Navigating the New Normal in Vascular and Neuro Interventional Radiology

Lessons Learned from the Epicenter and Beyond Webinar discussing:
1. Redefining Patient Safety
2. Reaching for Higher Level Efficiencies
3. Redesigning Critical Disease Protocols-STAR Registry (Stroke Thrombectomy and Aneurysm Registry

Good evening, I'd like to welcome everyone to our virtual discussion navigating the new normal in neural and vascular interventional radiology. My name is Kristen Mulch and on the customer Excellence Manager with the Advanced Therapies team at Siemens Healthineers. Today we are fortunate to be joined by three meters and familiar faces to many of you within the fields of vascular and neuro interventional radiology. First we have Doctor Joshua Weintraub, executive Vice Chairman and Chief of Interventional Radiology at New York Presbyterian Columbia Hospital. Head Dr Marcelo glamorous from the Medical University of South Carolina where he's the director of Vascular and interventional Radiology and Doctor Alex Piata, professor of Neurosurgery. An neuroendovascular surgery. Also at M USC, they'll be discussing the financial, operational and clinical challenges they encountered within their practices. In light of the COVID-19 pandemic. A few logistical items. All attendees are unmute will end with an open Q&A. You can submit your questions through the Q&A engagement tool and will be answered concluding tonight's presentations. Some networks may cause slides to advance more slowly than others, so logging off of your VPN is recommended, and if your slides are behind, pushing F5 will refresh. Replay of the event will be emailed to all registrants 24 hours after the event and with that I'd like to welcome our first speaker. Doctor Weintraub. Well good evening, everyone. Thank you for joining us. I'm here in New York City and I will be giving a little update on some basics of where we are in New York right now and then. Some interesting things that we experienced at New York Presbyterian Columbia. As we went through the covert epidemic. As most of you know, in New York City was really and has become the global epicenter for COVID-19. We have more cases per capita than any place else, and Fortunately our on the tail of what was quite an adventure here in New York, the Metropolitan New York area is estimated to be over 20,000,000 people and we really have one of the most dense populations. I'm located up in Washington Heights in northern Manhattan and we have a population density here felt to be over 100. Sing for square mile. New York Presbyterian Hospital, the largest hospital system in the New York area. We have a bed capacity of just about 27,000 and that was really put to all strains as we went through the epidemic. This is what the world looks like this week. Most of you are very familiar with this. the United States has fared far worse than many other countries with very high incidence initially. Now in New York, are incidences? Finally down below .8%, which is really miraculous at treatment and you'll see what we did at New York Presbyterian and throughout the New York community to help us get to this number. So this is what we experienced early on. This is the outbreak at the beginning of March through April and it really went through the ceiling throughout our hospital system where huge we have close to 2000 beds at about 250 ICU beds. Very rapidly at the beginning you can see here is our total number of covid in patients. We started out about 500 at the beginning of March and quickly approached 3000 patients. In terms of the ICU patients, they really mounted rapidly and we learn things that others sort of came to know Farhad that patients did not do well on fence, but we had patients with a lot of respiratory failure and very early on we went from needing these are the ICU patients. He said the ICU patients on ventilators, about 80 patients with covid invents rapidly getting to our limit of about 250 and then opening multiple ICU's to be able to challenge. I should be able to care for all these patients with over 700 patients in the ICU's on ventilators. We had a very good administration and a lot of organization. That's one of the key things. As you're going through this which is very important is to have transparency. To know what's going on in your area and be prepared for the next steps. Daily we had drinks with the hospital ministration, including geographic Maps of New York City. You can see Manhattan. These are patient populations by ZIP code. This is where we sit at your Presbyterian hospital, right in the heart of Washington Heights. It's always surprising to many people that were very underserved. Area in New York. We have very few physicians in northern Manhattan per patient population, and it's really also one of the poorest populations within the country. Over half of my patients do not speak English as a native language, and there's a high degree of poverty which accounts for the distribution that we're seeing. So by the end of April we had seen over 7000 patients. We are experiencing a little over 1000 deaths and throughout the system we had about a 15% mortality and for patients who ended up in the ICU, almost a 50% mortality. So that's where we started. Where we now as we get to mid August and this is data through the end of July. You can really see how flatten out that curve has become and this is really put us in good stead. We're down to under 300 cobit patients within our entire hospital system in the ICU's have really recovered with only about 45 of our patients in our ICU throughout the entire system. On in the ICU in about 40 of those patients on ventilators. So it's really been a miraculous turn around. Despite that, that's really haven't done as well. We've seen over 12,000 covert positive patients. Approximately 90% mortality for patients and over 50% mortality for patients who ended up in the ICU's. So it really sets a stage for where we are in radiology, how radiology helped out with the system as we went through the covid crisis and how we're starting to recover from this. This is my data through the end of July. Overall through our inpatient outpatient volume where used to seeing about 1.2 million visits a year. As we got to July, we saw over 50% hit in our volume and will learn more about the financials as we go through this discussion and we get to the last lecture, but you can see here the drastic changes are emergency room we didn't see as much volume, but we saw a massive increase in the plane films and in the acuity of those patients. Are inpatients were totally overwhelmed Baltes bugs out in our outpatient volume essentially in March, plummeted to almost 0. Dial we're just starting to see a comeback towards our baseline. These are numbers. The top lines are numbers from last year and the aquiline below that is our numbers from this current year. So Doctor Ramirez is going to talk a little bit more about this, and I just sort of wanted to talk some about the challenges that we saw in IR and how we address those as we went into this. And currently all of our patients were and continue to be required to be screened prior to procedures and that in of itself is a challenge. We had a massive shortage of PP and testing at the beginning. We still have challenges getting patients tested within a time period. We require all of our patients to be tested within five days of the procedure, but currently tests in New York require about 48 hour turn around time and so we're seeing a lot of challenges with that. Additionally, no family was allowed in the hospital or continuing that with patients who are undergoing procedures. We have LAX that somewhat, especially in the OBGYN Department, where we felt that the patients, the mothers, their significant others really benefited from having other people there. Initially we looked to divide our faculty by locations. We were very concerned about having faculty infect each other, maintaining a workforce as we went into this, and so we started out by having a hospital based team team based in our outpatient offices in our reserve team and rotating those through our workforce. At this point we really are on that tail under the curve where the incidence is much lower than we've really gone back to our standard work. Carter in terms of the pre procedure work up, I quickly ran out of staff are nurses were redeployed to the ICU's my doctors where we poured deployed to the ice use yet they still needed interventional services, particularly for the vast majority of patients who were in the ICU using needed vascular access. And So what we did early on was established. What we called SWAT teams. This was really moving interventional radiology to the bedside, so we set up teams directed by an attending with two or three of our senior residents and fellows on them to do all of the procedures at the bedside. Really putting our residents in the face of covid, starting lines, assisting with Angie tubes. Doing all those things that we can do better than the ICU. More timely in a quicker fashion, and so that really changed the paradigm of how we were working in interventional radiology. The procedures obviously became challenging. It was interesting. I was on a webcast early on and we're talking with some of our colleagues in Singapore who describing their anterooms and their negative pressure. And then they got to the point where they talked about the number of patients that they had seen with Covid and they were still looking at, you know, 1015 patients with covid in the entire system. We quickly got overwhelmed in a lot of that sort of became unrealistic, and every patient. We quickly, new and assumed had kovid and we. Really, we're required to maintain our universal precautions. Try to keep the room safe and maintain our turnover. And it became a challenge where to recover these patients. We tried to move them up to the rooms and a lot of this and a lot of what I'm going to talk about. Hopefully in the next 10 minutes that I have is the safety part of this in experiencing the safety and part of that was the transparency in the rules kept changing and nobody really knew what to do, how much the rooms need to be changed, trying to keep the cover cases at the end and all that sort of went out the window in the heart of the pandemic. So this really redefined safety. I think all of you know about basic universal precautions and what interventional. Department said, but part of safety and what we didn't realize. Knowing going into this was. Facing fear and how fear affected safety, the fear for our patients. The caregivers are hospital staff an having community awareness making sure that the hospital leadership was there daily to communicate with us and tell us what they didn't know. That was often as important as what they knew going into Coppit. Having routine staff meetings and it's interesting, you know, we went to zoom staff meetings like many of you and those became a major focal point of our entire Department during which our routine staff meetings. Used to have maybe 2030 staff members that would show up through the covert crisis. We had zoom meetings with 92100 of my staff made numbers on every single call. An equally important we went to division meetings. We had division meetings twice a week for people to be able to express their fears. Their concerns 1st and try to know the unknown and at least come to a grips as we went forward. The patient fears were really challenging in interventional. They often felt where we were feeling. The constantly changing message. Patients needing to be hospitalised by not wanting to be in the hospital. Worrying about. Infection and really that isolation from family members early on where we weren't letting family members come into the hospital and their main goal. I really came quickly to realize was they wanted to be safe and healthy and we needed to help them through this. And what patient feels really came down to was having a safe place with trusted care. And so we very quickly set up a lot of Internet ability and you can see that on the right side of the screen here for patients that hotlines where they could talk to physicians get video chats with our doctors an our Tele health is now changed to over 80% of our visits, helping them learn how to talk to their family, their kids, other people about Covid. We really were guided and try to continue be guided by our internal experts. In addition to recommendations from the CDC CDC partner. So as I said, initially we had no visitors. We now have expanded that some, especially in the OB wings. Masks are still required from staff visitors. Patients we have stemmed hand sanitizers just about on every corner, and now we screen all patients, all visitors and all staff, both with a verbal screen and as are saying all of our patients are required to have kobid PCR testing within five days of their procedures. Hi clean clean clean. Can't be stressed amount enough and also social or what I really prefer to call physical distancing. I hope we're not socially distancing from each other and there were socially there for each other, but to provide physical distancing, we've reorganized our our waiting room so that people are further away from each other. We've really changed our schedule, extended our day from early in the morning to late at the day so we have less patients overlapping with each other. And as I was saying, going to Tele Health. Constants. One of the amazing things that one of my residents here here shortly from Elizabeth West set up was a thing called Compassionate Care Coordinators. She did this very early on. She realized that with this isolation, families weren't getting to see their loved ones. And as I was saying, our residents were in the ICU's. They're helping us with our lines. They were on the frontline and she put together a group of physicians who on their off shifts would go with their iPads to be able to talk. With patience to their loved ones who might be into baited might be dying in the ICU's when they weren't able to communicate with. And this really provided a meaningful communication to the families and I want to put Elizabeth on now a little bit so you can hear from her. So hopefully we'll be able to see the Walmart by individually going into the rooms and just using my cell phone to connect families and patience. I know that these families were desperate for information and really scared and missing their loved ones. There were many patients who, after hearing their families voices or messages several days in a row, did start to improve clinic. There's something really intangible about having someone's love and support, and some that you care about and trust next to you supporting you. And that was something that I had never really appreciated before this. So this was really an amazing thing that Elizabeth did. She's I think she's publishing an article on it now. So if you have a chance to read it and see some of the stories from these patients, that was really impressive and it made a massive difference through our entire hospital system. So it was interesting seeing that our residents really didn't shy away from this. They had no hesitation stepping up and being on the frontline, but there was still a lot of fear among our faculty. By interventional radiologists were deployed to run ICU's at the beginning, move to the front lines right away. Now they're expensing. How do we turn to residents? And it's important for us as leaders in interventional radiology. To really be cognizant of this, the families worry about infecting family members at the beginning during the first almost two months of this, my family was up at our home in Vermont and I was on my own down here just out of the fear of Kovit. I've new people members coming back. Schools opening and worrying about what to do about childcare and finally the job itself. Will radiologists have job as we go forward? As I showed, are off, patient volume is just now starting to come back, but people have been very worried about layoffs. Decrease revenue. We've been very fortunate here that are Dean's guaranteed no salary cuts that we're maintaining our benefits, but that's really been a fear. And where we go into the future. Part of this are psychiatry Department really set up a resource called Cope Columbia helping to provide resources for our community counseling sessions which surprisingly many of our faculty members have taken advantage of. We had them join us at one of our interventional meetings and it was amazing that people were really able to open up and take advantage of this type of peer support and guiding suggested reading and other things as we've gone through this. So we're really hopefully on that flatten curve that you saw early on, and I know this is sort of a sort of a unique way of looking at the risks and looking at some of the fears, which I think are just as important and often not acknowledged. Our hospital infrastructures changed were coming out of this, but Tele Health is here to stay. We've converted as I said, to about 80% of our visits on Tele Health and radiology is really leading that ability. We have now set up destination radiology where Tele health patients come to get their labs done in radiology. Now, withdrawal at the same time as we start Ivs for season ever eyes. They get their imaging done and at the same time we've set up rooms where they can do Tele health. If they're not, I it savvy with their referring physicians, and we've had numerous patients take advantage of that. Really changing the infrastructure of how hospitals work. Right now as we go into the fall, we are planning for the second spike, making sure that our hardware is up to date and we'll see what the economic challenges have to drink. So with that, I'm going to turn it over to Marcelo to talk a little bit more detail of how Interventional Department themselves have specifically adapted on the ground in the changes that they've made. My cellar. Right, right? Thank you for an excellent talk. Appreciate that. Jimmy. Can you hear me Joshua? OK, so. The goal is to talk a little bit about what we have done since cover to heat this country in a in a very challenging way. And first of all, I'd like to think Siemens. For putting this together like to thank Kristen Welch and Lena gallons for your attention for putting this webinar. Important women are together. I think this is a good opportunity and I'm grateful to seems to understand. Who support the idea to discuss about COVID-19 and how we can identify and share ideas to identify new strategies on how we can have a normal life. If you will and be productive working productive, have a good life despite COVID-19. So thank you for Simmons for that and you are seeing Simmons build up by strong partnership is important to recognize that in the last two years on equipment and performance improvement projects in clinical practice, best clinical practices. We're very grateful for the partnership that USC has currently with annual with students. So I'd like to talk a little bit about corporate response in VR at anywhere. See basically we I never forget his dates due March 23rd. When we were told by the hospital that we needed to stop doing elective, our emergency cases or change our current schedule and only do elective cases. So in the following week we monitor our volume very close and we saw dramatic and drastic change in our volume and we started to put our heads together and think what can we do? What can we do to take care of patients? But at the same time help the hospital with the financial recovery because we knew that this could take a few weeks or could potentially take a few months and we didn't think that being. Clothes and not being not taking care of patients would be the way to go. So we decided to do is we discussed with colleagues and we participate in women are discussed with colleagues from different parts of the world where they had more experience than we did here in Charleston, SC, patients, colleagues from New Orleans from New York, lot like Doctor Vinero Bunch, Rob and then from Italy from Seattle from Singapore. We also tried to address, as Joshua explained, very well. The fear from our staff. Fear of getting infected fear for maybe getting laid off or again furlough a lot of people were furloughed and we have major layoffs in our institution. Order to balanced the financial situation, which is, today Fortunately, is much better. Most of our employees are back, but we need to address this at that time. And of course at the same time we want to build up best practices. So these are just to mention publications that came after what we did. Publications that can be reviewed. If you're interested in a basically before this publications came to live. We discussed with folks from China. We discussed with folks from Singapore and we basically learn from them before they publish about what they're doing. Also, our society also cited intervention. Radiology has a very strong Corbin 19 two kits before the attendees who are there would like to learn a little bit more about how to build up their best practices and be safe and take care of people in times of covid. Yes, IR website is an outstanding resource for learning about Corbin and how to manage your practice. So basically we decided to work collaboratively at an USC with infectious disease. Folks with infection control folks, and with facilities and maintenance with the idea to try to build up an environment where we could continue to take care of patients. Protector patients, protector staff, and protect the whole environment. So basically what we learn is we learned that we needed to, how to avoid contamination room, how we could have. About 20 minutes to have the turnover between the rooms to prevent infection, we decided to do all cover case at the end of the day so we were avoid to have contamination between patients and then we had time enough to clean those rooms without a problem. Of course, once we start to have more and more corporate patients, that rule became very challenging, but at least at the beginning, that's what we did at this point, every patient is being tested it in USC, but at the beginning were testing basically patients that were just. Asymptomatic and that was the initial thought process but today is universal testing. And also we discussed in detail with our journey seizure colleagues from anesthesiology, how we would be menu those patients you know who really need the journalist easier if we try to do everything we could without having journalist area if possible because of the risk of spreading the virus in the room to our staff into our patients, other patients. But part of our concept to build best practices was we defined we have 6 rooms in our campus. They to building so when room in each building was the finest October room. As you can see here, we work with facilities to build up an empty room is against his smaller space of the rights loaded, firing to wear her ring that the random zipper is open is the enter door so all the supplies that we need for the cases there. If the patient was covered positive all the the equipment was out of the room in the same thing in the upper picture. As you can see, that's the under room where we use that. To create a buffer between the Chobit case going on inside the room and the exterior to try to protect their staff as much as possible. So very early on when people were not using masks at all, we implemented the strategy in our division for every single patient that was coming to the property cover area. Every single staff was working. Should be wearing masks. There is no question about that. There was something that we took action since the get go all the pregnant staff members that we had were from working from home including one of our Atps there was working on our MPs that continue to do consultations and be working for our inpatient console service from home. All are atps. In order to avoid him to walk around the hospital, they were doing phone consultations from our division, not walking the whole building. We also in order to protect our staff to prevent them to be furlough into being laid off. Instead of shrinking, we actually expanded our schedule for Saturdays, and we decided to do elective cases for inpatients to expedite patient care because we knew those patients will need. Us so we also with that were able to keep the staff working hours. The staff became happier. We addressed their their concerns about how to get inspect and how it could use as two strategies to prevent infection. Basically was an amazing experience because we need to divide into groups to divide into two groups that were dividing two different buildings and we have much less number of staff members. So basically before we were having for example. Five to six members to do one particular task. We all ended up having two. And the people understood it was a pleasure to see the performance of our group. How, how much they put together in order to take care of patients working longer hours. But at the same time have a high performance. So we basically separate two teams. As I said before, one team of Attendings Fellows residents, Atps nurses and tax in each building. One team working every week. And they were not crossing coverage. There's no cross coverage or work in different buildings to avoid contamination. Basically, one team was when he off one week on. As you can see on this schedule, the green is one team, the blue is another team, and we're working on Saturdays as well as you can see here, in order to keep the working hours and take a good care of our patients. So for specifically about Kovid positive cases, as everybody know, at this point we're using 90 and 95 masks and goggles of frequent hand washing. We cleaned the rooms, wipe the rooms all the time, we remove all the necessary equipment from the room, carts, equipment in order to minimize the amount of supplies necessary and all that supplies were covered by a plastic bag in order to prevent contamination. We did not open up any Pyxis machine. If all the supplies were taken up front from the shelf in anything that we would potentially use, we captain that end to room. That would prevent people to go in and out. In as dark, Joshua presented as well, we started to do more and more procedures at the bedside in order to prevent patients that were in isolation to come to our facility, which is aligned with the CDC guidelines. In terms of our outpatient consulates or outpatient service, we used to be present in three areas across the Charleston Peninsula and basically now we consolidated the majority of our consultations through telemedicine, using tox INI, the exception or patient with PPD that we need to check posters to understand better what's going on, requires a better physical exam and also patient investor. Now anomalies, but all the other patients will do special in college and embolization's every perform. They're all done and virtual consoles. In the mean in the at the same time, nothing to do with kovid. We already had plans to open up our rapid access clinic and that was phenomenal. Coincidence, because we're able to decompress the ER it was filled with kovid patients or people is stressed out about covid and we continue the referral pattern there. Envy access to VR through our rapid access clinic. Seeing patients that was very important for patients were leaving from far away. So people who are. From 3 four hours from here, instead of coming just for a consultation with us, we saw them the same day they were seen. Other doctors from other specialties they were referring to us. And of course those consultations were also done by Tele Medicine. We also started to educate our patients in the Community with worked on our we are ready contained. This campaign basically was to educate our community that how much safe, how safe we were. All the precautions were taken. We put videos, testimony, social media and you can see here one of the pictures with a small group of our staff that was available that day to demonstrate how safe we were working. So in other words, the result of crisis and I think I see we see crisis and opportunity. Our team became much more available again working on Saturdays, but the team showed a phenomenal ownership. It was. More efficient than efficient than ever. We did not drop in in anything in terms of excellence in patient care. We provided very safe operations. We have one staff member that was became sick with Covid positive, but he actually contracted from his wife, not inside work and all our operations became Kovid safe and patient centric. In terms of numbers, if you see on the far left of the screen, this is March. The last week of March and on the far right of the screen is the last week of July. And if you see the numbers grew is financially since the end of March. I think our availability and the way we've been establishing safety has actually allowed us to grow and continue to provide safety, safety, safety, patient care and helping USC during the financial recovery. It was very important to allow. To help us to help him USC to do our part. Our contribution through the financial recovery. With that said, I'd like to pass the word through a doctor stealing. Thank you Marcelo and Joshua really phenomenal talks. I really enjoyed him both and learned a lot and really my hats off to both you for the working did in the leadership you provided. And also big thanks to Siemens for putting this together. This is such an important topic and I appreciate you putting this whole experience together for our viewers. So I'm going to speak about Cobin 19 and the Strokes are better. May experience insights from two large collaborations. My name is Alex Pioda, another surgeon and director of the Division of Neuron to Vascular surgery. In this talk, could also be properly called this the power of real time large databases to alter practices during unforeseen pandemic, as I'll show you, we leveraged our collaboration internationally to gather data in real time at the beginning of Pandemic and that created a two tier system that we applied as we approached our stroke patients. A big hat off to my friend and colleague Andy Ringer, who heads up the energy which is the endovascular Surgery research group. And star the Strokes on vector me. An aneurysm registry is an international research collaboration that I founded about 13 months ago, and the principle investigator for it. And currently this is this map is not quite up to date, where 55 sites you can see enrollment the bottom left or target for 2020 was 8000 were actually at 9000 plus. You see, your mission is really to to gain, expand the knowledge of stroke disease, not techniques, patient outcomes, an foster network and collaboration. And we had done. I'm also part of the energy collaboration and we had done it. An early evaluation very early in a pandemic, showing those delayed presentation for Huskie mix strokes. So there was a two hour and 20 minute delay across these multiple sites compared to two months prior to the pandemic. So clearly clearly there was fear even for stroke, and I commend Marcelo that social media campaign that he did. We also did a very similar, so we saw that there was a fear among patients presenting to the hospital out of fear becoming. Infected, and likewise there were fears from all of us, really, what was what was coming ahead. So let's take a walk back February of this past year. You know we're all watching New York or colleagues there being overwhelmed and hospitals being overrun as long as well as Seattle. And we really didn't know what to expect, you know? So we're all kind of here in the trenches looking. We knew the enemy was coming, which is the to know exactly when and how a fierce it would be in South Carolina. But we knew was coming. So everybody was adjusting protocols and really getting ready to take your patience as well as to keep a provider safe. At the same time, they're recommendations. Of course, at the beginning of pandemic, so there was no data to support it, but their recommendations based on expert opinions of how to manage specifically the care of stroke patients. And you can see here some of the highlight areas. Again, this is the beginning of the pandemic. We were expecting the worst and preparing for any possible scenarios. So for example, disruption of the circuits such as Cuffley suctioning in to take urine mulation could release air slice secretions, so therefore was recommended standard institutional protocols. And here's the key with a low threshold for intubation of stroke thrombectomy positive patients part of the industry. But this is applied to undocumented code patients. Integration of these patients prior to transport should be considered patients with risk factors for interprocedural into Bashan, and now is the key, and the fact is in our workflow, with the stroke patients, we often have no collateral information families not available with time obviously being of the essence, there's really no time to gather information. Obviously no time, even for a rapid Koba test, which at the time they were all New York City anyhow, where they should have been where they were needed the most. So really every patient was really going to be an unknown. Presumed chobit positive patient. Another societies came out shortly thereafter. Everybody had similarly themed recommendations, namely. In debating all stroke patients before coming over the Angel sweet and this is how we developed our media CL via protocol. And really it's a fascinating dichotomy, because here is the maximum that mechanical thrombectomy is generally low risk and then low at put in here low aerosol generating procedure. I give a credit to New York and Seattle College. They came up with these this terminology terminology. Of course, we never had thought about previously aerosol generating. But in Mechanical Turk, Timmy can be done and is most commonly done awake under minimal sedation. Local anesthetic. However. An unplanned innovation, an aerosol generation mid procedure would be the worst case scenario. So clearly the best and safest for everybody was to do the thrombectomy without into being. The patient would input our ancillary services, ER, anesthesia risk, for performing the actual innovation which cause the aerosol generation and we didn't put any burden on our new rice. You colleagues post procedurally. The excavator also generate aerosols, but we all wanted to avoid the worst case scenario, which is a procedure is going well and halfway through the procedure the patient starts coughing, gagging, vomiting. Materials from their stroke, either it progresses or the hemorrhage, and now you have an unplanned, unprotected intevation aerosol generation emergently, and now the entire team in the room. Is it contaminated and so early on I received input and there's many, many teams that are involved in patients. The really a very big and collaborative effort. Obviously, stroke, neurology and narrative after surgery neurosurgery, my team, emergency Department anesthesia new radiology in the new ratio. And we adopted our guidelines to the at the same time. In parallel we're emerging the PERI operative guidelines for surgical patients, and the key is here #4. These are untested patients for lowest procedure like a mechanical term ectomy. And here the recommendation standard PP across the board, except with the caveat here in red. If there's a risk of conversion to G8, and that's just the anesthesia perspective. That's the same way of saying there's a chance that it can become. The can be aerosol generation in an unplanned and unprotected setting. Like I mentioned, vomiting, coughing, gagging the patient is facing and starting to move into procedure and you must in debate just for patient mobility. Proceed safely then that would be the highest risk to everybody involved. So then it bumps to number 3, which is a lower procedure with general anesthesia because of that risk conversion. And really, that really was the crux. In our stroke thrombectomy patients really fell into #3 and #4 is I'll show and as will show. Also the data that we'll to collect through international collaboration in real Time helped us to adjust that as we were going along. So these are our criteria for patients that we would in debate prior to the procedure and these are patients that we necessarily would not have been debated previously, so the basilar occlusions, those are more likely to decompensate and have airway issues related to altered mental status as well as lower cranial nerve involvement. The high in age, the logi CS agitation and combativeness purely for patient motion and be able to do procedure safely, the aphasic patients. Those are the ones you can talk down and having stay still. They get nausea, vomiting and anybody respiratory distress. So that was the protocol we instituted back in February. And we all knew we were changing our protocols, and I'll mention that in debating thrombectomy patients, so performing a thrombectomy under GA. Is an established standard option along with performing under conscious sedation. The big changes that those minority of centers the majority do do some metrics patient awake. The minority of centers that do GA routinely, they have been established streamline very quick workflow to do so, and now we had a lot of centers that were not routinely performed Jie or into baiting pre procedure who now were and this is in the setting of. Let's be honest with kobid there's a lot of fears, anxieties, extra layers of protection. So really instituting an additional step and it wouldn't be surprising that step would add a lot more time than it would. Under different circumstances, and certainly more time than it would if this was done routinely on every case. So these are the centers that we reached out to the beginning of the pandemic. And really, we said, let's just study this to see. Let's understand the effects of these changing protocols. So again, this is the background given the risk of exposure to providers, frequently unknown Kobus status of patients presenting with emergent large vessel occlusion and stroke. And the acuity of intervention required no time to get history or talk to family. The scientific societies recommending lowering into Bashan, thresholds, and that was really adopted very broadly as I showed also muc, so the purpose of this study that we launched in February and this is a prospective observation. ULL study was twofold. How did our patients fare in the face of both the pandemic factors as well as the changing information protocols and how to providers fear? So for how to our patients very want to describe the mechanical thrombectomy experience during covid across a diverse demographical regions, including both hot stones and cool zones. Again, at the time we know who's going to be hot and who was going to be cool. And as we now know we were relatively cool and now we're hot, and now we're cooling off slightly, which is good. We wanted to assess rural versus urban settings, so really diverse practices and look at our metrics are all important time metrics. Can we get the vessel open on time? What? What delays to treatment incurred by these changes in protocols, and most importantly, how did these protocol changes impact or patient outcomes and then also equally importantly, number two had a providers fair. We have a very small select group. Our group is one of the smallest in the hospital. Hard to be replaced. We can't have other services cross cover so we go down. The whole service goes down. So how did our providers? How do the physicians, the text and nurses fair through either Corentin or actually Covid illness will be available for patients to provide the services. So that was launched back in February and for the first goal describing the mechanical thrombectomy experience again, we launched this prospective multicenter. International Observation ULL study using both the star and the energy collaborations, and these are the participating sites in my hats off to all our collaborators. This is certainly a time of extreme stress, you know, financial, fear, and otherwise many centers had research coordinators are furloughed at Luckily at MUC. We had enough funds, were able to keep our our rest research faculty as our research personnel on staff. But my hats off to 28 centers that committed in February to given us two months straight for this from Ectomy experience. And you see the centers were involved for United States. You can see some West Coast as well as the Midwest and the South were also represented so nice sampling across United States and a listing of the centers. Again, my hats off to the collaborators. True commitment in the time of adversity. Commitment to get the data so we could then see the impact of our changing protocols on our patient outcomes. Enough providers. And we did. It was 2 divided are participating sites into areas that were height kobid burden and low. We use criteria 500 cases. So whether or 500 cases or less over 100,000 patient population as I'll mention, none of the sites were really close to that. Threshold, like New York was 1800 or two 2100. Cases over 100,000 so well over the threshold and the time places like South Carolina MUC we're well below 500, so sites were either clearly very hot and as I'll show here momentarily red or or cool to start off so there one any that were sort of borderline you can see over the 28 centers that participated at the beginning. This is February, March in March, April. Five centers were Heiko, but Burden regions and the rest 20 three were low covid. And these are the participating sites and again the red is the hot so you can see Boston, New York, Philadelphia where hot zones back in February, Chicago and Seattle, United States and the rest of the time. Of course it changes overtime at the and I'll show how the data and the relationships we identified allows you flex your protocol overtime. Depending on your incidence of code in your population. But this is a study population at the time that we committed again two months prospectus arm ectomy data from each center at the beginning of the pandemic. And we resulted in 458 patients were gathered from these 28 sites. Again, data from North America, South America as well as Europe. And we found overall so 13 patients 2.8%. We're confirm code positive of those patients who were tested 242 now mentioned testing protocols changed in the beginning. Patient will be intested that have symptoms and tests are limited to the high code burden regions during the same time period that we gathered. Data testing was made more broadly available. You can see the 242 patients that were tested, 50 were in the hike, overburden regions of which 9 or 17% were positive 192. When the Lok overburden regions of which four? So much lower rate of Kovid positive ITI, two point 1%. Again, these are patients presenting with a large vessel occlusion for stroke thrombectomy. So two point 1% significantly lower positive rate as you'd expect in Alok overburden regions compared to the high cover burden regions. And among those that had confirmed COVID-19 positive infection. You can see 8.6%. When local hike, overburden region is 1.1% overall in the local bit, so significantly higher as you'd expect communities at a higher prevalence. We looked at the patient characteristics. Comparing those who are code positive compared to those that were not, and it's a large table with a fair bit of data, but I'm going to point you do the red regions so you can see a zit was significant difference. Those kovid positive 19 patients were significantly younger and they did have a higher in age so a worse stroke severity on admission. And then trend .06 of a door to re perfusion specially it appeared to have a longer Dori profusion the non kovid patients. In these, the practice patterns by Cobert Vernon location. So looking at the hot zones, the red versus the cool, and this was for the New York and Seattle areas. The two months or February March for the other sites. It was March in April. Just because of the timeline when Covid became problem in those in those communities and get a lot of data. But pointing you to the red areas of P value, which is significant. Looking at demographics here as well as procedural metrics, so insignificant difference, the ICP rates much higher in the Lok overburden regions, perhaps representing delayed presentation out of fear in the higher code burden regions and perhaps systems that overwhelmed because ICP obviously is is time sensitive. There's time window in which you can give it, so we're seeing significant delays and less TPA use in the hike, overburden regions, intubation rates actually higher in Lok overburden reaches. And that may seem counter intuitive, but with Alok overburden regions were doing, they were seeing the the experience of the hike. Overburden regions who are seeing Covid first. Namely Seattle, New York and Chicago, and the Lok overburden regions were reacting to their experience by lowering information thresholds. And you can see Jordan growing time. Significantly longer in the local covert burden regions, again, likely related to the lowering of innovation fresh. We looked at specifically general anesthesia. Those who were into baited pre procedure versus constant sedation. And we see here 52% of the patients underwent planned pre procedure general anesthesia and just as a baseline the baseline rate of one of those collaborating sites. We have data from the Star registry for these sites for several years now and that rate is about 10%. So there's a five times. Incidents of Intubating patients pre procedurally you can see here those undergoing Mac only two out of 217 or .9% converted it to GA. So the big fear having unplanned interprocedural innovation was very very low .9% when we look at J versus Mac and this is really important findings you can see he robbed use. Slightly higher in those receiving GA a couple different supposed to circulation but here Jordan groin. 92 minutes on average for the GA patients versus 67. So nearly 30 minute delay associated with integrating patients. Procedure duration was also higher in those intubated patients. Be all important door to re perfusion, so arriving to the yard and having the artery open. 38 minutes longer 138 compared to 100 in the conscious sedation and functional independence, where we all really care about. So good outcome. Modified ranking zero to 235% in the Moderate Consultation Group compared to 24% significantly lower. So this is what we found. Is that compared to Mac patients with pre procedural into Bashan? Again these happen to the local overburden regions at longer door to growing times. Longer procedure times longer. Georgia re perfusion times. And the lower likelihood of a good outcome. We looked at multi very analysis and we found that into Bashan pre procedure Lee was associated with a higher probability of death and a lower probability with the relative risk of .5 three, so having the likelihood outcome. So we found was that compared to non covid patients, kovid positive patients were younger, had a higher stroke severity, an admission below similar recanalization success and outcomes. But in the low there was a low number of COVID-19 positive infections among patients with elvio undergoing from Ectomy, Lok overburden counties. So the 23 sites to contributed data 19 of those of the 23 / 2 months performance from ectomy's and never had a kovid positive patient result. We also found a very low rate of the very, very much the feared complication unplanned into procedure. Bashan was very low .9%, and patients who were into baited prior to thrombectomy or more likely to have a death and a lower likelihood outcome. So taking that information, I'll come back to the minute we also looked at the work first, depletion 'cause that was also an important factor. However, providers faring so from those sites actually. In addition, additional 6 sites we have 34 centers across South America, Europe in the United States also sent his data over two months looking at nearly 600 providers. And we found that in the Lok overburden regions there actually zero physicians. Technologist or nurses. There were kovid positive. So while there are a number of technologies that nurses there were out for quarantine or symptoms, there was actually zero that became positive with the two months they just were not seeing the patients. And in the hike, overburden regions are actually fair amount of those providers were actually positive. So we took was that there was an evidence of self quarantine in both high and low Cooper in regions as we should. We were trying to keep our teams intact and keep cross contamination to ultimate low. In the beginning we don't have testing so we had to quarantine for longer. But again, in all low cover burden regions at that time in the early spring there were zero health care provider infections, so moving forward there really is a balance between patient outcomes and provider safety. And we propose is a two tier model. So this data was February and March for the high Covid early regions, New York, Seattle in March and April for the other regions we analyze the data in by the middle of May. So two weeks after we gathered data, we presented it to each other through webinars. Now about to be published in one of our high impact neuro journals. And every at the time low covered County reverted and change their protocol back to not into baiting pre procedure because the incidence of. Chobit positive ITI is very low into patient, had a risk and the threat to the provider never materialized. Now when as we rolled into the middle of June so for four weeks we. Reverted to our previous pre kovid protocols as Ark obit incidents in our community grew and then beginning of June, certainly by the middle of June, we were now Hot zone. We reverted back for the purpose of protecting providers because we knew we would have a relatively high rate of positive ITI now longer. We owe patients and that the the those extra layers of protection were justified to protect the providers. So release a two tier system. The hike overburden regions we currently are in that tier and once the Cobra population, the incident population decreases. Will revert back to the other or. Right now we're maintaining our code. Protocols were in debating pre procedurally. Again we had a month a month and a half. Based on this data we were last those protocols. And here too, if you are in a region as a loco big burden and we had those numbers 500 or less out of 100,000 population. You can revert to Triton. True local for particles which have been proven to be fast and Expedia. And again, this all important. Note that this can be flexed up and down depending on the incidence of code in your population. So thank you very much. I think I went a few minutes over the over the hour over the 15 minutes, but again, thanks very much to Siemens. We're very excited to announce we have a new partnership specifically with our start collaboration with Siemens and Rapid AI, which is software for looking at stroke thrombectomy triage in CAT scans and really size limit for star as well as MUC with the Siemens partnership. And really thank you very much for putting this together and thanks again for the previous speakers. I really enjoyed your talks. Thank you all for sharing your experiences. We've all been impacted immensely from this virus, and these were incorrect. Incredible examples of how you've developed innovative approaches to the challenges that many in the audience are facing today as well in their own practices. So with that, we'll field a few questions from the audience. I do realize we're a little short on time, but I'd like to get do at least a few of these. The first one is for you, Doctor Spiotta. Do you believe that with the additional time added due to kovid that it is more important to be able to have one stop shop and urine for stroke treatment? You know that's a great question and we are actually working towards doing that in the near future. We just don't have the capability right now. Our Angel Sweet is a positive pressure room, so those considerations with the guards then so ideally is if there's a negative pressure room available in the ER, we could in debate in the ER prior to bringing the patient procedure and then having to in debating the procedure. Then you have to see last the room we have. We do have a code protocol for patients that are unknown and presumed to be code positive when they come up. But you certainly have to know. Paired bear down the the contents of the room, and it does incur additional time, so I think that's a great point in the arrow. Cobin, I think is very, very difficult. No one has the right answer. I think the biggest thing to take away, as I've learned, is just being kind to your colleagues in the ER neurology then, or issue anesthesia. Everybody has concerns and everybody is feeling it. So the most important thing is to come up with protocols like we've all been doing together and really hearing everybody and trying to work on something. So you really addressed the concerns and needs of all the services. 'cause, for example, for stroke like I mentioned is 5 or 6 services particularly spacious to really hearing from all of them I think is very very important. Great, the next ones for the group. Do you see the ambulatory surgery centers as an area? You may look into for the future? Should hospitals once again shut down for elective procedures? So you know what's interesting in New York were saying a lot of change towards our. RAF season are outpatient units. People are much more hesitant to come into the Medical Center. An in fact, our volume at our outpatient offices. We have 300 suites in outpatient offices. Now is almost over well over 100% of where we were per pre convent whereas our hospital volume is still very low and I think that's going to be a trend as we go into the future that patients are going to want more therapy done closer to home, not coming into large hospitals, especially elective procedures. So we're even doing probably doing far mark mobilizations, uterine fibroid embolization's radio embolization's at our outpatient offices. Then we are doing in the hospital. So we've already seen that trend. Interesting Joshua at. Anyway see we are above 100% of numbers in terms of volume. If you compared to prior to Covid where above 100% we were. But I think maybe because of the. I don't know were community reach out and education social media in sending letter survey, tiens about educating them about the safety and how we're doing, how we're taking care of them, how they would be taking care of at the University. They have been coming without a problem to our Mother Ship Hospital which is in Charleston downtown. But we basically at this time to avoid cross contamination. We limit our our action off campus and we're trying to concentrate everything we can. Because we have negative rooms, negative pressure rooms in downtown where we built a pretty safe mechanism to take care of people. I think in the future agree with Doctor Vantrump. I think we the future we're going to go out back to the the the off campus facilities where we can provide outpatient care and I think that's the trend regardless of Cove in. I think that's the trend in the future anyways. To decrease costs in healthcare. Great, the next question, how have you managed communication to patients in your community about when it's safe to return to the hospital should they be having you know specific symptoms of emergent, you know illnesses? Yeah, I can take the first time with that Christmas. I think that's critical. We definitely saw, you know, there's a lot of misinformation about covid, and there's lot of areas of debate. But the one thing we definitely new in the narrow space was that patients were not presenting for strokes. And when they were there representing a very delayed fashion, that's the one thing that we all universally agreed on. So we started a campaign where we reached out to patient social media. I think it's critical just getting the word out that you can still come to the hospital. MUC very fortunate we had just right before Covid hit we had just opened up a Children's Hospital so we had vacated several units and we had a Children's Hospital. Wasn't yet full so we had extra capacity. I think that really helped us to escape. The worst of it, even when it became a hot zone the last two months. So we try to do is really have two parallel universes filling these several units that just. Between those Alex here. I can pick up the ball, then I think on Alex got disconnected for a second. Alex was trying to say that we increase our capacity. Fortunately at M USC due to the factory open up and you appears hospital and once the other Corbett units were getting filled up we definitely had the capacity at the Trueness hospital as needed. So I I believe M USC has is well positioned to take great care of patients. The answer your question objectively we again worked in social media. We send letter to our patients. Almost 100% of our patients especially having the rapid access clinic allowed us to change the way practice in basically almost 100% of their patients are being seen up front. So either of course scene. Face to face, for through Tele medicine and part of the consultation, we're taking the time to investigate into. Patients are symptomatic or not if they need to be tested, and also if educate them about how their care will be taking place during that. I think we build up strong collaboration and I strong trust that we are taking good care of them and we haven't heard complaints instead. So people are very happy with the way they're very happy to collaborate, to use masks to follow. You have tasks up front if necessary, especially if they're going to for generating seizure cases. So it has been a pleasure actually in the last few months to see that the engagement of the Community an with our with our staff. Yeah I would. I would echo it myself. Says that's really been one of the amazing things here you saw from our websites that we've really reached out to the community to try to engage them to be part of this process. You know, they all really know that it's safe to come into radiology that the patients are all being tested when they come in that we have social distancing. We've also obviously had a very strong governor, and all of this we went into Phase one early on, where we stopped all elective outpatient procedures. But we're very conscious to make sure that we were still providing care for patients who needed it, and now we've moved on to Stage 3, where we're starting to do elective procedures and slowly into stage four. Hopefully this week, gyms are supposed to open today, I think I haven't seen the news yet today. One last question for the group, are your hospitals seeing stability and capital allocation, and do you believe that more stimulus will be needed within the next year for hospitals? I'm happy to take the beginning part of that. We are estimated to be have lost be losing somewhere in the neighborhood about 500 million dollars a month. It has been a unbelievable financial burden on the hospital, a massive financial loss. It's been really a challenges. We went through this in radiology, particularly the first month into this. I was about $2,000,000 behind budget, the next month, another 2 million the next month. After that another 2 million. Dan, it's challenging to try to figure out how to financially survive this without help from the government. As we go through this, it's been very, very challenging and you know, it's interesting. I'm sure myself lot like us, we're and academic practices. And so when you hear about these layoffs and everything else as opposed to people in private practice, I don't share in the upside when we have, you know, Golden years. But all of a sudden we have trying times and we've been very fortunate that our. Dean has been very cognizant of this and really has insulated us realizing that there is good times and bad times and they can't expect us only two. Suffer when it's a bad time but not benefit when it's a good time and that's one of the benefits of being an academic that were a little bit insulated from that, and I don't know if you feel the same thing, but from the hospital standpoint and from my administrative role in radiology, it's a challenge. I've no doubt there when it bounced back, but it's never gonna be like it was before. I think Tele health Medicine's here to say, and I truly believe that radiology is going to be moving out of a big multi factor us. You know, MRI center in the hospital. The patients want to get their imaging closer to home and do Tele health with their doctor. Yeah, I agree 100% with what you said to Joshua. I believe Covid again comedy is a big problem. No question. But the crisis related to Corbett brightest opportunities. An enormous opportunities to learn that I was skeptical about doing telemedicine. Now 95% of my consultations are Tele medicine, right? So we learned there. We also learned that we can do more with last people. We have been more efficient. So I think the people are more engaged. I wouldn't say with less people would say we increase our capacity with the same number of employees. So those are phenomenal things that we learn. Seiko, instantly with not intentionally by no means with Chobit crisis, if you will, right, but the financial aspect is definitely a problem, and I think that our society, our hospitals, are going to fill the financial impact of Covid, which is not done yet for a long period of time. But instead of thinking in focus on the lack of money, I think it is important to do is to see what can we do to improve our quality of our service and also bring more money. I don't think we need to focus on that part. An not be complaining right? So what we did is we we basically our Department. Radiology has been excellent in facilitating access to patients in a Safeway. We have done the same thing and we've been partners with the administration to try to increase revenues and I have the previous to say that in the last few months we've been a strong partner of. Demonstration in order to help with the financial recovery. Yeah, right appears that that's been one of the most impressive things with that coordinated care where patients are now coming in for essentially no one shop. Stop shopping where they can get their imaging. They can get their labs that can get their doctors appointment by Tele Health all at the same time and tell how really has been revolutionary for us at New York Presbyterian Columbia. We were probably somewhere in the neighborhood of about 5 to 10% of visits being done. It by Tele Health to now being well over 80% of patients being visited by Tele Health and my patients. You know, love it. They've got you right there. Most of are very become very fast out with it and it's really changed the way that we do medicine. Agreed. Well, thank you again to our expert panel. You guys have all been wonderful. We truly appreciate the incredible insight that you've provided for our audience. And thank you to everyone in the audience that took the time to join us this evening. Thank you so much. Thanks so much. Have a good night. Thanks everybody. Enter Alex thinks everyone says safe. My question is much.

STAR: A Multicenter International Collaborative Registry of Real-World STAR: A International Collaborative Registry of Real-World increasing the risk of exposure to personnel. Intu- STAR SIEMENS •. SIEMENS • SIEMENS • SIEMENS .. SIEMENS •. Outbreak COVID OVID Int Int to Outcomes After Mechanical Thrombectomy for Ischemic Stroke VIRTUAL (ZIP) REDEFING PATIENT AND io f in . Vent utilization . Vent Vent Utilization Overall COVID+. vent Utilization Heatthineers • Healthineers Healthineers • Heatthineers • Heatthineers Health Matters COVID-19 Webinar: COVID response COVID rooms in VIR at MUSC Standards bated patients pose less of a transmission risk to UNDOCUMENTED COVID STATUS MT IN HCCVS. LCC MT IN I-ICC VS. LCC URGENT IR Challenges Staff Fears Patient Fears RESULTS: 34 CENTERS COVID+ Inpatient. ICU, Ventilator Utilization COVID+ Inpatient, ICU, Ventilator Utilization COPECOLUMBIA Today's Presenters Redefining Safety COVID crises? = opportunity March to COVID BURDEN HOTLINE: Compassionate Care Coordinators Where we are PATIENTS FEAR SEEKING TREATMENT Pandemic Future Challenges... COVID response in VIR at MUSC Navigating the New Normal in Vascular and Neuro Interventional Radiology: HERE PHYSICIAN SAFETY GENERAL ANESTHESIA VS. CONSCIOUS PARTICIPATING SITES (N=28) NYP neurointerventional staff given that their ventila- 'RECOMMENDATIONS' MUSC LVO PROTOCOL INTERVENTIONAL* Screening for fever and respiratory symptoms should be part P-value t Thrombecomy patients in high COV ID-19 Thrombecomy patients in COV ID-19 RESULTS: 458 PATIENTS Thrombecomy patients in high COV ID-19 patients in CO VID-19 European Society of Minimally Invasive Neurological RESULTS: 34 CENTERS 646-697-4000 Video chat with COVID-19 + PATIENTS Clinical, Operational, and Financial Challenges During COVID-19 Lessons Learned April, 2020 8.5 t burda (BCE) (—104) burda (—104) (EVEN WITH STROKE!) (—104) STAR? July, 2020 Distribution in NYC The Stroke Thrombectomy The Stroke Agenda: GENERAL ANESTHESIA VS. CONSCIOUS COVID-19 AND THE STROKE PRACTICE PATTERNS BY COVID BURDEN Total Admit Counts Total Discharge Counts Total Mortality• • 6 SEDATION doctor now a doctor now now tion is managed through a closed circuit. None- Outbreak Re ist de Re from the Epicenter and Beyond BACKGROUND: COVID / MT CONCLUSIONS (l OF 2) 2. DESCRIBE WORKFORCE DEPLETION l. DESCRIBE MT-COVID EXPERIENCE CONCLUSIONS (2 OF 2) CONCLUSIONS MOVING FWD? FEB 2020... METHODS PURPOSE ENRG VA VA is is of the screenin of all otential neurointerventional atients. NYP-AMSCH 402 Build best practices in VIR TOTAL CASES COMPUETED TOTAL CASES COMPLETED Safe Place Trusted Care Safe Place I Trusted Care Best practices in VIR Protocol / Operational Challenges COVID COVID-19 72 (60-80) • Build best practices in VIR: "opposite direction" -f STAR S AR STAR? Total Admit Counts Total Total mscha Total M Therapy (ESMINT) recommendations for optimal LOCATION SEDATION • Best practices in VIR: Joshua Weintraub, MD, FSIR Marcelo Guimaraes, MD, FSIR Marcelo Guimaraes, MD, FSIR Alex Spiotta, MD In response to COVID, the Department of Psychiatry has pannered with Action plan: FSIR Preparing IR for COVID•19: The Singapore 6279 926 1286 1279 1137 1937 1096 164 (46.3%) Build best practices in VIR: input from MUSC experts Build best practices in VIR: input from the MUSC theless, isruption of the circuit (such as for a cuff VIR outpatient clinics: Build best FIND A RADIOLOGY March to Reaching for Higher Level Redefining Patient Safety NYP-AH 10349 1034 196 NYC was the global epicenter for VID-19 Screening patients prior to procedure Welcome to our webinar Guided by our internal experts and recommendations from the Centers for Guided by our internal experG and recommendations from the Centers for THROMBECTOMY 0.885 Experience THE POWER OF REAL-TIME LARGE HERE CASES CASES COMPUTED COMPUTED IS 78 9286 Intubation of these patients prior to transportation to the angi- Constantly changing message Moved to front line / Redeployment Facing Fear: Patient Fears Medical University of South Carolina Medical University Of South Carolina Medical University Of South Carolina Medical University of South Carolina New York Presbyterian, Columbia 7421 Patients Radiology and System Wide Facilitated chance to see and speak to their loved ones Hospital infrastructure challenges 12685 Patients Columbia Doctors and NewYork-Presbyterian in developing CopeColumbia Columbia Doctors and NewYotk-Presbyterian in developing CopeColumbia Data from Johns Ho kins University Center for Systems Science and COVID+ CASES PRECAUTIONS •scnermc stroge jscnermc jscnermc stroge •scnermc 435 LKN - 286044-639) - 286 (144-639) 286044-639) 255 (105-490) 0.262 Joshua Welntraub, MD, SIR, Executive Vice Chairman of the Engineering (CSSE) &OVID- 19 tracking projecti: Best DOCTOR April, 2020 Disease Control and Prevention (CDC) YOW yow eak, suctioning, endotracheal tube manipulation) 51 experts interventional neurovascular management in the Learn from others (New Orleans, NYC, Italy, Leamn from others (New Orleans, NYC, Italy, v/ Learn from others (New Orleans, NYC, Italy, al al r No family allowed in hospital practices in VIR: Apoorva University University of On multivariate analysis, intubation status was associated with: __i The statements by Siemens Healthineers' customers DICTUM: 28 thrombectomy-capable stroke centers (STAR / ENRG) • Availability Availability Department of Radiology and Chief of the Division of Vascular and Sundeep MO. in the ICU. . WE WE 27430 2663 MO. FRCR. MO. in ICU. Constantly changing message Hospitalized patients • Week March 23rd: elective procedures only Standards Standard PPE ORIGINAL RESEARCH SPECIAL ography suite should be considered, especially in patients with Patient Different staffing model: Confirmed COVID- 19+ Infection Rates: Telehealth — Conversion of 80% 2378 Death 1137 Death Adminim NIHSS, DATABASES TO ALTER PRACTICES NIHSS, Surgery/Nursing/Scrub 16 (10-21) Anil MO. FRCR. Anil MD. FRCR. Anil Gopinathan. MD. FRCR. MD. FRCR. Scenario Anesthesia Provider Cleaning Crew 0.491 • Compared to MAC, GA patients : Provides information and resources for the CUIMC community Navigating the New Normal in Initially tried to divide locations, but then elected to teams an release additional aerosolized secretions. WEBNAR Acute stroke LVO patient route to Surgery (NES) for Acute stroke LVO patient en route to Surgery (NES) for EXPERIENCE STROKE: Acute stroke LVO patient route to Surgery (NES) for T.brorpbectogpy: —acc —ACC 196 Han Wei Maas. FRCR. Han Wei MBBS. FRCR. Han wei Ton. Maas. FRCR. Han Ton. MBBS. FRCR. input from the practices - 241/458 (52.6%) of patients underwent planned pre- Seattle, Singapore) TIER I (HCC): maintain 'covid' protocols (protective) described herein are based on results that were achieved MECHANICAL THROMBECTOMY IS GENERALLY A 'LOW RISK' (LOW AGP) PROCEDURE New York Presbyterian, Columbia University New York Presbyterian, Columbia — Metropolitan NY is over 20 Millio peopl — Metropolitan NY is over 20 Millio people Metropolitan NY is over 20 Millio peopl Delayed presentation of acute ischemic strokes SIEMENS • (EVS/Anes tech) Ownership PPE Wen Cheong. MBBS. FRCR, Suresh Babu, MBBS. FRCR. Wen Cheong. MBBS. FRCR, Suresh Babu. MBBS. FRCR. Endovascular Neurosurgery Research Group (2004 / 41 faculty) Given: North America, South America and Europe COVID-19 Retum to work with residents Risk of Infection Infection disease STROKE Majority converted to Telemedicine: I. Describe the MT experience during COVID pandemic across diverse Staff and patients with surgical mask all the time Radiology Residents and Faculty In this prospective, multicenter, international study we Majority Patients will fall into scenario #3 or g 4 (YELLOW highlight below from exec guidelines Majority Patients will fall into scenario g 3 or g 4 (YELLOW highlight below from exec guidelines Majority Patients will fall into scenario # 3 or g 4 (YELLOW highlight below from exec guidelines Prospective, multicenter, international COVID-19: What Should Interventional it.•adthestory it.•aldthestory lt.•adthestory thestory "As physicians. we know there are "As physicians, we know there are Caregivers ra BALANCE: Pre - Procedure Very early on: implemented universal precautions Bernard wee. FRCP. FRCR. Goh. Maas. wee. MBBCh, FRCP. FRCR. Goh. Maas. wee, FRCP, FRCR. Goh. Maas. wee, FRCP, FRCR. Goh. Maas. FRCR. Bernard wee, MBBCh, FRCP, FRCR. Goh. Maas. FRCP. FRCR. Goh. Maas. risk factors for intraprocedural intubation as noted above. Given Initially NO Visitors Open the VIR Rapid Access clinic Society of Neurolnterventional Surgery Vascular and Neuro Vascular Anomalies 129 (27.9%) 129 329 (27.9%) 19% Mortality Mortality Radiology moving to communities Iss (43.8%) Counseling sessions herefore, we recommend standard institutional DURING AN UNFORESEEN PANDEMIC Evidence of self quarantine in both high and low CANADA Bien Peng Tan. MBBS. Bien Tan. FRCR. Bien Peng Tan. Maas. Bien Tan. MBBS. FRCR. Bien Peng MBBS. FRCR. Radiologists Know and What for PPE) in the customer's unique setting. demographical regions ('hot zones' vs. not, rural vs. urban..etc) including time 1761 236 336 80 experts Procedurelly. procedure GA procedurally. Procedure during the COVID-19 crisis l. Low number of COVID-19 infections among patients l. Low number of COVID- 19 infections among patients —Area population is over 0 000 per $quare mile —Area population is over l. 0 000 per $quare mile —Area population is over l. 0 000 per square mile campaign 0.7063 <0.7063 8 (7-10) 6 (3-10) Reaching for Higher Level Efficiencies t o' COVIO•t9 on work.'orc• in t o' COVIO•19 on work.'orc• in 592 providers providers Higher probability of in-hospital mortality (RR 1.871, 95% Cl MBBS. MRCP. FAYS. MBBS. MRCP. FRCR. MBBS. MRCP. sviN Efficiency risk of exposure to providers Using mask (N95+ googles for COVID+ patients) in VIR found: Family Isolation of Family members Infecting family member Consecutive patients who underwent MT for LVO during the peak two months of the COVID- 1 9 Consecutive patients who underwent MT for LVO during the peak two months of the COVID- 19 How to avoid contamination Nursing and Staff Redeployed to ICU AMAZING Centers in Counties COVID-19 rate 500 cases / 100,000 = high COVID- 19 Centers in Counties COVID-19 rate 500 cases /100,ooo = high COVID- 19 Centers in Counties COVID-19 rate 500 cases = high COVID- 19 TIER 2 (LCC): revert to tried-and-true local protocols (fast, expedient) COLUMBIA RADIOLOGY can They Do? INSIGHTS FROM times when. despite our years of 2 hr observational study More than 300 calls in the first 3 weeks. Pregnant staff: working from home Interventional Radiology, Interventional Radiology: Maas, FRANZCR. Maas, Megs, Maas, MRCP, MRCP, Masks required / Staff, Patients, Visitors U.S.A PÄicr n (%) Hospital Staff 8 (7.7%) 8 (7.7% NYP-AMSCH NYP-AVCH NYP-HVCH 627 6279 97 3. Asymptomatic• or 4. Asymptomatic* or 38 (10.7%) 1096 standard PPE if NOT Standard PPE if NOT Country'StMe with Countryßt*e with with Single-use N95 + FOR You! You! Non-anesthesia providers metrics and outcomes. Identify any potential impacts of protocol metrics and outcomes. Identi9 any potential impacts of protocol metrics and outcomes. Identi9r any potential impacts of protocol metrics and outcomes. Identifr any potential impacts of protocol metrics and outcomes. Identi$• any potential impacts of protocol hoSpitaJs havea be capååty 2 hoSpitaJs have be capååty 2 Younger (70 vs 73, p=0.02) Younger (70 vs 73, p=O.02) t at t rom ectomy is suc a time-sensitive proce ure, t at at t rom ectomy is suc a time-sensitive proce ure, t at rotocols with a low threshold for intubation 50% Mortality for ICU patients hospitals have be capååity 2 hospitals have be capåéity 2 hoSpitaIs have be capåéity 2 Destination Radiology Marcelo Gulmaraes, MD, FSIR, Director of Vascular Interventional Marcelo Gulmarag, MD, FSIR, Director of Vascular Interventional Marcelo Gulmaraes, MD, FSIR, Director of Wscular Interventional Marcelo Gulmarag, MD, FSIR, Director of Wascular Interventional Marcelo Gulmarags, MD, FSIR, Director of Vascular Interventional Marcelo Gulmaraes, MD, FSIR, Director of Wascular Interventional Marcelo Gulmarag, MD, FSIR, Director of Wscular Interventional Marcelo Gulmarags, MD, FSIR, Director of Wascular Interventional Shaun Ju Min Chan. MBBS. SVIN COVID-burden regions Decompress ER Peer support groups Mohamed Aggour,l Phil White,2'3 Zsolt Kulcsar O Jens Fiehler,5 Patrick Brouwer6'7 uwer6.7 6.7 AVOIDANCE OF UNPLANNED (UNPROTECTED) AEROSOL-GENERATION IN ANGIO SUITE recommendations for the care of emergent with LVO undergoing MT in Low COVID burden counties HERE THINGS I. University of Carolina l, Medical University of South Carolina l. university of South Carolina l. Medical University of South Carolina Medical, University of South Carolina l. Medical university of South Carolina l. Medical. University of South Carolina Medical University of South Carolina Medical. University of South Carolina university of South Carolina University of Carolina NYP hospitals have a be capåéity 2 hoSpitaJs have be capådity 2 hoSpitaJs have be capacity 2 hoSpitaJs have a be capacity 2 hoSpitaJs have a be capåéity 2 hospitals have a be capacity 2 •2000 pop moo Pop Pop pop Phil Frequent hand washing Heatthineers • surge (February-March or March-April 2020) HeaLthiw Zhu. MD. Chu-Hui Zeno. BSc. Jian Lu. MD. and Zhu. MD. Chu-Hui Zeng. BSc. Jian Lu. MD. and NYP-WD 12 Criteria to bump to highlight contingency below) that WILL require intubation Clemens M Sdirrnéi O Andrew J Ringe2Adam S Arthüi O Marv J Binning, s Clemens M Sdhirméi O Andrew J RingQ2Adam S Aråui O Marv J Binning, s Clemens M Sdirméi O Andrew J Ringe2Adam ShArtuii 0 Marv J Binning, s Clemens M Schimei O,' Andrew J Ringe2Adam S Aråur 0 Marv J Binning, s Clemens M Schirmei O,' Andrew J Ringe2Adam S Arthüi 0 Marv J Binning, s Clemens M Schirméi O Andrew J Ringe2Adam S Arthüi O Marv J Binning, s Clemens M Sdirrnéi O Andrew J Ringe2Adam ShArtuii 0 Marv J Binning, s Clemens M Sdhirrnéi O Andrew J Ringe2Adam S Arthüi O Marv J Binning, s MACS. FRCR. MRCS. FRCR. EBtR. MRCS. FRCR. MRCS. SWAT team development Excellence burden counties (HCC) Drastic volume reduction •ouwer I .066-3.284, p=O.029) .066-3.284, p=O.029) freeuently unknown COVID status of patients presenting w face shield or present for airway leave room for intubation and I-ICC 9 (8.6%) HCC 9 (8.6%) Infecting family member Radiology, Radiologw Radiologw, •a 203 (57.3%) v/ Address staff fears: modifications? 2. Of Miami System 2. university Of Miami System 2. University Of Miami System 2. Of Miami Health System 2. University Of Miami Health System 38 (36.5%) -WE 203 (57.3%) SOCIETY FOR NEUROSCIENCE <0.001 <0.491 Clinical, Operational, and Hand Sanitizers lalk to kids. I alk to kids. Goo-Jun Tong. MO Goo-Jun MO Goo-Jun MD Tong. MO MO. centers education, all we have to offer is our education. all we have to offer is our I alk to lalk to l alk to Chow Wei Too. FAMS, Raymond Chung. MBBS, Too. FAMS, Raymond Chung. MBBS, APPs: inpatient consult serv/ice work done via video/phone APPs: inpatient consult service work done via video/phone APPs: inpatient consult sen/ice work done via video/phone APPs: inpatient consult senv/ice work done via video/phone APPs: inpatient consult sen./ice work done via video/phone APPs: inpatient consult setv/ice work done via video/phone Room turn-over protocol CAERE HERE HAERE Provided meaningful communication to patient families Provided meaningful comnmunication to patient families 20 min Grand Total 7421 5056 1137 f stroke thrombectomy COVID-19-positive Medical University of South Carolina W Christopher Fm. 6 Robert F Jarnes7 Michael R Levitt o. Rabih Tank, W Christopher Fm. 6 Robert F James 7 Michael R Levitt o Rabih Ta*. W Christopher Fm. 6 Robert F Jarnes 7 Michael R Levitt o Rabih Ta*, W Christopher Robert F Jarnesl Michael R Levitt o Rabih Ta*. W Christopher Fm. 6 Robert F Jarnesl7 Michael R Levitt o Rabih Ta*. W Christopher Fm. 6 Robert F Jarnes' Michael R Levitt o Rabih W Christopher Fm. 6 Robert F Jarnes'7 Michael R Levitt o Rabih Ta*. W Christopher Fm. 6 Robert F Jarnes' Michael R Levitt o. Rabih RISK procedure WITH general include: family members are often not available to provide a complete More likely to have received IV tPA (45.6% vs 34%, p=.01) ardian (IQR) 3. Sinai System 3- Mount Sinai System 3_ Sinai System (IQR) NYP-WC 'N 692 Jin Ong. FRCR. MESS. Jin Ong. FRCR. Jin Ong. Jin Ong. Andrew Tan. Jin Ong. FRCR. Tan. Meas. Jin Ong. FRCR. Tan. 18932 12685 68 (36-123) 68 goggles placement, otherwise 85 (54-127) 0.054 0.004 and the 15 mins Exceptions: clinic in person: There can be no guarantee that other customers will Infection control cot cm COL (19 of 23 saw zero) Mean SO the New the Sew Mean O Mean SO Cleaning of rooms protocol the in social media Telehealth, Labs, Care Coordination Procedure Guided meditations "One-stop" shopping for patients who live far away STAR/ENRG HAPPENING IN *ÆSTHESIOLOGY IN IN CARE Thirteen (2.8%) patients were confirmed COVID- 1 9 positive out of 242 MT who were Thirteen (2.8%) patients were confirmed COVID- 1 9 positive out of 242 MT patienÜ who were Thirteen (2.8%) patients were confirmed COVID- 1 9 positive out of 242 MT patients who were Bien Tan, Bien '-RCA. Bien - Of those undergoing monitored anesthesia care 4. Baylor Celege of Medicine 4. Baylor of ved'cine 4. Baylor Code-ge of Ved'cine 4. Baylor Co'lege of ved'cine 4. Baylor of Medicine 4. Baylor of Vedicine 4. Baylor Co'lege of Vedicine 4. Codege of Safe operations 99 251 RN Being safe and healthy.. CUIMC NYP and Siemens Child Care • Lower probability of functional independence on discharge Financial Challenges During neurointerventional patients in the setting of COVID-19 Erol Vemedaroglu, 9 Melanie Walker. Alejandro M On behalf of the Erol Vemedaroglu9 Melanie '0 Alejandro M On behalf of the Erol Vemedaroglu9 Melanie Walke Alejandro M On behalf of the from Screening all patients, visitors and staff elective 14 12 14 COVID-19 anesthesia 121 108 same as anesthesia Kiang MOBS. FRCR. SAMS Kiang Meas. FRCR. SAMS Meas. FRCR. SAMS following. The OR door should and develop close bonds with the families Gown v/ infection infection kindness and compassion." Open on Saturdays for elective cases COVID rooms v/ COVID rooms htqy:.:.:www. S. West S. West University S. We-st University S. West Virginia University S. West Virginia LCC 4 (1.1%) Awareness Communications I.XN atients prior to transport to the angiography COVID+: last case of the day if elective COVID+:. last case of the day if elective COVID+'. last case of the day if elective COVID+:• last case of the day if elective 350 (195-686) 352 (200-651) HERDS HERES 0.5219 0.529 0.52194 RECD INPUT 'VETTED Compared to non-COVID patients, COVID- 19+ patients: COVID-19 Toolkit SIR webpage Redesigning Critical Disease Protocols — achieve the same results. COLLABORATORS to Universal precautions Longer door to groin time (92 min vs 67 min, Carts and equipment moved out of the room acuity of intervention required 434 medical history, and that a neurologically impaired patient may occlusion Read the •torv Head the ston Read the stonv Read the story Head the stun 6. Of Arizona 6. Of Endovascular Research Group (ENRG) 6. University Arizona 6. In all low COVID-burden regions, there were zero 2378 providers remain closed. Anesthesia Planning for the second spike Double gloves 2. Very low rate of unplanned intra-procedural intubation PAD Discharge counts NOTE: Can be flexed up and down depending on the current COVID Suggested reading, and other resources for managing stress, fear and Patient-centric Patient Fears (MAC) or no sedation for MT: Telemedicine: COVID-19 Job Cleaning, cleaning, cleaning Centers in Counties with < 500 cases / = low COVID- 19 burden Insights from STAR and ENRG collaborations 228 (RR 0.53, 0.318-0.884, p=o.015). Wake Health 3aotist Health 3.aotist Health 3aftst Health UPDATE Health 99 'Saint Etienne, Rhone•AJpes 'Saint Etienne. Rhone-Alpes 'Saint Etienne, Rhone-Alpes Kept staff hours: happy and safe = high performance Health S Health • S • S of median of ædian of passa., ædian of passa, median 2 (1-3) 1 I Cmo1D-19 I coding and b"ing I 1 Cmo-19 I coding and b"ing I 1 I coding and biling I 1 19 coding and biling I 1 I COMO-19 coding and b"ing I 1 COWD-19 I coding and biling I I Cmo-19 coding and b"ing I STAR Registry (Stroke Thrombectomy laid-offs/furloughs availability of such management internally. It • internally. It internally. It INTRODUCTION Europe Keeping rooms safe and tum over 4. 1. NIHSS > 15 or GCS 9 STROKE NEUROL staff should not exit the room. v/ Negative uite, ideally in a negative pressure environment. Negative Hospital Leadership Draping of remaining items v/ Draping of remaining items S. Thomas Jefferson Jniversity Thomas Jefferson Jniversity Thomas Jefferson university Thomas Jefferson University Thomas university Thomas Jniversity Heatthineers • Heatthineers Health Matters Healthineers • Heatthineers Healthineers What patients should be tested? Marcelo Guimaraes, MD, MBA, FSIR Marcelo Gulmaraes, MD, MBA, FSIR Marcelo MD, MBA, FSIR Longer procedural time (47 min vs 32 min, VUSC is his VUSC his is his D'. his his MUSC Younger his o' anxiety. mind-set health care providers (MD/Tech/RN) testing positive 32. Jniversitåtsmedizin Germany 32. Jniversitåtsmedizin Gdttingen. Germany 2.3 Michael Chen, 4 Michael Levitt,5 J Mocco,6 Michael Chen,4 Michael Levitt,5 J Mocco,6 .evitt,5 J Mocco,6 France Lessons Learned from the Epicenter and not be able to answer screening questions, it is recommended counties (LCC). Now what? have been reports Of a material ABSTRACT 44% Justin F Fraser Adam S Arthur O Social (Physical) distancing 9. Beth Center The Coronavirus Disease 2019 (COVID•19) The Coronavirus Disease 2019 (COVID-19) might be beneficial to consider re-dispatching Timeline for IT and Hardware changes 9. Beth burden of the population any given hospital serves. Outpatient work disappear [Inpatient Chest Xray increase Vascular Anomalies If 15 mins interval not possible SAFE HERE 9 Europe Agitation / combativeness and Aneurysm Registry) 2. Evaltnte the effect of the pandemic on the provider workforce i.e. were 2. Evaluate the effect of the pandemic on the provider workforce i.e. were 3. Patients who were intubated prior to MT were more 23_ Yale University 23. Yale University 23_ Yale university w«ws during the pandenic. the SIR is releasing information Health Give during the pandenic. the SIR is releasing informatimn Facilities / Maintenance of during the pandenic. the SIR is releasing information of w«ws during the pandenic. the SIR is releasing information during the pandenk. the SIR is releasing informatimn MD 298 (84.2%) 33. Hospitalar universitårio de Lisbo, Portugal 33. Hospitalar Universitårio de Lisbo, Portugal 33. Hospitalar Universitårio de Portugal 33. Hospitalar universitårio de Lisbo. Portugal 33_ Hospitalar universitårio de Portugal <0.491 0.2621 'Institute for Ageing ard Health. ilnstitute for Ageing and Health. Post Recovery PATIENT OUTCOMES / PROVIDER TO Two buildings: 2 separate teams of attendings, fellows, COLUMBIA UNIVERSITY DEPARTMENT OF RADIOLOGY in of acute neurological injury. includi in of acute neurological Injury. m of acute neuroloøcal injury. includl m of acute neurological injury. includi of acute neurological Injury. of acute neurological injury. includi NS 1 NEUROSURGERY The COW 19 The COW 19 has The 19 has COW 19 has Director of Vascular Interventional Radiology, 10. University of Virginia 10. of 000. 10. Performing bedside procedures whenever possible to 9 This is a changing to the 1 9 patientS This is a changing 1 9 patient& This is a changing 9 This is a changing 1 9 patients This is a changing 9 patienw This is a changing to Of 9 patients This is a changing •WeA'eRex:iv gWeA'eRe.dv •W.A"Re.dv 24_ Rutgers Health How to Stav How to Staff Meeting pandemic began in December 2019 in Wuhan, patients after intervention to their primary care the pumal or Instance, patients wit ommant enusp ere the the puma' pumal journal Many scientific societies recommended and centers pressure rooms 34. Jnivegsity Hospital of Nancy. France 34. University Hospital of Nancy. France Beyond MEDICAL UNIVERSITY scenario 2 Scenario Prece&.re Felipe C Albuquerque, 7 Sameer A Ansar18 Guilherme Dabus,9 Mahesh V Jayaraman, 35 38 41 (25-69) 0.177 10 Longer door to reperfusion time (138 vs 100 min, Waiting rooms re-organized as new information is released, stroke. and also reports in del stroke. also reports in del Joshua L. Weintraub, MD, FSIR Bar row Neurological Institute Alex Splotta, MD, Professor of Neurosurgery and establtsred care pats Peet establtsred care pans Peent establisred care pats Poent establsred care pans Peet establsred care pans Peent establsred are pats Peet establtsred are pans Peet be as new informnation is released, as new information is released. as new in'ormation is released. Aphasia and/or inability to communicate, understand instructions to remain still Aphasia and/ or inability to communicate, understand instructions to remain still Barrow Neurological Institute Neurological Institute Institute )i.stancing: I. 1. centers able to maintain stroke services? How often were providers depleted 9 Beth Hearth Beth )istancing: Of the 242 patients that were tested: Emergency cases protocols w/ and wo GA V Jayaraman, < o.os € o.os Newcastle University. Newcastle for for COVID- 19 25, Johns Hopkins university 25. Johns Hopkins university COLUMBIA Higher NIHSS on admission I lealthy Whil Ilealthy Whil lealthy Whit that patients of unknown COVID status be treated as high risk likely to have in-hospital mortality and less likely to be I lealthy Whit I lealthv Whit I Whil lealthy Whil Whil Whit Lay offs / Decreased Revenue Where to move COVID patients SOUTH CAROLINA Economic Challenges 2/217 patients (0.9%) converted to GA residents, APPs, RNs and RTS Elizabeth West, MD University Of Washington University Of of the paromk and limitat:om .•nmsed of the paromk and limitat:om immsed Of the and limitat:O-s of the paromk and limitatom immsed Of the paromk and limitat•-s of the par*mk and limitat:om immsed Of the par*mk and limitat•-s Of the paromk and executive limitat•-s of the paromk and limitat:om•s .mmsed in pregntation for both neurological and cardiac in prernt•tion for both neurological and cardiac in pregnt•tion for both neurological and cardiac in prerntation for both neurological and cardiac intra- University W University Washington China. The outbreak is due to severe acute respira- hospital of origin if possible. It is important to Neuroendovascular Surgery, Medical University of South Carolina EMERGENCY DEPT What Standard PPE Standard PPE You 0.05 26. Spectrum Health adopted modified protocols, ex: presuming all patients be rather than transporting isolation patients to VIR upon Tyne. UK occlusions, very high National Institutes of Health Asia Executive Vice Chair, Department of Radiology Alejandro M Spiotta, MD Alex Spiotta, MD N ausea / vomiting N a usea / vomiting Staying I Staying Stay ing I Stay ing E-check-in 2. due to either quarantine and/or COVID illness? due to eiåher quarantine and/or COVID illness? due to eiåer quarantine and/or COVID illness? due to quarantine and/or COVID illness? 13. University of 10. of 10. University of University William J Mack, 11 James Milburn, 12 Maxim Mokin O Sandra Narayanan, 14 William J Mack, 11 James Milburn, 12 Maxim Mokin O Sandra Narayanan, (60-188) sugesting that patients are not *eking that patients are not *eking Door public life have the to public life have the grcept:on to public life have the grcepton to public life have the grcepton •f to public life have the •f to 127 (79-176) 10 19 14 Andy Ringer, MD Build best practices in VIR SAFETY Changing What's Possible Changing Possible Changing What •s Possible Division Meetings v/ Ante-room Ante-room COVID-19 Low COVID.19 ced to ecd to eed to Knov. ced to Knov. to Knov. 27 _ Bon Setours Medical Center 27 _ Bon Secours Medical Center eead to Know Know 0.05 0000 to Less likely mRS 0-2 discharge group: 45 (24.5%) vs 51 (35.4%), *Neuroradiology. Neæcastle *Neuroradiology. Ne.vcastle YNeuroradiology. Ne.vcastle untested patient for LOW tory syndrome coronavirus 2 (SARS-CoV-2) infec- 35. Chonnam National university Hosp.. Korea 35. Chonnam National university Hosp., Korea have daily feedback about available ICU beds, Room Cleaning VJ.JSC rayanan, 50 were in High COVID-burden Couny (HCC), of which 9 (17.3%) were positive functionally independent on discharge. Cornell University Cornell university Cornea University Asia university tQly and appropriate medical care for th tQly appropriate medical care for th tQly appropriate medical for th appropriate medical for th Of the 28 centers: 5 centers qualified as HCC, remaining 23 were LCC. care for We care for •cute some We care for some We care for •cute We COVID- 1 9 positive until proven otherwise, lowering COVID- 9 positive until proven otherwise, lowering Salary Cuts / Benefits / Vacation I Meeting Time Salary Cuts / Benefits / Vacation / Meeting Time One week on, one week off 28_ Alleghany General Hospital for COVID-positive (see above), provided institutional resources Respiratory distress, symptoms concerning for COVID (cough, SOB, fever, egg) or any known Respiratory distress, symptoms concerning for COVID (cough, SOB, fever, or any known Prevelance Similar recanalization success and Outcomes ANESTHESIA (CDC guidelines) 36. Hokkaido University Hospital. Japan Telehealth consults of of ande artde ande Read the Read the story Recd Read the •torv Head the stonv Read the Read the stonv Head the stony Read the «torv Read the story Read the I S _ Rush university Rush Rush University upon Tyne Hospitals Newcastle IS _ Rush IS _ Rush University I S _ Rush University IS _ Rush Jn:ive-rsity University Of Stroke Scale score or a low Glasgow Coma Scale conditicms.' On the other hand. some of the On the other hand, some of the • $(3-10) to study whethe is a in RISK procedure WITHOUT tion. Healthcare contamination and infection rates to whethe is a in to whether is a in to whethe is a *lay in as well as anesthesia and staff availability. (IQR) Ajit S Pun,15Adnan H Siddiqui O, 16,17 Jenny P Tsai, Richard P Klucznik19 Jenny P Tsai, 18 Richard P Klucznik19 29. Erlanger Health System 6(3-10) 0.364 0.885 Ajit S Pun, 15 Adnan H Siddiqui o, Ajit S Adnan H Siddiqui O, C.avaa via Getty Images C.avaa Images via Images Cavan via Getty Images via Getty via Getty Images via Getty 37. Hyogo College Of Medicine, Japan S' COVID+ last case of the day MUSC 16. The of Tennessee HSC the of Tennessee HSC thresholds of pre-procedure intubation p=o.03 ill COVID• 19 patients are presenting with ill COVID 19 patients are presenting with COVID positive patient J Vasc Interv Radiol 2020; 31:8769-875 J Vasc Interv Radiol 2020; 31:8769-881 acute isch6nc *tients acute ischenc acute ischenc wtients acute isch6c *tients rmth acute isct•ec ßtients acute *tients acute ischenc *tients acute isch6c ßtients acute 192 were Low COVID-burden County (LCC), of which 4 (2.1%) were positive (p

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