- 1.As cardiac surgical programs begin to ramp-up, care must be taken to instill confidence among patients and health care providers that their safety remains a priority. To this effect, cardiac surgical programs must continue to respect and enforce the precautions and guidelines that have been put in place by their respective institutions and by the public health authorities at all levels of government to manage and contain COVID-19, limit the risk of nosocomial infection, ensure patient safety, and protect health care personnel. These include, but are not limited to, hand hygiene, the use of personal protective equipment, the creation of COVID-19-free units, social distancing, self-isolation, and travel restrictions.
- 2.Comprehensive screening procedures to identify patients at increased risk for COVID-19 should continue to be respected and enforced as cardiac surgical programs begin to ramp-up. These include the following:
- A.Standardized clinical screening questionnaires before admission to the hospital, ideally via telephone, focusing on the clinical history of patients and their cohabitants (including viral-like symptoms compatible with COVID-19).
- B.Initial admission to an isolation room within the hospital where additional screening and/or testing is performed as needed.
- C.When admitted to the ward, daily clinical screening of patients to elicit signs and symptoms of viral illness and identify patients who might have been in the incubation or presymptomatic phase of infection on admission.
- 3.The validity of COVID-19 testing has been the source of significant debate, and there is presently no test available that can reliably rule out COVID-19, particularly in the absence of symptoms. Despite this, nasopharyngeal swab testing for COVID-19, including rapid molecular tests, are being performed routinely across Canada with many centres having the ability to obtain test results within hours. To this effect, the CSCS provides the following guidance to COVID-19 test interpretation in the ramp-up phase on the basis of best available evidence at time of writing.
- A.Nasopharyngeal swab testing for COVID-19 has a diminished sensitivity with false negative rates between 26% and 100%.2Clinical sensitivity is reduced because of poor-quality specimen collection,
Kucirka LM, Lauer SA, Laeyendecker O, Boon D, Lessler J. Variation in false-negative rate of reverse transcriptase polymerase chain reaction-based SARS-CoV-2 tests by time since exposure [e-pub ahead of print]. Ann Intern Med https://doi.org/10.7326/M20-1495, accessed June 6, 2020.3timing of collection as it relates to an exposure or the onset of symptoms (higher false negative rates have been noted in the asymptomatic or preclinical period),2or the presence of more advanced disease at which time the virus might be more localized to the lung as opposed to the nasopharynx.
Kucirka LM, Lauer SA, Laeyendecker O, Boon D, Lessler J. Variation in false-negative rate of reverse transcriptase polymerase chain reaction-based SARS-CoV-2 tests by time since exposure [e-pub ahead of print]. Ann Intern Med https://doi.org/10.7326/M20-1495, accessed June 6, 2020.
- B.Patients with negative molecular testing in whom the clinical suspicion of COVID-19 infection remains high should stay in isolation per the guidance of institutional infection control practitioners. Additional investigative tools that might be considered to help confirm the diagnosis of COVID-19 in the appropriate setting include repeating nasopharyngeal specimen collection, endotracheal aspirates for molecular testing, and/or computed tomography imaging.
- C.As testing for serologic immunity becomes more readily available, patients should be screened for antibodies, if possible, to assess for immunity secondary to previous natural infection.
- 4.Given the protracted nature of this pandemic, cardiac surgery programs must continue to proactively manage every patient on their wait list despite reexpansion of case volumes. Aspects of this management might include, but are not limited to, the following:
- A.All wait list patients must be contacted via telephone, teleconference, or videoconference at least every 2-4 weeks so that their clinical status might be assessed and reassessed on a regular basis.
- B.Each centre must have a clear mechanism in place to formally assess patients with deteriorating symptoms, unstable clinical characteristics, or high-risk anatomy and to order any noninvasive tests as needed.
- C.Peer review with other members of the heart team is highly encouraged for complex patients.
- 5.Efforts to ramp-up must be done within the local context of the pandemic, as a careful balance must be struck between the clinical needs of patients awaiting cardiac surgery, risk of nosocomial infection, and the overall resource requirements of the health care system. Any intention to escalate or reescalate cardiac surgical volumes requires regular communication between members of the heart team, intensive care units, hospital administration, provincial department of health, and/or public health officials. This communication should occur frequently, with consideration given to daily meetings if feasible. Ideally, a provincial dashboard that provides a real-time trend of resource utilization (eg, hospital admissions, intensive care unit admissions, ventilator use, personal protective equipment availability) should be created to facilitate forecasting, communication, and rapid decision-making.
- 6.When ramping-up, the CSCS proposes a phased implementation approach that is on the basis of what phase your hospital is at with respect to its reexpansion or increase in hospital capacity (Fig. 2). We have defined increase in hospital capacity as the percentage of resources previously allocated to the COVID-19 pandemic that have now been reallocated to the management of non-COVID-19 patients. Phase 1 reflects a 0-25% increase in capacity, phase 2 a 25%-50% increase, and phase 3 a 50%-100% increase, or a return to normal or near-normal institutional activity. Depending on which phase of reexpansion your institution is currently in, your cardiac surgical program will have a defined approach to which elective cases will be given priority during the ramp-up (Fig. 2). As far as the number of electives cases by which your program might ramp-up are concerned, this will depend upon the urgent case demands at your institution and your overall institutional capacity. It should be noted that the recently published International Study of Comparative Health Effectiveness With Medical and Invasive Approaches (ISCHEMIA) trial5supports the role of optimal medical therapy as first-line therapy in appropriately selected patients with stable coronary artery disease, thus allowing for the deferral of surgical revascularization in this patient population. It should also be noted that urgent case demands might increase as the result of having reduced or eliminated elective cardiac care services during the COVID-19 pandemic at your institution, which, in turn, could potentially lead to patients presenting with more unstable symptoms or complications of missed or delayed treatment of myocardial infarction.
- 7.Cardiac surgical programs must be prepared to immediately stop ramping-up or to even deescalate cardiac surgical volumes should there be a resurgence in the number of COVID-19 cases or COVID-19-related admissions and deaths.
- Cardiac surgery in Canada during the COVID-19 pandemic: a guidance statement from the Canadian Society of Cardiac Surgeons.Can J of Cardiol. 2020; 36: 952-955
Cheng MP, Papenburg J, Desjardinset M, et al. Diagnostic testing for severe acute respiratory syndrome-related coronavirus-2. Ann Intern Med. 2020;172:726-34.
Guo L, Ren L, Yang S, et al. Profiling early humoral response to diagnose novel coronavirus disease (COVID-19) [e-pub ahead of print]. Clin Infect Dis https://doi.org/10.1093/cid/ciaa310, accessed June 6, 2020.
- Initial invasive or conservative strategy for stable coronary disease.N Engl J Med. 2020; 382: 1395-1407
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