Cardiologists join COVID-19 front line in converted cardiac ICUs
The Mount Sinai Health System in New York is one of many systems in the U.S. that has been adapting in the attempt to care for the influx of patients with known or suspected COVID-19. As elective surgeries are no longer being performed, the cardiac ICU at this hospital has been converted into a unit strictly dedicated to the care of patients with COVID-19.
Conversions such as this have not only challenged cardiologists, but have also reminded them of the importance of teamwork beyond their specialty to care for patients with COVID-19.
“The COVID-19 pandemic has challenged us as cardiologists on two fronts,” Matthew Tomey, MD, FACC, FSCAI, director of the cardiac intensive care unit at Mount Sinai Morningside, associate director of the cardiac intensive care unit at The Mount Sinai Hospital and assistant professor of medicine at Icahn School of Medicine at Mount Sinai, told Healio. “First, we are directly engaged in care for people who are infected, including partnering with our cardiothoracic surgical colleagues, to transform our cardiovascular intensive care unit into a COVID-19 Heart Team ICU. Second, we need to maintain our ability to deliver a high quality of care for people with cardiovascular disease, including those with cardiovascular emergencies. Surmounting this challenge has required the full involvement of our faculty and fellows, who have been nothing short of remarkable in their commitment to service and teamwork.”
Cardiac ICU conversion
The Mount Sinai Hospital’s cardiac ICU originally had 20 beds total, with 14 strictly dedicated for ICU and six variable-intensity, high-dependency beds. Since the conversion, the unit now has 27 ICU beds, as seven of the existing rooms were converted into rooms with two beds. As of March 31, most of the 110 ICU beds within the entire hospital have been converted or are in the process of being converted into negative pressure rooms to care for patients with COVID-19.
“Right now, we have over 100 COVID-19 ICU patients throughout the hospital,” Umesh K. Gidwani, MD, MS, FACC, FCCM, director of the cardiac ICU at Mount Sinai Hospital and associate professor of cardiology, pulmonary, critical care and sleep medicine at Icahn School of Medicine at Mount Sinai, told Healio. “The vast majority of them have severe respiratory failure and are intubated. Those who are not intubated are getting some form of noninvasive ventilation. This is a very sick group of people across the hospital. The hospital is well on its way to becoming an almost completely COVID hospital.”
The change from cardiac ICU to negative pressure rooms has been a result of the hospital’s leadership being proactive in conjunction with state and city departments. Negative pressure rooms require a dedicated machine, although its form has changed, the function of the room itself remains the same — to enable care of the critically ill. The change minimizes the amount of space for health care professionals to move in addition to making the room hotter and noisier.
“As the pandemic reaches its peak in NYC, we are doubling the number of beds in each ICU room,” Gidwani said. “Our front-line staff are the real heroes. They work under extraordinary conditions, always with the single focus on saving every life.”
The hospital has also implemented protocols to keep the cardiologists and other health care providers safe.
“We have policies and protocols in place to ensure that everybody is putting on proper protective equipment before we go in the room,” Robin Varghese, MD, associate professor in the department of cardiovascular surgery at Icahn School of Medicine at Mount Sinai and system director of cardiovascular critical care at The Mount Sinai Hospital, told Healio. “We have a buddy system. When you are in the room, people are monitoring you for needs that are required of the provider that is in the room. Before you exit the room and remove your [personal protective equipment], we’re monitoring and watching people remove their [personal protective equipment] so that we don’t have contamination.”
Cardiologists and other health care providers currently take droplet precautions, as opposed to airborne precautions, with regard to how they protect themselves when entering a room with a patient with COVID-19. With droplet precautions, health care providers wear an N95 mask with a face shield, an impermeable gown and gloves. Providers may also wear a cap to cover their hair and booties, as SARS-CoV-2, the novel coronavirus that causes COVID-19, may be active on animate and inanimate objects for a while.
Further precautions are taken when performing aerosolizing interventions such as intubating a patient. Instead of a regular surgical mask, cardiologists may wear another high-particle mask, or a personal protection device with its own air supply.
In the cardiac ICU, cardiac surgeons and fellows, including those focused on general cardiology, intervention and electrophysiology, are also helping these patients.
“The cardiologists who have signed up, we do basic critical care training as it pertains to COVID,” Gidwani said. “They are taking care of some of the critically ill patients with COVID and some of the backfill of noncritically ill COVID patients. There’s tremendous teamwork here and it’s been fantastic.”
One major concern for cardiologists right now is the cancellation of elective surgeries, including valve repairs and CABG.
“Those patients have now been put on hold because of this pandemic,” Varghese said. “Some of them may go from becoming elective patients to becoming urgent patients. That’s unfortunate because the outcomes are not as good when we do surgery on an urgent basis than when we do it on an elective basis.”
Another concern is the cardiac manifestations of COVID-19 and the effect in patients with CVD or risk factors including CAD, diabetes, hypertension, HF and atrial fibrillation. These issues also cross over to other aspects of life.
“We worry about our patients who are among those most at risk for severe complications of COVID-19 infection,” Tomey said. “We worry about our colleagues who daily enter harm’s way when they come to work to take care of the sick. We worry about our families and do all we can at the end of each day to prevent bringing infection home. We worry about our communities already witnessing the social and economic tolls and anticipating worse to come. We worry about our country.”
Critical role of cardiologists
Cardiologists outside of the ICUs also play a critical role in reducing the prevalence of COVID-19 and in treating it, sources told Healio.
“The most important thing is to ensure that we practice the guidelines set up by the state to try to decrease the prevalence of COVID, but at the same time keeping an eye on our own patients who are cardiac patients, following them up on a regular basis to ensure that their symptoms haven’t changed while they’re awaiting their procedure so we can catch them early if their symptoms are worsening and bring them in for surgery, which becomes urgent,” Varghese said. “The follow-up with our own patients is very important so they don’t fall through the cracks.”
Cardiologists can also play a role in “flattening the curve,” by continuing to follow up with patients via telemedicine portals.
“At this time, social distancing is perhaps the single most powerful weapon available to mitigate the spread of COVID-19,” Tomey said. “As cardiologists, we need to encourage our patients to stay at home as much as reasonably possible, yet this guidance must be balanced by a recognition that our patients come to see the cardiologist for a reason: We are helping them to prevent cardiovascular illness and manage chronic disease. As we all work to take on COVID-19, we cannot lose sight of these charges, lest the surge in COVID-19 be followed by a surge in acute cardiovascular disease.”
Although COVID-19 is a deadly disease, its management has brought the medical community closer.
“We are not just cardiologists, pulmonologists, gastroenterologists or any of those; we are all one group of crusaders ... to go out on the front lines and really lead this fight against this horrible, horrible disease,” Gidwani said.
Developments in the COVID-19 pandemic are quickly evolving. Information in this article was up to date at the time of publication. For the latest news on COVID-19 including case counts, information about the global public health response and emerging research, please visit the COVID-19 Resource Center on Healio. – by Darlene Dobkowski
For more information:
Umesh K. Gidwani, MD, MS, FACC, FCCM, can be reached at firstname.lastname@example.org; Twitter: @umesh_gidwani.
Matthew Tomey, MD, FACC, FSCAI, can be reached at email@example.com.
Robin Varghese, MD, can be reached at firstname.lastname@example.org.
Disclosures: Gidwani, Tomey and Varghese report no relevant financial disclosures.