Annotated Bibliography On 2 Articles (ATTACHED)

Cardiology - (2020) 1e3

Canadian Journal of

Editorial

Feel Better, Work Better: The COVID-19 Perspective Michelle M. Graham, MD,a Lyall Higginson, MD,c Peter G. Brindley, MD,b and

Rakesh Jetly, MDd aDepartment of Medicine, University of Alberta, Edmonton, Alberta, Canada

bDepartment of Critical Care, University of Alberta, Edmonton, Alberta, Canada cDepartment of Medicine, University of Ottawa, Ottawa, Ontario, Canada

dCanadian Forces Health Services Group, Department of National Defence, Government of Canada, Edmonton, Alberta, and Ottawa, Ontario, Canada

The world appears to many to be a scary place at the moment. News outlets and social media are full of the latest horror stories of exponential increases in COVID-19 patients, dwindling medical supplies, heartbreaking decisions due to rationing of care, and infected health care workers. And, of course, there are tales of individuals who are not taking this pandemic seriously, who are defying physical distancing recommendations and even quarantine and putting others at risk as a result.

In the meantime, myocardial infarction, heart failure, and arrhythmias still happen in uninfected patients. Furthermore, COVID-19 illness is more serious in patients with underlying cardiovascular disease; similarly, dramatic cardiac manifesta- tions have been seen in people with normal hearts. Either way, cardiovascular professionals are now on the front line looking after these critically ill patients.

Thiscomes at a significant personaltoll. Some practitioners are making the decision to self-isolate when not at work in the hos- pital, to avoid risk to their families. Others, on the basis of age or underlyingmedical conditions,are already at high risk themselves. Even worse, there’s no end in sight, only the ongoing anxiety about “what, or who, is next.” Work-life balance has always been a challenge, but it has never been more important than now. We may feel confronted by the conflict between our patients and our profession versus caring for ourselves and our families. As an example, many of us are required to be front-line health pro- fessionals and simultaneously home school our children.

Strategies to Keep the Workforce Up and Running

As has often been said regarding this pandemic, it is a marathon, not a sprint, and it is affecting all aspects of society,

Received for publication April 8, 2020. Accepted April 13, 2020.

Corresponding author: Dr Michelle M. Graham, Division of Cardiology, Faculty of Medicine and Dentistry, University of Alberta, 8440 112th St NWdSuite 2C2 WMC, Edmonton, Alberta T6G 2B7, Canada. Tel.: þ1- 780-407-1590; fax: þ1-780-407-1496.

E-mail: [email protected] See page 3 for disclosure information.

https://doi.org/10.1016/j.cjca.2020.04.012 0828-282X/� 2020 Canadian Cardiovascular Society. Published by Elsevier Inc. A

not just the health system. Currently, many practitioners have transferred follow-up care and even consultations to a virtual realm, either by telephone or telehealth, with in-person visits reserved for those judged to require personal clinical assess- ment. The Canadian Cardiovascular Society (CCS) Rapid Response Team has already provided guidance on the use of procedures and clinic space during this time (Table 1).1-12

This is predicated, however, on cardiac sciences programs maintaining their workforce.

Most programs have schedules that have been set months in advance, often dependent on travel and vacation schedules, as well as the need for academic deliverables for some in- dividuals. Most of these schedules have been abandoned in favour of “crisis response” mode. With meetings and travel cancelled, the focus should be on both maintaining clinical expertise in all areas of cardiovascular medicine and reducing personal risk. Every effort should be made to avoid exposure for health professionals over the age of 60 years and those with certain underlying conditions, particularly in circumstances where risk may be higher (such as a COVID-19 patient requiring intubation). In a group practice situation, where each member maintains personal patients, now may be the time to “share” patients, such that follow-up can be done for these higher-risk individuals, keeping them safe while at the same time offloading the workload of other clinicians who are providing front-line care. We can learn from our colleagues across the globe, many of whom have specifically designated separate locations to care for noninfected patients with acute cardiac illnesses.

Given the potential physical, emotional, and mental stress of this pandemic, some consideration should be given to the feasibility of reducing the length of clinical rotations to allow all practitioners the opportunity to rest, recharge, and be with their loved ones. Key to this is skilled leadership and the close communication and coordination among group members, with flexibility for clinical assignments to cover those who may fall ill, even with the common cold.

CCS is working on a new initiative where our members can share practical tips and advice, ranging from safety to how groups are handling call schedules. Equally important, please

ll rights reserved.

Table 1. COVID-19 topics covered by the CCS Rapid Response Team.

Date Topic

March 15, 2020 CCS’s response to the COVID-19 pandemic12

March 15, 2020 COVID-19 and use of ACEi/ARB/ARNi medications for heart failure or hypertension11

March 16, 2020 COVID-19 and cardiac device patients: a message from the Canadian Heart Rhythm Society10

March 17, 2020 Guidance on ambulatory management and diagnostic testing during the COVID-19 crisis9

March 17, 2020 Joint letter to the Deputy Ministers of Health and Public Safety offering expert guidance on a coordinated strategy regarding the use of ECMO during the COVID-19 pandemic8

March 19, 2020 Guidance on hospital-based care and cardiac procedures during the COVID-19 crisis7

March 20, 2020 Updated. COVID-19 and concerns regarding use of cardiovascular medications, including ACEi/ ARB/ARNi, low-dose ASA and nonsteroidal anti-inflammatory drugs (NSAIDS)6

March 22, 2020 COVID-19 and cardiovascular disease: what the cardiac healthcare provider should know5

March 25, 2020 Guidance on community-based care of the cardiovascular patient during the COVID-19 pandemic4

March 30, 2020 Reducing in-hospital spread and the optimal use of resources for the care of hospitalized cardiovascular patients during the COVID-19 pandemic3

April 1, 2020 Is it COVID-19 or is it heart failure: management of ambulatory heart failure patients2

April 7, 2020 Management of referral, triage, waitlist and reassessment of cardiac patients during the COVID-19 pandemic1

ACEi, angiotensin-converting enzyme inhibitor; ARB, angiotensin re- ceptor blocker; ARNi, angiotensin receptor - neprilysin inhibitor; ASA, ace- tylsalicylic acid; CCS, Canadian Cardiovascular Society; ECMO, extracorporeal membrane oxygenation.

2 Canadian Journal of Cardiology Volume - 2020

share the strategies that are not working, and whydwe can all learn from each other, saving time and precious resources.

The Emotional and Mental Toll of COVID-19 The widespread measures taken to limit the spread of this

virus will have considerable emotional and mental health fallout for patients and individuals who have spent lengthy periods in isolation. We must also not underestimate the psychologic trauma that is being experienced by health pro- fessionals worldwide. The moral and ethical dilemma of rationing care, personal protective equipment, and even ven- tilators will likely have a toll.13

Lai et al. recently reported the mental health outcomes of 1257 healthcare workers caring for COVID-19 patients in China, using a series of validated instruments. Depression, anxiety, insomnia, and distress were reported by the majority of participants. Multivariate logistic regression identified nurses, women, front-line workers, and those in the epicenter of the pandemic (Wuhan) to be at higher risk for symptoms.14

Acute psychologic distress is not the only risk for our profession. Burnout is defined as a constellation of mental fatigue, physical fatigue, frustration, and disengagement.15,16

Some are now referring to this as “moral injury,” a term borrowed from those observing the “guilt, shame, and anger” present in military and veteran communities.17 A 2019 survey conducted by the America College of Cardiology suggests that 35% of cardiovascular practitioners were experiencing

burnout and 44% acknowledged symptoms of stress.18 Social support helps to alleviate burnout; in this pandemic, some of these supports are harder to find, or they look and feel different. We are not having coffee with our friends or going to the gym. We are potentially isolating ourselves from our families for their own safety; we are hearing of colleagues who are writing their wills, providing advance care directives, and deciding who will take their children. We are intubating our colleagues. Some are dying from this.

Mitigation Strategies One thing that has become abundantly clear is that

teamwork is sexy again. There’s no room for minor drama and frustrations in the midst of this big picture. And that feeling of teamwork is incredibly reassuring and humbling. It’s a reminder of why we all chose to do this work in the first place.

We need to be kind to ourselves and kind to each other. We need to model the right behaviour for our fellows, resi- dents, and colleagues, including nurses, pharmacists, respira- tory therapists, environmental services, etc. That means “do as I say and as I do.” Everyone is being told they need to eat well, sleep well, and make time for exercise. This applies to us, too.

We need to take our emotional temperatures as well as assessing physical symptoms. The management of this pandemic can be thought of as a mission. Health care workers can take advantage of the extensive work done by the Cana- dian Armed Forces Road to Mental Readiness (R2MR) program, which is designed to improve work performance and long-term mental health outcomes through a foundation in resilience. The app for it is free to download and contains a rapid assessment tool to assess a spectrum of healthy adaptive coping to distress and severe functional impairment (mood, attitude and performance, sleep, physical symptoms, social behaviour, alcohol, and gambling). Regular monitoring promotes self-awareness and the identification of areas requiring more attention and resources.19

It is important to note that there are many important self-care tools, and individuals need to identify and practice the ones that work for themselves. One person may find yoga and mindfulness calming, whereas others prefer a walk, a run, or lifting weights. Some will make more time to explore their spirituality. Choose the tools that work for you.

Everyone has their own (different) personal and profes- sional contexts; this will influence how we are feeling, and how we make decisions. Individuals react differently to some of the challenges we are facing. Some are taking this whole situation in stride, some are not. Remember, it’s okay to be okay, and it’s also okay to not be okay. But you are more likely to be okay in the long term if you take steps now. Don’t forget those basic building blocks of nutrition, sleep, and exercise. Our junior colleagues and trainees are vulnerable in that they are truly front-line, often with little experience. However, they are also our future and will lead the next time we face a challenge. Our senior colleagues, although more seasoned, were more likely to have symptoms of burnout before the pandemic. While we are looking after ourselves, we need to look out for each otherdif everyone reaches out to just a few others every few days, we will be stronger and healthier for it. On the other hand, the failure to reach out might come at an immense cost.

Graham et al. 3 COVID-19: Feel Better, Work Better

Finally, please remember what we learned as kids: Treat others the way you want to be treated. There is no place for comments like “being stressed is not a good reason to not come to work.” The CCS is a tight-knit community. The number 1 reason that members attend the Canadian Car- diovascular Congress is networking. Any time an affiliate group gets together, the respect and camaraderie are evident on the smiles on everyone’s faces. We are more than a pro- fessional organization; we are a team, a community and a family. This pandemic will end; and it has the potential to strengthen our personal and professional relationships.

Let’s play to our strengths.

Funding Sources The authors have no funding souces to declare.

Disclosures The authors have no conflicts of interest to disclose.

References

1. CCS COVID-19 Rapid Response Team: Management of referral, triage, waitlist and reassessment of cardiac patients during the COVID-19 pandemic. April 7, 2020. Available at: https://www.ccs.ca/images/ Images_2020/Refer_Triage_Wait_Mgmt_07Apr20.pdf. Accessed April 13, 2020.

2. CCS COVID-19 Rapid Response Team: Is it COVID-19 or is it heart failure: management of ambulatory heart failure patients. April 1, 2020. Available at: https://www.ccs.ca/images/Images_2020/COVID_or_HF_ RRT_doc_01Apr.pdf. Accessed April 13, 2020.

3. CCS COVID-19 Rapid Response Team: Reducing in-hospital spread and the optimal use of resources for the care of hospitalized cardiovascular patients during the COVID-19 pandemic. March 30, 2020. Available at: https://www.ccs.ca/images/Images_2020/NEW_CCS_RRT_Inhoptial_ infection_reduction_30Mar.pdf. Accessed April 13, 2020.

4. CCS COVID-19 Rapid Response Team: Guidance on community-based care of the cardiovascular patient during the COVID-19 pandemic. March 25, 2020. Available at: https://www.ccs.ca/images/Images_2020/ CCS%20Guidance%20for%20Community%20Care%2025Mar2020. pdf. Accessed April 13, 2020.

5. CCS COVID-19 Rapid Response Team: COVID-19 and cardiovascular disease: what the cardiac healthcare provider should know. March 22, 2020. Available at: https://www.ccs.ca/images/Images_2020/COVID_ and_Cardiovascular_Disease_22Mar2020.pdf. Accessed April 13, 2020.

6. CCS COVID-19 Rapid Response Team: Updated. COVID-19 and con- cerns regarding use of cardiovascular medications, including ACEi/ARB/ ARNi, low-dose ASA and nonsteroidal antiinflammatory drugs (NSAIDS). March 20, 2020. Available at: https://www.ccs.ca/images/Images_2020/ CCS_CHFS_Update_COVID__CV_medications_Mar20.pdf. Accessed April 13, 2020.

7. CCS COVID-19 Rapid Response Team: Guidance on hospital-based care and cardiac procedures during the COVID-19 crisis. March 19, 2020. Available at: https://www.ccs.ca/images/Images_2020/Guidance_ on_hospital-based_care_and_cardiac_procedure_use_19Mar2020.pdf. Accessed April 13, 2020.

8. CCS COVID-19 Rapid Response Tream: Joint letter to the Deputy Ministers of Health and Public Safety offering expert guidance on a co- ordinated strategy regarding the use of ECMO during the COVID-19 pandemic. March 17, 2020. Available at: https://www.ccs.ca/images/ Images_2020/ECMO_Coord_Resp_Team_CCS_CSCS_CANCARE_ 17Mar2020.pdf. Accessed April 13, 2020.

9. CCS COVID-19 Rapid Response Team: Guidance on ambulatory management and diagnostic testing during the COVID-19 crisis. March 17, 2020. Available at: https://www.ccs.ca/images/Images_2020/CCS_ Guidance_for_Ambulatory_and_Diagnostic_Testing.pdf. Accessed April 13, 2020.

10. CCS COVID-19 Rapid Response Team: COVID-19 and cardiac device patients: a message from the Canadian Heart Rhythm Society. March 16, 2020. Available at: https://www.ccs.ca/images/Images_2020/CHRS_ COVID-19_Update_EN.pdf. Accessed April 13, 2020.

11. CCS COVID-19 Rapid Response Team: COVID-19 and use of ACEi/ ARB/ARNi medications for heart failure or hypertension. March 15, 2020. Available at: http://www.ccs.ca/images/Images_2020/CCS_ CHFS_statement_regarding_COVID_EN.pdf. Accessed April 13, 2020.

12. CCS COVID-19 Rapid Response Team: CCS’s response to the COVID- 19 pandemic. March 15, 2020. Available at: http://www.ccs.ca/en/ccs- mission-and-vision/covid-19-update. Accessed April 13, 2020.

13. Rosenbaum L. Facing COVID-19 in Italy: ethics, logistics and thera- peutics on the epidemic’s front line [e-pub ahead of print]. N Engl J Med https://doi.org/10.1056/NEJMp2005492.

14. Lai J, Ma S, Wang Y. Factors associated with mental health outcomes among healthcare workers exposed to coronavirus disease 2019. JAMA Netw Open 2020;3:e203976.

15. Boudreau RA, Grieco RL, Cahoon SL, Robertson RC, Wedel RJ. The pandemic from within: two surveys of physician burnout in Canada. Can J Community Ment Health 2006;25:71-88.

16. Brindley PG. Psychological burnout and the intensive care practitioner: a practical and candid review for those who care. J Intensive Care Soc 2017;18:270-5.

17. Litz BT, Stein N, Delaney E, Lebowitz L, Nash WP, Silva C, Maguen S. Moral injury and moral repair in war veterans: a preliminary model and intervention strategy. Clin Psychol Rev 2009;29:695-706.

18. Mehta LS, Lewis SJ, Duvernoy CS, et al; on behalf of the American College of Cardiology Women in Cardiology Leadership Council. Burnout and career satisfaction among U.S. cardiologists. J Am Coll Cardiol 2019;73:3345-8.

19. Canadian Armed Forces: Road to Mental Readiness (R2MR) program. Available at: https://www.canada.ca/en/department-national-defence/ services/guide/dcsm/r2mr.html. Accessed April 13, 2020.