Return to Surgery in the Time of a Pandemic: Perspective of a National, Multispecialty Panel Originally Broadcast: September 14, 2020 | 11:00 AM - 11:50 AM CT
This panel brings together clinical leaders from different regions and specialties to share their experiences, successes, and challenges on the resumption of elective surgery and access to healthcare during COVID-19.
Learning Objectives:
Share valuable real-world experiences from different clinical perspectives on the resumption of elective surgery and access to healthcare during COVID-19
Explore the challenges and success of clinical and operational management in the current care environment
Discuss impacts to patients, practice, process, and prioritization
Moderator:
Ronald P. Silverman, MD, FACS
Guest Panelists:
Timothy B. Alton, MD
Richard C. Prielipp, MD, MBA, FCCM
Mark E. Rupp, MD
welcome. Uh, welcome to the return to surgery in a time of a pandemic panel discussion. I'm Dr Ron Silverman. I'm the chief medical officer for three M medical Solutions division. I'm also a practicing plastic and reconstructive surgeon at the University of Maryland. Uh, the Cover 19 pandemic, of course, has had an incredible and really unprecedented impact on patients, clinicians and healthcare systems. And as hospitals around the country have begun to resume elective surgery, there are considerable challenges around providing safe care while also allowing patients to feel comfortable and confident, confident in their safety. And as we are all learning about this evolving situation, we felt that would be very useful to bring together a multi specially panel from different regions of the United States to share their experiences and insights on also have an open discussion about their successes and challenges. I would mention that the audience, if you have a question you can could submit that question using the button below the screen, and we will be monitoring that. All right, So first I'd like to introduce our esteemed panel we have with us. Dr Timothy Dalton. He is an orthopedic surgeon with Prell I insist. Orthopedic Associates in Renton and Covington, Washington. He's a dual fellowship trained surgeon, one in one fellowship in fracture surgery, a second in adult reconstruction, hip and knee replacement. Hey, trains. Many surgeons in hip and knee replacement techniques and his interests include complex revision surgery, direct interior, total hip replacement and the movement to outpatient joint replacement surgery, which I think has a place for discussion in our panel today. We're also we also have with us. Dr. Richard Prilep is professor of anesthesiology at the University of Minnesota and past chairman of the Department of Anesthesia. He is currently executive section editor for Patient Safety for Anesthesia and Analgesia Journal Journal and a board director for the Anesthesia Patient Safety Foundation. His interests include cardiac anesthesia risk management, peri operative patient safety, including the study of infectious risks embedded within an anesthesia practice in the operating room. Which is, of course, vitally of interest today during the pandemic. And then we have Dr Mark Rupp, professor and chief of the Division of infectious disease at the University of Nebraska Medical Center. It's the medical director of the Nebraska Medical Center, Department of Infection Control and Epidemiology and has served as a consultant for the F d a C D C N i H, and also the V A system with interests in healthcare, associate ID infections and antimicrobial stewardship. So welcome. Thank you for taking the time to participate in this panel discussion. We'll start off with just mentioning that, you know, obviously, we are within a pandemic still, and in different regions of the world and of the country, we are in different, um, different states of that pandemic. And so I think it be good useful to start and go around. You know, in your particular geographic area, what is the what is the current state with your facility as it relates to Cove in 19. You know, in terms of, you know, are you back to normal with o our capacity? What's your you know, rough estimate of co vid census eso. Let's let's start with that, Dr. Alton, Maybe you could start us off. Yeah. Thank you. S Oh, I'm practicing orthopedic surgery out here in Seattle Washington area, and we had the sort of unique experience of getting cases really early on when all this started to pop up that nursing facility that had some of the first cases was just up the road from us. So things sort of hit home pretty early on, and at this point, we are back up and operating both at our hospital and that are ambulatory Surgery Center. So I'm a part of, ah, private practice group that has an affiliation with the University of Washington Hospital system. So we have both the freestanding A S C that we get to run and then the hospital system as well. And so we're back up to 100% capacity at both facilities. We had a period where right after we got back to work where we were operating and probably 100 and 2500 and 30% capacity trying to catch up on this backlog of patients that we had. And we've sort of worked our way through that and are back up to pretty much, um, standard rates in terms of our hospital system with co vid case is that something that's monitored obviously really closely and disseminated pretty widely amongst us. And there are a few patients in the intensive care unit who have active co vid. But the case is in the hospital are actually down a bit compared to where they were a few months ago. Um, so we are able to keep functioning at a really high rate in terms of our elective operations, without some of those constraints on personal protective equipment, in hospital beds and things like that right now. So we're in a pretty good position, I would say at the current time, out here in Seattle, much better than it was. You know, a few months ago, one of things you said was that you're 100% and at one point you were above 100%. But, you know, so please explain how that works, because don't you find that there's a little bit of a slowdown, Or at least that's what I'm seeing it at University of Maryland that things are taking a little bit longer. And so I would say honestly, at the University of Maryland, Although we are working full time, we're probably up to, you know, maybe 80 85% of our throughput because of the extra steps it's taking, Um, and also I would say, because of patients, maybe, maybe some some patients are not yet ready, and some people are delaying or canceling surgery. Can you comment on that? Because it sounds like you're maybe not having that experience. Yeah, What we experienced was in the realm of adult reconstruction, hip and knee replacement. We have a couple of months of a wait list. Those of us that do the operation here and then when we shut everything down pretty abruptly, we had to cancel those elective operations for, you know, the indefinite future. We didn't know how long we'd be shut down. So we, you know, we called our patients and told him what was going on and and shared with them some of the steps we were doing to try and get back toe elective surgery. And then once the governor here said we could get back to it. We have this big backlog of people that needed that operation, and for the most part we had a couple. They're like, I'd rather just wait until the pandemic passes. But for the most part, folks out here elected to go ahead with their operation, and the way that we were able to expand our capacity was what we had. This backlog of patients that we had to catch up with. And we just basically worked with the hospital and got mawr operating room days, right? So if usually just operate on Monday and Tuesday, you know, they allowed us to add additional operating room day, so we're running a couple of rooms and just catching up. So in terms of case volumes, the numbers went up as we were catching up with that backlog. But to your point, Dr Silverman, of course there are inefficiencies and additional steps, and I would not say that we are more efficient now, but we were able to operate a higher capacity just by expanding the number of days your operation. When you say when you're talking about operating capacity, you're talking about within your department within your group, not necessarily the capacity of the overall hospital. Yeah, I would say that's probably accurate. Yeah, in terms of our sort of orthopedic hip and knee replacement operations. Yes, because if you got extra our time, I presume someone else probably gave up. Someone's got to come from somewhere, I guess. Okay, Um, Dr pre lip. Maybe you could give us a perspective of the state current state at the University of Minnesota, you know, locally for you. Well, we I would agree with both of the prior observations that is, are operating rooms at both the ambulatory and university setting are fully staffed and running at quote full capacity. But as you highlighted, um, people working full time doesn't necessarily translate into 100% of surgical volume as we had experienced prior to February of this year. So there are intrinsic inefficiencies, um, including just getting patients into the operating room and particularly the dilemma of sorting out what is their covert status. How is the covert testing been done? And where are those results? Because, as I'm sure, we've all experienced, um, covert testing has a lot of nuance to it. And there's a lot of potential pitfalls in going between the clinic and getting the results before the operating room. Um, another co variable that I think is important both in Minnesota and probably around the country, is we are definitely starting to experience an uptick and the prevalence of disease in the state. And whereas a month ago we might have been having 56 maybe eight desperate day attributed to Cove it. We are now back up into the double digits per day, so it's more like 10 12 15. And this is, Ah particularly worrisome trend. In light of next week, we will have our major university campuses start to reopen with in person classes. So influx of thousands or even tens of thousands of 18 to 20 year olds into the major metropolitan area. It is certainly something that's gonna have to be watched very, very closely. So right now our prevalence of co vid is estimated to be right around 5%. That's been pretty consistent, but we certainly have seen an uptick in the fatality case ratio here, have you, Doctor Prilep, Have you also seen an uptick in? Um, you know, hospitalizations and I see you stays. We're just starting to see that that impact hospitalizations are starting to climb again. And we're I see you. Capacity is certainly more than sufficient toe handle our current load, but it's gradually appears to be starting to creep up in that fashion, too. To an earlier statement, Dr Alton mentioned, we two have tried Thio increase our overall our capacity, but we have had two in vogue on extensive elective Saturday morning, Saturday scheduling to our usual schedules of Monday to Friday, Uh, booked rooms. So we have had to expand that capacity with additional kind of a routine day's work. I see. Uh, you know, that's that's very interesting. We, um we have done that also at the University of Maryland. Um, it's a little bit hard to get takers from the surgeons on that side, but we do have some. Um uh, thank you. So, Dr Rob, maybe you can comment on the current state in Nebraska and your center. Sure. So, first of all, thank you, Dr Silverman, for this opportunity to participate on the panel. I'm delighted to join the group, and I'm looking forward to the discussion. Um, here at the University of Nebraska, we've had quite an experience with co vid. We had some of the first patients coming to the United States that were rescued US citizens from Wuhan. And then likewise, because we're the home for the National Quarantine Center. We had a group of patients that were rescued off of the Diamond Princess cruise ship. Uh, within the community itself, however, we started seeing our own community spread in March and April. I think like everywhere across the country, we shut down elective surgeries and elective admissions and tried to create surge capacity. And we did obviously see upswing in cases throughout the region. Um, we hear peaked probably right around Memorial Day, the first wave and then kind of natured back down. Maybe early in July mid July and then, unfortunately, as we really tried to open up businesses and social venues and whatnot, we did see an upswing in cases starting in mid July. And we've really just kind of platitude off at an elevated level and then, as has already been mentioned, there's really great concern now, with schools opening with just getting over the Labor Day holiday and with our state further relaxing the public health measures and opening up businesses even further, that will additional upswing in that in cases. Um, you know, we've reopened r o ours, and all of our procedural areas were pretty much back up to the same level of service that we had prior to the to the pandemic, obviously has already been alluded. Thio. You know, there's all kinds of things that we've had to put into place in order to have patients feel safe to come back into the O. R s and have their procedures performed, as well as the personnel, the surgeons, the anesthesiologists and everybody else in the peri operative area. And I know we'll talk about that further, and I'm looking forward to that discussion. And, you know, can you comment on your thoughts on you know, the chance of a significant second wave. I mean, obviously, there's been a lot of speculation about that. Maybe you could provide your thoughts. Is an infectious disease specialist. Well, I think that, you know, whether we call it a first wave or a second wave or just, you know, the continued evolution. I'm not sure exactly the terminology that's the most appropriate. But I do think that there is great concern here As we get into the fall in the winter, assed people move indoors in tow. Um, you know, the the heating season and having indoor air exposure, um, that there will be an increasing cases, and I think that, you know, the pandemic fatigue that everybody has had with regard to the physical distancing has certainly taken its toll. Um, you know, I fully expect that, as I already mentioned, that will continue to see cases and probably an upswing in those cases. I'm very hopeful, however, that people will continue toe practice masking whenever they're in any sort of a public setting, particularly an indoor public setting that will continue with our physical distancing and hand hygiene, and that we won't have quite the peak that we saw earlier in the overwhelming of, you know, our hospital system. And that's really the key is to being able to maintain those services for the public. Thank you. So you probably are aware that three m makes on 95 respirators. Um, who knew that they would be so important in the beginning of this year? But, wow, a lot of activity there, I can tell you. And so you know, this is of critical interest to us, not just around the 95 but about all the different, um, alterations in the normal process from beginning to end. A few of them have already been mentioned, you know, Covad testing, ensuring that every patient undergoing elective surgery has had the testing. Um, but I wonder if if I could get some comments about the process impacts that have had the largest impact. I think I'd like to start with Dr Prilep as an anesthesiologist. You know this idea about clearing the room of everyone that's, you know, other than the anesthesiologist and maybe one other person, Um, during our socializing procedures such as intubation in the beginning of the procedure. And then, of course, the time it takes for the air to clear with the ventilation system. And you know how many cycles and all that Maybe you can comment on where we are there. I mean, um, it seems that this has been instituted broadly, but perhaps you could give us some insight. And do you feel that this is here to stay? Thank you. I think I can summarize the impact on anesthesiology by early on. When he had our meetings in March, as this was an evolution, I think we literally took our standard procedure and policy book, basically shredded it and realized that we had to start all over because the impact of caring for certainly cove it positive patients or even those under investigation the p u i patients as their term, um, totally modified the approach and the procedures and the processing of each and every patient. So, um, what that meant from definitional E was that a routine? And the trachea, intubation by definition, was an aerosolized generating procedure. So the impact of that rippled across our system required full PPE with which meant an N 95 respirator or, in lieu of that, a paper type type device. But it also even modified the way we approach patients. Patients were intubated in a rapid sequence induction fashion, which minimize the amount of airway manipulation we no longer did. Routine bag, valve mask ventilation. The patients. You've probably seen some of these so called intimation boxes plexiglass boxes, which were promoted for a while to try and provide an additional barrier between the procedural A list and the patient themselves. And then, in addition, of course, there's a the impact on our equipment, so additional, uh, heap of filters were installed within the anesthesia circuit. In addition, obviously there was a great effort to use disposable equipment, including disposable oranges scopes, um, as well as really utilization of video there, Angus copy with disposable covers again, all in efforts to trying to maximize the distance between the patient's airway and the anesthesiologist. Uh, beyond that, of course, was the impact on people in and around the O. R. And indeed, if there was a covert positive patient in order to try and achieve somewhere between 95 99% clearance of the air within the all are there was a routine of waiting 18 minutes from the time of aerosolized procedure. The innovation thio entry of other people of other providers into the room. And this depends somewhat on the nuances of your air exchanges per hour and other elements like that. Um, but it really has been a permanent alterations in the way we approach patients who are No. One or suspected to be covert positive, and I don't see that changing in the foreseeable future. Do you have them? Wait the 18 minutes, Doctor Pre lip. If the patient has tested negative, we do not. The other people within the oh are. We do ask that they're either at a distance or outside the operating room during the aerosolized generating procedure. But if they have tested negative, it does change the algorithm because we are the anesthesia providers are are just wearing routine surgical mass. Not in 95. Respirators and the other providers will either enter the room as soon as the airway is secured and a closed anesthesia circuit is connected up to that airway. That's really interesting. You know, I would I would ask, maybe around to the three Panelists, starting with Dr Alton. And maybe you can say, you know, what is the routine at your where you operate? I know, Dr Alton, You have your a two different sites, but in terms of surgeon PPE and anesthesiologist PPE on. And you know whether or not the patient, You know, if the patient is co vid positive, Of course, that would only be for emergency type of situations in the are or if they if they test negative. So Dr Alton? Yeah, Doc Salman. Thank you. Um, so I think And this has been highlighted already, but testing is so important here because if you're able to test your patients and get a negative Covad test, it changes the algorithm like you just said. And if they have a negative test, we treat them much more like just a normal pre pandemic. This is what a hip replacement or knee replacement. Looks like we try to limit the amount of traffic into and out of the operating room, but we do that already, so it really feels like a normal operation. If we can get that patient to get tested, isolate themselves after the test, Um, and so that really helps a lot. Unfortunately, that's not possible in all of our situations taking care of trauma patients or are these unplanned operations. And so in that case, we're treating those patients as presumed positive, as he alluded to. So with regards to PPE, that means you just sort of assumed that they have the virus and we're wearing either n 95 respirators or the paper hoods, and so is anesthesia, and so is all the surgical staff. And we're operating in an operating theater. That is very very doesn't mean it has on Lee the the absolutely necessary items in there and really limiting the traffic. And so the amount of PPE that gets utilized if we don't know if a patient has cove it or if they are covert positive as you would expect, is significantly higher, and so it just sort of speaks again to the importance of getting testing out there so that we can know their status before their operation. Thank you, Dr Prilep. Again for your institution. Um, for surgeons. Are they wearing in 95 for every case or or papers, or are they doing it? Only if the patient test positive. And then what about the anesthesiologists again? I would agree with the prior comments that the covert testing is the key lifer cation on the approach for these patients. So with the PCR covert testing from the recognized laboratory facilities, um, if they test negative, it does become much closer to pre Colvin routine approach to the patient care and certainly the Patient Airways. So that's routine surgical mask and sort of the routine universal precautions as far as, uh, infection disease control. But for patients who are under investigation or for those who are obviously emergent and no one to be covert positive, um, it's full PPE for anybody in the room and absent the critical people during an aerosolized generating procedure. All those folks are outside the room for the 16 18 minutes to provide room clearance of the with room turnover of the air, having said that I would just add parenthetically, Of course. Um, sooner or later, everybody will find that they're testing has produced a false negative. And we have had that experience recently with a fairly complex Jurassic operation. And unfortunately, the confirmation of a cove. It positive test Onley arrived about three quarters of the way through that operation. And the consequence of that was about 20 of our peri operative staff were sent out on quarantine. So the adverse impact of false testing is very profound from both a personal anxiety and risk assessment as well as the financial impact. Um, it, uh, it's sort of decimated Arthur Acidic staffing capacity for 10 days. You know, it's interesting because the reason I'm asking this is because of my institution, University of Maryland, the anesthesiologist and also the surgeons are still required to wear a 95 for every case. And I must say, even though I work for three m, I hate that because it's extremely uncomfortable toe where these, uh, you know, in 95 for extended periods of time on the argument was about the, you know, the risk of false results with the testing. But Dr Rob, maybe you can comment about what's being done at at your center. Yeah, sure. You know, I think just some initial observations is that, you know, obviously the great concern about the transmission of cove in 19 in the period operative area was born out of, you know, just the horrendous cases that we were hearing from Wuhan and from Italy as their, you know, medical systems were overwhelmed. And there were those really scary reports of, you know, large numbers of very operative personnel falling ill and, in some cases, dying from Kobe 19. And that really is what you know, transformed the peri operative procedures that we're all dealing with. Now, um, I think what we've learned in subsequent months is that, you know, with the precautions that we've put into place, we've really been able to make the O. R s really a very safe environment. And you know what? We're not hearing those cases of, you know, peri operative personnel falling ill when appropriate safeguards were put into place. And, you know, the folks have already commented on what those are in the institutions are. They're very similar to what has been described that if we have a known positive case that's emergent. Obviously, if we are able Thio postpone that procedure will do so. But if it's an urgent or emergent procedure, we go forward with the appropriate PPE. Um, clearly, testing is ah, very important. Part of this whole scenario as is, um, hasn't really been mentioned is, you know, doing a careful assessment of that patient, making sure that they really don't have any symptoms and also, maybe even more importantly, trying to assess for exposure risk. And if you know, ah, patient is relating that they've got family members who have been diagnosed as positive, that should be a A really strong warning that, you know, that test that we've already talked about is being a false negative. With that exposure, we really need to take a look at that person and decide if this is a procedure that we can again postponed during that incubation period. Unlike the University of Maryland, if we have a negative case and a person who doesn't have an exposure risk, we're not requiring personnel to be using the, you know in 95 or higher level of protection. And it's important to realize also that all tests are not created equal and that, you know, you have to have a reliable lab that's doing ah really good job with this testing, which we have done an awful lot of quality control in the lab and and feel very confident in the test that's being offered here. But that's not necessarily true for every lab that's doing tests, and it's certainly not true for people who are doing the more rapid point of use. Imagine detection type of tests. Um, you know those air have, ah known higher false negative rate, and I think, you know, we're not going to be able to be relied upon for screening peri operative patients. But again, I would emphasize, with the placement of these precautions, we've created a very safe environment for both patients and for health care providers. And then the last thing I would mention is that we're by no means back to normal with regard to in 95 usage and PPE, and have had to put into place you know, you ve German Seidel radiation to extend the life of our N 95. We put that into place very, very early in our experience. I think a lot of folks have adopted the same sort of measures that that we put into place and we continue that. And it's only because of that that we have, ah, supply of n 95 that we can offer to people in the care of our covert units and also in our peri operative areas when appropriate. Thank you for that. I would ask the other Panelists, starting with Dr Alton. What are you doing? What is your group or your hospital doing in order to preserve P p e? I mean, just throwing it away. Are you in some way trying toe Extend the life? What do you guys dio So we tend to use and discard the PPE. I think that the U V ideas of fantastic one we probably all could do better with being stewards of our PPE. We haven't had an issue getting access to new PPE here, so I think I would say that we've been fortunate in that regard and really, for us, the thing that saved PP the most is what we talked about before, which is just testing. So we don't have to use as much because we unlike you guys if the negative test and we don't have to use the n 95. So our stewardship with regards to preserving RPP is not as good a Z they're doing in the Midwest. Uh, but we haven't had a problem with access. So I would say we've been fortunate. Dr. Prilep, any comments from your center in that regard in terms of, uh, preserving PPE, Yes. We've been quite aggressive in our PPE preservation process For the n 95 respirators, we have, ah, dual mode of extension one being a UV radiation sterilization process. And the other is for particularly anesthesia providers. Uh, we have a five day rotational preservation process where essentially after a period of five days in a dry, clean environment, the viral particles air fell to no longer be infectious. So we've utilized both of those modalities. In addition, um, obviously, when providers are actually wearing a 95 they also wear a routine surgical mask over top of that to avoid any sort of obvious contamination. And s o the outside surgical mask is always, ah, one time use and discard. But in order to try and avoid any any kind of surface contamination of the N 95 which might alter its, uh, effectiveness. We've used that sort of approach to it. I might just add, parenthetically that I think your earlier comment about the the proposal of kind of universal and 95 masking remains one under active debate. I believe the CDC is actually trying to convene kind of, ah, working group toe re examine that issue and certainly within the anesthesia community. And I believe the i d community as well. There are a number of advocates who promote the idea that universal precautions need to be expanded to include routine coverage for respiratory pathogens. And I think that's a, um, honest debate. And I don't think we really know the valid answer to that at this point. Well, I think a lot of that relates to this idea of what is the actual false, positive or false negative real, I guess in this case, false negative. Um um, you know, rate and and obviously depends on the testing in the lab. Maybe Dr Rupp, you can comment on that, and you know, what would you say? I think earlier PCR testing was mentioned. What would you say would be the the rate of getting false negatives or false positives, for that matter. Yeah, again, I think it depends a little bit upon the pre test probability of, you know, a person having covert. Obviously, if you're doing this testing in a very low prevalence population, your risk of having that test being a false positive, actually, you know is substantial. Um, if you're testing in, ah, higher prevalence population than obviously the you know, reliance upon the test results is probably better. So I don't have ah firm answer for you as far as what? The percentages for his particular ass A your test. And it really does depend upon the pre test probability that that that person actually has covered. Um, but, you know, it does bring up a lot of issues with regard, Teoh. You know, what should our standard level of protection be and what is, You know, normal gonna look like, ah, year from now, Um, you know, are we going to have more of an adoption of trying to prevent, um, exposure? Um, you know, and regulatory body is going to play a role in that To where health care providers are going to be much more highly regulated as far as what RPP use. I certainly wouldn't be surprised to see that type of action. And that, uh, that moment, um, carrying forward. Thank you. So, you know, in terms of the specific updated policies and procedures within a hospital within Noor environment, we just saw there recently. It was updated joint statement from the American College of Surgeons s A a r a h a. About maintaining a central surgery during a pandemic. Um, is this sort of document utilized by the hospital or let me Maybe a better way of asking is who are the Who are the decision makers for these sorts of policies and procedures within your within your institutions on. Do they use any particular guideline, or is it just sort of? Because we do see around the country, different things being done? Maybe I'll start with, actually, maybe Dr. Alton, you can specifically speak to the private, uh, surges center. Right, outpatient, Uh, surgical unit that you work in. How do you decide what you're going to do? There Was that just agreed upon by the surgeons working there, Or did you use a certain guidance document. Yeah. So the way that it worked for us was that we got guidance from other groups around town to know what they were doing. Being affiliated with the university allowed us toe lean on them and their recommendations as well, then also, these documents there have been a host of them, you know, released throughout the spring and summer that you alluded to and doing our best to be compliant with those recommendations as well a C. D. C. Recommendations. And, you know, the governor in the state of Washington had a lot to do with our ability to do elective surgeries and shutting that down. And so I mean, that came from a government level s. So I think it's all of those factors weigh in and ultimately in the private sector, you know, it's it's those of us who are who are owners of the group and protecting our employees and protecting our patients and sort of putting all of that information into the hopper and coming up with what we think is is not only reasonable, but if anything, erring on the side of extra safety eso. It's really all of those factors for us. Dr. Prilep is there are certain a t University of Minnesota? Is there certain guiding agency or document, or is it sort of input from various stakeholders? How do you make the decision on the protocols? Our our institutional protocols are driven by kind of a covert, ad hoc leadership committee that was put together, constituted by hospital leadership, nursing surgery and Anna Steve collectively. And that group has relied on sort of the routine documents from joint statements like you mentioned earlier. A swell as CDC documents on within anesthesia. There is an anesthesia patient safety foundation, which has been very active and, uh, printed a lot of material related to Cove it. So it's been a constellation of those. And in addition, in the particular state of Minnesota, we have, ah, very active and visible Minnesota Department of Health. And they have been instrumental in guiding, particularly the governor in the decisions about elective surgery, reopening and and then obviously expanded to business openings. But, um, those those documents have really forged our individual policies here. Thank you. And Dr Rut, maybe you can comment. What's the process for you? Is it similar? Um, it is very similar our decision making body here in the hospital very quickly we instituted our hospital infection are incident command system which you know has representation from high levels at the hospital administration as well as, Ah, lot of folks who are in the trenches and through that type of apparatus were able to determined our course forward. We have a few specialized committees that we've also put together. One of them is our PPE and testing Committee that has helped Thio adjudicate some of these competing demands for who need to test and what level of PPE must be worn. But quite frankly, it's It's been ah really rough and Rocky Road. And I think, you know, part of this is just inherent in having a pandemic and having such a level of ambiguity and anxiety. One of the frustrating things that certainly I observed was that suddenly everybody became an expert. I mean, everybody was a aerosol biologist and everybody was, you know, an expert on air handling and engineering. Everybody was an infectious disease specialist. And that was really frustrating, because I think that, you know, has already been mentioned. Uh, in those times, you really do need to defer to the folks who have the most experience, the most expertise and having public health stepped forward and really take a leadership role in certain states were very effective in other places. What was not. And then it became such a political thing that that really did impede. I think, our response in the in many respects. So there's just a whole lot of different, um, issues that are at play in this. Thank you. You know, I I do want to mention one thing. You know, this is a three M sponsored panel and so I must say that you know, there have been many, many ways that folks around the country and around the world have come up with, uh, to preserve PPE, particularly in 95. Andi, just one comment was made earlier about covering the in 95 with a face mask, and I would just I would just say that three m's formal recommendation. If you're going to try to prevent, like, gross spoilage on the outside of an N 95 to preserve, you know it's the life of that n 95 respirator. We recommend a face shield rather than a mask simply because when the N 95 is tested, you know, they look at one of things. They look at his breathing resistance and a mask on also filtration efficiency, although you would expect a mask may assist with that. But it has not been tested, but in particular there's a There's a concern that it may increase the breathing resistance. And that's one of the uncomfortable things I would say about wearing an N 95 particularly without a valve and an expiration valve. There's considerable heat generated with breathing in and out through it on DSO. So by wearing that that may avoid the by wearing a mask over top of it. It may avoid the NIOSH approval and may impact the performance. And so I'm just obligated to mention that make sure that the audience here is that e maybe interject for a moment. I mean, we we have that same recommendation here is that we were a face shield when we're trying to protect the respirator from any sort of ah, splash sometimes and and perhaps the other Panelists can get into this wearing a face shield actually eyes an impediment to doing the procedure either You can't see through it to the acuity that you need to, or it gets in the way between you and a ocular instrument or something like that. But wherever we you know can were wearing face shields over the in 95 then I would just put out a play that this whole pandemic has been such a call. Thio needed improvements in PPE in 90 fives that can be reused and decontaminated and our design to do that. Because, quite frankly, um, you know, we're in a situation, as I mentioned already, that if we weren't doing these maneuvers to extend the life of our 95 we would have no respirators to care for people with known covert disease. And you know, this just seems like such a clear call toe action that we need to devise better PPE that can be reused. That is more durable. Eso not not getting on three m's case, but it's a clear need for everybody out in the medical community. For you. No more work on PPE that is comfortable and wearable and functional s O. That would be one of the things that is a lesson learned coming out of this pandemic. No, Believe me, I could tell you from as a representative. Three m, we got ah, lot of people working on that. One thing I would tell you is you know, there's no question that the that the sort of plastic reusable, um, sort of stretchy, reusable and 95 where you have replaceable filters. Um, we actually use those reusable on 95 respirators for our at the University of Maryland for our surgical trauma. Surgeons particularly like the in the division of plastic and reconstructive surgery there in the face of the patients for facial trauma. And you don't know if the patients positive or negative. And so they all aware these reusable ones and there are far more comfortable than the disposable ones. Um, you know, you look a little bit like Darth Vader, but it is definitely, um, you know, obviously from a preservation standpoint, but also from a comfort standpoint, But, you know, there's clearly not enough of those and three times that, you know, working on making more of those and advocating them for certain teams like that one on. But I'll just I'll just put that common out there. I would add to that that I totally agree. If you watch people where routine and 95 they're constantly touching it, adjusting it, kind of trying to manage it to make it more comfortable. And I think there's, ah, great opportunity per side of human factors engineering, um, to make these mass not only obviously maintain that level of efficient filtering, but to make them ergonomically more usable and also to ensure that the fit that is initiated, you know, at eight o'clock in the morning is that that mass still has the same secure fit after six or eight hours away, or which is also a concern. Absolutely. So we're almost out of time. So I'll just ask each of you to maybe comment on, you know, maybe the best advice or recommendation that you might have, uh, in the current pandemic. And maybe something that you can see is a long term positive outcome that may come about from this experience. I'll start with whoever wants to go, maybe raise your hands. Uh, I'd be happy Thio couple things. I mean, I think that my best piece of advice for everybody is to truly follow the science, Um, to, um, you know, maintain a healthy level of skepticism with some of these initial pre printed, non peer reviewed type of papers that are coming out that, you know, oftentimes were caught by the media and just blown way out of proportion. And so clearly, you know, maintaining. Um, you know, just ah, faith in the in the scientific process, I think, is the bedrock that we all have to come back to and to practice evidence based medicine. And then I think the thing that will continue to go forward, at least in my area, is, you know, the whole reliance now on telehealth and how that really has been jump started. We talked for months and months and months prior to the pandemic about getting started with telehealth in various areas and then suddenly on a dime, we were able to institute it when necessary. And I think that's been something that a lot of patients do appreciate and something that we need to continue Thio Thio Use inappropriate settings. Obviously fantastic. Thank you, Dr Prelate, our institution has adopted the simple mantra off optimizing patients safety and care provider safety and to have that dual priority throughout all our decision making. So one of the positives has been, I believe, an increased collegiality and bringing together of disciplines which normally didn't interact on a routine basis. For instance, at our hospital, we've allied with our psychiatry department and instituting a buddy battles program in order to provide ongoing wellness programs to providers. Because clearly this has been a stress from both a physical and mental for perspective that very few people had money firsthand experience as faras Future Challenge One of the things we're facing, particularly as anesthesia preoperative testing center, is what to do with the patient who had supposedly recovered from Kobe two weeks ago or a month ago and is now entertaining the prospect of elective surgery. And we have increasingly recognized the multi system derangement that has been impacted by Cove. It, and particularly, obviously, the Maya card itis and vascular instability has really been something that we've were not anticipating but need to be appropriately cautious. And we're trying to figure out what's the appropriate screening that might be necessary to bring elective cases to the operating room. After knowing bouts of covert in the recent past. Thank you totally great a lot to learn for sure. Dr. On any final words from you? Yeah, I think you know, combination of what? The two speakers just pointed to number one, you know? No, the science, like Dr Rob said. And I think that we're obliged his health care workers to know it and to seek out the opinions of experts like him and others that are telling us, you know, the actual science behind these things and then recognizing that this is a big stress to not only healthcare workers but to our patients. And I think we have a big responsibility as their healthcare providers to not only know the science but recognize that this really is stressful to our patients and be able to both empathetically and intelligently speak to the science and the risks and provide our patients with some reassurance that we are doing our very best to keep them safe. And then, as with any stress to the system in terms of the future, I think that we will see some improvements coming out not only with efficiencies of telemedicine, but you know, selfishly on at least concerning to orthopedics. Moving away from an inpatient hospital setting. And this could be a big driving force for patients wanting to avoid inpatient settings and moving some of these elective procedures more to an outpatient environment. Eso I see some of those changes coming in the future as a result. Absolutely. I've I've had many patients also ask about that in particular. Ah, so very good point. Well, we are absolutely out of time, but I want to thank all of you for your participation in this very interesting panel. Andi, thank you for all that you're doing during this pandemic for your patients on before your colleagues and we will end it there. Thank you. Thank you. Thank you.
Ronald P. Silverman, MD, FACS 
Timothy B. Alton, MD 
Richard C. Prielipp, MD, MBA, FCCM 
Mark E. Rupp, MD 
