Chapters Transcript Video Module 1: Pre-Operative Session Highlights Review & discuss enhanced pre-admission process Strategies to best protect orthopedic teams and patients good evening. We would like to welcome you to tonight's WEBINAR title, resuming elected orthopedic surgery and new processes. Post Cove in 19 guidelines developed by the International Consensus Group Module one. Pre op. We're very excited to bring this program together. This is Module, one of a three part series that assembles top surgeon, were to discuss the comprehensive set of consensus guidelines and protocols for resuming elective surgery developed by the International Consensus Meeting on Musculoskeletal Infection, led by Dr Javid Harvey Z. This is an important information we'd like to share with you. I'd like to extend a warm welcome to our faculty. Our moderator this evening is Doctor Job in Harvey's E of the Rothman Institute at Thomas Jefferson University Hospital in Philadelphia. Our esteemed Panelists include Dr Tim Album from Pro Alliance Orthopedics in Washington State, Dr John Cooper from Columbia University in New York City, Dr Michael Cross from the Hospital for Special Surgery in New York City, and Dr Michel Malo from the University of Montreal in Quebec, Canada. With that, I'd like to turn it over to Dr Part Museum. Thank you very much. James and Janine wanted Thio. Thank three. Um and Casey are for providing this venue educational venue, where I have my great friends that have already been introduced that will join me over the next 30 to 45 minutes to discuss some of the challenges we face in today's world related Thio Covert 19 and how we're handling the situation with regard Thio Resuming Elective Orthopedic surgery This is my disclosure on this slide. The most pertinent is that I am a consultant to three M and K C I. And this particular educational activities is sponsored by that company. This is, uh, the conflict of interest of the remainder of the faculty, after all, to Dr Cooper and Dr Mellow and Dr Cross again, Thank you so much for being on this venue, and we hope that we will provide you with some educational material as, uh, as you all know before 2020 arrived them before the wheels came off. One of our biggest issues that we were dealing with was infection related thio or to be the procedures, basically the transfer of pathogen that calls these disastrous infections in our patients. So a surgeons were familiar with some of these disruptions in the chain of transfer of pathogen. We wear mask, we wash our hands, and we have known about some of these over the last, uh, centuries. The new challenge, of course, presents some unique issues for us because it is not transmitted exactly the same way as or pretty confections. It's not known exactly where it's ours Kobe to originated from, but the theories that it may have started in bat and then gone to an intermediate host, which then infected the human and the mode of transmission is really threefold. One is through droplets, either during coughing, sneezing or even talking. And these droplets could then land on four mites that another person can touch and that can lead to infection. And finally, Aircell Eyes. Viruses have also been proven over the last few months to be a mode of transmission of the disease. We all know that the pandemic has affected the entire globe. Here you are. Over time you can see how this pandemic started to spread across the globe to every single country on planet Earth. But it did affect some countries more than the others, most likely because of the way it was handled and United States wins the baton for being one of the worst in terms of its handling of the pandemic and how it's affected so many off our citizens, the Asian countries on to some extents, Europeans have had a better handling of this and they have been able to prevent the second wave off spread that we have seen in the US so badly over the last few weeks. And just about every state in United States has been now affected, with majority of them being in red, as you can see with a very, very high Ciro positive positivity rate. The interesting finding is that the mortality caused by SARS cov too has has differed from country to another, and this is one of the topics we will be debating a little later. It's possible that Italy, having the highest number of elderly people in the world, was affected much more than Iceland having youngest patient population. So perhaps age co, mobility's or mode of transmission or violence of virus play. They're all in influencing the mortality between different countries. Fortunately, the mortality from SARS cov to is not as bad as mirrors or some of the others. In fact, some of the seasonal flu it's could have a higher mortality rate. In this particular study, the mortality rate was thought to be about 10%. But recent studies have shown that that may not be the case when the pandemic hit. We have three options. One was to do nothing. Sweden took that route. One was to try to mitigate the spread of the virus in whatever way we could, and the third was to really bring down the hammer lock down, prevent movement in the society to try to get to the dance as they were reducing or flattening that curve, which we all heard so much about in the media. And most countries took the route of bringing down the hammer, and that meant stopping all elective procedures, uh, in the hospitals. The best estimate is that around 28 million operations were canceled around the globe during the 12 week peak of the pandemic. Worldwide, about two million would have been canceled per week, with 11 countries canceling more than 50,000 operations. And of that 7.6 million where actually the orthopedic procedures and majority of those 6.2 million of those were canceled during the pandemic. And here is the rate of cancelation of the elective procedures. And as you can see, Europe, North America, South America all had Australia, all at an extremely high rate of cancelation of elective procedures. During that time, we all said at home we don't have much to do, so we decided to start to think about how we will be resuming elective surgery. Unfortunately, majority of the centers have now resumed elective procedures. During that time, we spent, uh, way spend our week or so try to come up with some of these protocols and processes for resumption off. Like the procedure we utilize the Delphi method engaged faculty like what we have tonight and evaluated whatever evidence was available at the time to try to come up with the recommendations. Their recommendations were published in Journal Bone and Joint Surgery. I'm grateful to the international consensus about 80 members who participated in this. In particular, I'm grateful to the American Association of Japanese Surgeons Research Committee that actually did must much of the heavy lifting with regard to review of the literature and also we're grateful to J. B. J s for publishing the work and orto evidence for also highlighting us work on their website. So what you will hear over the next few minutes is a discussion between myself and the faculty to go through some of these protocols. And we hope that these will be useful to you in resuming elective our tip last if you haven't done so or perhaps changing some of the protocols you have if you are already doing some elective surgeries. So I'm going to start with Michael Cross now. Mike, this is question number one. When will the stars Kobe to pandemic end? Do we have any ideas? That's a good question there. I think we're all kind of answer asking ourselves when this mess gonna finally end. You know, I think it's really going to come down to either having an effective vaccine or an effective treatment for it, or it goes so long and we're not able to get it, that the virus eventually mutates that it's no longer affects humans. And then, you know, only then I'll be able to really get all of us immune to it. And I think, you know, unfortunately, that's not gonna be for a while with our normal process for approval for vaccines in the United States. E mean, we're just starting to be testing on human subjects for vaccine options. And it still has to go through a number of around the tests and approvals through the FDA Attn least in the United States. So I think we're gonna be dealing this with this, probably for at least a year. Maybe more. Two years. Um, so it's unfortunate. Unfortunate truth. Truth, I think. Yes, I read very interesting article today regarding herd immunity, and it is anticipated that in city like Mumbai, Bronx, New York, and a few other cities, herd immunity may already have been reached. Most of the epidemiologist feel that herd immunity is reached when about 60 70% of the population are infected. But new statistical modeling shows that even as low as 40 to 45% of the population when they are affected, herd immunity starts to kick in. Now it doesn't mean that dependent that the virus cannot be transmitted, but it means it will be substantially slowed down. So I think New York, you were the epicenter of the pandemic. You and John were in the middle of it. You guys really did an incredible job of getting your arms around this whole issue. Yeah, I think you know, we we couldn't. John can attest to this, too, but, you know, we shut down everything at the time when things were peeking in New York are at least starting to go up. And, you know, we've seen a dramatic decrease in the rates in terms of new cases per day, especially hospitalizations and deaths. But if you look at the New York numbers, we're still seeing, you know, several 100 cases, 5 to 600 cases a day. New cases so way have achieved that herd immunity. And maybe it's some communities across the state. We're still getting several 100 cases. I don't know, John. You want to comment more on that, too? No, I completely agree. I mean, the stats, that is some of the hardest parts of New York City, Queens and the Bronx. Certainly, Aaron, that are in that 40 50% range in some of the antibody, uh, serology tests. Um, and I think that that may decrease transmission in those at risk communities, but we've got a long way to go before were there a za larger country for sure. So we all know that there is at least four different companies working on the vaccine trials, and some of the initial vaccine data looks very promising. As you said Mike, unfortunately, the vaccine regulatory process is extremely long and arduous one, But it appears that FDA and the scientists and the companies may be able to curtail that lengthy process with the hope of perhaps seeing a vaccine towards the end of this year or the next. But that's what that's our best hope at this point. Eso second question. I'm gonna ask Dr Mellow High. Can hospitals for surgery know that they should resume elective procedure? I'm not sure if in Canada you shut. I assume you shut down the elective surgeries, and if so, have you resumed them? And if so, how do you decide when to do that? Well, this is an another important and crucial question. J and e think it has been It has been ill added quite well in the guidelines from the I c. M. So working in Montreal, Quebec, Canada. Uh, you're probably aware of the situation here in Canada and Quebec. I mean, There's been a numbers of cases, and the latest data is 120,000 cases in Canada and half of them are from Quebec. And the city center is being mantra where I work. So S O. R r hospital, there is a three installations and our main hospital, uh, was has been designated as a reference center for Cove in 19. So there's been a reorganization of many units and facilities and many protocols implemented in correlation with the recommendations from Department of Public Health. And mostly they are the same as the general guidelines from the I, C, M and S O. There is many requirements that have to be met to resume elective surgery. So here in Montreal, uh, there's been Well, there was a shut down for three months starting March 13 up up to June 2nd. So no elective surgeries done during that time. So we're back to work at the beginning of around 40% and now close to 70%. But the many requirements that have to be met before you you can resume elective surgeries or the following. I mean, first, you need to obtain the approval of the local health authorities Also, you have to make sure that there is a sustained reduction in the rate of new Covic cases, especially in the high prevalence area where I work. And also there's specific requirements concerning the hospital bed capacity. So you got to make sure that the hospital or surgical facility has the capacity to admit non co vid 19 patients to an area of the hospital completely separated from Cuba in 19 positive patients you also there's regards regarding staff availability. Our nursing staff has been relegated to nursing homes, so they're missing. There's also issues regarding personal protective equipment. Eso You've got to make sure that there is enough supplies and also testing policies and capacity will go. We'll talk about that a little bit later. But there is definitely some issues regarding testing capacity and S O that has to be part of the requirements. So and and and obviously, uh, the preventive measures have to be applied. So this'd is what you know we've done. And yes, we're back toe work progressively. But they've been there. It's been a hard time. Thank you for that comprehensive response. Wonderful. And I love the accent there. I'm glad that you've started Thio resume elective surgery and we have also most of the places in the U. S. Um, I think Dr Alton is on. I know he was having some issues. Uh, Tim, I was gonna ask you should patients with active covert 19 undergo elective service. So these air patients that actually are proven to have the SARS cov to virus? Yeah. Thank you, Dr. Part of Easy. Sorry about the lack of video, but definitely here on the audio side. Appreciate everyone joining us this evening. Um, I think that based on our current understanding of cove it and the guidelines that we probably shouldn't be doing elective surgery on people with Active Cove in 19. You know, the biggest concerns air obviously infecting other people and the surgical staff in the anesthesiologists and the nurses and our health care providers. And really, we've gone through a time where we didn't have very much personal protective equipment, and we're concerned we're going to run out, and so that sort of exposing us to even mawr risk and utilizing mawr of the personal protective equipment. And I think that what we're seeing a T least in Seattle and I think across the country is a transition towards trying to identify those people who have active Cove in 19 symptomatic or not, and just delaying things. I think, you know, 14 days is based on the evidence or reasonable amount of time, uh, toe where people don't have symptoms, and then you can have an elective operation done after that time. Thank you, Tim. I was gonna ask you. So we I had one patient who was tested to be positive, and we had to cancel the elective Arctic blast E One question that most people still have is after the 14 days I assume you would retest these patients. And do we know based on the literature is toe? How long does it take for that positive PCR test rt PCR test to become negative and patients who are not severely affected? I'm not sure. If anyone knows, do you any of you know, faculty that Do we have any much data on this particular issue? Well, I think it varies too. You know, I think there's some theory that we're might be picking up dead virus with PCR test, especially the nasal pharyngeal swabs. So, like for us. We were actually waiting four weeks. If you have a positive Kobe PCR test and then you'll still get retested after four weeks, and if it's still positive, we then wait another month. Eso in those situations, we might be picking up dead dead virus. But I don't think enough is known whether or not it's okay to proceed. After four weeks or not, it's still positive. So you basically Mike, you would wait for a negative test before you would do the elect Barta plastic? Basically, yeah, yeah, and I think some of these tests false positive rate varies for these tests, but it's anywhere between 3 to 25%. I think there was a paper from New York should that that point of care test has had quite a bit of a false positive rate. So but negative test nonetheless, before you do the elective art plastic. John, I would like to ask you because I know you have a case that would illustrate this is well, so should elective surgery delayed in elderly patients or those with coal mobility's? It's a it's a It's a really good question, and it's one that we considered a really long time before we got back into doing elective surgery. And there's obviously literature from China that shows higher mortality rates in patients who have on elderly patients or in patients about Cole mobility, specifically those with cardiovascular disease. And so we want to be careful about operating on these patients and potentially exposing them to the covert virus. Um, one of the things that we wrestled with and I know a lot of other organizations have wrestled with our the relative elective versus urgent surgeries, which has not really been clearly defined. I know a CS has come up with guidelines. Um, some orthopedic organizations have come up with guidelines about what selective and what's not elective, and I think you need to take into account. Certainly, co morbidity is and age, but you also need to take into account relative urgency of the elective surgery, and I'll illustrate that with the case waken go through. So this is a lady I met just before Cove. It happened. She had been managed non operatively by another orthopedist for over two years with this condition. She was morbidly obese, being my 61 2 years ago, her A when she was 9.0, and, uh, she batted down herself to just under seven. She had hypertension, cervical cancer, obstructive sleep apnea and a history of P e with her with her initial total knee replacement. And this need has done 10 years ago and over two years, it, uh, got worse and worse. And you can see on the lateral view her poly has worn away poster immediately. And it it is actually broken through the locking mechanism. And it's floating inside of her knee. And she'd worn away almost the entire poster. Medial metal tibial base plated. So is this electorate is not elected. Um, this is a case that I certainly wanted to do early on this based on how disabled she was. J and we tried to factor in disability in our decision to get patients back into the operating room. Um, so these air preoperative films and if you click through, we did a hinge on her and she was probably my happiest patient in the past two or three years, based on her changing function from pre operatively to post operatively, and she was really one of the earliest ones that that I did coming back after co vid. Um, even with those commodities and B m I and diabetes and sleep, you know, um, the benefit for her really outweighed those risks. I think you're absolutely right. Jump, because that's a very cloudy area. Some of these patients are incredibly disabled there in extreme pain, and on then some of them may even have impending fractures, etcetera. So the definition of elective really various depending, you know, on the type of patients we were dealing with, we were not dealing with patients who are waiting for some form of cosmetic surgery, etcetera. Some of these patients were in extreme pain, like the one that you've just illustrated. So it's great. But in this case, I noticed that you obviously did quite a bit of optimization of the patient and post operatively you were worried about, Uh, probably in the wound issues. And, uh, you sounds like you utilize the negative pressure dressing on this patient. And did you keep the patient the hospital for a while? Or did you let them go home and to tell the medicine for the post op to visit? Absolutely. And I'm sure we'll touch on that a bit a bit later in these modules, but this is somebody like all patients. We tried to minimize their hospital stay. She did need two nights in the hospital before going home. And we've done telemedicine for the first couple of visits before she came back. For for those postoperative X rays. Great. Thank you, John. That's great. Great case, Michael Cross. We're back to you, Mike. What about education? What are you doing at hospital for special surgery prior to doing elective procedures on the patients? Yeah, I think the education thrust has mostly fallen on the surgeon. I think Thio let patients know that. You know, there is still cove in 19 in the New York area and it's still not a 0% risk. Even though we take all the precautions necessary, Thio minimize their risk. We do tell them obviously, with in terms of the guidelines, we do recommend a strict hand washing a swell as New York it every page. Everybody in New York is really expected to wear a mask out in public as well as going through the the whole surgical process. Your you have to wear a mask throughout the entire part throughout the entire phase. So you'll get education from me on the potential risks. And, like Johnson, is really a risk benefit discussion in terms of their morbidity, with either either revision or primary joint replacement. And then when they see their medical attending, they also get a repeat medical education on the potential risk on DSO. They agree that they should get some education to know that that if they decided to go through with elective joint replacement that it's not a 0% risk. This isn't That's great, thank you. Yeah, very important, too. Make sure that the patients are on board with some of these things. Dr. Melo. At last, you can Patients and individuals who are infected with SARS cov to be re infected. I guess this is unclear from some some reports. There's there's been, uh, individuals who have contracted could be 19 recovered and then tested positive again. So, um, so this is it. So I think there's more data needed, you know, regarding specifically at that point, but unclear. Yeah, and I think, Well, my cross the earlier in terms of some of these may be fragments of R N A. That's being picked up. That's definitely one possibility. And again, the tests we have are not 100% accurate. There's false, positive and false negative. So there's multiple reasons to sort of explain this. And I think the document that we wrote goes into it. But as you said, it's unclear at this point. But most, like the patients who are infected, the source Kobe to develop long lasting immunity. And in fact, again, another paper came out and lancet a couple of days ago that shows that that immunity could be months, if not years, so hopefully they don't get reinfected. But we don't have enough data on where this is, and I agreed to. I mean, this is certainly very promising. Yep, Absolutely. Tim, I'm gonna ask you what additional steps should be taken during the pre admission process for patients undergoing elective surgery during South cov, too. So when I think about the steps that we take before admitting someone for an elective operation really comes down to three different categories for me, it's what we do with our patient. How do we handle their family members and their loved ones that often accompany them through this process And what can we do? What do we have control over with regards to the environment, to keep people away from each other and keep people safe? So with regards to the patient, I mean, that really starts at their preoperative visit. We screen everyone based on where they've been traveling, what their occupation is, what their exposures have been. Do they currently have any symptoms? I mean, just to get into the clinic, Yaakob, your temperature screened and everyone's given a mask. So there's already a bit of screening before you can even get into the clinic. Eso screening is really important. A zoo you guys discussed earlier re educate people about hand hygiene, masking and other different techniques that we've learned are really important for preventing infection in our location. As you guys know, we were kind of early on hot spot on. Do you know we're in a metropolitan area? We have access to testing so every one of our patients gets a PCR test before their elective operation. We tend to do it about three days before the operation. That's been a moving target based on how quickly we can get the results and then we asked folks to self isolated, possible in their home. Obviously, that's difficult to enforce, but that is something we ask our patients to do. And then again, all of our patients are wearing a mask. With regards to the families, we've limited the numbers of guests that can accompany people, you know, It used to be that there would be a half dozen people sitting in the preoperative room before before in operation. Now it's one person at most. Those people are screened on their way into the surgical facility. The masking mandate, uh, is present and applies to them as well. One change for me personally is that I don't go out into the waiting area and talk to families anymore. I used to do that, you know, shake their hand and tell them that their loved ones okay, But now we do that with a phone call. Eso that keeps people out of the waiting area as well and also limits my exposure to the public. And then finally, the environment, um, you know, cleaning all the common surfaces that people use. I think there's good data, you know, at least a 70% alcohol solution and cleaning all these surfaces, avoiding the large gatherings like the waiting areas. And then, you know, we've changed our check in areas that everyone goes to their own personal room. They don't have the large open rooms where six or seven patients are all checking in. So we keep them all in their defined rooms. And then, um, you know, just enforcing the PPE policies and just trying to create an environment in which people can stay away from each other. So I know there's a lot of information there, but, man, we've had to make a lot of changes. Uh, Thio do this safely. Yeah. No, that makes that. That makes perfect sense. Thank you. That's really excellent information. Very useful, I'm sure, to our audience. Thank you, Tim. And again, you know, the mask issue will come up in the next module what we discussed. But there's plenty of evidence to show that wearing a mask is very effective for the patients. And I think this was one of the issues that was that actually affected the patient that the population back in 1918 during the Spanish flu. Initially, they didn't believe in the mask and later they made mask mandatory and people would actually go to prison if they were not wearing a mask. Eso your as you said, you're asking the patients as well as the health care workers, all to wear mask during the hospital visit. That makes total sense. John. How about asymptomatic patients? Should they wear protective mask during SARS cov to pandemic? E think that masking in general is a great idea. Plenty of good data on how much a mask decreases risk of transmission. Both, uh, to yourself personally and also to others if you're asymptomatic. So regardless of who you are, I think everybody in New York is wearing a mask or should be wearing a mask on Do that. I think it should be a goal across the country and across the world does it, and I'm I'm putting you on the spot. Does the type of mask matter, in your opinion, the n 95 the surgical mask? And now we've seen Gucci and all these fashion companies come up with very stops of mask. I know in New York, you and Michael probably wearing the Gucci mask, but in like poor people like me in Philadelphia, were sticking to the surgical doesn't make a your opinion. I think I think we still have a lot to learn in that in that area. If you look at what's happening in the hospitals, it's about in my facility. It's about a 50 50 split between 95 surgical masks. Um, you know, that's a facility where people aren't wearing their own personal mask. When patients come in, we ask them to switch their personal masks. Thio Surgical masks. Um, some do come in wearing in 95. I think anything there is markedly better than wearing nothing. And we don't yet know enough about the distinction among the various mask types. Toe for me to say with certainty, that's true, but I think so. What we're saying is that wearing a mask prevents the macro droplets on probably the micro droplets from being spread into the air. It may not prevent the air civilization of virus because viruses so small 0.1 micron, but nonetheless it's very effective in preventing the droplets from touching phone mites and being transmitted to the person next to next year. So any type of mask is effective, but obviously the more, uh, smaller. The pore size of the mask, the more effective it may be in terms of the size of the droplets for transmission. But any type of mask is definitely important. Um, what about gonna ask Dr Mellow? What about patients undergoing elective surgery? Should they be screened for symptoms of covert 19 during the pandemic? Oh, yeah, definitely everybody going for elective surgery. You know, we will. You know, as mentioned previously, they will go through a questionnaire and then, you know, having their temperature taking, but also ah, part of a part of the the question there, you need to specifically look for a symptoms. A Z, you know, there are mentioned here. Eso This is, uh this is done on a regular basis in our institution, Uh, in addition to systematic and systematic testing, which is mandatory right now, a za recommendation for them from the Ministry of Health. So, as you know, Dr uh Walton said there is definitely, um, testing, uh, mandatory for everybody. So, uh, this is a does that include the health care workers in your hospital? Are they asking the nurses in the morning when they arrived? The doctors and nurses and other workers. Yeah, well, good question. I mean, they recommend that periodically testing on workers as well. I've been tested, uh, many times, and this is part of routine in our in our high prevalence area right now. So way. All aware that testing is probably the the most important one of the most important thing in preventing, uh, outbreak of the disease. So identifying the symptomatic people eso both for the patients, but also the staff hospitals. That's including doctors. Yeah, we get asked every the day we go to the hospital. They also measure out Paul sock symmetry and the temperature and this risk stratification. Michael is sort of not as as important now, you know, initially they were asking if you've traveled to China, Italy, Iran, etcetera. Now, obviously, most of the world has it. Most of the states has it. I don't know. The travel history is as critical is before. Do you think it still is? Do you include that as part of your questioners or not really not paying attention to it anymore? I think you're asking myself I was Yeah. Are you asking people? No worries. Are you asking people about history of travel. Yeah, we do, too. So it's part of the question there. So occupation, traveling on bond. These are definitely concerned. So it's part of the routine question. It's giving you a nice excuse to keep the Americans out of Canada. Uh huh. So, Mike, Mike Ross, Um, how about patients? Something elective surgery? Should they be tested? We're talking about, obviously, rt pcr. And if so, do you think there should be a difference in the low prevalence I prevalence area or should be just routinely do the test? No, I think we should just routinely do the test because I think the problem is is that even if they're asymptomatic from it, there's good data that they may be at higher risk for clots. So, you know, if you if you're not testing, they'll never know. You know, despite the limitations of the test, I think it makes sense. Is a blanket that way. You don't miss you, buddy. You know, s so what we're doing. We're actually doing in a body screening 2 to 3 weeks before surgery, and then you get the PCR test 2 to 5 days before the operation. So when we were writing this article. There was quite a bit of discussion. I personally happened to agree with you. But some of the delegates were worried about the lack of re agents and test and because, as you know, the testing was really being, uh, difficult, not availability of the agency. Several issue. But in recent months, we've seen the pooling, so Indo prevalence area, you could definitely pull the tests, right? So that would save a lot of the re agents and reduced expense to the society, don't you think? Yeah, I think that that you know, I agree. Back when testing was limited, I agree that we probably should be screaming just more of the symptomatic or the higher risk patients. But now that testing is becoming a lot more revenue readily available, I think it makes sense. Thio screen everybody Great on this is some of these symptoms. I think that Melo pointed those out. So this is the molecular test that you talked about, Mike? Obviously rt pcr still happens to be the so called the gold standard. You alluded to Neza Ferengi? Oh, versus Orel versus now Sputum. In your opinion, is there a difference between them. And what are you doing in terms off the testing at Hospital for Special Surgery? It's a good, good question. I don't think we know if which one's the best test yet. Way screen Course. The Biofire Biofire respiratory pathogen panel, which is actually screens for a number of different pathogens, including three stars to Kobe or stars covered thio virus. So, um, it's a way to capture all of them in case there's patients that have symptoms of respiratory illness, that it's not necessarily coping e in terms of which is better in terms of the saliva are days of ridgell. I don't know if there's a kind of data out there. You it's getting a little better. But is it fair? Is it fair? And would you agree with me to say that these apparent Jill Suave is a little bit more invasive than oral swab or sputum? Swab? Right, I've got a definitely I've had it done. If you feel like yeah, that there is no way Thio feels like it feels like brain by outside somebody is I don't know why they have to go so high, but it is really high. So fortunate. Yeah, wait a right. I mean, the media. I'm sure you heard over the last two days Yale University as the sputum test. We've actually been working with a company that does have the sputum test available. And we've been doing oral swabs over here. And your point. We don't really know the false, positive negative rate of each one of these tests. But for elderly people, especially those getting tested on multiple occasions, I think it is better to avoid doing the nasal Farron Geo, if if don't possible, we're constantly reevaluating the test. And if there's a better one available Obviously we're doing this with total sense. Tim, What about antibody testing? Are you doing it? Do you know much about this? Is there is there role for it? Can you share some of your insights with us? We are not routinely antibody testing our patients for our employees. I think that there is some interest in this and the general public I personally would want to know if I had had antibodies. It's almost more of a curiosity at this point because I don't know that we fully understand how protective they are or are not, and sort of how to necessarily interpret that data at this point, S o. I would say that I like the idea of it. We're not currently doing it, but there probably is a place for it. It's just not. It's not mainstay in our practice at this point, right? And it's not so When we were writing this document at the time, information about antibody testing was very, very skin, and I would say that that hasn't changed very much. Still, here are the issues, as you sort of highlighted. One is. Does any patient every patient who is infected with SARS Kobe to develop antibody response to the virus or not? One hopes they do, because that would, of course, be the whole rationale for developmental. A vaccine to number two is. How long does that antibody response last? Is it days, weeks, months and the third. And the most important question is, is there a cross reactivity between SARS CoV too, and some of the other coronaviruses we know not 20 to 25% of common cold is caused by coronavirus. So, uh, could a common cold also lead to a positive response with the antibody test? But it's becoming more and more common, and I've even seen, like in Philadelphia. We're seeing these banners and posters of people advertising them. But I just think that marketing is perhaps put before science right now. The more we learn, the better it ISS. But I completely agree with you that at some point, antibody testing will become a very valuable tool, especially if we're thinking about her immunity and other types of other issues etcetera pandemic. But for now, we're not doing it either. I don't know if any of you gentlemen doing this routine in your hospitals. E thought I heard my cross. You guys were doing anybody testing, and I was curious to hear about your experience with that and how you how you use that way are doing on everybody, and it's done in 2 to 3 weeks. They also get a chest X ray. At that time, I think was honestly helped me the most is that if they're antibody positive, I know they might have a possibility of being PCR positive, too. So in terms of my daily schedule, I will adjust people who are potentially PCR positive towards the end of the day, to avoid, you know, changes in your schedule. The second thing. I think it helps you with this. If they're positive, there is some data that they may continue to be at high risk for DVT. So I would have changed my DVT protocol on those to get higher agents more than aspirin. So I think it's beneficial, but they're certainly limitations. If you're positive, it doesn't necessarily mean that it was Kobe. 19 could just be another type of Corona virus, but I will still give them higher levels of those patients are still getting the PCR test even and about a positive correct. They still get the PCR test surgery, right? Or to that data would be really useful. Mike to see what percentage of patients were antibody positive were actually also PCR test positive and vice versa. That would be very interesting. Yeah, I'm sure it's been looking at rare. Yeah, and and it's been it's been rare that they've been antibody positive and then, three weeks later, PCR positive. But in J, then that's That's where my curiosity is, whether or not we're actually just picking up that virus in those situations if they because a lot of times they were even, you know, Said they had coveted maybe even in March and April 2nd. And the theater. It's the second infection, or it's still dead. Virus. Right? Um, eso you talked about John? Uh, what other tests? Uh, serology tests that should be dio you know, what about the role of C T scan a chest X ray? Are you doing that? And why you are Are you don't You're not believe in this. We're not doing any anything beyond the PCR testing for all patients. It's the only thing we're doing. I'm not aware of anybody who's doing things like CT scans or chest X rays, but it z a lot of we are doing chest X rays to, uh, yeah, and then any abnormal chest X ray or findings that we would follow that I don't e I don't think it's, you know, this is one of those you know, when when we started going back to elective surgery in New York was very, very still very high in terms of the number of cases. And so, you know, we didn't really have ah, good testing protocol down the road. If we find the chest. X rays are not all that valuable. Obviously, we'll get rid of that is part of our. But obviously, if a patient is presenting with symptoms, it would be reasonable to do all of these investigations right. Questions. Whether in symptomatic patients PCR positive, you should be subjecting them to chest X rays and C t or not. That's that. That's probably a question. It's a good question is something you know? You know, you don't know the answer. I think we'll have more information soon Whether or not been proven to be beneficial or not a za right now we're still We're still getting fantastic. Well, you have been incredible. The faculty again. I wanna thank you three m k c i for sponsoring this event. It's been incredible to be in your company, gentlemen. And I wanted to see if there are any questions, My little illiterate. If I can find questions that may be here, uh, I will be able to ask. I hope our audience has benefited from this. It's been a pleasure to have you, gentlemen. I've learned a lot from you. As always. Is the case uh, s Oh, I don't know If any of you feel there are any points you want to make before we finish. And if there are any questions, I'll be glad to take those. Obviously, they won. One question that didn't come up is whether or not we're screening family members when they come to the hospital to see with patients. We're not actually doing any testing of family members prior to surgery in terms of the visitation restrictions, but we are screening everybody. So I just wanted to make that clear. And a question just came through about how much additional time and we're spending, educating and communicating patients about surgical precautions. And that's a tremendous amount of time that we're spending on distillate. It hasn't decreased since we resumed surgery in May. Patients, Even though we're become a low prevalence area, we're still spending tons of time both personally as providers and also with our staff assuring patients that we're taking every possible protocol. Um, that we're have their safety at highest priority, and that's critical. That's critical to doing this successfully. Yeah, those are great points. Yeah, just just to make sure that we won't get to the second way. Janina, I don't know if you have any questions for us. I know there may have been questions from the audience, but for some reason I can't see those questions on my screen. J. J Well, one question just came through. Some surgeons have seen a spike in P J i when they started to resume elective surgeries and want to know if any of us have had similar experiences. A question. Yeah, E. I have not. But it's ah, bacterial. Super Super Infection, I guess, would not be uncommon with patients who have a viral disease. But because we're testing everybody and not operating on anyone who is positive, then I'm not sure why the p G I risk would be any higher. Dr. Parr busy. The person who asked the question mentioned possibly having an increased amount of traffic through the operating room due to staffing shortages as a possible hypothesis for their elevated PG I rates E. I guess you could say that there is an evidence to support that the more traffic you have through the operating room. That could be it could be an issue, so definitely something to pay attention to. But I'm with you. I haven't seen an increased rate of infections that are institution, you know, again, I know this is something we will cover later with the intra operative measures. One of the measures we have institute of my, uh places to reduce the number of people in the O R reduce the number of full mines and, uh, equipment etcetera and then the rooms air getting almost terminal cleaning between cases. So if anything, you would expect that these very drastic measures trying to limit the spread of SARS cov to would also have an impact on bacterial fallout, thes air. All great points to discuss people. Are you gentlemen seeing any other questions that we should cover before we call it today or night? It was a question. It was a question, you know, I just answered on whether or not our institutions are allowing visitors a to this time during the Kobe night. I think the answer is probably no. Is that right or not? No, we're not. I mean, we're not allowing any international and then, you know, now New York has such a high, you know, its restrictions on even travel or visitors from other states. I think we're there's now what? What? John? 35 36 people on the 35 36 states on the mandatory or even, you know, even medical students that rotates or to be the hospitals. They're not being allowed in my place, either. They're just and the research fellows have to go to the O. R to collect samples, collect data on the patient's. We've had to actually argue really strongly to try to allow one person, one research fellow for the entire day to go from one room to another call examples. So they really limiting the number of traffic. A number of visitors were exactly the same way about visitors, and we're still allowing industry reps to come into our hours. But I know a number of facilities have stopped. That practice is well, you know, for better, for better and for worse. Um, but I think these are good questions and a good segue for our module to next week. We're gonna talk about some of the inter operative um changes. With that. It's nine o'clock we had already at one hour. It's perfect. Thank you. Gentlemen. I know we're a little late getting started. I cannot thank you enough for dedicating or evening for this. And I hope our audience is taking some information out of this on once again. K C I on three m. Thank you for your support and sponsorship of this event. I want to thank the room Eddie team that have done a spectacular job of educating illiterate people like myself to get on this computer and be on this Webinar. Thank you so much and have a good evening, everyone. Published October 8, 2020 Created by
