March 20, 2020 — The Centers for Medicare and Medicaid Services (CMS) announced March 18, 2020, that all elective surgeries, non-essential medical procedures and dental procedures should be delayed during the novel coronavirus (COVID-19, SARS-CoV-2) outbreak. This includes all type of invasive and non-invasive cardiovascular exams and procedures, effecting all facets of cardiology departments from ECG and echo labs, to interventional and EP labs and cardiovascular surgeries. This moves into uncharted territory for U.S. hospitals in the modern age needing to determine what cardiac procedures are elective virus essential.
This move by CMS was already starting to take effect in many hospitals across the country where healthcare systems took stock of their own medical supplies on hand, staffing and potential impact of large numbers of patients coming into the hospitals with COVID-19 infections.
The cancellation and postponement of procedures by CMS and local hospitals has three goals:
1. It is to help with containment efforts by reducing patient and family travel to hospitals, which are at the center of the COVID-19 outbreak.
2. Delaying procedures will help preserve and inventory personal protective equipment (PPE), hospital beds and ventilators and other medical supplies.
3. With the start of social distancing and the shut down of all large gatherings, this has severely impacted blood drives and other blood donations, so the nation's blood banks have severely limited supplies.
Defining Elective Cardiovascular Procedures in the New Normal Under COVID-19
"This is a complicated issue and a moving target," said Ehtisham Mahmud, M.D., FSCAI, chief, Division of Cardiovascular Medicine, executive director of medicine, Cardiovascular Institute, director of interventional cardiology and cardiac cath lab at UC San Diego Medical Center, and president of the Society for Cardiovascular Angiography and Interventions (SCAI). We are doing things different this week than we did last week, and we might do things differently again next week."
In terms of cardiology, this means all procedures that are not life threatening where the patient is stable should be deferred to a later date. However, patients should be prioritized for therapy in the case of ST-elevated myocardial infarction (STEMI), hemodynamically unstable patients and others with acute, life-threatening conditions, or at high risk for a near term hospital admission. He said these patients will still receive cardiac catheterizations, cardiovascular surgery or structural heart procedures for MitraClip and transcatheter aortic replacement (TAVR) under certain circumstances. All other procedures are being postponed until further notice based on the spread and infection rates of COVID-19.
He said most hospitals, including his own, are moving to telehealth visits via phone or online to continue clinic work with patients, including those with chronic conditions such as heart failure.
"Patients who have troponin positivity that come in with mild to moderate symptoms and settle down relatively quickly, until we can demonstrate that they do not have COVID-19, then SCAI is recommending a more conservative strategy," Mahmud explained. "This is mostly as it relates to the unstable or inpatients coming in through the emergency room. There clearly are going to be patients who are COVID-19 positive and we need to take the appropriate protection for our Cath lab staff and physicians to ensure we do not endanger others."
Like many hospitals across the country, he said UC San Diego determined a week ago before the CMS announcement that they needed to review what procedures across the hospital would be considered "elective."
"I think a better term to use is essential versus non-essential elective cases," Mahmud said. "Presently, anyone with stable angina, whether they need a diagnostic catheterization or an interventional procedure, are clearly the first group of patients we can wait on." He said procedures and tests for these patients at UC San Diego are being delayed for at least two weeks to see how well containment efforts are going.
Watch the VIDEO: Cancelling Non-essential Cardiac Procedures During the COVID-19 Outbreak — an interview with SCCT President Ehtisham Mahmud, M.D.,
CMS Says Preserving Protective Equipment and Clinicians is Key in Containing Outbreak
“The reality is clear and the stakes are high — we need to preserve personal protective equipment for those on the front lines of this fight,” said CMS Administrator Seema Verma.
CMS said this move will not only preserve equipment but also free up our healthcare workforce to care for the patients who are most in need. Additionally, as states and the nation as a whole work toward limiting the spread of COVID-19, healthcare providers should encourage patients to remain home, unless there is an emergency, to protect others while also limiting their exposure to the virus.
The recommendations provide a framework for hospitals and clinicians to implement immediately during the COVID-19 response. The recommendations outline factors that should be considered for postponing elective surgeries, and non-essential medical, surgical and dental procedures. Those factors include patient risk factors, availability of beds, staff and PPE, and the urgency of the procedure. This will help providers to focus on addressing more urgent cases and preserve resources needed for the COVID-19 response. The decision about proceeding with non-essential surgeries and procedures will be made at the local level by the clinician, patient, hospital, and state and local health departments.
The recommendations can be found here: https://www.cms.gov/files/document/31820-cms-adult-elective-surgery-and-procedures-recommendations.pdf
These recommendations, and earlier CMS guidance and actions in response to the COVID-19 virus, are part of the ongoing White House Task Force efforts. Track the Task Force response to COVID-19
CMS Offers Recommendations on Reopening Healthcare in Areas of Low COVID-19 Cases - Update from April 20, 2020
Related Cardiology Related COVID-19 Content:
VIDEO: Cancelling Non-essential Cardiac Procedures During the COVID-19 Outbreak — Interview with SCCT President Ehtisham Mahmud, M.D.,
VIDEO: What Cardiologists Need to Know about COVID-19 — Interview with Thomas Maddox, M.D.
Additional COVID-19 Resources for Clinicians:
Johns Hopkins Coronavirus Resource Center with inteavtive map of cases in U.S. and worldwide