International Perspectives: Optimizing Cardiac Critical Care During the COVID-19 Pandemic

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Critical care cardiologists frequently practice in tertiary-care ICUs and routinely care for patients whose cardiovascular illnesses are complicated by multiple organ injuries and failure. Critical care cardiologists possess advanced post-graduate training both in cardiology and also critical care medicine. Such training and their experiences may position them well to manage the cardiovascular and respiratory manifestations of severe COVID-19.

In the Journal of the American College of Cardiology, David M. Dudzinski, MD, director of the Cardiac Intensive Care Unit in the Corrigan Minehan Heart Center at Massachusetts General Hospital, Jason N. Katz, MD, MHS, of Duke University, and Sean van Diepen, MD, MSc, of the University of Alberta Hospital, and colleagues from heavily impacted regions of Europe and the U.S. suggest how critical care cardiologists can lead adaptations to cardiac ICU staffing, apply triage protocols and promote multidisciplinary collaboration. In many hospitals around the world, critical care cardiologists have been deployed to lead clinical teams in non-cardiac ICUs.

Workforce Adaptations

The American College of Chest Physicians endorses a model in which a 25% capacity surge is considered minor (no change needed to the traditional organization of cardiac ICUs) while a surge eclipsing 200% is a "disaster."

During moderate surges (>25% to <100% increase in capacity) or major surges (100% to 200% increase in capacity), critical care cardiologists could assume a collaborative or consultative role in managing multiple health care teams. Physicians not trained in critical care (e.g., a cardiologist or other non-critical care trained medicine specialist) could care for intubated and critically ill patients with collaborative or consultative oversight from a critical care cardiologist or other intensivist.

In a disaster scenario, staffing will change often based on physician readiness and availability of bed space and equipment. Pre-established triage protocols should be applied. The flexibility and experience of the critical care cardiologist is useful in such disaster scenarios.

Triage

In times of war and mass casualty, military physicians often use the North Atlantic Treaty Organization triage system:

• Immediate — immediate attention required to prevent death
• Delayed — intervention may be delayed for several hours to days
• Minimal — minor injuries but ambulatory
• Expectant — survival unlikely (or already deceased)

Unlike restrictions related to age or comorbidities, this system allocates scarce lifesaving interventions in a utilitarian framework to those patients who have the highest chance of survival. Cardiac-specific scoring systems such as GRACE and TIMI could be added to generalized critical care scores such as Sequential Organ Failure Assessment (SOFA) when evaluating patients with COVID-19.

In consultation with medical ethicists, several U.S. states have adopted guidelines for ventilator allocation. There are many possible types of allocation systems, and in one type of ethical framework, patients requiring ventilation are ranked in tiers based on illness acuity, the likelihood of survival to discharge and the possibility of long-term survival. Resources are then distributed by priority based on availability.

Institutions should consider developing triage protocols for other resource-intensive lifesaving procedures that may have limited utility and which also put health care workers at high risk of exposure, notably cardiopulmonary resuscitation and extracorporeal membrane oxygenation.

Redefining Preparedness

Another tenet of military medicine is that the health care workforce must be able to adapt quickly during a crisis. Complete preparedness to treat COVID-19 is likely impossible, given the knowledge deficits and constant changes in staffing and settings of care. Health care workers may feel as anxious about not knowing a policy—or being given different policies in different settings—as about the virus itself.

Empowering team members to offer suggestions to leadership and providing mental health support are important measures for maintaining a nimble workforce and health care response.

Telemedicine

In order to reduce viral exposure, the number of team members entering patient rooms should be limited whenever possible:

• CICU providers should use ICU flowsheets and remote hemodynamic monitoring as able. The physical examinations might be performed by a clinical team member entering the room for another purpose (e.g., to titrate medications)
• Mobile devices can facilitate video-based discussions with patients
• Electronic stethoscopes, where available, can be used to vet certain physical examination findings

As critical care cardiologists are reassigned to non-cardiac ICUs, the non–critical care cardiologists staffing CICUs will need access to telemedicine critical care consultations, both "curbside" and formal.

Regionally and nationally, cardiovascular professional societies should try to disseminate critical care cardiology expertise via telecommunications and videoconferences. Through their international contacts, these societies should translate their experience to advise physicians in low-resource countries as the pandemic advances.

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