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3/19/2020: COVID-19 Symposium I - Shared screen with speaker view
pratikv
01:10:30
hi, could you do a mic check please on the presentation side?
nadlst1
01:11:13
Mic sounds good
pratikv
01:11:15
perfect. thanks. can hear you
Josh K
01:12:34
Hugo can you confirm this will be recorded for folks who miss it in real time?
HMC Pulmonary (Leila)
01:12:51
Yes, this is being recorded
HMC Pulmonary (Leila)
01:13:14
I will send out the recording link shortly after the conference.
terri
01:18:54
Wow--almost 200 participants! Thanks Hugo, Andy, and all for putting this together. Clearly a community need.
Engi
01:19:55
Yes, thanks so much, team!!
Bijan Ghassemieh (UWMC-NW)
01:27:48
Update: 2 patients from this case series now successfully extubated today at UWMC-NW
Hugo Carmona
01:28:10
great news!
Andrew Luks
01:28:12
Feel free to submit questions via the chat function as we go. If we have time left over at the end of each presentation, we will pose some to each speaker.
Rosemary Adamson (VA)
01:28:22
That's great news. How old were they, Bijan?
Bijan Ghassemieh (UWMC-NW)
01:28:46
Ages: 20s and 50s. Minimal comorbidities
Rosemary Adamson (VA)
01:29:15
Thanks. Had they had any cardiac dysfunction during their admissions?
Vikram Padmanabhan
01:29:31
no clinical cardiac dysfunction
Rosemary Adamson (VA)
01:29:41
Tx
Cliff
01:29:44
we haven't seen any of the late cardiac dysfunction described
Cliff
01:29:54
at HV micu
Ann Jennerich
01:30:16
Trial on lopinavir/ritonavir is out https://www.nejm.org/doi/full/10.1056/NEJMoa2001282
Basak Coruh
01:30:19
We had cardiac dysfunction in a patient at UWMC
Rosemary Adamson (VA)
01:30:54
How did that patient do, Basak? I've heard that cardiac dysfunction conveys poor prognosis
Vikram Padmanabhan
01:30:56
one patient at NW - started tocilizumab today
Laura Spece
01:30:57
i saw one at HMC with significant cardiac dysfunction
Melissalee
01:31:23
Evergreen has seen at least 5 with cardiac dysfunction.. with at least 2 as their presenting problem
Sara Nikravan’s iPhone
01:31:35
PT this AM with PEA arrest. DNR, passed
Sara Nikravan’s iPhone
01:31:47
UWMC
Basak Coruh
01:31:49
The patient with cardiac dysfunction died
David
01:31:53
Can someone put all these papers into one place?
Laura Spece
01:31:56
mine did too
Melissalee
01:32:05
We did have one patient that was dobutamine dependent… off dobutamine his bp would drop precipitously and on dobutamine he was bp was more than fine
Hugo Carmona
01:32:25
David - yes, we have collected these citations and will distribute as well!
Jaspal Singh
01:32:26
Any particular lessons related to ventilator management, like delirium, SAT/SBT differences, sedation/analgesia needs that you all have noticed?
Hugo Carmona
01:32:34
including the CDC running list of publications
Tonelli
01:32:48
The Evergreen series has a significant proportion of patients who developed cardiac dysfunction. Not surprisingly they did poorly
Vikram Padmanabhan
01:33:13
hypoxemia out of proportion to not terrible compliance
trevorsteinbach
01:33:23
Pubmed is keeping a list of COVID pubs here as well: https://www.ncbi.nlm.nih.gov/research/coronavirus/docsum?filters=topics.General%20Info
Michael Bishop
01:33:26
given relatively normal compliance, has anyone used cpap on intubated patients but without ventilator. this write save vents for most critical
Aaron Joffe
01:33:33
So, per the JAMA podcast from Italy, there is no specific therapy and we should stick with what we know works for ARDS, respiratory failure, MODS, no?
Alex
01:33:49
or a V60 on PS in lieu of full vents
Rosemary Adamson (VA)
01:34:22
@Michael Bishop: there's a lot of talk about avoidoing NIPPV bc it aerosolizes the patient's resp secretions
sound
01:34:28
At UW is the consideration of Toclizulimab being considered in patients with evidence of Cytokine Storm but while COVID status is still in question?
Basak Coruh
01:34:29
Yes, standard evidence-based care for ARDS. Reports of patients being very PEEP responsive, n too small here to know
Vanessa
01:34:29
Were myocarditis patients on ACE inhibitors/ARBs?
Jaspal Singh
01:34:30
can you talk about experience related to when it was okay to do PT/OT etc? Seems like there would be concerns and issues here worth discussing?
Basak Coruh
01:34:44
ID is recommending we check IL-6 levels for critically ill patients
Henry Kramer
01:34:50
How have you mitigated Plaquenil supply issues?
Rajneet Lamba
01:34:57
I think that the clinical characteristics article that just hit print in JAMA used noninvasive ventilation on some of their 138 patients
Robert Lee
01:35:09
On the topic of treatments, can we expand a little bit on the data behind hydroxychloroquine?
jbluhm
01:35:10
Any comments on the increased risk (? mortality) to health care workers?
Michael Bishop
01:35:37
I was referring to cpap via ett
Rosemary Adamson (VA)
01:35:53
@Bob Lee: yes, would love to understand HCQ mechanism
Jennifer Hartley
01:36:11
With IL-6 monitoring, are you monitoring ferritin too, Dr. Coruh?
Vikram Padmanabhan
01:36:13
they are both doing great! expect to continue to improve!!
wemplem
01:36:42
Does the UW lab do IL-6 and does it return quickly?
Rosemary Adamson (VA)
01:37:06
@Michael Bishop: how do you imagine doing that? Use standard CPAP machine with single limb to ET tube and vent exhaled gas into room?
kristina crothers
01:37:07
Will toclizumab be based on IL6 level, if so what threshold for dosing, and does the regular lab run IL6?
Molly Billings
01:37:39
Any updates on use of ACE inhibitors and ARBs. I’ve heard conflicting information on this. Any benefit to holding or starting these?
Basak Coruh
01:37:52
Hi Jenny, yes - recommendation is to check IL-6, ferritin, fibrinogen, CRP, ESR, D-dimer
terri
01:37:55
Check out LitCovid-- a curated literature hub through NLM. https://www.ncbi.nlm.nih.gov/research/coronavirus/
Vikram Padmanabhan
01:37:57
I sent IL6 and inflammatory markers. I gave toci with pending IL6 and very elevated inflammatory markers
Melissalee
01:38:08
Evergreen is looking to procure some trilogy vents for less ill patients: but the limits are primary it only delivers 40% and minimal peep
sound
01:38:29
@Vik, did you have COIVID confirmation with that patient?
kevinobrien
01:39:08
Heart Failure Society of America recommends against stopping or transitioning off ACEi or ARB in asymptomatic patients currently on them
Vikram Padmanabhan
01:39:08
yes. she has worsened despite ARDS care, diuretics, antibiotics hence we gave toci
Basak Coruh
01:39:15
Hydroxychloroquine has only been shown to inhibit viral replication in vitro
Basak Coruh
01:39:32
unknown if it’s effective, but minimal risk
Rosemary Adamson (VA)
01:39:38
@BasakC: thanks for info re: HCQ
sound
01:40:14
At Swedish we are still having a delay in COVID reporting, so the question is coming up if patients in CK storm should have earlier consideration of this even without a + confirmation.
shawnskerrett
01:40:42
We started tocilizumab in a COVID + patient today after markedly elevated IL-6, CRP, and ESR
William A. Altemeier
01:41:08
Hydroxychloroquine inhibits the intracellular PRR, cGAS. cGAS detects intracellular DNA that can be released during mitochondrial stress and also may recognize endocytosed neutrophil extracellular traps. For what it is worth. There are pre-clinical data that targeting NETs can reduce influenza-induced lung injury.
Mary Horan MD
01:41:42
some discussion by our Infection control folks about concern of hydroxychloroquine worldwide supply issues informing how we might decide to use. recommending high risk post exposure contacts
Vikram Padmanabhan
01:42:17
there is a HCQ clinical trial enrolling for exposed individuals or HCWs - I enrolled today
wemplem
01:43:04
So are we starting HCQ before COVID results come back?
wemplem
01:43:09
In ICU patients?
terri
01:43:43
Question for the crowd: what randomized trial do you want to see in severe COVID?
Sara Nikravan’s iPhone
01:44:26
what is the incidence of co-infection with other viruses?
erics
01:44:51
So when would a patient be non-infectious?
Bijan Ghassemieh (UWMC-NW)
01:45:38
Terri:
Bijan Ghassemieh (UWMC-NW)
01:45:52
1.) Steroids (cheap, unlikely to run out)
Basak Coruh
01:45:53
We are only using HCQ in inconclusive (thus likely positive) or positive patients
kristina crothers
01:46:19
Some of the groups in China reported on patients with high d-dimer who were treated with anticoagulation - What is the local experience?
Vikram Padmanabhan
01:46:20
great question as that impacts post ICU "usual care" such as bipap, PT, OT, swallow eval, dispo to LTAC, etc
Basak Coruh
01:46:21
Saw a recent paper with 20% coinfection rate (not necessarily with another virus)
Ann Jennerich
01:46:23
Big questions for me are: what type of PPE is actually needed to prevent spread in acute care patients? Drug studies of course. PEEP ladder or no (getting concerns from community about using traditional LPV with PEEP ladder in patients with underwhelming imaging)?
Basak Coruh
01:46:24
will try to find reference
Bijan Ghassemieh (UWMC-NW)
01:46:31
2.) Liberalized tidal volumes (given relatively good compliance) to minimize sedation/duration of mechanical ventilation (which will become an issue as we run out of beds and vents)
Guang-Shing
01:46:38
@terri: antiviral ie remdesivir +/- took
Guang-Shing
01:46:56
toci
Rosemary Adamson (VA)
01:48:00
I agree that knowing the right PPE would be really helpful. Not sure how to make that randomized. Might end up being a natural pre- / post- study as we run out of PPE....
Sarah
01:48:20
Re; coninfection - our Evergreen case series of the first 21 pts in ICU had 3/21 pts with another virus and 1/21 patients with a bacterial coinfection. See JAMA article out today.
Basak Coruh
01:49:07
Thanks, Sara - there’s the 20%
shawnskerrett
01:49:25
Has the lab considered changing to a faster test?
bhatraju
01:49:47
How many more tests could the lab do? What is the potential for growth in completing tests.
Melissalee
01:49:52
Patrick— what is the story about available test kits. Is this a rate limiting step?
Robert Harrington
01:50:02
Same targets with the Panther machine as with the UW virology test?
Guang-Shing
01:50:03
do the positive tests have to be confirmed by the state lab?
Melissalee
01:50:20
As more places start making test kits, do we need to continue doing control studies?
David
01:50:26
sorry if i missed, what's the timeline for high through put testing?
pratikv
01:50:27
why are the results for our resdients and fellows taking 48hours? we have a number of lcinical abscences
David
01:50:46
hear hear
Aaron Joffe
01:50:59
Per Andy’s comment just now, why not consider empiric antibiotics for VAE based on clinical criteria or even prophylactic given the smaller-is sample size of the ICU patients?
pratikv
01:51:03
some team members have been off for 2-3 days awaiting test results
Cliff
01:51:08
they're prioritizing inpatients but staff should be too
Patrick C Mathias
01:51:22
To answer a few questions re: lab
Rosemary Adamson (VA)
01:51:30
David - I don't think a timeline for high through-put testing was discussed.
Basak Coruh
01:51:32
Hi, Sharukh!!
Conrad Piper-Ruth
01:51:45
GO SHARUKH!
Patrick C Mathias
01:51:52
We have switched to the Panther for priority specimens and are brining automated Roche instruments in the next couple weeks.
kristina crothers
01:51:53
Need more research on whether, after clinical recovery but still shedding virus, if virus is viable and transmissible
Patrick C Mathias
01:52:23
Positives are no longer confirmed by the state but we are continuing to send them inconclusives
Guang-Shing
01:52:38
Thanks Patrick
Patrick C Mathias
01:53:04
Panther uses different targets than the adapted CDC assay we are running. We are working on a workflow to confirm inconclusives internally.
Cliff
01:53:08
what % of inconclusives are ultimately positive? in my experience its been almost all of them
Aaron Joffe
01:53:13
Are we repeating testing X2 before “clearing” patient after hospital course as per the Italian group?
bhatraju
01:53:41
Are any of in the indeterminates eventually reflexed to a negative test? Echo Cliff's comments above.
Mohammed Nayeemuddin
01:53:48
testing x 2? for inpatients?
Basak Coruh
01:53:54
We just had a inconclusive be negative on recheck
Basak Coruh
01:53:56
Checking again
Aaron Joffe
01:53:56
yes, inpatients
Rosemary Adamson (VA)
01:54:01
Looks like he had bilat pleural effusions
Basak Coruh
01:54:22
COVID-MD (ID) is helping us make decisions about whether second test is needed based on age, comorbidities, alternative diagnosis, etc.
Rosemary Adamson (VA)
01:54:27
Interesting - I had heard that pleural effusions have been rare in China
Vikram Padmanabhan
01:54:57
all icu beds at NW are negative pressure as well
Patrick C Mathias
01:55:03
We expect the inconclusives to confirm at a 50/50 rate because they are close to the limit of detection. One strategy is to retest after 2 days. With current capacity we hope to be able to accomplish that.
bhatraju
01:55:17
Thank you Patrick.
Aaron Joffe
01:55:24
It was my understanding that one of the patients at UNO still had nasal swab positive after 30 days despite being asymptomatic…
Molly Billings
01:55:30
What prompted you to send COVID as this was before knew it was here. Impressive ID to get that done without travel history.
benditt
01:55:34
BAL NEGATIVE BUT NASAL SWAB + ?
Basak Coruh
01:56:18
Know of one other case of inconclusive that was negative on recheck
Cliff
01:56:23
no covid testing on BAL probably
bhatraju
01:56:23
Any literature that remdesivir could cause cardiomyopathy?
Patrick C Mathias
01:56:45
Test kits are no longer a limitation but other reagents such as tips for instrumentation are a critical bottleneck. We are competing with the large commercial labs for that supply.
Patrick C Mathias
01:57:24
Current testing capacity is 3000 per day and we are pushing to 5000 per day in ~2 weeks.
Basak Coruh
01:57:40
Thanks so much, Patrick. Any hope of speeding up turnaround time?
Melissalee
01:57:55
Very impressive Patrick! Great job to you and your team
Patrick C Mathias
01:58:16
The new Panther instrument should help. We will get a better idea starting tomorrow. We are in final stages of configuring it to send results to our lab info system.
bhatraju
01:58:45
remdesivir is contraindicated in eGFR<50. I wonder if patients can develop toxicity as their renal function is rapidly fluctuating during critical illness.
Basak Coruh
01:58:49
Thank you for all you’re doing
Patrick C Mathias
01:59:04
Our target is 8-10 hr turnaround time for Tier 1 samples within UW Medicine. Longer for outside samples due to transport time.
Patrick C Mathias
01:59:31
4-8 hr turnaround may be possible when we bring in the Roche instruments.
Bernice
01:59:56
What is the time diagnosis to death?
Robert Lee
01:59:57
Incredibly impressed w/ lab's response to this—this is truly an extraordinary response. Really amazing. THANK YOU to Patrick and to all of your colleagues and collaborators.
Vikram Padmanabhan
02:00:31
Lab medicine are the unsung heroes of the US outbreak
Andrew Graustein
02:00:34
Thanks Patrick! Is there any possibility of antigen testing rather than a PCR based assay (like rapid flu testing as I understand it)?
wemplem
02:00:35
Interested to know experience with cardiac arrests, in terms of ROSC, and delays in initiation of CPR for IHCA.
Rosemary Adamson (VA)
02:00:36
Agree. Yay for Patrick & Lab Medicine
Mary Horan MD
02:00:41
agree with Robert Lee - thanks Patrick and Andrew and Geoff and all
Patrick C Mathias
02:00:42
UW Virology and Alex Greninger deserve a lot of credit. We would have been testing in early February if not for the FDA
Sarah H
02:00:53
are any of the patients who expired getting post-mortems? Would be curious to understand the cardiomyopathy better
wemplem
02:01:24
Thanks Sharukh and Evergreen!
Patrick C Mathias
02:01:27
We are working with multiple reagent manufacturers on antibody based tests. Hopefully we will see something in the next couple months.
Melissalee
02:01:35
I am overdue to talk to the ME about a few that she did do autopsies on
pratikv
02:02:15
why check a CK and not jsut trops?
Alex
02:02:25
quick rise/fall
Basak Coruh
02:02:30
UW not performing autopsies on any patients with suspected/proven COVID-19
Melissalee
02:02:32
curiously the scvo2 haven’t been very low, but they respond so robustly to dobutamine
Robert Lee
02:02:35
Sharukh- (1) Thank you. (2) Any experiences thus far w/ health system strain, triaging resources / transferring pts out, re-purposing of non-PCCM providers, etc.?
Patrick C Mathias
02:02:41
I have to drop off, feel free to email any lab questions I missed to pcm10@uw.edu
Frederick Troncales
02:02:44
have you looked into specific management for the cytokine storm? would this reduce incidence of cardiomyopathy/ myocarditis?
Basak Coruh
02:02:47
ME was assuming jurisdiction early on, but as of yesterday, they are no longer doing postmortems on these patients
Basak Coruh
02:03:28
Reason I got from ME: “we already have enough cases” :(
Monica Campo
02:03:55
@Sharukh How many of the patients who expired and presented cardiomyopathy received remdesivir?
Sarah
02:04:36
There is some autopsy data from China on pathology that showed nonspecific inflammation in the myocardium. Here is the recorded webinar for your reference: Epidemiology, CVD Treatment & ManagementListen to an ACC webinar held in partnership with the Chinese Cardiovascular Association on March 18 addressing myocardial injury with COVID-19 and the latest guideline published by the Chinese College of Cardiovascular Physicians.
Sarah
02:05:50
https://www.acc.org/latest-in-cardiology/features/accs-coronavirus-disease-2019-covid-19-hub#sort=%40fcommonsortdate90022%20descending
Hugo Carmona
02:06:22
thanks Sarah!
Sarah
02:08:27
-few interstitial mononuclearo inflammaotry infiltrates
Molly Billings
02:09:29
It seems that obesity may be a risk factor for poor prognosis with COVID. May be just marker for DM, HTN ? Usually obesity/OSA associated with better ICU outcomes in large administrative datasets
Sarah
02:09:34
- endothelial shedding with thrombus in vessels. No SARs-CoV-2 inclusions seen
Aaron Joffe
02:10:46
This case (and many like it that present to HMC from OD to trauma) illustrate the potential for widespread healthcare exposure unless a) everyone is treated as positive until proven negative and 2) PPE is used for droplet in every patient who presents until they are ruled out. This would require testing in every patient who comes to the hospital for any indication, no?
Alex
02:11:28
or at least those who cannot provide history and symptom screen to prove lower risk
Sharukh Lokhandwala
02:11:30
@MonicaCampo: have only had a few (I believe 2 or 3) that received compassionate use remdesevir, the rest are part of an RCT and thus I don’t know what they received
Sharukh Lokhandwala
02:11:57
re: SCVO2—I question whether there may be some mitochondrial toxicity leading to poor extraction—would rely on a real scientist to prove it though
Bernice
02:12:25
any improvement with remdesevir? if any at all?
Nick Johnson
02:12:31
We are working on the above issue extensively in the ED. We have now seen COVID patients present as trauma, cardiac arrest, and stroke with little collateral history available. Clearly, we do not have capacity in the ED or elsewhere to isolate every patient who cannot provide a history, but we are moving toward "hot" and "cold" zones until additional info can be obtained.
Melissalee
02:13:13
Mark- we just had another patient that followed this exact course…without the CVA piece
Melissalee
02:13:31
He just developed bradycardia and then asystole
thomaskeller
02:14:37
It is interesting that many patients who end up having severe courses develop worsening symptoms around the time that acquired T cell immunity would normally develop (7-10 days) — I wonder if this is related and if that argues more strongly for immunosuppression
kristina crothers
02:14:42
Thanks Mark!
Aaron Joffe
02:14:54
Nick, agree, but would suggest that the only way to contain healthcare exposure would be that PPE is used by all providers in all locations in ED. It would seem that all providers that see patients from EMS to ED, etc, should protect themselves and secondarily the patients and the wider community.
Rosemary Adamson (VA)
02:15:55
@Aaron: tricky. That will burn through PPE....
Nick Johnson
02:17:19
@rosemary: yep, that's the worry
Mark Wurfel
02:17:20
Melissa Lee: that's interesting. it was very rapid and unexpected. really no other evidence of cardiac involvement
Dustin Long
02:17:21
@Nick @Mark—we are looking at ways of using ML to triage pts based on other available data. More to come.
Sharukh Lokhandwala
02:18:19
@NickJohnson: any thoughts to using the more re-usable PPE (PAPR/CAPR) for those with the most undifferentiated patients and most frequent likely exposures (ED, EMS, etc)
Rosemary Adamson (VA)
02:18:46
@Dustin: what does ML stand for?
Sharukh Lokhandwala
02:18:52
machine learning
Dustin Long
02:18:52
Machine learning
Melissalee
02:18:54
The cardiomyopathies have been subtle… often start with just a slight increase in creatinine, or needing more norepinephrine. The scvo2 could be greater than 70, but their efx is deteriorating
Mark Wurfel
02:19:12
Aaron: i agree but if we surge PPE will be limiting. thinking carefully about the procedures/processes that are particularly risky may be more realistic.
Nick Johnson
02:19:47
@Sharukh: absolutely. we are looking at a number of options with infection control, including outdoor triage, hot/cold zones w/ universal PPE, etc. Lots of physical plant challenges at HMC, too.
Monica Campo
02:20:18
Agree with looking into re-usable PPE (PAPR type) following models like the ones that we use in the BSL3 where we each clean our own before fully doffing
Basak Coruh
02:20:30
We have already gone to reusable PAPR
Cameron
02:21:43
Same in Philly, and we haven't even started to upramp
Rosemary Adamson (VA)
02:21:58
Basak: could you send me the protocol for cleaning the PAPR hood please?
Monica Campo
02:22:08
I mean for the ED staff to use it most of the time
Vikram Padmanabhan
02:22:47
about two weeks on the vent
Mark Wurfel
02:23:06
central processing is doing the cleaning here at HMC. i would ask your infection control team to interface with ours
Sharukh Lokhandwala
02:23:08
FYI—we extubated a young man after approximately 13 days on MV, another woman in 50s on ventilation for ~6 days
Robert Lee
02:23:18
Laura- How much and how frequent is communication between the regional health systems to make sure resources are being effectively utilized across all health systems in the region, to delay movement to crisis standards of care?
Basak Coruh
02:23:22
@rosemary: yes, we’re not cleaning them ourselves
Andrew Graustein
02:23:28
Is there now or will there be a regional triage center that will make decisions about where patients and equipment should go that is acting above the level of individual hospital systems?
barnesc
02:23:51
Does anyone know how reallocation will apply to nonCOVID-19 patients during this crisis? new SAH, new high spinal cord injuries, etc?
ebulger
02:24:46
The Northwest health care response network is working on setting up a regional coordination center for this event with a platform to track the data better
Mark Wurfel
02:24:56
Estimate of how close we are to crisis mode? NYC is discussing sometime in the next few days.
nadlst1
02:24:58
What are appropriate triggers for implementing crisis procedures across the region?
Tonelli
02:25:13
Current median time on vent for those COVID patients liberated from mechanical ventilation is region is 13 days and will get longer
Rosemary Adamson (VA)
02:25:13
Mark & Basak - thanks. I suspect infection control is already working with HMC/UWMC but sometimes it helps to have a little input from elsewhere...
Basak Coruh
02:25:43
Bone marrow transplants have been stopped
bhatraju
02:25:44
What does crisis mode mean for clinical care. It seems NYC is close to this.
kristina crothers
02:25:45
How will the front line teams in ED and ICU communicate with the triage team real time? All critically ill not just COVID patients will be included in this triage if going to crisis level of care
pratikv
02:25:59
the federal officials that I have heard speak about this keep reiterating that it will be the "physicians" making these tough decisions. it seems like they are already trying to shirk their responsobilites
Mark Wurfel
02:27:21
That is a CRITICAL point. I think that the lay public are not the only ones who are not clear on this.
Bijan Ghassemieh (UWMC-NW)
02:27:22
Patients with IVDU are high utilizers of our critical care resources. How do they fit into this framework (may have good short term prognosis, but maybe not long term)?
Rosemary Adamson (VA)
02:32:42
And your kids are not behaving normally - maybe bc their lives have just been turned upside-down (or maybe just inside).
Aaron Joffe
02:33:41
how are those community providers being screened?
Aaron Joffe
02:34:07
Also, if we get a shelter in place order or similar, how will that be affected?
Rosemary Adamson (VA)
02:34:48
Great Q re: what happens with childcare for HCWs in setting of shelter in place order
Rosemary Adamson (VA)
02:35:30
There are many two-HCW families....
Robert Lee
02:35:49
Yeah. :-(
bridget
02:36:51
What have family visiting policies been for ICU patients in light of trying to conserve PPE?
Sarah H
02:37:21
what changes in staffing are being considered to make sure that we remain resilient and healthy for the months ahead?
Andrew Luks
02:37:28
Randy Curtis will likely chat a bit about visitation, which currently is very restricted for infection control reasons.
Aaron Joffe
02:37:43
No visitors at HMC (UWM policy) unless they are needed for behavioral therapy or on day of procedure. Can only have 2 total that have been screened, not at one time.
Andrew Graustein
02:37:52
I would like to see a daily tracker of COVID positive ICU patients, COVID positive floor patients, and PUI’s at each hospital in the greater Seattle area. Helpful both for my preparation as well as understanding what our colleagues are going through. Is something like this already out there?
barnesc
02:38:40
2 patients at end of life care allowed in patient rooms.
Dustin Long
02:38:45
COVID tracker for UWHC/HMC being worked on by HMC IM Chief
Dustin Long
02:39:23
..Resident: Kevin Seitz. They are open to incorporating input.
Rosemary Adamson (VA)
02:39:31
@Sarah H: Hospital leadership are thinking about how to best re-allocate staff eg how can endocrinologists best be utilized in this situation
Hugo Carmona
02:39:37
good to know Dustin!
Dustin Long
02:40:00
kseitz4@uw.edu if interested in contributing
bridget
02:40:00
@barnesc can they go in and out multiple times (with multiple PPE) or only once or once daily?
Andrew Graustein
02:40:08
Thx Dustin.
Dustin Long
02:43:15
@Laura: Considerations on the role of ICU physician age (any personal risk) in making plans for ICU surge staffing? Is this a component of the discussion? We are dealing with this in regard to OR staffing/airway team composition.
Bijan Ghassemieh (UWMC-NW)
02:43:52
Randy: We do a lot of CPR when we don't think it is beneficial. The difference here is obviously the disease transmission risk. Do you recommend including this aspect in the discussion with families?
Rosemary Adamson (VA)
02:44:04
VA perspective: unilateral DNRs NOT allowed
Rosemary Adamson (VA)
02:44:52
Our approach is: try very hard with conversations and then know that the first physician in the room after a patient codes can immediately stop the code.
Molly Billings
02:45:35
What about informed assent for DNI with limited resources before shift to crisis level care? In those we deem very unlikely to recover from ARDS.
Robert Lee
02:45:50
@Bijan- Echo your question. My personal hypothesis (Grade Z) is that discussion of this aspect is unlikely to resonate w/ families that are full code refractory to DNR by assent.
Rosemary Adamson (VA)
02:46:18
Actually, within the VA, you can rarely obtain a DNR without patient/family agreement (generally in setting of no surrogate available) after ethics consult and agreement from Chief of Staff.
Rosemary Adamson (VA)
02:47:56
National VA ethics experts have recommended including in the conversation that bc of need for full PPE, CPR will be slower to get started full force and that probably does impact outcoems
Ann Jennerich
02:48:08
Folks also discussing keeping COVID patients on the ventilator during CMO rather than have the RTs perform a terminal extubation, to reduce the potential viral exposure of the bedside care team.
Vikram Padmanabhan
02:49:32
ann - thats what we did over the weekend
Andrew Luks
02:51:22
Feel free to share any questions for the panel here in the chat function!
wemplem
02:52:13
Any experience with Code blues at hospitals and how they went. Obviously there are challenges.
Melissalee
02:52:14
Evergreen is following the DOH recommendations of no visitation outside of immediate EOL. One of the limitations is available PPE to keep them safe, even in EOL situations.
Melissalee
02:52:41
Evergreen has done some virtual visitation and are looking to launch a more robust program with families logging in from home
Randy Curtis
02:52:42
The issue of keeping patients on the ventilator after withdrawing life support and transitioning to CMO is in flux. I'm not convinced this is a good idea for patients and family members, but we are discussing this now at Harborview.
Andrew
02:53:13
Follow-up to labs: What minimal set of labs do we think would be necessary for patient care if responding to a high surge capacity? ie could POC instrumentation be sufficient for certain patients to save PPE on floors/ICU?
Cliff
02:53:17
would love to hear where we're at re: policies/protocols with other services.. continue to have some confusion on whether all covid rule outs should continue to come to the MICU service. overnight had neuro and cards patients admitted to our service
Cliff
02:53:51
as well as policies re: getting procedures done for r/o patients
Alex
02:57:47
@Andrew: I think ongoing case data will help us determine those lab monitoring parameters. Many non-ABG labs unlikely to change respiratory failure mgmt, unless monitoring drug toxicity or complications.
Sarah
03:01:47
Do you have the reference for hydroxychloroquine with azithromycin and viral clearance?
David Wenger
03:03:12
Can Laura (or others) speak to regional efforts to increase hospital capacity? For instance, we are hearing about filed hospitals being built in Shoreline currently. How will entities such as these be staffed and what critical care services will be available?
Alex
03:05:26
Seconded, and also the earlier question about distributing patients b/w hospitals to account for specific care needs (neuro, cardiac, etc)
barnesc
03:07:49
to add to #David Wenger- Italy was forced to expand to using operating rooms as make shift ICUs. at HMC there are 30 ventilators available each day, but at the expense of surgical patient care needs.
Angelika
03:08:11
For patients who have recovered from COVID but will need SNF or go back to their ALF: most of the facilities require repeat testing to make sure that they are COVID-19 negative, otherwise those facilities refuse to take them back. What can we tell them? What are the updated guidelines from CDC or DOH?
james
03:13:30
big shout out to all the EVS, facilities, RNs, RTs, house staff, admins, night & day MDs who are making it happen with all of this uncertainty
Rosemary Adamson (VA)
03:13:38
Proning using proning teams must use a lot of PPE....
Andrew
03:16:57
Re: discussions with SNFs/placement: Would consider comparisons to C. diff. Several facilitates are reluctant to accept C. diff pos (by PCR) patients, but with specific discussions, they may accept if asymptomatic.
Trish Kritek
03:16:58
thanks to the organizing group!!!
terri
03:17:00
Thanks!
Kayla Secrest
03:17:02
Medical students are reaching out to Apple and Microsoft to see if additional iPads can be obtained for patients
Cameron
03:17:08
Thank you all!!
erics
03:17:13
Great program! Thanks!
Erin Kross
03:17:19
This was terrific! Thanks Andy, Hugo, and all who participated!
Alex
03:17:19
thanks all and stay well!
cfhung
03:17:26
thank you for organizing this
Bernice
03:17:37
thank you all
Ann Jennerich
03:17:38
Thanks all!!
Rosemary Adamson (VA)
03:17:40
Thanks so much for organizing & speaking & contributing to chat. So good to "talk" to you all.
Sarah H
03:17:49
This was very informative, thank you everybody!!
goltryb
03:18:03
Thank you! What a great healthcare community we have!
Mohammed Nayeemuddin
03:18:08
hi guys, when the video link goes out can one of you please send it to mznayeemuddin@gmail.com
Nita Khandelwal
03:18:11
Thank you! This was very informative!!
barnesc
03:18:12
Agree with @Erin Kross, can we plan to cont. with this as we go forward for SACGRs as this evolves?
Mohammed Nayeemuddin
03:18:14
I would really appreciate it
Melissalee
03:18:22
thank you! Great job
Sarah H
03:18:29
Agree!