key: cord-0942110-cn9dm6ju authors: Anca, Diana; Reyes, Olivia; Mitra, Raman Lala; Epstein, Laurence; Shore-Lesserson, Linda title: Electrophysiology Practice during the COVID-19 Pandemic: A New York Tertiary Hospital Experience date: 2020-10-29 journal: J Cardiothorac Vasc Anesth DOI: 10.1053/j.jvca.2020.10.041 sha: db1a6f32be75ad4e094e528100d9844cc2c9804f doc_id: 942110 cord_uid: cn9dm6ju As hospitals became overwhelmed during the Covid-19 pandemic in March-May in New York, Cardiology and Electrophysiology (EP) departments rapidly developed protocols for case selection as well modifying the practice of managing the cases. This process involved applying the American Heart Association (AHA) and Heart Rhythm Society (HRS) Guidelines for triaging the cases based on acuity, postponing the elective cases and modifying the way Cardiac Implantable Electronic Devices (CIEDs) interrogation. Procedural revisions were necessary for the workflow in the electrophysiology laboratory and that involved modifying the EP suite to accommodate a Covid procedure room, a decontamination equipment area and repurposed room for recovery in the context of personnel (EP attendings and fellows) and the main recovery area being diverted to Covid-19 ICU. The anesthesiology team had an integral and essential role in this process. This article describes in detail the collaborative planning, preparation and implementation of electrophysiology practice at one of the major tertiary centers in New York. It describes the type of EP procedures performed during mid-March to mid-May at this center, the decision process in case selection, anesthetic management and outcomes and the comparison with the previous year. Recommendations by the AHA/HRS as well as American Society of Anesthesiology (ASA) were considered in the multidisciplinary collaborative approach to patient care and personnel safety. As hospitals became overwhelmed during the Covid-19 pandemic in March-May in New York, Cardiology and Electrophysiology (EP) departments rapidly developed protocols for case selection as well modifying the practice of managing the cases. This process involved applying the American Heart Association (AHA) and Heart Rhythm Society (HRS) Guidelines for triaging the cases based on acuity, postponing the elective cases and modifying the way Cardiac Implantable Electronic Devices (CIEDs) interrogation. Procedural revisions were necessary for the workflow in the electrophysiology laboratory and that involved modifying the EP suite to accommodate a Covid procedure room, a decontamination equipment area and repurposed room for recovery in the context of personnel (EP attendings and fellows) and the main recovery area being diverted to Covid-19 ICU. The anesthesiology team had an integral and essential role in this process. This article describes in detail the collaborative planning, preparation and implementation of electrophysiology practice at one of the major tertiary centers in New York. It describes the type of EP procedures performed during mid-March to mid-May at this center, the decision process in case selection, anesthetic management and outcomes and the comparison with the previous year. Recommendations by the AHA/HRS as well as American Society of Anesthesiology (ASA) were considered in the multidisciplinary collaborative approach to patient care and personnel safety. Key Words: COVID-19, Electrophysiology, protocols, anesthetic management, outcomes. The Severe acute respiratory syndrome-related to the novel coronavirus SARS-CoV-2, that originated in Wuhan, China in the last quarter of 2019, is now a global pandemic, affecting all aspects of life. The United States has been significantly impacted by this global crisis owning more than one third of the world's cases and being the country with the highest numbers of cases globally. This has strained the healthcare system and society, especially in New York State and New York City, which have been the hardest hit areas, thus far. (1, 2, 3) The disease conferred by the SARS-CoV-2 virus, COVID-19, is thought to be predominantly respiratory in origin with pneumonia and acute respiratory distress syndrome (ARDS) being responsible for most critical care unit patient admissions. The virus causes pulmonary illness by attaching to the angiotensin converting enzyme (ACE)-2 receptor on respiratory epithelium and entering cells through this mechanism. Cardiac myocytes and other cells contain ACE-2 receptors, therefore there are other targets of the SARS-CoV-2 virus and other end-organs at risk. Indeed, it is now appreciated that a significant number of cardiac abnormalities and arrhythmias are associated with COVID -19 disease. (1, 2, 6) We discuss the experience with our electrophysiology service during the fight against COVID-19 at North Shore University Hospital, a "hot-spot" hospital just outside the city limits of New York City. Our tertiary care center has a complex electrophysiology laboratory as well as an advanced heart failure and transplantation program. In a report from Wuhan describing 138 COVID-19 patients, 16 out of 36 patients admitted to the ICU As the outbreak of COVID-19 overwhelmed the practice of medicine, hospitals and healthcare systems formed task forces to address the management of procedures, allocation of resources, equipment, and staffing. In general, the important role of the electrophysiologist in cardiac health is primary as 40% of cardiology encounters are arrhythmia-related. A similar incidence of electrophysiologic disease has been reported during the COVID-19 pandemic. Teamwork is essential as the electrophysiologist might be called to address the arrhythmias in coordination with primary care, ICU, cardiology and anesthesia teams for any patient who needs urgent, emergent, or semi-urgent electrophysiologic procedures. In our institution, the task force that was formed to guide procedures in the EP/Catheterization laboratory worked in conjunction with the hospital administration, anesthesia department engineering and transportation departments, and providers to determine the steps and workflow required to assure appropriate isolation of the COVID-19 positive patient or person under investigation (PUI). In order to care for patients with electrophysiologic disturbances during the crisis, the Heart Rhythm Society (HRS) COVID-19 Rapid Response Task Force, in conjunction with the American College of Cardiology released a joint statement to provide guidance into the management of patients with COVID-19-related arrhythmias. (12) The statement addressed the management of invasive and non-invasive procedures, with attention paid to the importance of triage and the potential exposure risk to patients, healthcare providers, and industry representatives. (12, 13) The HRS/ACC/AHA statement described the triage of procedures into 3 categories. Urgent or emergent procedures should not be postponed, semi-urgent procedures are prioritized based upon clinical characteristics and health system resources, and non-urgent or elective procedures, should be postponed. The HRS/ACC/AHA recommendation to postpone or cancel non-urgent procedures was based upon federal and state executive orders and the strain on hospital systems who were diverting all resources to care for COVID-19 patients. (12, 13) . Table1 (adapted from the HRS (12) For persons under investigation for COVID-19-related illness, HRS/ACC recommended waiting for the viral infection test result so that equipment and resources could be judiciously conserved. The HRS/ACC guidance document also placed increased emphasis on the use of telemedicine, digital health, and remote device monitoring, as these under-utilized programs can prove to be highly effective methods of monitoring. Anesthesiologists are well-suited to be integrally involved in the management of care for patients having EP procedures during the COVID-19 crisis. Anesthesiologists provide specific consultation, provide appropriate anesthetic management, and coordinate the efforts of the involved teams in order to ensure the safest approach. Consideration is given to the prioritization of procedures, the work environment, anesthetic technique, airway management, and anesthesia equipment cleaning and maintenance. (14) Because of the highly contagious nature of the SARS CoV-2 virus, transmission by asymptomatic carriers, and a significant false negative rate in diagnostic testing, it might be challenging to accurately identify and isolate all COVID-19 patients. Thus, the American Society of Anesthesiologists (ASA) recommends an escalation of standard practice during airway management for all patients, using rapid sequence induction and minimization of positive pressure ventilation as a routine, in order to minimize the potential for aerosolization of droplets. Fiberoptic intubations should be avoided unless absolutely necessary. (14, 15, 16, 17, 18) . The HRS COVID-19 Rapid Response Task force has published guidance to healthcare providers for the management of patients with CIEDs with an emphasis on limiting exposure to both patients and clinicians. (19, 20) All outpatient monitoring should be done remotely, when possible. For inpatient or emergency room management, preliminary discussion should be performed via phone or telehealth consultation. Interrogation of the device should be performed only if will have an impact on patient care. Routine device interrogation should be avoided and should use the "in hospital" remote monitoring technology if necessary. The HRS Task force discourages routine checks for CIED evaluation, and pre-operative CIED interrogation if a patient is not pacemaker-dependent. Routine evaluation for MRI planning for patients with loop recorders is also discouraged. In the perioperative period, rather than interrogation, a magnet placement is encouraged for suspending anti-tachycardia therapies in patients with defibrillators and in pacemaker-dependent patients when electro-magnetic interference (EMI) is expected. Dedicated remote interrogation devices with cellular and internet connections are strongly encouraged. (19, 20) . Device interrogation would only be prioritized for the following logistic scenarios: suspected device malfunction (inappropriate pacing or shocking), suspected elective replacement interval (ERI), preoperative evaluation if no interrogation within 6 months, urgent/emergent MRI evaluation. Direct interrogation may also be prioritized for the clinical conditions of syncope, untreated tachycardia, and stroke etiology. (19, 20) . All interrogation equipment should be cleaned with disinfecting wipes after each use. Table 2 Both the Center for Disease Control (CDC) and the Occupational Safety and Health Administration (OSHA) have published guidelines for personnel protection and PPE use (21, 22). The ASA has offered specific guidance for provider protection during anesthetic management including endotracheal intubation and equipment recommendations (15, 16, 17) . The HRS recommendations include suggested modifications of the management of CIEDs in order to minimize personnel exposure. (19, 20) In our tertiary cardiovascular center, from March 16 th until May 16 th there were 115 cases performed, excluding 5 implantable loop recorders: These include 60 device implantations and generator replacements, 21 catheter ablations, 10 device lead extractions and 24 cardioversions. Among the catheter ablations, 8 were for ventricular tachycardia, and 13 were for either atrial fibrillation, atrial flutter or supraventricular tachycardia. Table 3 During the same interval in 2019 there were 426 cases and 106 implantable loop recorders performed. The triage of procedures was implemented by our institution as soon the ACC/AHA as well as HRS guidelines were published. The determination of urgent, semi-urgent or semi-elective and elective was made by the EP team in collaboration with the primary or ICU team for inpatients or the primary care physician for outpatients. Most were of the procedures were urgent and semi-urgent: device implantations or replacements for diagnoses such as syncope, high-degree atrio-ventricular block, or replacement interval indications. Urgent and semi-urgent lead extractions were performed for infection or malfunction while cardioversions and catheter ablations were scheduled for symptomatic arrhythmias refractory to medical treatment. Only 2 patients were known COVID positive at the time of their procedure and 71 were negative. The remaining 42 patients presented early during the pandemic when there was a relative paucity of COVID testing available and unreliable rapid-testing. The urgency of the procedure dictated if a procedure was performed before a COVID test result could be returned. Our hospital developed protocols for testing, and procedural management, and dictated that all patients who did not have a COVID test result would be treated as if they were positive. There were 6 fatalities for a death rate of 5%,which is much higher than our usual mortality rate on the EP service.2 of the fatalities were Covid positive .One patient having a leadless pacemaker died of sepsis. The second patient, who had a dual chamber pacemaker ,succumbed to cardiogenic shock due to extensive coronary thrombosis ,which was felt to be Covid-related. The other 4 fatalities occurred after discharge and the causes of death are unclear, but they remained Covid negative. Fortunately, the EP laboratory is located within the Catheterization Suite, which enabled creation of a procedure room that would serve COVID-19 patients for both EP and coronary catheterization procedures. The assigned procedure room was confirmed to have negative pressure ventilation and high efficiency particulate air (HEPA) filters were present on the anesthesia machine. The room was emptied of any redundant or unnecessary equipment, and a clean, isolated storage area in the adjacent monitoring room, was delineated with zippered plastic curtains. Nearby in the suite a specific soiled utility and a decontamination room were assigned. Another procedure room was repurposed and converted to a preoperative holding and recovery area for both EP and the catheterization laboratory, because these usual units had to be transformed in COVID-19 ICUs during the surge. Written protocols for care were developed in accordance with the HRS guidelines and elevators and routes of transport were assigned for COVID-19 patients. Our anesthesiology department generated videos detailing the proper procedure for donning and doffing of Personal Protective Equipment (PPE) while always ensuring that there was adequate supply to maintain the safety of our staff. Table 4 Clinically, the daily huddle addressed each case individually to review indications and the protocol to be followed. Outpatients who were scheduled for semi-urgent or urgent procedures were screened for COVID-19 viral antigen before being admitted to the hospital. For the COVID-19 positive inpatients, consent for anesthesia services was obtained telephonically and a full report on the patient was communicated before transport was activated. At the procedure room, all personnel entering the room donned personal protective equipment (PPE) before entering the room and doffed inside the room immediately before exiting. At the conclusion of the procedure, the patient was either recovered in the procedure room by a post-anesthesia care unit nurse, or was transported directly to a COVID-19 ICU. After recovery in the procedure room, the patient was transferred to a COVID-19 specific floor. The anesthetic technique used for each of case was discussed with the proceduralist and the patient taking into consideration the patient's symptoms, the common anesthetic technique that would have been used prior to the pandemic, and the risk of aerosolization associated with that particular airway management. For the device implantations in COVID negative or unknown patients, sedation using midazolam with fentanyl, or a propofol infusion was employed. For patients requiring general anesthesia with endotracheal intubation a rapid sequence induction with the use of video laryngoscope was used, in alignment with the ASA recommendations. Whenever possible, deep extubation was used in order to minimize aerosolization. For the 2 known COVID positive patients we used monitored anesthesia care, with very light sedation (1 mg Midazolam and 50 mcg Fentanyl) with an oxygen mask instead of nasal cannula in order to cover both mouth and nose. A surgical mask was placed on top of the oxygen delivery mask. For perioperative management of patients with CIEDs, the HRS recommendations were followed and device interrogation related to perioperative management was done remotely, as is routinely done for outpatient interrogation. In-person interrogation was performed rarely and only for emergency situations, such as pre-operative interrogation, in which case a designated device was used and was disinfected after each use In the epicenter of this major pandemic, our institution had re-deployed staff to cover the ICUs and Emergency Room. As such, some of the nursing and technology staff were re-assigned to the COVID-19 units and some of the electrophysiologists were deployed as back up consultants. Given the fact that only urgent and semi-urgent procedures were performed, the EP lab had a reduced schedule volume and functioned very efficiently despite a skeleton staff. Communication preoperatively and at the morning huddle was critical to implementing a plan that was appropriate for the patient, the personnel, and the procedure and recovery periods. The current pandemic has challenged the delivery of routine and emergency care worldwide and has forced changes to assure the safety of patients and healthcare personnel. EP laboratories in the hot spot areas with significant number of COVID-19 patients had to adapt. We did this by limiting cases to urgent and semi-urgent according to HRS guidelines, modifying the procedure areas and recovery areas to accommodate the COVID-19 positive patients, altering cleaning and disinfecting areas, and adopting a more proactive approach through telemedicine in order to limit personnel and equipment exposure. Anesthesiologists are a critical part of the electrophysiology team, often functioning as a central communication hub for care and clinical processes. This is especially applicable to the care of patients during the COVID-19 pandemic. 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