FEMALE SPEAKER: Welcome to Mayo Clinic COVID-19 Expert Insights and Strategies. The following activity is supported in part by an independent medical education grant from Pfizer Inc., and is in accordance with a ACCME guidelines.

MODERATOR: Welcome to the Mayo Clinic Critical Care Insights COVID edition. My name is Alex Niven. I'm a consultant in the Division of Pulmonary Critical Care and Sleep Medicine here at Mayo Clinic in Rochester, Minnesota, and also the education chair for both our division and for the independent multi-specialty critical care practice. The COVID pandemic has changed the way that we practice likely forever.

And the critical care community has been particularly impacted by the current pandemic. Critical Care Insights COVID-19 edition is intended for health care providers who are caring for patients with COVID-19 across the world in the ICU. Best practices to care for these patients have been rapidly evolving. And busy bedside providers, I know I have, struggle to keep up with the volume of information, especially given that the information sources that have been providing it are frequently less than rigorously peer-reviewed.

In response, Mayo Clinic has developed an Ask Mayo Expert COVID-19 task force that have collected and curated the available contents into a free public website under the Mayo Clinic Ask Mayo Expert COVID-19 Navigator. This source provides basically a curated site for best practice recommendations in the care of COVID-19 patients, developed collaboratively by an interprofessional stakeholder group of Mayo Clinic subspecialists. And this information is continuously informed by rapid literature scoping reviews performed by the current Center for the Science of Health Care Delivery.

This online CME course is designed to speed dissemination and implementation of these best evidence-based guidelines, best practice innovation, and provide discussion of ongoing clinical controversies that we face in critical care as we take care of these patients. These discussions will feature the original authors of the content that is available on Ask Mayo Expert, and allow them to discuss the evidence and best practices that they have used to provide these recommendations, and the why behind the information that they've shared.

We will be continuously updating this content as time goes on based on the available high quality evidence that comes through our rapid scoping reviews, and our evolving innovations and evolution of clinical practices within our own health care delivery platform here at Mayo Clinic. This initial CME offering consists of seven lectures, including topics from intubation safety, infection control, workflow considerations, navigating drug shortages, maximizing team performance, mindset training for the individual, humanizing critical care.

Respiratory therapy innovations, among others. We will continue to evolve this content as time goes on with new information on the epidemiology, virology, clinical features of COVID-19 patients, and also evolving recommendations with regards to testing and the care in addition to infection control considerations in this challenging population. We hope that you enjoy this work. This information has been provided as a series of Grand Rounds' presentations to our critical care community over the course of the last five weeks, and will continue to evolve over time.

Welcome to Critical Care Insights. I hope you enjoy our work. Good afternoon. Welcome to Critical Care Grand Rounds on Thursday. The format of our Grand Rounds remains the same from past weeks. So in terms of introductions, my name is Alex Niven, education chair for the subcommittee. And we'll go around the rest of the room. Julie, I'll start with you.

FEMALE SPEAKER: I'm Julie Schmidt. I'm a nursing education specialist, and I support our emergency response teams in one of our ICUs.

FEMALE SPEAKER: Christine [INAUDIBLE]. I'm the [INAUDIBLE] program facilitator.

FEMALE SPEAKER: Holly [INAUDIBLE]. I'm the NICU in [INAUDIBLE] respiratory therapist supervisor.

FEMALE SPEAKER: Good afternoon. Andrea Leonards, clinical [INAUDIBLE] specialist for Eisenberg 10-3-4, eICU, and I support the medical emergency response teams.

FEMALE SPEAKER: Good afternoon, everybody. Thank you for calling in. I'm Alice Gallo. I'm the chair of our Medical Emergency Response subcommittee, and I'm one of the critical care physicians here at Mayo.

MODERATOR: So welcome, guys. And thanks very much for taking the time to talk with us. So as with our recent themes, really our goal today is to talk about codes, RRT responses, how we've modified those processes and procedures over the course of the last month or so in light of the COVID pandemic, and some of the concerns that have come up with that. And then talk a little bit about the resources that we have available to get smart as a community, and then some anecdotes in terms of challenges or issues that have come up so far as we've implemented these things.

So I know as an individual, I am an consultant, which means I don't show up to a lot of these RRTs. And I don't know what was the processes and procedures, and I suspect I'm not the only one out there with that. So can we start telling, just describing a little bit who makes up the RRT team? Who makes the code team? And sort of what the common practices that you guys have emphasized over the years? So let's start with that.

FEMALE SPEAKER: I'll take that one then. So first important thing, things that have not changed is the reason for calling, if someone is worried about a patient, we're still here to help. That's the first point that I want to make clear right off the bat. So RRT team composition is a critical care fellow, or an anesthesia senior at Methodist, critical care fellow here at St. Mary's. The anesthesia consultant is the backup for them.

And so as an APP, as backup if we have multiple calls. We have a respiratory therapist that will come either from 10-3 or the MICU. And we also have an RRT nurse that will come either from 10-3 or the MICU depending on which hospital is activating the rapid response team. That team has not changed. We are favoring people to be scheduled for those roles who are N95 fit-tested and can use an N95. And we're going to go more into the PPE later.

For team, critical care fellow, both hospitals. An airway person that until two weeks ago used to be an anesthesia senior that was on call for both hospitals, and now at St. Mary's is the anesthesia consultant who comes from [INAUDIBLE]. And Methodist is the critical care consultant that comes from 10-3/10-4 with a code nurse that comes from CCU here. At St. Mary's comes from 10-5 at Methodist.

And the RRT nurse that comes from 10-3/10-3 at Methodist and MICU at St. Mary's. Those are our normal responding people. We have a pager going off so if someone-- For someone who is paging us for a question.

MODERATOR: So that latter part was the code team in terms of [INAUDIBLE].

FEMALE SPEAKER: So RRT and then code.

MODERATOR: I feel like there should be a multiple choice medical knowledge question at the end. So can you quickly describe a little bit, and we'll open this up to anybody in the group, for a typical workflow that happens for an RRT or a code. Because I know that we have very regimented protocols in terms of how we normally conduct these activities.

FEMALE SPEAKER: I'll take the RRT one.

FEMALE SPEAKER: Yeah. So for RRTs, it's dependent on location and what's happening with the patient so that the team will get a page, or the activation, then we'll go to the room. And provide a room nurse, or the primary service. We ask that primary service, can I be present? They [INAUDIBLE] been called if they come to the bedside, and ask for an [INAUDIBLE] and the situation going on with the patient.

They go into the room, assess the patient. Determine when intervention of the patient might be, what recommendations, and then disposition of that patient if they need a high level of care, if they need treatment there, intervention there, or PCU situation. So kind of a quick little overview of that.

MODERATOR: Perfect. How about codes?

FEMALE SPEAKER: Sure. I can take the code team. The code team is activated much the same way. The caller will dial 9-1-1, and the team will, from whichever hospital we're at, will immediately respond. And get to the patient, assess, and treat. Or assess and transfer, depending on if that's a true cardiopulmonary arrest, or an acute respiratory event.

MODERATOR: Perfect. And I think I'll say this because none of you guys will actually claim this, but this is one of the times where I can look from an outsider's lens because Mayo Clinic is my second home. I've been incredibly impressed since I got here in terms of the organization and structure of both the RRT team and the code system, and the really tremendous education program that Julie puts on. So now that I've embarrassed Julie, could you talk a little bit about the expectations in terms of training for that for a second?

FEMALE SPEAKER: Yeah, absolutely. So the training that we do for our medical emergency response teams, both code blue and RRT, is multidisciplinary training. And so the roles that Dr. Gallo listed, our team leaders for both code and RRT, as the physician group that APPAs who back up the RRT team as the team leader. Code nurses, RRT nurses, pharmacists, respiratory therapists all attend a multidisciplinary team training session at the Simulation Center.

And that is required for those roles before they can be a member of the these code or RRT teams. There is selection criteria amongst some of the groups. Especially the nurses, there is experience and requirements, and an interview process, and so on and so forth. And then depending on the level of education or experience of some of the other groups. The training is really focused on having the team work together.

Everybody comes with a tremendous skill set. Everyone knows ACLS, they are all ACLS-trained. But the course really focuses on how do they work together as a team, and it's about an orchestrated response. And then some of the variables like Christine alluded to, it's really about responding, how to communicate appropriately. Communication is the success to these teams. What their roles are, positions, understanding each other's roles, and then really being able to learn from each other and relying on each other as a team. So that's the initial education.

There's other components that go with it as far as some online content. The nurses do additional content as far as orienting on the unit, observing some calls, and then orienting into that role as well. Ongoing education for our team, a lot of it is communication-based. Either from Dr. Gallo, from the physician. And APPA side of things, [INAUDIBLE] from the nursing or [INAUDIBLE] respiratory, kind of multidisciplinary group as well. We do do forums for some of the-- Especially the nursing group as well.

So ongoing education, whether it's our stroke protocol, or the STEMI protocol, or issues or concerns that we've seen, theme over the years. We recently started to mock codes in our institution as well, which was a big win coming out of the critical care, thank you, for allowing us to start doing that. That's been something we wanted to do for a really long time in our institution. And mock codes are great because they let us really evaluate what is happening with the team and where areas of focus should be as well.

And so we've just begun that. But a lot of opportunities with that as well. And then there's a lot of online resources as well for the team on our MERs page, our Medical Emergency Response page. Also under critical care [INAUDIBLE], just our actual MERs page, not the COVID Corner page.

MODERATOR: Perfect. So you have a high-performing team, trained well, good process in place. The volume of events that you guys have on an annual basis?

FEMALE SPEAKER: Oh, annual basis.

MODERATOR: Well, just whatever numbers you have.

FEMALE SPEAKER: I have in my head about 200 per month, both hospitals. No, each hospital. I mean, like, 200, St. Mary's. 200, Methodist. Methodist numbers have been going up in the past three months, almost reaching 300. We still don't have enough data points to understand exactly why right now. Probably COVID has a little bit of a role in that because we're getting less patients here than average, and the [INAUDIBLE] practice has remained open.

Like Dr. Brown said because cancer care is time sensitive. So I'm guessing right now that that's one of the potential explanations, but I don't have more on that. And codes true cardiopulmonary arrest events, I would say about three or four per month in each hospital.

MODERATOR: Got it. So high volume activity by anybody's standards.

FEMALE SPEAKER: Yup, yeah.

MODERATOR: So talk to us a little bit about the impact of the COVID pandemic on RRT team and co-management processes. And if you don't mind, I would love it if you could march through some of the modifications and recommendations that you have on the COVID site, and give us a little bit of the rationale for why you made those recommendations.

FEMALE SPEAKER: So I'll start with this. So on the COVID site, if you have it open, we've really outlined why we've made the changes that we've made. And I think bolded right at the top is probably one of the most important aspects. It's that recognition that CPR and bag mask ventilation are considered high-risk aerosol-generating procedures. And therefore, warrant the N95 or [INAUDIBLE] in addition to the modified drop of precautions.

And the goal with the modifications that we've made to the medical emergency response teams have been related to that, and really about protecting our front-line staff and ensuring we still have the right resources to respond to patients in a timely manner as well. And so just what remains the same, as Andrea alluded to, how you activate the team. Getting that emergency equipment to the bedside quickly, applying that AED or defibrillator, whatever is in the work area while the team is en route, but not starting CPR or that bag mask ventilation without the appropriate PPE.

So some of the things that we have put into place as a team is both our rapid response team and code team are now carrying a limited amount of PPE for team members. So if they respond to a work unit that might not have that readily available, remember not all of our calls are in clinical areas, sometimes they're in parking ramps or hallways or lobbies, that type of thing as well. The code nurse who used to bring nothing to a cardiac arrest situation now brings a cart with two PAPRs, some limited PPE, and a LUCAS device, which is the automatic chest compression device.

I might as well talk about that now. So probably the biggest change that we've made to the code team is implementing, bringing a LUCAS, automatic chest compression device, to all codes outside the ICU. So currently, we have one LUCAS device at Methodist, and we have one at St. Mary's. The one at St. Mary's comes with the code nurse of the CCU, CICU. They had that in practice already for their CCU to cath lab practice, but it historically never left that practice.

Now that code nurse is bringing that LUCAS device to all housewide codes. The goal, and same with Methodist, these ICU 10-5 code nurses bringing a LUCAS as well. The goal of the LUCAS is to take place of a human doing compressions, and it really goes back to we're trying-- Two people, at least two people doing compressions. And it really goes back to trying to protect our staff by limiting the amount of people in the room and conserving PPE as well.

So with that, over the past couple weeks, all RRT nurses, code nurses, including the code nurses at Methodist who were not historically trained, and all of our team leaders both at St. Mary's and Methodist, have been trained in how to utilize that LUCAS device. And there's education on COVID Corner as well with more information about that.

FEMALE SPEAKER: So we need to give credit when credit is due. Julie and Andrea trained people on the LUCAS device in record time. It was pretty impressive. And I want to add something just in case we have any of our ED colleagues listening. The ED also has a LUCAS device that has been historically property of the ED, that has not changed. I just want to make sure that that's there because right now, we still have two LUCASs in the premises of St. Mary's.

But one is property of the ED.

FEMALE SPEAKER: We should also mention that the changes that I just outlined are specific to our adult team. Further down on COVID Corner are some more specifics to the pediatric practice. The LUCAS is not approved for the pediatric population, and they have similar modifications with bringing PPE. Some of the things Christine's worked with that group on, but their modifications are very slightly different than our modifications.

The other change that our teams have made is everyone on the team has a very specific role. But with trying to limit the number of people in the room, some of the roles have shifted a little bit, and the addition of the LUCAS. So who's responsible for the LUCAS, and then taking a responsibility off that person's plate, and shifting those roles around as well.

FEMALE SPEAKER: I would like to add something to the RRT team also. We also have a limited amount of PPE in our RRT team, I would call it luggage, because it's like a little bag. Luggage. Before we had none there, and now we have asked our team leaders to carry their own N95s. And all of the team members, I apologize, all the team members to carry their own N95s. And we also have a couple of sets of full modified droplet PPE in our RRT luggage right now.

So those have been changed. Before, we used to have extra bags of normal saline in case it was needed. Now we're just taking that from the floor then and providing our front-line amazing staff with PPE.

FEMALE SPEAKER: And one thing I want to add is Dr. Gallo outlined, I would say, those front-line responders from our code team who go in the room, have a specific role. They're the ones that we train, but there's multiple other disciplines that are part of the code team as well. Up to 20 people are patched into that code team pager. So we've really been trying to communicate that if those other individuals are not needed in that room that they really please should stay out of the room, decrease exposure, decrease PPE use.

And if the team leader needs them, then they could use that PPE and go in the room. Same with our pharmacy colleagues, trying to leave them outside the room with the code cart. Just taking the defibrillator in. So a lot of modifications like that.

MODERATOR: No, that's perfect. So if you're-- Let me just add one thing real quick. So I don't see a lot of questions yet on the Slido feed. So just as a reminder, the email that came out yesterday with Critical Care Grand Rounds has the QR code on it that you can just use your phone, or anything. That's the primary way to ask questions to this distinguished group. So as you're hunting through your email, I'll ask the question myself.

So when you-- So you're taking as little stuff in the room as possible. Do you have a place, a prescriptive place to put the defibrillator in terms of-- For both defibrillation and monitoring? Where does it go?

FEMALE SPEAKER: In the room, you're talking about?

MODERATOR: In the room. You're taking it off the cart, putting it in?

FEMALE SPEAKER: No, in the bed.

[INTERPOSING VOICES]

FEMALE SPEAKER: The feet of the bed.

MODERATOR: OK. So that's the preferred way, perfect. And then could you spend just a minute or two, there is a pediatric population that watches Grand Rounds, just outlining some of the changes in the peds protocol as well? And I've got it here if you want.

FEMALE SPEAKER: I'm happy to take, but please help me. So their team composition has not changed. They already had a very slim team to begin with, and that remains the same. Again, the LUCAS device has not been extrapolated to the pediatric population. LUCAS devices are not meant to be used in people who are too small. They were meant to be used in the average seven kilos, 1.7 meter tall person. And the LUCAS device will beep if someone is too small or too big for its use.

But since we wanted to take that stress out of our peds colleagues, we have agreed with Dr. Emily Levy, who is the representative at [INAUDIBLE] from the peds group that pediatric will not get the LUCAS. Their team composition has not changed, but they have also added PPE for their team to their little luggage too. I'm saying luggage because we just keep adding things.

MODERATOR: I like it. I like it. And so just to state the obvious as well. So if this is a closed unicode as well, I'm not going to have access to the LUCAS device just from an immediacy standpoint?

FEMALE SPEAKER: Thank you for asking that question. The answer is no. And the reason behind that was because as of now, I would say please correct me if I'm wrong in the numbers, but I would say 95% of our ICU nurses are N95 fit-tested, and fit an N95. So it would not be a concern that they would not have the appropriate PPE available. Our concern about having a LUCAS to go to house-wide codes was mainly because there were entire units that never needed to be N95 fit-tested.

They didn't care for TB patients before, for example. So we want to make sure that our front-line colleagues in those units were also protected, that they would not have to go into a situation that was not 100% safe for them. So that's why the LUCAS is still, for now, just house-wide. But the ICU's remain the same.

MODERATOR: Perfect.

FEMALE SPEAKER: And another concern also regarding ICUs, we do have patients with open chests, and a LUCAS should not be placed on someone who had a sternotomy within-- Depending on where you read, but within the past six to eight weeks. So that was also a concern regarding using that in closed units.

MODERATOR: OK, OK. Perfect.

FEMALE SPEAKER: And I want to add something. If my friends in neonatal medicine are watching, we do have a beautiful link in the COVID Corner [INAUDIBLE] Critical Care [INAUDIBLE] that is dedicated fully to neonatal. And Dr. Emily Levy also helped us put this together, and I would encourage you to go there. I confess that I do not remember all the neonatal changes by heart.

MODERATOR: I forgive you just this once.

FEMALE SPEAKER: Please go there. There is a whole neonatal [INAUDIBLE] baby [INAUDIBLE].

MODERATOR: So personally, I've laid hands on a LUCAS device exactly twice since I got here. So that's not something that I'm super familiar with. So the slides that are posted there are awesome. If we want to practice or get experience with the things because the changes that we have, how do we do that?

FEMALE SPEAKER: So you can notify me, Julie. And we would have to do the training either on 10-5 where the LUCAS is or over in the CCU. And I have been continuing to do that over the past couple of weeks as the fellows have been rotating so frequently through the MICU in 10-3. But we only have the two in there. The two in [INAUDIBLE] are the two that we would train on. So more than happy to give hands-on, or we have some colleagues who can help with that as well if I'm not available

But more than happy to do. [INAUDIBLE] overview. There is good videos linked in the LUCAS education as well.

FEMALE SPEAKER: And very important things about the LUCAS in case there are concerns raised regarding transmission and cleaning. So the device is cleaned the same way that you will clean a PAPR motor, that you would clean the [INAUDIBLE] with the fancy wipes. And the suction [INAUDIBLE] is one patient use only. So it's tossed, and the straps are also one patient use only. So they are also disposable.

And the LUCAS requires a special set of pads, and those are also one patient use only. And that was also, again, something we looked into before deploying the LUCAS device just to make sure that even in that pandemic, it was safe to be used for our entire patient population. Would it be OK if I invite Holly to say something about this awesome oxygen tent that Todd Meyer and Holly's group came up with?

MODERATOR: Absolutely.

FEMALE SPEAKER: For transportation?

FEMALE SPEAKER: Yeah.

FEMALE SPEAKER: So with all the talk of the AGPs and how can we reduce exposure to staff and others, we created-- It's an oxygen hood tent basically. It's an 18 by 18 hood, and we use it-- it's only used for BiPAP patients, BiPAP, CPAP patients if we're going to transport them. And so it fits nicely over the patient. The circuit of the CPAP or BiPAP would hang out underneath.

And then we would attach suction with a filter to the top, and that creates that negative air. And so it provides safe transportation for everybody, not to have that extra [INAUDIBLE].

FEMALE SPEAKER: To be used by the discretion of our respiratory therapist, colleagues, and the teams. And again, from ED to ICU's transportation, and patients who are non-invasive and need a test or something like that are COVID-positive, or under investigation.

MODERATOR: Yeah. I'm just thinking. So I saw a picture of that come across my email about a-- Well, within the last week. Has that been posted? If not, we probably should.

FEMALE SPEAKER: Yes.

MODERATOR: OK. OK. So we'll make sure that we've got a link to that readily available so people can see that.

FEMALE SPEAKER: Each workroom, each RRT workroom has access to those.

FEMALE SPEAKER: It has been posted, I believe, last Thursday or last Friday.

MODERATOR: OK. OK. I'll find it and make sure that it's readily available on the COVID Corner. So we have two questions that have come in that I'm going to sort of treat simultaneously. Well, we've got three actually, but two of them go together. So I think there is-- I think it's fair to read in between the lines of these and say that there is a little bit of concern with this idea of PPE first and then treat your patients because that's very much not what we typically do in codes.

So the first question that I'll ask you is the role of the floor team in code activations. So should they don PPE and get to work? Or should they wait for the code team to arrive? So what's your answer to that?

FEMALE SPEAKER: So that's the latest update to the COVID Corner with those bullets that we added to the top about what remains the same. Calling for help, getting their emergency equipment, and responding to the patient in the appropriate PPE. And I forgot the second part of the question.

[INTERPOSING VOICES]

FEMALE SPEAKER: So yes, we do want them to don the appropriate PPE with their N95s if they have them, and respond appropriately to the patient.

Now, that having been said, there has been a big-- Probably the biggest concern that we have heard. But in light of that decision that was made about the high-risk AGP, CPR being a high-risk AGP, a lot of work has been done to fit tests. Like Dr. Gallo said, many, many units, and ensure there is some PPE available so at least one person can go in. What we're asking from the MERS perspective is that we limit the number of floor staff that go in now.

So if one nurse can don PPE and get in there, and start CPR until the rest of the team can come, that is truly ideal. We're still seeing three of our nursing staff go in, four, five primary service. By the time the team gets there, there's already 10 people in there, and it's just that increased risk of exposure and overuse of PPE. So yes. If they don't have the appropriate PPE though, they can still respond to the patient, assess, defibrillate. We just do not want them to start CPR or bag the patient.

MODERATOR: OK, OK.

FEMALE SPEAKER: And I would just like to invite-- And we do understand how hard this idea is, we do. We fully understand and we fully agree. But I would like to invite all our colleagues to think in the following way. If you protect yourself first, you're going to be able to help more people throughout the day, throughout the next 15 days, throughout the next month. If you expose yourself and if you go in running towards the fire without the appropriate PPE and you get infected, or you get exposed, you are out for 15 days.

And for those 15 days, you can't help anybody. So I would invite people to think it this way. And again, please, please know that what we want is for everybody to be safe. We sincerely appreciate what everybody is doing. We just wanted to be safe.

MODERATOR: And I think that covers the top question here talking about nurses who aren't fit-tested not going into the room. Bottom line is we're aggressively fit-testing people so that we have first responders who can go in because time of [INAUDIBLE] is really a big issue when it comes to survival. So I think that addresses that question. So there's two other questions that are, I think, a little bit complicated.

So asking about if patients in cardiac arrest are still being considered for ECPR with ECMO, I don't know the answer to that question at all.

FEMALE SPEAKER: Yes. The answer is yes. We still, if it's someone who would otherwise, COVID or non-COVID, be considered for ECMO, we would still activate our ECMO colleagues and go through their algorithm. The ECMO algorithm, it's also in the Critical Care in COVID Corner. There is an ECMO algorithm that has been reviewed by Dr. Bowman, I believe, last week. So it's also updated. But ECMO is still on the table for COVID, non-COVID patients.

MODERATOR: Perfect. And then another question that just came in, the role of unconventional options like leg-raising or sternal thump. And whether the floor teams should think about those things.

FEMALE SPEAKER: So that's a fantastic question. COVID or non-COVID has fell off ACLS algorithm in 2010.

MODERATOR: Yeah. 16 joules, I think, was one article that I read about, the delivery for that.

FEMALE SPEAKER: So COVID or non-COVID, thump has fallen off ACLS algorithm in 2010. So we would discourage. And if you think about it, it's also a high AGP because you will be counting on someone's chest. Even though it's just once, I would say it's still an AGP. But again, it fell off a ACLS algorithm a while ago. Leg rise, it would not be an AGP, I don't see a harm in that. And it's a bolus, sure.

MODERATOR: And I guess the other question that I wanted to ask before we move on to some specific examples was actually a question that came up last week when we were talking about airway management issues, is sort of the role or lack thereof of bag valve mask ventilation during codes, recognizing the emphasis that the [INAUDIBLE] has on high quality CPR first and foremost in this setting. So you've already addressed this a little bit at the beginning, but I'd like to get into that in a little bit more detail if that's OK.

So should we be bag valve-masking? If so, what are the considerations with that? And I guess perhaps a little bit about airway management in a setting of a code.

FEMALE SPEAKER: Is it OK to clarify?

MODERATOR: Sure.

FEMALE SPEAKER: We're talking about a code that is happening in a room, and we're going to take care of the patient in that room.

MODERATOR: So I think, let's say to be specific with a scenario, this is a code that happens on the floor. The patient is in cardiac arrest. The team response comes in, is PPE'd up, what do you do?

FEMALE SPEAKER: So since the team is PPE'd up, you would attend to that code as you normally would. As long as everybody in the room has the appropriate PPE for high aerosolizing-generating procedures, proceed as you would. Once the patient has their airway secured, they have a filter, a viral filter, and they can be transported to whatever they are going if [INAUDIBLE] was obtained. So far, as of this morning, there was not an employee that has been documented infected while using the appropriate PPE.

So if everybody is using the appropriate PPE, we'll transport the patient with the a viral filter and we should be OK. If we're talking about transporting someone who is like, maybe intubate, maybe not, then I would say two things to consider based on bedside assessment, based on clinicians' assessment, based on the team comfort level. I would say, personally, that either put a simple closed face mask and run, and make sure that then you protect the airway in a safe, controlled environment.

Or if they are full code, intubate them right then and there, and then transport them with a protective airway with a filter.

MODERATOR: Perfect. Yeah. Holly, I'm going to ask, could you just review a little bit the respiratory therapy guidelines again with regards to filter placement both during bag valve mask ventilation, and if somebody is intubated or are non-invasive? We covered that a few weeks ago, but I think that's probably worth reviewing again.

FEMALE SPEAKER: We've added filters to all of our ventilators, inspiratory and expiratory site. The same thing with our non-invasive BiPAPs and our CPAPs. Every anesthesia bag and the code bags will have a filter with it now. Every room with an anesthesia bag has a filter with it. So if we need to bag a patient, there should be a viral filter in place.

MODERATOR: Perfect, perfect. And there's really nice pictures on the COVID Corner website, and all of those different areas in terms of explaining where the filter should go. So a couple of other comments that have come in. Very complimentary comments in terms of both the presentation, the amazing work that you guys have done in terms of thinking through this. And there's another question, which I'm not sure if you're ready to read the tea leaves here or not.

But it's recognizing the importance of high quality CPR. This question is whether or not you envision the LUCAS device becoming part of the standard practice after this pandemic.

FEMALE SPEAKER: Good question. At this point in time, I think no would be the answer. We're using it now for the fact to conserve PPE and to make sure our front-line staff are safe while doing high quality CPR. So I guess at this time, no.

FEMALE SPEAKER: I think it's important also that we highlight that while the LUCAS device is a good alternative right now so we can protect more people, as many colleagues as we can, the LUCAS device also comes with serious potential risks. Mainly because, again, please let us know if you want to see it. But for those of you who have not seen it, it has its own backboard that is attached to the device, but is not attached to anything. So the LUCAS device will move to arrange CPR.

And if someone is not paying attention-- If the entire team is not paying attention to the device, it will move as down as to a place where it would potentially fracture spleens and rupture pancreas. So again, that's our main concern right now. We are in a situation that we need to protect our front-line colleagues. And we felt like the LUCAS device was bringing more benefits than potential risks.

That's the reason why Julie trained all the team leaders, the RRT nurses, and the code nurses from both hospitals to make sure that at any given situation, there are two people in the room that can potentially be paying attention to the LUCAS device. And readjusting it if it moves downwards in someone's body too much. And again, in the units, we still have enough people who can appropriately have PPE to help with chest compressions. So I second Andrea's answer. It would be right now, hopefully no.

MODERATOR: Perfect. So one more question about the LUCAS device and I [INAUDIBLE].

FEMALE SPEAKER: Love it.

MODERATOR: So the question here is with regards to team member training and the formal program that you have. Especially thinking about the new academic year coming up, has LUCAS device-training been incorporated in the standard code and ERT team member training?

FEMALE SPEAKER: So great question. Knowing that we're on the heels of the new academic year, we will have to evaluate if the LUCAS is still in place come July 27 when we officially train the new group. We will have to incorporate it if we're still using it on July 27. So to be determined.

MODERATOR: And I lied. One more question about LUCAS devices.

FEMALE SPEAKER: We love it. We were expecting the LUCAS to be super popular.

MODERATOR: Question about a neck strap to help stabilize the device.

FEMALE SPEAKER: Yeah.

MODERATOR: So you're using that.

[INTERPOSING VOICES]

FEMALE SPEAKER: Yeah. And Dr. Gallo alluded to part of the training is about the mechanics, but so much is about the risk if it's not placed appropriately. So it's about how to get it in place, and then ensuring that it is in the right place. So the team carries, yes, the neck strap to help it prevent from migrating down, and they also carry a skin marker. So once it's in the appropriate place, they'll mark the top and bottom with blue markings so then everyone on the entire team can watch it during the event to make sure it's not migrating because it can go right, left, up, down.

It can go all different directions, but we do have all the safety [INAUDIBLE] in place.

MODERATOR: And then there was another question that actually has just been taken off the queue but I'll ask it anyway. So just a question about prone patients and CPR with prone patients. Can you guys just review?

FEMALE SPEAKER: I can speak to that. So yes, you can perform CPR on prone patients. And I believe they're also on the COVID Corner is a diagram of the appropriate positioning. And the question comes up about when to do it. So if you are in your patient's room and there's plenty of people that you can quickly place your patient back into the supine position and then start CPR, I would recommend that.

If you're having to wait for colleagues to arrive to help supinate your patient, you could do prone CPR for two to four minutes until your help arrives. And it also depends on the presenting rhythm as well.

MODERATOR: Perfect.

FEMALE SPEAKER: Can I add something to that?

MODERATOR: Yeah.

FEMALE SPEAKER: if we have any of our Mayo Clinic Health System colleagues listening to this, the Ask at the Mayo Clinic Health System site is that proning CPR is not started, that you flip them first in the Mayo Clinic Health System. But here at Mayo Rochester is exactly what Andrea said.

MODERATOR: Perfect.

FEMALE SPEAKER: It's not written yet in the actual proning guideline, but the adjunct is on COVID Corner.

MODERATOR: Perfect, perfect.

FEMALE SPEAKER: And Andrea and [INAUDIBLE] also have an amazing video on how to prone patients that is in the internet, and it's also in the COVID Corner. So please take a look at that. The medical ICU has not used [INAUDIBLE] since 2015, and we have been doing an amazing job.

MODERATOR: Yeah. Yeah. So we've got those resources linked both into COVID Corner and on the CCM education website right now. So lots of places to go for that. So I wanted to take a little bit of a break from questions and turn this to practical experience, sort of how we've seen these guidelines roll out. And some specific sort of common themes that have come up because I know you guys are reviewing the episodes as they occur to-- Maybe you could share that wisdom and the lessons learned with the broader community here.

FEMALE SPEAKER: I think one of the-- I can speak to one of the things we've observed most recently. Again, as Dr. Gallo and Julie had alluded to before, crowd control is still a significant concern in making sure that we're keeping each other safe. And one of the specific events is making sure as the team responding, now we're coming with all of our appropriate PPE ready to go in place.

But one example is there was CPR done prior to the team arriving and they had [INAUDIBLE], and the team not having that awareness. And so that is an AGP. And so that room that that patient's in would have to be treated as such. And so when you're in there, you need your appropriate PPE in place. So things like that, just making sure that-- To try to limit people in the room, I think, is the biggest thing.

MODERATOR: So again, just to reiterate but I think this is an important point, you have a patient who's unresponsive. You're going to have somebody who's going to put on their PPE rapidly, and I assume in the anticipation of this, they're going to have airborne precautions. Right? They're going to go in the room with an AED, they're going to assess that patient, and then do the standard things that we think about in that setting.

That's really the message that you want to put across there. So crowd control is always an issue with codes. I would imagine sort of a complicated dynamic here is the needed personnel, and how the needed personnel come in and out of the room when it comes to procedures that are performed. IO access versus venous access, and things along those lines. Labs that are drawn, and things along those lines.

Do you have any recommendations in terms of how to orchestrate that for the people who are outside the door? And how to control the flow back and forth? Because I'd imagine communication is a little bit more of a challenge.

FEMALE SPEAKER: So one thing that we did put in place that we forgot to mention with role modification is the team leaders will draw the blood if need be. So the [INAUDIBLE] team or our lab colleagues should remain outside the room. They can help with supply collection and knowing what the team leaders need to do, and so on and so forth. And then handing those into the room with the team leader being the one who physically would draw the blood during the event to eliminate, again, one more person needing PPE and getting exposure as well.

FEMALE SPEAKER: So the pharmacist staying outside with the code cart and meds, and handing meds. We also have asked that EKG and things like that stay outside. And yeah, pretty much it.

FEMALE SPEAKER: I think the big thing is just relying on that team leader, that they need them, that they're outside waiting for them to come in in their full PPE. And just kind of getting that prompt from that team leader running that code.

FEMALE SPEAKER: And I think even it's before the team gets there is where we're seeing a lot of concerns with crowd control. So even when the team is responding, sometimes they're running five, six people. We're hearing people are going because they want to see the LUCAS in action, which I don't think we've actually used it in the past two weeks that we've put it into place. So it has come, but hasn't, thankfully, been needed yet.

But just thinking from that primary service perspective, or that first responder, there is an issue with too many people going in the room. And then what we've observed is droves of people standing right outside the door. And so what if we truly have a true CPR event with high-risk AGPs, we're going to have significant exposure if we don't get this under control from a crowd control standpoint.