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The impact of the COVID-19 pandemic on the echocardiographic services and training in Poland

Writing Committee: Piotr Lipiec1, Andrzej Gackowski2, Jarosław D Kasprzak3, Katarzyna Mizia-Stec4, Magdalena Lipczyńska5, Piotr Szymański6

Contributors: Wojciech Braksator7, Maria Dudziak8, Dominika Filipiak-Strzecka3, Zbigniew Gąsior9, Piotr Hoffman5, Anna Klisiewicz5, Wojciech Kosmala10, Małgorzata Knapp11, Marcin Kurzyna12, Dorota Kustrzycka-Kratochwil13, Zofia Oko-Sarnowska14, Agnieszka Pawlak15, Wojciech Płazak16, Edyta Płońska-Gościniak17, Piotr Pruszczyk18, Piotr Scisło19, Grzegorz Skonieczny20, Bożena Sobkowicz11, Danuta Sorysz21, Lidia Tomkiewicz-Pająk22, Olga Trojnarska14, Paulina Wejner-Mik3, Andrzej Wysokiński23, Beata Zaborska24

1Department of Rapid Cardiac Diagnostics, Medical University of Lodz, Biegański Hospital, Łódź, Poland

2Jagiellonian University, Medical College, Institute of Cardiology, Department of Coronary Disease and Heart Failure, Noninvasive Cardiovascular Laboratory, John Paul II Hospital, Kraków, Poland

31st Department of Cardiology, Medical University of Lodz, Bieganski Hospital, Łódź, Poland

41st Department of Cardiology, Medical University of Silesia in Katowice, Katowice, Poland

5Department of Congenital Heart Disease, National Institute of Cardiology, Warszawa, Poland

6Clinical Cardiology Center, Central Clinical Hospital of the Ministry of the Interior in Warsaw and Center of Postgraduate Medical Education, Warszawa, Poland

7Departament of Sport Cardiology and Noninvasive Cardiac Imaging, Medical University of Warsaw, Warszawa, Poland

8Noninvasive Cardiac Diagnostic Department, Medical University of Gdansk, Gdańsk, Poland

9Department of Cardiology, Medical University of Silesia in Katowice, Katowice, Poland

10Department of Cardiovascular Imaging, Institute of Heart Diseases, Wroclaw Medical University, Wrocław, Poland

11Department of Cardiology, Medical University of Bialystok, Białystok, Poland

12Chair and Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre of Postgraduate Medical Education in Warsaw, European Health Center, Otwock, Poland

13Department of Echocardiography, Centre for Heart Diseases, 4th Military Hospital, Wrocław, Poland

141st Department of Cardiology, Poznan University of Medical Sciences, Poznań, Poland

15Mossakowski Medical Research Center, Polish Academy of Science / Department of Invasive Cardiology, Central Clinical Hospital of the Ministry of the Interior and Administration, Warszawa, Poland

16Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, Kraków, Poland

17Department of Cardiology, Pomeranian Medical University, Szczecin, Poland

18Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warszawa, Poland.

191st Chair and Department of Cardiology, Medical University of Warsaw, Warszawa, Poland

20Department of Cardiology and Intensive Cardiac Care Unit, Provincial Polyclinic Hospital Torun, Poland

21Department of Cardiology and Cardiovascular Interventions, University Hospital, Kraków, Poland.

22Department of Cardiac and Vascular Diseases, Faculty of Medicine, Jagiellonian University Medical College, Institute of Cardiology, John Paul II Hospital, Kraków, Poland.

23Department of Cardiology, Medical University of Lublin, Lublin, Poland

24Department of Cardiology, Centre of Postgraduate Medical Education, Grochowski Hospital, Warszawa, Poland

Correspondence to:

Prof. Piotr Lipiec, MD PhD,

Department of Rapid Cardiac Diagnostics,

Medical University of Lodz, Kniaziewicza 1/5,

91–347 Łódź, Poland, phone: +48 42 251 62 16,

e-mail: lipiec@ptkardio.pl

Copyright by the Author(s), 2021

Kardiol Pol. 2021; 79 (10): 1136–1139; DOI: 10.33963/KP.a2021.0102

Received: August 4, 2021

Revision accepted: September 1, 2021

Published online: September 1, 2021

INTRODUCTION

COVID-19 pandemic has dramatically influenced the healthcare systems around the world, including cardiology services. When infections rates were peaking, a significant part of available resources was repurposed towards fighting the pandemic. Moreover, in 2020 cardiology practitioners were advised by numerous guidelines and official recommendations to defer scheduled elective procedures, especially those associated with an increased risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission, such as transesophageal echocardiography (TEE) [1]. On top of that, patients’ fear of infection and the desire not to overburden the healthcare systems kept them from seeking medical care in case of symptoms unrelated to COVID [1].

Therefore, it comes as no surprise, that data published so far indicates a significant and abrupt reduction in cardiac care services in numerous countries and regions. It has been reported that the cumulative number of hospitalizations for acute and chronic cardiovascular conditions, as well as the number of outpatient cardiovascular visits, had substantially decreased [1, 2]. The latter was only partly compensated using telemedicine. There has also been a significant drop in the number of various inpatient and outpatient cardiac procedures and examinations, including echocardiography [1, 2].

Importantly, the COVID-19 pandemic has affected medical education, not only for undergraduates but also for residents and post-graduate trainees [1]. The reduction in the number of cases and supervised procedures, as well as canceled educational activities, a shift of educational curricula towards online didactics, postponed examinations and altered rotations have already been documented in some specializations [2, 3].

However, details of the pandemic’s impact on echocardiographic laboratories are still unclear. Furthermore, there is no data on the current state of post-graduate hands-on training in echocardiography. In order to shed more light on this issue and to identify the most important implications and possible obstacles for restoring the pre-pandemic activity of echocardiographic services and training, the Working Group on Echocardiography of the Polish Cardiac Society performed a national survey to evaluate echocardiographic practices and postgraduate training in echocardiography in Poland during the pandemic.

METHODS

This retrospective survey was based on questionnaires filled out by 23 participating Polish echocardiographic centers. We attempted to include a large number of laboratories to cover all regions of the country in order to account for practice variations related to differences in infection rates and local regulations regarding healthcare. To encourage participation, we reached out via e-mails and phone calls to experts working in echocardiographic laboratories with active post-graduate education programs identified in the database of the Working Group on Echocardiography of the Polish Cardiac Society. Each center was asked to fill out a questionnaire regarding their practices in the 9-month period representative of the pre-pandemic activity (AprilDecember 2019) and in the 9-month pandemic period (AprilDecember 2020). Importantly, because during the pandemic there were phases with various infection rates and different degrees of the potential impact on the echocardiographic practices, we concentrated not only on the average monthly test volume but also on the minimal monthly test volume in the analyzed periods.

Statistical analysis

Continuous variables were initially tested for normality of data distribution by the Kolmogorov-Smirnow test. Normally distributed variables are expressed as mean (standard deviation [SD]). Non-normally distributed variables are presented as median (interquartile range [IQR]). Categorical variables are presented as percentages (%). Paired samples t-test was used to compare the examination of volume between the pre-pandemic and the pandemic periods for data with normal distribution whereas, for non-normally distributed data, the Wilcoxon test was used (MedCalc Software, Frank Schoonjans, Belgium). The differences in the examination volume were considered statistically significant at P <0.05.

RESULTS AND DISCUSSION

The mean and minimal monthly test volumes in the participating centers in the pre-pandemic and pandemic period are presented in Table 1. During the pandemic, 9 centers (39.1%) were partially transformed into COVID-19 facilities, whereas 3 others (13.0%) were transformed into centers only for COVID-19 patients. Transthoracic echocardiography (TTE) and TEE were performed in patients with COVID-19 in 18 (78.2%) and 9 (39.1%) centers, respectively (the median/mean of cumulative numbers of tests were 21 (20100) and 5 (6), respectively). Stress echocardiography was not performed in patients with COVID-19.

Table 1. Monthly examination volume in the pre-pandemic period (April–December 2019) and during the COVID-19 pandemic (April–December 2020) in the Polish echocardiographic laboratories

Pre-pandemic period, mean (SD) or median (IQR)

Pandemic period, mean (SD) or median (IQR)

Mean relative change in test volume (%)

P-value

In-patient services

Mean monthly test volume

TTE

389 (261)

273 (226)

–29.9

<0.001

TEE

37 (30)

21 (18)

–45.9

0.004

TPM

8 (6)

5 (5)

–37.5

0.0497

Stress tests

8 (7)

3 (4)

–62.5

<0.001

Minimal monthly test volume

TTE

298 (202)

159 (147)

–46.4

<0.001

TEE

27 (23)

9 (12)

–64.3

<0.001

TPM

1 (0–5)

0 (0–1)

0.008

Stress tests

4 (6)

1 (1)

–75.0

0.02

Out-patient services

Mean monthly test volume

TTE

147 (127)

100 (91)

–32.0

0.009

TEE

12 (12)

4 (5)

–66.7

0.012

Stress tests

7 (5)

3 (3)

–57.1

0.04

Minimal monthly test volume

TTE

61 (27–200)

2 (0–15)

<0.001

TEE

3 (2–8)

0 (0–0)a

0.004

Stress tests

1 (0–5)

0 (0–0)a

0.03

aOnly 2 centers maintained minimal monthly test volume higher than 0 throughout the pandemic period

Abbreviations: IQR, interquartile range; SD, standard deviation; TEE, transesophageal echocardiography; TPM, transcatheter procedure monitoring; TTE, transthoracic echocardiography

Three labs (13.0%) underwent temporary suspension of all their activities due to either quarantine or diagnosis of COVID-19 in all staff members. Three sites (13.0%) suspended temporarily only their out-patients services due to local regulations. In 21 (91.3%) centers at least one staff member (on average 3 [2]) was quarantined, whereas in 18 (78.2%) labs there were confirmed cases of COVID-19 among the personnel (on average 2 [1]). Seven (30.4%) sites reported temporary shortages of personal protective equipment, which on average lasted 70 (83) days.

A negative COVID-19 test was required before TTE, TEE, and stress echocardiography in 9 (39.1%), 17 (73.9%), and 10 (43.5%) centers, respectively. Body temperature check was performed before TTE, TEE, and stress echocardiography in 18 (78.3%), 17 (73.9%), and 14 (60.9%) labs, respectively.

The indications for TTE, TEE, and stress echocardiography were limited in 6 (26.1%), 12 (52.1%), and 10 (43.5%) sites, respectively. Additional disinfection procedures visibly reduced temporal availability of resources in 12 (52.2%) labs by 21 (11)% on average. The examination protocols for TTE, TEE, and stress echocardiography were shortened in 5 (21.7%), 5 (21.7%), and 1 (4.3%) centers, respectively.

The scheduled examinations were delayed or canceled in 12 (52.2%) and 6 (26.1%) labs, respectively. Similarly, waiting times for elective procedures following echocardiography cardiac surgery, percutaneous coronary intervention, structural transcatheter procedure, and electrotherapy were prolonged in 15 (65.2%), 12 (52.2%), 13 (56.5%), and 12 (52.2%) centers, respectively. Furthermore, there was no possibility of scheduling elective cardiac surgeries, percutaneous coronary interventions, structural transcatheter procedures, or electrotherapy after echocardiographic examination in 3 (13.0%), 1 (4.3%), 2 (8.7%), and 1 (4.3%) sites, respectively.

Importantly, the pandemic significantly affected post-graduate hands-on training in echocardiography. The overwhelming majority (90.9%) of centers, which had been actively teaching before the pandemic, reported that they had either no or fewer trainees involved in activities (13 [59.1%] and 7 [31.8%] sites, respectively). At the same time, practical workshops, which had been regularly organized or accredited by the Working Group on Echocardiography of the Polish Cardiac Society before the pandemic, were either canceled or reformatted into online webinars and lecture-based courses.

To summarize, this survey documents a dramatic reduction of echocardiographic services, especially TEE and stress echocardiography, and confirms the need to urgently restore the full capacity of echocardiographic laboratories, as recommended in our recent Expert Opinion [2]. Furthermore, our data demonstrate a long pause in hands-on post-graduate training in echocardiography, which may adversely influence the quality of cardiology services for many years to come. To avoid such detrimental effects, we recommend a prompt reactivation of full-scale post-graduate hands-on training programs in the teaching centers, as soon as pandemic-related restrictions allow. Obviously, the level of personal protection of all trainees should be identical to the protection provided for the staff members (see the aforementioned recent Expert Opinion for details). Moreover, echo laboratories and other medical services should be prepared to maintain their activities despite the possible future pandemic waves.

Article information

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