Activating Cath Labs for Elective Procedures Amid COVID-19

May 8, 2020

Ramping Up Procedures and Selecting Patients

Two cardiologists share best practices for rebooting cath labs for elective procedures amid the COVID-19 pandemic. In these 2 videos, Duane Pinto, MD describes steps for moving from limited cath lab operations back to standard operations and Mark Ricciardi, MD explains a protocol for selecting cath lab patients.

In the first video, Dr. Pinto, chief of the interventional section at Beth Israel Deaconess Medical Center in Boston, describes the dramatic change in the makeup of patients in the hospital over the past weeks of the COVID-19 pandemic. With ICU capacity expanded to about 200%, resources were redeployed throughout the hospital. “And now, we’re relatively hobbled,” Pinto explains, “when it comes to being able to restart full operations.”

Nevertheless, Dr. Pinto highlights the importance of “rebooting” the cath lab and presents principles for doing so. These entail maintaining quality of care despite changing procedural and recovery environments, including COVID-positive and COVID-negative recovery and procedural areas and dedicated staff for each. Dr. Pinto also explains the importance of matching expansion of cardiac procedures to overall system capacity, especially in terms of in-patient and ICU beds, as well as repurposed nursing and technical staff.

Dr. Pinto highlights new limiting factors in this post-COVID era, including ICU/PACU capacity, anesthesiology availability, patient perceptions of safety, and potential misperceptions among referring physicians that hospitals do not have the capacity or ability to safely treat cardiac patients.

Dr. Pinto describes a 4-week ramp-up strategy, beginning with scheduling outpatients 2-3 days per week while catheterization staff are still limited due to repurposing. He recommends scheduling severely symptomatic patients and those waiting the longest first, including symptomatic TAVR and mitral patients with declining ejection fraction and progressive and escalating symptoms evolving over the last month, as well as patients at low risk for aerosolization and unlikely to need ICU care (e.g., peripheral arterial procedures and venous procedures). As the waves progress, the strategy entails opening services to less symptomatic coronary and structural patients and then stable patients. Dr. Pinto also provides suggestions for preventing nosocomial infection in patients and providers.

In the second video, Dr. Ricciardi, clinical and research program director for interventional cardiology and structural heart disease at North Shore University Health System in Illinois, provides additional insights on cath lab rebooting. “The key message here,” Dr. Ricciardi emphasizes, “and the impetus for any type of reboot, of course, is that our cardiovascular patients are suffering from the collateral damage of this pandemic... For most of us, this is the time—right now—for Phase 1 reboot.”

Dr. Ricciardi describes how measured and adaptable protocols and tools help guide the reboot by allowing clinicians to adapt to changes and by providing a framework for pivoting between phases as pandemic conditions change. Such tools also help administration understand, collaborate, and steward resources.

Dr. Ricciardi briefly reviews CMS guidance for a gradual process for restarting non-COVID-19 essential care. He highlights the gating criteria, including, most importantly for interventional cardiologists, establishing a system for prioritizing procedures.

Dr. Ricciardi describes a color-coded system to help determine the risk mitigation needed to restart each procedure. Green procedures can safely be done with a low volume of PPE for team members. Yellow procedures may require more PPE and the availability of acute care resources. Orange procedures are high risk to the patient and team, requiring more PPE, systems to assess COVID status, adequate acute care resources, and adequate patient understanding of risks and benefits. Diagnostic catheterization, CTO PCI, and Protected PCI are examples of green procedures as they are not aerosol generating, do not require general anesthesia, do not routinely require an inpatient bed, and do not require PPE for more than 3 people in the room. TAVR and MitraClip™ procedures are yellow, requiring some, or all, of the above.

Dr. Ricciardi also reviews drivers for restarting the engine of cath labs. “Institutions may need to provide a public service announcement. A message that cardiovascular services are open for those who need it.” He concludes with commentary on the phases for cath lab reboot presented by Dr. Pinto.

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