An interdisciplinary group of experts from across Mayo Clinic's critical care practice discusses the key challenges in the management of patients critically ill with COVID-19, lessons learned and innovative solutions that have been effectively implemented within our health care system.
Alexander S. Niven, M.D., consultant, Pulmonary and Critical Care Medicine; associate professor of medicine Featured expert:
Sean M. Caples, D.O., M.S., consultant, Pulmonary and Critical Care Medicine; professor of medicine Featured expert:
Sarah J. Bell, M.S.N., M.H.A., R.N., nurse manager, Enhanced Critical Care; instructor in nursing Featured expert:
Andrea (Annie) B. Johnson, APRN, C.N.P., instructor in surgery Featured expert:
Grant D. Wilson, R.R.T., L.R.T., instructor in pediatrics Featured expert:
Ayan Sen, M.D., chair, Department of Critical Care, Mayo Clinic in Arizona; associate professor of emergency medicine; assistant professor of medicine
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The views and perspectives shared in these resources are presented based on information available at the time of recording.
Welcome to Mayo Clinic Cove in 19 expert insights and strategies. The following activity is supported in part by an independent medical education grant from Pfizer Inc and is in accordance with a C CMI guidelines. So I think we'll go ahead and get started. Welcome to this latest edition of the Mayo Clinic Cove in 19 live Webinar Siri's uh, this is the second of two parts on the topic of caring for critically ill patients with Cove in 19 Top Lessons and Innovations. And I'll start off by passing things over to Jeff Pat Haruka to review a little bit about how our webinar will work. All right, Thanks a lot, Doc. You live in? Well, I'm Jeff Potter book. I'm a senior education specialists in our continuous professional development school s o just a few things. This webinar is accredited by the M A am A for one credit. There are no relevant disclosures for today's discussion. And of course, we'd like to thank fighter for the support of this educational activity. So before we get started, I just like to cover a few points with you on. The first is on how to claim credit so If you would like to claim credit for this webinar today, there's a few brief things you need to do. The first is toe Visit our Mayo Clinic website. What you can see here is a link ceo dot mayo dot e d u Backslash Covic 09 to 1. You'll need to log onto the site. If this is your first time, there's a quick, simple process for creating your own account. After you've logged in, you'll see that there will be an access code box for on this link. So what you wanna do is type in today's code, which is Covic 09 to 1. This will give you access to the course. You can complete our short evaluation and then you'll be able to download your certificate. The link and the code will be dropped into the chat box throughout the today's webinar, so you could just keep an eye out for that now, during this webinar and you could probably see at the bottom of your screen. Right now there are two functions. There's a chat feature, and then there's a Q and A feature. So what we're gonna do is if you have any technical questions or any issues that come up. Please use the chat feature on our support staff will be ableto assist you with that. If you have questions for our faculty today, what you want to do you do is use the Q and A box right there that will go right to the faculty, which the monitor throughout the discussion today. You'll notice when you're in there that there is an up vote function. So if you see that there's a question that's been asked that you had also in your mind, you like to see answered, you can go ahead and click the up arrow, and that will get to our faculty. So I'd like to share briefly the learning objectives for today's discussion. What you'll be able to do by the end of this is review the common clinical manifestations and challenges and caring for critically ill patients with Cover 19. Discuss innovative solutions to these challenges that have been implemented across the Mayo Clinic enterprise and identify the importance of inter professional collaboration to successfully deliver effective critical care to Kobe. 19 patients across the health care system, and with that I'm gonna bounce it back to Dr Niven, our moderator. Today he is a consultant within pulmonary and critical care medicine on associate professor of medicine and also the education chair of the division of Pulmonologist. Critical Care and Sleep Medicine is well as a critical care, independent, multi specialty practice doctor. Even thanks so much, Jeff. And it is a true pleasure and privilege to be part of a really fantastic faculty group today. It's my pleasure. Thio. Introduce my colleagues here, starting with Sean Capel's Who is, uh, who is a consultant here in the division of pulmonary critical care medicine and serves actually several roles. But in this webinar he is his primary capacity is of Section head for Critical Care Medicine here at Mayo Clinic, Rochester and also serves is the medical director for the Mayo E I. C. U program. Closely eso Sara Bell works very closely with the good doctor cables and the rest of us in all sorts of issues. She least until recently, was the nurse manager of enhanced critical care. She just recently got promoted eso. Hopefully we're trying toe pull her back in. Onda is also instructor in nursing here. Grant Wilson is the supervisor for quality and safety for respiratory therapy here in Rochester and instructor and Pediatrics. He's been doing some really fantastic and innovative things, Um, that you will hear about here shortly and I Ensign is joining us from Mayo Clinic Scottsdale. So he is the chair for the Department of Critical Care in Arizona. Andan is dual had it in terms of his academic promotions between emergency medicine and medicine. And last but certainly not least, Anne Johnson is a critical care nurse practitioner in our group and really not just the lead. I would describe her as the driving force behind our I see recovery program, which has been tremendously successful here in Rochester and is rapidly becoming an enterprise wide activity. So before we get started for those on the call who are less familiar with Mayo Clinic and our Enterprise Healthcare system, we wanted to spend just a minute telling you a little bit about our health care system so that you understand a little bit the context in which we will be having these discussions. So Mayo Clinic has three quote destination campuses, one in Rochester, Minnesota, one in in Phoenix, Arizona, and one in Jacksonville Florida And then the sort of cloud like area that you see in southern Minnesota, Iowa and Wisconsin is the Mayo Clinic Health System, which is a network of rural access and community based hospitals that surround Mayo Clinic Rochester. So when you hear us used these terms, that's what we mean. The Mayo Clinic Care Network is actually a network of affiliated institutions that that have been working with Mayo Clinic for, ah, variety of different lengths of time. Really, these relationships offer a collaborative opportunity for us to share our systems based practices, knowledge and and console services in addition to a variety of different knowledge based tools such as ask male expert next slide. So before we get started with our Panelists, I think it it goes without saying that it has been a brisk 2020 and the Cove in 19 Pandemic has really been historic in terms of its impact and disruption on health care services and, for that matter, everyday life across the globe. I think all of us have struggled to keep abreast of all of the rapidly evolving literature and innovations that have come out in this area since the pandemic hit all of our respective areas. And so what Mayo Clinic has been doing since the onset of this pandemic has been gathering our best practices and, when available, summarizing the best evidence that has been published in the literature in different areas and providing it in a concise and readily available form for the general public through the Ask Mayo expert Covic Navigator, the link to which is provided on this slide. What these Siris of webinars at least one eyes designed to do is to provide the why behind some of the information with the Koven Navigator and also highlight evolving and emerging information as it becomes available on DSO. This and a variety of other resource is, are are available through our online CPD site. You know, I think it goes without saying if you could go back just for a second there, Jeff. I think it goes without saying that the amount and rapidity of change has been a true challenge for everyone and especially in healthcare. And so I just wanted to highlight another available free public AP the Mayo Clinic Well being index, which provides some very simple tools Thio allow practitioners thio compare their level of stress and burnout toe other similar physicians across the globe. And, uh, at least for folks in the United States, also offers confidential access to a variety of different resource Is toe help keep us at our best performance, both for our patients and for ourselves and our colleagues. Aziz the sprints turns into a marathon, and with that, let's move on to the next slide. And it's my pleasure to introduce Sean Cables eso that he can give you a few focused lessons from his corner of the of the of the critical care practice. And I should just say upfront. What we're gonna do is focus 3 to 5 minute presentations from each of our faculty members, and then we're gonna leave a substantial time at the end for questions. So please do use that Q and a box to enter any questions, and we will address Justus many as we can in the time that we have remaining. Sean Alex. Thanks so much. It Zanon er thio take part in this webinar. Um, I'm going to focus on our experience in New York and you'll see on the slide here there is a There's a published paper in New England Journal of Medicine. Catalyst, which is which highlights innovations in health care delivery. Um, just to give you some context, I apologize, but I'll have to take you back to the spring of this year at the height of covert infection in New York City. And we got a call for help. Um, from a colleague who was close friends with one of my partners here in Mayo Clinic that they needed help. And we have been watching for weeks. Um, hearing from friends, colleagues, family members from the east coast of how devastating things were. And we really racked our brains for, um, probably the order of weeks to try and figure out how we could help. We knew we couldn't get there physically. We knew we had an existing Kelly. I see you program, uh, but it was pretty obvious that we couldn't implement that technology in the way that we were familiar with. So, for context tell you, I see you implementation takes generally on the order of months, um, for hard wiring of beds, developing work flows, making relationships, and that obviously couldn't apply in this situation. So the first thing that the first hurdle we had to overcome to help our colleagues in New York was to think differently about how we can deliver care. And we were able to develop in a very short period of time. Literally less than one week. We went from idea to implementation, and we did that with the development team on. The development team included people like Sara Bell, one of the other speakers today who who's the nurse manager of our telly. I see you program. The development team also included I T specialists, administrators, credentialing specialists. Um, but the other key to the success of this program were folks in New York. We partnered with New York Presbyterian who have very well developed infrastructure for things like information technology. Um, E H R. Systems credentialing. And we couldn't have done it without the governmental passage of legislation to simplify the process of credentialing and licensing So literally within two days, we were able to go from no license in New York State to full licensure on credentials at the hospital to give you context into what, um, we encountered when we got to become familiar with Presbyterian Waas, we were right at just past the peak of patients who had flooded all of the ice use in, um, in New York, Uh, patients spilled over from a full. I see you into a full pack you into a full, uh, ward on the general care floors full of ventilated patients. And so they needed bodies to help care for these patients. And so obviously they're they're intensive. Ist staff was overwhelmed, And so they recruited physicians from surgical areas from procedural areas from pediatrics um, from medicine residents, fellows to come into the icy use and deliver. I see level care and those physicians were excellent. But we're not accustomed to sort of the culture of ice you that we use intensive ISS are familiar with and comfortable with. And so we knew right away that our approach to telly medicine in this situation, um, was going to be different. And so we used what we like to call a light touch. We were able to utilize, uh, tablets, Um, ipads, if you will to connect to the bedside team at Presbyterian, um, to round with the team twice a day and we would bring the culture of critical care to the bedside twice a day and rounds and so easy things, little things that we consider to be easy and after thought came to them as, ah ha moments. And, um and we were able to really impact care in a very simple way. So things like a spontaneous breathing trial, a sedation vacation, um, from birth through amber prophylaxis, um, those sorts of things that might not be second nature to a pediatrician. I should also note that our colleagues at the University of Pittsburgh we're doing a parallel, um, implementation on their end with other hospitals across the the Presbyterian system. Um, one other very important point is that the folks on the receiving end need to be not only engaged, but bought into the concept of bringing critical care expertise to the bedside. And so we were really fortunate to have not only a colleague, Ed Presbyterian, but a good friend who was able to really drive the ship on their end, and he was able to get us really integration within the health care team had presbyterian. Um, the project lasted four weeks, Um, and by the end of the four weeks, the patients were beginning to clear out of the general care awards on things were coming back to some normalcy, but it was a really It was a real gratifying experience for us to think differently about delivering telly, medicine care, Andi, and understanding that you you can't accomplish this if you've got the right team around you. Um, I think that's my five. Yep. It's my six minutes, so I'll stop there. Thank you. Thanks so much on it was a fantastic experience to be a part off. I'm a move things to grant. Next. Who is going to talk a little bit about our auction alert system that he has been instrumental in developing? Thank you, Dr Nevin. And Good Morning, everyone. Early in the cove, it pandemic. The Critical Care Specialty Council was concerned about our ability to be aware of patients with increase or increasing oxygen needs spread out over a large area. And Dr John Charnin from Critical Care, Todd Meyer and Alicia Ledger, myself from respiratory therapy, all worked on on designed an alert within epic toe. Help us with this issue. And this rt hyo to support alert has been in production since May of this year and I'll go through the workflow here, um, with this slide. So the alert was intended to help us identify patients in general care areas that we're progressing toe higher levels of oxygen's. And it also helped us, um, provide the opportunity to pride and assessment by the respiratory therapist and involved the medical team. The alerts trigger based on oxygen support criteria that were predetermined by critical care. Things such as flow, oxygen device type or F I 02 are included in that criteria. And when the criteria is met, a rover push notification will be sent to the respiratory therapist if they're signed into the care team for that patient. And it also generates a work list task that appears in a report that that we've built and all of this these criteria come from flow, she documentation by the nurse or the third. Then, um, because it would be not practical for a therapist to sign in, tow hundreds of patients at a time. Um, we mostly get our information or get alerted to the patient by running this report and our lead therapists. We have a respiratory lead therapist on every shift every day and they. They run a report every four hours that identifies patients for follow up and an example. That report is the screenshot at the bottom of the slide, and patients that meet our inclusion criteria for an assessment then are followed up on DWI. Confirm that they're on the level of support. And in the report on then we also can contact the medical team to make sure they're aware that their patient may be increasing in oxygen levels. Andi also discuss the planet here. And, as you can see in the report slide, there's a number of different devices that have triggered this one. I mean, there's there's a nasal cannula, five liters a minute. There's a reservoir, nasal keano at six liters a minute, non rebreather mask and a nasal cannula. And our experience has been as it's as we've used it for a number of months. Now we get about one alert per hour, or when we run these reports somewhere in the range of 4 to 6 alerts in that four hour time period. The benefits that we found, um, in addition to it, doing what we originally intended, alerting us to patients on specific levels of oxygen. It's also let us see patients that were inappropriately set, and and this is something we struggled with prior to cove it nurses or other care providers not familiar with some devices in and setting them inappropriately, such as, Ah, simple mask. We found a number of those set in the 12 leader range, which puts the patient at risk for CO two retention because the mask doesn't get flushed, and it allows us to correct those in real time and educate the nurse right at the bedside. So that was kind of a side benefit of this of this alert. It's also allowed us just to connect with nurses in general and let them know we're involved or following this patient. The patients that are on this levels of support, the trigger, the alert and let him know it a call us if they've got questions or concerns about managing those devices. So, yeah, that's pretty much how that how it works and I'll let you move on to the next. Yeah, I'm sure that there will be more interesting questions about that grant, but I think Lett's let's keep on presenting Thea, the other other key. Take home that we have. Thank you so much for that. Sarah, do you want to go next? Thanks, Dr Nevan. Ah, lot of the challenges nursing has been experiencing in the I. C. U with Kobe patients. Is this PPE fatigue wearing the n 95 respirators all day? Um, it's hot there, there hard on your face. And it gets to be a long day, 12 hour shift. And the PPE, um, if they're hard to communicate and talking through a glass panel door out to the team outside of the patient's room could be complicated and difficult on, but can be very isolating in those rooms. And then Cove. It has presented challenges of staffing shortages for staff who are out ill or have cove it themselves or have sick family members that they need to take care of. It's going to be a busy fall. And so we're dealing with, um, staffing shortages throughout our I c E O. S. Um, during the pandemic and continuing on today, we've implemented in touch as a video support model on we've partnered that with our S U program. So the picture on the screen is the tablet device that we've deployed Thio all of the patient rooms who are quoted positive both in the ice use in Rochester, the General Care Cove, it positive patient rooms and also on our Florida campus. And this in touch device allows R E I. C U staff to camera into the room and provide a PPE kind of relief for the nurse. So if somebody is requiring continuous observation by a nurse, we could be on the tablet and interact with the patient, um, here, alerts and alarms and be able to relay out to the death staff if somebody needs to enter the room. This allows the room nurse opportunity to exit their PPE and get a break. Um, it also allows the nurse who may be in the room the opportunity to communicate more clearly with people outside of the room so providers can be on a a iPad or tablet and have this up. And instead of shouting through a door So, um, they can clearly communicate by a video from the nurse and the patient room in the provider outside of the patient room on their iPad. It's also affording us the opportunity to sort of staff are ice. You patients with nurses who are critically care trained and may have a nurse in the room that might not be critically care trained so that we can kind of provide that expertise to them in the room on denarii. Ice, you nurse. The other picture on our screen here is of R E I C. Operation center. So you can see we have multiple screens available to us so that we can have multiple patients. We can have, uh, diagnostic exams and imaging bedside monitors anything that we need to do so we can multitask and provide care to many patients over, um, this in touch video solution and through our ice, you program eso I'll stop there. Dr. Nevan, thanks so much. And it truly has been impressive to see this, uh, this system in action. Next we will move Thio Annie, who will talk a little bit about our I see recovery program. And just before any starts, I'll just remind individuals that as questions come up in your mind as you're listening to these presentations, please use the Q and A function down at the bottom of the screen toe type Those questions in and we will answer Justus many as we can once we're done with our formal presentations. Back to you, Anne. Perfect. Thanks so much, Dr Devon. And I'm really happy to be here with everybody today. Um, recovery from critical illness has been a focus of conversation amongst critical care professionals for the past several years. So it's It's not necessarily a new conversation amongst many of us, but now more than ever, post I see recovery is gaining really much more mainstream attention not only with non critical care providers but really with the general public as well. And this is really large hearted, thanks to the pandemic, of course, and the extra spotlight that's been focused on critical care over the past several months. Um, recovery from critical illness that is secondary to Kobe 19 is not entirely unlike recovery from any other critical illness. Really. Of course, there are some special considerations that we do have to keep in mind, but those just really largely deal with the unknown. We don't really quite know yet what we don't know about recovery for our Post Cove, it post ice you patients over the past five years or So here at Mayo Clinic in Rochester, we've really been building the foundations for post. I see you follow up. It was about a year ago we saw our very first patient in our outpatient setting and our newly developed Mayo Clinic. I see recovery program. Um, we were seeing patients were plugging away. We're getting people into this face to face clinic and then all of a sudden about March 2020 like everything else, it just came to a screeching halt. We took a momentary pause from our clinic, just kind of put the brakes on everything, just toe to evaluate things. But it quickly became really evident that now, more than ever, our post issue services, we're really badly needed. So it really it was just in a matter of days we took what had been a three hour face to face, um, impatient appointment and turned it into a virtual 60 minute follow up appointment that was done either via video chat with our patients and family members or through just a simple telephone conference call. And really, from that moment on, we haven't looked back, and we have kept all of our precise you follow up appointments virtual from from that point on. And we have a very full, busy, flourishing clinic in that manner. Uh, the key and evaluating post ice you patients, no matter which route you choose to do so. So if you're seeing patients physically face to face or if you're committing to virtual, um, the key is to make sure to assess the most commonly affected domains of the human experience. And we know from pre co vid precisely research and experience that those domains our physical, cognitive and mental health. So I'm just going to quickly walk you through our virtual post. I see you appointments on what we do in them, so you have a sense of what we do and how we address those specific domains. So prior to our patients scheduled appointments, they all receive standardized questionnaires, um, to complete. And those questionnaires really focus on mental health aspect. So we're looking at things like anxiety, depression, PTSD amongst a few other things. Um, the patient's submit thes and the review Dire team with the patient during their appointment. Right now we're scheduling virtual telephone conferences for all of our patients, and then our entire team which includes myself, our pharmacists and our occupational therapist joined the patient and, ideally, of possible family member. Caregiver loved one as well, all on the phone call, all at the same time. We start out the appointment with the patient, recapping what life has been like for them since being home from the I. C U. We hear it in their own words. We get a really good sense from them. How they're doing. We offer. I see debriefing both for the family member and the patient, as is needed. And then I complete focused head to toe review of systems with, um next, our pharmacist completes a full medication therapy management assessment. She answers any questions. I'm related to medications and provides counseling on things such a smoking cessation and immunizations. And then to wrap up the appointment are occupational. Therapist completes ah, functional reconciliation, and she really focuses on the patients physical and cognitive recovery. So she does this. We are really focused interview with patient as well as administering the mocha blind to get a general sense of what our patients, cognitive functioning eyes like Our occupational therapist also does return toe work assessment for all the patients who that is appropriate for. And then at the end of that appointment, each patient receives an individualized recovery plan to move forward with. It's really important to know that our clinic and many like it, function primarily as assessment and referral clinics, so that's kind of an important key. Take away. Um, we do offer some immediate interventions for with things like medication changes, prescriptions as needed. The ice you debriefing and education, of course. But really, our main focus is to really zoom out and get a really clear picture of the patients overall recovery story and then connect them with appropriate resource is as needed. Um, some examples of referrals that we have made for our patients include things like physical therapy, neurology appointments, speech, language pathology, pulmonary return to work programs, etcetera. Along with this virtual clinic appointment that we have created for patients, we have also developed a couple other exciting programs are just highlight really quick. We developed remote patient monitoring. This is a program where patients are discharged home, their district home with equipment that measures vital signs and then also a tablet, and for 30 days they check their vital signs, and they answer a series of of questions on this tablet and there followed very closely by a nursing team. And if there's any concerning trends, either in their vital signs that are being checked or in the questionnaires that they're submitting, the nurses were able to kind of flag that, um, intervene and then escalate any of those concerns as appropriate. And then the other program that were created is called Interactive Care Plan. It's essentially an app that patients go home with, um, and again there followed for 30 days. They don't do vital signs. Check necessarily. But they do dio like a symptom checker frequently with us, and that is sent directly back to our team. And if anything is flagged and is concerning, we get notified right away so we can intervene and connect with those patients. Um eso there's just kind of some some extra ways that we're staying connected to our post ice you post covered patients. So to summarize this, the overall key takeaways for everybody here today really should be that post ice you follow up can be as simple or as complex as your team is able to support. So it can really, honestly be a telephone call with a qualified team on one end, talking to the patient and the family member. Or it can be as sophisticated as APS and other monitoring programs. Whatever your team consent court, um, the main focus again should be on assessing for physical, cognitive and mental health. And then connecting patient's to available resource is if deficits are identified in those assessments. And then, finally, some special post covert considerations for these patients really includes screening for ongoing cardiopulmonary dysfunction. So the persistent cough breathlessness fatigue that patients might experiencing screening for throwing about embolism that we know can develop in this specific patient population, and then screening for the psychosocial sick quality that really developing a lot of our post. I see patients, but especially in light of different isolation that's going on right now for all of our patients during these times, Um, and also for the family members, um, there's also social stigma that we can't forget about. That is linked to Kovar 19 for your patients and family members, and then finally just committing yourself toe learning about the unknown in the recovery, and this really just starts with committing to focusing on follow up for these patients. Fantastic. Thank you so much, Anne, and we'll move to our last speaker. Certainly not least, Dr Sen. Do you want to talk a little bit about the ECMO team and the experience that you guys have had with Covad ECMO Transport down in Arizona? Most certainly. Thank you, Alex. And a great opportunity for me to be here on day joining this webinar from I see recovery to a group of patients who would certainly need I see recovery. Yes, it's the ECMO patients who patients who were calculated for ECMO, a za result of covert RDS. Now, um, inter facility transport of a critically ill patient with the RDS has been described in the past, and calculation of patients on ECMO has also been done in many different parts of the country as well as the world. It was first described in 19 seventies and eighties, but really the process started in year two thousands, mostly center, started having more, uh, already a centers of excellence. But when Colbert hit us, I think the big question that came to everybody's mind was, Is this something that actually works and more. So what of the resource implications off sending the whole team when there is a call for a patient who potentially is failing the mechanical ventilator and transport the patient that full P b e onda? How safe would it be? Not just for the patient, but for the staff, a swell well from looking at the also registry in the website. As of today morning, there were about 2584 patients worldwide, confirmed or suspected who have been put on ECMO, and the survival to discharge, as of now is about 53%. So I'm close to about 67 Patients are still in hospital at this time, so the question came to us and we've got a transport team in Arizona for the last 15 years. Is that something we can do? It Is that something that's feasible, especially because when we started seeing some of the surge down in Arizona, we were not entirely certain that we would be able to accommodate the group of patients who required a lot of resource management, but prepared we did because we wanted to take care of our patients, especially the young ones who were being referred from other regional hospitals in the Valley. And so we relied on the also the National Extracorporeal Life Support Organization guidelines that provided us with some information around which are the groups of patients, which potentially could benefit from this very resource intensive therapy. And so, based on that, the next big question was okay, we have these clinical guidelines. So what could be a potential inclusion criteria and what should be exclusion criteria? But the next big question came in with, you know, what is our capacity? Azaz 300 plus bed hospital. As the numbers started increasing, uh, would be be able to support caring for these patients. So these set of guidelines that you have on the slide were published in the latest also update as well that describe four different levels conventional to crisis capacity and some of the expectations that can be set as we manage the expectations of not just the family members but other regional hospitals as well. On the first stage is where your capacity exists and you can have judicial patient selection At the same time, ECMO can be offered, um, for the right, the patient population as well as for non corporate indications. But as you move to the Tier one and tier two, certainly your criteria or ability to care for these patients definitely becomes a lot more challenging. So we decided as hospital that we would limit the number of covert patients to five who could potentially be supported in our institution by this resource intensive technology. And so you may feel well, you know, is this fair? How did you make those decisions? The reality is we actually relied on a state surge line that was created based on the orders from the Arizona Department of Health. And the search line coordinated all the ECMO centers in the Valley, and we were able to decide which hospital has a bed available. Maybe banner. Phoenix has a bed available, while Mayo doesn't. Or Mayo could take a patient from Tucson. So we kind of strike to do that resource sharing. So the search line, which could distribute patients, um, as of now, if you have done about five transfers to Mayo Clinic Arizona. In the last few months, we've done a lot more Acma patients, but five have beaten, you know, calculated in the Regional Hospital Referral Hospital and brought in by our team and the pictures. These are team getting ready for transport, obviously before we embarked on this process. Although we've had a team for about 15 years, we wanted to ensure that all the do diligence was paid to manage PPE and that included having some checklists instituted what should be our modus operandi before leaving the hospital, what kind of resources would be needed as well as the donning and doffing process? When we arrived at the hospital, who would be in the ambulance? And you know how would be ensure the dolphin has done appropriately to prevent any kind of radicalization? Onda spread of the virus Because if you remember in March and April, we were still trying to argue and debate. Is this a drop letters? There's an aerosol generating virus and he wanted to take most precautions as well as we could. So we kind of do the SWAT analysis of what we learn from the past several months off, taking care of these patients and bring them, you know, with full PPE to our institution, our strength word that we do have a designated team a team that comprises an intensive is to cardiothoracic surgeon, um, ECMO specialist nurses profusion. And this designated team would take triage calls ensured that they met all the criteria for escalation of character ECMO and bring the patient back. So the collaborative team model that we have really made a lot off sense and overall outcomes through this pandemic has bean commensurate with what's been reported survival to discharge, being about 60% of so at this time. You know, in some patients still being on the circuit. Some weaknesses, definitely because absence of a dedicated team and dedicated team meaning, you know, physicians or nurses, um, waiting for a technical that's not feasible in the structure that we're in. And sometimes the team could be very busy doing other things, including surgeries a same time, and couldn't pull through a team to provide resources to the other hospital. The size of the hospital is also is also challenges. Sometimes on the I C U size I mentioned, we made a cut. About five patients of covert are ideas that are team could take care off, especially because you're fast rating Nursing resource is who were being pulled to take care off non EC Makovich patients as well, but it has brought open a lot of opportunities that we can explore and we hope to explore in the future. And that's increased regional collaboration. How we could potentially, you know, help eat other institutions out other states out. And I think our search line system in Arizona did work well. They're more opportunities to expand on that and, you know, explore other possibilities like transporting all because we've had very good success is by ensuring our staff have been kept safe by creating those guidelines and checklists off Phoebe management. Um, not something which we should forget about that the PP use and exposure. There's a lot that goes in, we need to have re sources. And in times when there is lack of resource is, I think crisis capacity doesn't warrant institutions. Um, that should be used eco as a option or an offer to patients. And we have to be mindful. Also, the prolonged act more runs for some of these patients or fatigue burnout. Some of the resource implications for other patients and ethical issues around selection and exclusion and inclusion criteria needs to be kept in mind in terms of the threats to this life saving technology that comes with a lot of challenges. So I'm going to stop here and happy to take further questions. Thanks so much. I am. And I think if we can take down the slides at this point, we have a little bit over 15 minutes to answer as many questions as we can. And there's certainly a lot of them in the queue. I'm going to go sort of from the top of the screen down in order because because certainly the thumbs up if you haven't noticed, it also helps to prioritize questions that more people are interested in. Uh, you know, unfortunately, I have no special knowledge in terms of the ongoing vaccine work that's out there other than there is ah lot of it going on from a variety of different get different companies. Is there anyone else on this call who can speak to that? Otherwise, I'm afraid we probably need a table. That topic. Yeah, there's a Madonna Phase three that's ongoing in United States and the Oxford vaccine outside. So still early days, I would think we'll get to Nome or I'm sure. Um, in the next couple of months. Yeah, I know. I listened to a presentation from Anthony Fauci a few weeks ago, and he listed actually six different initiatives that are ongoing, some of them fairly promising Onda. And short of that, I'm not going to speculate on timeline because because I don't I think that's anyone's guess. Eso the next question that has moved to the top is asking about new treatments, talking about convalescent plasma decks, Method Zone and Randy severe on dwhite else. And, uh, and perhaps I'll ask. I am followed by Sean Toe comment on that real briefly. Yeah, I think you know, we as an institution, a Z Everybody knows, you know, we were part of the expanded access, um, you know, support that we got initiative with using convalescent plasma. Dr. Joiner was the principal primary investigator on that, and we've been using convalescent plasma of all our patients, and we've had some good retrospective data that showed some reasonable outcomes. I think many trials are still being planned and ongoing, and I think again that would give us more indication off the real value of that therapy. As everybody knows, they did it approve it for emergency use access, which changes things slightly. I think more data needs to be available before we can say for certain that it definitely, you know, makes a huge improvement in overall outcomes. Steroids, definitely, I think, has had a big impact. And in my personal experience as well the last few weeks, where we have started using a lot more, we've been able to anecdotally, you know, see if mawr improvement in their primary function and ventilator being and all. But again, e think we'll have more information and data as we look at the SEC and Virus registry, which has 20,000 plus patients, that would provide a great night. It's for us, for while we await more and more trials to be published in this domain, Alex, the only thing I'll add to that is, um, there are some, uh, newer trials that are launching. Um, we're part of ah National consortium on the monoclonal antibody. It's one of the Mavs I would butcher than the name if I tried to say it, but I think there's, uh, there's a train of thought that interrupting the inflammatory cascade with monoclonal antibodies could have an effect on on outcomes, but it's it's very early. I think we've I think we've only recruited one patient so far across our health system. But that's something toe that will be coming down the pipe thanks to you both. So the next question really is headed towards the, uh Johnson with regards to what sort of things that you've been looking at in, uh, in covert patients, post recovery. I'll just e guess I'll just add an editorial comments to the question which, which states that when patients were intimate in the icy for more than seven days, their outcome is very poor. I think that that's still a bit of a moving target. I think one of the challenges that many health systems encountered early in the pandemic was an overwhelming volume of patients and considerable challenges in terms of wrapping our arms around this new disease process. But certainly best supportive care using evidence based critical care practices and and then the advances that we've been able to identify with Randy Severe Dixon Method Zone and perhaps convalescent plasma, I think has really moved the needle in terms of our perspective towards mechanically ventilated patients in their survival with cove it so they survive their hospitalization and come to you. And what are the specific things that you're thinking about and dealing with with covert patients? Yeah. So, um, we treat these patients really very much like we treat all of our post. I see patients. So we make sure that we're assessing for the physical, cognitive and mental health so quickly from critical illness. So we recover those baselines and then just like we do for any post I see you patiently individualized their assessment. So we looked specifically at what they were, you know, admitted with and four and kind of there. I see you story eso If they developed terrible delirium, we will kind of work through that a little bit. Um, etcetera. So we really individualize this for our post covert patients? I am being more specific in looking, um, and assessing their like I had mentioned the cardiopulmonary functioning. So really, maybe digging a little bit deeper into, um, breathlessness, cough oxygen. Need requirements. Still, um, kind of that functional assessment on being very thoughtful of screening for any concerning science for potential clots. So we have seen that in our in a patient specifically who developed, um, lower extremity DVT s and then ended up with bilateral pes after being home recovering from co vid eso I I ask questions and I assess very specifically for things like that. I would say that probably is unique in the cove in patients. I don't necessarily, um, do that as in depth for all of our post. I see patients. There is questions that will kind of lead us that way. But I'm a little bit more focused on that. Um being very thoughtful of pulling in family members and assessing family members and asking how they are doing so a thing to really remember, um is that ah, lot of these family members have also been sick. So we've had family members who, um, their whole family was sick. So, for example, ah, mom and all of the Children were sick at home, and Dad was also sick, but got sicker and ended up getting shipped off in into our I see you. So now she's at home sick, taking care of her sick Children and her family yet bearing the burden of worrying about her husband, who is in the ice. You, um even sicker than them. So following up with a family member and assessing how they're doing and connecting them with support such as therapy, social work, support groups. I can't stress that enough Getting people in to support groups for this type of thing. Um, so those are some of the more unique, um, looks that I will take for patients who are postcode, but otherwise we really, um we really kind of adhere to the kind of our main post ice you follow for these patients. And as far as kind of that initial comment about patients not doing well, doctor never know. Just kind of echo what you said. We don't really know yet. I'll tell you doing post ice, you follow up work, you will learn that we are really terrible at guessing which patients are going to do Great. You'll hear the patient's ice, you story and you think, Oh, my gosh, you're never gonna be okay and you'll follow up with them and be like I'm great. I'm fine. I have no problems. So it is really hard to know that's what makes follow up so important for these stations. Thanks Annie. And I guess I'll, uh, I'll just time in one other comment Putting my my hat on is the medical director of our PFT lab. We have actually been encouraging delaying pulmonary function testing for at least 90 days after after diagnosis, largely in recognition that Cove it likely similar to other viral related pulmonary infections will have sort of broncho spasm and transient effects that will take ah, wild to recover. The general guidance is at least 6 to 8 weeks. And, uh, obviously, testing is a really challenging these folks because we know that covert patients can remain PCR positive for an extended period of time. Eso because of those two things mixed benefit and challenges logistically in in terms of testing these folks prior to pulmonary function testing. We've been trying to delay those assessments a little bit, um, moving on to the next question, which asked about Mayo's Covic 19 critical order set. Um, and eso what therapies do you initiate for virtually all patients, intubated a non intubated admitted to the I C. U. And and perhaps we'll roll roll in a question about prone ing in there as well. That's further down, but I want to turn to Grant first, since he hasn't had an opportunity to speak, followed by Sarah, and then I'll open it up to the I C U directors. Was there a question you wanted me to address? Well, just thinking about some of the stereotypical things that you do and respiratory therapy with regards to enhancing both safety and efficacy management of Cove in 19 patients who are mechanically ventilated. Sure, let me just kind of along the lines of this high oxygen device alert. Prior to that, we had alerts prior to co bit for ventilator settings, and two of them one is, ah, high tidal volume alert. If we set a title volume above eight MLS per kilo, for instance, we get an alert. But the other one that we saw increased quite a bit through Cove. It was the high plateau pressure alert, and we tracked. That is, ah, quality metric for our department. We express it as number of alerts prevented later day, and we run that across the enterprise. But what was interesting in August in particular, I run those reports we saw higher, quite a bit higher ratio than the cumulative racial for the past year in Arizona and Florida when they had their surge and had a big increase in mental patients. So it was kind of interesting. Thio See that? But anyway, my area of expertise is more along the medical record and helping pull that out of it and do these alerts versus the clinical site. Sarah, you want to talk about some of the common things that we do for intubated patients on and even non intubated patients. There's been a lot of questions about Pronin were pruning early and often, um, were immediately when a patient is even admitted to our general care area, maybe just a nasal cannula. We're putting them on a pro ning schedule for the patients who are intubated, we try to skip. We try to prone them for three hour periods of time with a two hour break. In between, just we find that their breathlessness, shortness of breath and oxygenation greatly increases when we can prone them immediately on, often as they transition potentially to the I C u on day end up on, you know, high flow nasal cannula or by PAP. We we don't, uh, go away from pro name. We try to keep them in that prone position as they tolerate it. We can do different positioning with pillows to try and keep them primarily on their belly. And really, the key to the prone is keeping their chest cavity up in the sense that it could be like free falling. So stacking pillows on their upper sternum on their bellies that that chest can really, um, expand down and help them out. Um, when they're when they become intubated, well prone them for 16 hour stretches at a time. So typically they're deeply sedated. A lot of times paralyzed, and we'll we'll prone them. We have a special pillow that their face will into. We make sure that they don't have any major pressure. Points were putting up ilex in different type of padded borders. On bony prominence is to avoid pressure injury. One thing in covert that we've noted is we're having a lot of chin, um, deep tissue injuries from pro ning, and that wasn't usual when we would prone air D a r rds patients before cope. It s so we're seeing some of those clotting tendency is even in their chin from the pillow, and so an intubated patient will be prone about 16 hours straight, and then we'll flip them back for about six hours and then go for another 16 hours. Straight again. Um, and then we had a first last week where we had a patient on ECMO and they were maxing out their requirements on ECMO, and we decided to try and prone that patient. And before we, you know, switch them from kind of a VB circuit to more arterial based ECMO. We we prone them and had substantial results. Actually, um, and that's something we're looking to maybe protocal eyes moving forward. We prone them on the ECMO circuit, just like we would have normally 16 hours and then back for six and then back over again, and their P 02 had major benefit from that e think in the interest of time, since we just have a few minutes left. I'm going to address the anti coagulation questions there in the Q right now and then passed things over to Shawn and I am to continue the discussion in terms of standards of care, especially when it comes to connected care. So I I just wanted to highlight in the ask no expert Koven Navigator. There's actually a very detailed algorithm that has been put together by a collaborative group that I had the honor to be a part of with regards toe stratification and Venus thrown globalism prophylaxis. Um, I will highlight the fact that systemic anticoagulants shin for prophylactic indications, remains a very controversial practice and has been associated with some increased leading events in the literature. And so we do not do that as part of our routine algorithm. We were stratify people by largely icy you status and di dimmer level to determine the intensity of prophylactic doses of of either unfree action ated or low molecular weight heparin. And there's a risk stratification tool called the improved VT score. If that score is greater than three at the time of discharge, we continue profile access for 45 days, so that addresses the Your conference is scheduled to end in two minutes, so I'm going to throw things toe Sean next asking about the single best tool to implement from connected care in the hospital on home environment on Ben, any last best practices with regards to standard standard measures Yeah. Thanks, Alex. E think our experience early on with New York and other sites has allowed us to be to gain some comfort with, um, communicating via a tablet? Um, and it's uncomfortable. I I think what I've observed it can that sort of communication can undermine usual best practices. So a good example is I think we became more heavy handed with sedation, with benzodiazepines, for example, early on a pandemic because we weren't in the room. Often, we weren't able to interact with the patient as much as we normally do. And so it took. It takes a lot of emotional effort. Thio become comfortable with that. So I would encourage everyone Thio utilize that sort of technology across your practice iron thoughts from Arizona? Yeah, I think you know, having a consensus guidelines. Protocols are always beneficial, you know, to try and ensure that there is, um you know, synergy between the different teams and maybe different issues that are taking care of these patients. And we know very well that it's been so difficult to tease out what works and what doesn't work but the plethora of evidence being published in different journals. But I think we're in a better spot now, six months down the line, to know what doesn't work. And I think that's where we need to be very cautious about, because ultimately, for your conference is now over. Goodbye expectation. And you know that's That's just my closing remarks. Thanks. I in. I think I think they just pulled the plug on this here. We are still connected. We are still connected. Oh, good. Well, then I want to cover one last question because I think it's an incredibly important one and indulge everybody's, uh uh, permission just to continue for a minute or two more. So there's several questions here with regards to diversity and, uh, and the health care disparities that have clearly been highlighted by the Cove in 19 Pandemic. So eso there was questions with regards to basically, how to facilitate communication with non English speaking patients within our I see us and then other challenges and solutions to address sort of the healthcare disparity gap. And maybe I'll just turn to Sarah for a minute to ask how we how we communicate and then just open it up to the rest of the panel in terms of other considerations eso we are using. We're using virtual interpreters. So for our patients who are covert positive in the hospital, they obviously can't have any visitors or anything like that. And that includes Ah, lot of our interpreter staff has been removed to be a remote provider. So utilizing the equipment in the room that we use for ice you with the camera, we could get an interpreter on there to provide that interpretation between the care team and the patient on Ben. We also for connecting our family members to the patient where utilizing zoom. So each patient has, like an iPad that's designated to them. And then we can host to zoom calls between their loved ones and the patient several times throughout the day or, you know, to connect with the care team has needed a swell so that they can see their family members and have that kind of video updates. Hi. And any thoughts from Arizona? You you you have ah, very large, non English speaking community down there. Yeah. You know, we have been using as servant very similarly virtual. Um, you know, telly, interpreters and you know, many of our staff also our multicultural and speak different languages. But also we have collaborated with our colleagues from the Navajo Nation. We've had a lot of fish patients being brought down to Arizona, especially in Phoenix hospitals, and we have collaborated with the community to try and ensure that we have reached with them to thio, help them, you know, address some of the health care disparities and we have reached out to them by providing education and other means to ensure that the challenges with Covic are, you know, something that we can work on together. Andi cut down some of the health care disparities that we see and provide support from male clinic Onda. Hopefully, other institutions were also doing the same. Well, thank you very much, I think, out of respect for our faculty and our attendees schedule will need to bring this great conversation to a close. I think we could keep on going for another couple of hours if if we were able to thank you very much for everyone who participated in this in this conversation. And for all the thoughtful questions and just a reminder that this cove in 19 live Webinar Syriza's an ongoing activity. So for those of you who had questions in the chat box with regards to workforce management, we have a whole hour dedicated to this topic from 11 o'clock to 12 o'clock Central standard time on September 28th. So thank you very much again to everybody, for joining and participating. Have a fantastic rest of your Monday.