Critical care cardiologists suited to help combat COVID-19
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Critical care cardiologists may be uniquely experienced to help manage clinical manifestations of the virus that causes COVID-19 and supplement the staff of noncardiac and COVID-19-specific ICUs, according to a report published in the Journal of the American College of Cardiology.
Providers treating patients with COVID-19 may draw upon experience from critical care cardiologists to to improve health care delivery and implement telemedicine to optimize the efficacy and safety of clinicians working amid ICU capacity surges, the authors wrote.
“It is important to remember that the field of critical care cardiology is fairly new — developed in large part out of necessity. Over the last decade or so, an increasing number of reports began to highlight the evolving patient population and burgeoning complexities of care we were seeing in the contemporary cardiovascular ICUs,” Jason N. Katz, MD, MHS, advanced heart failure specialist, cardiologist and critical care specialist at Duke University Hospital, told Healio. “In response, a workforce of critical care-focused and critical care-trained cardiologists began to emerge. That same workforce has had to think about new ways to structure and staff ICUs for patients with cardiovascular disease, along with new ways to train providers who were helping to care for these patients. Our co-authors felt that — in light of this relatively recent experience with creating (and growing) a nimble and agile workforce, adapting to evolving patient demands and developing facile research approaches to complex problems — we might have some useful lessons to share amidst the COVID-19 crisis.”
Where COVID-19 meets critical care cardiology
As of April 12, approximately 1.6 million cases of COVID-19 had been reported globally with nearly 100,000 deaths, while reports describing CV presentations among patients with COVID-19 have been published, and up to 28% of those hospitalized have developed cardiac injury, Katz and colleagues wrote.
“This infectious illness may provoke a multitude of cardiovascular events including acute coronary syndromes, arrhythmias, thromboembolism, myocarditis, sudden cardiac death, heart failure, cardiogenic and mixed shock states,” the authors wrote. “The primary mechanism(s) underlying the development of each of these pathologies is unknown but is likely multifactorial, possibly involving vascular insufficiency, direct viral injury, tissue hypoxemia, systemic inflammation and cytokine release.”
Preexisting CVD among patients with COVID-19 has been linked to significant risk for the development of severe lung injury and subsequent mortality. According to the report, these same comorbidities also confer an increased burden of acute cardiac injury.
What critical care cardiologists can do
The report suggested that if ICUs are faced with a minor capacity surge (< 25% increase), a critical care cardiologist may continue to manage a single health care team in a traditional cardiac ICU model. However, during moderate (25% to 100% increase) or major (100% to 200% increase) surges, critical care cardiologists may need to help manage multiple health care teams, Katz and colleagues wrote.
“In such a model, noncritical-care-trained physicians care directly for intubated and critically ill patients, with oversight from a critical care cardiologist (or in joint partnership with a noncardiac critical care medicine provider and cardiologist), thereby expanding the reach of the cardiac critical care response to workforce limitations,” the authors wrote. “In addition, the number of patients per team and patient-to-nurse ratios would rise commensurate with the capacity surge.”
Moreover, in the event of mass casualties, the authors advised the application of the NATO triage system, which classifies patients into four categories:
- immediate, requiring lifesaving intervention;
- delayed, requiring intervention that can wait hours to days;
- minimal, injured but ambulatory; and
- expectant, too injured to save or already deceased.
“This will be a difficult shift in practice for many medical professionals, but several states have recently adopted — in consultation with medical ethicists and based upon principles of distributive justice — guidelines on ventilator allocation that can be extrapolated to other invasive and resource-intensive interventions,” the authors wrote. “Anecdotally, this has been done internationally as well. Under this framework, all patients requiring ventilation are ranked in tiers based upon illness acuity, likelihood of survival-to-discharge, and the possibility of long-term survival. Resources are then distributed top down based on availability.”
The authors added that modifications to existing ICUs may be required, with some already modifying single-occupancy rooms to double-occupancy or procedural suites.
In addition, the authors wrote, adapting principles from military medicine, from promoting team-based care to converting facilities into functions they were not intended for, may help.
Education, collaboration and telemedicine
Simulation-based training for central line placement, ventilator management and point-of-care ultrasonography have been effective methods to teach ICU skills to those with limited experience in the management of critically ill patients, Katz and colleagues wrote. The authors also advised the creation of protocols for providers in the ICU to help reduce clinical ambiguity, promote best practices and optimize resource conservation.
“Telemedicine has been used most commonly for the management of ambulatory patients but has found an increasing role in the care of hospitalized individuals,” Katz said in an interview. “In our document, we chose to highlight the potential applications of tele-critical care as a means for providing fast and effective consultation, to support care while limiting patient and provider exposure and to assist with family communication. We believe that there is a durable role for telehealth platforms to support critical care cardiology, even beyond the current crisis.”
For example, the report cited critical care providers in Singapore who conducted simulation training for various resuscitation scenarios. Reports of these exercises highlighted improvements in provider communication and a better understanding of the scenarios when advanced mechanical support strategies are most valuable.
In addition, ICU clinicians have been advised to reduce unnecessary exposure to patients with COVID-19 and use remote hemodynamic monitoring for patient evaluation and titration of medicine. That, combined with patient evaluations from bedside nurses, can help clinicians to optimize remote decision-making.
For noncritical care cardiologists who must staff the cardiac ICU as a result of the redistribution of critical care cardiologists, “curbside” and formal telemedicine visits must be readily available based on the regional impact of COVID-19 on the health care workforce. Moreover, cardiac and critical care departments may consider staffing critical care cardiologists in advisory roles and making them available by phone, video or, if absolutely necessary, in person.
The authors also noted that because family members of patients with COVID-19 are mostly prohibited from hospital visitation, it is prudent to consider telecommunication and video options for patients to speak with loved ones, review treatment choices and discuss goals of care.
“Paulo Coelho once wrote, ‘Life waits for some crisis to occur before revealing itself at its most brilliant.’ Although these are unusually challenging times, we have the unique opportunity to craft and employ novel strategies that focus on clinical agility and multidisciplinary collaboration — adaptations to care practices that, before this pandemic, may have been dismissed in favor of the status quo,” the authors wrote.
For the latest news on COVID-19 including case counts, information about the global public health response and emerging research, please visit the COVID-19 Resource Center on Healio. – by Scott Buzby
Disclosures: The authors report no relevant financial disclosures.
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