Pandemic and Practice – Considerations in Resuming Cardiovascular Procedures Q&A
Dr. Dillavou: I do not think that the cleaning process is timed, but we do a thorough cleaning of all equipment in the room after every patient, and we have specific COVID positive ORs.
Dr. Qureshi: Currently in our hospital, patients are tested regardless of which area of the country they are coming from. I think assuming a worst case scenario is appropriate, even if they are not coming from an area that has been affected much. Due to the variability in testing as well, we have chosen to standardize testing and make sure that all patients receive testing at our facility.
Dr. Qureshi: We have looked into this and with others in the country published some guidelines to help in this regard. In areas like ours, opening up or “ramping up” is certainly appropriate with proper guidelines and safety measures in place. Due to the postponement of elective surgeries and procedures, we are currently looking into those procedures that would be highest priority. In other words, patients who need procedures sooner rather than later although still elective. I think ensuring that proper safety measures in the hospital are in place is important for physicians and patients/families. This includes screening, masks, limiting visitors etc. and only opening up when enough PPE is available. All these measures will help mitigate the risk for physicians and patients/families. So far this process has seemed to work in our facility and by opening up we have not seen an increased risk to patients/families or healthcare providers.
Dr. Dillavou: That is handled by employee health on an individual basis, but yes; those employees at risk are kept at home and repurposed to work from there.
Dr. Dillavou: Some hospitals are limiting the repurposing of staff into the ICU or Emergency room to those 50 or 55 years and younger. It seems as though the threshold for these measures depends on the number of front-line staff needed.
Dr. Qureshi: This is an interesting question. I am not sure that we know the answer to this. However I can tell you from us re-starting cardiac procedures, it has become quite busy already. I think we will probably not reach the same number of cases we had for example say last year, but we will come close.
For clinical trials, do you believe your peers and institutions would support remote patient visits (when imaging/PE not required) moving forward or will this fade and resume historical patient visits? Would long term (beyond primary endpoint) safety outcomes be considered valid if moved to remote monitoring of events?
Dr. Qureshi: I think our peers and institutions would support remote patient visits, particularly for primary endpoints that can be easily evaluated by tele-health visits. There may be some secondary outcomes that will need face-to-face contact, for example if they need testing or exams etc.
Dr. Dillavou: For our work with clinical trials we are allowed to do remote / telemedicine visits. It is my opinion that these, should be adequate to bridge the gap until patients can safely be seen in the office again. I feel that this is adequate to provide data we need for long-term follow-up and to meet endpoint goals.
Dr. Qureshi: This is a very interesting phenomenon. Yes, there have certainly been reports on the vascular impact of COVID–19. It is now known that hypercoagulable states may result from COVID–19 and this could potentially be a cause of it affecting the toes as you have mentioned. We have not seen this ourselves but have seen reports.
Dr. Dillavou: Yes, we have definitely seen a wide variety of hypercoagulable manifestations of the antiphospholipid antibodies which develop.
Dr. Dillavou: We have a very high index of suspicion for all thrombotic events, and routinely initiate therapeutic anticoagulation on admission. Our agents of choice are heparin drip, then lovenox or warfarin long term.
Dr. Qureshi: We have monitors in the operating room and cath labs at our institution. While we were certainly using this technology before, it is clear that we are using them more now to limit exposure. I think telemedicine and tele-proctoring is probably going to be very common in the future regardless of the pandemic. Given the time constraints that individuals have in this busy world, it is inevitable that telemedicine and tele-proctoring will have a larger role in their lives in the future than it did pre-pandemic.
Dr. Qureshi: All patients undergo testing before the procedure at this time. If the test was performed (and was negative) more than 3 days before the procedure for an outpatient, it is repeated. If more than 14 days from the test has lapsed for an inpatient, it is repeated, regardless of symptoms or contact history. We make sure that patients are not exposed by isolation and social distancing within the hospital. Afterwards, periodic screening of patients/ families which include questionnaires and temperature checks are being performed.
Dr. Qureshi: Some patients and families certainly have reservations coming into the hospital or clinic. We have made it a point that, whenever possible, the physician of record reaches out to the patient and family. That sometimes alleviates their concerns. I think there are two points that are important here. First, we have to ensure ourselves that the environment is safe for everyone (patients, families, and health care providers), and that adequate PPE is available. Second, once we have ensured that the environment is safe, we need to make sure that we are transparent, relay this to our patients and families and continue to evaluate this process. Obviously healthcare is important and at some point patients and families will need to come to the hospital. Hearing from providers about what measures we are taking ourselves to ensure the safety of everyone will go a long way for patients in this phase of the pandemic.
Dr. Dillavou: This is a very good point. We are cleaning all areas many times per day. We are also encouraging all patients and staff to hand sanitize with every encounter and wear masks at all times. We are not allowing visitors or any non-essential people into the hospital, but there is still a risk.
Each speaker contributed to this presentation in a personal capacity based on individual experiences and observations. The views expressed are the speakers’ individual opinions and do not necessarily represent the views of the speakers’ employers or those of W. L. Gore & Associates, Inc.
Consult appropriate government, medical and healthcare sources for COVID-19 related guidance applicable to your own medical practice and hospital system.