This pattern played out around the world, with 40 to 60 percent fewer admissions for cardiac emergencies in the USA and 50 percent fewer in the UK.
But the problem had not simply disappeared. Anxiety about contracting COVID-19 in health environments, or putting additional pressure on busy healthcare systems, meant people in urgent need of care delayed seeking help—with deadly consequences.
With 2.1 million Australians living with heart disease or at high risk of heart disease, the National Heart Foundation of Australia calculates that more than 500,000 people missed potentially life-saving check-ups or management of their condition.
The British Heart Foundation (BHR) estimates that in England, almost 5000 more people died from heart problems than would be expected, from the beginning of the pandemic up to mid-October 2020.
A team of researchers in Flinders University’s Caring Futures Institute (CFI) are investigating these impacts for South Australia, with a view to creating dynamic tele-health solutions that mean self-isolating and remote patients with chronic conditions never have to risk their health again—not only during any future pandemic but at any given time.
This has involved a survey of clinical practitioners on how usual services were affected by COVID, and an examination of SA Health data for people who suffered heart attacks during lockdown.
“We’re very concerned that people with existing chronic conditions have delayed going to hospital when they had symptoms indicating they were deteriorating, and that this has increased out-of-hospital emergencies,” says team leader Professor Robyn Clark.
“We don’t have the data yet, but we already know that in rural areas there were a higher number of heart attacks than before.”
“The heart attack pandemic has been going a lot longer than the COVID pandemic, but the disruption of COVID has had all sorts of unseen consequences.”
This includes the fact that many people have not been visiting their elderly parents, grandparents or loved ones, for fear of putting them at increased risk of coronavirus, which has meant much less monitoring of health and wellbeing.
Both before and after a heart attack, time is critically important. Even without the obstruction of COVID concerns, Australians suffering the symptoms of a heart attack have a natural reticence about calling an ambulance, typically waiting an average of 3.17 hours, when every single minute counts.
The first three weeks directly after a heart attack are also crucial for physical rehabilitation—the loss of rehabilitative services has far-reaching impacts.
“It’s not just about converting a clinic to a phone call,” Professor Clark says. “Post-heart attack rehabilitation has to be structured with proper assessments.”
To help fill the gap, Professor Clark and the CFI team are creating a new approach to delivering cardiac rehabilitation that’s “like a menu”.
“It’s truly patient-centred care. You can choose a hybrid of telephone and web-based applications that best suit your needs. We’re also tapping into activity tracking devices, encouraging patients to walk to the shops rather than drive, and so on—these are an easily accessible alternative in the absence of gyms.”
Calling Nurse Cora
This builds on innovative work already undertake by Professor Clark, whose vision for the future of community health is a Princess Leia-like nurse hologram beaming directly into patients’ living rooms to deliver life-saving messages of self-care.
The Heart Foundation Future Leader Fellow is already halfway there, with the design of three innovative apps that support critical stages of a heart patient’s journey—a field in which Flinders University is a world leader.
App number one is The Heart Action Plan, more affectionately dubbed ‘Nurse Cora’ after the highly relatable avatar who delivers critical information on recognising and responding to heart attack symptoms. In engaging, evidence-based, word-perfect messages, Cora, spells out exactly what signs to look for, which can be missed even by those who have suffered a heart attack previously. Nurse Cora gets people into ambulances quickly.
“People say they ‘don't want to bother the ambulance’—they think it's just a set of wheels that gets them to hospital,” Professor Clark says. “But paramedics are your first point of care. When they hook up their machinery in your home, you're already at hospital.”
In a six-month pilot study, Nurse Cora increased symptom recognition by 24%, and the likelihood of participants calling an ambulance by 46%, compared to the control group.
The second app, Fluid Watchers, introduces users to Bob and Mary: avatar peers with lived experience of heart failure. Users get to choose whether they prefer to talk to Bob or Mary, and also customise their hair, clothes and accessories, before receiving practical day-to-day advice and tips on how to manage their heart condition.
The third and most recently developed app, Six Steps to Recovery, delivers information on the most important steps to rehabilitation post-hospital, to avoid re-admission.
The apps are designed to circumvent many of the challenges that quickly became apparent with the pandemic: low levels of health literacy and the challenges of rapidly disseminating vital information nationwide.
“The average Australian literacy is Grade 5; this means 41 percent of Australians can’t read a map, a recipe or the back of a medicine bottle. And then you have a significant population for whom English is a second language. Information on hand washing and social distancing has to be provided in a culturally, linguistically and educationally appropriate way to gain traction—COVID has shown us the consequences of not communicating effectively across Australia’s broad population.”
“In the context of heart health, a heart attack patient takes six tablets and a heart failure patient takes nine, and they have a world of questions. The usual practice is to give them a brochure when they leave hospital. Chances are these booklets are NOT going to be effective—particularly when cardiovascular disease has the highest incidence in our most vulnerable communities.”
The apps have been designed with the full participation of nurses, patients and tech wizards to ensure they are effective, engaging and fun.
“I used to be one of those stern shake-the-finger nurses,” Professor Clark says, “but these apps have taught us so much about patient education. It HAS to be fun. So, we’ve created ‘serious games’. We call it ‘gaming for good’.”
“We wanted Cora to be the kind of nurse you always want at your bedside. She's delivering an important message but in a cute, fun way. It’s also important the families of patients get to know Cora, because the person with heart disease might be unable to use their phone.”
The apps have strong endorsement from the Heart Foundation, which is keen to see the Fluid Watchers app adapted specifically for Aboriginal and Torres Strait Islander users. There is also high international interest for this world-first in patient care.
In the meantime, Professor Clark says the key objective is to translate the apps into the six most spoken languages in Australia: Mandarin, Arabic, Cantonese, Vietnamese, Italian and Greek.
“And then get them downloaded onto every heart patient’s phone.”
The development of these tele-health programs are important steps towards empowering individuals with knowledge they can readily apply—not only to improve their health wellbeing but potentially to save their own lives.
“Never before in my research career have I seen patient education as more valuable than it is today. Our goal is to be able to deliver the highest quality healthcare directly into people’s homes, using technology that every Australian has access to.
“From Star Wars to Avatar, this is quite the adventure we are on. And our Tonsley campus is already designing holograms, so my Princess Leia vision is not far away!”
The Flinders University Caring Futures Institute is using the pandemic experience to better understand how we prepare for such events, not just for physical health but exploring the care and caring relationships that both protect and nurture individuals, families and whole communities during such challenging times.
Let’s all thrive together! To support projects like these, responding to the pandemic and ongoing health and wellbeing challenges, please donate here.
 “Half-a-million Aussies neglect heart health during pandemic: new research” The National Heart Foundation of Australia, 29 September 2020, Half a million at-risk Aussies neglect heart health during pandemic (heartfoundation.org.au)
 “Where Have All the Heart Attacks Gone?”, The New York Times,6 April 2020, Where Have All the Heart Attacks Gone? - The New York Times (nytimes.com)
 “Heart disease deaths soar in England during Covid pandemic”, The Guardian, 14 November 2020, Heart disease deaths soar in England during Covid pandemic | Heart disease | The Guardian