We want to welcome you to

our presentation regarding

Maplin for the

strategic and tactical plan

to respond to covid-19.

I want to know Franco and I

am the chair for critical care

at Mayo Clinic, Florida.

I also lead quality for

our institution and

in the topics that we will discuss

today, I have no conflicts

of interest.

The only relevant

disclosure really is our passion

to do quality improvement and

to drive academic

excellence.

But again, that's

not any financial

conflict

regarding our learning objectives.

So we will discuss today

the lessons that we

learn from our response

to covid-19.

We will compare the differences

in critical care, planning versus

preparedness and how that shaped

the forces in our

clinical practice setting

at the Florida campus and

some of our other enterprise

clinics.

We also describe the role

that our treatment review panel

has had to define our

therapist, our research involvement

at Mayo Clinic Firda

and we will spend some time

talking about a few selected cases

that are really

were complex in

the sense of their clinical

presentation and how we manage

those covid-19 patients.

We want to give you a framework

that our

institution is had three hundred

four bed hospital

and the

mix of patients

tend to be about 30 percent

non elective admissions

versus about.

A 60 percent

that are urgent or emergent

missions, so as we were preparing

for covid-19, we really

didn't have an exact idea

of how many cases we would have.

So around that time, the

picture that you can see depicts

how our team got

together before we had any covered

cases.

And we started to test how

we would move a patient, for

example, from the

emergency department

to the floor and then to the ICU.

So we were really doing drills

before we had any covid-19

cases.

Are the planning.

It's understanding what your

capacity is in terms of space,

in terms of staff supply

and the resources and

not only the resources that we have

in our local hospital, but also what

resources are around the community

in our area and which

one of those resources we could type

in type of need.

So it's very different to

plan for conventional care like we

describe versus

having a plan for contingency

purposes in the sense of

once we get more ICU patients that

we're used to handle

versus what will be our plan

if we really got into a crisis

situation in which all

our ICU were utilized

and all our ventilators, for

example, were utilized to how we

would handle that.

So part of the planning process, for

example, you can see our

ICU teams in this other picture

just testing different equipment,

thinking about how do we

put the ventilator screens

outside the rooms we pump

outside the room so as

to better response to that

crisis.

We also had to plan

in terms of staffing.

So this is an example of

the plan that we made beyond

the usual ICU teams.

At the beginning of the pandemic,

we decided to have a dedicated

covid ICU team.

The advantage of that principally

was to be able to manage or continue

our usual operations.

That includes a lot of transplant

on immunosuppressed patients

and also at the same time trying to

meet patients with

covid-19 and manage them.

There was a lot of concern about

inpatient transmission

to the staff and to other patients,

so we felt having a dedicated team

would be best and we

did include that for the first few

weeks. We also had

onco providers that were

particularly including teams

from anesthesia as a backup for

procedures, but also thinking

about the possibility of

Egmont, including the perfusionist

and the more specialists

to help.

The other very important piece

of the preparation for covid-19

was the redeployment of

many of these telemedicine

strategies.

So we had very few technology

to be used for telemedicine inside

the hospital.

We did have one of the robots

that is depicted here that

was frequently used in the ICU,

but we quickly but

a number of tablets

and Intel installed software

in them so that we could use those

tablets.

That's a two way communication tool

in the rooms

so that our teams could not only

interview patients, but

also, you know, zoom

in to discuss

how they were feeling, what changes

have in their symptoms.

And that was a very important

way to minimize the number of

providers that were

exposed to those patients.

And we also

had to deploy particular teams

to set up family meetings

that could be carried out to give

updates to the family

while the patient was in our

hospital.

We want to start,

you know, showing the

example of our first

case that came to the hospital

and then became hospitalized.

So this patient had come from a

recent travel and is now

a year ago from Europe.

And he had the typical

symptoms presented to the

ADA and was found

to be hypoxic.

He was treated in the hospital for

a couple of days with oxygen,

but then he was able

to discharge home, went to air,

and he actually had a very good

course.

So that case

started to tell us,

yes, is here and we need to

get better at planning other things.

So, for example, how to safely

discharge a patient on oxygen,

off oxygen,

how can they be quarantined while

they're discharged?

And what Redflex symptoms we should

recommend for them to follow

to the site, to return to

the hospital or call the

providers a very important

thing that our institution

did was to set up an

ambulatory

telemedicine practice in

which we have providers

at telemedicine care for

patients.

The hospital medicine team was very

instrumental in developing

a model that

would occur daily to discuss

the covid-19 cases that were

admitted, including a

multidisciplinary team of

infectious disease providers

as well as ICU providers.

So we can better decide

resource utilization and

management for those patients.

And the hospital team really start

to work on how to scale up their

operations to respond to covid.

Another key element of the response

for covid-19 has been preventing

our staff from

getting infected.

And that was particularly true

before vaccines were available

and we knew very little about

transmission.

So at that time, we had very

clear delineation

between the different levels

of precaution, but

most importantly, always

educating our staff in terms

of the utilization of masks

and the utilization of eyewear

to prevent transmission, as well

as reinforcing

the use of

hand hygiene

standards.

The

other important piece regarding

transmission is understanding the

level of risk and the level of risk

has to do a lot

with the type

of procedure that is being

performed. So in

conversations with the Infection

Prevention and Control and

our pulmonary department, we

define which procedures where

low risk for our generation

and which procedures are

high risk for our generation.

So based on that, we created

guidance that

was given to all providers

regarding the level of protection

that would need to be used.

For example, high risk procedures,

including in ninety five eye

protection and poppers,

for example, for intubation or

CPR, tracheal suctioning

or bronchoscopy, versus

some other procedures of medium risk

and similar procedures of low

risk that would not require such

a level of

protection.

We also deployed

different tools for the teams,

including, you know,

mirrors for them to check their

PPE before entering the room.

And there was a lack of evidence

regarding how many particles

will be generating, for example, in

different procedures that outside

the room. So we had to do some quick

research evidence

based on the type of of

the need so we could define

the distance between different

equipment and measure exactly

the particles that could be

generated in that activity

so as to better categorize the

degree of risk.

The other thing that our teams did

was to stand up for

the quickly a

testing protocol.

And that testing protocol, as you

can see in some of these pictures,

included some.

Testing that was done

under a tent when the patients

were still wearing the Beatles were

still in their vehicles, and

that's when they found to be

one of the safest ways of testing.

But also, we have to continue to do

a lot of these testing before

patients came to get care.

So even patients that were

asymptomatic were

tested, especially.

We anticipated that they

will undergo a surgical procedure

or a proper procedure,

and that proved to be fairly

effective.

So, for example, in the month of

July, we

did a study to identify

any possible case of inpatient

nosocomial acquired covid.

Unfortunately, you know, we

followed those patients during their

hospital stay and also we tested

them seven days after discharge.

And during that time, we did not

find any case of

in hospital transmission of

covid.

Importantly, we had to

help our providers to again

define depending on the

infectious status that the patient

had, because some of the patients

were actually proven covid versus

some were suspected and some

some were negative, you know,

defined based on the degree of

of or covid status

of those patients and the degree of

our generation that was anticipated,

we could help them then define

what testing would be necessary

or also what

PPE should be utilized.

It's important to say that in order

for our practice to

ramp back up after the initial

slowdown, we had to really

ramp up the testing.

And we we're fortunate to have

in-house testing for

the PCR and

that allow our surgical

procedure practice to restart

fairly quickly.

And that also helped us have a

nearly undetectable level

of transmission in our campus.

That being said, in the past year,

we have had a number of cases

that have been flagged as

potentially a commonly acquired

about nine throughout the year.

For those, three were found

to be still comedia choir

three. What one determinant.

And there are actually three cases

that were proven to be

hospital acquired in this past

year.

The key element

for our staff was to also

help them feel safe and

decrease the level of exposure.

So the know few ways

that we did that is

we started

a process in which they

could lose, were treated, all of

them as an aerosol generating

procedure.

And not only that, but some

of that was

automated. So we did

acquire a number of automatic

chest compression devices

to be used so that

we can minimize the exposure

of some of our staff during

cold situations.

We also did research to include

different barrier mechanisms

to try to minimize the aerosol

generation and the particles that

would be produced.

And we actually start

to practice.

With the ventilator screens outside

the room, the baby pumps

outside the room and also

the dialysis that CRT

machines outside the room and

the majority of the audience being

nephrologist would appreciate that

a lot of the patients did

end up with acute kidney injury.

So having the ability to

manage that CRT machine and change

the fluid from outside the womb

proved to be very beneficial.

We also deployed a different

technology that

was based on UV light.

So we had fortunately

already purchased

a significant number of these

devices covered

for infection prevention control

itself.

But we were able to deploy

these robots, particularly

to the covid areas, to do

a lot of that terminal cleaning that

has helped us with the

terminal room

cleaning after discharge.

In terms of testing,

we

as we mentioned, we kept that

drive through testing,

nasal swab, and we've

continued to do that for all the

surgical cases that are

planned.

And we you, depending

on the time of the year, we've got

different levels of positivity in

that drive through testing

anywhere from single digits to

actually teens or 20 percent

in some times of the

year. So it's been important

also to test for other organisms,

including RSV and influenza.

No, this is very significant

to to to

explain that compared

to what we anticipated.

We have very, very, very, very

few cases of flu

this year, in fact,

towards the end of the flu season.

We almost didn't.

We stopped testing for flu because

it was just a test that

was just coming back negative each

time.

The I think what that

goes to show is that the influenza

virus itself doesn't trust

me as much when all the appropriate

precautions are being utilized

to prevent.

Another case we

wanted to share with you was

our second,

you know, covid admission, and this

was actually an ICU case, that

the story doesn't end as well as the

first one.

This one was an octogenarian

patient with no significant medical

history, but he was coming

from a facility I don't know.

His poker partner

was the first complication

identified in our city.

And based on that, this patient did

develop covid with significant

hypoglycaemia, shock,

pericardial effusion.

He was really managed with,

you know, a lot of our

machines, including paralysis,

nitric oxide.

He developed renal failure, but

we had conversations with the

family and they were not

interested in having

him continue to escalate

care or undergo dialysis.

A patient ended up dying in

our ICU.

So we really

had to learn fairly quickly how

to manage these patients depending

on their comorbid

conditions and their age.

So one of

the very important

tactics that we had

to manage the census in the hospital

was to look at to

which patients needed to be

admitted or not, because

initially, because of the

concern and we didn't have enough

testing, we ended up meeting a

significant Peche a number of

patients for a period

of time. We had about 30 or 40

patients just waiting to be

tested with respiratory symptoms.

So that proved not to be very

effective so quickly.

We learned to do the testing

as an outpatient and to only admit

those patients that had significant

amount of oxygen requirements.

So that allowed our senses to come

back into a much more

manageable setting of our own

teams.

And throughout the pandemic, we've

fluctuated, but mostly we've been

in the teens to

20 range.

This what you see in the screen is

the algorithm that we apply in

the emergency department to

investigate for other causes of

respiratory symptoms.

But really also, if nobody

suspected were identified

to understand what

their exceptional

saturation oxygen saturation

is. And based on that number, we

can better determine who

should be admitted or not.

And some of these patients who

do not get admitted can go home

with oxygen put under

close monitoring, but

by our covid

virtual clinic.

And they do get a number of devices,

including an iPad for

vital signs,

Bluetooth enabled pulse oximeter

and other things to to

help their care.

We also made some changes to the

structure of our hospital.

So the picture you see on the screen

is when we start to change

the airflow in some of our units.

So for the past year, really,

two of our units, one in

the ICU on one of the progressive

care unit, they have been fitted

to be negative pressure

rooms. And that's important

to minimize the transmission

or their association outside the

room and the transmission

to our staff.

The.

There were many things that we

learned with covid, so one of

the important things that we have to

really optimize was

the concept of airflow

and negative pressure rooms.

So particularly because a lot of

these aerosol generating procedures

needed to be done in a negative

pressure environment so that,

again, we could minimize

the exposure and the risk to

our staff.

The story is quite good there

because, of course,

we had staff who was positive,

but the majority of those cases were

actually community acquired and

hospital acquired.

We wanted to highlight also

the role of our Treatment

Review Panel for Treatment Review

panel, these multidisciplinary

team that was put up since

early on.

And initially we were meeting

several times a week.

Lately we've just been meeting once

a week. But the objective of this

group is to stay abreast

of the latest literature

related to covid-19 and

provide recommendations to

the physicians who are at the

bedside making decisions

to provide recommendations to them

regarding the best therapies

and strategies to manage these

patients. So you can see some

of the usual inpatient testing

that has been recommended.

We did develop a particular

anticoagulation algorithm that we

will discuss in more detail.

We also have very standard

hyperkalemia management algorithms.

But as far as

covid therapy itself, so

it depends on the condition of the

patient.

Majority of them will get severe.

And if they start to have

increased functional requirements

and if they're in the first week

of their disease process,

they receive high titer convalescent

plasma either.

Beyond that, first week is really

not recommended to to

give the convalescent plasma

patients who are much more

symptomatic are not only

hypoglycemic, but also to Kubelik

or requiring high amounts

of of oxygen.

Those patients are also on

dexamethasone.

So they receive that standard for 10

days. And

there's a number of other trials

that we have participated

on or participate on

currently to test

in covid and

also patients who end up in

the ICU there as being

other medications

trial, for example.

Looking that the

advantage then also of these

two men review panel is that we've

also provided recommendations for

the management in the outpatient.

So we did participate in the

Cochrane or Colchicine trial

in the outpatient world.

And that paper still in progress.

But the initial

data is very

beneficial in terms of decreasing

inpatient admissions and also

decreasing mortality.

So more to come was that paper comes

out.

The treatment

review panel also

tasked our Punti coalition

subcommittee to come up with

recommendations, particularly to

the management of the

covid.

So I'm not going to go into all the

details of the algorithm,

but suffice it to say that

all the patients receive trommel

prophylaxis unless there's some

particular contraindications.

And then we apply a diamond

level to try to define which

patients should undergo

further testing, for example,

with ultrasound

of extremities,

with doctor to look for clots or

even in some cases that we suspect

of pulmonary embolism to undergo

a CTP protocol.

It's also important to say that in

the intermediate dimer

levels, for example, between

the

higher and

of normal to the three

thousand range in those patients,

if there's suspicion, we also check

other markers like fibrinogen and

Wollaston, Graffy, so we can

then determine if

those are showing signs

of hyperconnected ability and

if that is the case.

A lot of times we also do the

ultrasound or CETP protocol

depending on the severity.

So the advantage

here is that only those

patients who have a proven

thrombosis then get therapeutic

anticoagulation.

So we're not giving therapeutical

people unless a clot

is identified.

So that's different from what was

done, for example, initially

in New York when they had the

first set of

cases.

The other piece that is quite

important about these management

recommendations.

Is that in those patients who are

being discharged?

We also provide

recommendations regarding which

patients should receive long

term prophylaxis

for six weeks or more and

what they should receive, because

we've seen that there's an

increased number of activity

even after covid patients are

discharged.

The other algorithm

to to preview this calls is

that of the hypoglycemia

management.

So in terms of hyperkalemia

management, we have

relied very heavily on hyphenates

or canula, particularly

with nitric oxide, those

I have seen with good

results.

That has allowed us to minimize

the number of patients requiring

non-invasive ventilation and

intubation.

That being said, it is true that not

everybody responds to high flow

systems and we

have to sometimes provide

non-invasive ventilation.

We've done that with the typical set

ups, but also we've used

the hyperbaric

hood or helmet to

help with the comfort of

the high flow system or positive

pressure.

But the truth is that if a patient

does not respond to those measures

within 24 or 48 hours,

we move we move pretty quickly

to intubation.

And once we intubate, we can look

depending on their elastomers

and phenotype.

We can decide who can

be treated with a low

pip and

inhale therapy like nitric

oxide for which patients

need the usual,

you know, classic

A.D.s phenomenon.

And then those patients tend to need

higher numbers

of people.

Importantly, in the majority

of these patients, we do look

for the possibility of a

coma. So every time really we

integrate a patient, we move

to a decision making or

two to the side.

Is this a patient who in

Home EC, more could be indicated

or is contraindicated?

So, of

course, patients who have malignancy

or advanced age, more than 70

or have irreversible conditions,

organ failure, some conditions

are not considered or patients who

have been on mechanical ventilation

for a prolonged period of time, more

than one week.

So really, if if those

conditions are not present fairly

quickly, we try to move

towards Tecmo.

And in the past year,

we've had about 10

patients from

covid-19.

We've only lost one

of those patients.

And we can talk more about some

of their success that we've had with

with the actual therapy

in our institution.

In terms of communication,

I think this has been extremely

important to to maintain the

the the

outcomes in our institution.

So, you know, it's really hard

when you have no visitation

for certain patients with covid.

So you have to maintain a good

relationship with the family using

Zoome or other

connected care type technology,

but also, you know,

advocating for for palliative

care in certain cases that we feel

that kind of life care is more

appropriate.

Our staff has

really been through a lot.

Like in all other hospitals

in the world with covid so

really trying to keep them

motivated,

finding wellness opportunities,

creating different environments

so that they can refresh

and reenergize has been

very important.

The other thing to talk about is

Corbett has brought up a lot of

innovation. So these are just

a few examples of our team

testing robotic arms to

adjust IBE pumps

or silencing alarms

in the monitors or even adjusting

the ventilator.

And those activities

has been published.

We did not move any of these

activities to actual clinical work

because the transmission was

ended up being much lower than we

anticipated to our staff.

So it was safe for them to remain

in the room and do these changes

themselves in

terms of outcomes, we want to

really celebrate that

involve Mayo Clinic institutions.

We've been able to maintain a

mortality rate in the

single digits, and that's

independently of the

race

or gender of this individual.

So it's been a really good story

for the Mayo Clinic in terms

of mortality.

So this chart shows

the mortality in single digits

for all those positive cases

that have been identified to drive

through or test in

the next graph shows more about

the mortality

in the inpatient setting.

So the mortality in the inpatient

setting has varied

across the site and

across the different ethnicities.

But in reality, the

average mortality has been

low going

on average about

10 percent.

And what it's also important to

say is that even

though the initial mortality was a

little bit higher in the

teens lately, that mortality

has dropped to around

eight percent.

It's also important to say that

we've tracked, for example, a number

of cases after

discharge to try to identify

the mortality after discharge

and that it's also very low, about

seven point eight percent.

But in those cases, we did identify

a number of mortalities

by thrombosis.

That's why our indications for

trommel prophylaxis became

more relevant after discharge.

So this is

a smooth average length of stay

curve that

goes from March.

Of 2020 until the end

of 2020 and beginning

of twenty one, and you can see

that as the time has gone by,

our lenses, they have decreased

from an average of about 12 days

to really about five days.

That can only be

accomplished by a couple

of interventions, including

early discharge to our

home hospital or advanced care at

home,

as well as the

admission of only patients

who have a

Eappen oxygen requirement.

But also important is that we

also track the number of

readmissions and the absolute

number of covid readmissions

was a little bit higher when we had

the waves

or surgeons, for example,

during the wintertime.

But the absolute number

being high, the rate remained

particularly

stable.

This is that graph

that I was mentioning about

the peaks in

the readmission

rates, and they tend to

be associated with the surges,

but overall have been very

manageable.

So in closing, we wanted

to share a third case with you.

So this is this case is very

near to our heart because it's

a patient that was admitted

on January of twenty one

and has spent about three months

with US patients, was

initially placed on Dbag from

January 17th to February 7th

and had made significant

improvement, unfortunately, after

being of actual patient

again develop significant refractory

hypoglycaemia.

So on February 14th, the

patient was restarted.

Make more on the lung transplant

team was consulted and

they evaluated these patients and he

ended up listed for lung

transplantation.

Fortunately, he remained very

active, even though on

XHTML his

renal function remained fairly

stable and patient

did undergo bilateral lung

transplantation on March

25th.

And in this picture, you can

see the day of

the transplant with the Egmont

Cannulas and.

Then the day right after transplant

with the new lungs and

a significant

improvement in his chest x ray,

you can also see in the bottom part

of the slides they

planted and transplanted lungs.

So we that we wanted to close and

see that, you know, the success

of our management and response to

my team has been really

the product of a

multidisciplinary

work, a lot of consensus

driven decisions, and that

includes anywhere from patient

to patient.

And that has been associated with

lower hospitalization rates

and lower mortality.

These best practices, we feel, could

serve as a template to

continue. The response seems

to be no cases have decreased

with vaccination, whether they have

not completely gone away.

We also have been able to decrease

through time the average length

of stay there

readmission rates and

mortality.

So even

if we.

If we control for

Apache's corner another comorbidity,

the standardized mortality ratios

have been modestly

decreased or

reduced compared to other

institutions.

So we need to

acknowledge that times have changed

and nothing will be the same after

covid.

But we can honestly

say that our teams and our

institution is coming

out stronger from from this

pandemic.

So we want to acknowledge

many, many of the members of

our critical care team and also our

transplant team in

in Lakeland, Florida.

We also want to thank

the nephrology

and the kidney transplant team for

the invitation to this

symposium, to shareholders

information with you.

We hope that you find it valuable.

And if there are any questions or

comments, please feel free to

let us know via email.

Thank you very much for your

attention. Have a wonderful

day.