The COVID-19 pandemic is, at least temporarily, changing how everyone lives. Caution has become the operative word as people adjust their daily habits to maintain protective distance. The phrase “out of an abundance of caution” is now imprinted into the national consciousness.
This is especially true in health care, as clinicians refine their approaches to protect patients and medical staff. Recently, in an article published in the journal Catheterization & Cardiovascular Interventions, interventional cardiologist Mauricio Cohen, M.D., and colleagues from around the nation described advanced precautions to protect cardiology patients and staff during COVID-19.
“We provide a nice framework for catheterization labs to implement best practices to protect patients, staff and the community,” said Dr. Cohen, professor of medicine and director of the Cardiac Catheterization Laboratory at the University of Miami Miller School of Medicine. “Decisions have to be made based on patient risk, potential benefits and protecting cath lab personnel.”
Many of the guidelines in the article are simply common-sense precautions. All STEMI (ST-elevation myocardial infarction – heart attack) patients suspected of having COVID-19 are tested. This is especially important, as COVID symptoms can sometimes be mistaken for a heart episode. In suspected infection cases, cath lab teams are encouraged to wear full protective gear for all procedures.
Heart patients are especially vulnerable to COVID-19; however, this can create an ethical dilemma. Donning protective gear can take extra time and, during a heart attack, time is muscle.
“The longer you take to start a case, the higher the risk to the patient,” said Dr. Cohen. “The problem is that patients will have to be tested, and they will have to be stabilized. If patients need to be placed in a breathing machine first, we may have to transport them to another procedural area, rather than the cath lab, and staff will have to don personal protective equipment. That will take extra time.”
The authors suggest that, in some cases, it may be more appropriate to treat patients with fibrinolytic therapy (clot busters), rather than a catheterization procedure. These drugs can be easily given through an IV, reduce time to treatment and prevent medical team exposure.
This approach can be controversial – fibrinolytic therapy increases the risk of internal bleeding, and it’s unclear how it might affect COVID-9 patients with compromised lungs. Still, it may sometimes be the best choice during this pandemic and could become especially important if protective gear is in short supply.
The authors also recommend bedside procedures, such as intra-aortic balloon pumps and temporary venous pacemakers, when appropriate. Clinicians should prepare carts in advance to maintain easy access to the necessary equipment.
Another issue is airflow. Cath labs usually have positive pressure airflow – higher pressure in the procedure room – to prevent pathogens from getting in. However, the goals have shifted, and it may be more appropriate to use negative pressure to keep the coronavirus from getting out.
“Many of the procedures that were classically done in the cath lab should now be done at the bedside, the ICU or in a dedicated procedure room with a negative pressure airflow,” said Dr. Cohen.
In addition, diverting some patients away from the cath lab can help hospitals maintain a precious resource – healthy cardiologists and staff.
“The resources to run a cath lab are finite,” said Dr. Cohen. “You have a limited number of interventional cardiologists, as well as trained staff. If anyone gets exposed to COVID-19, they will be out of action for at least two weeks, whether they are sick or not. We cannot afford the loss.”