FOR HEALTHCARE PROVIDERS IN LMICS Project ECHO Etiquette - - PowerPoint PPT Presentation

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FOR HEALTHCARE PROVIDERS IN LMICS Project ECHO Etiquette - - PowerPoint PPT Presentation

Mar 24, 2023 483 likes •1.09k views

COVID-19 TELE-EDUCATION SERIES FOR HEALTHCARE PROVIDERS IN LMICS Project ECHO Etiquette Foundation of love and respect (Respond kindly rather than react if you disagree) It is everybodys responsibility to keep ECHO a safe space

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COVID-19 TELE-EDUCATION SERIES FOR HEALTHCARE PROVIDERS IN LMICS

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Project ECHO Etiquette

❖ Foundation of love and respect (Respond kindly rather than react if you disagree) ❖ It is everybody’s responsibility to keep ECHO a safe space ❖ Test your equipment ahead of time (both audio and video) ❖ Introduce yourself before speaking ❖ Avoid making noise (i.e. potato chips, shuffling papers, whispering, cell phones, loud bags, etc.) ❖ For questions during Q&A session use the chat box ❖ Mute microphone when not speaking (Left bottom corner of your screen) ❖ If you are to speak, speak remember to unmute before speaking and speak close to the microphone ❖ Position webcam effectively to show your face if alone or to capture the whole group ❖ Have a light source from the front (Avoid being backlit) ❖ IT issues? Send a message through chat/email

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COVID-19 and Implications for Surgery

COVID-19 TELE-EDUCATION SERIES FOR HEALTHCARE PROVIDERS IN LMICS

  • Dr. SaeedahAsaf, MBBS

Associate Professor and Head The Department of Anesthesia, The Children's Hospital & Institute of Child Health, Lahore, Pakistan Assistant Professor, Arkansas Children's Hospital Little Rock, AR, USA

  • Dr. Mark Newton, MD, FAAP

Professor, Anesthesiology and Pediatrics Vanderbilt University Medical Center (VUMC) Nashville, Tennessee, USA Head, Department of Anesthesiology AIC Kijabe Hospital, Kenya

  • Dr. Christopher Chanda, MMed

National Coordinator, Anesthesia Services Ministry of Health, Zambia Head, Department of Anesthesiology and Critical Care Consultant, Pediatric Anesthesiologist University Teaching Hospitals, Zambia

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Disclosures

I have no financial conflicts

  • f interest to disclose
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Objectives

  • 1. Describe the Impact of COVID-19 on surgery in LMICs
  • 2. Explain the healthcare worker safety issues related to the

Operating Room and COVID-19

  • 3. Describe some possible algorithms for surgical systems and

COVID-19

  • 4. Discuss a Case Report at the hospital level in Pakistan
  • 5. Discuss a Case Report at the national level in Zambia
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COVID Changed the World: How are we going to face this challenge?

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COVID -19 Education Community: >27 Countries

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COVID and Healthcare Workers

COVID-19 Dashboard by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University (JHU)

  • 1. China’s National Health Commission,

by early March, 3300 HCW’s infected and from local media, 22 have died

  • 2. In Italy, 20% of responding healthcare

workers have become infected

COVID-19: protecting health-care workers www.thelancet.com Vol 395 March 21, 2020

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COVID Spread to SE Asia and Africa: April 2020

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Mapping Risk Factors for the Spread of COVID- 19 in Africa

Africa Center for Strategic Studies, April 3,2020

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Estimation of Surgical Procedure need by world regions

Lancet Glob Health. 2015 Apr 27; 3(Suppl 2): S13–S20.

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Operating Rooms in South-SE Asia and Africa

Global operating theatre distribution and pulse oximetry supply: an estimation from reported data Luke M Funk, Thomas G Weiser, William R Berry, Stuart R Lipsitz, Alan F Merry, Angela C Enright, Iain H Wilson, Gerald Dziekan, Atul A Gawande Lancet; Vol 376 September 25, 2010.

>45,000 Operating Rooms

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Will the surgical burden allow us to stop

  • perating?

Infectious and Parasitic Diseases Surgical Procedures Lowest Median Highest Region of the World Western Europe Andean Latin America Western Africa Percentage of Surgical Burden 0.32% 3.0% 35.3% Maternal Conditions Surgical Procedures Lowest Median Highest Region of the World Western Europe Andean Latin America Eastern Africa Percentage of Surgical Burden 2.1% 7.5% 20.4 %

Estimated need for surgery worldwide based on prevalence of diseases: a modelling strategy for the WHO Global Health Estimate Lancet; Vol 3 (S2) April 2015

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Ti, L.K., Ang, L.S., Foong, T.W. et al. What we do when a COVID-19 patient needs an operation:

  • perating room preparation and guidance. Can J Anesth/J Can Anesth (2020)
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COVID-19 and the Risks Posed to Personnel During Endo-Tracheal Intubation

  • Severe Respiratory Distress inpatients from COVID-19 : 8 % will require

intubation and mechanical ventilation

  • Aerosol-generating procedures will generate more infectious respiratory aerosol

than coughing, sneezing, talking, or breathing

  • No general definitions: intubation, extubation, manual ventilation,

bronchoscopy, tracheostomy

  • High viral loads of SARS-CoV-2 are found in sputum and upper respiratory

secretionsof patients with COVID-19

David N. Weissman, MD1; Marie A. de Perio, MD2; Lewis J. Radonovich Jr, MD1

  • JAMA. Published online April 27, 2020
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Exposure to a Surrogate Measure of Contamination From Simulated Patients by Emergency Department Personnel Wearing Personal Protective Equipment

  • Where are the droplets spreading during intubations?
  • Scenario 1: 74 yo male with respiratory distress in ED who then needed an IV

line and intubation, during the management the patient coughed twice, patient intubated by most experienced doctor, one other doctor, one nurse pushing drugs, one nurse recording the vitals and drugs

  • Simulation 2: pediatric patient with secretions on nose, mouth, upper chest,

hands and similar respiratory distress and intubation.

  • Methods: 8 total participants, UV light post scenario and pre-removal of PPE,

with photography of the participants and video recording

Oren Feldman, MD1; Michal Meir, MD2; Danielle Shavit, BSc3; et al

  • JAMA. Published online April 27, 2020.
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Droplet Spread via Simulation: Conclusions

Oren Feldman, MD1; Michal Meir, MD2; Danielle Shavit, BSc3; et al

  • JAMA. Published online April 27, 2020.
  • Fluorescent markers found on

Uncovered skin, shoes, neck

  • PPE needs to cover the neck and the

removal of the PPE material was not tested which could also induced droplet spread

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When evaluating patients with concern for Coronavirus Disease 2019 (COVID- 19), providers should wear a surgical mask, gown, gloves, and eye protection. This is a (WHO) and (CDC) recommendation.

Conserve PPE:

  • Do multiple tasks when caring for the patient

such as BP, VS and all preoperative history

  • Limit the numbers of non-essential personnel in

the ORs.

  • Do not take off N-95 between cases
  • Wear a normal surgical mask on the outside of

the N-95

  • Always wear a face shield over your N-95 when

with patients

  • Construction glasses or googles work to cover

eyes, if needed and clean outside with bleach

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Make your own Face-Shield:

  • Clear Plastic PVC Binding/ Report Covers (A-4), Pack 100
  • Masking Tape, Pieces of Foam
  • Adhesive Glue
  • 8 mm Elastic Bands in rolls
  • Total cost: 8/$1 USD

PPE: Clear Plastic Face-Shield

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PPE: N-95 What can we use? Surgical Masks do not block the virus

Filtering Face Piece Grades 2,3 (FFP 2,FFP 3) Euro Standards = N-95 Mask

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N-95 Reuse Ultraviolet Germicidal Irradiation

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How to do this in LMICs? Very Expensive UV Light

https://www.nebraskamed.com/sites/default/files/documents/covid-19/n-95-decon-process.pdf

https://www.youtube.com/watch?v=P5HsKmTTa-c

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How to Prepare the Anesthesia Machine?

Viral Filtration Efficiency (VFE) rating of 99.9% is commonly used Reusing filters is not recommended but you can, if you have limited supplies and not necessary to place

  • n inspiratory limb
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Intubation and COVID

Consensus guidelines for managing the airway in patients with COVID-19 T. M. Cook, K. El-Boghdadly, B. McGuire, A. F. McNarry, A. Patel and A. Higgs; Anaesthesia 2020, March

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Intubation in LMICs: Algorithm Adjustment

Capnography not available, use clinical signs Use stethoscope, post ETT cuff inflation, and visual with uncuffed pediatric ETT No video-laryngoscope, no problem Have clamp available to clamp the ETT, if disconnect the circuit

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Intubation Box

https://www.youtube.com/watch?v=e-wOGnr0OLk Raj Gupta, MD Associate Professor Anesthesiology VUMC

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Intubation Box: PVC Pipe and Shower Curtain

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Intubation Assist Devices

  • Dr. Raj Gupta and Dr. Matt McEvoy VUMC Dept of Anesthesiology
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COSECSA Surgery Guidelines

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Guidelines on Cancer Treatment During Pandemic

A War on Two Fronts: Cancer Care in the Time of COVID-19. Annals of Internal Medicine. 31 March 2020

Alexander Kutikov, MD; David S. Weinberg, MD, MSc; Martin J. Edelman, MD; Eric M. Horwitz, MD; Robert G. Uzzo, MD, MBA; Richard I. Fisher, MD

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Surgery Algorithm with Testing Available

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PPE USE in the Operative Environment

  • Suspected (PUI) or Confirmed COVID Positive
  • Wear N-95, Face Shield, Gown, gloves for the entire case
  • After extubation, the drapes and disposables are removed by those with PPE in the room,

then you wait 30 mins until you clean with PPE on the cleaners

  • High Risk Procedure (Bronchoscopy, airway, sinus surgery)
  • Use all PPE as above for the entire case and N-95 used for the entire day
  • Other Procedures and Intubation and Extubation
  • Anesthesia team limited numbers, most experienced person intubates
  • All other personnel outside the room, only enter once ETT in place and cuff inflated.
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PPE Use in the Operative Setting

Credit: Matt McEvoy. MD Brent Dunworth, CRNA

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Guideline for PPE Use in the Operating Room

Credit: Matt McEvoy MD Brent Dunworth, CRNA

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Recommendations for COVID in the Operating Room

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The Children’s Hospital: Lahore, Pakistan

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Case Study: Discussion Points

  • Establish safe Perioperative Covid-19 patient flow
  • Procurement and distribution of PPE on-going need
  • Training of Staff: PPE Donning/Doffing
  • Define Intraoperative care standards
  • Duty roster
  • Guidelines for pregnant and over 60 years
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Perioperative COVID Response Team

Administration Response What’s App In-Hospital Group Formed Identify Four Lead Anesthesiologists Leaders Assign One Lead Anesthesia Tech or Assistant

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COVID-19 Care Guidelines in Lahore, Pakistan

Liaison with surgeons & admin: criteria for surgery? Semi elective/urgent/emergency Set up screening of patients

History illness, sick contact Temp, SpO2

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ED/ICU/Ward to OR, recovered in OR, back to isolation/ICU Use OR with least overlap with other patients Established clear pathway for Covid-19 positive/PUI perioperative care

No negative pressure Air exchange non- functional OR Closest to entry/exit

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Minimize Staff & Surfaces in the OR

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Procurement and Distribution of PPE in Pakistan

Funds for PPE: Hospital, Companies, Crowd Funding Beware: Fake PPE, Price increases, no delivery

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Challenges

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Staff training

Donning/Doffing Cleaning of Operating room, laryngoscope Sign up sheet & Buddy check system Identified master trainers Cognitive aids each OR/ Changing area

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Hidden Opportunity

Infection Control is now a Priority What do you need to do in your hospital to improve in the area of infection?

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Zambia: Case Study

COVID-19 UPDATE 2nd MAY, 2020 Confirmed: 119 Deaths: 3 Recovered: 74

  • Central southern Africa and landlocked.
  • Population of 17million
  • Size – 290,587 sq. mil.
  • Classified as lower middle-income country
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Emerging Crisis

  • Emergency/essential surgery and preserving precious HR

commodity.

  • PPE availability and provision of emergency and routine

anesthesia.

  • Impact of quarantine on anesthesia workforce in low resource

settings.

  • Cancellation of ALL electives and impact on the already huge

surgical burden and long-term outcomes.

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Current Issues Decisions

  • Delay in diagnosis and emergency surgery.
  • Impact of community transmission and

current WHO COVID-19 diagnosis.

  • Lack of guidelines on management of

emergency surgery and COVID-19 suspect in low resource settings.

  • Post-Anesthesia care for COVID-19 suspect –

isolation

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Intervention Steps

  • Setting up regional ICUs with designated COVID-19 operating Rooms
  • Designate Operating rooms for COVID-19 suspect patients requiring emergency

surgery

  • COVID-19 and emergency Obstetrics
  • Setting up of a resource center for training at the National Teaching Hospital
  • Infection prevention and control
  • Airway management for COVID-19 suspect or confirmed
  • Training OR management.
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Strategic Plan

  • Urgent needs assessment of equipment and

infrastructure for A/E, HDU, ICU and theatres.

  • Human resource and commodities.
  • Establish the required number of HDUs and ICUs to matching

infrastructure and human resource.

  • Designate COVID-19 OR especially COVID19 suspect requiring

emergency life saving surgeries.

  • Formulate Guidelines on perioperative management of

suspect/confirmed COVID-19.

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Operating Room Locations for COVID + Cases

  • One set for Emergency obstetrics at WNH – University Teaching Hospitals.
  • The main isolation center – has operating rooms for confirmed and

suspect.

  • Hoping to find a strategy for district hospitals
  • Need to confirm location of recovery
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Critical Care Strategy for the Country

  • Critical care assessment capacity
  • Facility assessment - Assessment tool adapted from the WFSA facility assessment

tool.

  • Human resource Mapping and capacity.
  • Quantification and procurement
  • Training for COVID – 19 response
  • District level training
  • Tertiary level training
  • Setting up regional Intensive care Units – level II/III
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Zambia: Regional ICU’s with Bed Numbers

CHINSALI ? Ndola-8 CHIPATA/ KALINDAWARO 7 LUSAKA - 22 Mongu ? Livingstone-8

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Critical Care Leadership and Referral

COVID-19 response Critical Care Team

  • National coordinator/MDT
  • Regional ICU in-charges/MDT
  • District in-charge
  • Triaging and Referral from District

level hospitals to Regional ICUs.

  • Triage tools – using oxygen

saturation life box

  • Referral guidelines.
  • Transfer protocol.
  • Communication and Transport
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Education to Upskill Healthcare Workers

  • Critical Care Trainings – District level training
  • Infection prevention and control
  • Donning and doffing
  • Optimizing Oxygen Therapy where there is no Ventilator.
  • Oxygen delivery Devices
  • Triage Tools
  • Airway management strategy for COVID-19.
  • Tertiary level training – expanding capacity
  • Basic introduction to Mechanical Ventilation
  • Management Specific to COVID-19
  • Air way management for COVID-19 suspect and confirmed.
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Questions?

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Join our WHATSAPP GROUP!

WhatsApp Chat

If you have more questions following this session, we have created a WhatsApp chat group for sharing relevant information about caring for COVID-19 patients. A link has been sent to your email with the registration link. Please reach out to ECHO@assistinternational.org with any other questions.