How Our Heart Program Has Prepared for – and Responded to – COVID-19

By Lars G. Svensson, MD, PhD

At present, Cleveland Clinic finds itself in the position of being well prepared for the challenges that the COVID-19 pandemic has brought to the communities we serve in Ohio. Thanks to the foresight and policies of Ohio’s governor and public health leaders, our state has kept community spread of the virus relatively contained, allowing Cleveland Clinic and other Ohio healthcare providers to avoid a surge of high-acuity COVID-19 cases to date. Indeed, we are now opening up again to offer surgery and procedures to patients beyond those requiring immediate intervention.

Cleveland Clinic health system has made extensive preparations to be ready for worst-case scenarios under the direction of our CEO and President Tom Mihaljevic, MD, and other physician leaders who have closely advised Ohio’s governor. While we do not have direct lessons to share from managing an excess of COVID-19 patients like our colleagues in the pandemic’s major hot spots, we offer here an overview of a few ways that we have prepared for and responded to the pandemic, particularly within our Miller Family Heart, Vascular & Thoracic Institute. My hope is that this might provide some helpful guidance to others who may be girding for a worsening of the pandemic in their communities.

Current state of COVID-19 care at Cleveland Clinic

We continue to care for patients with COVID-19 at our hospitals and have discharged many patients who have recovered from COVID-19.

We have preliminary data from an analysis of COVID-19-positive non-ICU patients at Cleveland Clinic hospitals who underwent remote cardiac telemetry monitoring early in the pandemic’s course in Ohio. These data show that 83% of these patients remained free of a composite endpoint of death, ICU transfer, emergency response team activation or increased oxygen requirements. The remaining 17% of patients tended to present with dyspnea and elevated troponin T and C-reactive protein.

On March 18, Cleveland Clinic suspended nonessential surgeries and procedures to conserve hospital beds, equipment and supplies. More recently, Ohio’s governor asked the state’s hospitals and physicians to submit a plan by April 22 for resuming some additional surgeries and procedures; as a result, we are restarting procedures. Patients will be tested for COVID-19 before coming in for procedures and surgery. Scheduling will be based on careful consultation with patients about symptoms, risks and benefits.

Preparing for a potential surge

The suspension of nonessential procedures freed up many of our 2,100 Heart, Vascular & Thoracic Institute caregivers to cross-train for new roles to help staff three labor pools (physicians/advanced practice providers, nurses and other caregivers) to support overall Cleveland Clinic efforts to prepare for a potential surge in COVID-19 patients. These efforts included the swift conversion of an education building into a potential surge hospital, as detailed two paragraphs below. Fortunately, we have not needed to activate the surge hospital to date.

A major component of cross-training was fresh instruction in the use of ventilators and post-intubation management, conducted with our cardiothoracic anesthesiology and pulmonary/critical care colleagues. Also key has been preparatory work to ensure adequate extracorporeal membrane oxygenation (ECMO) capacity. Our respiratory ECMO management team has carefully prepared an ECMO triage algorithm to cover our usual ECMO demands for lung transplant patients and others needing urgent procedures while maximizing the ability to meet new COVID-19 demand. We supplemented our existing ECMO machines with an order for more, and our perfusion team devised means to covert other pumps for use in ECMO if needed.

As mentioned above, the centerpiece of Cleveland Clinic’s preparations has been the temporary conversion of our 477,000,000-square-foot Health Education Campus building from an education site to a surge hospital to house up to 1,000 beds for low-acuity COVID-19 patients. That feat, which was accomplished in less than a month (as profiled in this Consult QD article), was undertaken to meet projected demand under modeling-based worst-case scenarios in which minimal or no social distancing was adopted. The surge hospital — located just across the street from the hospital buildings of our main campus for easy transfer of patients and supplies — was ready to accept patients on April 15. It has not yet been needed, but it remains a reassuring supplement to the 2,800 general medical beds and 550 ICU beds in our Northeast Ohio hospitals (including some 120 beds in the Heart, Vascular & Thoracic Institute). Shannon Pengel, MSN, RN, NE-BC, Clinical Nursing Director for our Heart, Vascular & Thoracic Institute, helped lead the charge in conceptualizing and executing this monumental facility transformation.

Keeping patients and caregivers safe

Like other health systems across the nation, Cleveland Clinic has witnessed a concerning decline in demand for emergency care. For instance, acute activations of our cardiac catheterization labs decreased by 58% in the month from March 15 to April 15 compared with the average for that period over the prior five years. We also have anecdotal reports of patients delaying coming to the hospital for acute myocardial infarction, including one patient with a post-infarction ventricular septal defect who survived emergency surgery. Our clinicians have responded by doing public education via the media about the importance of not delaying emergency care-seeking during this pandemic.

For those patients we’ve been able to see, we have revised or introduced a host of care protocols to reflect the new COVID-19 reality. Revisions include everything from protocols for ST-elevation myocardial infarction to enhance patient and provider safety to protocols for remote cardiac telemetry monitoring of inpatients to ensure increased vigilance for QT interval prolongation in those receiving hydroxychloroquine and azithromycin, who represent half of our non-ICU patients with COVID-19. Newly introduced protocols include, among others, guidelines for COVID-19 testing before patients undergo surgery or cardiovascular procedures (including transesophageal echocardiography) and a protocol for diagnosis, prevention and treatment of venous thromboembolism in patients with COVID-19. The latter was developed by our Section of Vascular Medicine in conjunction with medical ICU, cardiology, pharmacy, hematology and lab medicine colleagues. A consensus document was created to address risk stratification in view of these patients’ elevated thrombosis risk, and more-aggressive anticoagulation strategies were devised.

We have asked established patients to use virtual visits to receive care whenever possible, to limit in-person appointments to cases where a physical exam is essential. Virtual visits are also offered to new patients in Ohio and, when possible, patients from other states. Additionally, our Heart, Vascular & Thoracic Institute physicians are using telemedicine platforms to remotely conduct some inpatient rounding and consultations via iPads in patient rooms to reduce the bidirectional risk of patient-provider virus transmission and help preserve personal protective equipment.

Another crucial element of safety is supporting our caregivers’ mental health at this stressful time and helping them meet new work-life balance demands. While much of this caregiver support is offered at the enterprise level through excellent Cleveland Clinic programs for counseling, mentoring, childcare assistance and more, our Heart, Vascular & Thoracic Institute has developed supplemental offerings, such as our Neighborhood Groups project. Under this initiative, caregivers are divided into small groups based on their home ZIP codes and then connected digitally to help and encourage them to keep in touch and provide practical support to each other at the local level.

Ramping up research efforts

On March 17, Cleveland Clinic’s IRB approved creation of the COVID-19 Research Registry to expedite COVID-19-related clinical research across our health system. Drawing on data from all patients who undergo COVID-19 testing, the prospective registry is designed to use predictive analytics to address three broad questions:

• Who tests positive?
• Why do some patients become sicker from COVID-19?
• Which available treatment options are effective against COVID-19?

Data collection is enabled in our electronic medical record system, and outcomes to be assessed include mortality, hospitalization, ICU stay, need for ECMO and need for mechanical ventilation. In addition to fueling data research to aid individualized risk prediction and more, the registry will support clinical trials and collection and analysis of specimens for Cleveland Clinic’s enterprise-wide biorepository.

The registry includes workstreams to coordinate research ideas and efforts within and across specific therapeutic areas; our Cardiovascular Research Workstream is led by Mina Chung, MD. Proposals submitted to this workstream have involved topics ranging from the use of echo to predict outcomes to questions around the role of cardiovascular medications that act on the ACE2 receptor.

Cleveland Clinic is involved in various national studies of proposed treatments for COVID-19, such as a randomized controlled trial of hydroxychloroquine plus azithromycin. Among notable efforts coming out of our Heart, Vascular & Thoracic Institute is an investigator-initiated study of the IL-1 antagonist canakinumab for acute myocardial injury in patients hospitalized for COVID-19 with elevated troponin, C-reactive protein and brain natriuretic peptide.

On the road again

While we are gearing up for a return toward our standard cardiovascular and thoracic care offerings, we are receiving requests for patients without COVID-19 to be sent to Cleveland Clinic from cities hit badly by the pandemic. Additionally, Cleveland Clinic has sent nurses and physicians to help meet the demand for care in COVID-19 hot spots such as New York and Detroit.

I suspect many patients will continue to use virtual visits when feasible, but many will need in-person testing for proper investigation of their health. We will be prepared to meet their needs in whatever setting is required.

In the weeks and months ahead, policymakers and the healthcare community here and nationwide may need to apply the brakes again in view of pandemics’ tendency to sometimes return in waves. We may not always have a green light to proceed as soon as we’d like for our patients, but our profession’s resiliency in recent weeks suggests we can have a bright future ahead.

Dr. Svensson is Chairman of Cleveland Clinic’s Sydell and Arnold Miller Family Heart, Vascular & Thoracic Institute.