In Germany, new national regulations urged health care providers to increase capacities for SARS-CoV-2-positive individuals. Hospitals were advised to postpone elective operations/interventions to create free capacities for primary care and to double the capacity of 28,000 intensive care unit (ICU) beds [1‐3]. Simultaneously, the German Cardiac Society (GCS) addressed the need for maintenance of guideline-adherent clinical practice in cardiac patients despite the emergency plans for COVID-19 patients [4, 5].

At the time of outbreak, German certified chest pain units (CPUs) are building a nationwide network with currently 287 certified units (due date: March 2020), thereby offering a minimum of four fully monitored beds per unit [6‐8]. From a survey from 2016, we know that about half of all CPUs are structured as an integral component of the emergency room (ER) and as much as 11% are even located on an ICU, whereas only about 40% are operated as an independent unit or as part of a cardiologic intermediate care (IMC) unit (40%) [9]. Thus, we hypothesized that the increase of ICU bed capacities as well as the set-off of isolation zones in the ERs might interfere with the given CPU structures. The current study aimed to analyse potential changes of CPU set-up and/or bed capacity based on the individual implementations to the COVID-19 emergency plan by each individual hospital housing a certified CPU.

The study design comprised of a standardised telephone interview survey with a questionnaire focusing on the characterisation of the respective CPU. The interview was carried out either by interviewing the head of the CPU or contacting a CPU hotline where available. Following formal oral consent to participate, the CPU’s medical professionals were assisted to respond to the questionnaire. Data collection included all certified CPUs across Germany. Certified units were identified by the official website of the GCS [1]. Telephone interviews were performed within 15 days. The due date was April 1st 2020. At this time, 67,366 individuals were ‘tested positive’, 732 were reported ‘dead’ and 18,700 cases were reported ‘recovered’ in Germany [10].

The response rate to the telephone interview was 91%, allowing data collection from 261 certified units by April 1st 2020.

Cardiovascular disease patients are at particularly high risk by COVID-19, either directly due to frailty, susceptibility, SARS-CoV-2-related myocardial injury and medication or indirectly because of negative implications resulting from medical system changes [12‐15]. The latter may bear the risk of postponing possibly life-saving procedures or vice versa to produce additional patients with acute coronary syndromes and late referral, additionally stressed by reduced access to medical care because of fear for contagion [16]. Resulting from the pandemic outbreak of the novel SARS-CoV-2, the caregivers worldwide pass through a process of reorganisation and restructuration trying to maintain adequate coverage for chest pain patients. Due to limited resources especially in regional hospitals, but also due to limited medical personnel due to infection or quarantine, given diagnostic and even therapeutic standard operating procedures (SOPs) had to be adapted and/or reorganised leading to potential shortening of diagnostic protocols as well as pre- and in-hospital delays [16‐18]. As such, German CPUs as part of the German emergency structure were facing a new and unknown situation with no former experience or planned coping strategies. Very early in this process, the GCS took position and addressed the need to maintain infrastructure for handling patients with acute cardiac symptoms [4, 5, 19].

In contrast to 2016 findings, where the nationwide German CPU network—including 230 certified CPUs at this time—provided a mean of 1 CPU bed per 65.000 inhabitants, we found a pre-pandemic versus pandemic CPU bed capacity of 1 CPU bed per 47.700 inhabitants versus 1 CPU bed per 49.000 inhabitants, respectively [9]. While university hospitals were able to increase the total CPU beds, academic teaching hospitals and other health care providers had to reduce CPU beds. Nonetheless, the type of facility did not automatically predict structural resources. As a consequence of restructuration of the first hospital medical encounter location, e.g. enlargement of ER bed capacities or creation of alternative pathways for infectious patients, we saw a relocation of CPU beds out of the ER into separate wards. In some individual cases, this led to a total lack of standardised monitoring. Interestingly, we observed no reduction in CPU beds when being located next ICU beds. This may be due to a massive increase in overall ICU bed capacity or by the low admittance of ICU COVID-19 patients so far and thus may change in times with higher patient volume [20]. Some IMC unit beds may have been upgraded to ICU beds, which may explain at least in part the decrease in CPU beds in IMC units. The observed expanded capacity of mechanical ventilation could be explained as possible preparation for upgrading CPUs in case of rededication to a ventilation ward. We primarily hypothesised that the burden of infection cases per federal state will be reflected in the number of CPU beds per inhabitants. Nevertheless, the observed north–south gradient could neither be explained by the number of infection cases nor by population demographics. With the growing need in ICU beds for COVID-19 patients, we see a possible competition for the 25 CPUs integrated into ICUs, as relocations of beds may become necessary in a short time frame. Reorganisation also bears implications on CPU-specific SOPs. As to the pandemic-adapted plans, about one-fourth of patients presenting with acute chest pain and suspected SARS-CoV-2 infection would have been admitted to pre-existing separate CPUs, where existing SOPs are established and trained. With the restructuration of first hospital medical encounter location and ERs being the place to go for many patients, one-third of the patients would have been admitted to the ER, where CPU processes were implemented, although dedicated CPUs are likely to provide certain superiority with respect to diagnostics and treatment [21].

So far and with all necessary methodical caution, we see a comparably low fatality rate of 1.2% across Germany (due date: April 1th 2020) [22]. We do not anticipate that maintaining high CPU capacities directly affected this rate. However, the lower rate of patients with acute chest pain being admitted and, therefore, treated raises deep concerns towards an evolving substantial increase in early and late infarct-related morbidity and mortality. As this phenomenon is partly explained by system-related factors such as increased critical time intervals or reduced diagnostics, offering enough capacity for cardiac patients at risk will still contribute to reduce collateral fatality rates [16, 23, 24]. Further studies should be performed in the transition and inter-pandemic phase to elucidate COVID-19-associated cardiovascular morbidity and mortality as well as COVID-19-associated morbidity and mortality of non-COVID-19 patients due to structural changes in hospitals and possible delays in first medical contact and emergency medical services. To maintain a high-standard care for cardiovascular patients and especially those with acute ischemia or critical cardiac condition, development of inter- and intra-hospital clinical guidelines on managing acute cardiovascular diseases to support medical care providers during COVID-19 pandemic is highly recommended [18].

Germany has a strong and tight network of CPUs. With the present survey, we can demonstrate that the CPU bed capacity was held constant despite all reorganisation pressure during the COVID-19 pandemic allowing us to maintain adequate coverage for all chest pain patients. CPUs organised in a separate setting within the department of cardiology seems to be in favour. Providing uniform, central and binding guidelines on managing chest pain patients in SARS-CoV-2-infected and non-infected patients to unify care may be profitable, at least each CPU should be advised to develop corresponding clinical SOPs. Such system may be transferred to a European level, which has recently been put into action [25, 26]. To implement obligatory partaking in central data collection to ensure nationwide quality control could bear further benefit.