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.

ALEX NIVEN: 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-- struggled 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 sub specialists. And this information is continuously informed by rapid literature scoping reviews performed by the Kern 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.

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

CHRISTINE WOLF: I'm Christine Wolf. I'm the RRT program facilitator.

HOLLY BEHRNS: Holly Behrns. I'm the MICU and 10-3, 10-4 respiratory therapist supervisor.

ANDREA LEHNERTZ: Good afternoon, Andrea Lehnertz, clinical care specialist for Eisenberg 10-3/10-4 eICU, and I support the medical emergency response teams.

ALICE GALLO: 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.

ALEX NIVEN: 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 a consultant, which means I don't show up to a lot of these RRTs, and I don't know always 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 ROT team, who makes the code team, and what the common practices are that you guys have emphasized over the years.

So let's start with that.

ALICE GALLO: 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 is 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 N-95 fit-tested, and can use a N-95. And we're going to go more into the PPE afterwards-- 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 7 DNE. And at 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 an RRT nurse that comes from 10-4, 10-3 at Methodist, and MICU at St. Mary's

Those have not-- those are our normal responding people.

We have a pager going off. Someone is paging us for a question.

ALEX NIVEN: So that latter part was the code team, in terms of composition?

ALICE GALLO: Correct, so RRT and then code.

ALEX NIVEN: I feel like there should be a multiple choice medical knowledge question at the end.

So just can you quickly describe a little bit, and we'll open this up to anybody in the group, a typical workflow that happens for an RR or a code? Because I know that we have very regimented protocols in terms of how we normally conduct these activities.

JULIE SCHMIDT: I won't take the RRT one.

CHRISTINE WOLF: Yeah, so for RRTs, it depended on location and what's happening with the patient, so that the team will get a page for the activation, and we'll go to the room and provide the room nurse, or the primary service-- we ask that primary service be present, if they haven't been called, if they'd come to the bedside, and asked for an S-bar on the situation going on with the patient.

We enter the room and assess the patient and determine what intervention the patient might need and what recommendations. And then, disposition of that patient-- if they need a higher level of care, if they need treatment there, intervention there, or PCU kind of situation. So kind of a quick little overview of that.

ALEX NIVEN: Perfect, how about codes?

ANDREA LEHNERTZ: 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 it's a true cardiopulmonary arrest, or an acute respiratory event.

ALEX NIVEN: 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 my 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 you, Julie, could you talk a little bit about the expectations in terms of training for that, for a second?

JULIE SCHMIDT: 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 are team leaders for both code and RRT, are as the physician group, that APPAs who back up the RRT team as a team leader.

Code nurses or 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 these code or RRT teams.

There are 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 warranting 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, us from the nursing, or Holly, respiratory, kind of that 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, themes over the years.

We recently started 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 our areas of focus should be, as well.

And so we've just begun that. A lot of opportunities with that, as well.

And then there's a lot of online resources, as well, for the team on MERS page-- our medical emergency response page, also under critical care end, but just our actual MERS page, not the COVID corner page.

ALEX NIVEN: 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?

ALICE GALLO: Oh, annual basis?

ALEX NIVEN: Well, just whatever numbers you have.

ALICE GALLO: I have in my head about 200 per month-- both hospitals. No, each hospital. I'm sorry, I mean like 200 at 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 HemOnc 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.

ALEX NIVEN: Got it, so a high volume activity by anybody's standards. So talk to us a little bit about the impact of the COVID pandemic on RRT and code 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.

JULIE SCHMIDT: So I'll start with this. 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 N-95 or PAPR, in addition to the modified droplet 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 frontline 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 is, like Andrea alluded to, how do 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-- which we 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. That one at St. Mary's comes with the code nurse of the CCU-- CICU.

They have 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 house-wide codes. The goal-- and same at Methodist, the ICU 10-5 nurse, code nurse, is 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-- or 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.

ALICE GALLO: We need to give credit where 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 LUCASES in the premises of St. Mary's, but one is property of the ED.

JULIE SCHMIDT: 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 have been 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 is responsible for the LUCAS, and then taking responsibility off that person's plate, and shifting those roles around, as well.

ALICE GALLO: I would like to add something to the RRT team, also. We also have a limited amount of PPE in our RRT-- 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 N-95, all of the team members-- I apologize-- all the team members to carry their own N-95s. And we also have a couple of sets of full modified droplet PPE in our RRT luggage right now.

So those have been changes. Before, we used to have extra bags of normal saline, in any case it was needed, now we're just taking that from the floors, and providing our frontline amazing staff with PPE.

JULIE SCHMIDT: And one thing I want to add, is Dr. Gallo outlined those-- I would say those frontline responders from our code team, who go in the room and have a specific role, they're the ones that we train. But there's multiple, 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.

ALEX NIVEN: No, that's perfect. So if you're-- I'll ask-- actually, so 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 a question myself. So when you-- so you're taking as little stuff in the room as possible. Do you have a place, a proscriptive place, to put the defibrillator, in terms of for both defibrillation and monitoring? Where does it go?

CHRISTINE WOLF: Like in the room, you're talking about?

ALEX NIVEN: In the room-- you're taking it off the cart, and putting it in--

CHRISTINE WOLF: No, on the bed.

ALICE GALLO: The bed, the feet up in the bed.

ALEX NIVEN: OK, so that's the preferred way. Perfect.

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

ALICE GALLO: I'm happy to take for [INAUDIBLE]. 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 7 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. Amelie Levi, who is the representative at Morris from the peds group, that pediatric would 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.

ALEX NIVEN: And so, just to state the obvious as well, so if this is a closed unit code, as well, I'm not going to have access to the LUCAS device, just from an immediacy standpoint?

ALICE GALLO: Thank you for asking that question. The reason for-- 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 N-95 fit tested, and fit N-95, so it would not be of 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 N-95 tested. They didn't carry it for TB patients, before, for example. So we want to make sure that our frontline 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 has remained the same.

ALEX NIVEN: Perfect.

ALICE GALLO: And another concern, also, regarding ICU, is we do have patients with open chests. And the 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 them in closed units.

ALEX NIVEN: OK, perfect.

ALICE GALLO: And I want to add something-- if my friends in neonatal medicine are watching, we do have a beautiful link in the COVID corner MERS critical care imp that is dedicated fully to neonatal. And Dr. Amelie Levi 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.

ALEX NIVEN: We'll forgive you just this once.

ALICE GALLO: Please, please go there. There is a whole neonatal [INAUDIBLE].

ALEX NIVEN: So, personally, I've laid hands on a LUCAS device exactly twice since I got here. So that's not something 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-- the changes that we have-- how do we do that?

JULIE SCHMIDT: So you can notify me, Julie, and we would have to do the training either on 10-5, where the LUCAS is, or up 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 and 10-3.

But we only have the two, and they are the two in practice of 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 a little demo and overview.

There is good videos linked in the LUCAS education, as well.

ALICE GALLO: 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 would clean a PAPR motor, that you would clean the ZOLL, so with the fancy wipes.

And the suction cup is one patient use only, so is 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 a 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?

ALEX NIVEN: Absolutely.

ALICE GALLO: For transportation.

HOLLY BEHRNS: So, with all the talk of the AGPs, and how can we reduce exposure to staff and others, so we created-- it's an oxygen hooded tent, basically. It's a 18 by 18 hood. And it's only used for bi-pap patients, bi-pap, c-pap patients if we're going to transport them.

And so it fits nicely over the patient. The circuit of the c-pap or bi-pap would hang out underneath. And 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].

ALICE GALLO: To be used by the discretion of our respiratory therapists, 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, that are COVID positive or under investigation.

ALEX NIVEN: You know, I'm just thinking, so I saw a picture of that come across my email about-- well, within the last week, has that been posted? If not, we probably should.

ALICE GALLO: Yes.

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

ALICE GALLO: Each work room, each RRT work room has access to those.

HOLLY BEHRNS: [INAUDIBLE]

ALICE GALLO: It has been posted, I believe, last Thursday or last Friday.

ALEX NIVEN: 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 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 between the lines of these to 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?

JULIE SCHMIDT: So that's the latest update to the COVID corner, were those bullets that we added to the top about what remains the same. Calling for help, getting their emergency equipment, and responding to a patient in the appropriate PPE.

And I forgot the second part of the question.

ALEX NIVEN: So assign PPE and getting to work.

JULIE SCHMIDT: Yes, we do want them to don the appropriate PPE with their N-95s, if they have them, and respond appropriately to the patient. Now, that having been said, that has been 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 test, 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 for the MERS-- 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, four of our nursing staff go in, four or five primary service. By the time the team gets there there are 10 people in there. And 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.

ALICE GALLO: 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, like 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.

ALEX NIVEN: 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 pulselessness 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.

ALICE GALLO: 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 on the critical care in COVID Corner.

And there is an ECMO algorithm that has been reviewed by Dr. Bellman, I believe, last week. So it's also updated. But ECMO is still on the table for COVID, non-COVID patients.

ALEX NIVEN: 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.

ALICE GALLO: So that's a fantastic question. COVID or non-COVID, the thump has fell off ACLS algorithm in 2010. So--

ALEX NIVEN: 16 joules, I think, was what one article that I read about, the delivery for that.

ALICE GALLO: So, yes, so thump or no-- COVID or no COVID, the thump has fallen off ACLS algorithm in 2010. So we would discourage. And if you think about it, is also a high AGP, because you would be pounding on someone's chest, even though it's just once. I would say it's still an AGP. But again, it fell off 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.

ALEX NIVEN: Well, 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, what we were talking about airway management issues, is the role, or lack thereof, of bag-valve mask ventilation during codes, recognizing the emphasis that DHA has on high quality CPR first and foremost in this setting.

So you 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 the setting of a code?

ALICE GALLO: Is it OK to clarify?

ALEX NIVEN: Sure.

ALICE GALLO: Are we talking about a code that is happening in a room? And where you're going to take care of the patient in that room?

ALEX NIVEN: So I think-- let's say, to be specific, with the scenario, this is a code that happens on the floor. The patient has-- it's a cardiac arrest. You know, the team responds, comes in, is PPEed up, what do you do?

ALICE GALLO: So since the team is PPEed 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 ROSC 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 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 clinician's 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.

ALEX NIVEN: Great. And 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 on non-invasive? We covered that a few weeks ago, but I think that's probably worth reviewing again.

HOLLY BEHRNS: We've added filters to all of our ventilators, inspiratory and expiratory side. Same thing with our non-invasive bi-paps and our c-paps.

Every anesthesia bag in the code bags will have a filter with it now, every room with anesthesia bag has a filer with it. So if we need to bag a patient, there should be a viral filter in place.

ALEX NIVEN: Perfect, and there's really nice pictures on the COVID Corner website in all of those different areas in terms of explaining where the filters 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 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?

ANDREA LEHNERTZ: 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 frontline staff are safe, while doing high quality CPR. So I guess, at this time, no.

ALICE GALLO: 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 during CPR. And if someone is not-- 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 that's our main concern right now. We are in the situation that we need to protect our frontline colleagues. And we felt like the LUCAS device was bringing more benefits than potential risks.

That's the reason why Julie trained all of the team leaders, he 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, and we'll be-- right now, hopefully no.

ALEX NIVEN: Perfect. So one more question about the LUCAS device, and then we'll move on.

ALICE GALLO: Love it.

ALEX NIVEN: 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 on, has LUCAS device training been incorporated in the standard code and ERT team member training?

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

ALEX NIVEN: And I lied-- one more question about LUCAS devices.

ALICE GALLO: We love it. We were expecting the LUCAS to be super popular.

ALEX NIVEN: Question about a neck strap to help stabilize the device? So you're using that?

JULIE SCHMIDT: So, as 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 those safety [INAUDIBLE] in place.

ALEX NIVEN: 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?

ANDREA LEHNERTZ: Yes, I can speak to that. So yes you can perform CPR on prone patients. And I believe they're also on the COVID Corner as 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 to supinate your patient, you could do prone CPR for two to four minutes until your help arrives. And also depends on the presenting rhythm, as well.

ALEX NIVEN: Perfect.

ALICE GALLO: Can I add something to that? Our Mayo-- if we have any of our Mayo Clinic Health System colleagues listening to this, the ask at the Mayo Clinic Health System sites is that proning CPR is not started. That you flip them first, in the Mayo Clinic Health System.

But here-- here at Mayo Rochester, is exactly what Andrea said.

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

ALEX NIVEN: Perfect, perfect.

ALICE GALLO: And Andrea and Jenna also have an amazing video on how to prone patients that is in the intranet, and it's also on the COVID Corner. So please take a look at that. The medical ICU has not been used a roto-prone bed since 2015, and we have been doing an amazing job.

ALEX NIVEN: So we've got those resources linked both in the 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 common themes that have come up-- because I know you guys are reviewing the episodes as they occur.

But maybe you could share that wisdom and the lessons learned with the broader community here?

ANDREA LEHNERTZ: 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 ROSC, 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 to try to limit people in the room, is the biggest thing.

ALEX NIVEN: So again, just to reiterate-- but I think this is an important point-- you have a patient's 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 would 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 a complicated dynamic here is the needed personnel, and how the needed personnel coming 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.

JULIE SCHMIDT: 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 that team, 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, but 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.

Trying to think beyond that.

ALICE GALLO: 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.

CHRISTINE WOLF: I think the big thing is just relying on that team leader, that they need them, they're outside waiting for them to come in, and therefore would be just kind of getting a proper med team leader running that code.

JULIE SCHMIDT: And I think it even is 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 finding 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 if we truly have a true CPR event, with high risk AGPs, we're going to have a significant exposure if we don't get this under control, from a crowd control standpoint.

ALEX NIVEN: So if you've got a job, come. If you don't have a job, stay away. Sounds like the bottom line.