Tips to Address the Challenges of non-COVID Care in the Time of a Pandemic
Guidance from the CDC
In addition to managing the enormous burden of COVID-19 infection and mortality, clinicians are also charged with how we can best provide ongoing regular care for non-COVID patients with both chronic and acute and chronic cardiac diagnoses. Although virtual care (discussed further below) has been extensively leveraged for non-acute visits, in-person clinical evaluation is often indicated as part of a comprehensive assessment. The CDC provides basic guidance in a Framework for Healthcare Systems Providing Non-COVID-19 Clinical Care During the COVID-19 Pandemic, in an effort to support healthcare systems as they balance the need to provide necessary services while minimizing risk to patients as well as clinical and non-clinical staff.
Non-Acute Clinical Visits: Leveraging Virtual Care
What Do Patients Say?
For many regular clinical follow up visits, virtual care has been utilized, and overall, it has worked quite satisfactorily, from both the clinical and the patient perspective. In a June 2020 survey of 1,000 patients who had recently experienced a virtual visit demonstrated that over 75% reported being very satisfied with the experience (citing convenience, safety, and speed of access), and would like to continue to incorporate it into their care in the future.
In June, the Heart Failure Society of America published a helpful document “Virtual Visits for Care of Patients with Heart Failure in the Era of COVID-19: A Statement from the Heart Failure Society of America” a helpful document that provides an outline of the benefits and challenges of virtual care, reviews recent changes in policy and reimbursement and provides a vision for the future of virtual care.
What Might Make Virtual Care Even Better
Care of the patient with heart failure could represent an important application of virtual care, in particular, if combined with remote monitoring as an adjunct to real-time clinical visits. The most basic remote monitoring might include monitoring and communication of weight and blood pressure via electronic scales and blood pressure cuffs to an implanted pulmonary artery (PA) monitor hemodynamic monitor that transmits PA pressures as a means of guiding therapy.
Does Virtual Care Improve Adherence to Follow up?
Results of a pilot (pre-COVID) trial of “Virtual Versus In-Person Visits and Appointment No-Show Rates in Heart Failure Care Transitions” was recently shared in Circulation: Heart Failure. While the data indicate that follow-up visits for post-discharge HF patients can be done just as safely via telehealth as they can in person, making virtual visits an option doesn’t reduce the significant “no-show” rate. Importantly, a clinical follow-up visit within 2 weeks of discharge is a tactic used to improve clinical outcomes and decrease hospital readmission rates.
Acute Care: Data Regarding Decrease in ACS and Acute Stroke Presentations
In June 2020, an early analysis at the beginning of the COVID pandemic showed an estimated 38% reduction in U.S. cardiac catheterization laboratory STEMI activations, which was similar to the 40% reduction noticed in Spain. The potential reasons for patients avoiding or delaying care are not completely understood. Fear of contracting COVID-19 infection in the hospital, skepticism about the capability of an overwhelmed healthcare system are likely contributors.
Data were gathered from comprehensive stroke centers at 12 participating institutions across six US states, based on the prospective ongoing data collection associated the American Heart Association ‘Get With The Guidelines’ (GWTG) database. It was demonstrated that there was a decrease in the number of patients presenting with acute stroke symptoms from Feb 2020 (227 patients) to the # presenting in March 2020 (163 patients). Of particular concern is that the mean interval from the “last known well time” to ED presentation was significantly longer in the COVID period (603±1035min) compared with the baseline period (442±435min, P<0.02) in February/March2019.
For Heart Attack or Stroke Care: Hospital ED is Still the Safest Place to be!
The American Heart Association has issued public service messages regarding the importance of seeking prompt treatment for acute heart or stroke symptoms, and in particular, to call 9-1-1. Likewise, Martha Gulati, MD, FACC, editor of the American College of Cardiology’s CardioSmart, advised those experiencing acute heart or stroke symptoms should respond immediately by activating their local emergency response system and that “hospitals… are taking the utmost precautions to ensure that the novel coronavirus not be spread. The faster a patient is treated, the higher the outcome of survival and lower the risk for complications. No patient should delay their care.”