key: cord-344104-592r71l1
authors: Ardati, Amer K.; Mena Lora, Alfredo J.
title: Be Prepared
date: 2020-03-17
journal: Circ Cardiovasc Qual Outcomes
DOI: 10.1161/circoutcomes.120.006661
sha: 
doc_id: 344104
cord_uid: 592r71l1

nan

nation can contribute to a 15% to 45% reduction in acute coronary events. 5 The development of a vaccine for COVID-19 is of significant interest and a research priority. As we wait for this vaccine, developing strategies to reduce the likelihood of infection with COV-ID-19 will be critical for healthcare systems to protect vulnerable populations like cardiac patients during this surge of cases.

Patients with congestive heart failure, acute coronary syndrome, and arrhythmia account for a substantial proportion of the inpatient census in the United States. The American College of Chest Physicians Task Force on Mass Critical Care recommends that during a crisis that medically fragile patients may need to be supported in the ambulatory setting to conserve hospital-based resources and to limit nosocomial spread. 6 Addressing length of stay and reducing admissions for select cardiac patients could significantly improve access to acute care resources and help protect at-risk individuals who might be exposed during an inpatient stay. Of course, this may not be easy, but it could be effective. Models for the outpatient management of acutely decompensated heart failure have shown that ambulatory infusion of furosemide can reduce all-cause hospitalization at 30 days. 7 Successful outpatient management of heart failure requires an investment in home-based healthcare services including visiting nurses, 24-hour telephone access for advice and protocols for the management of electrolytes, and changes in renal function.

Chest pain accounts for millions of emergency department (ED) encounters annually and frequently results in admission. Implementation of accelerated diagnostic protocols that safely triage low-risk chest pain patients to early discharge have been shown to reduce hospitalizations without the necessity of resource intense specialist consultation, stress testing, or angiography. 8 Observational data of STEMI and non-ST-segment-elevation acute coronary syndrome admissions suggest that extending length of stay beyond 48 hours is not associated with a reduction in postdischarge mortality. 9,10 Regional variations in length of stay suggest a substantial opportunity to systematically reduce resource utilization in acute coronary syndrome patients nationwide. Atrial fibrillation accounts for a majority of arrythmia presentations in the ED setting and often results in admission despite potential outpatient management strategies. A process to identify and triage patients to early ED discharge reduced admissions without a concomitant increase in repeat ED visits. 11 One tool with immense potential to continue care while limiting exposure is right in our pocket. Smartphones have the ability to expand our access to vulnerable cardiac patients while decreasing on-site healthcare utilization and the possibility of infection. Mobile health has been used during infectious diseases outbreaks and can improve communication between patients and pro-viders, triage the need for inpatient care or acute visits, and monitor patients while they are in their communities. 12 Telemedicine can help leverage our resources in an effective manner and may align with patient behaviors during outbreaks. Telemedicine has also been used to expedite consultations for myocardial infarctions in the ED. 13 This may help improve ED throughput during infectious disease outbreaks. A resilient healthcare system that leverages mobile health to reduce acute care needs protects vulnerable patients from possible exposures, while adapting to a more enhanced communitybased network of care is within our grasp.

The Queen Mary Hospital STEMI report identifies 2 areas of concern for patients requiring acute cardiac care: (1) delays in presentation and (2) delays in treatment. The causes for late presentation for STEMI are likely multifactorial and may include patient fear of contracting an infection from the healthcare system or by limited emergency medical services due to sick staff or systemic overload. Public health departments, emergency medical services, and hospitals will need to maintain the highest standards of infection control to earn community trust. Additionally, mass public education efforts will need to assure patients that healthcare services remain operational and safe for use. Internal process delays need to be anticipated especially since stresses on the system are likely to affect critical supply chains for essential medicines and equipment. Cardiac centers should consider the need to defer elective procedures and to carefully monitor employee health and availability for duty. Crucial conversations will need to be had with staff to ensure their ability to provide services and step in for sick colleagues at a moment's notice. Care providers may be subject to travel restrictions and cancelation of elective leave. Employers and community leaders will need to support first responders and healthcare workers who may be under quarantine. In the event of school and day-care closures, child-care alternatives will need to be identified for critical staff. Regional STEMI systems should develop reliable alternatives to default receiving centers that go offline due to lack of capacity. Cardiologists, ED staff, and intensive care nurses accustomed to the 24/7 availability of primary percutaneous coronary intervention for STEMI should refamiliarize themselves with the use of thrombolytic therapy.

The scouting motto "Be Prepared" has never been more prescient. Strategies to maximize acute care resources, maintain access to services, and limit nosocomial spread will rely on careful planning, teamwork, and investment in education and training. Our ability to adapt to the demands of a global pandemic will be determined by our willingness to develop resilient systems of care that are lean and protective of vulnerable patients. This is as true for cardiac specialists as it is for all of the house of medicine.

The time to act is now. Will we Be Prepared?

Impact of coronavirus disease 2019(CO-VID-19) outbreak on ST-segment-elevation myocardial infarction care in Hong Kong, China

Transmission characteristics of MERS and SARS in the healthcare setting: a comparative study

Air, surface environmental, and personal protective equipment contamination by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) from a symptomatic patient

Outbreak of middle east respiratory syndrome-coronavirus causes high fatality after cardiac operations

Influenza vaccine as a coronary intervention for prevention of myocardial infarction

Introduction and executive summary

Intravenous diuretic therapy for the management of heart failure and volume overload in a multidisciplinary outpatient unit

Safely identifying emergency department patients with acute chest pain for early discharge

Discharge timing and outcomes after uncomplicated non-ST-segment elevation acute myocardial infarction

Hospital length of stay and clinical outcomes in older STEMI patients after primary PCI: a report from the National Cardiovascular Data Registry

Impact of an emergency department observation unit management algorithm for atrial fibrillation

Taking connected mobile-health diagnostics of infectious diseases to the field

Emergency department telemedicine consults are associated with faster time-to-electrocardiogram and time-to-fibrinolysis for myocardial infarction patients