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\begin{document}

\title{Los Angeles's Perspective of COVID 19 Effect and Impact on Cardiac
Surgery}



\author[1]{Tiffany Worthington}%
\author[1]{Ali Khoynezhad}%
\affil[1]{Memorial Care Heart and Vascular Institute}%


\vspace{-1em}



  
  \date{May 22, 2024}


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\selectlanguage{english}
\begin{abstract}
Coronavirus 2019 (COVID 19) captured worldwide attention as the virus
spread from initial detection as a pneumonia of unknown cause in Wuhan,
China in December 2019 to the declaration of a pandemic by the World
Health Organization only three months later. This paper describes the
impact of COVID 19 on cardiac surgery services in the greater Los
Angeles area. Discussion includes public health response to the
pandemic, how local hospitals reacted to the expected surge in COVID
patients, establishment of telemedicine services, and the projected
future impact on California healthcare as a result of the COVID 19
pandemic.%
\end{abstract}%



\sloppy


\textbf{Los Angeles's Perspective of COVID 19 Effect and Impact on
Cardiac Surgery}

Tiffany Worthington, DMSc, PA-C and Ali Khoynezhad, MD, PhD

Department of Cardiovascular Surgery

MemorialCare Heart and Vascular Institute

Running Title: COVID-19 in Los Angeles

Corresponding author:

Ali Khoynezhad, MD, PhD

Department of Cardiovascular Surgery

MemorialCare Heart and Vascular Institute

2801 Atlantic Ave

Long Beach, CA 90806

akhoynezhad@memorialcare.org

Phone: 562-933-7174

Fax: 562-933-7178

Author contributions:

A.K. and T.W. both contributed to data collection, drafting the article,
critical revision of the article. A.K. performed final approval of the
version to be published.

This manuscript did not involve research of human subjects, therefore is
exempt from Institutional Review Board (IRB) or Ethics Committee
Approval.

Los Angeles's Perspective of COVID 19 Effect and Impact on Cardiac
Surgery

Los Angeles County is home to over 10 million residents. As comparison
only nine states in the US have more population than Los Angeles county.
It serves as home to professional sporting teams, the entertainment
industry, theme parks, and a variety of outdoor recreation activities.
LA County is a popular destination for approximately 48.3 million
tourists annually.

On December 31\textsuperscript{,} 2019, an initial report of pneumonia
of unknown cause was reported to the World Health Organization (WHO)
office detected in Wuhan in the Hubei province of China. By January 30,
WHO declared a ``public health emergency of international concern'' as
COVID-19 cases had been reported in five WHO regions in the course of
one month.{[}1{]} That same day, LA Times headlines read ``For
Americans, flu remains a bigger threat than coronavirus''.{[}2{]} As a
community, LA was still recovering from the news of Kobe Bryant and his
daughter dying in a helicopter crash along with several other
passengers, headlines of novel coronavirus spread were buried within the
newspapers, with limited appearance on the front page.

As concerns worldwide continued to grow surrounding the COVID-19
pandemic, WHO issued a notice of impending shortage of personal
protective equipment (PPE) on March 3, 2020. {[}3{]} The following day,
LA county officials issued a declaration of local public health
emergency. By 5 days later, the first community spread case was reported
in LA. On March 11\textsuperscript{th}, the first death from COVID-19
was reported in Los Angeles County. {[}4{]} March
18\textsuperscript{th}Governor Newsom wrote to President Trump
requesting federal funding and additional support with concern that more
than half of the population of California would be infected with the
virus over the following 2-month period. As awareness of the impact of
the pandemic in the greater LA area continued, a ``safer at home''
emergency order was issued on March 19\textsuperscript{th}. This order
entailed the closure of all non-essential businesses, no gathering of
more than 10 people, and all persons to remain home unless visiting an
essential business or participating in outdoor activities at least 6
feet apart from others. The order to wear face masks whenever out of the
home and interacting with people was issued as an official guidance on
April 1 and became a requirement on April 10\textsuperscript{th}. On
April 23\textsuperscript{rd}, COVID became the leading cause of death in
LA county, surpassing coronary artery disease, emphysema, influenza, and
COPD. {[}4{]}

As the number of COVID cases continued to grow, certain trends were
emerging, including a significant impact on residential care facilities
and in lower-income areas. In response to a growing shortage of staffing
in nursing homes, the medical director for LA county EMS made a
temporary allowance for EMTs and paramedics to staff the nursing homes.
As of mid-June, there were 321 nursing homes in LA county with a least
one resident who has tested positive for COVID. {[}5{]} The number of
deaths related to COVID have been three times higher in areas of poverty
than in higher income areas within LA county. Ninety-four percent of
deaths in the LA area related to COVID were patients with underlying
health conditions. Of those who died, 42\% occurred among Latino
residents, 28\% White, 17\% Asian, 11\% African American, and less than
1\% Native Hawaiian/Pacific Islander residents. {[}6{]}

\textbf{Surge Planning}

Convention centers and arenas in the area were converted to field
hospitals to handle the predicted patient surge. The US Naval Ship
Mercy, a Navy hospital ship with patient capacity of 1,000 beds was
dispatched to the Port of Los Angeles where it remained for seven week
before returning to its homeport in San Diego. The ship treated 77
patients with non-COVID medical complaints during the deployment.
California Health Corps, a state-wide volunteer program was initiated
which yielded substantial interest, 82,000 volunteers signed up in the
first week.

Surge planning was initiated with emergency triage drills, development
of labor pools, immediate cessation of scheduling elective cases, and
daily policy updates were provided via email communications across the
healthcare system. In preparation for numerous patients coming to the
emergency department, designation of zones within departments for
persons with suspected COVID, confirmed COVID, and those who were being
treated for non-related medical conditions. Online dashboards were
created for reporting daily hospital capacities throughout the county
for up-to-date status monitoring.

Emergency medical services developed interventions to minimize
unnecessary patient volume in emergency departments by aggressive field
triage measures including postponing transport of cardiac arrest
patients for at least five minutes after revival on scene and
establishing a videoconferencing platform for emergency department
physicians to provide telemedicine services to patients at home and
managing non-urgent issues remotely.

\textbf{Cardiac Surgery}

The transition from standard operative practice to complete shutdown of
elective cases was immediate in mid-March. Operating room boards were
wiped clean as hospital administration scrambled to devise a protocol
for triaging which cases would be appropriate to continue as planned and
which cases could be safely postponed, minimizing PPE use and maximize
available resources. Daily updates were issued reporting number of COVID
cases within the healthcare organization, county, and state. Initial
projections for the LA county area impact provided an expected two week
timeline to exceeding ICU bed and ventilator capacity. During this time,
surgical cases were restricted to emergencies only. Aortic dissections
and patients with severely symptomatic valve disease were among the only
cardiac surgical cases to be performed. Over the following month, the
number of COVID patients fell drastically short of predicted. Throughout
the state, there was a 62\% decline in ED visits in April and a 35\%
decline in total hospitalizations when compared to previous years.
{[}7-8{]} Triaging protocols were developed to begin a controlled
re-integration of services in the cardiac surgery unit while actively
monitoring COVID patient volume, ICU bed capacity, and availability of
PPE. In mid-April, surgery services were resumed with team-based
decision making on which cases could safely continue to be postponed
versus those that took priority to be managed as early as possible.
Patients with symptomatic disease have been amenable to proceeding with
surgery, however some with asymptomatic disease such as aortic aneurysm
have shown hesitation in rescheduling their previously planned surgery.
Some changes to the pre-operative process include COVID testing within
48 hours of surgery and the restriction of visitors within the hospital.
IPads are used to facilitate patient communication with their family
members during their hospital stay, and daily telephone updates to
family members, and Facetime communication between the patients and
respective family members became part of the new routine.

\textbf{Outpatient Response}

As news spread of the COVID pandemic, patients became hesitant to come
to the outpatient clinic. During the first few weeks, patients were
hesitant to participate in videoconferencing visits, however by April,
telemedicine visits became routine practice. Nationally, telemedicine
prior to COVID accounted for 0.25\% of medical services provided to
Medicare beneficiaries. {[}9{]} With the emergency passage of waiver
1135 and Coronavirus Preparedness and Response Supplemental
Appropriations Act, prohibitive barriers in telemedicine were eliminated
allowing for rapid expansion to continue managing patients that are
safer at home during a pandemic. During peak telemedicine service
between March and April, 45\% of all patient encounters were performed
remotely using a videoconferencing platform within our healthcare
organization. With the simultaneous interruption of cardiology and
diagnostic imaging services, new referrals during the restriction period
were limited.

An active surveillance program was initiated for all patients who had
been scheduled for surgery that had been cancelled due to hospital
restrictions. Patient check-ins were performed on a weekly basis with
videoconferencing and telephone visits to evaluate for changes in
symptoms or progression of disease necessitating more immediate
intervention.

In mid-May, as outpatient services continued ramping up, the two-month
backlog of patients who had declined telemedicine visits started to
return for follow up. Currently, chronic aortic dissection and aortic
aneurysm patients have been the most challenging to recapture, with 30\%
requesting deferral of their routine imaging to a later date.

\textbf{Future Impact}

The re-introduction of social activities in the LA area has been
cautious and closely monitored. Initially hiking trails and beaches were
opened for recreational use mid-May. Near the end of May, restaurants
were permitted to reopen with the agreement that certain safety
protocols were met such as outside seating, maintantince of 6-feet
distance, offering electornic menu, and hand hygiene protocols for
employees. Health officials inspected over 2,000 LA restaurants two
weeks after opening and found that approximately 50\% were not in
compliance with the safety protocols issued.

As of June 20, 890,793 have been tested out of a total population of
over 10 million residents. {[}5{]} There have been 79,609 confirmed
cases with 3,063 deaths. {[}5{]} Of these 7,632 have required
hospitalization. {[}5{]} The predicted surge has not happened to date,
and this may have to do with early state and county-wide shut-down,
however a progressive and gradual increase of COVID-19 postive cases has
been occurring recently. As the LA area continues to relax restrictions,
health officials closely monitor for changes indicating the need to
resume at-home restrictions.

The next crisis facing California hospitals will likely be the financial
impact of cancelling elective cases, costs related to surge preparation,
a ravaged economy, and a predicted increase in uninsured or underinsured
patients as job losses push people towards Medi-Cal, the California
Medicaid insurance coverage. The University of California health system
reported losses over \$140 Million over 6 academic health centers from
the cancellation of elective procedures. Across California, hospitals
are reporting average losses of 20-30\% with a predicted net loss of up
to \$14.6 billion across about 400 hospitals by the end of 2020. {[}8{]}
In addition to direct losses from COVID impact, California passed a
state law requiring hospitals to update earthquake preparedness
infrastructure by 2030, which was estimated to cost up to \$100 billion
over the next 9 years. {[}10{]}

\emph{References}

\begin{enumerate}
\tightlist
\item
  World Health Organization. Statement on the Second Meeting of the
  International Health Regulations. Emergency Committee regarding the
  outbreak of novel coronavirus (2019-nCoV); 2005. InURL: https://www.
  who.
  int/news-room/detail/30-01-2020-statement-onthe-second-meeting-of-the-international-health-regulations.
\item
  Karlamangla S. For Americans, flu remains a bigger concern than
  coronavirus. LA Times. 31 Jan. 2020
\item
  World Health Organization. Shortage of personal protective equipment
  endangering health workers worldwide. 3 March 2020.
  https://www.who.int/news-room/detail/03-03-2020-shortage-of-personal-protective-equipment-endangering-health-workers-worldwide
\item
  County of Los Angeles Public Health. Los Angeles County announces 68
  new deaths related to 2019 novel coronavirus (COVID-19); 1081 new
  cases of confirmed COVID-19 in Los Angeles county. {[}press release{]}
  23 April 2020
\item
  County of Los Angeles Public Health. LA county COVID-19 by the
  numbers. 23 June 2020
\item
  County of Los Angeles Public Health. Los Angeles County announces 34
  new deaths related to 2019 novel coronavirus (COVID-19) -- 2,364 new
  cases of confirmed COVID-19 in Los Angeles county. {[}press release{]}
  23 June 2020
\item
  Office of Statewide Health Planning and Development. Hospital annual
  financial disclosure report FY17-18.
\item
  KaufmanHall. The financial impact of COVID-19 on California hospitals
  -- CHA member survey. June 2020
\item
  Centers for Medicare \& Medicaid Services. Information on Medicare
  telehealth. CMS. 18 November 2018
\item
  Preston, Benjamin Lee, Tom LaTourrette, James R. Broyles, R. J.
  Briggs, David Catt, Christopher Nelson, Jeanne S. Ringel, and Daniel
  A. Waxman, Updating the Costs of Compliance for California's Hospital
  Seismic Safety Standards. Santa Monica, CA: RAND Corporation, 2019.
\end{enumerate}

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