As COVID-19 continues to spread across the country, hospitals are preparing for (if not already experiencing) a potentially overwhelming influx of patients requiring acute care and lengthy hospital stays. Cardiovascular (CV) patients are one of the groups most likely to experience complications and require intensive care as a result of contracting the virus. Because of the implications of the virus for CV patients in particular, the CV service line will not only be on the frontlines of the clinical battle against COVID-19, but also key to the responsible management of severely strained and limited hospital resources.
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Clinical implications for CV patients
Early data on the virus has established a sobering prognosis for coronavirus patients with CV comorbidities. The American College of Cardiology (ACC) published data indicating that 40% of hospitalized COVID patients have cardiovascular disease. Likewise, according to data from the Chinese Center for Disease Control and Prevention, mortality is highest for patients with underlying CV health conditions (at just over 10%) than for any other comorbidity, including respiratory disease.
Moreover, by targeting and inhibiting the lungs, coronavirus makes patients more susceptible to developing CV disease once infected. According to the ACC, 16.7% of patients developed arrhythmia and 7.2% developed acute cardiac injury during the course of their inpatient stays. There have also been cases of acute-onset heart failure, myocardial infarction, myocarditis, and cardiac arrest.
The resources and time required to care for COVID-19 patients have sparked concerns that hospitals lack the necessary infrastructure and capacity to handle a sudden influx. This is particularly true for ventilators and extracorporeal membrane oxygenation (ECMO) units. According to the CDC, 41% to 71% of patients admitted to ICUs require ventilation and 3% to 12% require ECMO. Although there are studies questioning how pervasive the use of ECMO to treat coronavirus may become, even a small spike in utilization can overextend resources and force difficult decisions about patient triage.
CV providers on the frontlines of care
Because of the high risks associated with CV patients, cardiologists need to be involved in the care of infected patients as early as possible. This is particularly true for existing CV patients.
The most preventative steps may include sending thorough education to known CV patients on how to limit opportunities for exposure to the virus and the signs and symptoms to watch for before coming into the hospital. The ACC provides one example here of a patient-friendly summary of the ACC Clinical Bulletin that can be sent for patient education. Once a potentially infected patient with CV comorbidities is admitted, the CV service line should be among the first to know so that it can be involved early in care decisions. Administrators may want to institute flags in the EHR to ensure that CV providers know when their patients are in the system with coronavirus. Given the risk of COVID patients developing complications such as arrhythmias, CV providers should also expect to be in higher demand for consults on new patients. Consider establishing a central call line for COVID-related CV questions from PCPs and other physicians.
Protect bed capacity
There are also steps that CV administrators can take to protect bed capacity for patients most in need. Perhaps most importantly, care pathways for routine or low-acuity patients can be redesigned to incorporate telehealth to alleviate capacity constraints and limit opportunities of exposure to infection. For rapid implementation of telehealth in clinic settings, we recommend this ACC article, which provides a blueprint on logistics such as patient selection and CMS billing.
Tertiary or quaternary centers most at risk of exceeding capacity for intensive care patients should highly prioritize telehealth as a means of providing support to physicians in referring hospitals so that they can keep their patients local.
For example, a few years ago, Parkview Heart Institute in Indiana developed telecardiology protocols for its community and rural spoke hospitals. Using the pathway, providers at spoke hospitals could access virtual consults with providers at the tertiary center for patients with designated CV short-stay conditions such as heart failure. The consults helped identify patients who needed transport to the tertiary center compared to patients who could continue to receive care locally. As a result of the protocols, 89% of patients were able to stay in their local hospital, greatly alleviating capacity at the tertiary center.
For more details and implementation guidance, see the case profile in Blueprint for CV Growth in a Transitioning Market
Action steps for CV administrators
We are learning more about COVID-19 every day. Fortunately, there are continuously updated resources that you can turn to for help as the pandemic develops.
Your top resources for coronavirus readiness
You're no doubt being inundated with a ton of information on how to prepare for possible patients with COVID-19. To help you ensure the safety of your staff and patients, we pulled together the available resources on how to safely manage and prevent the spread of COVID-19.