Cardiac catheterisation labs are being asked to prepare for the worst-case scenario in a bid to stem the collapse of critical interventional services amid the COVID-19 pandemic.

In the first Australian consensus guidance on how catheterisation labs should prepare for COVID-19 the Cardiac Society of Australia and New Zealand (CSANZ) offers specific advice on which cases to defer, how to minimise risk of transmission to health workers and how to allocate resources.

The guidance comes as many hospitals brace for the anticipated surge of acutely ill patients testing positive for COVID-19 without enough intensive care beds or personal protective equipment (PPE) – a situation that could see ‘little or no service provision being possible’ if exposed or infected staff need to be self-quarantined or worse, admitted as patients, say the authors.

CSANZ’s Interventional council and the COVID-19 Interventional cardiology working group, who jointly drafted the statement, say the indication and urgency of interventional cardiac procedures will need to be balanced against the risk of staff exposure in the wake of a PPE shortage.

PPE shortages

Dr Sidney Lo, Chair of CSANZ’s Interventional Cardiology Council tells the limbic he’s ‘unclear’ about the national PPE stockpile.

“We think there’s a shortage but we don’t really know – it’s a real concern that’s been a major issue covered in the news and across social media and that does increase anxiety among health care workers.”

While so far COVID-19 hospitalisations in Australia are low, Dr Lo says numbers are increasing.

“Right now we have no idea if social isolation is working – whether it will reduce the number of patients coming into hospitals with really critical illnesses like the type of patients that were being admitted to hospitals in Italy. There’s a fear that we’ll be swamped.”

In this situation, with resources scarce, there are limited choices, says Dr Lo.

“In an ideal world you would don PPE all the time but we don’t have enough equipment for that so there are only two options – either you protect yourself fully or you determine that you don’t need to protect yourself because the risk [of transmission] is very low.”

The risk is never zero, he adds, because even a negative swab could turn out to be a positive case a couple of days later.

And there may come a time – if the community transmission rates are high enough – when cath teams will need to consider everybody as potentially transmissible.

“Then everyone would be high exposure risk and because we’re taking them into a lab it becomes a very complex process – can a lab be truly cleaned?”

Cath lab guidance

Cardiac catheterisation laboratories aren’t designed to isolate infection, says Dr Lo, with most having either normal or positive ventilation systems. Bringing a confirmed or suspected COVID-19 patient to the lab would expose all laboratory staff to the risk of infection and disable laboratory use for a prolonged period of time for terminal cleaning.

That level of cleaning, as well as teams having to don full PPE, which Dr Lo says could take up to 45 mins, would also introduce unacceptable procedure delays.

STEMI care for instance, with its inherent time dependency, poses particular challenges, notes Dr Lo.

The consensus report suggests for relatively stable STEMI patients with active COVID-19, or at intermediate- to high-risk, fibrinolysis may be considered, or even preferred, in hospitals even with catheter laboratories.

But lytics haven’t been used across metropolitan hospitals for close to 20 years, notes Dr Lo adding that clinicians may be unfamiliar with them.

“Regional areas are very experienced with these agents because they’ve had to keep using them in the absence of cath labs in close proximity. But some of us providing primary PCI services in metropolitan hospitals may be a little rusty on the criteria for prescribing these therapies and so we’re re-educating everyone about the nuances of these drugs.”

Particularly pointing at reducing bleeding rates in people over the age of 75 years, Dr Lo notes these patients should receive half the weight-adjusted TNK-tPA dose with clopidogrel.

Primary PCI

He is clear though that primary PCI would always be the first choice when possible.

“We’re not saying stop primary PCI as preferred therapy but when resources are swamped your capacity will be very low – it will be impossible sometimes to deliver much service at all.

We’re bracing for the worst case scenario and somewhere in between reaching worst case and the point where you have high volumes of this is the question, how do you protect your staff – how do you go on delivering care as well as not disadvantaging patients? It’s a very tricky balance.”

In anticipation of ramped-up demand on catheterisation services, ‘non-urgent’ procedures have already been put off, since these cases use up potentially needed resources and put patients in a hospital environment where the risk of contracting COVID-19 might be higher, notes Dr Lo.

Examples of procedures that might reasonably be put off include invasive angiography in stable ischaemic heart disease, non urgent TAVI and Mitra-clip and all ASD/PFO and LAA closure procedures.

Dr Lo says while everyone is clear on minimising non-urgent cases, there are concerns about potential long-term delays for these patients.

“We’ve pretty much cancelled all our out patient cases which are not urgent but the longer this drags out – if it goes for six or even three months – it does disadvantage these people, some of who need bypass surgery and that’s very difficult to deliver at a time where there’s not enough intensive care beds.”

The statement also covers how hospitals should handle patients who require intubation, suctioning, and CPR – patients who are at risk of creating aerosolised pathogens – suggesting a lower intubation threshold.

“Elective intubation prior to catheter lab is the preferred option in “high exposure risk” patient with high oxygen requirement. If required, elective intubation in dedicated negative pressured room outside of catheter laboratory is preferred prior to procedure,” the guidance states.

Team reorganisation

The consensus group is also urging hospitals to rethink safety protocols and staffing arrangements suggesting primary angioplasty services be centralised and staff fragmented into two or three teams to prevent risk of exposure and protect workforce numbers.

Teams would include junior medical staff, cardiology advance trainees, fellows, consultants, nursing staff, radiographers and cardiac technologists.

Each team should remain physically separate both during working hours observing the 1.5m social distance rule as well as socially from other teams in a service.

“You can’t necessarily know if the back-up team also becomes infected unless they were isolated at home for instance,” says Dr Lo arguing that staff would have to be paid their normal hours.

“It may not come to that but it’s something we’re asking everyone to think about.”

The consensus statement will be updated as the situation changes, Dr Lo advises.

“We worry about the numbers going up and we’re hopeful that this wont eventuate into a scenario similar to what’s been happening in Europe so all we can do is plan for the worst and we ‘re preparing on a daily basis,” he assures.

“This is a time to be very close and collegial working through issues about how patients go from one department to another, minimising risk to the hospital and healthcare workers. We want to make sure that we don’t disadvantage patients, that our healthcare workers stay healthy and that we can continue to deliver care to patients optimally. We’re all very committed to that – on all fronts, across all departments.”

The full consensus statement can be found here.