The Impact of the COVID-19 Pandemic on Cardiac Electrophysiology Training: A Survey Study.

INTRODUCTION: The coronavirus disease 2019 (COVID-19) pandemic has resulted in a significant decrease in volume of electrophysiology (EP) procedures. There has been concern that trainees may not achieve the procedural numbers required to graduate as independent electrophysiologists within the usual timeline. We sought to determine the impact of the COVID-19 pandemic on the percentage of clinical cardiac EP (CCEP) fellows in jeopardy of not meeting procedural volume requirements and overall sentiments regarding preparedness of fellows for independent practice. METHODS: We surveyed CCEP fellows and program directors about baseline procedural volumes, curriculum changes due to the pandemic, and attitudes about preparedness for board examinations and independent practice. RESULTS: Ninety-nine fellows and 27 program directors responded to the survey. Ninety-eight percent of responding fellows reported a decrease in procedural volume as a result of the pandemic. Program directors reported an overall decrease in annual number of ablations and device procedures performed by each fellow during the 2019-2020 academic year compared to the preceding year. Despite this, a minority of fellows and program directors reported concerns about meeting Accreditation Council for Graduate Medical Education procedural requirements for devices (9% and 4%, respectively) and ablation (19% and 9%) or preparedness for independent practice after a 2-year fellowship. CONCLUSIONS: The COVID-19 pandemic has resulted in a decrease in procedural volume for CCEP trainees, but the majority of fellows and program directors do not anticipate major barriers to timely graduation. This may change with COVID-19 resurgence and further interruptions in training.

Risk of COVID-19 infection after cardiac electrophysiology procedures.

BACKGROUND: During the COVID-19 pandemic, attempts to conserve resources and limit virus spread have resulted in delay of nonemergent procedures across all medical specialties, including cardiac electrophysiology (EP). Many patients have delayed care and continue to express concerns about potential nosocomial spread of coronavirus. OBJECTIVE: To quantify risk of development of COVID-19 owing to in-hospital transmission related to an EP procedure, in the setting of preventive measures instituted in our laboratory areas. METHODS: We contacted patients by telephone who underwent emergent procedures in the electrophysiology lab during the COVID-19 surge at our hospital (March 16, 2020, to May 15, 2020, reaching daily census 450 COVID-19 patients,) ≥2 weeks after the procedure, to assess for symptoms of and/or testing for COVID-19, and assessed outcomes from medical record review. RESULTS: Of the 124 patients undergoing EP procedures in this period, none had developed documented or suspected coronavirus infection. Seven patients described symptoms of chest pain, dyspnea, or fever; 3 were tested for coronavirus and found to be negative. Of the remaining 4, 2 had a more plausible alternative explanation for the symptoms, and 2 had transient symptoms not meeting published criteria for probable COVID-19 infection. CONCLUSION: Despite a high hospital census of COVID-19 patients during the period of hospital stay for an EP procedure, there were no likely COVID-19 infections occurring in follow-up of at least 2 weeks. With proper use of preventive measures as recommended by published guidelines, the risk of nosocomial spread of COVID-19 to patients in the EP lab is low.

Enhanced electrocardiographic monitoring of patients with Coronavirus Disease 2019.

Background: Many of the drugs being used in the treatment of the ongoing pandemic coronavirus disease 2019 (COVID-19) are associated with QT prolongation. Expert guidance supports electrocardiographic (ECG) monitoring to optimize patient safety. Objective: The purpose of this study was to establish an enhanced process for ECG monitoring of patients being treated for COVID-19. Methods: We created a Situation Background Assessment Recommendation tool identifying the indication for ECGs in patients with COVID-19 and tagged these ECGs to ensure prompt over reading and identification of those with QT prolongation (corrected QT interval > 470 ms for QRS duration ≤ 120 ms; corrected QT interval > 500 ms for QRS duration > 120 ms). This triggered a phone call from the electrophysiology service to the primary team to provide management guidance and a formal consultation if requested. Results: During a 2-week period, we reviewed 2006 ECGs, corresponding to 524 unique patients, of whom 103 (19.7%) met the Situation Background Assessment Recommendation tool-defined criteria for QT prolongation. Compared with those without QT prolongation, these patients were more often in the intensive care unit (60 [58.3%] vs 149 [35.4%]) and more likely to be intubated (32 [31.1%] vs 76 [18.1%]). Fifty patients with QT prolongation (48.5%) had electrolyte abnormalities, 98 (95.1%) were on COVID-19-related QT-prolonging medications, and 62 (60.2%) were on 1-4 additional non-COVID-19-related QT-prolonging drugs. Electrophysiology recommendations were given to limit modifiable risk factors. No patient developed torsades de pointes. Conclusion: This process functioned efficiently, identified a high percentage of patients with QT prolongation, and led to relevant interventions. Arrhythmias were rare. No patient developed torsades de pointes.

Remote monitoring of implantable cardiac devices: current state and future directions.

PURPOSE OF REVIEW: Recent evidence has demonstrated substantial benefits associated with remote monitoring of cardiac implantable electronic devices (CIEDs), and treatment guidelines have endorsed the use of remote monitoring. Familiarity with the features of remote monitoring systems and the data supporting its use are vital for physicians' care for patients with CEIDs. RECENT FINDINGS: Remote monitoring remains underutilized, but its use is expanding including in new practice settings including emergency departments. Patient experience and outcomes are positive, with earlier detection of clinical events such as atrial fibrillation, reductions in inappropriate implantable cardioverter-defibrillator (ICD) shocks and potentially a decrease in mortality with frequent remote monitoring utilizaiton. Rates of hospitalization are reduced among remote monitoring users, and the replacement of outpatient follow-up visits with remote monitoring transmissions has been shown to be well tolerated. In addition, health resource utilization is lower and remote monitoring has been associated with considerable cost savings. A dose relationship exists between use of remote monitoring and patient outcomes, and those with early and high transmission rates have superior outcomes. SUMMARY: Remote monitoring provides clinicians with the ability to provide comprehensive follow-up care for patients with CIEDs. Patient outcomes are improved, and resource utilization is decreased with appropriate use of remote monitoring. Future efforts must focus on improving the utilization and efficiency of remote monitoring.

Preventability of 30-day readmissions for heart failure patients before and after a quality improvement initiative.

The objective of this study was to estimate the frequency of heart failure (HF) readmissions that can be prevented through a quality improvement (QI) program. All HF patients at the University of Connecticut Health Center who had a readmission within 30 days of discharge in the year before (2008) and the year after (2011) a QI program were studied. Through chart review, the percentage of patients who had preventable readmissions in each year was estimated. Prior to the QI initiative, chart reviewers identified that 20% to 30% of readmissions were preventable. The decrease in readmissions after the QI program was similar at 28%. Fewer readmissions after the QI initiative were deemed preventable compared with before. In conclusion, this study found a percentage of preventable readmissions similar to the actual 28% reduction in readmissions after a QI program was launched. Preventable readmissions were less common after the QI program was in place.

Change in readmissions and follow-up visits as part of a heart failure readmission quality improvement initiative.

OBJECTIVES: The study objectives were to quantify the change in 7-day follow-up visits and 30-day readmissions as part of a hospital quality improvement initiative and to characterize events at 7-day follow-up visits. Some data suggest that outpatient assessments of patients with heart failure within 7 days of hospital discharge may prevent readmissions, although little is known about patient needs at 7-day follow-up visits. METHODS: We performed a single-center, retrospective chart review of all heart failure discharges at the University of Connecticut Health Center (398 patients) the year before (2008) and the year after (2011) a quality improvement initiative that included mandatory 7-day follow-up visits. We quantified the change in 30-day readmission rate after the initiative, frequency of 7-day follow-up visits, and events at follow-up visits. RESULTS: The average age of patients with heart failure was 79.9 years in 2011, with 45.9% having systolic heart failure. Thirty-day all-cause readmissions decreased from 27.5% to 19.1% after our quality improvement initiative (P = .024). Frequency of 7-day follow-up visits increased from 19.6% to 46.9% (P < .01). Eighty-one percent of 7-day visits occurred in the University of Connecticut Heart Failure Center with a cardiologist or heart failure nurse practitioner. Fifty-one percent of patients had blood work drawn, and 26% had a medication dose changed. Only 13% of patients had no discrepancy between the discharge and follow-up medication lists. CONCLUSIONS: Our hospital's 30-day readmission rate for patients with heart failure decreased in parallel with an increase in 7-day follow-up visits. Patients with heart failure were complex and often had diagnostic testing and medication changes at follow-up visits.