key: cord-347790-7h25gzzl
authors: Calligaro, Keith D.; Dougherty, Matthew J.; Maloni, Krystal; Vani, Kunal; Troutman, Douglas A.
title: COVID (Co-Operative Vascular Intervention Disease) Team of Greater Philadelphia
date: 2020-06-17
journal: J Vasc Surg
DOI: 10.1016/j.jvs.2020.05.058
sha: 
doc_id: 347790
cord_uid: 7h25gzzl

We established the COVID (Co-OperativeVascularInterventionDisease) Team of Greater Philadelphia because national guidelines may not apply to different geographic areas of the United States due to varying penetrance of the virus. On April 10, 2020, a ten-question survey regarding issues and strategies dealing with COVID-19 was e-mailed to 58 VSs in the Greater Philadelphia area. Fifty-four VSs in 18 surgical groups covering 28 hospitals responded. All groups accepted transfers due to continued ICU bed availability. Thirteen groups were asked to “re-deploy” if the need arose to function outside of the usual duties of a VS. None imposed age restrictions regarding older VSs continuing clinical hospital work. The majority restricted non-invasive vascular laboratory studies to those studies where findings might mandate intervention within 2-3 weeks, restricted dialysis access operations to urgent revisions of arteriovenous fistulas (AVFs)/ grafts that were failing or had ulcerations, converted from in-person to telemedicine clinic interactions, and experienced moderate/severe anxiety or fear about personal COVID-19 exposure in the hospital. The majority of VSs in the Philadelphia area have dramatically adjusted their clinical practices before the COVID-19 crisis reached peak levels experienced in other metropolitan areas.

COVID-19, also called coronavirus disease, has spread rapidly through the world and the 16 United States with high infection and mortality rates. Recently the Society for Vascular Surgery 17 (SVS) made a concerted national effort to better educate its members regarding the disease. We 18

Philadelphia because 1) we believe vascular surgeons (VSs) should be the driving force in 20 decisions concerning vascular disease during this crisis and 2) national guidelines may not apply 21 to different geographic areas of the United States due to varying penetrance of the virus. The 22 function of the team is to gather opinions and strategies of VSs in the Philadelphia area to 1 address the impact of COVID-19. 2 3 METHODS 4

On April 10, 2020, a ten-question survey was e-mailed to 58 VSs in the Greater 5 Philadelphia area regarding issues and strategies for dealing with the coronavirus. Response time 6 was limited to three days so results could be analyzed at a specific point in time and re-examined 7 in the future as virus penetrance changes. Responses were classified according to individual VSs 8 or VS groups depending on the question. 9

Surgeons were identified by contacting the Chief of each vascular section or division and 10 asking for email contacts for each member of their group. The Greater Philadelphia Area was 11 loosely defined as those medical centers in the city boundaries of Philadelphia and inclusion of 12 medical centers within approximately one-hour drive of the city. This area included northeastern, 13 eastern and southeastern Pennsylvania and southern New Jersey. Delaware (TABLE I: six questions) accepted transfers at the time of the survey 3 due to continued ICU bed availability. Thirteen groups were asked to "re-deploy" if the need 4 arose to function outside of the usual duties of a VS. Seven groups needed special permission 5 from the Chairman of Surgery or other supervisor to schedule urgent or emergent surgery that 6 was not required prior to the pandemic. Only one group (private practice) had an office-based 7 laboratory (OBL) where endovascular arterial procedures were performed. Due to lack of a large 8 sample size, willingness to allow other VSs to perform procedures at these non-hospital-based 9 facilities could not be determined. Of the 15 university/hospital-employed groups, none 10 expected > 50% salary reduction whereas all 3 private practice groups had already experienced 11 this drastic decrease in income. None of the 18 groups restricted older VSs from performing 12 clinical duties in the hospital. 13

Among the 54 VSs who responded to the survey (TABLE II: Twenty-percent (11) continued to perform routine follow-up and diagnostic NIVL studies 21 (essentially no change) and 2% (1) closed their laboratory. Sixty-seven percent (36) restricted 22 dialysis access operations to urgent revisions of arteriovenous fistulas (AVFs) or grafts that were 23 failing or for impending hemorrhage due to skin ulcerations overlying the conduit. Seventy-eight 1 percent (42) converted from in-person office visits to telemedicine clinic interactions. Of the 39 2 VSs at teaching hospitals, all had transitioned to digital platforms for educational conferences. 

Philadelphia for two reasons. First, we believed VSs should be the driving force in decisions 15 regarding vascular issues during this crisis. VSs best understand the complex decision-making 16 regarding emergent, urgent, and non-elective interventions, and the type of interventions, most 17 appropriate to treat vascular disease. For example, VSs are best suited to determine timing of 18 elective first-time AVFs and grafts if a patient already has a functioning tunneled dialysis 19 catheter, although a discussion with the patient's nephrologist is appropriate. VSs can best 20 determine the timing to repair an asymptomatic AAA during the COVID-19 crisis based on the 21 patients' risk factors, aneurysm diameter and morphology, and potential need for an ICU bed. 22

VSs possess the judgement necessary to determine whether endovascular procedures might be 23

preferable to standard open surgeries in the context of the pandemic. Second, national guidelines 1 proposed by the SVS and other societies may not be appropriate for different geographic areas of 2 the United States due to varying penetrance of the virus and clinical resource saturation. At the 3 time of the survey in mid-April 2020, 60% (248/410) of ICU beds in the University of 4 Pennsylvania Health System (seven hospitals) were occupied with COVID -19 patients. This 5 percentage was significantly lower than experienced in other major metropolitan areas such as 6

New York City and Seattle, WA. The impact of the virus at local and regional levels might affect 7 attitudes and strategies of VSs practicing in those areas more than national data. 8

We wished to examine the availability of ICU beds in hospitals in the Philadelphia area at 9 varying times of the Coronavirus crisis. If certain hospitals were overwhelmed by the virus and 10 could not accept transfers such as ruptured AAAs or other vascular patients requiring an ICU bed, 11 other hospitals might have available ICU beds and be able to accept those patients. By 12 establishing lines of communication among VS groups, the hospitals accepting transfers could be 13 made known to the vascular community. Due to the relatively low penetrance of the virus at the 14 time of the survey, all 18 VS groups continued to accept emergency transfers because of 15 continued availability of ICU beds. We did not want to wait until our area became so 16 overwhelmed that our collective response was too little too late. 17

Hospital administrators asked the majority (13) of VS groups to "re-deploy" to perform 18 duties other than the usual functions of a VS if the need arose due to an overwhelming number of 19 COVID-19 patients. These duties included placing central venous or peripheral arterial lines and 20 caring for patients in the Emergency Department or ICU. Hospital administrators asked 11 of 21 the 13 groups to function as "first-line" responders, meaning VSs were as likely to be called as 22 general surgeons or other specialty surgeons, to help deal with the crisis. Hospital administrators 23 asked two of the 13 groups to serve as "back-up" responders only if medical and surgical 1 residents, other attending surgeons, anesthesiologists, and ICU attendings were unavailable. 2 Several VSs expressed the concern that if they were "first-line" responders and became infected 3 with the virus, they might not otherwise be available to treat true vascular emergencies. 4

Eleven of the 18 VS groups were empowered to schedule urgent or emergent vascular 5 surgery without permission by the Chairman of Surgery or other supervisors. The argument to 6 allow VSs to schedule cases without oversight is because they understand when urgent 7 intervention is indicated, such as for lower extremity rest pain or tissue loss, failing lower 8 extremity bypass, or symptomatic carotid disease. However, the counter-argument of having a 9

Chairman of Surgery oversee these decisions may be reasonable if there is resource saturation 10 such that triage is necessary. Our survey showed that a clear majority of VSs did not need this 11 type of permission. Our data would support those VSs needing permission to approach their 12 Chairman and inform that most medical centers do not have this requirement. 13 14 Only one (private practice) of the 18 groups operated an office-based laboratory (OBL) 15 that performed arterial endovascular interventions in a non-hospital-based facility. Therefore, we 16 could not gather reliable data concerning willingness of VSs at OBLs to allow other 17 interventionalists to perform procedures at their facility. 18

We questioned the financial impact of the virus on VS practices. Of the 15 19 university/hospital-employed groups, none expected more than a 50% salary reduction, whereas 20 all 3 private practice groups experienced this income reduction by the time of the survey. This 21 reduction was largely due to cancellation of all elective surgical and endovascular interventions. 22

The increasing penetration of the hospital-employed model of practice will likely accelerate as a 1 result of the pandemic. 2

None of the 18 groups imposed age restrictions on older VSs performing hospital-based 3 duties. Although increased age has clearly been shown to be a significant risk factor in acquiring 4 the virus and experiencing worse symptoms with worse outcomes than younger members of the 5 population, none of the groups adopted these precautions. This attitude "Do as I say, not as I do" 6 could prove harmful to older VSs, as significant death rates have already been documented 7 among health-care providers. The mantra "stay at home!" does not seem to apply to older VSs 8 and may not apply to older health-care providers either. 9

Of the 54 VSs who answered the survey, elective repair of AAA in a good-risk 75 year-10 old patient was recommended at a median diameter of 6.0 cm (avg = 6.35, range = 5.0 -8.0) if 11 EVAR could be performed compared to 6.5 cm (avg = 6.53, range = 5. Sixty-seven percent (36/54) restricted dialysis access operations to urgent revisions of 16 arteriovenous fistulas (AVFs) or grafts that were failing or for impending rupture due to 17 ulcerations overlying the conduit. Some VSs continued to place new AVFs or grafts in patients 18 with functioning tunneled dialysis catheters [(24% (13) ) and in patients not yet on dialysis [9% 19 (5) ]. There are two concerns with performing purely elective AVFs and grafts during this 20 pandemic. Patients with chronic renal failure are immunocompromised and therefore at higher 21 risk of viral infection coming into the hospital for surgery and being exposed to carriers. Health-care providers, including VSs, are also at greater risk of contracting the infection 1 by exposing themselves to a population that has a higher prevalence of the disease. 2 Seventy-eight percent (42/54) of VSs had converted from in-person to telemedicine clinic 3 interactions. Avoiding direct patient contact in the office-setting is advantageous for patients, 4 office staff, non-invasive vascular laboratory technologists, and VSs. Even though the penetrance 5 of COVID-19 in the greater Philadelphia area was lower than in some other metropolitan areas, 6 the majority of VSs quickly adopted this telemedicine strategy. The disadvantage of this 7 approach is the inability to perform a physical examination, and in some cases obtain a NIVL 8 study, that may lead to less accurate diagnoses or need for more urgent interventions. It has been 9 noted that there has been an increase in non-COVID-19 cardiovascular mortality in the last two 10 months which may reflect the risk of delayed care 2 . 11

Thirty-five percent (14/39) of VSs at training programs believed the number of weekly 12 conferences increased since the onset of the crisis, 21% (8/39) believed the number had 13 decreased, and 44% (17/39) believed the number remained the same. Academic VSs realized that 14 continuing to hold teaching conferences seated together in one room was hazardous and quickly 15 converted to digital platforms as a means to continue academic conferences. The fact that 16 teaching conferences did not dramatically decrease during the beginning of the crisis is testament 17 to the flexibility of VSs addressing this problem. 18

Lastly, 63% (34/54) of VSs experienced moderate or severe anxiety or fear regarding 19 personal COVID-19 exposure in the hospital. VSs likely have a high rate of unease and 20 apprehension not only because of concern regarding themselves but also for their family. VSs 21 and other health-care providers should acknowledge the emotional impact of dealing with these 22 critically ill patients and understand part of their concern is knowing they might become infected 1 with COVID-19 the next time they enter the hospital. 2 3 CONCLUSION 4

The majority of VSs in the Philadelphia area have dramatically adjusted their clinical 5 practices before the COVID-19 crisis reached peak levels experienced in other metropolitan 6 areas. The survey revealed only a modest shift in VSs' attitudes regarding recommendations for 7 elective repair of AAAs. Older VSs have not adopted precautionary "stay-at-home" 8 recommendations urged for elderly members of the general population. We will monitor 9 evolving practice strategies as virus penetrance changes. 10 

Co-Operative Vascular Intervention Disease) Team of Greater Philadelphia -12

Abington Hospital: Danielle Pineda

Capital Health System

Crozer Hospital: Mark 15

Einstein Hospital: Rashad Choudry; Evan Deutsche; Nadia 16 Awad

COVID-19 Guidelines for Triage from Vascular Patients