Abstract: Objectives. Coronavirus 2019 (COVID-19) significantly impacted cardiac care delivery in a manner that has not been previously experienced in the United States. Attention and resources have focused on physicians, patients, and healthcare systems with little information regarding the effects on nurses and technologists in the cardiac catheterization laboratory (CCL). Methods. A national, online survey was conducted for nurses and technologists working in the CCL in the United States. The survey was self administered, anonymous, and included 45 questions assessing baseline demographics, logistical changes to workflow and responsibilities, staff preparedness, and mental health. Results. A total of 450 respondents completed the survey, including 283 nurses (63%) and 167 technologists (37%). A total of 349 (78%) were female and mean age range was 41-50 years. Responses indicated that 68% were the primary financial provider for their families, and 74% experienced >75% decrease in case volume despite a low inpatient COVID-19 census (54% of respondents with census <10%). There were high rates of direct care for COVID-19 patients (47%), relocation (45%), lay-off/furloughs of part-time or per diem staff (42%), lay-offs of full-time staff (12%), and decreased work hours (65%). A total of 95% expressed decreased morale with an increase in mental distress, including depression (36%). Predictors of depression included relocation status, staff preparedness, and work hours. Conclusion. Logistical changes to CCL staffing resulted in relocation, lay-offs, furloughs, and diminished work hours, with financial and emotional ramifications. Particular attention should be paid to those in large urban hospitals, those at risk for relocation, layoffs, and furloughs, and when preparedness and administrative communication is perceived as poor.
J INVASIVE CARDIOL 2021;33(1):E9-E15. Epub 2020 December 6.
Key words: depression, stress, survey
As coronavirus 2019 (COVID-19) swept through the United States in the early half of 2020, healthcare delivery had to adapt rapidly in order to prioritize this disease within hospitals and healthcare systems, while managing associated personnel and logistical changes. This was particularly challenging for areas of the hospital previously devoted to non-infectious, yet highly specialized diseases, such as the cardiac catheterization laboratory (CCL). Numerous consensus documents and position papers have discussed successful implementation of cardiac care within the CCL and the significant concerns raised by an infectious and highly communicable disease.1,2 Often overlooked, however, are the challenges faced by healthcare workers, including economic, health, and psychological, not fully evaluated or addressed due to the rapidity of the changes. In particular, insight regarding nurses and technologists within the CCL has been deficient.
A unique aspect of COVID-19 is the widespread impact to all specialties of healthcare, including those who have been immune or minimally impacted by crises in the past, including interventional cardiology. Changes in work dynamics and both financial and emotional stressors may negatively impact workflow, job satisfaction, well-being, and overall functioning in delivering optimal care to cardiovascular patients. Indeed, the professional and personal impact of COVID-19 on CCL staff remains unknown. Most research and surveys have been targeted at patients, physicians, or healthcare systems, with little devoted to those on the extreme frontlines, such as nurses and technologists, who may also be financially vulnerable populations. The purpose of this survey was to conduct a national evaluation of nurse and technologist perspectives, measuring the direct and indirect impact of the pandemic on their work and personal environment and experience, with the goal of informing healthcare and CCL leadership on staffing best practices for current and future pandemics of similar magnitude or impact.
A cross-sectional survey was conducted from May 8, 2020 to June 4, 2020, during the first wave of the COVID-19 pandemic. The survey was developed using an online platform (http://www.surveymonkey.com) and distributed via social media targeted at CCL personnel and forums. The target audience was CCL staff, including nurses, radiology technologists, cardiovascular technologists, and advanced practice providers within the United States. The survey was self administered and anonymous, and was therefore exempt from institutional review board approval. It included a total of 45 questions assessing baseline demographics, logistical changes of workflow and responsibilities, staff preparedness, and mental health (Appendix 1). There was no financial sponsor.
SPSS, version 26 (IBM) was used for data collection and statistical analysis. Respondents were analyzed together and comparatively as nurse and technologist. Values are presented as n (%). P-values for qualitative values are from the Chi-square test or the Fisher’s exact test if theoretical frequencies were <5. A backward, stepwise, logistic regression, multivariable analysis was used for predictors of depression among all subjects.
There were 545 respondents who engaged in the survey, with a total of 450 completed unique responses (83%), which were subsequently included in the analysis. Table I represents the baseline demographics, which included 283 nurses (63%) and 167 technologists (37%). A total of 349 (78%) were female and mean age range was between 41-50 years old. Respondents represented a total of 46 states. Regional breakdown was 29% Northeast, 24% Southeast, 12% Southwest, 24% Midwest, and 11% West (Appendix 2). A majority of nurses had ≤10 years of experience, while a majority of technologists had >10 years of experience in the CCL (P<.01). Respondents were primarily employed full time in a hospital-based CCL, with 50% of respondents working in urban or metropolitan regions, 35% in suburban regions, and 15% in rural regions. A total of 68% indicated that they were the primary financial provider for their families, and 18% were members of a union.
Logistical and financial impact. The logistical impact of workflow and staff relocation is described in Table 2. A majority of respondents (54%) indicated that <10% of hospital volume was occupied by COVID-19 patients. Despite this low prevalence, there was a >75% decrease in CCL case volume reported by 74%. Direct care for COVID-19 positive patients was provided by 47% within the CCL. Both nurses and technologists experienced relocation to different areas of the hospital (46% and 44%, respectively; P=.41). Of those relocated, 57% provided direct care to COVID-19 patients and were more likely to be nurses (31% nurses vs 16% technologists; P<.001 ). A total of 42% of respondents indicated that their labs had laid off part-time, per diem, and traveler/agency staff, with 12% being laid off or furloughed themselves as full-time employees; 65% experienced a decrease in work hours.
Cath lab preparedness assessment. The respondents' assessment on CCL and staff preparedness is described in Table 3. There were 54% of nurses and 67% of technologists who felt adequately trained to take care of COVID-19 positive patients (P<.01). For those relocated, 79% did not feel adequately trained for their new position. A total of 41% felt that they did not receive adequate personal protective equipment (PPE) for COVID-19 patients and 80% reused their PPE. Only 25% felt that staffing and relocation assignments were fair.
Psychological impact. A total of 96% of respondents indicated a decrease in CCL morale during COVID-19 (Table 4). Inadequate support from leadership and administration was felt by 53%. The biggest concern for both nurses and technologists was exposure to COVID-19 and subsequently increasing exposure risk to their families (43%), followed by job and financial loss (33%). There was an increase in anxiety/stress (80%), fear (39%), depression (36%), and anger (38%). Outside of work, 89% felt an increase in mental anxiety/stress.
Predictors of depression. A logistic regression analysis was performed to evaluate the predictors of depression in this population (Table 5). Positive predictors for depression included staff who were relocated to other areas, regardless of whether they cared for or did not care for COVID-19 positive patients (odds ratio [OR], 4.71 and P<.01; OR, 3.13 and P=.01, respectively), those who experienced more anxiety/stress outside of work (OR, 3.42; P=.02), those working in an urban/metropolitan area (OR, 2.41; P=.02), and those who felt scared to go to work (OR, 1.84; P=.03). Negative predictors for depression were large hospital size, those who felt adequately trained to care for COVID-19 patients (OR, 0.44; P<.01), and those who did not have a decrease in work hours or on-call time (OR, 0.17; P<.001).
This paper uniquely describes the socioeconomic and mental health impact of the COVID-19 pandemic on CCL staff. The survey demonstrated that most labs experienced a >75% decrease in case volume despite a low inpatient COVID-19 volume census. This had several implications, including relocation of nearly 50% of staff to other areas, widespread layoffs of part-time and per diem workers, over 10% layoffs of the full-time staff, and decreased work hours for the majority of employees overall, with resultant financial implications. Indeed, the majority indicated that they were the primary financial providers for their household. Accordingly, almost all CCL staff expressed a decrease in morale with several concerns, including fear of job loss, exposure to COVID-19 and increasing exposure risk to family, inadequate preparedness, lack of administrative support, and lack of sufficient PPE. Together with financial stress, this resulted in negative psychological reactions, such as anxiety, fear, depression, and anger.
Many hospitals did not experience the anticipated influx of COVID-19 patients, but had to adhere to national- and state-implemented restrictions resulting in a significant decrease in CCL volume. A majority of CCL procedures, such as diagnostic angiography, percutaneous interventions, pacemakers and defibrillators, peripheral diagnostic and interventional procedures, and structural procedures require a <24-hour observation in the hospital. Accordingly, it would be reasonable to COVID-19 test these patients prior to their procedure, and then utilize designated COVID-free areas for observing these patients post procedure. This may decrease the socioeconomic and mental stress to the staff by maintaining work hours and decreasing relocation, while continuing to provide optimal care for patients with non-COVID-19 cardiac problems. Allowing elective procedures to continue in this manner would also counteract the known increase in non-COVID-19 cardiovascular mortality that was seen.3,4 Furthermore, a phased model of relocation depending on hospital COVID-19 census, rather than on CCL volume, could be advocated. If relocated, it does not seem reasonable for the majority of CCL staff to perform direct COVID-19 duties when the census is relatively low; instead, they should be placed in lower-risk situations that allow for their expedient return to the high-revenue CCL without quarantine or illness, once the pandemic subsides.
Due to the crisis in PPE availability, hospitals strictly monitored and distributed minimal supplies for healthcare workers, which continues to be an issue. When directly caring for COVID-19 patients, 41% felt that they did not receive adequate PPE. Furthermore, 80% of respondents reported reusing PPE. Moving forward, labs need to take safety and preparedness measures to be able to maintain adequate supplies for staff, assure training and competence in proper donning and doffing of PPE, and enhance communication between leadership and staff regarding personal protection. Given that a high percentage of nurses and technologists were deployed to care for COVID-19 patients, this aspect of preparedness cannot be overstated.
Working in the CCL is associated with increased health risks, not experienced in other specialty areas.5 Changes brought about by COVID-19 have a significant mental health impact on CCL staff that could contribute to long-term psychological and economic consequences. In a previous study before COVID-19, CCL staff experienced greater mental distress with significantly higher rates of depression and anxiety compared with their counterparts working in other areas (12% vs 2%, respectively; P<.001).5 In our survey during COVID-19, there were very high numbers of reports of mental distress with negative reactions such as depression and anger, with more than 1 in 3 relaying either one or the other of these mental states; stresses were identified both inside and outside the work environment. Stress outside the work environment could have been contributed by the economic aspects already discussed, in addition to the normal stress all individuals were experiencing working at the frontline during a pandemic.
Our analysis revealed several predictors of depression, both positive and negative, that deserve discussion and then conversion to best practices. Of these, hospitals should attempt to avoid relocation, layoffs, or furloughs by maintaining safe elective procedure volume, prioritize communication and effective leadership, have systems in place to uncover and support mental distress both inside and outside the workplace, and provide adequate PPE and training for staff to feel comfortable and prepared for the pandemic. Urban hospitals need to pay special attention to these factors given their prevalence of COVID-19, although larger hospitals also presumably have the resources to implement the best practices discussed herein.
Study limitations. This study has several limitations. First, distribution through social media has limited reach, which could increase response bias and limit generalizability of results. Second, in this cross-sectional survey, major geographical regions were experiencing different stages of the pandemic, which could have impact on responses based on the time the survey was conducted. Subsequent surveys during the second wave may allow further insights. Third, psychological impact can be considered continuous and variable, which may lead to under- or overestimation in this study. Finally, the psychological results from self-reported questionnaires could be divergent from clinical diagnostic tools.
A pandemic with such diverse global and local impact as COVID-19 has not been experienced in this lifetime within the United States healthcare system. A majority of attention and resources has been placed on the patient and physician experience, both in the media and within professional societal consensus documents. Our study suggests that particular attention and resources should also be paid to nurses and technologists for their wellbeing and potential for increased mental and financial distress, particularly for those in large urban hospitals with high COVID-19 census, those at risk for staff relocation, layoffs and furloughs, and when preparedness and administrative communication is perceived as poor.
1. Szerlip M, Anwaruddin S, Aronow HD, et al. Considerations for cardiac catheterization laboratory procedures during the COVID-19 pandemic: perspectives from the Society for Cardiovascular Angiography and Interventions Emerging Leader Mentorship (SCAI ELM) members and graduates. Catheter Cardiovasc Interv. 2020;96:586-597. Epub 2020 Apr 21.
2. Driggin E, Madhavan MV, Bikdeli B, et al. Cardiovascular considerations for patients, health care workers, and health systems during the coronavirus disease 2019 (COVID-19) pandemic. J Am Coll Cardiol. 2020;75:2352-2371. Epub 2020 Mar 19.
3. Garcia S, Albaghdadi MS, Meraj PM, et al. Reduction in ST-segment elevation cardiac catheterization laboratory activations in the United States during COVID-19 pandemic. J Am Coll Cardiol. 2020;75:2871-2872
.4. Tamman M. At-home COVID-19 deaths may be significantly undercounted in New York City. Reuters website. April 8, 2020. Accessed August 10, 2020. https://www.reuters.com/article/us-health-coronavirus-fdny-idUSKBN21P3KF
5. Andreassi MG, Piccaluga E, Guagliumi G, Del Greco M, Gaita F, Picano E. Occupational health risks in cardiac catheterization laboratory workers. Circ Cardiovasc Interv. 2016;9:e003273.
From the 1Hendrick Medical Center, Abilene, Texas; and 2Westchester Medical Center, Valhalla, New York.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.
Manuscript accepted November 30, 2020.
Address for correspondence: Bailey Ann Estes, BSN, RN-BC, RNFA, CNOR, RCIS, Hendrick Medical Center, 1900 Pine Street, Abilene, TX 79601. Email: Baileyann1123@gmail.com