Table 1.

An International Comparison of CICU Modifications in High-Impact Regions During the COVID-19 Pandemic

Location	Changes to CICU Staffing Models	Examples of Support for Noncardiac ICUs	Changes to CICU Admission Criteria	Integration of Expertise Between Cardiology and Critical Care for COVD-19 Patients	Changes in Delivery of Care for ACS, Cardiogenic Shock, and Cardiac Arrest	Critical Care Education for Other Cardiologists and Trainees	Changes in CICU Workflow in Response to Pandemic	Other Key Considerations
Pavia, Lombardy, Italy	Dedicated COVID-19 CICU for patients with cardiac critical care diagnoses and COVID-19 Dedicated medical and nursing staff	Noncardiac intensive care physicians, senior fellows, and nurses redeployed in general ICUs or COVID-19 ICUs Government reallocation of medical staff from less affected regions	Patients with confirmed COVID-19 or high clinical suspicion ED patients admitted to dedicated COVID-19 hospital wards until confirmed diagnosis	Co-rounding with general intensivists twice per day Multidisciplinary admission triage decisions based on distributive justice	PPE requirements, altered response, and procedure times Reduced diagnostic testing Required integration of PPE with usual pathways and availability of trained staff (e.g. cardiac catheterization laboratory, echocardiographers, technicians)	ICU training sessions for non-ICU physicians, including cardiologists, nephrologists, and internal medicine	Enhanced use of POCUS with limited use of other imaging modalities (X-ray, CT, etc.) Dedicated equipment for COVID-19 areas (e.g., echocardiography)	PPE courses for staff Promoting human connection with patient families, opportunities to help mitigate patient (and provider) distress Research integration was facilitated
Barcelona, Spain	Reduced CICU admissions CICU staff and residents were re-allocated to a joint ICU for confirmed COVID-19 patients Separate ICU for COVID-19 negative patients	12-h shifts for all COVID-19 critical care staff	Admissions similar to Lombardy region Two ED entrances stratified by COVID-19 status Designated ED area for non-confirmed diagnosis Low risk (N) STEMI admitted to the cardiology ward with telemetry	Joint COVID-19 critical care team includes anesthesiology, cardiology and general intensive care Implementation of institutional COVID-19 clinical practice guidelines	No formal changes for any of the established networks (STEMI, NSTEMI, cardiogenic shock and cardiac arrest) Reduced availability of diagnostic imaging	PPE training No specific training in critical care for non-critical care specialists (of note, cardiologists in Spain receive 1 year of critical care during training) On-line clinical and COVID-19 training for all ICU staff	Dedicated COVID-19 equipment and staff	Visitor restrictions and inability to have direct contact with family members Expedited process for IRB COVID-19 research reviews Hotels are providing housing for patients with milder symptoms and for health care providers
London, United Kingdom	London-wide consolidated management of primary PCI and cardiac surgery, maintaining protected services Rapid expansion of ICUs (including CICUs) to take COVID-19 patients Maintaining cohorted zones based upon illness severity and acuity in every hospital as long as possible	Beds to support COVID-19 ventilated patients, expansion to surge bed capacity all requiring staffing from “pool” of intensive care capable providers Self-declaration of staged ventilator bed capability within networks across London Redeployment of doctors to work within critical care	Admission according to clinical requirements and dispatch to appropriate cohorted zone and for intervention according to acuity Acute, emergency cardiology, and cardiac surgical interventions triaged within London system (i.e., acute aortic dissection) and COVID-19 risk managed on individual patient basis	New ICUs pop-up, co-rounding with critical care providers Cardiology opinions/input available as required Cardiologists redeployed within intensive care, skill-based team approach for delivery used Implementation of COVID-19 practice-based guidelines	Resuscitation as per latest guidelines – including PPE first Established networks of care modified as London collaborative (i.e., aortic dissection, primary PCI) to ensure delivery of life-saving services during pandemic MCS services for cardiogenic shock increased, admission triage decisions based on distributive justice	Introduction to intensive care: online resources as well as face-to-face didactics	Use of POCUS	Intensive review of PPE procedures
New York, New York	Non-critical care cardiologist staffing CICUs Relocation of the CICU to smaller unit	Critical care cardiologist being deployed to COVID-19 ICUs Non-critical care cardiologist assisting critical care providers in admission of COVID-19 patients .	Low risk STEMIs being admitted to telemetry ward Repatriation of patients to community hospitals Patients with cardiac critical care diagnoses admitted to COVID-19 ICU (not CICU) but managed by critical care cardiologist or co-managed between general critical care provider and non-critical care cardiologist	Co-rounding model and multidisciplinary cardiac consultation in ICUs caring for COVID-19 patient Telemedicine consult service for other hospitals in network	Use of fibrinolytics for off-site STEMIs in selected patients Enhanced POCUS for evaluation of acute coronary syndromes Restructured evaluation and use of advanced therapies for cardiogenic shock Chest compression devices for cardiac arrest Changes in frequency of laboratory testing for patients undergoing therapeutic hypothermia	Simulation and boot camp for non-critical care physicians	POCUS before formal TTE to limit exposure	Integration of palliative care in daily rounds Multidisciplinary rounds with nephrology and nurse leadership to prioritize use of renal replacement therapy Creation of a prone positioning team for manual proning of patients Enhanced multidisciplinary collaboration to rapidly create and implement research protocols and registries Local hotels providing housing for providers involved in care of patients with COVID-19

ACS = acute coronary syndromes; CICU = cardiac intensive care unit; CCM = critical care medicine; COVID-19 = coronavirus disease-2019; CT = computed tomography; ED = emergency department; ICU = intensive care unit; IRB = institutional review board; NSTEMI = non-ST-segment elevation myocardial infarction; PPE = personal protective equipment; POCUS: point-of-care ultrasound; STEMI = ST-segment elevation myocardial infarction; TTE = transthoracic echocardiogram.