How Has COVID-19 Affected Your EP Practice?

EP Lab Digest talks with some of our board members located across the U.S. about ongoing preparations and changes in regards to COVID-19:   

 

• Dr. Matthew Latacha, a cardiac electrophysiologist at Methodist Health System in Omaha, Nebraska

Andrea Robinson, MSN, ACNP, AACC at OhioHealth Heart and Vascular Physicians in Columbus, Ohio

• Dr. Suneet Mittal, cardiac electrophysiologist and Director of Electrophysiology, Associate Chief of Cardiology, Medical Director of Snyder AF Center, and Director of Cardiac Research at Valley Health System, which is located in Ridgewood, New Jersey

• Dr. James Kneller, a cardiac electrophysiologist at Astria Heart Institute in Yakima, Washington

Chris Atherton, RN, BSN, MPA, Regional Director of Cardiovascular Services at LaPorte Hospital in LaPorte, Indiana, Porter Regional Hospital in Valparaiso, Indiana, and Starke Hospital in Knox, Indiana.

 

(Editor’s note: these interviews were done March 15 and 16, 2020).

 

How have day-to-day aspects of your practice changed since the World Health Organization (WHO) named the COVID-19 a pandemic this past week?

Latacha: Our hospital had the first documented case in Nebraska, so many of the changes implemented were in response to that rather than the WHO designating COVID-19 a pandemic. All physicians and staff that have travelled outside the country or to high-risk states must call in prior to returning to work for triage. Vendors are being restricted from the hospital unless they are directly involved in patient care. Patients are given a hotline phone number to call if they have respiratory symptoms rather than coming to the ER/Clinic, and testing for COVID-19 is done based on CDC guidelines. All hospital-sponsored employee/provider travel has been suspended, and all non-essential non-patient care meeting has been cancelled. The travel restrictions had a unique impact on our EP lab as were planning on implanting our first WiSE CRT (EBR Systems, Inc.) leadless CRT devices this week. The clinical specialist working with us was planning on covering cases in Ireland prior to ours and had to cancel his trip abroad.

Robinson: This is changing on a daily and even hourly basis. Our team has adhered to the Ohio Department of Health regulations and recommendations for social distancing including the implementation of regulating vendor access, restrictions for visitors in the hospital, increased use of virtual visits, and cancelling non-essential visits. Our leadership team is presently evaluating the prioritization and cancellation of non-urgent cardiac procedures. Our atrial fibrillation (AF) clinic staff continues to triage patients over the phone, identifying patients with acute symptomatic episodes of AF, and will arrange in-person evaluation only if deemed absolutely necessary. We are using our previously established pathways to then arrange same-day outpatient procedures, such as TEEs and cardioversions, allowing them to bypass the Emergency Department (ED) and/or inpatient hospitalization. I think it will be imperative that other areas develop similar protocols to help keep non-emergent patients out of the ED. A lot of our patients use mobile devices, such as Kardia (AliveCor) and the Apple Watch, and it will be interesting to see the value in using these tools, along with virtual visits, to help patients self-manage at home in times when acute resources are limited.

Mittal: Even before the WHO named COVID-19 as a pandemic, the reports coming out of Italy made it abundantly clear that we were on the precipice of a global crisis. Essentially, all conversations at home and work with friends, family, and coworkers began to center on what we must do personally and professionally to survive the COVID pandemic. This means we are all trying to balance our own personal safety and the safety of our patients with the urgent medical needs of our patients.

Kneller: We acknowledge this is a dynamic situation and our response may change at any time. To date, we continue clinic operations and procedures with little change to our routine. We are highly aware that our patients are elderly and frail, and represent a high-risk cohort vulnerable to COVID-19. Our clinic doors remain open. Some patients have asked to reschedule, most have not. Some staff choose to wear face masks, but most do not. Some patients come wearing face masks, but most do not. We are particularly careful with hand sanitation, and perform this before and after physical contact with patients, as well as with wiping down stethoscopes. We encourage patients to use our hand sanitizer as they leave the office and caution them not to touch their faces.

Atherton: My facilities have been prepping for the influx of patients. As with any healthcare facility, we constantly drill for emergencies and disasters, but rarely have to respond. We are taking that training and planning for the "what ifs" that may occur with this pandemic. As of this moment, there is only one confirmed case in our area (at one of my facilities). There are several "potentials," but no other confirmations. However, we are anticipating increased numbers. Our management teams are frequently assessing the situation to see if we need to further change our processes. We have not yet cancelled outpatient testing or procedures, but that is a potential and will be assessed often. Cardiac rehab classes have been cancelled because of the vulnerable population aspect and lack of social distancing in the exercise areas. Any public education classes or gatherings have been cancelled. Access is limited to the facilities. Anyone entering the building will be screened (questions/temperature) — at this time, we will start limiting visitors Tuesday morning to all areas except Labor and Delivery, Pediatrics, and essential family members in Surgery. This includes not only patients and visitors, but also the medical and clinical colleagues. Vendors are allowed access, but only when they are supporting cases. All other vendor-related activities are conducted by phone/webcast. We will be setting up a mobile unit close to the hospital ER for triage of symptomatic patients. We are also evaluating our supply levels of masks, gowns, and gloves, and implementing processes that will assure these items are available when needed. Fortunately, in EP, remote monitoring is available to us for a large majority of our patients, so those patients have been asked to stay at home as long as they are stable, with enough medications, etc. The only device patients coming into the clinic are those with a battery life less than 1 year and those that have received multiple therapies. Clinic staff is calling all patients with routine follow-ups and confirming that they are alright to reschedule at a future date. This leaves room for the patients that truly need to be seen as well as new consultations.

 

Do you agree with the cancellations and postponing of cardiology conferences as a result of the COVID-19 pandemic? 

Latacha: I do agree with cancelling these large meetings. With so many people from all over the world gathering in such close proximity, I think it would provide a perfect breeding ground for infection. Considering how infectious this virus is, it could prove catastrophic. 

Robinson: To be honest, I was a little disappointed at first, but now realize that it was absolutely necessary to make these decisions in order to get ahead of containment and for mitigation of virus transmission, as well as to protect exposure opportunities that may have resulted in mandatory quarantine for essential healthcare providers. I appreciate the quick action of some of the conferences to now offer a virtual experience to allow the educational formats to continue. 

Mittal: Yes, it is important that all conferences scheduled for the upcoming few weeks be cancelled. As Biogen taught us, a large number of people can get infected from a single source. What is still unclear is when it will be safe to resume these conferences. As an example, the Heart Rhythm Society’s (HRS) annual sessions are almost 7 weeks away, but the question is whether they should be cancelled now, whether we should wait a bit longer to develop a more accurate assessment, be converted to a virtual meeting, etc. Under the leadership of Pat Blake, CEO of HRS, and Andrea Russo, President of HRS, these difficult questions are currently being addressed. 

Kneller: Yes, I agree with the cancellations. This is a time for an overabundance of caution. It would be devastating for COVID-19 to sweep through one of our major national conferences, leaving the nation without a large number of its cardiologists. It’s more prudent to cancel. As we sometimes say, "first do no harm." 

Atherton: Yes, I agree with the cancellations. I always attend the Heart Rhythm Society’s annual sessions, but due to the current climate, I have already cancelled my travel and registration because of my responsibilities here at home.

 

What changes are you seeing in the city(ies) where you practice and live? 

Latacha: The most significant change I have seen here in Omaha is at the grocery store. The stores have been packed with people. Staples such as bread, milk, and of course, toilet paper are selling out as quickly as they are stocked. There are also signs on local business asking people to kindly not enter if they feel ill. Schools are closed and activities have been cancelled. My daughters were to have a gymnastics meet over the weekend, but it was cancelled. My family was excited to see Dear Evan Hansen next week, but that also was cancelled.

Robinson: Ohio took an aggressive approach implementing the nation’s most restrictive plan on cancelling not only large gatherings but also both K-12 schools and university classes, all prior to even having a handful of confirmed cases. This was seen as an aggressive move by many last week, but again, just a few days later, people are realizing that it is absolutely necessary to be proactive. As of March 15th, all restaurants and bars have also been instructed to close for sit-down dining.

Mittal: I live in Manhattan. I am waiting for a complete lockdown of the city — no buses and trains, no bars and restaurants, no schools, etc. We will need to adopt the European model — keep only grocery stores, pharmacies, and gas stations open for now. 

Kneller: I see people are practicing social isolation and electing to say home when possible. Restaurants and gyms are much emptier than usual. Supplies at grocery stores and drugstores are lower than usual, but shelves aren't empty. 

Atherton: Many social gatherings have been cancelled, and public/municipal buildings and schools have been closed. As of March 16th at 10 am, our state has also closed all bars and restaurants. Drive-up is still allowed. Hours have been decreased at many 24-hour retail stores to allow additional time for restocking and cleaning/decontamination. There has been increased awareness of social media as the local healthcare facilities have been attempting to provide confirmed information and squelch rumors. I'm seeing varying behaviors in the community. There is the group that is helping those in need — the elderly who are afraid to get out to run errands, the healthcare workers with no one to care for their children. Then there is the group of non-believers who feel this is all political hype and there really isn't a problem, and are ignoring all alerts and precautionary measures. I'm hoping that kindness will overcome! As I'm telling my staff — preparedness is not panic!

 

What precautions are you taking as a result of the COVID-19 pandemic? 

Latacha: I am of course taking standard precautions, including frequent handwashing and making sure I change clothes when I get home from the hospital. I was hoping to get my family outside over the weekend and away from indoor activities and businesses, but Omaha was hit with a late March snowstorm this weekend. I am hopeful warm weather will follow quickly, and that getting outside will slow the spread of the virus.

Robinson: I have cancelled all of my travel plans and am adhering to the recommendations for social distancing by avoiding large gatherings. This pandemic starts to hit home when you have to make tough decisions to miss things such as a funeral or a family gathering, but I think we all need to do our part, particularly as healthcare professionals, and heed these recommendations. I think most of us would agree that we would rather look back at this time and have it viewed as an overreaction to take such precautions than one in which we are regretful that we did not.

Mittal: My biggest concern is my family. How do I go to work (where my risk of infection is relatively high) and then not infect my family upon my return home? In China, doctors were often separated from their families to prevent this possibility. I doubt this would be possible in the United States. Thus, I am resorting to common sense things. For example, when I arrive at the hospital, I immediately change into scrubs and hospital-only shoes (no lab coat or stethoscope). Patient contact in the office and hospital is being limited to patients who require emergent care; elective office visits and procedures have already been cancelled. When leaving the hospital, I change back into my street clothes, immediately put my clothes into the washer when I get home, and change again. During the day, I also use gloves, wipe down surfaces when necessary, and wash my hands frequently.

Kneller: I suspect I have already been infected with COVID-19, although I haven't been tested. Just before this went viral in the media, I experienced a strange flu that appears to be classic for a mild case of COVID-19. In addition to the protective measures that are circulating, having a strong immune system should help ensure that we only experience a more mild case of COVID-19 if infected. While there are no guarantees and this may be voodoo, I'm gargling with salt water twice daily even without a sore throat, swallowing 1-2 blended lemons twice daily, supplementing with plenty of garlic and turmeric, and adding apple cider vinegar to drinking water. [Editor's Note: On March 17th, 2020, we asked Dr. Kneller to further clarify. His response is as follows: "I wonder if the flu-like symptoms I experienced several months back represented a mild case of coronarvirus. Even now, we're learning that most viral syndromes are not due to this particular agent. Must we quarantine forever? Transmission risk is thought not to extend beyond 35 days post infection. Maintaining a strong immune system will help to ensure that any case of coronavirus is mild. While there are no guarantees, I am gargling with salt water twice daily even without a sore throat, swallowing 1-2 blended lemons twice daily, supplementing with plenty of garlic and turmeric, and drinking water with added apple cider vinegar."]

Atherton: I have a plan in case I'm needed at the hospitals for a long period of time. My household is prepared and all will be cared for. I am also delaying travel and visitation with my 88-year-old mother in another part of the state. I have educated and convinced her that this situation should be taken seriously, and she is following all the precautions that she should follow as a member of a vulnerable population. I also will forego that trip to Mexico that I had planned as a last-minute getaway.

 

Stay tuned for more COVID-19 coverage in EP Lab Digest!