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ORIGINAL ARTICLE
Year : 2021  |  Volume : 22  |  Issue : 3  |  Page : 174-183  

Influence of COVID-19 pandemic on cardiac services in bahrain: Building cardiovascular protocol for future pandemics


Mohammed Bin Khalifa Bin Cardiac Center, Awali, Kingdom of Bahrain

Date of Submission09-Aug-2021
Date of Acceptance10-Aug-2021
Date of Web Publication11-Oct-2021

Correspondence Address:
Dr. Fawaz Khalil Bardooli
Mohammed bin Khalifa Bin Cardiac Center, Awali
Kingdom of Bahrain
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/heartviews.heartviews_81_21

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   Abstract 


Background: There are different protocols initiated to maintain the workflow in cardiovascular units around the world. Variable responses were seen in different populations. We adapted certain protocols during coronavirus disease-2019 (COVID-19) pandemic because we want to know the key element that maintains an acceptable standard of cardiovascular care during future pandemics.
Methods: Four hundred and fifty-four cardiac patients were admitted during COVID-19 era. Patients from March to July 2020 were included in this study. Those patients were divided into two periods: strict-COVID-19 from March 19, 2020, to May 18, 2020 (132 patients) and mid-COVID-19 from May 19, 2020, to July 18, 2020 (322 patients). These were compared to admissions at the pre-COVID-19 era from January 19, 2020, to March 18, 2020 (600 patients). All patients' data were collected through the quality department from the electronic medical records.
Results: Throughout the COVID-19 pandemic, the admission number and ST-elevation myocardial infarction (STEMI) cases were dramatically reduced during the strict-COVID-19 time yet recovered back in the mid-COVID-19 period. The admission rate was reduced from 600 to 132, while the STEMI cases dropped from 91 in pre-COVID-19 to 41 in strict-COVID-19 and then back to 81 cases in mid-COVID 19 period (P > 0.05/P = 0.02 between pre and mid-COVID-19 periods).
Conclusion: Our cardiac center continues to serve our population without a complete lockdown period due to multiple key elements adapted during this pandemic. The flexibility in the protocols of managing acute cardiac cases has maintained the mortality rate stable through all COVID-19 periods and return to working efficiently to near-normal levels.

Keywords: Acute coronary syndrome, pandemic, protocol, ST-elevation myocardial infarction


How to cite this article:
Bardooli FK, Hasan J, Hussain T, Abdulrahman A, Al Shaikh S. Influence of COVID-19 pandemic on cardiac services in bahrain: Building cardiovascular protocol for future pandemics. Heart Views 2021;22:174-83

How to cite this URL:
Bardooli FK, Hasan J, Hussain T, Abdulrahman A, Al Shaikh S. Influence of COVID-19 pandemic on cardiac services in bahrain: Building cardiovascular protocol for future pandemics. Heart Views [serial online] 2021 [cited 2021 Dec 1];22:174-83. Available from: https://www.heartviews.org/text.asp?2021/22/3/174/328027




   Introduction Top


Coronavirus disease-2019 (COVID-19) was first discovered in Wuhan, China, and propagated to be a pandemic afterward. The pandemic is caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2).[1] Although the coronaviruses family gave us epidemics in the past like the SARS-CoV in 2003 and Middle Eastern respiratory syndrome-CoV in 2012,[2] the novel coronavirus is characterized by a high pathogenicity rate implicating a high number of deaths.[3]

One primary problem with COVID-19 is that it has a high mortality rate for patients with comorbidities such as hypertension, diabetes mellitus, and ischemic heart disease.[1] Part of the COVID-19 infection course is acute myocardial injury as evidenced by increased cardiac biomarkers which is attributed to multiple factors, in particular immune-mediated myocarditis, demand-supply mismatch secondary to respiratory failure, downregulation of angiotensin-converting enzyme endothelial injury, and plaque rupture mediated elicited by inflammation or stress.[4]

In Bahrain, one interventional cardiac center serves 0.5 million populations. During the COVID-19 era, the cardiac center that provides the leading cardiology service in Bahrain has adapted strict protocol to deal with COVID-19 pandemic before the corona heatwave arrival. Acute coronary syndrome (ACS) possess a huge burden on mortality and community safety.

The management of ST-elevation myocardial infarction (STEMI) involves different departments starting with emergency access, cardiologist and interventionist, mode of revascularization, cardiac catheterization team, and finally, cardiac care unit (CCU). During the COVID-19 era, all elements of this chain have been affected in variable degrees.

Here, we elaborate on the flexibility of the protocols managing the STEMI during different phases of COVID-19 era and report changes in presentations and outcomes in patients admitted to our institution following the adapted protocols. This experience should set up a model to deal with future disaster situations.


   Methods Top


Data of all admission in a single cardiac center (Mohammed Bin Khalifa Bin Salman Al Khalifa) in Bahrain were collected from January 18, 2020, to July 19, 2020. We compared three time intervals: Pre-COVID-19, strict-COVID-19, and mid-COVID-19 era, each of 2 months duration. The testing and management protocols will be explained for each era as required.

Pre-COVID-19 era

Two months before implementation of the COVID-19 protocol, patients visiting cardiac center were retrospectively retrieved from the electronic medical records admission system. This represents the period from January 18, 2020, to March 18, 2020.

Strict-COVID-19 era

This period describes the time from March 18, 2020, to May 18, 2020. This is when the COVID-19 pandemic wave initially hits Bahrain. On March 18, 2020, strict protocol was adapted to ensure the safety of the center, patients, medical staff, and operating theaters. There was a fear of that we would lack catheterization laboratory materials due to the lockdown situation. The cardiology center serves percutaneous intervention and cardiac surgery procedures.

Education was focused on improving the awareness of medical practitioners and the population about hygiene measures and methods of transmission.

COVID-19 testing protocol

The only available method of testing during this phase was the real-time-reverse transcriptase–polymerase chain reaction test (RT-PCR). The current diagnosis of COVID-19 infection relies mainly on the centralized laboratory-based-PCR. It is the major workhorse in the field of molecular diagnostics. RT-PCR can amplify and detect a single copy of the specific genomic sequence, and therefore, it is extremely sensitive.[5] Furthermore, RT-PCR is a quantitative technique as the number of copies of RNA generated in a PCR increases exponentially, and it is proportional to the viral load.[6]

Although RT-PCR provides a relatively rapid result (average 3–4 h), it is limited by transportation to the laboratory and the requirement to batch samples in a large run.

Acute coronary syndrome management

All ACS patients were admitted after obtaining a negative result of COVID-19. They were treated medically for an average of 48 h then discharged home if pain-free. If medication failed to control the symptoms, the invasive strategy was planned. These patients were contacted in a month's time with telephonic consultation to ensure the absence of angina pain on optimal medical therapy.

Special protocol for ST-elevation myocardial infarction patients

All patients with STEMI were assessed initially by the emergency triage team for thrombolysis. A checklist of contraindications for thrombolysis was available for the admitting physician. Once a patient fulfilled the criteria, metalyse (tenecteplase thrombolysis) injection intravenously was given according to the body weight and local protocols.

If thrombolysis was contraindicated, then the patient followed up the primary percutaneous coronary intervention (PPCI) protocol. Those who failed thrombolysis, re-infarcted, or developed instability post thrombolysis were listed for urgent rescue percutaneous coronary intervention [Flowchart 1].



Emergency unit

During this period, the Chest Pain Clinic (CPC – a special unit receiving emergency patients with chest painhad been temporarily closed. All patients were directed to the main hospital emergency department. A cardiologist evaluated those with genuine cardiac sounding chest pain or cardiac illness after routine COVID triaging.

Cardiac care unit and critical conditions

As a plan in combating the COVID-19 pandemic and redistributing workforce and medical facilities, CCU activity had been reduced by 50%. Six beds were only open out of the 12 beds. This ran parallel to the shortage of nurses and physicians who had been both assigned to COVID-19 facilities.

Catheterization laboratory elective procedures

During this time, elective activities were on hold. The catheterization laboratory was serving only emergency intervention and lifesaving procedures.

Mid-COVID-19 era

This period comes after the country's restrictions had been slightly eased (guided by the national Bahrain COVID-19 taskforce team protocols). This describes the period from May 19, 2020, to July 18, 2020. The medical community was more liberal and open to receive more variety of cases. However, the spread in the community became more rapid. The concern of acquiring a COVID-19-positive case in a cardiac unit with no full isolation was still worrisome, but the feeling of resuming near-normal activity was on demand.

COVID-19 testing protocol

Whereas in the early COVID-19 era standard RT-PCR was the only available test, in May 13th, the rapid-RT-PCR test machine, GeneXpert, was available. The Xpert Xpress SARS-CoV-2 (Xpert) test (Cepheid, Sunnyvale, CA, USA) received Emergency Use Authorization (EUA) status on March 20, 2020.[7] The Xpert test platform integrates specimen processing, nucleic acid extraction, RT-PCR amplification of SARS-CoV-2 RNA, and amplicon detection in a single cartridge. Specimens can be tested as soon as they are received, as the testing instrument provides random access to individual cartridges. The results were generated in approximately 45 min.[6]

Acute coronary syndrome management

During this period, patients were admitted after COVID-19-negative swab to cardiac wards, and within 24 h patients undergo invasive percutaneous angiography/angioplasty. Patients were then discharged within a day or 2.

Special protocol for STEMI patients

All STEMI walk-in patients either received thrombolysis or underwent PPCI, as per the decision of the interventional cardiologist on call. However, a mandatory GeneXpert nasopharyngeal swab was required before the admission. If the patient was unstable, then a full preventive precautionary equipment (PPE) would be considered, and PPCI was proceeded before the COVID-19 results arrived. Patients with COVID-19-negative swabs would remain in the cardiac unit, whereas those with positive were directed to a COVID-19 facility after stabilizing their acute event. They were followed up by a dedicated cardiologist at the COVID-19 facility to ensure continuity of the treatment [Flowchart 2].



Emergency unit

During this time, Chest Pain Clinic (CPC) had reopened. Certain precautionary measures were adapted, including:

  1. Mandatory full PPE wear to all working staff, including clerks,
  2. Special visual triage was modified to cover patients who may be in home isolation [Checklist 1]
  3. Two closed rooms with high-efficiency particulate air filters were spared for patients with suspected or positive COVID-19 symptoms who presented with chest pain for evaluation
  4. Special training program for physicians about ventilator support and COVID-19 questions to cover in an emergency.



Cardiac care unit and critical conditions

As are many hospitals around the world, our CCU has been negatively affected by the COVID-19 pandemic. Shortage of staff, limitation of beds, and extra PPE precaution measures all contributed to the difficulty in handling patients.

Our CCU beds increased from 6 to 8. During this period, hospital transfers from tertiary cardiac units were accepted if patients fulfilled the criteria for intervention. However, same-day procedure and discharge were encouraged if feasible. Positive noninvasive ventilation was avoided to eliminate the risk of aerosol spread.

Catheterization laboratory procedures

In addition to the acute emergency cases, elective catheterization laboratory activity has been resumed gradually. A maximum of 6–8 cases per day were allowed. All these cases underwent a COVID-19 swab preprocedure (24–72 h prior procedure). Hospital-to-hospital patient transfers had been resumed with COVID-19-negative swab.

Cardiac catheterization laboratory preparation during COVID-19 pandemic

Four points were the cornerstone for the establishment of safe and effective catheterization laboratory activity during the COVID-19 era: first, patient measures which focused on ensuring patient testing before entering cath lab; second, staff measures, these focused on continuous education and practicing donning and doffing among all the staff; third, department measures, this included access to protocols and reference about safety measures when handling COVID-19 positive or suspected cases; and fourth, testing measures, the catheterization laboratory team had the access to all patients' results of swabbing to ensure complete and correct results before accepting the elective cases [Figure 1].
Figure 1: Catheterization laboratory preparations during COVID-19 pandemic

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Noninvasive laboratory preparation during COVID-19 pandemic

A strict protocol has been adapted [Figure 2] to limit the time of the procedures, test patients undergoing a special procedure, and select educated staff of COVID-19 pandemic.
Figure 2: Noninvasive laboratory preparations during COVID-19 pandemic

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Cardiac clinic activity during COVID 19 pandemic

Since the beginning of COVID-19 wave, the cardiac outpatient department adapted telephonic consultation. All patients were contacted through their following team to arrange further visits and/or blood tests if needed. All patients were contacted by their physician team to discuss their concerns, arrange future visit and/or tests if needed. Furthermore, all patients were instructed to register full address details through a link in SMS to receive their own medication through a dedicated delivery company. A structured flowchart has been distributed among all cardiac teams to ensure a uniform process [Flowchart 3].



Statistical analysis

Continuous variables were represented as mean ± standard deviation for symmetric distributions and median (lower quartile–upper quartile) for skewed distributions. Discrete variables were summarized as frequency (percentage). To compare between the time periods, for discrete variables, normal approximation and Fisher's exact test were used, and for continuous variables, Student's t-test and Mann–Whitney U-test were used. The resulting P values were adjusted by false discovery rate. P < 0.05 was considered statistically significant. Analyses were performed using SPSS ver. 25.0, (IBM SPSS Statistics, Version 25.0 Armonk, NY: IBM Corp.) Minitab 17 and R System for Statistical Computing.


   Results and Discussion Top


Between January 18, and July 18, 2020, all admissions were followed up by the quality department in the cardiac unit. The total number of patients included from March 18 to July 18 was 454 patients, while total admissions between January 18 and March 18 were 600 patients [Table 1].
Table 1: Baseline characteristics of admitted patients in the studied time periods

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Admissions and re-admissions

Due to the implementation of different protocols, the total number of admissions declined in the strict period but slightly increased in mid-COVID-19 period reaching more than 50% of the pre- COVID-19 period [Figure 3]. This is partially due to the persistent fear of people to visit the hospital and catch the COVID-19 virus [Table 1]. This finding was consistent with previous studies.[8] [Figure 3].
Figure 3: Monthly cardiovascular admissions during COVID-19 pandemic

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Among three COVID 19 periods, majority of the admission were ACS. The percentage, however, varies from 38.5% in pre-COVID-19, 70.4% in strict-COVID-19, and 50% in mid-COVID-19 period.

Arrhythmia cases were contributing to 2.67% of total admissions in pre-COVID-19, this increased to 6% during strict- and mid-COVID-19 periods.

Throughout all the three periods, the rates of readmission were similar as no statistically significant difference was found, except in elective cases, which were not booked during the strict period of COVID-19. During the mid-COVID-19 period, the elective admission rate increased back to 3.4% [Table 2], [Table 3] and [Figure 4].
Table 2: Clinical findings and outcomes of admitted patients during the studied time periods

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Table 3: Adjusted P Values for Pairwise Tests

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Figure 4: Re-admission rate during COVID-19 pandemic (acute and elective)

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Myocardial infarction

The total STEMI cases pre-COVID-19 was significantly greater than the STEMI cases in strict and mid periods: 91, 41, and 81 cases, respectively (P < 0.001) [Table 2].[9],[10] The number of primary PCI cases was significantly lower in the strict period (7 cases) compared to pre- COVID-19 (61 cases) and mid-COVID-19 (50 cases) [Figure 5]. This is purely related to the protocol adapted by each institute.[8] On the other hand, thrombolysis cases were greater in strict cases in comparison with the other two periods (73%, 28%, and 10%, respectively).
Figure 5: Revascularization strategy in ST-elevation myocardial infarction patient during the COVID-19 phases

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As for STEMI mortality rate and overall mortality rate, no statistically significant differences were found between the three periods. Surprisingly, there was no difference in the average length of stay for all STEMI patients in pre- and mid-COVID-19 times.

The patient's average length of stay was shorter in the mid-COVID-19 period compared to pre-COVID 19 (P = 0.012). This reflects the effect of both early discharge protocol with the reintroduction of early invasive management strategy of ACS admissions at the mid-COVID-19 period [Figure 6].
Figure 6: Average length of in-hospital stay in ST-elevation myocardial infarction patients during the COVID-19 time

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Despite the thrombolysis treatment strategy in the strict-COVID-19 period, ejection fraction in all STEMI did not differ significantly from pre- and mid-COVID-19 periods. An interesting finding that may be explained by the sicker patients coming late requiring immediate invasive procedure ending with poor left ventricle function compared with those receiving thrombolysis. Another explanation, during the mid-COVID-19 period, most of those who received thrombolysis had undergone pharmacoinvasive strategy within 24 h. This may have helped to preserve the myocardium. In STEMI, the mortality rate was 3.3% in pre-COVID-19, 9.7% in strict-COVID-19, and 3.7% in mid-COVID-19. However, it was not statistically significant (P < 0.05).

Cathlab procedures

It is obvious that during the strict-COVID-19 time, less invasive procedures were performed, mainly emergency cases when failed medical therapy. This has eased later with the decrease of the daily new cases of COVID-19 in Bahrain and the liberal protocol was implanted.

Diagnostic and interventional coronary angiogram procedures were reduced during strict-COVID-19 period. While the numbers of diagnostic angiogram continued to decline, percutaneous angioplasty procedures increased during mid-COVID-19 era. This is mainly due to selection criteria.

Percutaneous coronary intervention declined by 24% but then returned to almost the same level during mid-COVID-19 (161 patients). Certainly, there was a more strict indication for coronary angiogram after COVID-19 compared to pre-COVID-19 era.

Intracoronary imaging, intravascular imaging, and optical coherence tomography were used in 27 cases in the pre-COVID-19 and 22 cases in mid-COVID-19. No intracoronary imaging was performed during strict-COVID-19.

Peripheral artery disease, carotid intervention, and trans-aortic valve procedure services were completely shut down during strict-COVID-19 period and resumed gradually later.

Electrophysiology and structural heart disease procedures were reduced during strict-COVID-19 and most of the procedures returned to pre-covid levels gradually in mid-COVID-19 [Figure 7].
Figure 7: Catheterization laboratory activity during COVID-19 time. IABP: Intra-aortic balloon pump, TAVI: Transaortic valve insertion, ASD: Atrial septal defect, PS: Pulmonary stenosis, PDA: Patent ductus arteriosus, PPM: Permanent pacemaker, ICD: Implantable cardiaoverter-defibrillator, EPS: Electrophysiology study

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Mortality in hospital

There was a nonsignificant increase of in-hospital STEMI mortality cases during strict-COVID-19 period, which may be related to the use of thrombolysis as the main therapy for STEMI patients. On the other hand, there was a nonsignificant increase in all-cause mortality during strict- and mid-COVID-19 (3% and 2.8, respectively) compared to pre-COVID-19 (1.67%). Some cardiac cases probably died in the COVID-19 facility and did not come to our pool.

The key factors in setting up model to combat future pandemic

COVID-19 virus is genuinely a new virus; therefore, the adapted protocol dealing with this virus may change accordingly. Safe work environment is an important key to compete any pandemic. The availability of PPE protection tools to all health workers ensures high-quality services. Patients should feel safety when entering the hospital, this is achieved by continuous education and explaining the precautionary measures.

Initiating a protocol to organize the workload is important, but having the flexibility to adjust it based on the total daily COVID-19 cases detected is essential. Departmental measures organized the workflow and reduced the unnecessary exposure to patients. Video illustrations played an important key element in educating staff and drawing scenarios of dealing with COVID-19 positive patients.

Treating cardiac patients during a pandemic is not as ideal as in normal times, yet maintenance of a standard care is crucial. At the beginning of the pandemic, thrombolysis was the main therapeutic treatment for all patients with STEMI presentation unless contraindicated. However, introducing back the invasive strategy once the curve became flattened contributed to maintain low mortality and reduce hospital stay.

A strict plan of testing and isolation algorithm supervised by the infection control team was a core key element to maintain the floor clean. Teleconsultation practice in outpatient clinic visits, selective physical clinic visit strategy, and home-delivery medication have reduced the spread of infection among patients and the medical community while maintaining doctor–patient relationships.

There are few limitations in this study. It is a retrospective study, so selection bias is a possibility. It is a single-center study; a certain number of cardiac patients were not included in the study as they went to the COVID-19 facility.


   Conclusion Top


The admission rate was reduced during strict-COVID-19 time like many other reports, but the acute readmission rate was the same throughout the COVID-19 times compared to pre-COVID-19 period.

Switching to conservative approaches during an early pandemic is not a bad idea to preserve resources and buy time to understand the disease's nature. Yet, providing a safe invasive alternative in emergency cases is very essential. There are a few key steps that are essential in any protocol against future pandemics to maintain a safe environment, initiate rules at each department according to the nature of the pandemic, and minimize staff interfering with the patients and early isolation of pandemic patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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