How the Montreal Heart Institute has kept out COVID-19 and kept right on performing surgeries

In mid-March, as hospitals across Quebec scrambled to cancel surgeries, all but shutting down their operating rooms to free up beds for COVID-19 patients, the Institut de Cardiologie de Montral came up with a very different plan: how to keep its operating rooms going full steam ahead through a pandemic.

The specialty hospital, also known as the Montreal Heart Institute, was told by the government if at all possible, it would not be treating COVID patients. That meant it could keep doing surgery as long as it remained COVID-free.

It has been largely successful. Of the first 300 patients who underwent surgery at the Universit de Montral-affiliated institute after the start of the pandemic, only six tested positive for the virus in the days and weeks after they were discharged.

"That's two per cent," said Dr. Louis P. Perrault, the institute's chief of surgery. "None of them had to be in the ICU or on a ventilator."

Of those six patients, three may have caught the virus at the institute, although that is unclear. The remaining three contracted COVID-19 after they were transferred to another hospital that had COVID patients, Perrault said.

This week, the institute submitted a case study of its experience of keeping out COVID to the prestigious New England Journal of Medicine, in the hope those findings will be published as a special report.

Perrault and his colleagues believe the strategies they used could be replicated in other hospitals, helping to prevent cardiac patients from becoming collateral damage of the pandemic in the event of a second wave.

"Cardiovascular disease doesn't wait," said Perrault. "We are fighting sudden death."

Girding for battle

Keeping the coronavirus out of the hospital required the same kind of military precision and meticulous planning that goes into preparing for the battlefield.

As soon as the province designated the Montreal Heart Institute COVID-free, a committee made up of infectious disease experts, surgeons, cardiologists, anesthesiologists and pharmacists got to work.

At first, they met several times a day to fine-tune screening protocols. A separate entrance was set up for hospital staff. Masks were made compulsory everywhere, except in the cafeteria where physical distancing was the rule.

From the outset, four cardiologists were designated so-called "COVID officers."

On call 24/7, these medical gatekeepers have the final say on who is admitted to the hospital.

"This is a luxury that other hospitals don't have stall the patients before they enter," said Perrault. "It was very important that we were able to turn back patients that were COVID-positive."

About a third of the patients the institute receives come from other Montreal-area hospitals.

Forty-eight hours before any patient is transferred, they are tested for the virus. But the institute can't rely on that test result alone, said cardiologist and intensive care specialist Dr. Mark Liszkowski, one of the COVID officers.

"We know very often these patients can test negative because they still haven't manifested the disease," said Liszkowski. "They might be contagious after five to seven days."

In the case of a patient being transferred from another hospital, the infection control team calls that hospital to check the COVID status on the ward and find out if the patient had any possible contact with anyone who has been COVID-positive.

The team also checks with public health authorities, to find out if there has been an outbreak in the patient's community before they entered the hospital.

"It's a lot of investigative work," Liszkowski said.

Triage tent

Another third of the institute's patients arrive through the emergency room.

Patients are screened before ever setting foot in the door.

To do that, a triage tent was set up outside the hospital.

Nurses check each arrival for fever and for other signs of a viral or bacterial infection.

If they are suspected of being COVID-positive and their situation is not urgent, patients are referred back to their family physician or an outpatient clinic and tested there.

If the patient must be admitted for cardiac care, the person is brought into the emergency room and tested in a designated hot zone.

Patients with an underlying cardiac condition may manifest symptoms that mimic those of COVID-19, said Liszkowski: they may be short of breath, have a cough or spike a fever due to standard pneumonia or a urinary tract infection.

"We have to really be careful when we test these patients and screen them properly and isolate them until we know what the true result is," he said.

Minimal protective gear

After the 2003 SARS crisis, it was recommended each hospital have a three- to four-month stockpile of personal protective gear.

Perrault said the institute had that set aside. Since it remained COVID-free, it was able to use N95 masks sparingly.

"We didn't fear running out, and we stocked up on anesthetics," he said.

Anesthesiologists and respiratory therapists are in close contact with patients, both in the operating room during intubation and in the ICU, when the breathing tube is removed.

But the rigid screening and intubation protocols gave them peace of mind.

"We were pretty secure that who we had in the operating room, were pretty low-risk," said Dr. Alain Deschamps, the institute's chief of anesthesiology.

It also meant the team did not need to be wearing full personal protective equipment all the time, Deschamps said, which would have cut by half the number of surgeries the institute was able to perform.

"From 8 to 10 patients a day, we would have probably done three or four, at most, every day," he said.

Surgeries continued at a normal rate, which meant sick patients weren't left piling up on waiting lists, getting sicker.

The hospital also drew up simulation exercises, in the event the institute had no choice but to operate on a COVID-positive patient or a suspected case.

Deschamps said they mapped out everything from how they'd clear the corridor to who would be in and outside the operating room.

"It brought down the stress level a great deal," he said.

Internal communication was also key.

Deschamps said as soon as the hospital was designated COVID-free, everyone from the institute's CEO to its cleaning staff was brought on board.

He said he's never witnessed the level of collaboration he's seen in the last few months.

Everyone's opinion has counted, and employees with concerns were listened to.

"It's like you are in a building where there are 55 little fires going on, and all you are trying to do is make sure they don't take over the place," said Deschamps.

"This is basically what we did just put down the fires everywhere."

Lessons learned

Perrault said what he and his colleagues have learned from their experience during this first wave of the pandemic is that all the key players must be included in Quebec's contingency planning.

The province made the right move when it designated COVID-free hospitals, Perrault said, but he thinks other cardiac units in McGill or the Universit de Montral's network should have also had that designation, to help reduce the volume of patients in need of care.

"Patients have been waiting and in our specialty, that's very dangerous," he said. "In a city the size of Montreal, with the weekly volume we have, another designated centre is a must."

He understands the institute is in a unique position, as it is not attached to a larger hospital. But he thinks the strategies it adopted could be replicated in sections of hospitals, so other critical care can continue, even in a pandemic.

"We need to keep operating and diagnosing these patients," Perrault said.