Hospitals Plan Cautious Restart to Elective Procedures as COVID-19 Wanes

COVID-19 forced hospitals to cancel all elective procedures and cardiologists to focus on the most urgent cardiac patients. Now, amid hopes that the worst is over, many are mulling how to tackle the backlog of elective cases while still protecting against infection and preserving hospital resources.

“Around the country, everybody is talking about reopening as early as this week,” Arnold Seto, MD (UC Irvine Medical Center/Long Beach VA Medical Center, CA), told TCTMD. “In the more conservative [Veterans Affairs] system, we’re talking about June. People are starting to adjust to this being the new normal where it might not be a short-term crisis but something that we’ll all have to get used to, a marathon instead of a sprint, and that’s how we’ll approach this.”

Samir Kapadia, MD (Cleveland Clinic, OH), said their center delayed all “nonessential” procedures when COVID-19 struck, leaving the lab only for essential procedures as defined by their hospital and the Ohio Department of Health. Patients at risk of dying without an immediate procedure, those with intractable symptoms, or conditions with a risk of end-organ damage, such as the heart or kidney, were treated immediately.

“Now, we’re able to do elective procedures, which is everything,” said Kapadia. “At the beginning of last week—the days are running to each other—we have a process in place to say we will do all cases, the elective and nonelective. The idea is that we will test everybody within 3 to 5 days of the procedure for COVID-19. We are testing everybody currently in the cath lab for elective cases. For the urgent cases, such ST-segment MI, we can’t wait for the COVID-19 test to come back positive so we take precautions for the caregivers and do the case urgently.”  

The Centers for Medicare & Medicaid Services (CMS) recently issued new recommendations for reopening facilities to provide nonurgent care for non-COVID-19 patients. In states or regions with areas of low or relatively low incidence of COVID-19, CMS said healthcare systems can restart clinically necessary care for patients provided there is adequate facilities, workforce, testing, and supplies across the different phases of care (doctors, nurses, anesthesia, pharmacy, imaging, and so on). All facilities should continue to monitor the incidence of COVID-19 in their area, with plans to halt procedures if there is a surge, according to the agency.

The American Medical Association, following up on the CMS guidance, laid out four signposts that must exist before states and local governments relax the stay-at-home orders that would enable physician practices to slowly reopen. These four criteria include: 1) minimal risk of community transmission; 2) a robust, coordinated, and well-supplied testing network; 3) a public health system for surveillance and contact testing; 4) and fully resourced hospitals and healthcare workforce.

You don’t need to get through the backlog right away, because the demand is likely to be suppressed going forward. Arnold Seto

“That’s a lot to ask, but at least in California, our hospital has these resources and seems to have all these things in place,” said Seto. “I think we’re really lucky in that regard, and I don’t think that applies to every practice.”

Prioritizing Cases

Back in March, the American College of Cardiology (ACC) Interventional Council and Society for Cardiovascular Angiography and Interventions (SCAI) issued a statement suggesting it would be “prudent” to put a moratorium on elective cardiac procedures, particularly in patients with significant comorbidities and those who might require a hospital stay of more than a day or two.

CMS made a similar recommendation, stating that all elective surgeries and nonessential medical procedures should be delayed during the SARS-CoV-2 outbreak. That included invasive and noninvasive tests and procedures, including ECGs, echocardiograms, and interventional procedures for conditions not deemed life-threatening.

“As we’ve gone through the past 6 to 8 weeks, we believe that at least in our community we have seen what we have to face,” Kirk Garratt, MD (ChristianaCare, Newark, DE), told TCTMD. “If you go back to March, the rate of COVID-19 cases continued to climb, admissions were climbing, ventilator demand was increasing, and mortality was rising. We didn’t know if the curve would flatten, so we kept the rules in place. Now, things have started to change. Our daily census of COVID-19 has been relatively stable in our hospitals since the middle of April.”

As the number of COVID-19 cases stabilizes in certain parts of the United States, hospital staff are gearing up for a slow, controlled reopening. For Garratt, the focus is less on COVID-19 than on addressing the medical needs, deemed nonurgent at the time, that have built up in the community. As the medical director of the ChristianaCare’s Center for Heart and Vascular Health, Garratt said they will be reopening the hospital to nonurgent procedures in several phases, the first beginning in the middle of May.     

“That’s still the plan,” he said. “We have been talking about being in phase zero right now, that’s how we’re referring to it, and that is emergent cases only. We’re not ready to pull the trigger on phase one, and what we’re actively doing this week is an expanded phase zero.”

In this expanded phase, different committees representing surgery, coronary and structural interventions, vascular medicine, and electrophysiology, among others, have been meeting to adjudicate cases that need to go forward for treatment. As the rollout expands and they move into phase one, there will be a gradual expansion of elective cases that can proceed. “That process has worked very well,” said Garratt. “We’re going to maintain that process in phase zero, but as we progress, the standards for approval are being relaxed a bit.”

A, B, and Now a Little C, D, and E

Numerous professional societies, including the ACC, SCAI, and the American Heart Association, among others, have recently issued guidance for the safe reintroduction of cardiovascular services during the COVID-19 pandemic. In the initial phase of reopening, these experts are selective in their recommendations, noting that elective cath lab cases may include outpatients with symptoms and a noninvasive test suggesting a high risk for cardiovascular events in the short term. The writing committee, led by David Wood, MD (St. Paul’s and Vancouver General Hospital, Canada), recommends TAVR and MitraClip (Abbott) for those with severe symptomatic aortic stenosis and mitral regurgitation, respectively, and selective treatment of patent foramen ovale (PFO), atrial septal defects, and left atrial appendage. They also provide direction for cardiovascular surgery, electrophysiology cases, echocardiography, cardiac CT, and cardiovascular MRI.  

To TCTMD, Andrew Goldsweig, MD (Nebraska University Medical Center, Omaha), said their plan as of right now is to resume elective cases on May 18, 2020. To prioritize cases during the height of the COVID-19 pandemic, his center classified procedures into five different categories. Class A cases, where life or limb was at risk, were done immediately, while class B cases were also considered extremely time-sensitive by virtue of needing treatment within 24 hours. 

Class C cases, such as patients with stable angina and severe ischemia, required treatment within 4 weeks, as long as hospital resources permitted. Finally, class D and E cases were those where the patient could wait 4-12 weeks or more than 12 weeks, respectively, without substantially affecting clinical outcomes. Only the highest-risk TAVR and MitraClip cases were done within 24 hours, while others were rescheduled for a later day (class C or D). Patients with stable angina and mild/moderate ischemia were rescheduled for treatment within 4 weeks, while PFO and chronic total occlusions were put off for at least 3 months.

Ramping back up this month will largely depend on the availability of COVID-19 tests, said Goldsweig. At his center, they are able to perform 300 PCR-based tests per day, which turnaround results within 24 hours, and 90 rapid COVID-19 antibody tests. “We’re lucky that we’re behind the curve as we have followed the [Centers for Disease Control and Prevention], ACC, and SCAI guidance carefully and we’ve had the opportunity to learn from the experiences of others who are ahead of us in the COVID-19 curve,” he said.

These are patients in the urgent category. It’s not an emergency, but on the other hand, they could only wait a week or two. Tamin Nazif

In New York City, one of the hardest-hit areas in the US, semi-elective/semi-urgent cases have also started again at one high-volume center. Tamim Nazif, MD (NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY), said they just started doing some of these last week. Nazif, who has spent time in the ICU dealing with COVID-19 patients, performed several TAVR procedures this week, including the treatment of two patients who came to the hospital with heart failure symptoms, worsening leg swelling, and worsening shortness of breath at rest.  

“We were always doing urgent cases, those emergency cases like STEMIs and pericardial drains, but we really just started doing TAVI, for example,” he told TCTMD. “These are patients in the urgent category. It’s not an emergency, but on the other hand, they could only wait a week or two. They were having bad heart failure and they’d be admitted to the hospital.” 

In April, Nazif, along with lead author Christine Chung, MD (NewYork-Presbyterian/Columbia University Irving Medical Center), published a perspective in the Journal of the American College of Cardiology on how to rethink a structural heart disease practice during the COVID-19 pandemic, with examples of their own decision-making. Like others, they classified cases as emergent/urgent, semi-urgent (requiring an intervention within 1 to 2 months), and elective (could be postponed for 2 months or longer), and they will use this algorithm to scale back up. Right now, the labs are operating at less than 25% capacity, he said.

Nazif stressed that the key principles during this unprecedented time include treating appropriate patients in a timely fashion, protecting staff and patients from infection, and being appropriately sensitive to the utilization of resources, such as personal protective equipment, ICU utilization, nursing staff, and so on.

“At our place in New York, where the system and resources were almost completely overwhelmed, we were only doing true emergency cases, which might be very different from areas of the country that are less resource constrained,” he said. “We’re still in a fairly constrained environment at Columbia, but less than it was a few weeks ago.”      

All Decisions Are Local

Like Nazif, Jay Giri, MD (Hospital of the University of Pennsylvania, Philadelphia), said individual hospitals will need to assess their resources and make a decision about reopening based on potential COVID-19 cases, and that this process might involve some guesswork. For example, some local considerations might include whether the area is a potential hot spot for a spike or surge, such as hospitals located near a nursing home or long-term care facility. There are logistical factors to consider, too, such as whether there is sufficient staffing. Children are out of school, and doctors, nurses, and technicians are facing unprecedented challenges to their work-life balance.

However, as things start to relax, Giri said the focus will be on nonemergent patients who need to be treated as soon as possible, such as patients with stable ischemic heart disease but significant angina despite optimal medical therapy. Another group includes those with heart failure in need of either an invasive diagnostic or therapeutic evaluation, such as a right heart catheterization or temporary mechanical circulatory support.  

“Most places have classified different diagnoses in terms of urgency and have tried to triage people who have more symptomatic presentations or things that are really impacting their overall course of care,” said Giri. “We’re trying to encourage those patients to come in first.”

As her hospital recovers from the surge in COVID-19 patients, Ghada Mikhail, MD, who leads the cardiac catheterization lab at Imperial College Healthcare NHS Trust in London, England, said that there is a tremendous combined team effort within the cardiology department there to reconfigure the cath lab into dedicated COVID-19 and non-COVID-19 areas. At the start of the pandemic, they identified a single dedicated COVID-19 lab for treating patients with confirmed COVID-19 or who were highly suspicious of having COVID-19. The new dedicated areas will allow the unit to keep infected patients separate from other patients and ensure the safe treatment of patients. While this is being set up, private hospitals are supporting the National Health Service (NHS) by delivering care for patients awaiting elective procedures who are COVID-19 negative to reduce their risk of contracting coronavirus.

Beds are being made available in private hospitals for NHS-elective cases, which is of course very helpful. Ghada Mikhail

“Beds are being made available in private hospitals for NHS-elective cases, which is of course very helpful,” she said. “The private hospitals provide clean, non-COVID-19 sites. We have, therefore, just recently started treating elective NHS patients at these sites. However, as our NHS bed capacity has increased as we admit and receive less COVID-19 patients, we are now planning and going into our recovery phase to allow elective patients to be admitted and treated safely within our Trust. Whilst we plan for this, in the last week or so, we have treated some of our elective NHS cases in the private sector. Only today we completed a full day of TAVR and PCI cases.”

She noted that at Imperial NHS Trust they also have used TAVR to treat some patients initially scheduled for surgical aortic valve replacement.

“These are patients who were at high risk of dying—they were highly symptomatic and had critical aortic stenosis,” she said. “They were on the surgical waiting list for aortic valve replacement with no prospect of getting their surgery in the midst of the pandemic. In fact, some of them were discharged the same day because they are a lower-risk group for TAVI. They did very well, and we managed to get them in and out of hospital very quickly in order to minimize their risk of contracting coronavirus. This was a huge TAVI team effort, and we worked closely with our cardiac surgeons.” 

Giri said the number of patients requiring an elective procedure has continued to mount even while the COVID-19 pandemic spread throughout the US. At one of the hospitals where he treats patients, there are “many dozens” awaiting procedures.

“There are concerns that as we get ramped up to work this off, we’ll still have patients added on top of the regular flow we’re expecting to be coming in normally,” said Giri. “There’s no perfect solution, but I expect to be working hard for a few months at minimum. Some hospitals plan to go to extended schedules, with Saturdays, although it’s not something we’ve decided on yet. That’s an option, although that might be something that some people would suggest could cause more harm. Weekends for nonemergent cases isn’t something we’d be jumping up and down for.”

Like everybody else, Mikhail said they also have a backlog of elective patients that need cath lab procedures.

“Although COVID-19 is a huge challenge, I think we will be facing an even bigger challenge going forward,” Mikhail told TCTMD. “There is a long list of elective cardiac patients waiting for their procedures, and I think we are going to be even busier than we were during the pandemic. We are going to be dealing with a long waiting list of cath lab procedures. Also, as the lockdown eases, patients are going to be more confident in coming into hospital by contacting the emergency care services. As we know worldwide during the pandemic, we saw a significant reduction in the number of hospital admission with STEMI and NSTEMI.”

There’s no perfect solution, but I expect to be working hard for a few months at minimum. Jay Giri

What hospitals are now seeing is a “trickle of admissions” of patients presenting late from these acute MIs who have severe complications from delaying, such as such as left ventricular impairment and cardiogenic shock, she said. “I think what will happen is that as well as dealing with the long waiting list of elective patients, we may well start seeing a surge of acute cases also.”

Other Factors at Play

Others are less convinced that a second surge in the form of elective and more-urgent procedures is inevitable and predict that, for a range of reasons, the number of elective cases might be down in the weeks and months to come.

In Nebraska, Goldsweig said they have two dozen patients awaiting TAVR, but that the number of MitraClip cases is less than a handful. There are eight PFOs and 19 left atrial appendage closures in the queue as well. Garratt said they also have a backlog of cardiovascular patients, but the demand isn’t quite as large as would be expected considering that elective cases have been suspended for the past 8 weeks.

“It’s because when we stopped doing the scheduled procedures, offices shuttered at the same time,” he said. “Usual operations in the various cardiology and primary care offices that referred to us also stopped. The demand we know about represents patients that were in the queue when we closed off operations. Meanwhile we believe that there are people in the community who have been passing on the opportunity to get medical care because they’re afraid. They’re also afraid to go to doctor’s offices.”

In other words, there could be an initial flood of patients who had been waiting for procedures, but after that practices may see a bit of a lull as referring physicians get back up to speed.

To TCTMD, Kapadia said they are actively reaching out to patients scheduled for elective or nonessential procedures that were canceled over the past couple of months to rebook their procedures. One important consideration they are dealing with as a large referral-based hospital is accommodating family members who want to be present before and after the procedure.

“The patient should have a convenient and humane way of having the procedure done,” he said. “The idea is that we have to have some family [available], some discussions with people, some legitimate way of informing people and having open communication, not just with the patient but also with the family. Many of these patients are elderly and have several family members.”

Currently, the hospital is allowing relatives to selectively visit patients before and after their cardiac procedures. “In all areas, from the time of decision-making to the procedure to recovery, and for that matter discharge and after, the outcomes are very dependent on proper family support,” Kapadia observed.

At least at the Cleveland Clinic, internal data suggest that the SARS-CoV-2 infection rate within the hospital is extremely low, with nearly all occurring in the community. This factor alone will affect how and to whom the hospital opens its doors.

“We have to keep the hospitals safe—we can’t have a lot of people visiting,” said Kapadia.

And there are larger social and economic factors that at least in the short term will end up limiting hospital procedures, and these go beyond any financial restrictions set by the hospitals themselves. This alone will help hospitals reopen slowly and judiciously, Seto said. “You don’t need to get through the backlog right away, because the demand is likely to be suppressed going forward. People will be afraid to go to the hospital, and at least in the US, one-quarter of people have lost their jobs and lost their insurance. The last thing they’ll want to do is come in for a large hospital bill. We’re not going to see a huge volume, and many physicians will see their volume suppressed in the near future.”