 Welcome to Texas Heart Institute Educational Programs on Cardiology in the Time of COVID-19. I'm your moderator and host for this session. My name is Juan Maria Crazier. I'm an Interventional Cardiologist at Texas Heart Institute and CHI Health, Baylor St. Luke's Medical Center, and program director of peripheral vascular intervention at Texas Heart Institute. Our co-moderator today is Dr. Stephanie Coulter, Welcome, Dr. Coulter, and join me during this presentation. Thank you, Dr. Crazier. Dr. Coulter is assistant medical director at Texas Heart Institute and director for Center for Women's Heart and Vascular Health, and also program director of cardiology disease fellowship and director of cardiology education at Texas Heart Institute. Today, we're very fortunate to have two special guests dear to my heart because I'm also really an echocardiographer. And we have with us today Dr. Raymond Stainback, who's the chief of the non-invasive section of cardiology at Texas Heart Institute at Baylor St. Luke's Medical Center. And he's also the vice president of the American Society of Echocardiography and was recently tasked to write the guidelines for echo utilization during the COVID-19 pandemic. As well, we also have, fortunately, Dr. Juan Carlos Plana, who's the chief of clinical operations in the section of cardiology of medicine, section of cardiology and medicine at the Baylor College of Medicine, the director of the Cardio-Oncology Center and the co-director for the Center for Advanced Cardiac Imaging at Baylor St. Luke's Medical Center. So I think this is a wonderful opportunity to discuss how we have taken our medical center in this time of a pandemic and modified things that we are doing and we're going to learn from the policies that we've implemented here and within our division across the state of Texas to better able ourselves to take care of our patients and to protect our staff as well. Thank you. Ray and Juan Carlos, welcome to this program. Thank you so much, Juanco. Thank you. Let's start with the current status of COVID-19 pandemic. As we can see here, from many different countries, the rising number of patients affected with COVID-19. And we can see now that U.S. is leading the world in the instance of this deadly pandemic that's affecting us and increasing in numbers from day to day. As a matter of fact, COVID-19 is the worst viral infection that our society and the world community has experienced since Spanish flu in 1918, when 50 million people died worldwide and 675,000 people died in the United States from viral infection. As we can see, the numbers are increasing exponentially and not only the numbers of infected people but also mortality is increasing exponentially. And it's affecting every single segment of our society. Now, as we can see here, if we look at the forecasting model as far as potential incidence of infection is concerned, we can see that up to over a million individuals can be infected if we continue with the same rate of infection as we are expecting currently in the United States. And as far as peak of infection in most of the areas that we can anticipate, it might happen in a month from now or even a little bit later. So what are the numbers that we can anticipate as far as infection is concerned? It is estimated that approximately between 53 to 79% of population here in the United States might get infected with this virus if we don't take aggressive and very appropriate measures. And the question is, are we prepared for this type of a scenario? Because pandemic is here and it's involving every single sector of our society and also the way we practice medicine. We've noticed that there's, with the planning for COVID-19, there's been great disruption in the health services in our hospital and ECHO labs are certainly not an exception. So to improve the safety of our patients and our staff, we recognize that our patient flow, procedural steps and implementation of new restrictive measures were necessary to determine when and how we perform procedures. We have implemented these measures before the outbreak of this pandemic in our Houston area community in order to be ready for when it hits. So in order to reduce ECHO lab procedures, we've categorized elected and emergency procedures, we postponed unnecessary procedures, we're performing ECHO procedures safely and in certain instances, we've limited the movement of COVID patients into our lab. We're trying to make effective PPE decisions for procedures. And most importantly, we're trying to ensure the health of our healthcare workers and order to deliver the care that we have become accustomed to. So Dr. Plana, can you let us know what the current situation and impact of coronavirus on cardiovascular care is at our institution? So thank you so much, Stephanie. I think that I would like to start with this reflection. This was actually included in the email from the headmaster of the school that my kids attempt. He says we are building the cheap as it sells. And I think that this represents pretty much the sentiment that I have and the rest of my colleagues have about COVID-19. We have the patients now in the hospital, but we are learning on the go how to treat them. The literature is just emerging in front of our eyes. But I want to talk a little bit about the impact on cardiovascular care from the cardiovascular service line standpoint. These are the list of things that we have been asked to address within the last few weeks. Number one, and you guys have already heard a little bit about these PPE. I think that this is the most important one. This is for me, the priority number one. We just want to make sure that our team has the appropriate personal protective equipment that they are safe, that they stay safe so that they can actually care for our patients. And there's not any other way of doing it. We don't want any of our staff, physicians, or fellows to get sick. And number two, cancellation of elective cases. We have got marching orders from the American College of Surgeons, the Surgeon General, and more recently from the Texas State Board about the need to cancel elective cases. Right now, they are allowing us to do emergent and urgent cases, which we call tier one and tier two. On daily basis, I get the list of patients that have been proposed to get procedures. We review them trying to make sure that they are appropriate and that indeed they represent emergent and urgent cases. Bear in mind that we have some guidance from the American College of Cardiology, but sometimes it's not that simple because the patients that we deal with are not necessarily black or white. I'm going to talk about two things in the next few slides. One of the situations that we needed to address. Number one is what is the telemetry admission criteria. And number two, who gets an echo when you are a COVID-19 patient. In fact, we talk a little bit more about the TEs and point of care ultrasound. There's going to be a complete section devoted to the management of STEMI cases that Dr. Junis and Dr. Perrin are going to cover. And I'm going to finish up by talking a little bit about the search plan that we have over here at Baylor St. Luke's. Before I talk about our criteria for telemetry and our criteria for echoes in the COVID-19 patients, I need to review with you this very important article because as you will see our strategy for the telemetry criteria and also for the echo criteria is completely based on biomarkers. This is the article by Chi Erol reporting on 416 patients in China. 57 of them died, which represents 13.7% of the population that they are reporting on. And very important, 20% of these patients had positive biomarkers. The one that they use was the highly sensitive troponin I. Very interesting patients who had cardiac injury, the ones that had positive troponins had a higher mortality. As you can see, it was almost 12 times higher were compared to the ones that did not have positive troponins and also a higher incidence of ARDS, 58% versus 14%. So cardiac injury and ARDS were independently associated with mortality, cardiac injury with a hazard ratio of 4.2 and ARDS with a hazard ratio of 7.89. So again, talking specifically about the telemetry criteria, we need to review how frequent these arrhythmias are. The manuscript from Wang et al. also from China reports that it happens in 17% of the cases. Unfortunately, they didn't specify whether they're dealing with atrial versus ventricular arrhythmias. To no surprise, the incidence was higher among those requiring ICUs. And the recommendation that they provide to us is that number one, patients with pre-existing cardiovascular disease should be in telemetry. Number two, patients with elevation in cardiac biomarkers. And number three patients that had severe COVID-19 disease, which most likely will already be in the ICU and will be monitored with telemetry there. So if you have, over here in front of you, our telemetry admission criteria. So if you have somebody that is COVID-19 positive or a PUI, then the first question that you ask yourself is, do you meet criteria by Baylor St. Luke's Medical Center telemetry criteria? If the answer is yes, obviously, you will go into telemetry. If you do not meet criteria, then we will do troponins. And if the troponins are positive in admission, then we will admit you to telemetry. We will keep you there for 72 hours and we will train troponins at least once a day for the duration that you stay in telemetry. If you did not get a positive troponin admission, we will get daily EKGs if you will be treated with the specific medications that are mentioned there, calitra, antivirals or plaque when ill. And we do not initiate telemetry if your troponin was completely negative. In terms of the criteria for echoes, as you know, we will frequently end up dealing with patients that have a troponymium upon arrival to the emergency room. We will not get an echo on every patient. We will only get an echo if you are having troponins that are going up with hemodynamic compromise or with evidence of signs or symptoms of cardiovascular disease. If your troponin is elevated when you get admitted to a hospital more than two times the upper limit of normal, what we will do before you get an echo is we will repeat your troponin 24 hours later and we will only consider getting an echo if, as I mentioned before, your troponins are going up. Yes, to finish up, let me share with you what is the search plan that we have over here at Baylor's and Luke's. It's color coded, as you can see here, goes from yellow to orange to red, depending upon the number of patients that we have on mechanical ventilation. So it goes from 19 to 59 to 148. As you can see, obviously, we will need to initially display patients from their original locations from so patients that were in CCU were moved to the cath lab holding area. Patients that were in the intermediate unit were moved to the cardiovascular pre-op area and patients that were in our LBAT and heart transplant units were moved to cardiovascular recovery. I have been asked to come with four different crews of cardiologists that could work along with intensivists and along with hospitalists in the different units of the hospital so that we can create enough manpower to care for 148 patients on mechanical ventilation. With that, I pass the torch back to you, Stephanie and Esbonco, and thank you for giving me the opportunity of being with you guys today. Thank you, Juan Carlos. I actually think that that schema that you've put up is super important. I'm part of an email blog with program directors from across the country who are concerned about, you know, upsurging their medical facility and how are we, can we add value to showing others how we've done it and how we're covering these units, which ordinarily a hospital of our size, which has maybe five or 600 beds at any other time, we really have 30 intensivists at any one time. And to go to a place where you have to cover 150 beds is going to take a lot of manpower and cardiology is one place in the hospital where we actually have a lot of manpower if you can teach us how to work the vents on the on the side. So we're going to have another session as well talking about ventilator management in the future. But Dr. Stainback, thank you for joining us and Ray's going to talk to us now about what we've done to make arrangements for really specifically the echo lab. So thank you. Thank you, Stephanie. And thank you, Dr. Crazier and Dr. Pona. Thanks for setting this up for me as Stephanie mentioned, I've been the chief of noninvasive cardiology and specifically the echo lab here at Baylor St. Medical Center for a long number of years and I have really been in a good position actually when it comes to getting advanced notice from other centers. And first of all, I want to shout out a concern for our patients ourselves and our families, our hearts and prayers grow out to the many patients and suffering from COVID-19. And as each of our speakers had mentioned, while dedication to patient care is at the heart of our profession, we also have a duty to care for ourselves and ourselves and our loved ones and protect all of our patients by preventing spread of disease. And this is from the recent ASC COVID guidelines document that was just published. I did participate in the editing of that document as part of the executive committee. And this was published online. I really recommend that you go to this website. It's published online and the authors on this document included Dr. James Kirkpatrick, who is at the University of Washington, which was one of the earlier centers to experience a large outbreak. This also was presented on a webinar on March the 20th very recently that also came from the ASC. It's a YouTube video as you can see here, and that will cover some of the material that I am going to talk about. However, I think some of this information can be a little bit generalized and one of my aims today is to get very specific. What exactly are we doing in our medical center that you can modify and what are specific strategies you can use? I've given a couple of other sides. The American College of Cardiology, who has actually endorsed our statement from the American Society of Echocardiography. So as we've heard, ECHO is essential to patient care. Its portability is tremendous. That's always been an advantage of our procedure, but the portability also causes a risk. We can spread infection. We can spread infections from outpatients coming into the facility. The machines we use can be vectors that can spread infection all over the hospital and to each other. So very key technique, but also very high risk. And for any facility this and don't forget EKG testing other noninvasive tests, it's a very high area of risk. As I mentioned, today's discussions will be focused on specific strategies to mitigate risk. With that risk individuals, we've talked about these other things to consider our appropriate use criteria. Dr. Pona mentioned that. And I actually participated in the writing of most of the ECHO appropriate use criteria. And I can say this is a complete rethinking of what is appropriate in the COVID era. It's very much focused on what's going to benefit us now in the near term and we can defer other things. There are specific ordering and schedule policies that you can admit, administer in very precise terms so that they're followed out. We've talked about patient classification and whether the patient's low or high risk makes a big decision point on what your plan would be. The procedure type in the ECHO lab we're talking about surface echoes, would they be in the lab, portable, their handheld options. What about T and stress echo, we'll mention those and we've talked again and again about personal protective equipment. And what are the noninvasive other noninvasive equipment environmental vectors that we need to cover so let's go through this. Quickly, I'm going to post this as a PDF to because there's material that you can print out and use as handouts and also modifying your own institution. This is just a screenshot from the cover page of the American Society of Echoes protection of patients and echo cardiography service providers during the COVID outbreak. And it's formatted in this way starts out with whom to image indications where to image how to image and this would include protocols protection for personnel equipment, the role of learners in your lab if you have trainees and other considerations that you may not have thought about. Who to image. I think we can look at the appropriate use criteria mainly from the standpoint of really trying to eliminate any rarely appropriate exam as a start and many exams will come as an order in your lab that they're actually appropriate but are they may not be appropriate in this circumstance. So you need to really think is there a clear near term benefit for this patient that will very much influence your management plan. If not, then you have to question the procedure. Can another high risk test be avoided if we do an echocardiogram look at it in context. We've created, I think it's important to create a triage and approval process and not just perform the echoes that are coming into your lab that sort of the workflow that we've had in the past but you have to really be on top of it and just not have people go out and scan patients. There really has to be a consultation with the ordering physician and a prioritization that's very active and engaged. Patients under investigation. Can we await the coven test results sometimes you know what you know you can tread water. A lot of our patients get orders and we'll have the conversation look at things. And the good thing about this if there's one good thing is under normal circumstances, the lab is running full out doing all the work that we can do. Because we've ratcheted back so much our usual care we actually we actually have more time to think and that's a very good thing to use use that time to really study every case. Discuss the limitations you know in this case could a handheld device be used or could another imaging tests suffice you don't need an echo for everything. A highlight is that the TE procedure is a risk for aerosolization of droplets you can get into the airborne precautions phase and so there you need the N95 mask. PPE conservation becomes an issue if you're doing too many teas you're burning through supplies. Stress echo is one of these things that came up literally after we did a revision of the document and we hadn't thought about the fact that we really should eliminate treadmill or any form of exercise stress testing in the lab even if it's an elective outpatient because of the heavy breathing and perspiration in the room with somebody so we really made a rule that pharmacologic stress only and particularly with our nuclear lab. Some labs do echo research studies that are scheduled. They just appear so you have to actively work the list. What is the research pertaining to. Is it something that can be really deferred unless it's life safety life saving procedure. All of this to say is you have to actively manage the echo order list. It may require calls and consultation but number one identify elective or non urgent exam request and defer. Identify urgent or emergent exam request and perform only these and defer all others so if you got those two for lines of thinking you should be okay and mitigate some of your risk risk is related to the numbers of studies that you're doing and exposure to outside patients especially in this situation with this virus where we have we really have seen that there is a symptomatic spread so you really have to limit who's coming into our lab what is our hospital policy at this point. This is something that's more specific that's in the guideline document this is something that we wrote it's been handed back and forth a couple of times between our nursing supervisor and our technical director because sometimes when I would write things in a bullet last it wasn't exact enough for it to be complied with so we have a policy where outpatient procedures if they're non urgent. They cannot be scheduled. We don't want to backfill where it's something appears on the schedule and then we have to call and cancel and so that's been very effective it's a huge change of practice. Outpatient urgent exams sometimes need to be performed. And they can be scheduled if they're approved with a direct communication actually with me and if I'm not available then I'll refer them to the core medical staff and people have gotten on board with this has been very low maintenance in fact. The inpatient low risk. These can be performed in the non invasive floor area, but we prefer not to perform any exams in the lab if possible we can do portable studies. An exception for low risk is inpatient TEs that need to be done in the lab they need suction sedation we have the procedure rooms downstairs but we don't want to bring bring anybody to the lab that's covered positive or a patient at interest if we rule that out we will bring the patients down. And so we had to perform with droplet precautions. One thing we were a little bit blindsided by and I didn't really pick up on this and for a while as we have a holding area in our echo lab. And despite all the other precautions we were taking I went by there one day and we had a bunch of patients just sitting there they hadn't been received, you know they, they didn't, they were brought and dropped off. So we had to formally close our non invasive her holding area patients have to be received by a sonographer in the lab taking directly to the exam room and then they're discharged from the, from our exam rooms on the third floor and they go back to their room directly there's no holding area there's no way station where patients are commingled or can that that that really is something we recognize pretty quickly. One of the most important things that you need to do is echo machine modification you need to strip that sucker down, because everything on that machine. If it's a cart model, you have to decontaminate it afterwards and the more stuff that's hanging on the more difficult that can be it increases your risk so our carts have only one probe the probe that will be used. No cables so we have deferred any EKG capture during studies that we've removed the cables. There's no stickers on the card. We do two second capture with normal rhythm if it's tachycardia we can if they're brady cardiac we can go up to three seconds. That's driven by the sonographer. No gel bottles. We only carry single use disposable gel containers they become in foil and you can use them if you're worried about your supply you can create your own squirt some gel into a bandage cup something like that use it and then throw it away. And these are for our low risk patients. Now, what about the high risk patients. These patients may not be transported to our lab area. Only nuclear studies are an exception that we have we can sterilize the pet scanning room if we have to it's a closed environment and base of dilator stress only this would be a rare indication. The studies are always performed in the patient's room. Very important here. We have an ordering system where almost by default it gets people to order a comprehensive exam and this is a long study which can if you do all the images it can be up to, you know, 80 100 loops. We have defined a limited protocol exam that will be performed by default, as opposed to a full echo but a full echo protocol can be done if needed, and we just adjudicate that on a case by case basis it certainly can be done. Another thing is with people calling down and wanting studies on patient under investigation or high risk we we are keeping a log system if it's a patient under investigation, particularly we note it in red so that we kind of go back and make sure we determine whether that patient had a positive or negative test and that person had to perform that study. Lab surfaces is something that actually came up in the guideline documents we weren't as attentive to that even at baseline as we should have been so daily assignment for am and late p.m. are in the afternoon and update any two or three times a day, who's going to take responsibility for surface cleaning of all your keyboards, your computer mouse door handles and other surfaces. Again stripped down machine for all all the machines we don't have any machines that have all the paraphernalia anymore. Protocols I've already mentioned the problem focused limited protocol now I have to be very clear that a limited protocol never means just a two dimensional study we need for the text to do a limited protocol but they apply all the 2D views they use m mode. As appropriate and the Doppler protocols to address the indication and to detect and adequately assess unexpected pathology so these can be short exams are more extensive but this. But the main thing is to defer all non essential exams and avoid these long exams where there's more protocol you know exposure. This is also a limited 2D and mode and Doppler protocol. I get this question all the time this is the one that we use in our lab is the default protocol now this is a new thing, regardless of the order type. A comprehensive exam can be done with approval and the thing is here we found that you know this is kind of a scout exam we would use before some of our stress echo studies where we had no prior. And they did sort of a stress study in a high risk patient so it's a 10 to 15 minute at most study with 30 to 40 views. Okay, we're going to get wall motion ejection faction pericardial fusion yes or no significance required right atrial and PA pressure LBOT stroke volume screen and appropriately evaluate for significant valve disease we're not going to bend over backward if they have mild to moderate MR. And if there's a pericardial infusion so this is our protocol you can adjust it. It includes IV sailing contrast when appropriate contrast agent when appropriate so take that there you know don't you don't want to have to go back. Key understand the indication and a properly address without having to go back be prepared. So we have our to go packs. We take IV sailing contrast infusion with paraphernalia if needed. Evaluate the patient risk you really have to understand that and be prepared for the proper PPE which I'm not going to go into here. The exam can be extended or abbreviated if you've got a physician standing there and says this we have everything we need done in our ICUs that the first COVID patient we did I went up. We have a glass door. She asked you know I could have gone in to do it and I was ready to she was far more experienced with PPE than I was. Because they they use these for influenza patients I mean it's part of their routine. I had was more deer in the hairline headlights and she was but she did the exam. I could see the screen through the window and I said we're we're done you know you get out of there with all it was a half a half patient with no valve disease. The right atrial pressure was high we got the pressure we were done. And so if there's somebody kind of guiding the state that's one thing that's possible. You don't want to take any paperwork folders or worksheets into the exam room if you bring those back to the lab and they're contaminated. It's bad. No end of you know no bottles the jail packs like I said in the how to image category in our guideline document there's personal protection we talked about this this is not something I'm going to review in great detail. Other than to state again that with standard care we have to assume everybody could be infected meticulous hand washing hand sanitation gloves. I think we're going to have more discussion about wearing mask more often than we have been. Droplet precautions for patients that are suspected or proven positive gown gloves head cover mask I shield airborne precautions if there's a risk for aerosolization so that's the transesophageal echo patient suctioning a vented patient and you're in the room high flow oxygen this has to be something that we're very careful about. This is a slide capture from the very wonderful webinar that's it's not very long that's similar to this you know it's this is Dr. Daniel chair towel from the NIH allergy infectious disease he gave some great perspective on this. Human to human red human to human spread. I think it's very important to teach your sonographers about this if they're not. You know, savvy and just even lay people who are coming into the hospital these large respiratory droplets are thought to fall to the ground within six feet and a mask can block them airborne is not what we normally would treat on the street. CDC guidance for personable protection. Again, I'm not going to cover that in detail in this specific talk other than to say that we are really having to balance risk with the potential for scarcity in this environment huge topic of conversation. How to image probe and cart disinfections. Again, these should be integral to the usual standard of practice and labs at baseline a hospital should be experienced for donning and doffing PPE and decontaminating machines for hospitalized influenza cases, which is very similar to coven and mechanism of spread. Our sonographers and the rest of us should be able to do airborne precautions if we are scanning a patient this tuberculosis active. This is a situation. So, the main risk with coven is just the increased numbers of exposure so we have to be very careful and meticulous and just not let our guard down take that extra time and think. Let's talk about environment of care which is huge in an echo lab their desk keyboards computer mouse phone doors doorknobs people love to come to our reading room and congregate and hang out and socialize and we love that. It's toast right now. This is our reading room. Look at the gel thing that Lynn had placed by the front door I was like, yes, because you know you have to go find these things it needs to be right there we leave the door open so that's one less doorknob. Look at, look at the social distancing here. The fellow is on his phone there's one attending reading as old as analyzing a study. So that's, that's what I call real social distancing some echo labs are very crowded and you have to keep that in mind. And you may really have to do remote reading to do that distancing, keep any paperwork out of there and somebody. You know, some of us are less busy we've assigned somebody to, you know, wipe down all that stuff here's here's our hospital approved sanitizer, phone, me keyboard mouse, you know you just don't want to have anything that you regularly touch, potentially get in to contaminated. I had to do a personal disinfectant inventory because I saw the stuff around and our text know how to use it but I what what are these different things so know your facilities approved disinfectant agents and approved applications we've matched these to our vendor recommendations. The purple one is for all surfaces it can actually be used in different situations the other ones are either bleach based or alcohol based primarily and they have to be very adequately available and in the right numbers you can't really run out. You have to read the instructions, I want to emphasize that if you've got a contaminated probe. You actually have to observe what are the wet times right after you pull you know your imaging probe off a patient that's positive, you really need to keep that probe white for two minutes that's the saddle period and a high risk probe. Look at look at probe sheets and use of handheld devices also these are a couple of different types of facility probe sheets that we had their sterile that can be used in the cat lab they can be used in procedures where you really need a sterile probe because of a wound. There's blood also in line placement so the one on the right actually a line placement kid and it comes with the gel pack and little little gizmos to put your needle in and the reason I'm talking about handheld devices here is because the handheld devices are actually an opportunity to have a completely contained system. If you put these properly inside a sheet and fastened the ends you've got a contained system and so then you can use the device peel everything off and you don't have to content decontaminate a big cart. And so this can be very helpful notice that the smartphone this is one vendor their other vendors other types of devices which all work very well in this environment. Many of them are working with smartphones in the face of these will work through the sheath cover allow you to visualize the exam use controls very important I think cardiologist in particular and pulmonology is going to learn much more about the progression of illness looking at the lung windows and these things. And remember to if you've got a trained person that can do an adequate handheld device, they can do a study while they're already in the room taking care of a patient. Rule out heart failure reduce versus normal ejection fractions you scratch screen for pericardial effusion plural effusion screen for valve disease. Sometimes you know look at the right age pressure they can do this and and may negate the need for an echocardiogram to be done where we go in with a sonographer attending and burn through another PPE set. We are actually implementing that strategy. And we are going to be doing that in a very very short time period. And we will very soon catalyze by this whole movement. Here's a cart that has a cream covered a clean green covered T to go pack. So this is a pack that's got our t pro Bennett, or any of your other equipment's in a in a nice green clean bag, and that includes a contaminated bag for return. and is returned, although we do clean outside the room directly inside too, if necessary. Here you can see one of our machines outside of the room and she's put a screen cover on it. So this controls the screen and the console, which has lots of little nooks and crannies for droplets to get in, impossible to clean. We like to use these from the CAFLAB. They're actually the screen covers for the X-ray covers. I don't know what if we'll run out of them. To me, they look like laundry container bags, but they're much tougher and you can work and easily remove them. There are sterile console covers, which I find tighter and hard to work around. There at the bottom right, you can see her in the room. She's scanning a patient under investigation. She's got the screen cover on. She's gowned, gloved appropriately and she's got an eye shield mask over an N95 mask. The N95 mask in this condition was thought necessarily because of the high flow oxygen the patient was on. I will note the absence of a head cover. After exam probe disinfection for a high-risk patient, many labs, especially peripheral vascular labs, have a closed system, high-level decontamination, device and we forget that at baseline, we're supposed to use this, especially in PV lab where there are a probe, may touch a wound, blood, a mucus, membrane. We actually have been using it as belt and suspenders for cases where we don't do this. It's gonna, this can kill C-diff spores and everything, but we like to use that. If you don't have that available, then try the probe sheath usage. If you have the sheath available and there can be supply issues there, you can use the probe sheath. Then when you take that off, wipe it down. If you're going bare, no sheath, immediate post procedure, wipe down in the area of that wet time up to two or more minutes where if it dries out, you wet it again and keep doing that, that's the sidle period. Then you can take it downstairs, it dries out and we wipe it again. And then it gets this seal of approval. So we see if this little, this covers on it, it means, hey, this probe's ready to go, it's clean. And we treat them all this way. Huge headache, but worth it. Here's the individual gel packs. Like I said, you can make your own. Remove, this is what the stripped down machine, this folder would stay outside the room. We've got that covered, ready to go, clean probe. There's nothing on the machine except one probe. No miscellaneous equipment. And to wrap up, I really love this, seeing this particular presenter at our webinar that the ASC put on. This is Anita Sajapur. She's at Duke University now, but she represented her hospital at the Rajay Cardiovascular Medical Center in Tehran, Iran, which has had one of the highest outbreaks. And I think it's very representative of the fact that, we have a great debt to these other institutions that sort of paved the way, we've learned from them and we've had this window of opportunity that we can take advantage of. And she said that the current time until now, none of the Echolab personnel who had followed the PPE have been infected with COVID-19 at that facility. This is tough to measure. I think some of our staff, we don't know if they got exposure outside the hospital, very difficult, but I found this, I did sigh a relief when I saw that. And so I wanna encourage everybody that this stuff works. It is very scary, but if you follow the recommended precautions and protocols and really in a detailed way, and it gets to be your practice, then I think we're gonna be okay. In conclusion, I'm showing a summary of recommendations. It's nice to have some bullet points just to refer to without going into so much detail. These are from the ASC's guideline statement. A review of what type of PPE is recommended in different situations. And I'll say that these are from the CDC guidelines. Indications, I will not review anymore. There are a lot of indications for echocardiograms. The other societies are recommending that we use these judiciously despite the indication as much as the echocardiogram can be crucial in caring for patients. So thank you. And here are my email addresses if you have any questions. Right. Thank you very much on this very detailed information, particularly related to the ASC guidelines that have been done in advance. I believe this will be available in a PDF format for those that are interested. I would like to conclude this program by thanking all the participants, Dr. Coulter, Dr. Plana, and Dr. Steinbeck for your very valuable and very up-to-date contribution to this program, COVID-19 in cardiology. Now for those of you that have tuned in to this program, I would like to inform you to join us for our next program on the impact of COVID-19 in cardiac cath lab that will be available soon. Thank you very much for your participation. It's extremely valuable to have the information from the experts like you. And I think it's important, not only for saving lives, but also for educational purposes. Thank you once again. Thanks, Dr. Grazier. That was great. That was great. Thank you guys.