Coronavirus HTM/IT Townhall
March 29, 2020
During this March 24 online town hall, healthcare technology management and IT professionals shared their insights, experiences, and answers to your questions about the COVID-19 virus and its implications.
This event was hosted by the Health Technology Alliance a coalition between ACCE, AAMI, and HIMSS, dedicated to bridging the gap between IT and HTM professionals by providing solutions to common challenges and sharing relevant information between the two communities. Visit healthtechnologyalliance.org to learn more.
As of March 24, COVID-19 has infected 300,000 people globally, as well as more than 33,000 cases in the United States, and caused more than 14,000 deaths. The town hall includes HTM and IT professionals who represent a wide range of different size healthcare organizations:
- Danielle McGeary, vice president of HTM at AAMI (host and moderator).
- Jeff Ruiz, HTM director at Holland Hospital, a small community hospital in rural Michigan.
- Michael Marchant, a health information technology director at UC Davis Medical Center, a large teaching hospital in Northern California, which had the first identified case of COVID-19 from community spread.
- Mark Manning, HTM director from the Mayo Clinic, a large health delivery organization that spans across many regions in the United States.
- Yadin David, providing an update about the steps the World Health Organization is taking to combat this crisis and assist HTM professionals internationally.
- Umberto Nocco, an HTM professional working on the front lines at a major hospital in the Lombardia region of Italy. Lombardia had been one of the hardest hit regions of Italy, making up nearly half of Italy's total COVID-19 cases.
Update from Italy (00:04:22)
Umberto Nocco: It's a pleasure to be here and to share with you some of the things we've been dealing with for the past month, actually, because it hasn't been longer than that. Lombardy is the region in the northern part of Italy where I live in. It's been one of the most struck from the virus inside our state. Basically, data shown today shows that we have some 30,000 cases among the 70,000 gross numbers throughout Italy. This happened basically in three weeks. Patient one, as we call him, was found positive on February 21st. Since then, we add an exponential incremental ratio of known patients basically based in kind of a defined area throughout the region. But later on, the outbreak expanded over the entire nation.
The point is that the rest of Italy aside Lombardy seeing cases after two weeks from the start in our region, so that at least they had the time to get ready to some extent before the outbreak reaches them. Of course, we all wish it doesn't happen, but it's an option, of course, that this might end up having quite a number of cases.
Just to give you an idea, the difference between Lombardy and Rome, for example, although I'm saying they did a great job, they had the time one week, not very much, to remodel a closed hospital to accept COVID-19–positive patients only. While in our region due to the birth and the continuous flow of patients to the hospitals, we had to work day by day and try to find out the solution to have them inside our hospitals.
From an HTM point of view, I would like to outline three major problems.
- Machine availability plus space inside the hospitals (e.g., ICU beds).
- Organizational issues.
- Acquisition problems for devices.
One of the main problems we had to cope with was that the need for ventilated beds, not only did we use ICU beds which were more or less full because of standard patients. We were just running normal routine, and we are normally running at 95% better in Lombardy and I think that more or less the same number throughout Italy, but we had to define new areas where positive patients were to be placed.
The more patients, the more ICU beds were needed. Those that could create new ICU beds out of nowhere did so, while other suffered the way even and they had to figure out a place where to put them, whether it be a normal ward, or some hospitals are starting to put tents outside the hospital at least to do the first screening when a patient comes in with the ambulance or with their car or however they get to the hospital.
This means that the major issue about acquiring technology is basically on four to five types of assets. I'm talking about continuous positive airway pressure systems, ventilators, monitors, infusion systems, and beds being the last and the easier to describe and with difficulties to be found on the market and to be acquired. Although, in the end, we ended up using normal ward beds even if we are to handle intensive care patients because, in some places throughout our region, we are basically a war zone. It's really whatever you have available, that's fine for the patient.
Italy: The Most Important Devices Needed (00:09:13)
Umberto Nocco: The point is that if you get the continuous positive airway pressure system, they are the first line because patients come in with some sort of breathing problems. You might use noninvasive ventilation but usually requires a mechanical ventilator which is precious because we don't have a lot of them. We immediately swapped to continuous positive airway pressure systems.
These can be used outside the ICU, especially if you already have training personnel like in lung department or other specialties or medical departments. But you have to be aware that you are risking a lot more aerosol spreading outside the system rather than with the invasive ventilators. We have come to the point where we are making basically our own gas blenders because vendors can't keep up with the need we have.
When it comes to ventilators, if you ask an anesthesiologist, he will ask for the top quality of the product. The point is that we had so many patients that we have become greedy rather than specific, if you see what I mean. We had to acquire devices really fast. The typical call we used to make a couple of weeks ago was calling the vendor and saying, "How many ventilators do you have in stock that can you bring me, say, tomorrow?"
What we had to consider especially devices that could run without compressed air since we don't usually have that in ward. If you end up installing ICU beds in what yesterday used to be normal wards, of course, you don't have all the facility you may have in an ICU as usually defined. Of course, I don't know how many of you are familiar with the Italian way of setting up at hospitals. We usually don't have a room for the patient regardless of his type of treatment that goes from the ICU to the general ward before he goes home. We have specific areas of the hospital dedicated to a different level of intensity of care we have to give to the patients.
The next kind of asset we need to acquire really fast and in good big numbers were monitors and monitoring systems. They are, of course, important for an ICU but also for patients who are taking care in normal wards. General conditions that we want to monitor are oxygen saturation, which is probably the best for a meter to look at, together with CO2, to figure out whether the lungs are working correctly. But they asked for monitors rather than simple telemetry systems because they want to be able to view the monitor without going too close to the patient. So they avoid getting dressed up with protection clothes and breathing all the aerosols, which is, of course, one of the major issues.
As far as I figured out in this past three weeks, you don't need a high-level monitoring. You don't need a lot of parameters. Basically, basic parameters: pressure, of course, invasive pressures because the more the patient becomes bad and more ill, the more you may need to have some invasive pressure, and plus CO2 monitoring unless you have it on the ventilator, of course, because you need to be really aware of the condition of the oxygen exchange in the lungs.
The point is that we needed a lot. In my hospital, we have in standard conditions, some 50 intensive care beds. We've come up to almost a hundred. We basically doubled the number of ICU beds in the hospital to handle this kind of patients and you have to be aware that the hospital I work in, it's not one of the most involved in the outbreak. We have a lot of cases but not as many as in other parts of the region.
The last thing is the infusion systems, both syringe and IV lines. The thing is you never know how many you need. At least, that's what happened to me. If you talk to different anesthesiologists, they may ask you for different numbers. I wouldn't be able to say the correct number, but probably a gross number is something around four pumps per patient, but the problem is always the same.
We're talking about 20, 30 beds at the time, so numbers go up real, real fast. In Italy, at least, we don't have a sort of organization where we have stocks of medical devices that can be used by hospitals without too much effort. I mean we had to buy all the devices to get them running inside the hospitals. Of course, the more you get into it, the more requests come up from clinicians because, then basically, you need to put up a COVID-positive, as we call it, patients and a non-COVID patients ICU.
There are really two different ICUs for different kinds of patients. Hopefully, once this empties, the COVID-positive, while the other doesn't, but then everything is doubled up. So, you need two more ultrasound machines, more point-of-care diagnostics, and many other devices. For example, the emergency ward requires for extra ultrasound machine to do first screening of the patient's, portable x-rays because they're easy to handle. They give you a good shot at the beginning, and then, they're really easier to assess rather than CT scans.
Italy: What Supplies Are Running Out (00:15:56)
Umberto Nocco: One of the problems we are starting to face right now, and we are talking about right now and in the past two or three days, is the problem about spare parts. I don't have data on this, but one thing I must say is that probably ventilators run more steadily, if you see what I mean, because they're running on the same patient for a long time, so they suffer less failure if compared with the time when you have a higher patient turnover in the ICUs. So basically technology is more stable, but then you need a lot more oxygen cells because they fail more often, probably it is due to the higher oxygen concentration used.
And also one of the other problems is the consumption of oxygen. I don't have calculations handy, but lump figures say that we kind of doubled up, or maybe more than that, the oxygen used in the hospital. And so you need to increase the capability of the tanks, of the oxygen tanks. And also you need to be sure that you give an extra boost to the oxygen in the flow because continuous pressure airways support system use very high flows. And when you have many of them connected to the same pipe, you might end up figuring out that you're not really giving the patient the wanted flow of oxygen because everybody's sucking up from the same reservoir. So basically that's what it is.
Italy: Tackling Organizational Issues (00:17:37)
Umberto Nocco: At the beginning of the outbreak we had to divide production lines, especially in the ERs, sorry for my poor English, and I hope you understand what I mean. Basically you need to define which wards and which ICUs, if you have them, you want to put positive patients in and which wards you want to put non-positive patients in.
I know it's a stupid point of view, but the thing is that normal patients will show up anyway. So if you have a contagious disease ward, which is usually designed also with regard to air flux and isolation of the rooms, then you're quite ahead. But at least in Italy, those are really a few and usually they don't have so many beds as needed in this kind of an outbreak. So you need to use a general ward, which is usually not designed to handle this kind of situation.
You need to set it up with monitors, continuous pressure airway support system, point of care diagnostics, personnel, which we're really running short of personnel, and protection devices. These can be set up in advance. Of course, if you know where to put patients, where you're really staying there.
And this process division has to, at least we experienced, you have to figure it out also in the emergency ward, especially if you need to have basis for clean patients because unfortunately, as I said before, strokes, trauma still happen. Although we experienced a significant decrease, especially after lockdown, it seems like patients don't have strokes anymore. We're kind of asking, “Why?” But there are fewer cases that have come up to the hospital, luckily.
Of course, you have to have completely different spaces for known or suspect positive patients and known positive patients. This basically is like having two emergency departments inside the same hospital. Also from an asset point of view, so you need to have the space, and you need to have the technology to make it run.
Another thing is about biomeds and biotechnicians and as hospital technology management people who kind of walk around the hospital just to have everything set. We need to be alert. Of course, this is easy to say, but it's hard to handle. But one thing is that you may need to define where to go and especially when it's worth or needed. By this, what I mean, this is mainly to prevent exposure to the virus, to the biomeds, and to your people in your organization, plus, to reduce the use of the protection clothing and devices, which are always short.
And so this might not be liked by the personnel, at least it is not liked in Italy, they don't like to attach cables, but sometimes some really easy basic line maintenance probably should be given out by nurses and people who can do that inside the ward without biomeds and people from the health technology department going inside a kind of positive area, which has all kind of problems.
Italy: The Challenge of Acquiring Devices (00:21:20)
Umberto Nocco: Last, but it's still a major problem, probably it's more local because it's probably it's more related to the way we acquire devices in Italy. I won't get into the details related to public tenders, which probably don't apply to the U.S. market, but to some extent we faced a kind of saturation of the capability to produce devices, which is probably typical of medical device market, which is not usually accustomed to producing by the hour in great numbers, if you see what I mean.
So, we were the first, and so we were able to use stocks, and we were able to acquire some numbers of devices at the beginning of the outbreak. But after a short time, we started experiencing a longer and longer time to hospital, as they call it, for ordered goods. Orders given today are scheduled to be given to the hospital by the mid of April. So that's way too long. We need the devices before that. And we also experience lower quality due to a certain, probably to the speed on the production line, details that are not present on the devices, things that are missing, things that probably are not assembled very well and stuff like that.
Last thing, is how many devices do I need? Basically, it's another way of putting the question I started with. We had hospitals where more was never enough, still today, and hospitals where you had the feeling that you were doing something wrong in acquiring all that kind of technology because it didn't seem like needing more devices and beds and somebody else might have a need rather than you.
The problem is that you never know. You never know what's going on tomorrow. Also, all these nice curves of patients that we see every day, we're not really sure they're correct. So we don't know what will be happening in the hospital tomorrow, how many cases we have at home, and they're are not even aware that they have COVID-19, and they might end up in a hospital in a couple of days. So it's really hard to find the balance when you have to decide how many devices, which type, what you want them to do, and how you want the thing run.
The IT Perspective (00:24:23)
Michael Marchant: We here at UC Davis had the first community-spread patient transferred in on February 19th. And when you have CNN in front of your hospital for three or four days, you know it's a pretty big deal, so we are mustering all the resources.
And really as we've moved along from an IT perspective, our big challenge has really been getting our staff and technology up to speed, actually support 5,000 or 6,000 staff telecommuting simultaneously. What do we need to do for the security of the building and limiting access to visitors? How are we getting people screened appropriately at the entrances?
Things like our Citrix environment, which is what we access our EHR and a lot of the central technologies. Staff who we do dual factor authentication, staff need to have a cell phone that they're willing to use. Can they use their personal one? Do we need to give people for accessing remotely through our environment, through our VPN, a device? Providing laptops, equipment in the house, really trying to figure out how to get a workforce that hasn't traditionally been someone... The IT staff specifically are more equipped for that. But really the business office staff, the people that as we have these shelter-in-place requirements by our governors, really need to get up to speed with being able to connect. The increased call volume from people who have never accessed the staff remotely. I think in the first couple of days as we moved this forward last week, we had probably 1,000 to 1,200 calls just specifically from staff who were having access issues or trying to figure out how to get their dual authentication processes set up.
So as organizations have more and more people telecommuting and doing those things, we're really challenged with getting... We still have laptops on back orders. I walked by one of our conference rooms here at the office. We probably have about 500-staff IT office, we've got about 50 of us in the building trying to coordinate and collaborate with the healthcare side, with the people providing care in the hospital, making sure that they have all of the things that they need.
So those cell phones, I had a meeting room full of cell phones that they're trying to get assigned out to people, and how do we assign them, and how do we ensure people who, as we get staff testing positive for the COVID-19 virus, how are we managing that and managing staff? So we've actually set up some teams where we can, if we have some pods that test positive, we can get them quarantined, but have some backups, especially with, again, a majority of our staff working remotely.
And also just looking at what the relaxation for the federal telemedicine technologies. We had some technologies in place. We're moving as many of those to virtual visits as we possibly can and leveraging the technology that we have here in place, and extending those licenses, and working with our vendors on licenses.
So those are the sorts of things that in the IT space that we're really challenged with, have been challenged with in the first couple of weeks, while not only spinning all these people to work remotely, but also supporting the caregivers. As we talk about creating a drive-up testing facility, what does that look like? What kind of technology do we have to put in place from a networking and infrastructure standpoint? Label printers, all the types of things that you need to actually have someone in the field doing clinical work. So those are the sorts of things that we've seen here at Davis and have worked through, and those types of challenges and trying to meet the needs in this time of crisis.
The HTM Perspective (00:28:31)
What is your action plan if you suspect one of your staff members has interacted with someone who has tested positive or has been around someone who has tested positive for COVID-19? Jeff, do you want to take that one?
Jeff Ruiz: Just a few a weeks ago, we would have a standard process where if that person was interacting with someone that had COVID, they would be on a 14-day quarantine list, and that has a 14-day quarantine, self-quarantine at the home. That has changed as of today. What the big indicator is now that here... We hear the story from Umberto. Italy seems like such a faraway place for us folks here in Michigan, but this virus is right in our backyard here. And now the process has changed where if you're showing signs and symptoms, that's when you are going to be on self-quarantine. Until then, you're still able to come into work. We have a screening process here at the hospital to help identify any risk on any symptoms, but that's the process that we have now, which has just changed.
We’re trying to do is minimize risk, and we are a TRIMEDX site, and we have a great leadership team and a great district in Michigan that we've had lot of conversations and try to strategize. And what we've developed at Holland is two teams, a team A and a team B. The first team is set up for Sunday through Tuesday. They have three 12-hour days. And then our second team is Wednesday through Friday. So we are actually, and our last day that we were completely together was last week, and now we're going to be in isolated two teams now until this crisis is over.
What that helps to achieve is, again, isolate, minimize the potential risk, and in the event if one of the teams is infected, we are able to have a backup team then that can take on that full responsibility and help support our clinicians fight and provide that care to their patients.
What are your guidelines or action plans if a staff member shows symptoms of COVID-19? (00:30:58)
Mark Manning: The guidelines for us at the Mayo Clinic is if somebody is showing signs or is definitely or has been exposed to somebody that tested positive is to refer them to their primary physician. They go through a verbal triage. If they are referred to test, of course they're sent to one of our testing facilities, and then sent home for self-quarantine until those results come back. We've got quite a testing facility set up now in Rochester alone, Rochester, Minnesota, the largest location. We have the ability to run 700 tests through a day and for our own uses for Mayo clinic. And then we're also north of 40,000 tests for the other regions across the Midwest. So we've got a very quick turnaround testing process.
The Mayo Clinic is a 65,000-employee organization spread across several states. The HTM department alone is 290 staff. We've come down to essential employees only on site and managing as needed with remote telework or being at home on call. That's quite a change for us of our HTM group. About 20% of them were able to go home immediately and telework, some of which were alternating home and onsite regardless. So we put that to full time. We took the remaining staff, most of which are technicians who need to put their hands on the stuff to fix it and we're at about 50% staffing on site now. That's expected to reduce even more with the plan to stratify and rotate staff, as needed, on site with a very clear set of expectations for response times for those folks who may get called in.
We've also shut down any elective procedures across the whole organization. We're focusing on COVID and COVID prep. We've built out areas that we're calling surge capacity areas, so taking units that were down for construction remodel or areas that could be converted and outfitting them with the needs of the equipment and technologies monitors and then we use … to bring the signal back to the EHR. So we're doing all those types of things in preparation along with shoring up equipment inventories, parts, and then really the way we'll have to strategically shift and change our priorities related to equipment maintenance and preventative maintenance and those types of things, if some of our staff start to turn up as infected.
What is your contingency plan to support the operations in case the HTM shop has to be locked down to a confirmed staff exposure? (00:34:44)
Jeff Ruiz: We had the two separation of teams. So we are set. If one of those teams were to be infected, the other would take over. So we have that in place right now.
Mark Manning: We’re specialized. The way the organization is set up with the main hub in Rochester, Minnesota, we're very specialized. We have 42 MRIs in one town. However, we get out into the regional health system sites where our biomed techs are more of the jack-of-all-trades. We've done our best with our leadership group, our front lines managers, of which there's, I think 15 now, we've asked them to identify a primary and a secondary person for every modality or type of equipment, especially those that relate directly to the COVID effort and the direction that I think we're going to be headed real soon. We've identified the primary and backup or primary secondary person. We do our best to make sure that they're not in the same location or working on the same things at the same time. Try to keep one of them at home.
We've also started to try to develop a plan to move people around if we needed to. If one of our health system sites, God forbid, also the folks who are able to support ventilators, are affected, then we might have to have somebody come from one of the other regions to provide backup support. So we're building this flow and the what-ifs with all the staff.
What is the biggest bang for the buck of what we can do and what we should do for our patients and staff as IT and HTM professionals? (00:36:34)
Michael Marchant: I think all of us have experienced this in different ways, is really the move to telemedicine and how do we support keeping our professionals safe, our physicians safe, and our patients safe. And I think that that move to telemedicine and the equipment necessary to provide direct feedback to our clinical staff on the condition of those patients. So what type of equipment can be deployed into a patient's home or being used by the patient that can give that real clear and direct feedback. I think the relaxation of those telemedicine rules that I talked about earlier are expanding people's ability to use it.
But really now what we need is a full feedback loop—is how do we get that information that's available for that patient that a physician needs real time to diagnose something. Think about the COVID. If you had the ability to take the patient's oxygen saturation and temperature and get that information back to you electronically via Bluetooth or something else. Again, that would be something that they could do without having to interact with a caregiver, that information could be transmitted back to the provider's office, and then we would have a better sense of what the next option of care is. So when you talk about bang for your buck is let's keep people safe and healthy, and if you're sick, how do we get information so that we can care for them the best way? And I think that some of that remote medical, having medical devices in the patient's home and being able to safely get information back for those caregivers is probably one of the big learnings. And I think something that we'll take and move forward with.
How are you handling the shortage of medical equipment parts? (00:38:32)
We've got a very large footprint of 3D printers, especially again in Rochester, Minnesota. There's north of 20 of them. And they're the big production ones. They're not the consumer models and we, actually, part of our team supports them. There's now a centralized effort with a very small group to take every request—and believe me, there's a lot of them from across the enterprise—to prioritize based on practice, leadership, guidance, what parts we should be looking at, potentially manufacturing in house with our own 3D printers and our local partners for injection molding and machine shops, versus what we're going to continue to try to source from other providers or, I'm sorry, resources manufactured outside of our normal. and/or what we're willing to wait on and take a risk as our supplies already start to get depleted.
We've looked at a lot of possibilities with the 3D printers all the way from PPE, so, face shields, an early-on effort we looked at an N95 mask with a replaceable cartridge, which has now been abandoned because the supply is starting to become available. So at this point we're focused on certain ventilator parts. And ECMO circuits, there's a lot of different things. So the priorities have yet to be defined as, yes, go deliver, start to produce this item. They've changed quite a bit in the last few days. However, we're ready to jump when we need to. We could produce a lot of these things if we have to, but we don't want to waste our resources on something that will all of a sudden not be needed. So we've struggled with that along with, of course, trying to source parts from our vendors as much as possible, initially.
What about from a small-hospital perspective, for facilities that may not have access to 3D printers? (00:40:41)
Jeff Ruiz: We’re fortunate that we are in the TRIMEDX district here, so we do have brothers and sisters out there that we can reach out to and tap on their shoulders for any excess parts they may have, but from our local level, the hospital has always done a very good job over the years of their capital purchases to have extra items. So we have built up the extra supply of vents, beds, and monitors, not only for a scenario similar to this, but also for other projects that we have that we're able to pull from. So the hospital has done a great job at positioning themselves to be as prepared as best they can.
I think one of the things that we also have to be concerned with, and this is kind of what you hear a lot in the news today, is you're hearing a lot of these vendors that are mass producing these ventilators. And I think I heard Umberto say this too about, we're going to have 2,000 ventilators donated here and here. It may make sense when those situations occur to work with those manufacturers to provide additional parts because I got a feeling if they're mass producing, they might be making some shortcuts there and, let's face it, with that amount of inventory that's going out, I don't think they have enough field service to support that. So, whatever we could do on the front end of those acquisitions to help maybe have some extra units, I think that would help very well in addition.
What does the hospital entry/exit procedure look like these days at your facilities? Are urgent care facilities in full force? What impact has COVID had on non–life-threatening medical care, for example, orthopedics, dental, etc.? (00:42:21)
Jeff Ruiz: We have five entranceways that are open, and then it's parsed down to three, then to one, based on the hours of the hospital. You walk in, they ask if you have any contact with anyone with the COVID and then they take your temperature. When you leave for the day, you're going to be going through the same questionnaire and you'll have your temperature taken again. From the physician standpoint, a lot of physician office hours have been reduced and we've actually seen we have two urgent care facilities that have been reduced to one. Our offsite rehab facilities have been closed as well. So what you're seeing this hospital and this community really trying to do is anything that is, we talk about that word, “non-essential therapy,” is being reduced and we're just trying to ramp up for this storm that's around the bend here.
Michael Marchant : When you talk about the entry and exit pieces, we've actually locked down the hospital to two entrances and you have to fill out the questionnaire and as well as get a temperature before. We've also limited visitors, so there's only one visitor, and really I think that depending on the unit they're limiting those as well. But one other interesting thing that you asked about was elective procedures, and there was actually an article written in the Bee because what you define as an elective procedure is up to question. And so our CEO actually sent out an email yesterday because of that article kind of breaking down the cases that people may have thought were elective but they're not really elective.
32% of yesterday's cases were related to trauma injury or physical repair, 24% were oncology related, 15% were to relieve immediate pain, and 29% were other things that were patient safety issues that possibly could have been delayed but were not for patient care. And the comment at the end really is there are certain things that you might consider elective, but for the patient that's receiving some of those procedures to alleviate pain or to remove discomfort, I don't think that they'll find those to be elective. So we'll have to be careful when we throw that term around, “elective procedure.”
So, yes, we're minimizing what procedures we do, and as we're impacted by an influx, our census is actually down, our ED visits are actually down because people are staying home. We expect that to change as the virus spreads, but for now we're making intelligent decisions and trying to care the best that we can for our community with some of these things.
Mark Manning: We have a zero-visitor policy. There is an exception process for that of course, we're not locked on that 100% but that's where it starts. Also, our leadership handed out 10,000 thermometers to staff who needed to be on site. We're expected to take our own temperature and record that twice a day. Our entrances and exits have been monitored with volunteers, some non–practice-type areas, who were quickly trained to have the questionnaire for anybody who wants to come in or out, and some of those people are simply not allowed in if they don't answer the questions the right way. And I would agree with the elective procedures. We're down substantially. I'm not sure about the volumes, but it's a shocking change throughout our square footage, very few people around. And that's expected to stay that way until further notice from the clinical leadership.
Is anyone using UV devices to disinfect N95 masks, goggles, face shields, etc., for reuse? (00:46:51)
Jeff Ruiz: Yes, we have the Tru-D system here at the hospital and we are using them for our COVID patient rooms. But we have not looked at doing that for the N95 masks. I've heard some things anecdotally out there, but I think this would be something where you would want to reach out to your local central service team and see what would be a best practice.
Danielle McGeary: those of you who are looking for sterilization and infection control resources, AAMI has made some sterilization and PPE standards free that are normally paid resources, available at www.aami.org/coronavirus.
What sort of system or plans can be put in place that prevent the level of impact that times like these have on production teams? For example, operations, supply chain, and inventory. (00:47:37)
Mark Manning: I think communication is key, of course. We get weekly reports from our supply chain, so the enterprise supply chain, that really helps us look at what we have and what we might have to communicate back to them from HTM to say the number looks healthy and I see that your number of days is translated to this many items. However, we know for a fact that because of the different things that we're doing now in a much higher quantity with COVID, that these will likely not last that long. So redefine those metrics that they're sending out and then get practice leaders involved to collaborate and really help redefine what some of those numbers used to mean related to supply quantities, because it's ... these things are game changers and just as simple as the excretory filters for ventilators. I mean, they're going to be a challenge for us and we know it.
What are other biomed departments or HTM departments employing to reduce spread: only critical PMs, work shifts to limit the number of people in shops, etc.? (00:49:48)
Jeff Ruiz: With our two-team processing, we've separated similar roles so we're able to have a good continuity of care, and that helps in meeting our PM requirements. Starting on a Sunday, and with our low census, and what we're seeing at our hospital, we're actually able to make some good work on our preventative maintenance PMs for the month. But I do know there's a lot of hospitals out there that, and I've seen this in the AAMI discussion groups about what... How should we handle some critical PMs as this thing starts to escalate? And I think we'll have to have some good conversations about what are the appropriate at risk teams and hear what, Joint Commission, DNV, and CMS are able to maybe come to a consensus on how to address that as we get ... as this crisis starts to expand more.
Mark Manning: We have north of 123,000 assets in our inventory that we maintain. So at some point with what's happening, I feel there's a high potential that we're going to have to reprioritize our work, especially if we start to lose some of our more highly trained people in the areas of COVID equipment support. So I've asked my very upper leadership group, who I'm blessed to have because of their experience and diversity, to look at a way that we could possibly redefine with a complete plan how we will choose to extend PMs, or even not PM equipment if it should come to that.
So I want a program that's built much like the AEM within our CMMS to track it very closely so we can report on it, etc. So there's a lot of thoughtfulness and logic built behind it. Again, if we have to do this and that plan should also—will also—include milestones or markers along the way that clearly define a recovery plan after all this starts to settle down. So we might have to make some difficult decisions and this isn't something we want to do, but I want my staff to be prepared for this.
Danielle McGeary: There's a lot of great information at the CDC’s website and just please make sure that whatever you do at your facilities, that it's coming from a reputable source and that you're running all suggestions on this call and that you hear through your environment of care committees, infection control, in other various committees at your hospitals.
Mark Manning: There's a lot of information out there. I've read as much as 24 hours on cardboard and as much as three days on smooth surfaces. So there's quite a broad spectrum. I completely agree with what you said, though. Everything should be treated like it's contaminated as part of our universal precaution.
If you are sending field service reps into ICUs for equipment support now, have you given those field reps instructions for cleaning and disinfection prior to performing their work? (00:53:42)
Jeff Ruiz: We all have vendors that actually will come into the ICUs. I'm looking more from a rental perspective. So here you already have a bed that potentially is from a COVID patient. Now that has to be picked up. And how has that ... is that individual going to be picking up a dirty bed? Our process is that our environmental services will clean that equipment. It will be ready for pickup and will be already clean for that vendor to take out of the hospital. But that vendor is also going to be going through that screening process, I mentioned before the question of temperature. So we think we've got a pretty good process set up to help minimize any potential cross-contamination because that's what you're really concerned with.
Will The Joint Commission allow leniency for PMs during this time? (00:55:27)
Danielle McGeary: Herman McKenzie, The Joint Commission’s director of engineering, standards interpretation group, had a conflicting engagement but provided us with an answer. The Joint Commission and all regulatory accrediting bodies, such as the DNV and other agencies, accredit on behalf of CMS. CMS sets the rules. So, PM completion is a condition of participation that is set by CMS and they cannot waver from that unless CMS issues a waiver. Since the president has issued a national state of emergency that gives CMS the ability to issue waivers for certain conditions of participation such as PM windows and whatnot. At this The Joint Commission is working very closely with CMS right now. They are aware of the issue and at this point there has not been any waiver granted. I stay in very close communication with Herman McKenzie and if anything changes or we get any different information, we will let the field know, but right now they cannot grant any variance because CMS has not issued any type of waiver in response to that. And, also, The Joint Commission and the DNV have halted all routine surveys for the time being, so none of them will show up at your facilities to perform a survey at this time.
What steps are being taken around the country to increase access to ventilators? (00:57:12)
Jeff Ruiz: There's a lot of manufacturers that are partnering. We'll say nonmedical manufacturers partnering with medical manufacturers, ventilators to help ramp up the production of that. Just knowing that that will cause a challenge as far as those vents are going to need to be inspected, tested. I think what Umberto had mentioned again before, so we're looking at quality issues here. It’s not just, ‘hey, we've got these 40,000 vents, 100,000 vents here, take them and have your way with them.’ There still has to be a structured process for that incoming inspection and making sure that they're operating properly.
Perspective from the World Health Organization (00:58:04)
What have we learned from our healthcare colleagues in China, Italy, and other nations that we should be aware of? What is the World Health Organization is doing internationally to help the HTM and clinical engineering communities?
Yadin David: The International Federation of Medical Biological Engineering, IFMBE, with the division of clinical engineering is working with World Health Organization hand in hand. We just have a phone call today about the urgency of doing things. And what we learned from clinical engineers around the world is that there is an avalanche of demand, do this, do this, do that. And there is a gap of knowledge. So the problem is where are the assets, where are the inventory, who produced, for example, the question about the ventilator that you have. Not only the ventilator, but circuits as well as the diagnostic kits. And there is proposals with CT that have AI that can detect the COVID disease, COVID-19 disease, and it's obviously putting demand on individuals that don't have sufficient capacity but have tremendous bombardment of requests by national response teams to do things right now. So the big issue is how do you find correct information about the product, not only who manufactures the product but who are refurbishing, because around the world in lower resource countries there is a lot of refurbishing that is taking place, not necessarily in high quality.
And lastly is how do you get the commissioning that is rapidly but yet effectively. So I think those are the three issues is inventories, refurbishing of the inventory, and the accessories. And how do you commissioning in a field service type hospital, not in a permanent location.