STEMI Triage Can Free Up ICU Beds for COVID-19 and Beyond

Up to two-thirds of STEMI patients have a low enough risk to safely skip ICU-level care, without sacrificing safety or outcomes, physicians assert in a new Catheterization and Cardiovascular Interventions “core curriculum” paper. This concept, they say, may be particularly valuable as hospitals face strained resources during the COVID-19 pandemic.

Data from the Chest Pain-MI Registry have shown that, after primary PCI, more than 80% of STEMI patients are treated in the ICU. That’s likely unnecessary, John J. Lopez, MD (Loyola University Medical Center and Stritch School of Medicine, Chicago, IL), lead author of the new paper, told TCTMD.

This question—which patients require ICU care—has taken on new urgency for hospitals facing COVID-19, when bed availability is a key concern, he said. “For us, every time that we send a patient to the floor instead of an ICU, it’s freeing up really a very precious bed.”

At the height of Chicago surge, their center had 50-plus COVID patients in ICU beds at a time; this resource need impacted every part of their operation, said Lopez. “I suspect that, even cities and hospitals where the pandemic won’t be quite as overwhelming, they’ll still feel the pinch. . . . You could imagine even 10 or 15 ICU beds converted into a COVID unit puts a big stress on any system at all, and we found that out the hard way.”

We’ve seen no ill effects of this strategy. . . . It really is a very safe approach. It’s a very resource-efficient approach. And it doesn’t skimp on quality at all. John H. Lopez

But at Loyola University Medical Center, their shift toward low-risk STEMI triage began even before COVID entered the picture, Lopez reported, describing what he called a “confluence of events.”

Lopez recalled: “We had started to get some pressure late last year from our administration about: how can we be more efficient with STEMI care, how can we improve our resource utilization?” And so, he continued, their team “embarked on a program of investigating how to do it. We had just started to put together our protocol,” borne out of earlier research by his co-authors Joseph E. Ebinger, MD (Cedars-Sinai Medical Center, Los Angeles, CA), and Timothy D. Henry, MD (The Christ Hospital, Cincinnati, OH).

By February, he continued, “we saw what was coming down the road [in] Chicago and said this is the right time to pilot this and see if we can do it.”

Chicago, like other regions, saw an overall drop in STEMI presentations during the pandemic. But COVID hit their three-hospital system gradually, and initially there was an uptick of STEMI cases at Loyola University Medical Center, Lopez noted, as patients were transferred there from the more acutely affected Gottlieb Memorial Hospital and MacNeal Hospital. Over time, their STEMI numbers then decreased.

To triage, his group uses the Zwolle risk score, modified with the addition of cardiac arrest as a factor that automatically categorizes a patient as high risk. “We’ve found it pretty easy to use, meaning what we will do is take a patient to the lab and at the end of the procedure we will calculate that score right in our [electronic medical record],” he explained. “We have within the Epic system a ‘smart set’ that our fellows have created that allows us to calculate [risk] in our procedure notes, so that we can right there and then have for everybody to see what the risk score is. And we can make a determination right at that time whether to send them to the floor or not.”

Another option for gauging risk in this setting, Lopez et al note, is the CADILLAC score.

A ‘Clarion Call’

Lopez described the widespread reluctance to avoid the ICU post-STEMI as an “anachronism.” What he’s heard from his peers is that, for some, there is concern over potential vascular or arrhythmic complications that might require a higher level of care. “Other colleagues know that sometimes when they’re working at smaller hospitals [these are] not staffed well enough to feel comfortable keeping a patient on the floor as opposed to an ICU bed,” he added.

“What we’ve tried to point out is that if you can triage patients well, [identifying those] who are not at high risk for any of the complications we’re worried about in that first day or so after a STEMI presentation, [then] the risk of some complication that actually requires ICU care is very, very small,” Lopez said. “It’s well under 1%, and I’m not sure that that’s widely appreciated.”

As to whether the COVID-19 experience will produce a lasting shift in triage patterns, Lopez predicted it will. “We’ve seen no ill effects of this strategy,” he said. “It really is a very safe approach. It’s a very resource-efficient approach. And it doesn’t skimp on quality at all.”

What the researchers are curious to see is how much this takes hold elsewhere in the coming years. Lopez said he hopes that their paper will serve as a “clarion call” to inspire next steps.

In the paper, the authors propose “a newly developed consortium of institutions to collect prospective data” on the impact of standardized STEMI risk stratification protocols to guide post-procedure care. “We welcome sites and investigators to join us in this important endeavor,” they write.

Things have begun to settle down in Chicago, but even so, COVID-19 continues to influence hospital operations and will likely have a long-lasting impact, Lopez observed. “By no means has it gone away. What we’ve seen and we expect is that the number of patients in our ICU is still enough to affect our system and our resources and how we do things in ways that make it very hard to get back to normal quickly. I don’t see us going back to the way things used to be for months and months. . . . It is manageable, but there are lot of people still working very, very hard. And it’s still affecting every part of our operation.

“It’s the right direction,” Lopez concluded, “but by no means over.”