Singapore and 62% (95%CI 50-76%) for Tianjin, China [6].

• the long incubation period for COVID-19 of up to 14 days, during which time a person may be asymptomatic and yet unknowingly spreading the infection to others.
• the stability of SARS-CoV-2 in aerosols [7] and on surfaces (up to 3 days for plastic) contributes further to the high risk of transmission of the virus
• limitations in diagnostic testing for COVID-19, including the fallacy of an initial negative COVID-19 test report; Further compounded by-
• a lack of understanding of these issues and of the concept of adequate personal protection in this situation by many healthcare personnel, specialist doctors, institutional heads and policymakers worldwide as corroborated by a breaking news item reported by MSNBC on second April 2020, that the Georgia Governor Brian Kemp wasn’t aware that asymptomatic people could pass coronavirus. It comes as no surprise, and he definitely is not the only one; many hospital administrators, policymakers, and institutional heads may similarly not be aware of the same.

Existing protocols in many hospitals worldwide still allow hospitals to keep healthcare workers exposed to COVID-19 patients on the job with the stipulation of a daily screening for symptoms. Hence there are concerns regarding the spread of disease to healthcare workers who continue to see patients and to perform procedures on them, thereby risking spread to others. The CV disease (CVD) patients are known to have a higher fatality with COVID 19. As patients with significant cardiovascular risk factors, or established CVD get affected by COVID 19 infection, cases of Acute coronary syndrome (ACS), ST-elevation acute myocardial infarction (STEMI), in the setting of COVID-19 may increase.

Since patients presenting with ACS and STEMI, require immediate admission and often urgent intervention, without allowing time for assessment for COVID 19 status in these patients; this increases the risk of exposure of cardiologists, healthcare personnel and other admitted patients. A low rate of detection of infection in early stages of the disease makes it even more difficult to accurately diagnose the disease early, leading to a dilemma for the cardiologist as to the best course of action for saving the life of such a patient, without compromi-

Fig-1a: WHO data on cases of COVID 19 worldwide as on 30^th March 2020 (From https://www.worldometers.info/coronavirus/, last updated 28 March 2020.

Fig-2. Inadequate Personal protection for operator performing echocardiogram in COVID-19 patient. The illustration shows an echocardiographer with a cap, mask, and face shield with the use of a barrier. This does not constitute appropriate personal protection. Level 1 PPE is mandatory for CCS I or II (see text for details); while Level 2 PP may suffice for CCSI II (see text for details).

Fig-3: An innovative suite equivalent alternative to a HAZMAT suit. Though it has no

(including at least one additional plastic and one additional non-porous fabric in addition to the usual), to safeguard the personnel from risk of infection from COVID-19 patients and suspects (Appendix A-C).

To recall the words of Charles Darwin 'It is not the fittest who survive, nor the most intelligent; but those who adapt to change'.

The pandemic may abate over next few months; the steep rise of new cases may reach a plateau, but it is reasonable to believe that the disease will remain at varying levels around us for long; hence we need to adapt to change and change our practices accordingly to meet the challenge for years to come. Hence the guidance in this document should be considered a suggestion for a change in practice, to adapt to COVID-19; not just a short- term, stop-gap measure for a few weeks. This document, from the COVID-19 Working Group of the Wellness and Radial Intervention Society, also describes considerations for management and care of cardiovascular disease (CVD) patients with the concept of COVID-19 `designated` Vs. `enabled` centers for those with symptoms of and/ or confirmed COVID-19 disease Vs. asymptomatic suspects. It also provides guidance to healthcare professionals, hospital administrators, and policymakers in general and to those managing patients with CV and other diseases, regarding the concept of `levels of personal protection` for staff; with suggestions for equivalent alternatives, and a` protection plan` for patients to prevent the spread of disease. The guidance can also be broadly applied to surgical branches in general and to other specialties such as gastroenterology, urology, anesthesiology, otolaryngology, and ophthalmology involved with invasive, semi-invasive, and non-invasive procedures. The latter three specialties carry a higher risk of exposure for healthcare professionals.

Proposal for Triage of all patients countrywide: The patients presenting to any hospital country-wide should be triaged based on their infection status category, referred to as 'clinical COVID-19 status Category(CCSC)' (see below) and managed in an appropriate center, as described below under B.

A. Clinical COVID 19 status Categories (CCSC)-(Table-1)

1. Confirmed COVID-19 positive: To be managed in `COVID-19 designated` centers only

every city, region, or town for managing CVD and other patients, based on their CCSC, as described below. The considerations for other non-cardiology, semi-invasive and invasive procedures (NCSIIP) such as intubation, trans-oesophageal echocardiography, endoscopy, and various ophthalmology and otolaryngology, dental and other miscellaneous procedures, with respect to healthcare personnel and patients, at such centers, would be similar to that for cardiology procedures.

Though such segregated centers were available in China and also in India in Stage 2 of the epidemic; the caveat is that if numbers overwhelm the capability of the existing facility then it may become difficult to maintain such segregation. In India, at the time of going to press, this differentiation is now being lost; since with increasing numbers, several private hospitals in Delhi and Mumbai are catering to both COVID-19 and Non-COVID-19 patients in different wards in the same hospital. This is contrary to what was done in China [9] and endangers the spread of infection, and risks hospitals becoming epicenters of infection and should be discouraged.

Rationale: The rationale for such segregation of centers or hospitals is to minimize the risk of cross-infection and maximize care. This is so because in a designated center, the health care personnel and set up is completely geared to deliver care without delay to all such CCS I and II patients without hesitation, regardless of specialty. Unfortunately, for countries which got overwhelmed by the pandemic such as the USA in stage 4 or Italy and Spain in stage 7 of the epidemic; differentiation into COVID-19 designated or enabled centers was not possible as was done initially in India, where these steps were taken in early stages of the epidemic.

If a patient of CCS I or II were to be treated in a hospital shared by all three categories of CCS and if such a patient, for example, were to have a cardiac arrest, then there could be hesitation and delay in the steps of cardiopulmonary resuscitation (CPR), as is observed in the directive issued from the British Resuscitation Council for CPR in suspected or confirmed COVID-19 cases, where the new directive is to delay chest compressions till a ``FULL COVID-19 PPE is worn. This is so because COVID and non-COVID hospitals have not been segregated in the UK. In a COVID designated hospital, staff would already be in full PPE; hence this delay would not be necessary. In the USA however, most hospitals have a policy of no CPR in critically ill COVID-19 patients, to avoid exposure to staff.

1. Non-invasive and conservative management (including CCU).
2. Semi-invasive, Invasive and interventional procedures including all procedures in the cardiac catheterization laboratory (CL).

Patient protection policy: Single or isolated room for every single patient is necessary for such patients for initial 5-7 days, following which the patient can be re-screened and tested for the exclusion of COVID-19. Only after COVID-19 is excluded on repeat testing, should the patient be shifted out of the isolation room [8] to the floor or discharged. The policy of social distancing, avoidance of crowding, use of hand-rub for patients and maintenance of hand-hygiene, along with appropriate protective gear including surgical masks [10], caps of non -porous fabric, hospital dress, non-porous gowns, and footwear, and disallowing any contact with visitors must be strictly followed. Visitors should be restricted and should wear masks. All visitors should be screened to exclude CCS categories I and II.

b) COVID-19 'designated' center

Few centers in every region should be 'designated' for managing COVID-19 positive cases. These centers should be fully- equipped to provide in-hospital services in all specialties and have Level-1 PP for all categories of staff (please refer to Appendix A-C for details), in addition to institutional standard operating protocols (SOPs), adequate staffing and a staff roster to match the requirements as discussed in detail below. The choice and number of such centers should be based on the estimated burden of disease per million population in the region which can be decided by the regional authorities. These COVID-19 positive cases should be treated in such designated centers only.

These centers should be geared to provide care in all specialties; including both of the following in Cardiology:

1. conservative care in outpatients, on the floors as well as in coronary care or other intensive care units
2. invasive and interventional management in the cardiac catheterization laboratory (CL) as described below.

A. Plan of Management (POM) for various CCS categories

Following would be a suggested plan of action

It may be preferable to perform invasive and interventional procedures transradially because risk of bleeding [11] and therefore contact time between staff and patients and hence risk of cross -infection may be less with transradial, compared to transfemoral access; performing left radial access with the patient in prone position is also a suggested option to minimize exposure of staff.

2. CCS Category III:

Until the curve of new/ active COVID 19 cases flattens, which for India, is not anticipated before July 2020 [9], it is suggested that CCS category III should be managed as for CCSC I and II. Level-1 PP should be used. After the curve flattens, it may be possible to perform invasive procedures on patients as per American College of Cardiology(ACC) guidelines, which means directly taking patients to CL for PCI for STEMI and early invasive treatment for ACS. Other countries in Stage 4 of the epidemic, or beyond would have to decide on their anticipated timeline based on advice from WHO and from the public health experts and epidemiologists.

B. Infrastructural considerations and arrangements and space plans.

'COVID 19 designated centers' for various procedures, including the CL should have a separate segregated corridor for movement of patients in and out of the CL or equivalent procedure areas. A separate chamber is required for donning and doffing PPE by the staff, which should be adjoining space for showering and sanitization of personnel after doffing. Personnel assisting in donning and doffing of PPE should be adequately protected. Re-use of PPEs should be prohibited. It is useful to have runners standing by outside the door of CL or OR for an initial few CCS category I or II cases, to cater to

in OR s and all other areas such as CCU. The COVID 19 virus can survive on cardboard for prolonged periods of up to 24 hours.

• Modification of ventilation system: An air-handling unit (AHU), in a standard positive pressure ventilation system distributes air-conditioned draught to different rooms, including the CL and its control room. The risk of cross-contamination from airborne infection is low if the staff is adequately protected with appropriate PPE [10,12].

While a positive pressure room is capable of rapidly eliminating viruses from the CL; it may contaminate other adjacent rooms. Negative pressure ventilation [14] on the other hand optimally protects adjacent areas;

however, when a temporary negative pressure is changed to positive pressure it may cause cross-contamination of adjacent areas. Further such conversion from positive to negative pressure is time- consuming and may not be available for emergent procedures at all times.

D. Staffing for 'COVID-19 designated' facilities

For COVI19 `designated` facilities, the suggested work plan could be that teams should work for 7 days and be in quarantine for the following 14 days. If tested negative after 14 days, they can rejoin duties or take off to meet their families. Thus 4 teams will be required.

In addition, backup arrangements for staffing are required to cover for situations where a staff member reports sick or is quarantined. In addition to institutional costs is unavoidable and has to be dealt with per institutional, departmental, and health policy rules of the region.

E. Considerations for staff working in COVID 19 `enabled` and `designated` centers

In those on duty in areas such as COVI19 enabled or designated center CCU or other areas, including outpatients, echocardiography or non-invasive cardiology laboratories, wherever the PPEs cannot be doffed for 8 hours, because of cost of such equipment; staff have to be aware of their personal food and drink consumption prior to donning as well as of their toilet requirements. For these reasons, hygienic disposable diapers have been used by such staff on long shifts in China, prior to donning PPE. Alternatively, per local SOPs, the shifts can be divided between staff to shorten its duration.

spectacles. A face shield is to be preferred to cover sides of the face, if hooded suits are not worn.

10. Sanitize hands by rubbing with Sterilium^TM
11. A Level –C (US classification) Hazmat or equivalent innovative suite (Figure 3) made of non-porous fabric, plastic (± rubber). Should preferably have a hood to cover the head and neck. It covers the entire body including, trunk and upper and lower extremities up to legs.
    OR
    Wear unsterile gown with 3^rd Cap of non -porous fabric. Must cover head and ears and neck and prefer face shield instead of goggles - if HAZMAT or equivalent hooded suit not worn.
12. 1^st Sterile Gloves
13. 2^nd gown: a Sterile disposable Gown made of non-porous fabric, available in a universal protection kit; for those performing or assisting in any sterile procedures.
14. 2 sterile gloves: preferably including 1 pair of latex gloves for those performing or assisting in any sterile procedures; only 1 sterile glove is adequate for those not performing sterile procedures.

Note: For those not performing sterile procedures, such as those doing outpatient, inpatient, or non- invasive work:

• Unsterile gown in Step 13 and examination gloves instead of sterile gloves may be used by those not required to perform sterile procedures.
• Specific change areas should be made available.

Doffing (Adapted from CDC) is done in a sequence reverse to Donning:

1. Hand rub (HR1) with Sterilium/methylated Spirit/70% isopropyl alcohol
2. Remove Sterile disposable surgical gown- breakneck/back straps and discard layer3 sterile gloves.
3. HR2 with Methylated spirit or sterilium in CL or OR /procedure room (PR)
4. Remove face cover/eye goggles
5. Remove surgical mask
6. Remove the second headcover in CL/OR/PR
7. Remove Hazmat suit or equivalent and glove layer-2

• Use of an Ambu bag, nebulization, and positive pressure non-invasive ventilation should be avoided to minimize the risk of the spread of the virus.
• Early intubation is advisable in patients with desaturation and severe breathing difficulty.
• Frequent cleaning of equipment and furniture, including keyboards, mouse, CL controls, echocardiographic machine controls, keyboard, plugs, transducers, and doors, doorknobs should be performed using 70% isopropyl alcohol.

Unused stuff in the work area can harbor infection and must be sanitized or removed and discarded as soon as work is complete, including covers from lines, catheters, sheaths, stents, balloons, etc.

1. Appendix -C(1)

2. Appendix- C (2)

3. Appendix -C (3)