PRIORITY PLAN
The overarching principle is that all invasive cardiac electrophysiology
procedures that can be reasonably postponed without compromising patient
safety should be, until further guidance is available. It is unclear how
long postponement of elective procedures will continue to be advised.
Reasonable non-invasive options that allow for expedited discharge are
preferred.
Challenges for cardiac electrophysiology, like many medical and surgical
specialties, are present when differentiating elective versus
non-elective procedures.10 However, guidelines and
consensus statements have been issued by ACC, AHA, and HRS. These have
standardized systems that categorize therapies by “Classification of
Recommendation.”11 The following priority plan,
presented in the Figure , builds upon these documents.
The first consideration, “Guideline or Consensus Statement
Classification of Recommendation”, allows for the assessment of a
multitude of procedures already systematically studied by several
guideline and consensus statement committees. It avoids the need for an
exhaustive list of procedures and clinical scenarios. The second
consideration, “Anticipated Short-term Morbidity or Mortality
Benefit”, allows for tailoring to the unique clinical characteristics
and presentations of each patient. A 30- to 90-day definition of
“short-term” may be adjusted based on individual scenarios and
projected time frames to reschedule procedures. Procedures and scenarios
with class IIb recommendations, by definition, have weak support, so
there are no circumstances to expect high short-term benefit. This
priority plan allows for adoption by other countries and regions with
their own guidelines and consensus statements that use a similar
“Classification of Recommendation” system.12 It may
also be used or adapted for future pandemics.
Pacemaker and implantable cardioverter-defibrillator (ICD) generator
changes are not addressed well in guidelines. Devices within the
elective replacement interval should be considered emergent/urgent or
equivocal, depending on the indication and the estimated remaining
battery life. Same-day discharges for new implants may be encouraged to
lower inpatient time and resource utilization.
Hospitalization status may have some bearing on determining potential
benefit, particularly if an arrhythmia incited the index hospitalization
and may recur in the near future. Hospitalization per se is not a
justification for recommending expedited therapy as some may be safely
discharged at low risk.
Legal issues should be considered since CMS recommendations were
issued.8 Hospitals were investigated and fined by the
United States Department of Justice nearly one decade ago, in part due
to violating CMS policies for the primary prevention ICD. Gross
violations to the “no elective procedures” recommendation during the
COVID-19 pandemic could conceivably trigger investigations. Proactively
documenting the rationale for non-elective procedures is worth
considering.