Considerations for Managing EP Cases During the COVID-19 Pandemic: Experience at Genesis Health Center in Davenport, Iowa

Cardiovascular Medicine, P.C. (CVM) is a private cardiology group that provides services to the Quad Cities of Illinois and Iowa, with a broad outreach population in both states. The Iowa CVM Division, which consists of 10 general/interventional cardiologists and 3 electrophysiologists, provides cardiac care at two Genesis hospital locations in Scott County, Iowa. The Genesis Medical Center (GMC) East Campus has two dedicated EP labs, where complex radiofrequency and cryoablative procedures are performed, along with all types of CRM device implants and extractions. The Illinois CVM Division has 7 general/interventional cardiologists and 3 electrophysiologists providing complex EP services primarily at Trinity Hospital in Rock Island, Illinois and basic EP services at the Genesis Medical Center-Silvis campus in Illinois. 

In February 2020, during the early planning stages of the COVID-19 pandemic, Genesis Health established a COVID-19 internal governance structure consisting of the GMC-Davenport Physician Executive COVID-19 Committee, which put in place multiple subcommittees to ensure proper hospital operations in accordance with the principles outlined by the Governor of Iowa and the CDC. I presently serve on the Surgical and Procedural Services Subcommittee, which was developed to make recommendations regarding operations and procedures to leadership, and to ensure that the proclamations outlined by the Governor are followed. 

The week of March 16th, 2020, Genesis leadership ended all elective surgeries and procedures at Genesis to protect the safety of our patients and caregivers, and to preserve PPE in accordance with the state proclamation and CDC recommendations. At the same time, many rooms and areas in the hospital were converted to negative pressure, and the ICU was expanded to accommodate any COVID-19 patients. Multiple vacated floors that roomed elective surgical patients were prepared for COVID-19 patients in the event of large volumes of patients in Davenport. Visitors were no longer allowed in the hospital unless accompanying a minor or during labor and delivery. Many staff members at both Genesis and CVM were laid off and furloughed. Nurses in surgical and procedural areas were floated to the ICU and emergency rooms. 

During this time, there was a tremendous slowdown of all hospital and clinic operations and services in the Genesis and CVM systems, with little COVID-19 volume. Patient volumes in the ER and hospital declined significantly, with many floors previously at capacity (eg, cardiac step-down unit) now at very low census. We found that many patients were not coming to the hospital for significant, life-threatening symptoms and illnesses (eg, angina, stroke, and heart failure) due to the pandemic. In fact, there was a 50% reduction in our ER visits during the pandemic, with two patients going to a walk-in clinic with acute myocardial infarcts because they wanted to avoid the hospital. Too many patients were staying home and presenting at the later stages of their illness. Therefore, CVM and Genesis implemented public service announcements and worked with local media outlets¹ to inform patients that they should come to the hospital for chest pain, stroke, and heart failure symptoms. As a result of the pandemic, we also continue to experience a tremendous shortage in blood supply due to the slowdown of blood collections from the fear of having to leave home to donate.

At the CVM offices, social distancing measures resulted in a significant decrease in patient volumes in our outpatient center, including office visits, consultations, and outpatient testing (eg, echocardiograms, stress testing, Holter monitoring, and CT scanning). We quickly transitioned to telehealth services, with a number of our physicians doing virtual visits with patients to enhance social distancing throughout the months of March and April. Our office was operating on minimal staffing, with a number of staff members being furloughed or placed on low census. Our device clinic utilized remote monitoring almost exclusively. Our outreach clinics were cancelled, which significantly impacted our procedural volumes. We limited our patient volumes in clinic to two per hour, per physician. 

Presently, we continue to perform telehealth, mixing telehealth visits with clinic visits to continue taking care of our patients. We are almost back to full staffing in our clinic, and our outpatient procedures are almost back to full capacity. We are restarting the outreach clinics, with two healthcare workers traveling with masks in one vehicle. 

Mitigation measures controlled the spread of the virus, allowing the local healthcare centers to restart elective procedures much earlier than the original date slated for May 15th. On April 30th, we had 50 COVID-19 patients in the entire Genesis system and had planned for a capacity of 10x that number.² We continued our ban on elective procedures for six weeks until Governor Kim Reynolds signed a proclamation on April 24th that allowed for provisional resumption of elective surgery and procedures on April 27th. The provisions included the ability to secure PPE with access to a reliable supply chain, with the ability to support continued operations in a timely manner in the event of a surge. In addition, the hospital must be able to provide timely COVID-19 testing to rapidly mitigate potential clusters of infections. For scheduled surgeries, patients should have a COVID-19 test performed within 48 hours of the surgery date; if testing is not available, alternate methods of determining probability of COVID-19 should be considered. The hospital must also continue to treat COVID-19 patients without transferring them to make room for elective procedures; a total of 30% of ICU and med/surg beds must be reserved for COVID-19 patients. 

At the end of April, the Genesis Health System secured a rapid turnaround PCR testing system for COVID-19 testing, allowing for reopening of the EP lab for elective procedures on May 4th. Even though the test itself can be completed in two hours, one machine is available to cover the entire system. We also developed a drive-through system in our ER department to allow patients to come two days before the procedure for testing to ensure the results are available within a 48-hour window. The EP lab, which was initially converted to negative flow, was converted back to positive flow with availability of a HEPA filter to be used if a patient with or suspected of having COVID-19 required a procedure. All patients undergo enhanced phone screening before their scheduled procedure, and receive a temperature check on arrival to the hospital. 

Per the state proclamation, patients having surgery or undergoing aerosol-generating procedures (AGP) are tested. The AGP procedures pertaining to the EP lab include intubation/extubation, bag-valve mask ventilation, CPAP/BiPAP, TEE, and procedures requiring general anesthesia. Those patients having non-surgical outpatient procedures that are not aerosol generating do not require COVID-19 testing. The patients are placed in green, yellow, or red categories depending on the results of their COVID-19 screening and whether they had PCR testing to determine PPE use (Table 1). We started at 50% usual capacity due to a limited number of testing supplies, but over a few weeks, we were able to go back to 100% capacity. We initially faced challenges with staffing, and quickly called back the hospital employees that were placed on low census or furloughed. We have now been operating at full capacity in the EP lab for over a month without issue. 

Another factor limiting procedural startup was the visitor policy. Many patients deferred their procedures, as they wanted to be accompanied by a friend or family member. After two weeks into performing elective procedures without visitors, the visitor policy was modified to allow one visitor to accompany the patient, as there were still very few infections in the hospital and community. Visitors are screened for COVID-19 symptoms upon entry to the hospital, they must stay in the patient’s room until 1800, and must wear a mask at all times. In order to limit visitors in the hallways, they cannot leave the patient’s room once the patient is admitted. Restarting procedures was also limited by patients’ fear of becoming infected by COVID-19 at the hospital. This is no longer an issue, as patients and family members have become more comfortable with the hospital environment, which has proven to be safe at Genesis. 

At nine weeks back into resumption of performing elective EP cases, we began to approach pre-COVID-19 procedural volumes. The leadership of both CVM and Genesis has allowed caregivers to safely return to our baseline with no increase in infection rates or deaths from COVID-19. Since starting elective procedures, none of our staff members, physicians, or patients have had symptoms of COVID-19, and to our knowledge, no patients have become infected during their time spent at the hospital during their procedure. 

We look forward to a productive summer, and we are cautiously optimistic about the future. As of July 12th, the total number of infections in Scott County has risen to 1,060, with the death count at 10. We have experienced an increase in positive cases in the community over the past few weeks, in line with the rest of the country, without an increase in the number of deaths. We are vigilant with our requirements for social distancing and mask use in the clinics and hospital. We are much better prepared in the event that we have a surge in hospital patients with infrastructure in place and well-educated employees at Genesis and CVM. We are prepared at any time to alter our operations depending on any surges we may experience. We continue to educate the public with respect to the need to come to the hospital if they are ill and to not stay home. We are here to serve the public for all illnesses at all times — that is why we exist. 

Disclosures: Dr. Airey has no conflicts of interest to report regarding the content herein.

1. Flores A. Genesis Health says hospital is prepared to handle any possible coronavirus cases; Risk remains low in QC. WQAD. Published February 22, 2020. Available at https://bit.ly/3gEHEAk. Accessed July 9, 2020. 
2. Pappas M. Forging ahead: what quad-city CEOs learned guiding companies through COVID-19. Quad City Times Insight. Published June 5, 2020. Available at https://bit.ly/2ZVPZbY. Accessed July 9, 2020.