Listen to this manuscript’s

audio summary by

Editor-in-Chief

Dr. Valentin Fuster on

JACC.org.

J O U R N A L O F T H E A M E R I C A N C O L L E G E O F C A R D I O L O G Y V O L . 7 6 , N O . 1 , 2 0 2 0

ª 2 0 2 0 T H E A M E R I C A N C O L L E G E O F C A R D I O L O G Y F O U N D A T I O N .

P U B L I S H E D B Y E L S E V I E R . A L L R I G H T S R E S E R V E D .

THE PRESENT AND FUTURE

JACC REVIEW TOPIC OF THE WEEK

COVID-19 and Disruptive Modificationsto Cardiac Critical Care DeliveryJACC Review Topic of the Week

Jason N. Katz, MD, MHS,a,* Shashank S. Sinha, MD, MSC,b,* Carlos L. Alviar, MD,c David M. Dudzinski, MD, JD,d

Ann Gage, MD,e Samuel B. Brusca, MD,f M. Casey Flanagan, MD,b Timothy Welch, MD,b,g Bram J. Geller, MD,h

P. Elliott Miller, MD,i Sergio Leonardi, MD, MHS,j Erin A. Bohula, MD, DPHIL,k Susanna Price, MD, PHD,l

Sunit-Preet Chaudhry, MD,m Thomas S. Metkus, MD,n Connor G. O’Brien, MD,o Alessandro Sionis, MD,p

Christopher F. Barnett, MD,q Jacob C. Jentzer, MD,r Michael A. Solomon, MD,f,s David A. Morrow, MD, MPH,k

Sean van Diepen, MD, MSCt

ABSTRACT

ISS

Fro

Me

NY

ch

Ce

Ma

La

Me

Me

do

Ho

Me

Bio

Me

Cr

Na

Me

Na

be

ha

of

The COVID-19 pandemic has presented a major unanticipated stress on the workforce, organizational structure, systems

of care, and critical resource supplies. To ensure provider safety, to maximize efficiency, and to optimize patient out-

comes, health systems need to be agile. Critical care cardiologists may be uniquely positioned to treat the numerous

respiratory and cardiovascular complications of the SARS-CoV-2 and support clinicians without critical care training who

may be suddenly asked to care for critically ill patients. This review draws upon the experiences of colleagues from

heavily impacted regions of the United States and Europe, as well as lessons learned from military mass casualty

medicine. This review offers pragmatic suggestions on how to implement scalable models for critical care delivery,

cultivate educational tools for team training, and embrace technologies (e.g., telemedicine) to enable effective

collaboration despite social distancing imperatives. (J Am Coll Cardiol 2020;76:72–84)

© 2020 the American College of Cardiology Foundation. Published by Elsevier. All rights reserved.

N 0735-1097/$36.00 https://doi.org/10.1016/j.jacc.2020.04.029

m the aDivision of Cardiology, Duke University, Durham, North Carolina; bInova Heart and Vascular Institute, Inova Fairfax

dical Center, Falls Church, Virginia; cLeon H. Charney Division of Cardiology, New York University Langone Medical Center

U Langone Medical Center, New York, New York; dDivision of Cardiology, Massachusetts General Hospital, Boston, Massa-

usetts; eDivision of Cardiology, Cleveland Clinic, Cleveland, Ohio; fCritical Care Medicine, National Institutes of Health Clinical

nter, Bethesda, Maryland; gVirginia Heart, Falls Church, Virginia; hDivision of Cardiology, Maine Medical Center, Portland,

ine; iSection of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut; jCoronary Care Unit and

boratory of Clinical and Experimental Cardiology-Fondazione IRCCS Policlinico San Matteo, and Department of Molecular

dicine, University of Pavia, Pavia, Italy; kTIMI Study Group, Cardiovascular Division, Brigham and Women’s Hospital, Harvard

dical School, Boston, Massachusetts; lRoyal Brompton and Harefield NHS Foundation Trust, Royal Brompton Hospital, Lon-

n, United Kingdom; mDepartment of Cardiology, St. Vincent Hospital, Indianapolis, Indiana; nDivision of Cardiology, Johns

pkins University School of Medicine, Baltimore, Maryland; oDivision of Cardiovascular Medicine, Stanford University School of

dicine, Palo Alto, California; pIntensive Cardiac Care Unit, Cardiology Department, Hospital de la Santa Creu i Sant Pau,

medical Research Institute IIB-SantPaul, Universidad Autonoma de Barcelona, Barcelona, Spain; qDepartment of Cardiology,

dstar Washington Hospital Center, Washington, DC; rDepartment of Cardiovascular Medicine and Division of Pulmonary and

itical Care Medicine, Mayo Clinic, Rochester, Minnesota; sCardiovascular Branch, National Heart, Lung, and Blood Institute,

tional Institutes of Health, Bethesda, Maryland; and the tDepartment of Critical Care and Division of Cardiology, Department of

dicine, University of Alberta Hospital, Edmonton, Alberta, Canada. Drs. Brusca and Solomon receive research support from the

tional Institutes of Health Clinical Center intramural research fund. *Drs. Katz and Sinha are co-first authors. Dr. Metkus has

en a consultant for BestDoctors Inc. and Oakstone/EBIX; and has received royalties for a textbook from McGraw-Hill. Dr. Sionis

s received consulting fees from Sanofi. All other authors have reported that they have no relationships relevant to the contents

this paper to disclose.

HIGHLIGHTS

� Acute complications of COVID-19 canresult in severe perturbations of therespiratory, cardiovascular, and immunesystems.

� Critical care cardiologists may beuniquely positioned to develop anddisseminate novel solutions to meetpatient and workforce demands.

� Many opportunities exist to developscalable models of critical care deliveryand effective research collaboration.

AB BR E V I A T I O N S

AND ACRONYM S

CICU = cardiac intensive care

unit

COVID-19 = coronavirus

disease-2019

ICU = intensive care unit

PPE = personal protective

equipment

SARS-CoV-2 = severe acute

respiratory syndrome-

coronavirus-2

STEMI = ST-segment elevation

myocardial infarction

J A C C V O L . 7 6 , N O . 1 , 2 0 2 0 Katz et al.J U L Y 7 , 2 0 2 0 : 7 2 – 8 4 Disruptive Modifications to Cardiac Critical Care During COVID-19

73

According to Darwin's Origin of Species, it is notthe most intellectual of the species that survives;it is not the strongest that survives; but the spe-cies that survives is the one that is able best toadapt and adjust to the changing environment in

which it finds itself.—Leon C. Megginson (1)

T he coronavirus disease-2019 (COVID-19)daninfectious illness characterized predomi-nantly by its pulmonary manifestations and

caused by the severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2)dhas endangered ourglobal population, jeopardized our world’s economy,and threatened to overwhelm and change the medicalprofession as we know it. Access to health care andclinical resources, including diagnostic tools, hospitalbeds, a healthy workforce, personal protective equip-ment (PPE), and advanced critical care modalities(e.g., renal replacement therapies and ventilators)are now limited, and, in some instances, scarce dueto the impact of the current pandemic. This virusshows no favoritism; although older patients withmedical comorbidities are at the greatest risk fordeath and disability (2), emerging evidence suggeststhat increasing numbers of young and seeminglyhealthy individuals have been hospitalized and maycontinue to succumb to coronavirus-associated com-plications (3). SARS-CoV-2, the causative respiratorypathogen, can injure most organ systems; many criti-cally ill patients with COVID-19 will develop concom-itant cardiovascular, renal, neurological, or hepaticdysfunction (4). In some cases, acute cardiac injury

The authors attest they are in compliance with human studies committe

institutions and Food and Drug Administration guidelines, including patien

visit the JACC author instructions page.

Manuscript received April 4, 2020; revised manuscript received April 13, 20

will be an important manifestation and the pre-dominant cause of clinical deterioration (5).

Therefore, management of a disruptiveillness like COVID-19 calls for disruptivehealth care adaptations and innovations,particularly when treating the highest riskcritical care cohorts. The critical care cardi-ology community may be uniquely posi-tioned to help establish, test, anddisseminate novel solutions for the currentcrisis. Straddling the overlapping specialtiesof critical care and cardiovascular medicine,many critical care cardiologists have alreadybeen called upon and deployed to COVID-

19�specific intensive care settings. We offer our in-ternational perspectives on necessary modificationsto existing care delivery platforms and potentiallyimpactful collaborations that might optimize thecritical care response and patient outcomes in theCOVID-19 era.

EPIDEMIOLOGY OF COVID-19 AND ITS

CARDIOVASCULAR MANIFESTATIONS

As of April 12, 2020, >1.6 million COVID-19 cases werereported globally, resulting in nearly 100,000 deaths(6). Although much of the morbidity and mortalityassociated with COVID-19 has been due to respiratoryfailure, cardiovascular complications of the SARS-CoV-2 virus, as well as primary cardiovascular pre-sentations of COVID-19, have become increasinglyreported (5,7,8). This infectious illness may provoke amultitude of cardiovascular events, including acutecoronary syndromes, arrhythmias, thromboembo-lism, myocarditis, sudden cardiac death, heart fail-ure, cardiogenic, and mixed shock states (9,10). Theprimary mechanism(s) underlying the developmentof each of these pathologies is unknown but is likelymultifactorial, possibly involving vascular insuffi-ciency, direct viral injury, tissue hypoxemia, systemicinflammation, and cytokine release (9,11).

Pre-existing cardiac disease appears to be a sig-nificant risk factor for the development of severe lunginjury and subsequent mortality among infected pa-tient cohorts. These same comorbidities have alsobeen associated with an increased burden of acutecardiac injury. Cardiac injury has been described inup to 28% of hospitalized patients with COVID-19. In 2

es and animal welfare regulations of the authors’

t consent where appropriate. For more information,

20, accepted April 13, 2020.

TABLE 1 An International Comparison of CICU Modifications in High-Impact Regions During the COVID-19 Pandemic

LocationChanges to CICUStaffing Models

Examples of Support forNoncardiac ICUs

Changes to CICUAdmission Criteria

Integration of Expertise BetweenCardiology and Critical Care for

COVD-19 Patients

Pavia, Lombardy,Italy

Dedicated COVID-19 CICU forpatients with cardiac criticalcare diagnoses and COVID-19

Dedicated medical and nursingstaff

Noncardiac intensive carephysicians, senior fellows, andnurses redeployed in generalICUs or COVID-19 ICUs

Government reallocation ofmedical staff from lessaffected regions

Patients with confirmed COVID-19or high clinical suspicion

ED patients admitted to dedicatedCOVID-19 hospital wards untilconfirmed diagnosis

Co-rounding with generalintensivists twice per day

Multidisciplinary admission triagedecisions based on distributivejustice

Barcelona, Spain Reduced CICU admissionsCICU staff and residents were re-

allocated to a joint ICU forconfirmed COVID-19 patients

Separate ICU for COVID-19negative patients

12-h shifts for all COVID-19 criticalcare staff

Admissions similar to Lombardyregion

Two ED entrances stratified byCOVID-19 status

Designated ED area for non-confirmed diagnosis

Low risk (N) STEMI admitted tothe cardiology ward withtelemetry

Joint COVID-19 critical care teamincludes anesthesiology,cardiology and generalintensive care

Implementation of institutionalCOVID-19 clinical practiceguidelines

London, UnitedKingdom

London-wide consolidatedmanagement of primary PCIand cardiac surgery,maintaining protected services

Rapid expansion of ICUs (includingCICUs) to take COVID-19patients

Maintaining cohorted zones basedupon illness severity and acuityin every hospital as long aspossible

Beds to support COVID-19ventilated patients, expansionto surge bed capacity allrequiring staffing from “pool”of intensive care capableproviders

Self-declaration of stagedventilator bed capability withinnetworks across London

Redeployment of doctors to workwithin critical care

Admission according to clinicalrequirements and dispatch toappropriate cohorted zone andfor intervention accordingto acuity

Acute, emergency cardiology, andcardiac surgical interventionstriaged within London system(i.e., acute aortic dissection)and COVID-19 risk managed onindividual patient basis

New ICUs pop-up, co-rounding withcritical care providers

Cardiology opinions/input availableas required

Cardiologists redeployed withinintensive care, skill-based teamapproach for delivery used

Implementation of COVID-19practice-based guidelines

New York, NewYork

Non-critical care cardiologiststaffing CICUs

Relocation of the CICU to smallerunit

Critical care cardiologist beingdeployed to COVID-19 ICUs

Non-critical care cardiologistassisting critical care providersin admission of COVID-19patients

.

Low risk STEMIs being admitted totelemetry ward

Repatriation of patients tocommunity hospitals

Patients with cardiac critical carediagnoses admitted to COVID-19 ICU (not CICU) but managedby critical care cardiologist orco-managed between generalcritical care provider and non-critical care cardiologist

Co-rounding model andmultidisciplinary cardiacconsultation in ICUs caring forCOVID-19 patient

Telemedicine consult service forother hospitals in network

ACS ¼ acute coronary syndromes; CICU ¼ cardiac intensive care unit; CCM ¼ critical care medicine; COVID-19 ¼ coronavirus disease-2019; CT ¼ computed tomography; ED ¼ emergency department;ICU ¼ intensive care unit; IRB ¼ institutional review board; NSTEMI ¼ non-ST-segment elevation myocardial infarction; PPE ¼ personal protective equipment; POCUS: point-of-care ultrasound; STEMI ¼ ST-segment elevation myocardial infarction; TTE ¼ transthoracic echocardiogram.

Katz et al. J A C C V O L . 7 6 , N O . 1 , 2 0 2 0

Disruptive Modifications to Cardiac Critical Care During COVID-19 J U L Y 7 , 2 0 2 0 : 7 2 – 8 4

74

studies from China, its development was associatedwith a significant risk of death (2,11).

Worldwide, hospitals have mobilized resources tocombat an influx of critically ill patients, whereas amore agile critical care workforce has emerged andcontinues to adapt to rapidly changing priorities. Forperspective, Table 1 highlights key clinical observa-tions, unique modifications to cardiac critical caredelivery platforms, novel educational initiatives, andsolutions to workforce limitations shared by in-vestigators from high-impact pandemic regions.

POTENTIAL WORKFORCE ADAPTATIONS TO

MEET EVOLVING PANDEMIC DEMANDS

Critical care cardiology, as a discipline, developed inlarge part out of necessity to meet the demands of an

evolving patient population with evolving clinicalneeds (12). Substantial changes in demographics,medical comorbidities, and resource requirements ofpatients with cardiovascular disease requiring criticalcare were described in a series of initial reports(12–15). As the prevalence of respiratory insufficiency,heart failure, structural heart disease, and multi-system organ dysfunction in cardiac intensive careunits (CICUs) surpassed the number of patients withcomplicated acute myocardial infarction (14,15), pro-viders in the CICU found an increased demand forproficiency in general critical care medicine andleadership of collaborative multidisciplinary teams.This evolution of care toward greater medical andoperational complexity necessitated changes to boththe structure and organization of cardiovascularintensive care units (ICUs), as well as the training and

Continued on the next page

TABLE 1 Continued

Changes in Delivery of Carefor ACS, Cardiogenic Shock,

and Cardiac ArrestCritical Care Education for Other

Cardiologists and TraineesChanges in CICU Workflow in

Response to Pandemic Other Key Considerations

PPE requirements, altered response,and procedure times

Reduced diagnostic testingRequired integration of PPE with

usual pathways and availabilityof trained staff (e.g. cardiaccatheterization laboratory,echocardiographers, technicians)

ICU training sessions for non-ICUphysicians, including cardiologists,nephrologists, and internal medicine

Enhanced use of POCUS with limiteduse of other imaging modalities(X-ray, CT, etc.)

Dedicated equipment for COVID-19areas (e.g., echocardiography)

PPE courses for staffPromoting human connection with

patient families, opportunities tohelp mitigate patient (and provider)distress

Research integration was facilitated

No formal changes for any of theestablished networks (STEMI,NSTEMI, cardiogenic shock andcardiac arrest)

Reduced availability of diagnosticimaging

PPE trainingNo specific training in critical care for non-

critical care specialists (of note,cardiologists in Spain receive 1 year ofcritical care during training)

On-line clinical and COVID-19 training forall ICU staff

Dedicated COVID-19 equipmentand staff

Visitor restrictions and inability to havedirect contact with family members

Expedited process for IRB COVID-19research reviews

Hotels are providing housing for patientswith milder symptoms and for healthcare providers

Resuscitation as per latest guidelines– including PPE first

Established networks of caremodified as London collaborative(i.e., aortic dissection, primaryPCI) to ensure delivery of life-saving services during pandemic

MCS services for cardiogenic shockincreased, admission triagedecisions based on distributivejustice

Introduction to intensive care: onlineresources as well as face-to-facedidactics

Use of POCUS Intensive review of PPE procedures

Use of fibrinolytics for off-siteSTEMIs in selected patients

Enhanced POCUS for evaluation ofacute coronary syndromes

Restructured evaluation and use ofadvanced therapies forcardiogenic shock

Chest compression devices forcardiac arrest

Changes in frequency of laboratorytesting for patients undergoingtherapeutic hypothermia

Simulation and boot camp for non-criticalcare physicians

POCUS before formal TTE to limitexposure

Integration of palliative care in dailyrounds

Multidisciplinary rounds with nephrologyand nurse leadership to prioritize useof renal replacement therapy

Creation of a prone positioning team formanual proning of patients

Enhanced multidisciplinary collaborationto rapidly create and implementresearch protocols and registries

Local hotels providing housing forproviders involved in care of patientswith COVID-19

J A C C V O L . 7 6 , N O . 1 , 2 0 2 0 Katz et al.J U L Y 7 , 2 0 2 0 : 7 2 – 8 4 Disruptive Modifications to Cardiac Critical Care During COVID-19

75

skills of critical care cardiologists (12,16). In thismanner, the field of critical care cardiology and thecontemporary structure of advanced CICUs arosefrom a responsive redesign of clinical care. Althoughthis evolution in cardiac critical care has better pre-pared us for the challenges that we now face, theCOVID-19 pandemic necessitates that we again takeaction to adapt to the changing needs of our patientsamidst this new crisis.

PROPOSED CICU WORKFORCE AND STAFFING

REORGANIZATION STRATEGIES. Pandemic anddisaster planning is a subspecialty that comprehen-sively encompasses hospital capacity, staffing, med-ical supply and distribution chains, training and/orsimulation, and adaptive leadership response struc-tures (i.e., challenge-driven leadership skills). It isimportant to identify any bottlenecks throughout thesystem. Although a comprehensive review is well

beyond the scope of this paper, resources are publiclyavailable (17,18). We describe potential adaptive CICUstaffing, organizational structure, medical treatment,and regional care pathways. Recognizing that theyfrequently practice in tertiary care CICUs androutinely care for patients with primary cardiovas-cular diagnoses complicated by multisystem organinjury (19), critical care cardiologists are arguablywell-positioned to take a leading role in hospital- andregional-level pandemic surge responses. Althoughthere are no universally accepted capacity surgestages, we propose a framework that builds upon anAmerican College of Chest Physicians�endorsedmodel in which a 25% capacity surge is consideredminor, whereas a surge eclipsing 200% is considereda “disaster” (17). We believe critical care cardiologistscan use our 4-component pandemic classificationsystem (Central Illustration) to complement staffingand adaptive structural decisions. If faced with a

Katz et al. J A C C V O L . 7 6 , N O . 1 , 2 0 2 0

Disruptive Modifications to Cardiac Critical Care During COVID-19 J U L Y 7 , 2 0 2 0 : 7 2 – 8 4

76

minor surge (#25% increase in capacity), a criticalcare cardiologist can continue to manage 1 health careteam in a traditional CICU model. During moderate(>25% to <100% increase in capacity) or major (100%to 200% increase in capacity) surges, we propose thatthe critical care cardiologist could take on a collabo-rative or consultative role in managing multiplehealth care teams. This is a suggestion that mirrorspreviously proposed tiered staffing models thatbroadens the reach of physicians who have both res-piratory and cardiovascular disease managementexperience (18). In such a model, noncritical caretrained physicians care directly for intubated andcritically ill patients, with oversight from a criticalcare cardiologist (or in joint partnership with anoncardiac critical care medicine provider and cardi-ologist), thereby expanding the reach of the cardiaccritical care response to workforce limitations. Inaddition, the number of patients per team andpatient-to-nurse ratios would rise commensuratewith the capacity surge.

In a stage 4 disaster scenario (>200% increase incapacity), we suggest adaptive and dynamic staffingreorganization based upon physician skill and readi-ness, hospital bed space and medical equipmentavailability, and patient care needs, while also usingpre-established hospital disaster triage protocols,principles of distributive justice, and military medi-cine, which will be discussed in the following text.The Central Illustration provides an overview ofstaffing, regionalized care systems, resources, andtriage practices that may be considered in such cir-cumstances. Notably, although disease-agnosticscoring systems (e.g., Sequential Organ FailureAssessment) may be used to create triage protocolsand have been endorsed by certain professional so-cieties (19,20), we suggest also including other vali-dated cardiac disease-specific scores (e.g., GlobalRegistry of Acute Coronary Events or Thrombolysis InMyocardial Infarction scores for patients with acutecoronary syndromes) as appropriate because tradi-tional ICU illness severity is not generalizable tocontemporary CICU populations (21). Accurate riskstratification will be necessary to help inform de-cisions regarding appropriate resource allocation andessential care rationing should the workforce andsupply pool be overwhelmed.

POTENTIAL HOSPITAL-LEVEL ADAPTATIONS TO

NEW CARE PATHWAYS. With the prospect that peakdemand for intensive care services may eclipseexisting hospital capacity, every ICU bed and associ-ated personneldcritical care physicians, nurses,trainees, and allied health professionalsdshould be

considered precious resources that must be carefullyallocated. To maximize bed capacity, elective cardiacprocedures that require CICU or post-anesthesia careunit recovery periods should be deferred, whereasrisk�benefit decisions based on hospital capacity willbe required for semi-elective procedures (e.g., trans-catheter aortic valve replacement) in which delaysmay be associated with potentially increased patientmorbidity or mortality (22). Even traditional emer-gency procedures and CICU admission practices (e.g.,routine CICU admission for ST-segment elevationmyocardial infarction [STEMI] after revasculariza-tion) will require reexamination in the COVID-19 era.This is underscored by a lack of clear benefit with theroutine CICU admission of low-risk patients withSTEMI and marked interinstitutional heterogeneityaround these admission decisions (23,24). This pre-sents an opportunity to update historical triagepractices using validated post-revascularization riskscores to help identify which patients with STEMI(e.g., those without hemodynamic or electricalinstability and those without noncardiac organdysfunction) might require ICU level care and whichpatients can safely be managed in a cardiacintermediate-care bed (25). In addition, STEMI treat-ment metrics, such as door-to-device times, may nolonger be reasonable quality metrics to considerduring periods of crisis, like COVID-19. As anexample, the Hong Kong experience with COVID-19reported delays in revascularization necessitated byassessment of patients for infection, the donning ofPPE, competing care priorities, and the use of otherinfection control measures (26). In response, Amer-ican and Chinese professional societies recommendedthe consideration of fibrinolytic therapy for somepatients with STEMI (22,27). Similarly, hospitals thathistorically admitted patients with non�ST-segmentelevation acute coronary syndromes to a CICU or ICUwill need to transition stable patients to telemetry-enabled wards in keeping with more contemporaryguideline recommendations (28).

Opening more CICU beds to patients with COVID-19will necessitate additional changes to operationalworkflow, including daily care rounds and diagnostictesting (10). The traditional CICU philosophy is toconcentrate intense resources, simultaneouslyaddressing all active issues of a critically ill patient.However, during the COVID-19 crisis, a more utili-tarian approach must be used, evaluating operationson the basis of efficiency, equity, and justice for pa-tients and the hospital system as a whole. Forexample, routine laboratory studies and daily chestradiographs that may offer low clinical value relativeto the costs associated with health care worker and

CENTRAL ILLUSTRATION Proposed Pandemic Stages to Guide Cardiac Intensive Care Unit Restructuring

Additional temporarywards and structures

Severe restrictions ofacute care services

High ratiospossible

High ratiospossible

Any licensed health careprovider

May not be possible

Additional intermediatecare and recovery units

Disruption of many acute care services and

pathways

1:1 to 1:6

1:3 to 1:4

Cardiologist ornoncardiac specialist

Limited to critically illpatients most likely tobenefit from tertiary

care transfer

Additional MICU, SICU,CSICU

Minimal changes to acute care standards;

significant restrictions in non-urgent care

1:1 to 1:4

1:2 to 1:3

Cardiologist

High-acuity transfersonly

CICU

Disaster-Level Impact>200% Capacity

Major Impact>100-200% Capacity

Moderate Impact>25-100% Capacity

Minor Impact≤25% Capacity

STAGE 4STAGE 3STAGE 2STAGE 1

Usual acutecare practices

1:1 or 1:2

1:1 or 1:2

Critical carecardiologist or

cardiologistMinimal impact for

high-acuity conditions,restrictions for low-to-

intermediate acuity

Usual care

Care Location

Standard of Care

Nurse-to-PatientRatio

Critical Care Cardiologist-to-Team Ratio

Team Lead

Inter-Hospital Transfers

Triage of Patients Hospital or regional triage protocols using disease-specific and disease-agnostic risk stratification scores to help determine anticipated therapeutic

benefit, designated triage officers; restricted CICU admissions and withholding of critical care therapies may be needed

For Stage 3,4 – consider NATO triage system

Katz, J.N. et al. J Am Coll Cardiol. 2020;76(1):72–84.

Disruptive changes to care delivery as dictated by pandemic surge level and capacity impact. CICU ¼ cardiac intensive care unit; CSICU ¼ cardiac surgical intensive care

unit; MICU ¼ medicine intensive care unit; NATO ¼ North Atlantic Treaty Organization; PPE ¼ personal protective equipment; SICU ¼ surgical intensive care unit.

J A C C V O L . 7 6 , N O . 1 , 2 0 2 0 Katz et al.J U L Y 7 , 2 0 2 0 : 7 2 – 8 4 Disruptive Modifications to Cardiac Critical Care During COVID-19

77

patient exposure should be reconsidered and poten-tially eliminated (29). Analogously, the use ofcomprehensive echocardiography should be limitedto those situations in which full imaging is essential,replaced instead by more focused study protocolsusing handheld devices performed by physicians whoare already examining their patients (30). The verynature of CICU team-based bedside rounds may need tochange to facilitate social distancing. We suggest thatphysician�patient contact be minimized and thatrounds be reengineered with technological links tofacilitate distanced discussions between the care teamwhenever possible (10). Furthermore, to prevent patient-to-patient spread, it may be reasonable to structurerounds temporally so that providers can examine in-dividuals without COVID-19 before approaching thosewith suspected or confirmed illness.

To meet ICU surge capacity, new ICU environmentswill need to be created in some institutions (31). In

the event of a regional stage 4 pandemic disaster,hospital systems must be prepared to expand ICUcapacity by using other regional facilities, such asambulatory and surgical centers, hotels, and evenpublic spaces for noncritical care needs. For example,in Barcelona and Madrid, hotels have been re-purposed as medical facilities for lower risk patientsand have also been used to accommodate health careworkers who do not have the means to safely isolatethemselves at home. In addition, modifications toexisting ICU spaces may be required. Within somecenters, single-occupancy critical care rooms are be-ing converted to double occupancy, and proceduralsuites have become ICU ready.

Anticipated hospital-level challenges to these ad-aptations will include engineering problems (e.g.,when and where to create these new ICUs, whethercreation of airborne isolation rooms is possible, andhow to equip new ICU spaces with industry standard

FIGURE 1 Leveraging Regional Care Pathways and Partnerships

Patie

nts w

ith h

igh

acui

ty p

rimar

y ca

rdia

c pre

sent

atio

n or

COVI

D-19

card

iac c

ompl

icatio

ns w

here

tert

iary

hos

pita

lth

erap

ies o

r adm

issio

n is

expe

cted

to b

e be

nefic

ial

Repatriation of convalescing patients, decanting of lower-to-

intermediate risk patients. Telephone and virtual consultative

services to mitigate inter-hospital transfers.

Card

iac I

nten

sive

Care

Uni

t Lev

el /

Hosp

ital T

ype

Leve

l 3 C

ICU

Com

mun

ity H

ospi

tal

Leve

l 2 C

ICU

Med

-Lg

Com

mun

ity H

ospi

tal

Leve

l 1 C

ICU

Tert

iary

Hos

pita

l

Using resources and bed availability across system institutions will allow for optimal allocation of key services. CICU ¼ cardiac intensive care unit; COVID-19 ¼coronavirus disease-2019.

Katz et al. J A C C V O L . 7 6 , N O . 1 , 2 0 2 0

Disruptive Modifications to Cardiac Critical Care During COVID-19 J U L Y 7 , 2 0 2 0 : 7 2 – 8 4

78

features like medical gas, vacuum systems, andelectrical outlets attached to backup emergency po-wer sources), optimal staffing of nurses (including theneed to retrain or reinstate out-of-scope nurses tomeet new clinical demands), and how best to facili-tate physician reactivation or recruitment fromnoncritical care environments. Perhaps, moving for-ward, all ICU beds should have the ability to easilyswitch between both negative and positive pressurecapabilities, and include high-efficiency particulateair filtration systems. Institutional leadership willhave to embrace a flexible approach to implementa-tion based upon local staffing demands, physical ca-pacity, expertise, and resource availability.REGIONAL MEDICAL COLLABORATION. In recentyears, many CICUs have moved to “airline type” hub-and-spoke models of critical care delivery. Tertiaryand quaternary care centers serve as regional hubs,providing the highest level of subspecialty intensivecare. This has become the standard for managingpatients with STEMI, cardiogenic shock, pulmonaryembolism, and acute aortopathies (32–34). Thesesystems could place additional pressure on hub hos-pitals that are experiencing a COVID-19 pandemicsurge, particularly because COVID-19 is associated

with significant cardiovascular sequelae (10). Theability to accept transfers from spoke facilities may beseverely limited at this time, but critical care cardi-ologists can remain a valuable resource for thesecenters by providing remote guidance.

Current pandemic preparations have highlightedthe need for increased regional collaboration andcooperation between public and private institutions,academic and community hospitals, individual healthcare systems, and local, state, and federal governmententities. Because many state governments havealready mandated the cancellation of elective pro-cedures, hospital systems must plan to use lessaffected facilities within their networks to help easeboth ICU and CICU capacity strain. As highlighted inFigure 1, this strategy may include repatriation ofconvalescing patients and decanting of low-to-intermediate risk patients to community sites,whereas patients with higher acuity primary cardiacpresentations or COVID-19 cardiac complicationswould be transferred to better resourced and highervolume centers. In addition, regional cooperation canimprove the management of the critical care supplychain. As shortages of PPE continue, local govern-ments have pressured their national counterparts to

J A C C V O L . 7 6 , N O . 1 , 2 0 2 0 Katz et al.J U L Y 7 , 2 0 2 0 : 7 2 – 8 4 Disruptive Modifications to Cardiac Critical Care During COVID-19

79

assist in securing supplies historically obtained by in-dividual hospitals. As of April 1, 2020, the state ofOhio began mandatory reporting of all ventilatorsand respiratory equipment to a centralized database(35). The regional government in Catalonia, Spainhas done the same. Compiling such inventory mayallow hospitals to exchange life-saving supplies andmore effectively deploy resources to areas most inneed.

LESSONS LEARNED FROM MILITARY

MEDICINE AND ITS APPLICATION DURING

THE COVID-19 PANDEMIC

The escalation in the COVID-19 pandemic hasrequired medical professionals to take on unexpectedclinical and organizational roles and responsibilities.In addition, institutions have made profound proce-dural and structural alterations, including the sus-pension of elective procedures and the retro-fitting ofexisting clinical spaces. These adaptations align withestablished disaster and mass casualty care plansoften used in military medicine. CICU providers, likemilitary medicine practitioners, may be compelledinto “battle” against COVID-19 with limited resourcesand will need to adapt to challenges using bothinnovation and ingenuity. The strategic objectives ofmilitary medicinedhoned over decades of experiencewith mass casualtiesdoffer a blueprint for CICUs andcritical care cardiologists to rise to the many chal-lenges of the current pandemic (36). Table 2 illus-trates some of the major tenets of military medicineand their potential usefulness in influencing a CICUpandemic response.

EFFECTIVE TRIAGE AND DISTRIBUTIVE JUSTICE. Ifa surge in the number of patients becomes over-whelming, bottlenecks will need to be quickly iden-tified and care plans may require alterations to betterallocate essential resources. There are establishedmilitary and disaster medicine tenets that may help toimprove patient care and aid in difficult triage de-cisions. In times of war and mass casualty, militaryphysicians have often operationalized the NorthAtlantic Treaty Organization triage system, which is asystem that classifies patients into 4 categories:1) immediate, requiring life-saving intervention;2) delayed, requiring intervention that can wait hoursto days; 3) minimal, injured but ambulatory; and4) expectant, too injured to save or already deceased(Table 2) (37).

The aim of this triage system is to rationally allocateavailable resources to those in need of life-saving in-terventions with the highest chance of survival.Although seemingly impersonal, these criteria may be

imperative when necessary resources are either scarceor absent (38). This will be a difficult shift in practicefor many medical professionals, but several stateshave recently adopted (in consultation with medicalethicists and based upon principles of distributivejustice) guidelines on ventilator allocation that can beextrapolated to other invasive and resource-intensiveinterventions (39). Anecdotally, this has been doneinternationally as well. Under this framework, all pa-tients who require ventilation are ranked in tiers basedupon illness acuity, likelihood of survival to discharge,and the possibility of long-term survival. Resourcesare then distributed top down based on availability.Unlike strict age or comorbidity restrictions, thismodel allows for the ethical application of resourcesand provides the flexibility necessary for day-to-daycare. Using this framework, clinical decisions can bemade by a multidisciplinary group or individual pro-vider based on medical expertise, patient de-mographics, health system capacity strain, and theaccessibility of resources. Development of consis-tently applied institutional triage protocols shouldalso be considered for resource-intensive, life-savingprocedures that involve a high risk for health careworker exposure and may have limited usefulness,including cardiopulmonary resuscitation and the useof extracorporeal life support.

PREPAREDNESS, TEAM-BASED CARE, AND EFFORT

AUGMENTATION. Although clinically actionableCOVID-19 data are rapidly emerging, ongoing knowl-edge deficits preclude any medical systems fromcomplete preparedness. This uncertainty has moti-vated medical professionals to propose and adaptnovel care strategies. As previously described, staff-ing has been enhanced through the hiring of newnurses and reengagement of former nurses with pre-vious critical care experience. PPE procedures havebeen significantly refined, and patient transportationand necessary isolation processes have been imple-mented. Teams throughout the hospital, both at unitand system levels, must collaborate for the commongood to benefit each other and their patients. Thelargest threat to health care workers during thispandemic may not be the virus itself, but rather thefear and anxiety invoked by either not knowing apolicy or having differing policies across care set-tings. Empowering team members to offer sugges-tions to leadership and providing mental healthsupport to colleagues will be important measures toenhance patient care and protect the workforce.Rather than expecting readiness for every possiblescenario, teams must be agile and ready to respond tochange (40).

TABLE 2 Potential Adaptations of Military Medicine Principles to the CICU During the COVID-19 Pandemic

Tenets of Military Medicine Military Medical Examples CICU Examples

Preparedness Maintaining appropriate staffingCreating field hospitals

Staff alignmentPPE inventoryModifying telemetry units and holding areas for care of cardiac

critical care patients

Team-based care Ensuring adequate body armor/PPEPerimeter securityImproving morale

Limiting exposureEnsuring safety (PPE, security)Feeding staff/improving morale

Echelons of care Stabilization at point of closest medical contact Referring centers asked to exhaust capabilities before transfer

Augmenting the effort Oil tankers converted to hospital shipsNonsurgical specialties playing operational roles

CICU rooms converted to have negative pressure capabilitiesProceduralists or surgical specialties augmenting the

intensivist pool

Effective triage NATO classification of injured (immediate, delayed,minimal, expectant)

Effective triage of critically ill patients using clearly definedand ideally evidence-based protocols

Servant leadership Aligning teams Frequent updates and Q&A sessions (Town Halls with staff,virtual meetings, etc.)

NATO ¼ North Atlantic Treaty Organization; Q&A ¼ question and answer; other abbreviations as in Table 1.

Katz et al. J A C C V O L . 7 6 , N O . 1 , 2 0 2 0

Disruptive Modifications to Cardiac Critical Care During COVID-19 J U L Y 7 , 2 0 2 0 : 7 2 – 8 4

80

Institutional leaders should also be prepared toaugment critical care physician pools with nontradi-tional providers. Flexible call schedules and addi-tional levels of backup clinicians may be required tofill in when work-related exposures and infectionsde-stabilize the workforce. Finally, we must be pro-active in safely reintroducing care providers back intothe workplace once they have recovered from illness.

THE CARDIOGENIC SHOCK TEAM DURING COVID-19:

AN EXAMPLE. Many centers have developed exten-sive regional networks to facilitate uniform andtimely multidisciplinary interventions for patients incardiogenic shock. These shock teams focus on earlyrecognition, treatment, and transfer of patients totertiary centers capable of offering more advancedtherapeutics. In this model, definitive clinical de-cisions are often made by a multidisciplinary teamwithin the CICU and frequently at the bedside.However, with anticipated pandemic-influencedresource shortages dictating careful and deliberateuse of intensive care beds, together with socialdistancing and the need to minimize unnecessarypatient-provider exposures, modifications to existingteam-based structures may be required. For instance,device candidacy and interhospital transfer decisionscan be moved earlier in the triage and/or carepathway. In other words, mechanical circulatorysupport decisions can be shifted from the bedside to aphone call with referring institution practitionerswho can provide detailed patient information, he-modynamic, and metabolic data. This process ensuresthe transfer of only those patients in cardiogenicshock with a clearly delineated plan for temporarymechanical circulatory support and/or clear exitstrategies in line with available resources,

multidisciplinary consensus, as well as patient andcaregiver expectations.

A PRACTICAL BLUEPRINT TO ENHANCE

EDUCATION AND COLLABORATION

METHODS FOR EDUCATION AND TRAINING. Overthe preceding weeks, reports from Europe havedescribed overwhelmed ICUs and the need to mobi-lize health care professionals who do not typicallycare for critically ill patients (31,41). The limitedavailability of intensive care beds has even led to theprovision of acute care therapies in non-ICU settings(42). Colleagues from high-impact COVID-19 centershave already called upon the cardiovascular com-munity to take proactive measures (43). Critical carecardiologists and other CICU practitioners, particu-larly if called upon to staff other COVID-19�specificICUs, can take a proactive role in helping to educateproviders who may have limited experience orexpertise in the management of critically ill car-diac patients.

We propose several potential avenues by whichCICU leaders can educate others. First, simulation-based training has long been an effective way toteach ICU skills, including procedural competency(e.g., central line placement, ventilator management,and point-of-care ultrasonography) and promotinginterdisciplinary communication (44). Second, thecreation of care pathways, order sets, and protocolsfor providers in the ICU can help to reduce clinicalambiguity, promote best practices, and enhanceresource conservation (45). These may be particularlyimportant for providers less experienced in the com-plex ICU environment. Similarly, parsimoniousintensive care checklists may be useful and have been

FIGURE 2 The Role of the Critical Care Cardiologist

Pilot noveltechnological

solutions to extendcritical care reach

Consultation forinfected patientswith acute cardiac

complicationsEducate general

critical careproviders on

principles of cardiacmanagement

Lead heart teamsdeploying mechanical

support, includingECMO

Expertise inCardiovascular

Medicine

Expertise inCritical CareMedicine

Provide focusedcritical care trainingto primary cardiac

clinicians to extendICU capacity

Expand echoservices through

application of point-of-care ultrasound

(POCUS)

Help triageuninfected cardiac

patients to optimizeinpatient resources

and ensureemergent cases arerapidly evaluated

Leverage inpatientacute care

infrastructure tofacilitate clinical trial

enrollment

Assist withinstitutional

planning aroundnew ICU physical

plants

Direct critical carein COVID-19 ICUs

Testing, isolation, &treatment strategiesfor cardiac patients

with COVID-19 CRITICAL CARECARDIOLOGIST

The many opportunities to leverage the unique skill set of the critical care cardiologist during the COVID-19 pandemic. ECMO ¼ extracorporeal

membrane oxygenation; ICU ¼ intensive care unit.

J A C C V O L . 7 6 , N O . 1 , 2 0 2 0 Katz et al.J U L Y 7 , 2 0 2 0 : 7 2 – 8 4 Disruptive Modifications to Cardiac Critical Care During COVID-19

81

shown to improve patient safety and reduce errors(46). Third, avenues for rapid communication anddissemination of information must be developed.These can be leveraged to share both clinical suc-cesses and failures during a time when many bestpractices related to the management of SARS-CoV-2are being learned “on the fly.” Communication willalso need to be streamlined and, if possible, central-ized to prevent the sharing of inconsistent informa-tion from a myriad of sources. Finally, we will need totransfer knowledge from regions with more experi-ence treating these patients to regions just beginningto treat these patients, and we need to do it globally.As an example, critical care providers in Singaporeconducted simulation training exercises to address amyriad of resuscitation scenarios. Reports of theseexperiences have helped to improve providercommunication and have also led us to a better un-derstanding of where and when advanced mechanical

support strategies are most useful (47). Clinical “bootcamps,” didactic sessions, and on-line trainingmethods have similarly been used in Europe and NewYork (Table 1). In addition, educational imperativesare likely to evolve across various pandemic stages(Central Illustration) and will need to include facileresearch collaborations. Important lessons will belearned from prospective registries that define riskfactors, patterns of presentation, and variables asso-ciated with specific cardiac and respiratory outcomes.Pragmatic and adaptable trials will be required todetermine optimal care pathways, staffing models,and methods for efficient and equitable resourceallocation. Undoubtedly, operational aspects of clin-ical research have and will continue to be affected bythe pandemic. Although beyond the scope of thispaper, decisions regarding optimal trialmanagement will need to be fluid in response toevolving demands.

Katz et al. J A C C V O L . 7 6 , N O . 1 , 2 0 2 0

Disruptive Modifications to Cardiac Critical Care During COVID-19 J U L Y 7 , 2 0 2 0 : 7 2 – 8 4

82

LEVERAGING NOVEL TELEMEDICINE APPLICATIONS

TO ENHANCE CRITICAL CARE. The COVID-19pandemic has already affected both ambulatory andinpatient cardiac consultative practices, with manyinstitutions now transitioning to a telemedicineapproach either universally or on a case-by-case ba-sis. Telemedicine is not a new addition to the car-diovascular armamentarium because it has beenpreviously leveraged to improve access to patients inrural health environments and to augment homemonitoring programs (48,49). Over the past decade,telemedicine has also expanded into the intensivecare realm, allowing critical care physicians to treatpatients across geographically and resource diversehospital settings using advanced audiovisual in-terfaces (48,49). However, this has generally beenapplied to low-intensity sites, such as community-based, medical-surgical ICUs, and thus, there iscurrently little published guidance regarding CICU-specific telemedicine care.

Although there are considerable cost and time in-vestments required to institute telehealth systems ofcare, certain tenets of virtual medicine should beconsidered in response to the COVID-19 crisis. CICUproviders have been instructed to limit unnecessaryexposure to affected patients, using ICU flowsheetsand remote hemodynamic monitoring to evaluatepatient progress and titrate medications. These ob-servations can be combined with examinations per-formed by bedside nurses to generate operableclinical conditions for safe remote decision-making.Furthermore, the number of team members enteringpatient rooms should be limited whenever possible;instead, they should use tools such as mobile devicesto foster video-based discussions and even electronicstethoscopes to broadcast and vet certain physicalexamination findings and their pathologicalsignificance.

As more critical care cardiologists are ultimatelydeployed to noncardiac ICUs, it will also becomeincreasingly important that noncritical care cardiolo-gists left to staff the CICU have access to immediatecritical care consultation. Both “curbside” and formaltelemedicine consults should be readily availabledepartmentally, institutionally, regionally, nation-ally, and even globally, depending upon the impactthis pandemic ultimately has on both the workflowand workforce. Cardiology and Critical Care Medicinedepartments should consider staffing critical carecardiologists in advisory roles, making them availableby phone, video, or in person (when absolutelynecessary). On regional and national levels, theremay be opportunities to leverage cardiovascular

professional societies to support the disseminationof critical care cardiology expertisedvia HIPAA-compliant telecommunication and video-conferencing mechanismsdto those in need.Globally, these same societies, through their inter-national contacts, should prepare to help the devel-oping world as the pandemic advances.

COVID-19 has also presented us with new and un-usual barriers to effective patient�physician, phys-ician�family, and patient�family communication.Because family members are now frequently pro-hibited from hospital visitation, it would be advisableto consider novel telecommunication and video op-tions for patients to speak with loved ones, reviewtreatment choices, and even discuss goals of care.Particularly in the event that a patient is unable tocommunicate directly, these telemedicine platformscould then be used to assist physicians in providingdaily family updates in lieu of traditional face-to-facediscussions.

CONCLUSIONS

The COVID-19 pandemic has and will continue tostress our workforce, health care systems, and crit-ical resource supply and distribution chains. Inresponse, we need to be committed, cohesive, andinnovative to optimize care efficiency, ensure pro-vider safety, and improve patient outcomes. Criticalcare cardiologists must familiarize themselves withthe SARS-CoV-2 virus and its numerous clinicalmanifestations. Its unique cardiovascular pre-sentations and devastating cardiac sequelae willlikely lead many patients into CICU beds. Further-more, critical care cardiologists may find themselvesleaving their CICUs to staff non-cardiac and COVID-19�specific ICU settings (Figure 2). It is important forus to learn from the experiences of our colleagues inheavily affected regions of the United States,Europe, and Asia so that we can proactively developefficient and scalable models for health care de-livery, cultivate practical educational tools for teamtraining, and embrace technologies (e.g., telemedi-cine) that will enable us to collaborate effectively,despite social distancing imperatives. Finally, thispandemic should serve as a clarion call to our healthcare systems that we should continue to develop animble workforce that can adapt to change quicklyduring a crisis. We believe critical care cardiologistsare well positioned to help serve society in thiscapacity.

Paulo Coelho once wrote, “Life waits for somecrisis to occur before revealing itself at its most

J A C C V O L . 7 6 , N O . 1 , 2 0 2 0 Katz et al.J U L Y 7 , 2 0 2 0 : 7 2 – 8 4 Disruptive Modifications to Cardiac Critical Care During COVID-19

83

brilliant” (50). Although these are unusually chal-lenging times, we have the unique opportunity tocraft and use novel strategies that focus on clinicalagility and multidisciplinary collaboration, adapta-tions to care practices that, before this pandemic, mayhave been dismissed in favor of the status quo.

ADDRESS FOR CORRESPONDENCE: Dr. Jason N.Katz, 2301 Erwin Road, DUMC Box 3126, Durham,North Carolina 27710. E-mail: jason.katz@duke.edu.Twitter: @JasonKatzMD, @ShashankSinhaMD,@seanvandiepen.

RE F E RENCE S

1. Megginson LC. Lessons from Europe for Amer-ican Business (Presidential address delivered atthe Southwestern Social Science Associationconvention in San Antonio, Texas, April 12, 1963).Southwestern Social Science Quarterly 1963;44:3–13.

2. Shi Y, Yu X, Zhao H, Wang H, Zhao R, Sheng J.Host susceptibility to severe COVID-19 andestablishment of a host risk score: findings of 487cases outside Wuhan. Crit Care 2020;24:108–11.

3. Wu Z, McGoogan JM. Characteristics andimportant lessons from the coronavirus disease2019 (COVID-19) outbreak in China: summary of areport of 72314 cases from the Chines Center forDisease Control and Prevention. J Am Med Assoc2020 Feb 24 [E-pub ahead of print].

4. Jiang F, Deng L, Zhang L, Cai Y, Cheung CW,Xia Z. Review of clinical characteristics of coro-navirus disease 2019 (COVID-19). J Gen InternMed 2020 Mar 4 [E-pub ahead of print].

5. Inciardi RM, Lupi L, Zaccone G, et al. Cardiacinvolvement in a patient with coronavirus disease2019 (COVID-19). JAMA Cardiol 2020 Mar 27 [E-pub ahead of print].

6. World Health Organization. Coronavirus Disease2019; Situation Report – 70. Available at: https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200330-sitrep-70-covid-19.pdf?sfvrsn¼7e0fe3f8_4. Accessed March 31,2020.

7. Clerkin KJ, Fried JA, Raikhelkar J, et al. Coro-navirus disease 2019 and cardiovascular disease.Circulation 2020 Mar 21 [E-pub ahead of print].

8. Xiong TY, Redwood S, Prendergast B, Chen M.Coronaviruses and the cardiovascular system:acute and long-term implications. Eur Heart J2020 Mar 18 [E-pub ahead of print].

9. Madjid M, Safavi-Naeini P, Solomon SD,Vardeny O. Potential effects of coronaviruses onthe cardiovascular system: a review. JAMA Cardiol2020 Mar 27 [E-pub ahead of print].

10. Driggin E, Madhavan MV, Bikdeli B, et al.Cardiovascular considerations for patients, healthcare workers, and health systems during thecoronavirus disease 2019 (COVID-19) pandemic.J Am Coll Cardiol 2020 Mar 18 [E-pub ahead ofprint].

11. Guo T, Fan Y, Chen M, et al. Cardiovascularimplications of fatal outcomes of patients withcoronavirus disease 2019 (COVID-19). JAMA Car-diol 2020 Mar 27 [E-pub ahead of print].

12. Morrow DA, Fang JC, Fintel DJ, et al. Evolutionof critical care cardiology: transformation of thecardiovascular intensive care unit and theemerging need for new medical staffing and

training models: a scientific statement from theAmerican Heart Association. Circulation 2012;126:1408–28.

13. Katz JN, Shah BR, Volz EM, et al. Evolution ofthe coronary care unit: clinical characteristics andtemporal trends in healthcare delivery and out-comes. Crit Care Med 2010;38:375–81.

14. Sinha SS, Sjoding MW, Sukul D, et al. Changesin primary noncardiac diagnoses over time amongelderly cardiac intensive care unit patients in theUnited States. Circ Cardiovasc Qual Outcomes2017;10:e003616.

15. Bohula EA, Katz JN, van Diepen S, et al. De-mographics, care patterns, and outcomes of pa-tients admitted to cardiac intensive care units: theCritical Care Cardiology Trials Network ProspectiveNorth American multicenter registry of cardiaccritical illness. JAMA Cardiol 2019;4:928–35.

16. Brusca SB, Barnett C, Barnhart BJ, et al. Roleof critical care medicine training in the cardiovas-cular intensive care unit: survey responses fromdual certified critical care cardiologists. J Am HeartAssoc 2019;8:e011721.

17. Christian MD, Sprung CL, King MA, et al.Triage: care of the critically ill and injured duringpandemics and disasters: CHEST consensus state-ment. Chest 2014;146. e61S�74S.

18. Halpern NA, Tan KS. US ICU resource avail-ability for COVID-19. Available at: https://www.sccm.org/getattachment/Blog/March-2020/United-States-Resource-Availability-for-COVID-19/United-States-Resource-Availability-for-COVID-19.pdf?lang¼en-US. Accessed April 1, 2020.

19. Christian MD, Hawryluck L, Wax RS, et al.Development of a triage protocol for critical careduring an influenza pandemic. CMAJ 2006;175:1377–81.

20. Devereaux AV, Dichter JR, Christian MD,et al. Definitive care for the critically ill during adisaster: a framework for allocation of scarceresources in mass critical care: from a Task Forcefor Mass Critical Care summit meeting, January26-17, 2007, Chicago, IL. Chest 2008;133:51s–66s.

21. Jentzer JC, Bennett C, Wiley BM, et al. Pre-dictive value of the sequential organ failureassessment score for mortality in a contemporarycardiac intensive care unit population. J Am HeartAssoc 2018;7:e008169.

22. Welt FGP, Shah PB, Aronow HD, et al. Cathe-terization laboratory considerations during thecoronavirus (COVID-19) pandemic: from ACC’sInterventional Council and SCAI. J Am Coll Cardiol2020 Mar 16 [E-pub ahead of print].

23. Shavadia JS, Chen AY, Fanaroff AC, deLemos JA, Kontos MC, Wang TY. Intensive careutilization in stable patients with ST-segmentelevation myocardial infarction treated with rapidreperfusion. J Am Coll Cardiol Intv 2019;12:709–17.

24. van Diepen S, Katz JN, Morrow DA. Will car-diac intensive care unit admissions warrantappropriate use criteria in the future? Circulation2019;140:267–9.

25. De Luca G, Suryapranata H, van’t Hof AW,et al. Prognostic assessment of patients with acutemyocardial infarction treated with primary angio-plasty: implications for early discharge. Circulation2004;109:2737–43.

26. Tam CCF, Cheung K-S, Lam S, et al. Impact ofcoronavirus disease 2019 (COVID-19) outbreak onST-segment elevation myocardial infarction care inHong Kong, China. Circ Cardiovasc Qual Outcomes2020 Mar 17 [E-pub ahead of print].

27. Han Y, Zeng H, Jian H, et al. CSC expertconsensus on principles of clinical management ofpatients with severe emergent cardiovasculardiseases during the COVID-19 epidemic. Circula-tion 2020 Mar 27 [E-pub ahead of print].

28. Anderson JL, Adams CD, Antman EM, et al.ACC/AHA 2007 guidelines for the management ofpatients with unstable angina/non ST-elevationmyocardial infarction: a report of the AmericanCollege of Cardiology/American Heart AssociationTask Force on Practice Guidelines (Writing Com-mittee to Revise the 2002 Guidelines for theManagement of Patients with Unstable Angina/Non ST-Elevation Myocardial Infarction): devel-oped in collaboration with the American College ofEmergency Physicians, the Society for Cardiovas-cular Angiography and Interventions, and the So-ciety of Thoracic Surgeons: endorsed by theAmerican Association of Cardiovascular and Pul-monary Rehabilitation and the Society for Aca-demic Emergency Medicine. J Am Coll Cardiol2007;50:e1–157.

29. Ganapathy A, Adkihari NKJ, Spiegelman J,Scales DC. Routine chest xrays in intensive careunits: a systematic review and meta-analysis. CritCare 2012;16:R68.

30. Salik JR, Sen S, Picard MH, Weiner RB,Dudzinski DM. The application of appropriate usecriteria for transthoracic echocardiography in acardiac intensive care unit. Echocardiography2019;36:631–8.

31. Grasselli G, Presenti A, Cecconi M. Critical careutilization for the COVID-19 outbreak in Lom-bardy, Italy: early experience and forecast duringan emergency response. J Am Med Assoc 2020Mar 13 [E-pub ahead of print].

Katz et al. J A C C V O L . 7 6 , N O . 1 , 2 0 2 0

Disruptive Modifications to Cardiac Critical Care During COVID-19 J U L Y 7 , 2 0 2 0 : 7 2 – 8 4

84

32. Jacobs AK, Antman EM, Faxon DP. Develop-ment of systems of care for ST-elevationmyocardial infarction patients. Circulation 2007;116:217–30.

33. van Diepen S, Katz JN, Albert NM, et al.Contemporary management of cardiogenic shock:a scientific statement from the American HeartAssociation. Circulation 2017;136:e232–68.

34. Harris KM, Strauss CE, Duval S, et al. Multi-disciplinary standardized care for acute aorticdissection. Circ Cardiovasc Qual Outcomes 2010;3:424–30.

35. Ohio Department of Health. Director’s Orders.Available at: https://governor.ohio.gov/wps/wcm/connect/gov/5e89f600-3775-4bbd-9274-77163f36ba70/Director%27sþOrder-þVentilator.pdf?MOD¼AJPERES&CONVERT_TO¼url&CACHEID¼ROOTWORKSPACE.Z18_M1HGGIK0N0JO00QO9DDDDM3000-5e89f600-3775-4bbd-9274-77163f36ba70-n4OvUkA. Accessed April 3, 2020.

36. Demers G, Wightman J. Mass Casualty pre-paredness and response. In: Fundamentals ofMilitary Medicine. Fort Sam Houston, San Antonio,TX: Army Medical Department (AMEDD), 2019:503–29.

37. Brennan JA. Mass casualties and triage. In:Otolaryngology / Head and Neck Combat CasualtyCare. Fort Sam Houston, San Antonio, TX: ArmyMedical Department (AMEDD), 2019:171–85.

38. Seletz JM. Flugtag-88 (Ramstein Air ShowDisaster): an army response to a MASCAL. Mil Med1990;1554:152–5.

39. White DB, Lo B. A framework for rationingventilators and critical care beds during theCOVID-19 pandemic. J Am Med Assoc 2020 Mar 27[E-pub ahead of print].

40. Nessen SC, Cronk DR, Edens J, Eastridge BJ,Blackbourne LH. US Army split forward surgicalteam management of mass casualty events inAfghanistan: surgeon performed triage results inexcellent outcomes. Am J Disaster Med 2009;4:321–9.

41. Remuzzi A, Remuzzi G. COVID-19 and Italy:what next? Lancet 2020;395:1225–8.

42. Nacoti M, Ciocca A, Guipponi A, et al. At theepicenter of the Covid-19 pandemic and humani-tarian crises in Italy: changing perspectives onpreparation and mitigation. N Engl J Med 2020Mar 21 [E-pub ahead of print].

43. Biondi-Zoccai G, Landoni G, Carnevale R,Cavarretta E, Sciarretta S, Frati G. SARS-CoV-2 andCOVID-19: facing the pandemic together as citi-zens and cardiovascular practitioners. MinervaCardioangiol 2020 Mar 9 [E-pub ahead of print].

44. Seam N, Lee AJ, Vennero M, Emlet L. Simu-lation training in the ICU. Chest 2019;156:1223–33.

45. Bjurling-Sjoberg P, Wadesten B, Poder U,Jansson I, Nordgren L. Struggling for afeasible tool – the process of implementing aclinical pathway in intensive care: a groundedtheory study. BMC Health Serv Res 2018;18:831.

46. Pronovost P, Needham D, Berenholtz S, et al.An intervention to decrease catheter-relatedbloodstream infections in the ICU. N Engl J Med2006;355:2725–32.

47. Liew MF, Siow WT, MacLaren G, See KC. Pre-paring for COVID-19: early experience from anintensive care unit in Singapore. Crit Care 2020;24:83.

48. Harrington RA, Califf RM, Balamurugan A,et al. Call to action: rural health: a presidentialadvisory from the American Heart Association andAmerican Stroke Association. Circulation 2020;141:e615–44.

49. Kuehn BM. Telemedicine helps cardiologistsextend their reach. Circulation 2016;134:1189–91.

50. Coelho P. Eleven Minutes: A Novel. New York,NY: HarperCollins Publishers, 2004.

KEY WORDS cardiac critical care, crisis,pandemic