Jessie Guercio describes her experience as a volunteer frontline caregiver at the height of the COVID-19 pandemic in New York City this past year. Dr. Craig Uejo discusses Scripps Health’s response to the COVID-19 pandemic from a corporate standpoint and outlines the process of developing a central command center to ensure consistent policies and procedures are followed throughout a large health system.
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Hello again, everyone. We're going to go ahead and keep moving along with our next presentation. We have two speakers that are going to share this next topic that's being spoken on, and I'll introduce both of them now. So the first speaker that you'll hear from his doctor, Quick Way Joe he's an occupational and preventive medicine specialist with a focus on workers, compensation, injuries, wellness, disability management and employee health. Dr. Wagih believes that taking care of patients is a privilege. It's philosophy of care is based on trust between the patient and physician. This includes treating patients as individuals with bearing expectations, personalities and cultural differences. Is the current medical director for workers compensation, wellness, employee health and employee care clinics at scripts, Health. When he is not working, he enjoys spending time with his family, golfing, snowing, snow skiing and playing tennis. And then our joint speaker that will be speaking alongside him after he does his presentation is Jesse Greco. Uh, she is a family nurse practitioner who specializes in family medicine and Avenue 3 60 Health and Wellness in Houston, Texas. Jesse was a stem cell transplant registered nurse for over eight years prior to completing her master's degree. She completed her bachelor of science in nursing at UT Health Sandy or San Antonio, and then earned her master of science degree at U T N B in Galveston, Texas. She holds a national certification with the American Academy of Nurse Practitioners. Both of them will be speaking on Kobe 19 from clinical operations to the corporate command center. Firsthand experiences and lessons learned. Thank you both. Mhm. Thank you, Laura. I appreciate that introduction. Um, and I would just want to start with saying that I've known Dr Sandhu Z for quite some time now. And every time I I hear speak, it's a It's a joy and a privilege. And I'm a big sap. Um, I go to the movies, uh, where I cry, my wife doesn't cry. And I would have to tell you that some of her stories just hit me pretty hard right now. So again, as usual, thank you so much to Ronnie. Um, so you know this I think hit. It's always surprised as well, to some degree, this being the cove in 19 and, um, you know, I'll tell you the journey scripts went on, I'll go through some of the the multiple aspects of what we had to do in the command center where I sit right now. And I have been sitting for more than 270 days in the corporate command center of scripts. And many of you have probably talked to or dealt with in terms of what? Why we're testing who were testing, um, many of those different circumstances. So I hope this, uh, presentation is is help. Excuse me? It's helpful for you. Um um, I am trying to advance slide. There we go. Um, went a little too far. So, Mike, many of us, whenever there's something that occurs, we get tasked oftentimes to do more than, uh, more than our usual. And that's sort of what happened here, where I do have multiple roles in terms of scripts, um, with the employee health, peace and the occupational health peace. Um, but recently I've been asked to take on more of the Kobe issues, and again, um, this has been a large part of what I do right now. I have no nothing to disclose in looking back, um, back to 1963. Let's say if you look at this slide. It's, um, pretty amazing when you when you look at what the slide says, we can look forward with confidence, Um, to a considerable degree of freedom from infectious diseases at a time not too far in the future. Indeed, it seems reasonable to anticipate that within some measurable time, all major infections will have disappeared. And this comes at a time when there was a lot more broad spectrum antibiotics coming out so funny to take a look back and see what people were predicting back then, Um, my objectives for the talk is, uh, I think we'll all look back at this. And where were you at the Time Cove? It started, and the disaster response of what we had to do. The response timeline of again, what we did, how we did things, the multiple protocols that we have to put in place I'll describe for you and then some takeaways specific for cancer care, which obviously is pertinent for you guys for for sure. So, um, back when we were training, I guess, for what was called the Haider, we developed a hider response so highly infectious disease emergency response plan and it za plan that we began using back with Ebola. And, um, the Ebola sort of, um, topic started recreating itself were coming back up. Uh, Ebola started presenting itself because there was, if you weren't aware, that was another outbreak that was occurring in Africa, West Africa, Um, in 2019. And so many of the plans that we have developed back previously when the first outbreak occurred for Ebola were out of date and we were looking to try to update things. Eso was the county, by the way. And so we were working hand in hand with the county. Dr McDonald and others am are the ambulance service. Um, because we had to try to figure out if we did have some sort of outbreak again that spread into San Diego, What we were going to Dio. And so we started advancing our plans again on what we're going to do in terms of a circle call and whose who's gonna be on and who's gonna be making decisions. And so it was in the works and we were starting this plan back in, um, October, November December timeline for 2019, and we actually had a tabletop emergency response plan that was going to be, uh, performed again, along with the county and others Fire department, Um, in February of 2020 But then cove it hit. And so everything stopped on Bond. Obviously, at that point, who knew that what was going to develop into? But it turns out it really helped us start down the journey of redeveloping and establishing our Haider plans. One topic and you probably saw when the slides were going through quickly is, um, the pandemic of 1918, um, sort of rings, unfortunately, deadly reminder of what again could occur. And and I think partly what has started to occur with Cove. It's certainly not to the same degree, but I think you know, right now there's more than 50 or near 50 million cases worldwide of co vid. We've got 1.2 million deaths. Three US alone has more than approximately 10 million cases, and we've got approaching 250 million deaths are 250,000 deaths. So it's definitely something that not only were taking serious now, but we wanna, um, look to what we can learn from this and how how we can prepare for the future from a timeline stance. Um, just to give you again a little recollection. December 31 2019. The first case was reported out of China and Wuhan. Um, in January 19, the first case in the US in the state of Washington, where there was a traveler who came back from Wuhan was identified January 20 that confirmed this was the same virus the in Kobe. Um, they declared a public health emergency on January 30 January 21 through February 23. They started to have 14 cases in six states in the US Um, the by late February, there was a really community spread identified where they couldn't do any identifiable contact tracing between cases. Um and then by mid march, there was rapidly increasing case counts and the W h O declared the pandemic. By April 21 we had a total of 793,000 confirmed cases, so it expanded pretty rapidly. Um, it caused us to, uh, develop our Haider plan initiation, Um, pretty rapidly as well. We were already talking about it. Scripts, leadership. It was amazing and sort of getting on top of this. So quickly and we developed, um, a understanding that we needed to open a corporate command center, Um, in January. And so we opened it as the cases started developing on February 12th and the way again, it's a hicks set up, instant command set up. And so there's multiple levels that we established in trying to determine what levels of the command center we had to activate. And I'm not gonna bore you with the details. But it was some arduous decision making because there's, um, there's different things that you have to take into account, including what we're going to do with our clinics and hospitals. Who's gonna, um, man, the corporate command centers on the command centers of the sites who's gonna be communicating and with the county or the other regulatory body? So there's a lot that goes into this, and, um, other than just the logistics of it, um, the practical nature of trying to figure out how to support our colleagues, you folks and surgeons and primary care doctors. How do we support our colleagues to support our patients and eso? There's multiple resource guides that we developed, and I think we've had over 150 types of documents now created. Um, and we've had multiple revisions Where I think we have 440 documents revisions all included to that we created during this whole process. So it zits quite an endeavor. We had to maintain many relationships with the regulatory bodies because, as you recall, things were changing drastically by the It seems like by the day, C, D. C and C. D. PH were changing definitions, changing recommendations. And we had to try to figure out best ways to implement, oftentimes with difficult messaging to staff, that perhaps we didn't have enough and 95 to go out to everybody or we didn't have enough testing supplies to test everybody and these air difficult messages to put out there. But there the reality of the situation in the and, um, the response other than that from closing clinics, um, prioritizing surgeries, um, performing morte element visits, all these things were implemented as part of our process. Um, the first document showing you certainly not something I need you to read thoroughly. But it's a document that has had multiple revisions. Um, and it basically is our testing criteria document. So um, through this whole process, there's been, you know, multiple uh, testing algorithms with multiple testing options. Specifically, the one that's really the gold standard is the PCR test, right? And that's what we're looking for for the RNA tests. What may do the nasal differential swab. But there are antibody tests there, an urgent tests and some of these have their varying degrees of sensitivity and specificity. Um, that places it in, um, not the best light for all situations. An example being for the an urgent test. While it's fairly inexpensive and available, Um, it's most effective for people that are symptomatic eso to test everyone with an urgent tests, including asymptomatic. Um is not the recommendation at this point, although many people are. So these are all the things that we try to sort through as best we could began taking all the scientific data, and we have amazing um um, specialists and knowledgeable people within scripts. But we reached out thio areas again across the country to try to figure out what the best options were. Um, so to complicate matters, the supply chain issues for many things was limited and supply chain issue, for example, for testing to stay back on the testing document again. I'm sorry. The slides keep going forward. Um, but for the testing document, um, there's re agents that we had to play with, and our lab team was amazing and supply chain amazing to try Thio collect as much, um, re agents and what they call them t can tips. So these pipette tips, these plastic tips that were short supply collecting all those as best we could to sort of save one for not just our current use, but save for a rainy day, just in case. And, um, those those efforts were were tremendous and got us through some hard times during this whole testing. I'll tell you again, it didn't come without controversy. Didn't come without folks having some significant concerns as to why we aren't testing everyone. Um, and we worked hand in hand with the county. The county was very helpful in trying to maintain some form of testing if we couldn't test and so oftentimes are. Ability was limited. So we referred people to the county. Um, we specifically set up methods for us to test, and we have the cabana test is you're familiar with where you can drive through and just get tested and swabs without leaving your car. We had Pelham Ed visits and are, uh, corporate telephone service line that was able to take tree and triage calls. Answer questions. We had a specific provider and in health care worker for scripts. Uh, call in line that we're able to prioritize and get testing done for our health care workers. Eso all those things again was part of and parcel of how we try to prioritize testing for this next document. The decision tree This again had multiple iterations. And if you could see the version 27 is the latest newest document. Although it's now gonna be 28. I'm working on that one right now, but many again of these issues started with G. What do you do with you? Have a specific exposure. Um, when we had our first case on bond, the staff were maybe wearing PPE, But some maybe we're not, um what do we do with them? Do we send them home? We don't have enough staff. If we sent everybody home. Our first case out of Green was a surgical case and it was a surprise, uh, case. So we didn't anticipate it. Um, they became sick after surgery, but then because there wasn't PPE worn during the initial visits and during the operating procedure, many of those people were exposed and we had to figure out who was going to be quarantined and who wasn't. And, um, difficult decisions were being made on. I recall into the late hours of the morning one weekend just because we had to try to figure out how we're going to staff Green. And, um, you know, again, who was potentially going to be ill? Sadly, we had a staff member that did become ill. That was our first staff case that was related to that exposure. And then, um um, it really brought things home toe light, How serious this this exposure can be in terms of spreading to staff. But it's come a long way since then because again, our our ability toe toe have PPE at the time. We need it when we need It has really improved. And way had to go through multiple iterations of what kind of PPE people could wear on what settings were best. How to reuse PPE um, and ar cfl liar training arm education. Enormous scripts was incredibly helpful. Um, they helped build some guidance documents, helped do some videos for donning and doffing. Um, but many of these documents again, was, I believe helpful. And I'm I'm hopeful you thought it was helpful to provide a visual aid to what was appropriate, what was necessary in terms of the proper PPE. And again recall that this has gone full circle from early beginning being it was airborne droplet enhanced precautions then hey, no, it's not airborne. It's only droplet enhanced. And then lately it's it's come back full circle. Thio, give us more concerned about airborne now, at least coming now from the C. D. C. That's the latest, um, we established some form of protective layer for US facilities for our patients, for our staff, um, the we needed to protect from anyone coming into our facilities. So we had to formulate some questions to screen. How do we screen folks? Um, do we screen them outside? Do we screen them inside? Who's gonna be doing the screening after we screen them? Who is not appropriate? Um, my light just turned off my office here. Um, there we go. But how? We, um um, identify someone who might be, um, ill or sick on Ben. What do we do for those that we are passing through? When we decided to do a wristband for for those folks, so many of these things again went through different iterations. Um, on, Do we do temperature checks? Do we not? Um, do we stop all visitors and way had many folks who are coming in with masks and the masks that we were providing, or either cloth mass or dust mass or surgical masks. Uh, if they didn't have one, but many were coming with their own masks. But we quickly realized that certain mass, though we're just not safe, even though they were wearing the mask, they may have had a one way X elation valve. And there's a picture of a couple of months top on this one. And these thes air not helpful because they don't filter out the X elation breath. And so anybody that's wearing these X elation valves, the air is coming out completely, um, unfiltered. And so it's one that we're not authorizing anybody visitors to come in the, um um, other types of masks and scarfs, and, uh, things that we had thio go through to try to clear people are not clear. People. Also was was an endeavor because you could imagine there's some emotions, uh, at the front desk when we're doing some of these screenings. Okay, um, some people brought, in example bringing different statements or cards as to why they didn't have to wear a face mask. Eso this added. Unfortunately to some of the emotions also at the front desk, visitors screening didn't stop there. You know once, folks, so we're able to screen. Who did we let who do we let through? Do we let people through if they if they want to go visit someone that's coated positive? Um, the concern we have there obviously is. We want to protect the visitor to eso if they go in and they there, um, wanted to sit with their their their loved one. Who's sick with Cove it could they get cove it and obviously from a public health stance, then they're going to go back home potentially and infect others. So there's, uh, many indications where we had to try to stop that from from occurring. We had unfortunately tried to set up different things specific for end of life, though I think that's an issue that we had toe be careful of. We had Thio develop goals of care to try toe allow for, let's say, someone in labor, a woman in labor whether they can have a partner if the unfortunately, what if she's sick with co vid s o Many of these things had to be developed and we did, with the help of the Caroline leadership and experts across the country. Um, so our response Andi, I would just go through this more of a summary is, um it was critically important for us to have frequent and detailed communications. Um, when we had, um, not enough communications or not enough detail, we were called on, and not just from staff, but leaders across the system. So I think we learned pretty quickly we needed to be detailed, and we needed to put that up on an Internet, which is what we did and the help of Markham toe. Make sure that we got the information out that was necessary. We had to develop triggers because, especially in July, time frame. We had to surge where we were getting close to the peak of our hospital beds close to the peak of our of our I C U beds and ventilators. And so we had to have multiple surge plans to try to figure out how the best support. Um, you all best support the patient care and try to figure out how we're gonna manage yourselves through the pandemic. The supply chain, at least scripts, has been amazing. Um, team of folks and I think unfortunately, we're going to see still see a many different supply chain shortages still, throughout this next year. Maybe including the co vid vaccine is one of those items that's gonna be in short supply because there won't be enough vaccine. But, uh, we learned quickly of what the needs were to try to make sure we have enough supplies. Um, a Z I mentioned earlier we had to do clear and enforce the visitor screening. We advanced or tell a med visits where I think now we've done over 250,000 telehealth visits. One out of five visits now is a telehealth visit. Even though we've we've gone back and reopened our clinics, but for a period of time, multiple. Our of our clinics were closed early on in, um, into March early April. Eso At that point, we were we were, um, doing I think, more than 6000 visits a week, Um, in telehealth visits, and we had ah 1000 doctors doing telehealth, um, calls eso It ramped up very quickly, but we we knew we needed to do that in order to maintain the health care of our patients. Um, we talked about the Kobe Cabana and doing testing options. We're gonna have to think about the same thing for potentially giving vaccines out on beer, working through those options right now as to how best to to vaccinate all of you and help. And maybe your family's a zone option through our cabanas. Uh, I mentioned earlier about our multiple protocols, and then, uh, one thing that was a big thorn in our side was reporting, um, numbers from a regulatory stance Similarly to the changing environment of the clinical realm. The changing environment of what was asked for us from a state and federal um um guidance was was incredible. And so there's a lot of effort, Um, that was put into trying to create what's called the president's dashboard to Kobe dashboard. And that dashboard has multiple fields that were automatically being pulled from epic. And so people didn't have to necessarily go in all the early on they were going in and and tabulating numbers. And I'm trying to calculate what was accurate in terms of how many beds were being used and filled with cove in patients. Um, you know how many events were being used? And, uh, every day we were reporting those out because we had a circle call every day eso gradually again we were able Thio automate that. And now we're ableto pull the data automated and send it automated thio the regulatory bodies that needed apologize again. It looks like my slides now are not forwarding. Okay, there we go. I just want to show you. So this is the president's dashboard again. That gives us the daily census, um, and the active patients for co vid the et volume that Zinn place eso again. Very helpful. The next slide is a supply chain, um, dashboard that is kept on a daily basis to keep track of exactly what our supplies are like and make sure that we don't have anything that's impending doom. And with the loss of certain supplies, I was eso will switch. How is, uh, code potentially impacted cancer care? Um and you know, initially, just like all the other AM batory clinics out there, there's a lot of clinics that were closing. And there's a Lancet article in August that came out that oncology patients potentially are at higher risk. But we're not being seen. Um, and they're at high risk for more severe disease from Kobe, but potentially have and have hard mortalities. But because they won't be seen, is there great immortality now because of their oncology diagnosis is, Well, um, they were being triaged because the officers were being closed. Surgeries were being delayed and sometimes canceled or oftentimes canceled. Andi. The different therapy modalities were also being reduced in terms of what was being available or an option for care. Um, the social and economic impacts, as the many patients were, were losing their job or not being employed. Um, were they impacting their insurance coverage? What was what was happening in their ability thio to maintain their their care. Those were all part of, unfortunately, the the long arm of the pandemic. Um, there's, ah, recent cancer consortium. That and a cancer study that came out that had some key takeaways. The probable survival benefits and receiving cancer care still far outweigh the risk of death. From co bed, you reduce the risk of transmitting Kobe through infection prevention practices and use of P B. E s. You want to triage and prioritize and modify your work flows potentially all in a way to maintain the patient flow. And one options are, for example, no waiting room visits. We have patients or staff communicate via cell phone or texting. They could wait in their car and then immediately come up for their visit when needed. And then, um, just like we talked about with our staffing, modeling and education and communication. You wanna maintain that for patients and their family members? Um, innovative therapies need to be considered, uh, making sure that we can get the correct therapy at the right time. Um, but maybe they don't all go through the infusion center. Maybe there's more Orel therapies that could be provided. Um, we don't wanna cancel care. Cancel er, surgeries, chemotherapy. Do we do we need to postpone their maybe needs to postpone things if someone is active for the sick with Cove it. But again, it's critical to try to get these treatments on board as quickly as possible on guy. No, I'm speaking to the choir because you really want to prioritize the cancer care despite the pandemic, not vice versa. And then the last point is to make sure that you have multiple specialists involved in coordinating the care. Um, there there's, uh, concerned up there certainly, that there's maybe specialists who are limited their practice. And if they're limiting their their practice, are we not being able to diagnose the patients in a timely manner? And then are those patients again not getting the care they need in a timely manner? Um, I was asked to leave about five minutes for questions. I want to thank you for inviting me, and I appreciate that. Good morning, everybody. My name is Jesse Greco. I'm a nurse practitioner and I'm based out of Houston, Texas, at Avenue 3 60. Health and Wellness. Um, that's a federally qualified health center in Houston. Um, again, Thank you, Laura, for the introduction. Eso What I'm presenting on is about my experience on the front lines of co vid during April and May of earlier this year. I have nothing to disclose. Okay, so I got the opportunity to go to New York City from a company called Crucial Staffing. And crucial is a staffing agency that does large scale deployment for natural disasters and natural emergencies. And to date, there are deployment in New York City. What's the biggest companies had? Um, I'm not sure the total amount of health professionals that were there, but there were, I believe, five hotels full of medical professionals from around the country who came to help. And we were dispersed amongst the bureau's and New York City. Um, I was assigned to what, Hall Hospital, which is ah, hospital in Brooklyn And would haul is known for its mental health care in the community. Um, I was an impatient nurse practitioner on an alcove. It stepped on unit. So this was patients who weren't intubated but who still weren't okay to be just on a normal floor. We did. Team based rounding our teams consisted of one attending one resident and to mid levels and at what hall. It was kind of all hands on deck. So the residents could be pediatric residents and the attendings were usually the outpatient attendings who are coming in in patient. So we're all kind of little in over our heads and learning together. Um, when I arrived at what hole? It had five ice use. Normally, it only has one or two. Um, there are three medical covert units that had been set up in a cove, a designated er again on our teams. We had about 12 patients per team. Um, and I was deployed from April 1st to May 9th. And of those 40 days, I worked 36 of them, and they were 12 hour shifts, so we worked a lot. Um, so I've included this slide of the Kobe 19 timeline in New York State. Um, just kind of put it in perspective of how quickly everything kind of snowballed. So you had your first case. Um, documented in New York on March 1st had the first death that march 14th, um, essential businesses were shut down or non essential. Businesses were shut down on March 20th, and by the time I left in May, everything was still pretty much closed. Um, you can see April 8 through 14th was our peak and hospitalizations. But by the end of April, we were upto 18,000 deaths and over 304 1000 cases. And New York, New York City, specifically is a large population in a little bit of areas, so and they rely heavily on public transportation. So a lot of the patients we were seeing were transportation workers, taxi drivers, bus drivers, people who worked on the subway as well as New York in my PD. Okay, so ah, lot of us have different at the different hospitals had different admission criteria. I'm going to specifically speak to what we did at Wood Hall s O. The protocols vary from hospital the hospital admission criteria, oxygen saturation, less than 92% on room air or any acute signs of respiratory distress in the way, we kind of balanced it with inpatient or outpatient, because again, the testing wasn't rapid. It took a a day or two to get the test results back. You can't just have patients sitting in the er, so if you presented with symptoms of Kobe. You were treated as assumed, coated positive for out patient monitoring. Um, fevers that responded to Tylenol oxygen saturation greater than 92%. And they had to be ambulatory. So you had to make sure that these patients held onto that 92% respiratory saturation as they were walking. It couldn't just be arresting one and send them home, because when these patients dropped their respiratory saturation, they dropped quickly and need immediate intervention. As I'm sure all of you have seen outpatient treatment, isolate for 14 days were giving a zip throw and doxa cycling for pneumonia coverage. And then this was the time of hydroxy Clark win. So pretty much everyone that we saw was on hydroxy Chlor Quinn again. Before sending out patient, you would do a baseline e k g to check the q t c interval because you don't want these patients having prolonged QT intervals and then come back in with the heart complications from treatment. Sure. Look, yeah, um, impatient evaluation. This is going to be really important for the nurses who are there. So you can kind of know what the physicians were looking for. Um we're doing CBC's daily and the main thing we're looking at is the lymphocyte count. Uh, we're doing C and P's daily, really looking at the liver, enzymes and the kidney function. Because Kobe had that ability, it binds to that H two receptors, and we're seeing a lot of patients with kidney complications as well as the respiratory symptoms. Um, a BGs were done at baseline and then for any change in respiratory status. Blood cultures, Times two on admission. Again, we wanted to see if it was truly cove it or if we could possibly rule out sepsis or something else. We also did ldh toe as a measure to predict severity of disease. On admission, Um, de dimmers, pro calcitonin and fair 10 were also ones that we focused on, um, inpatient evaluation Extras on admission and we only repeated for any changes and acute respiratory status. We did a lot of C T angiograms for elevated D dimmers to rule out p e. And if we noticed any abnormality on the e k G, we ordered an echo again Cardiology e. K G. On admission and daily e k G. If on hydroxy clerk win or is it thrown? Liasson And I will tell you I had a patient who was stable on nasal cannula. Um and we then overnight his saturation were dropping and he had a you can an x ray down on admission. And then when his saturation dropped, we did another one. And that was day three of admission and it was just white everywhere in the contrast between Day one and Day three was breathtaking. And it was just so hard to see because you can see these the lungs looks like they're drowning. I really wish I had that to share, just to the contrast, to see how fast this was happening for these patients. Thankfully, that patient ended up being OK. Um, so we did oxygen therapy. Obviously, that's a big thing that we focused on. You start with your nasal cannula and your goal is to maintain 90 to 95% saturation. Um, after Maxie on a nasal cannula. And typically we like to max out nasal cannula at six. I'm telling you, we're going up to 10 liters per minute just because we wanted Thio avoid any further interventions. Um, what Hall had oxy masks? It was almost impossible to find a non rebreather. So after the nasal cannula, we put them on the Oxy mask and even combined the two of them to keep that saturation above 90%. Um, some patients were placed on CPAP or by PAP to avoid intubation. But this was back in the beginning. Where we didn't know Is Kobe airborne is Kobe droplets? So it was really terrifying seeing patients being placed on CPAP and by Pat because that Aircell eyes the virus and then as healthcare professionals, you know the risk you're taking when you're walking into that room. You know, you're just praying like I hope my in 95 steel is okay. I hope my glasses don't slip off, and that was really terrifying. And I really have thio hats off to the nurses who were in that room multiple times a day versus me as a advanced practice provider who was only in there a couple times a day a rounding, um, and also we had several patients that were intubated on the floor prior to I C transfer because, like I said when they would start dropping that saturation, it wasn't a gradual drop it was a quick drop. I I have a picture later on in my side presentation of how maney anesthesia stat calls and how many respiratory stat calls we had because we're intimidating people. It seemed like left and right, and there were even patients in the ER who are left intubated because there's nowhere else to put these patients. Um, as faras are supportive measures for oxygenation incentives. Perama tree If you could find the incentives parameter, otherwise you wanted your patients sitting up and taking deep breaths. You know, 10 deep breaths every hour, like we recommend with the incentives parameter. We also encourage prone positioning even in patients who weren't sedated. Um, and the patients that did this, we're like, Oh my gosh, it feels so much better because you're allowing the lungs in the back to fully expand. And it was really bizarre walking past the i C u everyday seeing intubated patients prone. But it did. It did prove to help in their respiratory status. Also encouraged coughing. Back at this time, we did not give cough suppressants because we wanted everything to come up to clear that airway again. Keep in mind this was very early on in co vid um medication treatment hydroxy Chlor Quinn. This is what we used. This is what we had, um, the Q t c cut off was 4. 50. However, if they had a prolonged Q t C interval, but they had no cardiac history. We went ahead and gave it. Anyways, um, and daily EKGs were done to monitor this. And then is it through Madison stuff? Try Axon while impatient again. We're just throwing the kitchen sink at these people because we didn't know exactly what was going to help. We also did convalescent plasma again. This was for patient. This was reserved for patients. Um, we had I gave it to one patient, he was on CPAP, and he just wasn't improving in his oxygen saturation. We tried to wean him several times, and we're also trying to prevent him from being intubated. And he was able to get the convalescent plasma. So we only had it in a couple of instances that I saw, um, supportive care Tylenol as needed for fevers or pain. No cough suppressant. And also we weren't using steroids because we didn't know if it could affect the side of kind storm. We just didn't know at the time. I believe that they may have used in. I see you on some patients who had severe respiratory complications, but I can't speak to what the i. C. U did, um, personally. But it's just bizarre now because part of the outpatient treatment is it through index the method zone. So it's kind of interesting to see how far we've come in terms of what we know. Okay, this is another big slide anti coagulation because we were seeing several complications from co vid. Um, I had one patient she recovered from Cove. It was not having any respiratory symptoms, came back in and was admitted and had a stroke that paralyzed her on the left side. Um, all because of Cupid on DSO, it's just terrifying because we're focusing. We're focusing so much on the respiratory status that now we're seeing the impact it has on the cardiovascular system. I will say the highest did I ever I saw was over 45,000, and we thought it was a lab. Air repeated it. It was not a lab air. Eso definitely did a lot of C t angiograms just to assess. And if we found anything, of course. They were sent immediately to the I. C. U. Um, So for the D timers, less than three, you had the throb of prophylaxis. And again, this is going to be very different for the oncology population because they're thrown beside of Penick. Eso I personally didn't treat cancer patients for covitz, so I really can't speak to that. Um, but we do have to be very careful in the oncology population because of their complications with their own. Beside a pina, we were using a packs a band, the 2.5 mg twice a day. And this was really good for our patients that had that impaired renal function that we were seeing on Ben. You also have your Lovenox and then for the anti coagulation. It was 5 mg of a packs a band twice a day. Um, I even saw them using high dose heparin, Um, as well as Lofa knocks. But again, you have to be sure of their kidney function. So in the beginning days, we were kind of grabbing any research we could find. Um, this is a very busy slide, but this is just a picture of, like, the golden standard for what are residents and attendings were using for. I see you. Um this was just floating around. I snapped a picture of it. I thought that it was really interesting to share because this was from bring them in women's health. I mean, we had to work as a medical community to help figure this out, and you can see in the therapeutics it says, Do not give steroids. Um, and then also underneath that is where it talks about the trials for both Tosi and room death Severe. Um, when I left in May, that's when there was just talk of the room desk severe, but I know it would haul. They were unable to get for patients. Um, and now it's kind of becoming the gold standard in terms of what we're treating now. So this is that picture I was telling everybody about. I kind of would count overhead. How maney codes we had per day. How maney, Rapid respiratory stat, rapid anesthesia. Um, and I crucial called this a deployment, and I was kind of bothered by that word at first. But as I was there longer. It felt like we're in a war against an invisible enemy. Because I can't tell you how many of these codes we heard, How many coats I saw personally, Um, and then you're seeing on the news like, Oh, it's not a big deal, But I'm in here seeing this, and that's why I took this picture to stay like, No, this is happening. Look at what is happening to these people. Um, care was clustered. Obviously, as a provider, I rounded maybe two or three times a day. But like I said, my hat's really go off. Go off to the nurses because they were in there at least every hour, and these patients weren't allowed to have visitors. So, as a nurse, you're making that choice to risk your own health, to help somebody and be there. And again. I can't imagine what it's like to be an oncology nurse now at the bedside, because these patients they don't have their families and cancer is a family disease. And so you're risking your own health because that's what we do as nurses. We don't think of ourselves first, and you become that patient support system so really hats off and then in terms. We also have daily rounds with social workers. Because what Hall had a very big homeless population on do you can't send these patients out with an infectious disease to a homeless shelter, because then it's going to spread like wildfire. Um, and the social workers also really helped organize home health and then oxygen therapy at home. Um, and then in terms of PPE, we were provided we got one in 95 mask per week unless it broke eso they didn't always have the size. Like I wear size small. They didn't always have that. So thankfully, I had family back home and friends that would send them to me. So I had enough to be protected. Um, hair covers and shoe covers were hard to come by again. I'm very thankful that I have family that was able to send that to me, but it was kind of like you see anything lying around you take it. Um, we did have plenty of gallons. Plenty of gloves. We got one face shield the whole time I was there. Um, so and I think that what Dr Sandoz you talked about earlier about self care is very, very important. Um, I know that I personally came home with a little bit of PTSD, and I didn't realize it until I was, like, being very triggered by things that I would see in the news or things that I would hear of, like, this is a hoax. This isn't Riel. Um, so I really encourage you guys to if you need to seek out mental health therapy, mental health counseling, because you are on the front lines of this. And no one has ever seen anything like this before. So please again take care of yourself as well, because you can't pour from an empty glass. Yeah, um, shaping practice. I kind of took some of the things I learned there. Um, when do you recommend inpatient versus outpatient treatment? Again? An oncology. This is going to be very critical. This is where we really have to take our critical thinking as nurses and kind of see the trajectory of where this patient can go. Um, our biggest predictors of critical illness. Oxygen impairment on initial evaluation that is not responding responsive to oxygen therapy and elevated inflammatory markers and risk factors for hospitalization over age 65 obesity, heart failure and chronic kidney disease. And I found that obesity want to be interesting. Um, but as we know, obesity is a pro inflammatory state, and that's kind of what puts these patients more at risk. I've also seen complications of things to look out for. We had a patient recover from co vid, came back in with rhabdomyolysis and had to be put on short term dialysis. This patient was even. We're monitoring his cardiac function in his enzymes were turning up, so we ended up having to send him to another hospital for a cardiac cash. So just keep in mind. It's not just the lungs that this can affect its a circulatory system. It's your kidneys and get to your heart, um, and how to protect immuno compromised patients. I think this is the biggest take home point. Be very strict with your PPE test and retest. We need to keep these patients safe, and also, this may be a little bit controversial, but take care of yourself outside. You're going into the hospital daily. Things you do in your personal life outside of the hospital can impact your patients We don't want nurses getting sick and we don't want nurses infecting patients. Eso just be really mindful of some of the choices that you're making in your own life again. Very controversial. But it's something that has health providers. We put other, we put our patients first, and we need to practice what we preach. Um, and again, this is my contact info. Any questions you guys have, um, going back and putting this presentation together? It was really interesting to think like we we think that we haven't come very far in this cove. It fight, but looking back at, like the early therapies we were using, we've come so far in just a few months. And I just think that if the medical community can keep sticking together, keep doing all that research. We've come so far and we're going to keep going. Um, and here's my contact info on guy. Really want to thank everybody for this opportunity? Specifically, Jinbo. She was my colleague, Beckett and the Anderson, and it's just been really an honor. I did my nursing experiences and stem cell transplant at M. D. Anderson and that Methodist Hospital in San Antonio, so It's also a big honor to be on the faculty, along with Joyce Newman and Patty Johnson. So thank you guys so much. If you'll have any questions, let me know. Please stay safe. Thank you, Jesse. And thank you again. Dr. Ways you ways you both for your presentations that you just went through. And it has been definitely quite the journey and one that we have not finished yet. So definitely more for us to keep a ni out on and what's coming next. Um, we do have some questions that were submitted, so I will just read through those. I think the first one will be for you, Dr Wage. Oh, so, um, from our attendee Lindsay, she asked. I'm curious about what kind of telehealth visit other systems are providing. They're only able to do video visits, but they do. But they do not want us doing telephone visits because they're not billable. She's curious what other systems air doing. And if others are doing telephone visits. And I know you might know some things about within the area within our other health systems maybe what they're doing. So, uh, probably the only example I can give you is Kaiser. I think Kaiser is doing pure telephone visits. Um, I don't know what the other systems and they are doing, but Kaiser was actually, um, on the forefront of these to tell him that and telehealth even before co vid. I mean, as you all know, we telehealth tell him that visits have been around for years. Um, it certainly accelerated as a result of co vid. Um, but Kaiser was doing these visits earlier on DWI had obviously tell him that visits as well, but obviously exploded. And but yeah, I think that's the only example I can give you a pure telephone visits, not video visits. Thank you so much, Jesse. I think this one's directed to you from our attendee Gene. Did you draw lactic acids as well? Azaz pro calcitonin is. And if not, what was the reason behind it? Is this just a sepsis test? Does the profile shows something else regarding Kobe 19? No, it was mainly for sepsis. We did do the lactic acid, of course, in our patients with suspected sepsis. Um, but profile again, sign of tissue damage. So that's another one we focused on. But it wasn't one of the main ones. We focused on both. Let's see. Also, we have another one here from Connie. Are attendee Connie? She says are asked, What was the gold standard treatment you use? Jesse, this was for you. She heard you say hydrochloric win on. Was it effective? So yes. Hydroxy claure Quinn was the gold standard. Um, in terms of it being effective, I think I think it did. Okay, I don't think it's doing as well as Randy Severe did. Um, but along with the is a throw medicine. That was our gold standard. E think it did decent. Um, but then again, some of these patients were so far gone. It was really hard to kinda pulling back by the time that we got to them. So some of the thank you, Jesse some of the comments that have come through the chats that weren't necessarily questions. Um, they said this was fascinating. Hearing your experience. Thank you so much for your work and sharing your experience on DSO. And definitely for both Jesse you and Dr Wei Zhou Wei Joe's operational side of the work behind the scenes of how you get supplies and for your staff. And what do you decisions that have to be made about visitations within hospitals And what you do in the clinics and then, Jesse, your front line experience? Um, definitely. Both of your topics that you spoke on were very pertinent to what our health care workers are experiencing right now. And just toe kind of go through that journey of where this all started and what we've come through just was like a good reminder of how eye opening this has been for everybody.
