Rapid Communication

Surge-in-Place: Conversion of a Cardiac Catheterization Laboratory Into a COVID-19 Intensive Care Unit and Back Again

Miguel Alvarez Villela, MD1,2,3; Thomas Boucher, BSc3; Juan Terre, MD1,3; Barbara Levine, PA, MBA1; Marianne O’Shea, RN, MPA1; Joane Luma, MPA1; Ulrich P. Jorde, MD1,3; Mario Garcia, MD1,3; Jose Wiley, MD, MPH1,3; Mark Menegus, MD1,3; Azeem Latib, MBBCh1; Anna E. Bortnick, MD, PhD, MSc1,3,4

Miguel Alvarez Villela, MD1,2,3; Thomas Boucher, BSc3; Juan Terre, MD1,3; Barbara Levine, PA, MBA1; Marianne O’Shea, RN, MPA1; Joane Luma, MPA1; Ulrich P. Jorde, MD1,3; Mario Garcia, MD1,3; Jose Wiley, MD, MPH1,3; Mark Menegus, MD1,3; Azeem Latib, MBBCh1; Anna E. Bortnick, MD, PhD, MSc1,3,4

Abstract

In Spring 2020, the United States epicenter of COVID-19 was New York City, in which the borough of the Bronx was particularly affected. This Fall, there has been a resurgence of COVID-19 in Europe and the Midwestern United States. We describe our experience transforming our cardiac catheterization laboratories to accommodate an influx of COVID-19 patients so as to provide other hospitals with a potential blueprint. We transformed our pre/postprocedural patient care areas into COVID-19 intensive care and step-down units and maintained emergent invasive care for ST-segment elevation myocardial infarction using existing space and personnel. 

J INVASIVE CARDIOL 2020 December 22 (Ahead of Issue). 

Key words: cardiac, catheterization, COVID-19, SARS-CoV-2


In December 2019, a viral pneumonia of unknown etiology was described in Wuhan, China.1-3 The cause was identified as a novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on January 3, 2020 and by March it had become a pandemic.1-3 The number of confirmed SARS-CoV-2 cases in New York State exponentially increased in early Spring 2020 to nearly 84,000, with over 41,000 of these in New York City (NYC) alone.4 An executive order was issued on March 23, 2020 mandating all hospitals to increase in-hospital bed capability by 50%.5 The borough of Bronx, New York was highly affected by coronavirus disease-2019 (COVID-19).6,7 Population density, socioeconomic disadvantage, poor health status, a large number of essential workers, and frequent public transportation usage contributed to cases in the borough.7-10 COVID-19 cases are once again surging across the Northeastern and Midwestern United States, and there is a second wave across Europe. Practical information on how hospitals successfully dealt with the first surge-in-place is of great importance in combating the current crisis. We provide our experience converting our cardiac catheterization laboratory (CCL) patient care areas into COVID-19 intensive care units (ICUs). Adapting cardiac cath lab patient care areas for COVID-19 care is a model that could be rapidly employed in the current pandemic. 

Reconfiguration of Physical Space in the CCL COVID-19 ICU

During the surge-in-place, Montefiore Health System rapidly expanded its capacity and capability, repurposing physical spaces, reorganizing teams, roles, daily functioning, and logistics of patient care at its Bronx campuses with CCLs (Moses Hospital and Jack D. Weiler Hospital) to significantly expand available hospital beds for critically ill COVID-19 patients. Conversion of the Children’s Hospital at Montefiore (CHAM) to adult COVID-19 care has been previously described.11 CCLs at Moses and Weiler perform approximately 2000 percutaneous coronary interventions (PCIs) per year and serve the largest number of ST-segment elevation myocardial infarction (STEMI) patients in the NYC area.12 As part of the surge-in-place, CCL patient care areas at the 2 campuses were physically and operationally transformed into COVID-19 ICUs and step-down units. Meanwhile, we continued to provide primary PCI services for STEMI patients and emergent invasive services, opening a new chest pain unit for evaluation of COVID-19 negative (-) patients to decompress the Emergency Department (ED). A state-wide cancellation of elective procedures made hospital resources available to face the ongoing epidemic.13 As a result, daily cardiac catheterization cases decreased, allowing for effective repurposing of available resources.

Weiler Hospital converted 7 patient rooms with glass doors, typically used for pre- or postprocedural care, into a COVID-19 ICU with restricted access from a single entrance. The unit was run by attending physicians from the Heart Failure section, with a general cardiology fellow, internal medicine residents, nurses (RNs), and technicians from the CCL team. Limited services for emergent catheterization were provided ad hoc by an on-call interventional team. Airflow direction was reversed in the new COVID-19 ICU for negative pressure. Stable STEMI and emergent cases, in coordination with the ED and Fire Department of New York, were clustered at Moses Hospital where interventional attending physicians, fellows, and physician assistants (PAs) were reassigned because of increased staff and bed capacity at that site. 

Moses Hospital has 3 CCLs. Two of them are in proximity to each other (Labs A and B), with recovery rooms typically used for outpatients (Figure 1A). A third (Lab C), distanced from the others by a hallway, connects directly with bays typically used for pre- or postprocedural care for both outpatients and inpatients. During the surge-in-place, the CCL patient care areas were divided into 2 major zones: one for COVID-19 (-) patients and one for confirmed COVID-19 positive (+) patients (Figure 1A). Patients under investigation (PUI) pending COVID-19 results were isolated and triaged accordingly. 

Lab C and the attached patient recovery areas constituted the COVID-19 (+) zone. This was separated from the COVID-19 (-) zone by a door and traffic was separated between the COVID-19 (+) and (-) zones. Access to the COVID-19 (+) zone was through a new, designated donning area for staff personal protective equipment (PPE). Administrative staff were assigned on a rotating basis to a newly enclosed booth to perform their usual duties while also assisting members of the team inside the COVID-19 (+) zone to obtain medications from the pharmacy, transport blood chemistries to the laboratory, field calls from patient families, monitor traffic flow, stock PPE, and verify proper PPE use for personnel entering the zone (Figure 2A). Traffic followed a unidirectional pattern and a new, designated doffing station was created at the zone exit. Outpatient rooms with glass doors constituted a 6-bed ICU (Figure 2B). A separate inpatient recovery area was transformed into a step-down unit for lower-acuity COVID-19 patients. Patient rooms in the CCL COVID-19 ICU and Lab C were set to negative pressure. Signage reminded staff of traffic flow, green (clean), and red (dirty) areas. The zone exit served as a highly restricted entrance limited to transport of patients directly into the CCL COVID-19 ICU or for STEMI primary PCI going directly to Lab C. 

Labs A and B, and adjacent patient care rooms were converted into the COVID-19 (-) zone. Access to this zone was through a separate CCL entrance from the PPE donning area. Patients transported for emergent procedures underwent screening prior to entrance into one of the labs. Febrile or suspicious patients were triaged to the COVID-19 (+) or PUI zone. 

The COVID-19 (-) zone also served as an acute chest pain unit in coordination with the ED, outpatient clinics, and referring hospitals in order to provide streamlined care and inpatient admission for cardiac patients in an area that could reduce potential nosocomial exposure. The acute chest pain unit was staffed by an interventional attending, interventional fellow, PAs, RNs, and technicians from the CCL team. We noted a decrease in COVID-19 (-) acute coronary syndrome cases, as others have reported.14

Team Organization and Roles in the CCL COVID-19 ICU

The integrity of usual working teams was maintained by reassigning roles to our staff under this new structure. Interventional cardiology attending in-house coverage was provided on a 24/7 basis. Attending physicians were scheduled in teams of 3 to provide coverage for each 12-hour day shift and teams of 2 for each night shift. During the day, 2 attending physicians would staff the COVID-19 (+) zone, including Lab C. The inpatient service in this zone was often divided between them for rounds and the step-down unit attending was assigned to perform primary PCI for COVID-19 (+) or suspected (+) STEMI. The third attending would cover the COVID-19 (-) Labs A and B, as well as round on the inpatients in that zone. During the night shift, inpatient coverage was divided between 2 in-house interventional attending physicians. Emergent catheterization was performed favoring same-day discharge, if appropriate, and the hospital supplied dual-antiplatelet therapy for 30 days.

We platooned interventional cardiology fellows when possible, with 2 in hospital and 2 out of hospital per week. One interventional cardiology fellow, one general cardiology fellow, and 1-2 PAs covered the COVID-19 (+)/PUI zone. The other interventional fellow worked with an interventional attending, PAs, RNs, and technicians in the COVID-19 (-) zone. Overnight, a general cardiology fellow provided primary coverage for the COVID-19 (+)/PUI zone while a PA covered the COVID-19 (-) zone. An interventional cardiology fellow was assigned overnight home call for primary PCI.

Cardiac catheterization and electrophysiology RNs, PAs, technical staff, and support staff were assigned to the CCL COVID-19 ICU rather than being deployed to other services. Staff adjusted their schedules to provide 24/7 coverage. A small number of clinical cardiology staff and “manpower pool” staff were also deployed to the unit. Procedural RNs with prior ICU experience educated and supported the RN team. Cardiovascular technicians/specialists transitioned to the role of patient care technician. RN/patient ratios were flexed based on patient acuity and staff availability/skillset. Attempts were made to maintain a higher RN/patient ratio for the critical care beds in our COVID-19 (+) zone and for high-acuity COVID (-) patients on mechanical support, with hemodynamic instability, or with altered mental status.   

We minimized staff assigned to the COVID-19 (+) zone to limit exposure and conserve PPE. Prior to opening the COVID-19 ICU, interventional cardiology physicians, PAs, RNs, and technical staff rounded with Critical Care Medicine (CCM) ICU teams to adopt a common approach to patient management. We held grand rounds with physicians from China and Italy to review their experience of COVID-19 critical care. During the surge-in-place, Cardiology Grand Rounds and Cardiac Catheterization Conference were dedicated to the review of published data and sharing knowledge among cardiology teams caring for COVID-19 patients across campuses and outside hospitals. Many interventional cardiologists across the city communicated through a centralized group chat, leading to cross-institutional collaboration and research. After the surge-in-place, conferences were converted back to a broader cardiovascular focus and a YouTube channel was established for remote learning. 

Rounding Structure and Logistics for the CCL COVID-19 ICU

Rounds were led by the interventional cardiology attending physician. Full PPE was always worn by staff while in the COVID-19 (+)/PUI zone. Fellows and PAs prerounded with a systems-based checklist modified for COVID-specific information like ferritin, IL-6, D-dimer and pro-calcitonin levels, ventilator settings, blood gas, and P/F ratio. Hospital medication and research protocols were centrally posted, readily available online, and reviewed daily on rounds. Patients were preliminarily screened and referred to research teams for evaluation, with the majority enrolled into clinical trials of remdesivir, leronlimab, and convalescent plasma. Communication with families and healthcare proxies, mostly by video, was integrated into daily rounds, and physicians who were not actively rounding in the COVID unit collaborated with the unit team to deliver daily updates as well.

Bedside procedures were performed by interventional and general fellows. Procedures were performed in batches to minimize traffic in and out of rooms. Infusion pumps were placed outside of each patient’s room using extension tubing to allow for dose adjustments without entering the room (Figure 2B). Laboratory values, ventilator settings, lines and dates of placement were listed in erasable marker on the glass doors of patient rooms and updated in real time to facilitate communication among team members across shifts. Temporary plexiglass dividers were added to enclose the workstations in the COVID-19 (+) step down unit to further protect staff.

Free online resources to train physicians in ventilation management and other critical care issues were accessed through the Society of Critical Care Medicine. CCM distributed videos on the use of specific ventilator models available in our healthcare system and new sedation protocols adjusted to drug availability. These resources provided useful and practical information to better manage patients beyond the usual scope of interventional cardiology practice. Additionally, CCM established a central command telemedicine consultation service, which the CCL COVID-19 ICU team contacted daily to review ventilator settings, arterial blood gases, sedation, and paralytic infusions, as well as other general management questions. CCM provided in-person consultation in coordination with the needs of the CCL COVID-19 ICU team, improving efficiency. Telemedicine consultation was useful, for example, in discussing management of a case of persistent hypoxia due to collapsed lung from mucus plugging, and in the clinical diagnosis of pulmonary embolism, suspected due to prone-resistant hypoxia. 

Patient proning was identified early-on in the pandemic to be an effective maneuver to improve oxygenation and a dedicated proning team staffed by physical therapists was available.15 During rounds, patients requiring pronation and supination were identified and indicated on a central board, which alerted the proning team upon their arrival. The CCL COVID-19 ICU team learned the process and, in several cases, was able to acutely prone patients to avert cardiac arrest from severe hypoxia.

A standing conference call occurred 7 days per week with participation from physician, PA, RN, and operations leadership. Decisions and plans were made regarding patient care, patient triage/admission/transfer, urgent/emergent catheterization cases, physical plant, equipment/supply availability and distribution, staff assignment and allocation. The call provided a time to check in on the status of team members regarding their health, challenges, and concerns. The leadership team also maintained a group text chat for improved communication as the situation evolved.

Resumption of Elective Cases and Reconfiguration of Physical Space Post Surge 

As the COVID-19 (+) and general patient census in the hospital diminished, surge-in-place units were rolled back to their original functions. Admissions to our unit were halted by the CCM central command when the hospital census decreased below a predetermined threshold. Initially, semielective cases were brought to the COVID-19 (-) unit and tested with a molecular-based assay for SARS-CoV-2 before procedure. We discontinued that practice given the variability in time in getting the results, ranging from 1-6 hours, and recognition that there could be asymptomatic COVID-19 (+) patients. The differential diagnosis between COVID symptoms and refractory shortness of breath or worsening fatigue due to obstructive coronary artery disease was also challenging. Instead, we prioritized external SARS-CoV-2 testing at walk-in or drive-through testing sites to accommodate more patients. Test availability and result turnaround time were initial limiting factors that we overcame in order to restore elective case volume. 

Once hospital patient census decreased significantly and all admitted patients were discharged from the CCL COVID-19 ICU, it was closed for renovation and/or terminal cleaning and returned to its original functions, and staff returned to their usual roles in the CCL. Interventional cardiology fellows returned to their original roles in the CCL with the goal of maximizing procedural training. 

Once allowed to resume semielective procedures, a negative SARS-CoV-2 assay within 3 days of the procedure was required for all patients.16 Semi-elective cases were concentrated on 1 campus, until all COVID-19 patients were discharged from the second CCL Covid-19 ICU. Elective procedures were resumed later at both campuses, with a negative molecular-based assay for SARS-CoV-2 required within 5 days of the procedure.17 These tests were coordinated with the referring teams and procedures were canceled or delayed in patients with COVID-19 (+) results, unless urgent or emergent. Those cases continued to be performed at both campuses, where 1 CCL remained designated for COVID-19 (+)/PUI patients. 

At the Weiler campus, CCLs and recovery areas are physically distanced by design; hence, additional measures were not necessary to isolate the labs after the surge-in-place. However, for the Moses campus, Lab B and a patient recovery room were physically isolated from the rest of the labs and pre/postprocedural areas by newly constructed walls and it was designated as a COVID-19 (+)/PUI lab. Workstations were enclosed in plexiglass. This lab was subsequently designated for inpatients and ED arrivals. When a COVID-19 (+)/PUI case was performed in this lab, transit to the area was restricted to personnel in full PPE. COVID-19 decontamination protocols were performed in COVID-19 (+) labs post procedure. 

Conclusion

Beyond reconfiguration of physical space, we reorganized members of the interventional team for COVID-19 intensive care. The approach of the CCL COVID-19 ICUs fit into the broader context of the system-wide COVID-19 effort and was flexible enough to adapt to newly identified best practices, while also meeting changing patient needs and reverting to usual operations when the surge resolved. Lessons we learned while navigating the first US surge-in-place can assist others currently dealing with the COVID-19 pandemic and may be applicable to future crises.

Key Points

(1) We prioritized the following key objectives and organized a systematic approach to executing them: to provide intensive care for COVID-19 patients, maintain guideline-based care for STEMI, protect staff health, conserve material resources, conduct scientific research, and educate trainees.

(2) Interventional cardiology team members are well suited for treatment of critically ill COVID-19 patients due to familiarity with shock and can be rapidly organized into an effective CCL COVID-19 ICU team, in concert with colleagues from Heart Failure and CCM. 

(3) In-person rounding with CCM colleagues and review of Society of Critical Care Medicine online materials were vital in preparing CCL physicians and staff for opening the CCL COVID-19 ICUs. 

(4) An interdisciplinary approach, incorporating physicians, PAs, nursing, and technicians, pooled diverse expertise for the benefit of critically ill COVID-19 patients. 

(5) A structured rounding checklist and posting vital signs, laboratory values, and ventilator parameters on patient doors organized complex patient management and streamlined communication among team members. 

(6) Telemedicine consultation across services made clinical care more efficient in the CCL COVID-19 ICU. 

(7) Centralized, system-wide communication of clinical and research protocols, and conferencing with colleagues, locally to internationally, was paramount in providing contemporary management for COVID-19.

Acknowledgments. AEB acknowledges Jeffrey Shannon, PhD, NIH Rocky Mountain Laboratories, Hamilton, Montana, for useful discussions on biohazard safety. The authors recognize the interventional cardiology nurses, technicians, physicians, physician assistants and administrators who organized and ran the Montefiore CCL COVID-19 ICU for their extraordinary contributions to patient care.


From the 1Department of Medicine, Division of Cardiology, Montefiore Medical Center, Bronx, New York; 2Department of Medicine, Division of Cardiology, New York Health and Hospitals Jacobi Medical Center, Bronx, New York; 3Albert Einstein College of Medicine, Bronx, New York; and 4Department of Medicine, Division of Geriatrics, Montefiore Medical Center, Bronx, New York. 

Funding: AEB recognizes support from an AHA Mentored Clinical and Population Award 17MCPRP33630098 and K23 HL146982 from the NIH NHLBI. 

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.

Final version accepted December 4, 2020.

Correspondence to: Anna E. Bortnick, MD, PhD, MSc, Jack D. Weiler Hospital, 1825 Eastchester Road Suite 2S-46 Bronx, NY 10461. Email: abortnic@montefiore.org

References
  1. Li Q. An outbreak of NCIP (2019-NCOV) infection in china — Wuhan, Hubei province, 2019−2020. China CDC Weekly. 2020;2:79-80.
  2. Tan W, Zhao X, Ma X, et al. A novel coronavirus genome identified in a cluster of pneumonia cases — Wuhan, China 2019−2020. China CDC Weekly. 2020;2:61-62.
  3. World Health Organization. Rolling updates on coronavirus disease (COVID-19).  https://www.who.int/emergencies/diseases/novel-coronavirus-2019/events-as-they-happen. Accessed December 11, 2020.
  4. NYC Health. Coronavirus disease 2019 (COVID-19) daily data summary. https://www1.nyc.gov/assets/doh/downloads/pdf/imm/covid-19-daily-data-summary-05012020-1.pdf. Accessed December 11, 2020.
  5. Governor Andrew M. Cuomo. No. 202.1: Continuing temporary suspension and modification of laws relating to the disaster emergency. https://www.governor.ny.gov/news/no-2021-continuing-temporary-suspension-and-modification-laws-relating-disaster-emergency. December 11, 2020.
  6. Johns Hopkins University. COVID-19 dashboard by the Center for Systems Science and Engineering (CSSE) at the Johns Hopkins University (JHU). https://coronavirus.jhu.edu/map.html. Accessed December 11, 2020.
  7. United States Census Bureau. U.S. Census bureau quickfacts: Bronx county (Bronx borough), New York. https://www.census.gov/quickfacts/bronxcountybronxboroughnewyork. Accessed December 11, 2020.
  8. Rubin D, Huang J, Fisher BT, et al. Association of social distancing, population density, and temperature with the instantaneous reproduction number of SARS-CoV-2 in counties across the United States. JAMA Netw Open. 2020;3:e2016099.
  9. Sy KTL, Martinez ME, Rader B, White LF. Socioeconomic disparities in subway use and COVID-19 outcomes in New York City. medRxiv. 2020.
  10. United States Census Bureau. United States Census Bureau: comparative economic characteristics. https://data.census.gov/cedsci/table?t=Earnings%20%28Individuals%29%3AEducation%3AEmployment%3AFamilies%20and%20Household%20Characteristics%3AFamilies%20and%20Living%20Arrangements%3AFamily%20Size%20and%20Type%3AHousehold%20Size%20and%20Type%3AHousing%3AIncome%20and%20Poverty%3ALanguage%20Spoken%20at%20Home%3AOccupation%3AOfficial%20Poverty%20Measure%3APopulations%20and%20People%3APoverty&g=0500000US36005&tid=ACSSPP1Y2017.S0201&vintage=2017&hidePreview=true. Accessed August 2, 2020.
  11. Philips K, Uong A, Buckenmyer T, et al. Rapid implementation of an adult coronavirus disease 2019 unit in a children's hospital. J Pediatr. 2020;222:22-27.
  12. New York State Department of Health. New York State report on mortality after acute myocardial infarction (heart attack) 2015. https://www.health.ny.gov/statistics/diseases/cardiovascular/heart_disease/docs/2015_mortality_post_heart_attack.pdf. Accessed December 11, 2020.
  13. Governor Andrew M. Cuomo. No. 202.25: Continuing temporary suspension and modification of laws relating to the disaster emergency. https://www.governor.ny.gov/news/no-20225-continuing-temporary-suspension-and-modification-laws-relating-disaster-emergency. Accessed December 11, 2020.
  14. Mafham MM, Spata E, Goldacre R, et al. COVID-19 pandemic and admission rates for and management of acute coronary syndromes in England. Lancet (London, England). 2020;396:381-389.
  15. Pan C, Chen L, Lu C, et al. Lung recruitability in COVID-19-associated acute respiratory distress syndrome: a single-center observational study. Am J Respir Crit Care Med. 2020;201:1294-1297.
  16. New York State Department of Health. COVID-19 directive regarding the resumption of elective outpatient surgeries and procedures in general hospitals in counties and facilities without a significant risk of COVID-19 surge. https://coronavirus.health.ny.gov/system/files/documents/2020/05/elective-surgery-notification_4_29_20.pdf. Accessed December 11, 2020.
  17. New York State Department of Health. Updated guidance for resumption of non-essential elective surgeries and nonurgent procedures in hospitals, ambulatory surgery centers, office based surgery practices and diagnostic and treatment centers. https://coronavirus.health.ny.gov/system/files/documents/2020/06/doh_covid19_electivesurgery_update_061420.pdf. Accessed December 11, 2020.
/sites/invasivecardiology.com/files/articles/images/Bortnick%202020%20Dec%2022%20AOI%20wm_0.pdf