority of staff without direct patient contact have been sent home with the ability to work remotely. Inevitably, frontline staff treating cardiac surgical patients may at some point expect to have to self-isolate either as a result of themselves becoming symptomatic or inhabiting with someone who is symptomatic. As such staffing plans must inherently assume a high rate of attrition. It is envisaged that the PLECS protocol will be able to draw on a pan London pool of cardiac surgical staff including surgeons, anesthetists, nurses, and technical staff. Each unit should consider which staff would be suitable for redeployment to a delivery center if needed. For example, perfusionists, if not working in an extracorporeal membrane oxygenation delivery center, could be used to cross cover services at the two delivery centers. Consideration should also be given to any senior staff members over the age of 70 to work in roles outside the hospital to minimize their risk of contracting the virus. The cessation of cardiac surgery in cardiac surgical centers outside the two delivery sites should enable the redeployment of staff from cardiac surgery services to help other essential services dealing with the outbreak. The PLECS command center will be based at Barts Heart Centre staffed 24 hours, seven days a week. The command centre at BHC will coordinate the transfer of referrals to both treatment centres (BHC and HH). During main working hours (8 AM-8 PM) staffing will consist of two members of the cardiac surgery scheduling team, a senior surgical registrar/resident, and a dedicated PLECS consultant surgeon. The consultant surgeon does not necessarily have to be from the delivery center and it is possible that surgeons from other local cardiac units may be asked to cover if there is a staff shortage. Outside of normal working hours, the hub will be primarily staffed by the registrar and the on-call consultant surgeon. In general, the role of cardiac surgical staff at local cardiac surgical hospitals will be determined by local policies. If surgeons are required from local cardiac units at the delivery center, then fast-tracking of honorary contracts and induction arrangements will be necessary. Flow-through the delivery centers will be paramount to allow the pathway to function. Wherever possible, a preplan to discharge patients home from the delivery center will be followed. However, in the event of the need for prolonged hospitalization following surgery, repatriation to the local cardiac surgery unit may be required. This would be decided on a case by case basis. All options for ongoing care for patients not able to be discharged will be explored, including step down to the private sector. Before the COVID-19 pandemic a small portion of all outpatient clinic appointments for postoperative patients at BHC was performed in HUSSAIN ET AL. The Independent Sector cardiac surgery providers are in discussion with NHS England about how they can support urgent cardiac surgery provision in the capital incorporating an appropriate governance structure. It is likely that the independent sector will be asked to support patient flow and ongoing hospital treatment for patients after cardiac surgery who cannot be discharged from a delivery center. It is also possible that independent hospitals could deliver some level 3 and level 2 operations where capacity allows. These patients would be triaged and processed through the command center, to ensure the most urgent in-hospital patients are treated quickly and that capacity is optimized. The Independent Sector support will have representatives on the weekly interhospital meeting. At the time of writing, the independent sector is not taking an active role in the delivery of the PLECS pathway. The COVID-19 pandemic is causing a paradigm shift in the way we practice cardiac surgery. The nature of our specialty mandates the use of the very precious resources that are required to combat this unprecedented pandemic. This protocol is an initial pathway aimed at delivering safe care for patients with an urgent need for cardiac surgery without compromising on healthcare resources. Due to the lack of precedent in the current pandemic, the majority of the measures proposed are based on limited, sometimes anecdotal evidence. As such, the protocol will be continually reviewed and updated as our understanding of the disease process improves, and our experience of operating in these challenging circumstances increases. Many questions remain unanswered as to how to optimize outcomes for patients presenting with heart disease in the midst of the pandemic. It is not yet clear who should be offered surgery and who would be better served with watchful waiting. Work is ongoing regarding how to optimize cardiac surgical patients to prevent the development of COVID-19 in the postoperative period and outcome data is being collected on all operated and nonoperated patients referred via the PLECS pathway. It is hoped that analysis of this data over time will allow a picture to emerge of who should be offered surgical treatment, at what time points, and how best to minimize the risk of concomitant COVID infection. It is imperative that we are meticulous in this process during this pandemic, as it is likely that COVID-19 as a disease process will persist for many years to come. In the spread of coronavirus, London has so far borne the brunt of cases and mortality. However, as the pandemic spreads through the population we can expect that centers around the UK will be similarly affected. In this initial report, we outline our experience of setting up and delivering a pan-regional service for the delivery of urgent and emergency cardiac surgery with a focus on maintaining a COVID-free in-hospital environment. In doing so, we hope that other regions can use this a starting point in developing their own region-specific pathways if the spread of coronavirus necessitates similar measures be put in place across the United Kingdom. The following are members of BSC (Bart's Surgical Consortium): Stephen Edmondson (Clinical Director for Surgery), Kulvinder Lall World Health Organization. WHO announces COVID-19 outbreak a pandemic Next Step on NHS Response to COVID-19 Society for Cardiothoracic surgery Stability issues of RT-PCR testing of SARS-CoV-2 for hospitalized patients clinically diagnosed with COVID-19 A role for CT in COVID-19? What data really tell us so far Laboratory parameters in detection of COVID-19 patients with positive RT-PCR: a diagnostic accuracy study Lymphopenia predicts disease severity of COVID-19: a descriptive and predictive study Bartholomew's Hospital Theatre Standard Operating Protocol for COVID-19 Can an office practice telephonic response meet the needs of a pandemic? Telemed e-Health The Pan London Emergency Cardiac Surgery service: Coordinating a response to the COVID-19 pandemic AH is the guarantor of the paper. All sources are referenced. No patients were involved in this analysis. http://orcid.org/0000-0003-3941-4553