Emerging from the Lockdown - What we have Learned about the Effect of COVID on Sleep Med. (6-3-20).mp4

June 04, 2020

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00:00OK, so let's move on
00:02to the next flight and and so
00:05my name is Meher Kriegerin.
00:07We're going to be.
00:09Starting this right now,
00:11and so if you want credit for the CME credit,
00:15here are the instructions and we're
00:18going to send out the instructions a
00:21little bit later or put them into the
00:24chat so you can get some credits for this.
00:28And so we're going to start off here.
00:31So Karen, let's have the next slide.
00:34So basically, there's no commercial
00:35support for this grand rounds,
00:37and we have looked at everybody
00:40slides and what we're going to
00:42talk about an all the conflicts of
00:45interests have been resolved next.
00:48So my world here at the ale changed
00:52on March the 10th, 2020 at 7:51 PM.
00:57Next slide.
00:58So everybody on faculty at DL got this email,
01:02and on the next slide I'm going to
01:05show you what the email showed next.
01:09Slide Carne. So basically this was before.
01:15Prove it became a big deal in our community.
01:18So the all the students that
01:20they'll they were on spring break
01:23an what they were being told here
01:25is that they should stay home.
01:28All the classes are going to be online.
01:31None of the faculty was
01:34allowed to travel anymore.
01:36Research was sort of done and
01:38all teaching was done except
01:41for using zoom and so forth.
01:44Next slide.
01:47So this was our new reality,
01:49so the email that I just sent you came
01:53about a week before my last day in
01:57clinic which was about March the 14th.
02:00The reopening of our clinic and I'm
02:03using the word reopening here in
02:06quotation marks occured about two
02:09or three days ago and what I mean
02:12by reopening is that in the interval
02:15between March the 15th and now we
02:18were only doing a telemedicine visits
02:21either by phone or or by video.
02:24And we were doing very limited sleep testing.
02:28Uh, no titration studies no split
02:30night studies.
02:31And during this interval what I'm
02:34showing you here is the number of
02:37patients in the hospital at Yale
02:40New Haven Hospital.
02:42Uh, yeah, during this time,
02:43so the number of patients peaked at
02:46about 4:50 and now the yesterday
02:48morning was 122.
02:50And as you can see below,
02:52the patients on ventilators most of
02:54the time we had about 70 patients
02:57on Ventilators,
02:58an now we're down to about 30.
03:01So things are getting better and when
03:03you look at something like this,
03:06what we're seeing is is really a
03:08spike and one of the things about
03:11this spike is that it affected.
03:13Everybody, uh, in our community,
03:16but it affected some parts of our
03:19community more than others in particular,
03:21the African American patients in
03:24our community were twice as likely
03:27to be in the hospital and twice
03:30as likely to be on on ventilators
03:32as as the rest of the population.
03:35So right now you know,
03:37all of you know there are a lot of
03:41protests going on out there because.
03:44Of disparities uh in in many parts of
03:47American Society, but this is a disparity,
03:50a healthcare disparity that we're
03:52looking at so we quote reopened and
03:55now I'm gonna hand the baton over
03:58to Carney who's gonna tell us about
04:01what people been thinking about
04:04and what's going to happen next?
04:06So yeah we're going to have
04:09a number of presentations.
04:11Overall, we're going to basically hold the.
04:14Questions until the sort
04:15of panel discussion part,
04:17but please start sending a Mens so
04:19we can try to collect them and put
04:22them together and please try to use
04:24the Q&A function rather than the chat
04:27box for sending in your questions.
04:29And again most of us will be available
04:32till 4:00 PM eastern Standard Time
04:34to help talk about what's going on.
04:37Hum. So a man we have seemed a list
04:41of of panelists joining us today.
04:45Most that you'll hear from a man and
04:48a man will summarize this at the end,
04:52as we're getting towards the panel part.
04:55So as a little background,
04:57you know, as we all know,
05:00COVID-19 has had a particular
05:02impact on sleep medison,
05:03especially with the in lab testing sins,
05:07pap, Canaris Allies the Cove
05:09in viruses as far as we know.
05:12And because patients with this virus can
05:14be effective starting six days prior,
05:17the symptoms which is earlier than
05:19pass viruses like SARS and Murs,
05:21it's you know there's more of that
05:24potential of being a spreader
05:26before you even get symptoms,
05:27which again puts a sort of in a different
05:31light for this virus than any prior ones.
05:34So with this in about mid March,
05:36national organizations,
05:37including the SM gave guidance to
05:40limit testing around that same time.
05:42A lot of states were placing
05:44limits on testing a lot of medical.
05:47Centers were needing to close down,
05:49and since then sort of follow-up guidance
05:51about how and when to reopen and expand
05:55services have started coming out,
05:57but there are just so many local
05:59factors related to the code that
06:01levels as Doctor Krieger just mentioned
06:03the availability gpe testing other
06:05governmental restriction in place.
06:07So we're going to try to touch on some
06:10of this with some of the talks today.
06:14We did do two prior presentations.
06:16If you haven't seen them yet.
06:18They're available on on the website
06:21and again will post these links
06:23on the chat function during the
06:25talk so you can get them there,
06:28um,
06:28but what I'm going to focus on today
06:31is we had sent out a survey at the end
06:35of April through the first week in May,
06:38and obviously providers,
06:39and so I'm going to go over that.
06:43So in that one week that the survey was open,
06:46we had 379 completed surveys and they seem
06:49to represent about 297 unique centers.
06:52Another unique respondents.
06:53For 75 positions in 283 technologists,
06:56an we had responders from 46 US states
06:59and territories in 13 countries,
07:01so we had a pretty wide breadth of
07:04respondents and they really reflected
07:06all different sorts of lab types and
07:09specialties and seems to be a quite broad.
07:13Population so one of the sort of
07:15a top questions we asked was what
07:17was the effect that people were
07:20seeing locally due to COVID-19 in
07:22about 90% of respondents said that
07:24they stop there in lab testing
07:26or significantly reduced it by at
07:28least 90% an about 60% said they
07:31significantly reduce their home sleep.
07:33Testing an when you look at sort of
07:35the dates of when this testing came in.
07:38Sort of as suspected the highest
07:40numbers were sort of around that week.
07:43Of March 16th, when a lot of the
07:47different recommendations and changes at
07:50the governmental level we're changing.
07:52But there was a sort of a little bit
07:56earlier into the North East and West,
07:59and a little bit later in the southeast
08:02and Southwest and Midwest for some
08:04of the places we really didn't see
08:07any otherwise significant regional
08:09differences or urban suburban
08:11differences in terms of the 90 and 60%,
08:15it was pretty across the country
08:17that most people did stop testing.
08:20So then we asked about some of the concerns.
08:24We asked how concerned are you
08:26about exposing patients or the
08:28technologists COVID-19?
08:29And it was definitely a high
08:32concern for both.
08:33Interestingly,
08:34there was sort of higher concern about
08:37exposing the text then the patients.
08:40Another question we asked was about what
08:42PPD should be used for in lab testing,
08:45and interesting that the physicians
08:47in the text had very similar answers,
08:49but there was no real consensus of answers,
08:52and I think this is where the importance
08:55of getting sort of guidance so that
08:57we might start hopefully come together
09:00with what we think would be the best answers.
09:03So we had about 50% feeling that Eris
09:06allies aerosol precautions should be
09:08used at any for all patients in about 25%.
09:11Feeling that the aerosol precautions
09:13only needs to be used when Pat therapy
09:16was used and then another 25% that
09:18thought different strategies could be used.
09:20So again,
09:21just a wide variety of what people
09:24thought were important.
09:25Um,
09:26in terms of other mitigation strategies
09:28for in lab testing over about 3/4 were
09:32planning on screening their patients
09:35for symptoms prior to the studies,
09:37about 65% thought that they would be
09:40kept taking the temperature patients
09:42when they came in for studies.
09:45About 1/4 looking to see if there
09:48was any prior testing and only about.
09:52You know about 17% thought they
09:55would actually be doing covert
09:57testing prior to the test,
09:59so I'm very interested to see you know,
10:03pretending the fob what was actually done
10:06versus what people sort of expected to do.
10:10We asked them the question of what
10:12type of testing was expected to be
10:15offered in the next month and about 60%
10:18thought that they would be offering
10:20diagnostic testing about 20 to 30%.
10:22Thought that they would be offering
10:24in titrations with a little sort of
10:27smaller numbers for the Pediatrics
10:29as opposed to the adults.
10:31Uhm, and then when we asked,
10:34was there certain populations of
10:36people you'd offer testing to?
10:38Um, most people weren't Nestle.
10:40Restricting to certain populations,
10:41but but the highest were sort of
10:44restricting to people who had been
10:47tested negative and or people that
10:49had recovered from prior to bed.
10:51Only about 13% thought that they would limit
10:54it to low risk patients without Comer base.
10:58That would put him at risk for severe kovid.
11:01In about 1/4 of people said that they
11:04would be offering testing the any
11:06willing patient that would come in.
11:08Um, so we. We then asked about, uhm,
11:12sort of would PCR testing change your
11:15mind about about strategies and so?
11:18About 65% of respondents felt that no matter
11:22Wat Aerosolizes precautions should be used,
11:25even if there was recent PCR testing.
11:28But when we asked sort of a question
11:32of if you are going to do testing,
11:36how close to the test?
11:38You know what it needs to be done
11:40for you to feel confident about it?
11:43Again, a pretty widespread but about 1/4
11:45thought that rapid testing would be needed.
11:47A man about 20% said doesn't really
11:50matter if you do testing 'cause I think
11:52you need to use all the precautions
11:54no matter Wat and then so the rest
11:57were sort of spread somewhere in
11:59the middle between sort of one and
12:01mostly two to three days before.
12:03Another big issue is how many patients
12:06are willing to come in for testing.
12:08So overall is only felt that about 30% of
12:11patients would be willing to come in in
12:13the next month if we were offering testing.
12:16Now we are that month later, so again,
12:18I don't know what people would say a
12:21month from now or two months from now.
12:24Um, and their sum of guard regions.
12:26We didn't have a ton of data,
12:28but the northeast seemed to think the less
12:31the least number of patients would come in.
12:33And more in,
12:34in the South felt that felt their
12:36patient come in,
12:37but still only less than about 50%.
12:40So I think as we open up,
12:42this is going to be a big issue for all of us
12:45is we may have best intentions to full laps,
12:48but if patients won't come,
12:50then we're going to have have issues there.
12:53In terms of home sleep studies up,
12:56about 10% of the lab said they were
13:00using disposable devices and about 25%
13:03said they were using mailable reusable
13:06devices and in terms of different
13:09strategies for processing equipment.
13:11It was sort of variations and
13:13certainly no consistency,
13:15and in what type of procedures
13:17would be used up, and so you know.
13:21Interestingly,
13:21only 62% said they were disinfecting
13:23the device that may go with some with
13:27the people that were using the disposal
13:29device instead only about 35% said
13:32they would be waiting the 72 hours.
13:35That has been recommended between reusing.
13:38So moving on to clinic.
13:41We have had major changes in clinic,
13:44so about 75% of of people a month
13:46ago said they were only offering
13:49virtual visits and about 4% closed
13:52all visits and so only 4% of lab said
13:55that they had no limitations on who
13:58they allowed to come in for visits.
14:01And then when we ask sort of where
14:04you were
14:05before and where you were after,
14:07like about 70% of people said they did no.
14:11Virtual visits before an almost all the rest
14:15were less than 5% virtual visits before,
14:18but when we asked about after.
14:21Almost 75% of people felt that
14:23they were going to be at least 25%
14:26of their visits after Um Cove it.
14:28That would state virtual.
14:29So this is, I think,
14:31going to be a, you know,
14:33a huge shift in the way Sleep
14:36Medicine is practiced that I expect
14:38to really stay for a long time.
14:40And then the last area we sort of ask
14:44people about some of the insurance issues,
14:48and so over 70% of respondents felt
14:51that insurance should at least
14:54temporary temporarily cover C,
14:56Pap and rad devices without the
14:59need of prior testing.
15:01And then when we ask so if a person
15:04got a a device sort of empirically,
15:07should they get follow-up testing
15:09in about 60% of people thought
15:11they needed follow-up testing.
15:12However, there was even more if we said,
15:15what if that patient gets the fault
15:17testing and it isn't diagnostic,
15:20you know,
15:20I think particularly Medicare patients
15:22who might not meet Medicare's 4% criteria,
15:25but might still have OSA in about
15:2771% felt that if the patient
15:29got a machine and was using it,
15:32and benefiting from it.
15:33That day it still should be covered,
15:36but my guess is unless we have some
15:38real advocacy around that that that
15:41won't be the reality of what's happening.
15:43Another area that it was thought
15:46that the insurance is should help
15:48with is if a patient need extra
15:50supplies because they got coded
15:52or they had some other respiratory
15:54illness and needed new master.
15:56Two beings,
15:57most respondents or 73% of
15:59respondents felt that that those
16:01extra supplies should be covered.
16:03In terms of adherence requirements,
16:06especially given the limitations on
16:08clinic visits and in person visits,
16:11we should ask what what things would be,
16:15uh, built,
16:16a sort of able to qualify a patient
16:19for keeping keeping an initial
16:22equipment and getting it paid for,
16:25and so about 77% thought that any fault.
16:29Visit note about adherence and
16:32benefit could be.
16:33Used to qualify for patients and about
16:36half felt that a phone note was adequate.
16:39Adequate,
16:40but 39% also thought that if the
16:43insurance data showed good use and
16:45had a low hi that there should be
16:48automatic approval for the machine
16:50with even if the patient didn't
16:53have any follow-up visit at all.
16:56In terms of annual supplies,
16:58about 59% thought that an annual
17:01visit about adherence and benefit
17:04could be used and 34% again feeling
17:07that the phone note was adequate.
17:10I was actually surprised that more
17:13people didn't feel the phone would
17:16be an adequate way to qualify
17:19someone for supplies.
17:20And in about 25% felt that
17:23supplies should be covered even
17:26if adherence wasn't met.
17:28Um, when we sort of followed up on that.
17:31So despite only 25% saying that that it here,
17:35it's uh, or that things could be paid for.
17:38There was actually a lot higher numbers,
17:41about 80% when we asked about
17:43reasons that a patient could be non
17:46adherent that it should be paid for.
17:48Did feel it should be paid for in
17:51certain circumstances where we could
17:53potentially right at a node in document Y.
17:56They couldn't meet the adherence,
17:58so you know.
17:59So if a patient has a short sleep time,
18:02either because of shift work or
18:04just because that's how they sleep,
18:07but we're using it regularly.
18:08Oh, 81% felt that these supplies recovered.
18:11If a patient had a recent hospitalization
18:13or illness or the family was ill
18:15and they couldn't use the supplies,
18:17those again were felt by most people to be
18:20reasons why insurance should be paid for.
18:23You know,
18:23people that got put on the machine
18:25but never made adherence because
18:27their pressure wasn't quite right
18:29or they didn't have supplies
18:31that were working well for them.
18:33As long as there was a plan
18:35to make that change.
18:37Again, 3/4 felt that that was a reason.
18:39To get new supplies.
18:41So again I think this is room where we can,
18:45you know,
18:46potentially use kovid to think about
18:48how we can advocate to get our patients
18:51treated as well as possible that
18:54this is a time to sort of work on.
18:57Some of these issues that patients
18:59get hooked up in.
19:01So we are working on the publication
19:04of some of these original results,
19:07but I have reopened the survey and
19:09will continue to collect ideas and
19:12especially for some of the insurance.
19:15Um, ones if I can get more results back,
19:19I'd love to incorporate them into
19:21some of the stuff we're working on,
19:25and again,
19:26I'll put this link in the chat function.
19:30So I am going to now passes are first
19:32to doctor Nuñez and Doctor Lee Chong
19:35to give us sort of an update from the
19:38res Med an respironics side of things.
19:40Great thank
19:41you honey. Hear me OK, perfect
19:43great and just
19:45wanted to thank
19:46you again for inviting us back.
19:48It's always nice to help inform
19:50the discussion from the industry
19:52perspective so I just want to touch
19:55on the three bullet points that you
19:57see there on the slides you update on
20:00the current state of the pandemic.
20:02Response from that industry viewpoint
20:04and then go through the other points
20:07around current considerations and what
20:09this post pandemic world could look like.
20:11So as you're all acutely aware, most of us,
20:15at least on the panel in the United States,
20:20we are in a period where it appears that
20:24the first wave has begun to subside.
20:27We're seeing both political and
20:30other reasons for reopening,
20:32driven largely by it.
20:34You know pretty cautious approach
20:36that relies on testing,
20:38but from an industry standpoint,
20:40most of the manufacturers are global.
20:43And we are still seeing the late
20:461st wave countries peeking and Latin
20:48America comes to mind specifically.
20:50Also second or subsequent waves in
20:53certain pockets around the globe or
20:55areas where the first wave has not
20:58really yet subsided. Many of us I know.
21:01Personally,
21:01I'm still involved in some of the work
21:04through the World Health Organization.
21:07Their pandemic supply chain network is
21:09something that were closely involved in.
21:11We've even work together on some
21:14epidemiological modeling where we look at.
21:16An approach to um provision supplies
21:19and devices on ethically based on need
21:22for patients who actually need them to
21:24breathe and not to go into a stockpile
21:27are things like that preferentially.
21:29So it's been really interesting
21:31and it's still not over,
21:33and when Doctor Krieger at the beginning
21:36was talking about the email that he got,
21:38I probably speak for all
21:40of the manufacturers.
21:42It began for us in late December
21:44when a lot of the.
21:46People that work in our companies
21:48in China were alerted to what was
21:51happening and we saw ventilator orders
21:54spike threefold in late December,
21:56so it's been.
21:57It's been interesting and it's not yet over.
22:00But um, Speaking of what we're doing today,
22:04the pandemic is dovetailing and that
22:06response is dovetailing with some very.
22:09Yeah,
22:09the current considerations are very
22:11timely based on what is happening
22:14on the ground in the in,
22:16in in the countries where the
22:18pandemic has already peaked.
22:20So for example,
22:21the manufacturing events and devices you
22:24heard from all of the manufacturers,
22:26including some nontraditional manufacturers,
22:28automakers, Tesla people like that,
22:30saying,
22:30You know we're all going to be making
22:3310s and hundreds of thousands of ventilators.
22:36Well, Fortunately,
22:37the supply chain from the traditional
22:39manufacturers of Ventilators.
22:41Related devices like by level devices,
22:44even high flow oxygen therapy, etc.
22:47The the, uh,
22:48the native supply chain, if you will,
22:50was able to ramp up considerably,
22:52and most of the large countries.
22:54Most of the large markets fulfilled
22:57what they needed.
22:58With some exceptions, you know,
22:59northern Italy, New York City.
23:01There were examples there.
23:03Were they outstrip the capacity
23:05at times to get them the devices
23:07that they needed?
23:08But overall you look at
23:10either than California,
23:11the most populous state,
23:12the 1st place where community
23:14transmission was recorded.
23:15But we got really lucky in that we started
23:18social distancing and isolation soon.
23:20And our peak looks very different.
23:22We never ran outta ventilators Here at.
23:24Hopefully we do not in second or
23:27subsequent waves that they arrive.
23:29So what we're modeling is that even
23:31if a big second wave comes back
23:34to Europe or the United States,
23:36the systems are probably been
23:38preloaded with enough devices and
23:40stockpiles have begun to grow,
23:42and so the the shift in Manufacturing
23:45is really around supplies,
23:46circuit components, disposables,
23:47at least from our perspective.
23:49But it's really all of the supplies
23:52and disposables that are going to go
23:55into both managing the pandemic and
23:57the volume of patients as well as
24:00managing the reopening in the return to.
24:02The new normal uhm,
24:04which brings me to the third bullet
24:06point and just real quick again.
24:08Supplies circuit components.
24:09Disposables are going to be
24:11important from from the manufacturers
24:13perspective that from like a res Med
24:15or Philipson Respironics Viewpoint.
24:17But think about things like PE and all
24:20of the other medical supplies you're
24:22going to need in your office is in your labs.
24:26In your procedure rooms that that
24:28supply chain is really going to have to
24:31continue to do what we did for vents.
24:34For those for those disposables,
24:37uhm you know the previous.
24:41Slides about the results of the
24:43survey are really telling because we
24:46are really in this reopening period
24:48and trying to understand what are we
24:50going to do around PE workflow procedures.
24:52How does the patient journey change?
24:54Where are the ways in which we make
24:57it safer in those acute visits
24:59where your face to face and there's
25:01a risk of transmission?
25:03And then how do we take advantage
25:05of some of the trends that were
25:07exposed in the survey?
25:09A greater use of telemedicine
25:10and virtualization of visits?
25:12I'm at the beginning of the call.
25:14You know,
25:15when we were having a little
25:17technical difficulties.
25:18Both Doctor Krieger and I'm sorry.
25:20In German I don't want to mess
25:22up your last name.
25:24So if you don't mind,
25:26I'll use your first name were talking
25:28device is being used for telemedicine
25:30visits and so Webex notwithstanding
25:32here you've got physicians every
25:34single day taking care of patients.
25:36Virtually.
25:36How can industry help both in the
25:39advocacy that will be surrounding
25:40that new normal and the.
25:42Mechanisms through which we can help?
25:44How can we help a patient,
25:46you know,
25:47have a successful virtual visitor
25:49virtual set up with the tools
25:51that we provide so that outcomes
25:53remain great and get better and
25:55care becomes more efficient.
25:57We've learned a lot through this
25:59pandemic and just to give one
26:01last example as I close when you
26:03think of traditional medicine,
26:05there a few icons that come to
26:07mind and the New England Journal
26:09of Medicine is one of those icons
26:12of the traditional thinking in Madison.
26:14And I read it an amazing article
26:16about them a few weeks ago.
26:18At the peak of the pandemic as it raged
26:21across Europe in the United States,
26:23they were receiving over 200 submissions
26:24a day, just uncovered, related research,
26:26and many of us have worked,
26:28you know, and submitted papers
26:30to the New England Journal.
26:31We know how long it takes to hear back,
26:34and it's a big process.
26:35They committed to turning around and answer
26:38for every single one of them in 48 hours.
26:40So if the New England Journal of
26:43Medicine can adapt to a new, normal and.
26:45Work at a different Clock speed.
26:47I think all of us industry providers and
26:50patients are going to enter a new normal
26:53where the tools we've been building,
26:55you know connected devices tell a Medison
26:58and the ability to take advantage
27:00of a base of patients who is much
27:02more tech savvy and expects the same
27:05sorts of efficiencies for health care
27:07as they do in their everyday lives,
27:10amplified through the lens of the
27:12pandemic were really in a really in a
27:15very interesting place to help usher in.
27:17A new era in Madison and Sleep
27:19Medicine in particular stands at
27:21a really privileged pipes.
27:22Because if you look at the numbers of
27:25connected medical devices in the world,
27:27connected sleep devices dominate
27:28over every other category,
27:29so this is great to be a part of
27:32this discussion and I hope we can
27:34have a wonderful collaboration as
27:36we move into the reopening.
27:38Hum,
27:39there you go.
27:40I'm
27:41done, thank you. Yes,
27:43can you hear me?
27:47Can you hear me? Yes, thank you.
27:50So I've been asked a day to
27:53represent Philipson asleep industry.
27:55But as I have shared with me,
27:57a Keurig are being a clinician
27:59and researcher, like most of you,
28:01I feel somewhat inadequate for the task,
28:04kind, alarmed, explained.
28:05I've been in touch constantly
28:08with our colleagues in Europe,
28:11Germany, France, Italy, Portugal,
28:12the Middle East, South America, Asia,
28:15Australia and one things made very
28:18clear that directly or indirectly.
28:21The covered pandemic has affected all of us,
28:25our families, our communities,
28:27and this common experience
28:29reveals our shared humanity.
28:31However, like what mere had said earlier,
28:35to covet virus has not
28:38affected everyone equally.
28:39And the loss of lives and burden of
28:42illness is far worse for some than others.
28:45And this,
28:46in equities magnified by social
28:48dislocations and business
28:49disruptions on the global stage.
28:51It has exposed major flaws and
28:53weaknesses in our medical response and
28:56responsiveness in it is in this time
28:59facing this confluence of medical,
29:01social and economic challenges that
29:03we must remind ourselves of our
29:05collective shared responsibilities
29:06in Healthcare.
29:07It is this vital second point that I
29:11would like to share with you today.
29:14Industry, like all of you know,
29:17has a social responsibility.
29:19It is tempting to reassure everyone
29:21that supplies will be available.
29:24At all times at anytime.
29:27But it would be reckless not
29:29to admit the reality of triage
29:31due to limited resources.
29:33We are still today in the midst of
29:35a global pandemic and the outbreak.
29:38The next outbreak can occur anywhere.
29:41Differing needs, therefore,
29:43may require different commitments.
29:46Likewise,
29:46it is easy to create programs
29:48to enhance clinical efficiency,
29:50including telemedicine, at remote monitoring.
29:52However,
29:52we must seek to provide this
29:55service is not only to those
29:58who are most able to use them.
30:01But more importantly also to
30:03those who need them most.
30:05And have no access to
30:07reliable web connectivity.
30:08We must also consider issues so data privacy.
30:12Data security and data ownership.
30:16Cyber crime is a real threat in our patients
30:20are among its most frequent victims.
30:23Industry also has an
30:26ecological responsibility.
30:28It might seem expedient to turn
30:30to single use disposable testing
30:32devices in order to reduce the
30:34risks of viral transmission,
30:37but is this in the long term sustainable?
30:40Are we unnecessarily
30:42creating unnecessary waste?
30:43Are we needlessly wasting much
30:46needed funds for our sleep programs?
30:50And finally,
30:50industry too has to be
30:53economically responsible.
30:54It needs to address the new variety
30:57of patient needs, volume of care,
30:59velocity of change in voice of
31:02advocacy today and in the incoming.
31:05Who's covered era?
31:07It has to provide connections
31:09with tools for cold learning.
31:11Had initiatives. Education.
31:15How to reach?
31:16In each moment industry strike that
31:19balance this different concerns
31:21concerns relate to legal regulatory
31:24processes and that are each
31:27taking four by scientific review.
31:29Government oversight.
31:30Pier negotiations alot of things
31:33manufacturing supply change,
31:35business agreements and most
31:37importantly the needs of patients.
31:39None of which, by the way,
31:41can be predicted with certainty or
31:44constancy in the near or long term.
31:47And there are still so much
31:48more that we do not know.
31:50It is this reasons why I felt inadequate.
31:54It is easy to Oversimplify and merely convey
31:57a compelling narrative on reopening labs,
32:00but this would be naive and I think.
32:05Be responsible.
32:06Who among us still believe that with
32:09a few filters and valves with a few
32:13blood testing it is business as usual,
32:16or that one size fits all?
32:20I believe that as we opened our labs,
32:23we have to think of three things.
32:25First, sleep health care.
32:27By design, I repeat,
32:28sleep health care by design,
32:30not rationing of care by inconvenience,
32:32not provision of care by the lowest bidder.
32:35Second,
32:35I think we have to humanize our technology.
32:39I like to change and so
32:41too much on technologies.
32:43I understand the current concern regarding
32:45filters and valves and remote monitoring.
32:48I do this Armada questions that my hospital
32:52sleep lab needs answers to as well.
32:55But you have to understand the
32:57promise of technology is a larger.
32:59Much larger you should expect.
33:02You should demand minimal touch
33:04or nearly touch free solutions.
33:07More eco friendly and more importantly
33:10morcos appropriate single use home testing
33:14real time imaging guided mass election,
33:17better adherence tools,
33:19Internet based coaching and has.
33:22Remote monitoring features to support
33:25more precise and proactive care.
33:28Not to mention safer interfaces and
33:31effective non pet therapy for sleep apnea.
33:34The next speaker will be talking about
33:37or appliance and I think we should
33:40consider those into discovered pandemic.
33:42Lastly,
33:42and I speak to you as a colleague in Madison.
33:47For 25 years.
33:51To build a new road,
33:52we have to walk it again.
33:55None of us can be bystanders.
33:59None of us can be silent.
34:02Eye witnesses No, not not,
34:06not this time.
34:08Thank you for helping me.
34:10Thank you, um, and we're going
34:14to keep moving. Uhm, and, uh,
34:19we're gonna have Doctor Dioguardi.
34:22Hi hey, how are you? Thank you
34:25for inviting me to speak at this.
34:28As you can see the left picture
34:32is made before March 18th and
34:35the right picture is me now.
34:38Uh, it's been a tremendous challenge.
34:40I am a private practitioner.
34:41About half of my practice is in
34:43dental Sleep Medicine on the
34:45other half is in dentistry.
34:46And in dentistry, uhm,
34:48we are unique in that we're creating
34:50aerosols, an orb out a foot,
34:52and a half from the patient's mouth,
34:54and one of us isn't wearing a mask, so.
34:58We have the responsibility of.
35:03Protecting our patience and
35:04his private practitioners.
35:05We're pretty much it as far as we don't
35:07have maintenance services and things
35:09like that to create environments,
35:11we really have to create our own environment.
35:13and I took that very very seriously.
35:15And In addition,
35:16I'd like to point out doctor Lee.
35:18Chong mentioned that how much
35:20waste are we going to be creating?
35:22So I wanted to protect us in a way that
35:25we were generating the least amount of.
35:28Plastics and things like
35:29that that are going to.
35:30Come back in his later on the next slide,
35:33please.
35:35I have no conflicts of interest.
35:37These are the appliances I make.
35:39I have no allegiance to any
35:41one particular appliance.
35:42Next time please. And so.
35:46When we closed on March 18th,
35:48but I was presented with the challenge
35:51will how can I maintain how can I
35:53follow my patients who are already?
35:56Catholic appliance that are
35:58waiting for sleep appliances.
36:00Um? That it had appliances
36:03that are ready ready to go.
36:05So I explored some telemedicine options.
36:07Now it becomes a little easier for me.
36:10In the there are no real insurance.
36:13Considerations in my practice
36:14in that I don't.
36:16I don't charge for consultations
36:17for follow up visit,
36:18so that made it a bit easier and I
36:20wanted to just examine how my patients
36:22can best be served by telemedicine.
36:24How can I get all the information I need,
36:27answer all their questions in a way?
36:30Then everybody be satisfied,
36:31yet not miss anything.
36:33And personally I found it a
36:35lot of my patients are not
36:37particularly technology friendly,
36:38so my patients are senior citizens.
36:40Some just don't have access
36:42to a computer with a phone.
36:44And as we experienced early.
36:47In in the symposium of there can
36:50be technical limitations and
36:51snack foods that happen as we
36:54try to connect video wise,
36:55and so I have found myself.
37:00The telephone can actually be
37:01a wonderful way to do this
37:04without having to deal with all
37:06the technical limitations and.
37:08Video is another is another option.
37:10Also summer not summer not have
37:12come pick compliant.
37:13It was nice that HIPAA Drop some
37:16of the requirements early on.
37:18So I have used FaceTime and
37:20WhatsApp and there's another tip
37:22compliant platform that I've been
37:23using recently called Doc.
37:25See me which is another option.
37:27But as I progressed I'm finding
37:29more success with actual telephone
37:31in emails next slide.
37:35And in some ways I was
37:38surprised to discover that.
37:40This way of doing a consultation
37:42was in some ways more productive
37:43than a face to face by explain why,
37:46as with every consultation,
37:47that we need all of the basics,
37:49his dentist before we can go ahead.
37:52So we need a sleep test referral from the
37:54position letter of medical necessity.
37:57The questionnaire for the
37:58patient and the insurance info,
38:00which is generally discussed
38:02on the first visit,
38:04but what I've been doing is I send
38:07a letter to patients explaining.
38:10How to click on the video which
38:12explains sleep apnea and these
38:14are all things that I normally
38:15do during initial consultation.
38:17A diagram and I asked them to
38:19send me some general photographs
38:21of their teeth and I use the ones
38:24on the bottom as a demonstration.
38:26For. What I'd like to them to do,
38:29and they, even though not all of them,
38:31have a computer with a camera,
38:33just about everybody, has a cell phone,
38:34and they can either send it or email,
38:36or set it to my text Ann.
38:38Once we receive all that,
38:39we schedule a visit next slide, please.
38:44And we have a wonderful conversation.
38:47As a dentist, as as a clinician,
38:49I'm of the belief and I saw a
38:52doctor Johnson's slide before.
38:54What precautions should be used and when?
38:57I like the philosophy that there's way
39:00too many unknowns in this disease,
39:03and especially because I'm doing dentistry
39:05all day where we're creating aerosols.
39:08I like to use as many ways of minimizing.
39:12Potential transmissions from the patient
39:14to us and vice versa as possible.
39:17One way, if you notice on the upper left,
39:20it's a poor man's negative pressure room.
39:23It's a. Basically a window fan.
39:26It's pointing out an in order so that
39:28we're not drawing from the intake
39:30of the building to large building.
39:32I have another fan blowing from
39:35an empty room.
39:36Blowing in so it supports sort of push pull.
39:39Add this slide in the middle is
39:41something I came up with Because I felt
39:45it was important to capture Aerosoles.
39:48Close to the source as possible.
39:51And so this is basically a high
39:55speed evacuator.
39:56Hooked up to a face mask face shield
39:58that I wrapped around a cylinder that
40:00fits into evacuator and it's stabilized.
40:02I wasn't quite sure how to stabilize it,
40:05but if you notice from the back I'm
40:07also a musician that is a microphone.
40:09Boom stand an so it works exceedingly
40:11well and I've got them in every
40:14Operatory and it really something
40:15that's worked out wonderful.
40:17The item on the right is called
40:19an ice light and we use it when
40:22we first see patients.
40:23When we scan teeth,
40:24which is basically with scanning,
40:26is it replaces the traditional impressions?
40:27What we do is we have to wand over
40:30the teeth that you can see in the
40:32photograph on the right and make it 3
40:35dimensional image and the device on
40:37the right is called an isolate and
40:38what it does is it's cooked up also to
40:41vacuum and it retracts and such and so
40:43basically it's catching the patients
40:45breath out before it leaves their mouth.
40:47So with all these things in place,
40:49I'm very,
40:49very confident that I'm able to protect.
40:52Hold my staff myself an our patients in a
40:55lot better way than I saw available before.
40:58Next time please.
41:01The one visit the cannot.
41:06Be done by telemedicine is
41:08obviously the examination and.
41:10The scanning visit.
41:11Follow up visits I find have been
41:13wonderful and patients in very,
41:15very appreciative of the fact that they
41:17didn't have to come into the office.
41:19And what I need to see in follow up
41:22visits for the most part is number one.
41:24I need to hear the patient find
41:26out what what either benefits
41:28they're getting from the appliance.
41:30Subjectively,
41:31are they sleeping better or they snoring?
41:34Or waking up at night?
41:37Uh, and I also like to know how
41:40much protrusive range they have,
41:41because as I adjust the appliance,
41:43the Protrusive range increases
41:44as their ligament stretch,
41:45and I want to know how their
41:47appliances doing so by taking these
41:49photographs able to ascertain how
41:51far they've advanced the appliance
41:52by looking at the amount of
41:54screw threads that are available.
41:56Next slide,
41:57please.
41:59And of course there are also said
42:01there also filling out this form
42:03with email it to them and it.
42:06They didn't get a chance to email it back.
42:08I simply go over it verbally and enter
42:10it into the chart and what it does is
42:12basically the top is an airport scale.
42:14As we all know and the bottom just just
42:16talks about any changes that might pertain.
42:19So what's going on?
42:20I have found in about 80 or 90%
42:23of the patients prefer to do this.
42:26Who telemedicine?
42:27I've even had a case where I delivered
42:30a case with with with telemedicine,
42:33and that was a little trickier,
42:35but it was done.
42:36The situation was a young male student
42:39who was having found sleepiness and
42:41he was all set to get his appliance.
42:44On But he was on vacation when
42:47Yale closed the doors and said,
42:49Don't come back and so he went from
42:52Mexico to his home in Fairbanks, AK and.
42:54He wasn't going to come back
42:56to New Haven until September,
42:58and I just did not think it was
43:00reasonable in this situation to
43:01deny him the treatment to them.
43:03So I FedEx did too, and with a video.
43:06By using a video chat,
43:08he and put it in his mouth.
43:10Fortunately with the appliances I make,
43:12about 90% or more just go in without
43:14any adjustments to scanning is
43:16extremely accurate and the lab
43:18is really got it right and we
43:20went over the insertion.
43:22We went over the post operative instructions
43:25and he's doing fantastic so even the
43:28insertion can be done if necessary.
43:30The follow up visits again
43:32a relatively simple.
43:34I just did three this afternoon.
43:36The patient tells us what's going
43:38on and if there's any issue.
43:41We discuss it, and if there's a problem,
43:44they can always come in.
43:46The gum wrapper is basically
43:48to ascertain whether or not.
43:50There's pochette posterior contact
43:51of the appliance and what I do is
43:53normally I just I just visualized
43:55outputs articulating paper between
43:56the back teeth and see make sure that
43:58I can't pull it out and so I
44:00thought gum wrapper was it was a
44:02great solution that everybody has
44:04their house and Israel is clean
44:05and they could put it in their
44:07mouth and it's worked out well.
44:09Next time please.
44:13And the last thing I want to mention is
44:16the ASM. Exactly John mentioned that oral
44:20appliances might be considered as far as
44:24an alternative or an adjunct to see Pat.
44:27Because of the problems with their
44:30Association, potentially other virus
44:33that we're all concerned about.
44:36Next one. And that's it.
44:39Thank you very much.
44:42Thank you, um, an now we are.
44:47Moving on to doctor Gore,
44:50Abuka Batula might have got that right.
44:53Talking about reopening of sleep
44:56settings from the ASM perspective. Thank
44:59you card. So almost overnight you know
45:01as as all of us went through this,
45:04this transition from business as
45:06before to the new way of life.
45:08We had to kind of scramble and put
45:10things together as part of the
45:12Public Safety Committee for the
45:14American Academy of sleep Medison.
45:16And we did this with essentially
45:18very little data and if you could
45:20show the next slide what you could
45:22see is that the centers that are
45:24relying on us for for help and
45:27guidance are very diverse in terms of.
45:29The age group serve the region
45:31in the affiliation,
45:32whether their hospital affiliated or not.
45:34So 80% serve adults and kids Anna
45:36minority would do only children up there.
45:39About 1/3 of labs located in the southeast,
45:411/4 in the Midwest and 15 to 20%
45:44in the northeast and on the West
45:46coast and in the Southwest,
45:48about 10% and as you can see more than
45:51half or hospital affiliated next slide.
45:54And this diversity in in our populace
45:56is accompanied by a tremendous
45:58diversity in the way that COVID-19
46:00played out across America,
46:02and this is a slide from one of
46:04the pages of the Johns Hopkins
46:06website and what you can see is that
46:09there are the kovid epidemic.
46:11Surveillance curves are widely
46:13varying depending on which region
46:15of the US you're looking at.
46:17So many regions of the Midwest.
46:19The curve stayed relatively flat,
46:21but you can see over in
46:23the East Coast Northeast.
46:25In New York, New Jersey,
46:26Massachusetts, Connecticut,
46:27there there were huge spikes in activity.
46:30A man,
46:31the Midwest wasn't completely quiet either.
46:33States like South Dakota.
46:34So it's like, you know,
46:36because of an outbreak related
46:38to a meat processing plant,
46:40and similarly Louisiana with Mardi Gras.
46:42So,
46:42so every locality in region it even
46:45in a state that seemed to see low
46:48levels of activity might have had a
46:51big outbreak in a specific around
46:53a specific laboratory next slide.
46:56So, uh,
46:57and as we can see in recent times,
47:00we've had protests because of math
47:02and shutdowns.
47:03We've had people lining up to vote.
47:05We had beaches reopening and in
47:07the last few days we've seen a
47:09lot of civil unrest and so many
47:12unpredictable gatherings where there
47:14are opportunities for these super
47:16spreading events to occur where a
47:19single person can be responsible for
47:21infecting hundreds if not thousands
47:24of people exline So how do we do
47:26this then how do we provide guidance
47:28in this type of an environment well
47:31we intended for this to really be
47:34viewed as a living document and
47:36what that means is that we we we
47:39advised everyone to expect that
47:41there could be sudden spikes in
47:43local activity and that if you
47:45open up you may need to close down
47:48again based on what's happening and
47:50so to stay connected with federal
47:52state local and hospital guidance.
47:54In scientific data,
47:55as was mentioned earlier,
47:56there's a huge volume of
47:58publications coming out and so
47:59staying attuned and often in spite of
48:01how much is coming out, it still seems
48:04to lag behind what we need right now,
48:06but Anna's new evidence comes out sometimes.
48:09What things we were doing
48:10before need to change.
48:11So being nimble and being quick
48:13in the way we adapt is going to
48:16be what's necessary. Next slide.
48:18So in the midst of all this change,
48:21then what can we? What can we do?
48:23Well, we just we chose several
48:25goals that we thought should be,
48:27uhm, anchor points.
48:28The first of course first and foremost is
48:31to minimize viral exposure to all patients,
48:33staff and health care providers.
48:34And the 2nd is that if we're going to reopen,
48:38there's going to be a steep learning curve.
48:40So let's not Russian.
48:41Let's do things gradually and keep
48:43building on our experience and knowledge
48:46and do things gradually and safely.
48:48And the third to implement best practices
48:50for infection control and Prevention and
48:53refer to the authorities in these areas.
48:55And finally, as we differ,
48:57patients delay care.
48:58Postpone an urgent care.
49:00It's really important that we maintain
49:02communication with these individuals and
49:04continue to maintain access and continuity.
49:06And the patients aren't lost to follow up.
49:09And finally,
49:10really important to maintain and
49:12promote public health and public safety.
49:14OK, next slide.
49:16Um,
49:17so we all we went through general
49:20considerations for reopening and
49:22that included what the patient's
49:25COVID-19 statuses screening of.
49:27Staff and patients infection
49:29control procedures,
49:30personal protective equipment or
49:31PE and then specific strategies
49:33based on how services are provided.
49:36Next slide.
49:36So next slide again soko VAT
49:3919 status we can.
49:40There are five different categories
49:42that a patient or a health care
49:45provider could belong to so they
49:47could be quarantined for two
49:49weeks because they've had an
49:51exposure or suspected exposure.
49:52They could be presumed positive because
49:55of symptoms or because they have either.
49:57A test that spending or because
49:59of symptoms that seem suspicious,
50:01perhaps with unknown contact or not,
50:04their status could be completely unknown,
50:06or they could be presumed negative
50:08or recovered,
50:09and as these last two categories,
50:11next slide that we're talking about
50:13when we talk about reopening,
50:15who should be first in line to be
50:17to be coming in and the presumed
50:19negative cases we need to be
50:22aware that you know there are pre
50:24symptomatic and asymptomatic carriers,
50:26so a negative test doesn't necessarily.
50:28Rule out disease and so if
50:30clinical suspicion remains high.
50:31May need to be repeated.
50:33An recovered patients similarly could have.
50:35At least they should be a febrile
50:37for at least 72 hours and their
50:39symptoms need to have improved
50:41an what CDC recommends is that
50:43at least 10 days is passed since
50:45symptoms started or that they've had
50:47at least two negative cova tests
50:49at least 24 hours apart in time.
50:51But we need to be aware that some
50:53patients shed viral DNA for a really
50:55long time without positive cultures.
50:57It could be weeks before they clear.
51:00Are any friends from their blood?
51:02It's not clear that they're actually an
51:05infectious transmission risk, so again,
51:07that's a place where more scientific
51:09evidence would be helpful. Next slide.
51:13Um, so moving on to screening infection
51:15control and personal protective equipment.
51:17Next slide in terms of
51:18screening for patients,
51:19we recommended that there should be at
51:22least two different points in time,
51:23and screening is done.
51:25One is well before the appointments
51:27that you can identify.
51:28Those patients who are potentially Cove
51:30in positive and advise them not to come
51:33and then again at the time of appointment.
51:35Ask about symptoms,
51:36shortness of breath, cough,
51:37fever, check their temperatures.
51:38An if there is a coded test available
51:41if asked them if they'd been
51:43tested and if they are aware of.
51:45Results and we don't want patients
51:47coming in because they're worried
51:49they're going to be charged a co-pay,
51:51or miss an opportunity.
51:53So be generous with policies regarding
51:55penalties for cancellation and missed
51:57missed appointments because the
51:58rest Realness and as far as staff
52:00we recommended checking temperature
52:02at least twice a day.
52:03And if they're febrile with 100.4 more,
52:06send them home.
52:07Um,
52:08flexible or reduce scheduling
52:09is really important,
52:11especially at the height of the pandemic
52:14when many people were out with illness,
52:17were quarantined or redeployed
52:18to other areas,
52:20and in those situations where
52:22staff is working.
52:23There are a few people handling everything.
52:25It's important that they get many
52:27rest breaks to prevent burnout.
52:29Sick leave policies also need to
52:30be consistent with what CDC another
52:32health Department sat recommending.
52:34Advise your employees not to
52:35report to work when they're ill,
52:37because a lot of cases of transmission
52:40that have occured with health care
52:41worker to health care worker.
52:43And finally the point of contact
52:45testing patients before they come
52:47into the visit and staff regularly.
52:48And this is heavily dependent on
52:50availability of tests. Next slide.
52:52In terms of infection control
52:55these recommendations,
52:56it's really important for
52:57somebody to stay on top of these,
53:00so we advise,
53:01recommended designating a staff
53:02member to stay up to date on what
53:05local health Department state Health
53:07Department since EDC or recommending
53:09as well as manufacturers physical
53:11distancing is still a very very key
53:14component of control, infection,
53:15control and telemedicine is a
53:17big component of that,
53:19so we advocated using telemedicine
53:21as much as possible and then.
53:23Uh, if patients do need to come in on site.
53:26Physical distancing,
53:27which includes not having a lot
53:29of people in the waiting rooms or
53:31piling up and check in areas or check
53:33out areas facing chairs far apart,
53:35studying only a few patients at
53:36a time and limiting FaceTime.
53:38So between the technician or the
53:40health care provider and the patient
53:41and any instructions that need to be given,
53:44give them in advance or afterwards
53:46and do it remotely.
53:47Limiting visitors,
53:48unless they're absolutely necessary
53:50for patient care,
53:51and even for translation services.
53:53Try using online services.
53:55Have copious signs of advising patients
53:58on proper hand hygiene and
54:00keep looking at your pee PE,
54:02because that's going to drive everything.
54:04Is there available
54:06accessible PE for your staff?
54:08An enough masks for patients
54:10if they need them?
54:11An review the control procedures?
54:13As I said with.
54:15With all of your staff next slide.
54:19As far as PP monitoring supplies is primary,
54:21there were many times when shortages
54:24have been faced by by many of us.
54:26What we advise is that staff should
54:28be everybody should be masked all
54:30the time and that staff should be
54:32wearing at least surgical masks
54:34when they're on site on duty,
54:36except when they're eating and patients
54:38should have at least a cloth covering
54:40or bringing their own surgical masks.
54:42If you have enough supplies to loan
54:45patience for surgical mask, that's great,
54:47but state and federal guidelines should
54:49be consulted as to how best to use PP.
54:52Because as you be all know,
54:54those recommendations did
54:55change over the course.
54:56The pandemic, and there is mixed data,
54:58but there's definitely data.
54:59That path can,
55:00potentially ERISA lies the virus,
55:02and so anytime path is being delivered
55:04using in 95 respirator along with
55:06full PB and 95 respirator's need
55:08to because you could test it in
55:10accordance with OSHA guidelines.
55:12Next slide and as far as specific strategies.
55:14Next slide.
55:15Um,
55:15we recommended that OK on the
55:18far right column.
55:19If you really have no disease
55:21activity or very minimal,
55:23then you can pretty much
55:25conduct business as usual.
55:26But if you have at least minimal
55:28to moderate or substantial
55:29of community transmission,
55:31then changes in order.
55:32So in terms of Papus in clinical settings,
55:35we had concerns about potential spread
55:37because of this error civilization risk.
55:40There have been multiple
55:41studies to suggest this,
55:43so unless very special procedures
55:45are taken to limit transition,
55:46we recommended as a general
55:48rule that it should be avoided.
55:50In terms of titration, PS GS in,
55:53in,
55:54in regions with substantial
55:55transmission where there's a lot
55:57of community spread and staffing
56:00has been significantly impacted.
56:01Consider using this Medicare option
56:03for the older patients of offering
56:06empiric path therapy an if it's
56:08minimal to moderate transmission.
56:10Then limit those pap titrations
56:12to emergency patients.
56:13Use adequate pipian,
56:15consider using negative pressure rooms
56:16in terms of diagnostic testing in
56:19substantial with substantial transmission.
56:21We advised restrict only to
56:23emergencies for in lab studies,
56:25an use plenty of PP,
56:27and follow social distancing policies
56:29that we talked about earlier.
56:32And with minimal to moderate transmission.
56:34Uhm, it's it's we,
56:35which is kind of where a lot of
56:38reopening labs are right now.
56:40Look at your patience and consider
56:42whether they are at high risk for
56:44severe disease an it really should
56:46be reserved for those patients who
56:48are not considered to be a very high
56:50risk for severe disease in terms of
56:52clinic appointments in restrict in
56:54person visits to only urgent cases
56:56and use PP and social distancing,
56:58an really use telemedicine
56:59as much as possible in areas
57:01with substantial transmission
57:02and in minimal to moderate areas.
57:05Um again, limit, uh, if you can,
57:07to those at high risk.
57:09For severe Cove it or not,
57:11at high risk for severe coded and only
57:13if there's no telemedicine option.
57:15So really pushing telemedicine here as a
57:17as a key component of maintaining physical
57:20distancing and in terms of visitors,
57:22they should be restricted and prescreen
57:24just the same way you would prescreen
57:27patients and restrict them to only
57:29those who are absolutely needed.
57:31For for patient care.
57:33And and finally,
57:34home sleep testing.
57:35We have specific service parameters
57:37we recommended.
57:38If you are using reasonable devices,
57:40follow the disinfection protocols
57:42recommended by the manufacturer and CDC.
57:44There very clearly outline and we
57:47provided links on the web page.
57:49Remove them from service for at
57:51least 72 hours based on data that
57:54buyers can be viable for that time on
57:57services and disinfect before use.
57:59Using appropriate PPA and consider using
58:02fully disposable devices or components.
58:04Again,
58:04there is the cost concerned that
58:06others have mentioned earlier and
58:08really use a service model that
58:10can help with physical distancing,
58:12so either curbside drop-off
58:13or pick-up or Mail delivery,
58:15and as much as possible in structure
58:17patients using remote methods you know,
58:20Mail them brochures or pamphlets called
58:22them up and do a telephone call or video.
58:26At next slide.
58:28So an an finally really in,
58:31you know,
58:31in an era where we don't be used
58:34the best possible available judge.
58:37Evidence that we have and when
58:39evidence is not available,
58:40we come to conferences like this
58:42and really share our knowledge
58:44and use expert consensus.
58:46But at the end of the dates
58:49are clinical judgment.
58:50It's going to be extremely
58:52valuable in this environment.
58:53It's really important that we keep
58:55health and safety first of our
58:58patients anavar staff and of the
59:00greater public good an above all.
59:02Air on the side of caution when you're
59:05making decisions about reopening.
59:06Thank you very much.
59:08Thank
59:08you Indera and finally a doctor Cannon Ramar,
59:12who's the president elect of the ASM. Thank
59:16you and Good afternoon everyone
59:19really appreciate this opportunity.
59:20An invitation to be here with you
59:23all and first of all I just wanted
59:26to express my sincere gratitude
59:29and thank each and everyone of you
59:32for everything that you've done.
59:34Gone through in the last few weeks
59:37to months in terms of adapting to
59:40these significant ongoing changes
59:42related to arc over 90 Lation
59:45and showing resilience and.
59:46I'm getting lessons to learn from
59:48all these two to hopefully make these
59:51things better has been moved forward,
59:53so thank you again for all of that.
59:57Um, what I said might actually resonate.
59:59Share a little bit with this particular
01:00:02slide that's in front of you.
01:00:04This is the slide or a figure that
01:00:07I borrowed from the CDC website,
01:00:09and here you can see at the center
01:00:11is a pandemic phase and then they
01:00:14talk about different types of phases,
01:00:16including transition phase and the
01:00:18Inter pandemic phase transition phases
01:00:20where believed to be the second surge
01:00:23that we're anticipating to happen.
01:00:24Then your future,
01:00:25and the reason to keep.
01:00:27These different faces,
01:00:28at least at the back of our mind,
01:00:31Isba cause in terms of not only from
01:00:34a risk assessment but also in terms
01:00:37of how we end up responding to.
01:00:39It might also depend on the hyper phase.
01:00:42We might be again and I think it's
01:00:45also very important that the lessons
01:00:47learned during this current time is
01:00:50going to be needed much more when
01:00:52we look at the second search are
01:00:55another panic in the near future
01:00:57and I think that's why webinars
01:00:59an conferences like these.
01:01:01Where we continue to learn and hopefully
01:01:03with publications related studies that
01:01:05are being done as they come through,
01:01:07they're going to be able to help us
01:01:09figure out what needs to be done.
01:01:12As we move forward here.
01:01:14Next slide, please. So I thought.
01:01:18A doctor,
01:01:20uh Indra.
01:01:20There are fantastic job in covering
01:01:22what she was doing from a public
01:01:25Safety Committee point of view,
01:01:27so I thought I'll take the big
01:01:29picture roll off at least outlining
01:01:31what we are currently doing and
01:01:34what we plan to do from an ASM POV
01:01:37and would love to get your thoughts
01:01:39input in terms of what else we could
01:01:42be doing to help our members and
01:01:44our sleep providers during and in
01:01:46the post code with 19 face as well.
01:01:49And uh, doctor good about Ella,
01:01:52who chairs the Public Safety Committee,
01:01:54nicely outlined what's currently being done.
01:01:56A lot of work has been done by that
01:01:59particular community through the ASM,
01:02:02and kudos to her and her team with
01:02:05excellent work that they have done
01:02:07so far and the continuing to be
01:02:10periodic updates.
01:02:11and I would encourage you if you
01:02:13have questions related to anything
01:02:15that might be discussed.
01:02:17Probably well covered under the
01:02:19resource section within the code 19.
01:02:21And there's a website that's listed out here.
01:02:25The.
01:02:25Another initiative that is,
01:02:28I'm mistaken as a startup code
01:02:3019 task force that's
01:02:31actually going to get going here pretty soon,
01:02:34and doctor Phil is actually going
01:02:36to be heading that task force along
01:02:39with Shannon Sullivan as well.
01:02:41And we what we ended up doing was more
01:02:43a few members from the Public Safety
01:02:46Committee onto the code 19 task force
01:02:49so that the Public Safety Committee can
01:02:52continue to focus on what needs to be
01:02:54done from the public safety perspective.
01:02:57And move all the cover 19 related.
01:03:01Discussions and uh and anything
01:03:03related to that to the code.
01:03:0519 passport. Apart from that,
01:03:07it's also very important for the board,
01:03:10and there is some leadership to be aware
01:03:12of what's happening on a regular basis,
01:03:15so that with these data points we
01:03:17might be able to better strategize in
01:03:19terms of what needs to be done of help
01:03:23our field are members of providers,
01:03:25and of course,
01:03:26our patience as we go through
01:03:27these different faces.
01:03:29That's coming up in the near future.
01:03:33Also wanted just let out of providers.
01:03:35Be aware that there are there is
01:03:38a help line that's available if
01:03:40you were to just call the ASM.
01:03:43Phone number there will be a properly
01:03:45triage right away to the right person
01:03:48to have a discussions related to cover
01:03:5019 or any other questions that you might
01:03:53have related to this particular issue.
01:03:55Next page please.
01:03:59But telemedicine, presidential comedy
01:04:01has been initiated as well and for
01:04:05the reasons that we all very well now.
01:04:08At this point, I think thanks
01:04:10to the national emergency,
01:04:12and then subsequently the
01:04:14Public Health Emergency Act.
01:04:16There's been a significant waivers,
01:04:18an related to use of
01:04:21telemedicine through see MSN,
01:04:22other players and and to make sure that
01:04:26we are providing the resources and and.
01:04:29And information to our members and
01:04:31to providers we created created the
01:04:34celebration presidential comedy.
01:04:36It's a way to make sure that we are
01:04:39putting the necessary resources together
01:04:41that could then be made available and
01:04:45also as a way to answer any inquiries
01:04:48from providers in members who might
01:04:50be interested in knowing more about,
01:04:53uh, how best to use telemedicine?
01:04:55And questions for later that.
01:04:57It's also important to know.
01:05:00That the Public Health Emergency Act.
01:05:02I think at this point is till end of June.
01:05:06It's probably going to be renewed after that.
01:05:10And if when that happens,
01:05:12hopefully whatever the way was
01:05:14that are in place will stick.
01:05:17A whole aware what's going to happen
01:05:19after that is a bigger question,
01:05:21and of course we need to be on the
01:05:23forefront to make sure that we are
01:05:26advocating or some of these waivers
01:05:27to stick in place to help the help
01:05:30out providers to be able to do what's
01:05:32needed to take care for patients.
01:05:34And I'll come back to that here in a second.
01:05:38Sleep TM through the ASM just so
01:05:40that everyone is aware there's a pre
01:05:43access and there's nothing offer in
01:05:45still in existence till end of July.
01:05:47And when you do sign up you have free
01:05:50access for a three month time period.
01:05:53Also,
01:05:53there's been other thoughts on
01:05:56telling Medison in the last few years
01:05:58and we have bundle that together
01:06:01to make it free to all our members.
01:06:03Next slide,
01:06:05please.
01:06:05And this is where the advocacy
01:06:08committee comes into play.
01:06:10And this is a new committee that we
01:06:12at the Asian recently commissioned
01:06:15because it's very important that,
01:06:17particularly with the with the
01:06:19issues that we just touched upon
01:06:22from a telemedicine perspective,
01:06:24as we as the public agency act.
01:06:27Tends to potentially go away
01:06:29in the near future.
01:06:30We want to make sure that whatever
01:06:32waivers have been put in place,
01:06:34it sticks and and so we want to
01:06:37make sure that we are taking are
01:06:39wanting to make sure our voices
01:06:41heard at legislator levels to make
01:06:43sure that some of these important
01:06:45waivers that have come through are
01:06:48going to be in place to help our
01:06:50providers in members to do what's
01:06:52needed to take care of patients.
01:06:54Emily is this ongoing
01:06:56patient advocacy efforts,
01:06:57and this is actually a part of our
01:07:00a new strategy plan and we want to
01:07:03make sure we continue to hear the
01:07:06patient voices and there's more to
01:07:08come related to this in terms of some
01:07:11of this study strategy priorities of
01:07:13from ASM in terms of advocating for
01:07:16patients to and as part of that,
01:07:19they SM is also planning to
01:07:21hire A public health manager to
01:07:23highlight the importance of.
01:07:25Sleep issues and sleep health and what?
01:07:27And also from an advocacy point of view,
01:07:30in terms of what they could be doing to help.
01:07:33Help themselves as well as
01:07:35the field sleep Madison.
01:07:36I threw some of these ongoing changes.
01:07:39Next line please.
01:07:43Return to Accra, Dacian.
01:07:44There's been a lot of changes.
01:07:47Uh, that's either being made or
01:07:49will be made here pretty soon.
01:07:52I would really encourage anyone
01:07:54who's interested in seeing what's
01:07:57happening out here to go to
01:07:59the to the S m.org/application
01:08:00to see some of these changes.
01:08:03And similarly,
01:08:04if you have any questions related
01:08:07to whether contacting the email
01:08:09address out share that's mentioned
01:08:11would also be very helpful.
01:08:13But there's been a bundle of
01:08:16standards that have been relaxed.
01:08:18A time extensions related to
01:08:22submission of materials for.
01:08:25I've also been extended.
01:08:27And I again for a certain lab that
01:08:30I mean that might have been closed.
01:08:33Basin is completely understandable.
01:08:34Understanding in terms of what's going on,
01:08:36and so we want to make sure
01:08:38that we are there to help you.
01:08:41We want to make sure at the same
01:08:43time that right here and safe care
01:08:46is being provided to patients.
01:08:48If your lab is getting reopened,
01:08:50and when it comes to standards
01:08:52from an aggregation point,
01:08:53if we want to make sure that you are at
01:08:56least making the right intention efforts to.
01:08:59Address these standards,
01:08:59at least the ones that are in place compared
01:09:02to the ones that have been relaxed.
01:09:04And so I'm happy to touch upon
01:09:07any questions related to that.
01:09:09Or if you have any questions,
01:09:11don't hesitate to reach out to
01:09:14to a semantic is aggregation.
01:09:17Next slide,
01:09:18please.
01:09:19A few other resources and opportunities
01:09:21that I've listed out here and as
01:09:23mentioned by the previous speakers.
01:09:25The studies are coming,
01:09:27they're being published and JCSM.
01:09:29The Journal of Clinical sleep, Madison.
01:09:32Thanks to doctor Nancy.
01:09:34Call approves editor in chief,
01:09:36has created a section for COVID-19
01:09:39and so that's definitely a place
01:09:42that you could visit to see.
01:09:45What information,
01:09:45at least from a study perspective,
01:09:46what's coming out and see if that
01:09:48might be of some help or guidance
01:09:50as you're trying to figure out the
01:09:52next steps in your own practice too.
01:09:54Similarly,
01:09:54there's ongoing ace on webinars similar
01:09:56to the one that we are in right now,
01:09:59and I would encourage you to look at
01:10:02that as well for further information.
01:10:05Could be forthcoming,
01:10:06has a has been cutting it all
01:10:08learn together here.
01:10:10Uh, is some sleep.
01:10:11I saw the underscore reliability,
01:10:13at least for our members.
01:10:15It's currently a free for
01:10:17a three month period,
01:10:18so if there's a little bit of downtime
01:10:20and you're looking to see or looking
01:10:23for opportunities from a development
01:10:25cycle development point of view,
01:10:27this might be something that one
01:10:29could take advantage of this page.
01:10:32There's more to come related
01:10:34to the state sleep societies,
01:10:36because of course with with
01:10:38our current situation and
01:10:39everything else that's going on,
01:10:41it's they are in.
01:10:43From a financial perspective,
01:10:44an from other issues may be
01:10:47needing some help.
01:10:48And at ASM level we are looking
01:10:51to see what is it that we can do,
01:10:54and so the board is definitely
01:10:57approved of moving forward
01:10:58with some resources from a funding
01:11:01perspective and there's more to
01:11:03come related related to that,
01:11:05but at the same time we also want
01:11:08to hear from the slaves, states,
01:11:11sleep society, presidents and chairs.
01:11:13In terms of what is it that we
01:11:15can do to help you out as well
01:11:17during this particular situation?
01:11:18And finally, I'll just close
01:11:20up is talking about a PS is,
01:11:23as you all very well now are in person.
01:11:26Meeting has been moved to a virtual
01:11:29meeting between August 27 and 30th,
01:11:31and so if you're doing some
01:11:33work related to cover 19,
01:11:35we all want to hear it and so
01:11:37feel free to put in proposals.
01:11:40I think that deadline is coming up here soon,
01:11:43sometime in June,
01:11:44and so if you do have proposals,
01:11:46please do submit them because I
01:11:48think we all need alone together.
01:11:51OK.
01:11:51And I think next slide please.
01:11:56Big bad is it
01:11:58wonderful. I'll stop
01:11:59here and again thank you
01:12:01for this opportunity.
01:12:04And sorry, I I don't know if people
01:12:06can hear the tractor trailer that
01:12:08decided to park outside my window.
01:12:10So sorry about the
01:12:12noise up. I want to thank all the
01:12:14speakers. Uh again, we're gonna
01:12:16still be on for quite a while trying
01:12:19to just have more of a discussion
01:12:21so please send in through the Q&A.
01:12:23Any comments, experiences you've had and
01:12:25will help breed them of- any questions
01:12:27you have for any of the panelists is talk.
01:12:30We'll eventually get on to the website.
01:12:33I will say last time it took a
01:12:36little while to get it on so.
01:12:38So don't expect it there tomorrow.
01:12:40If you want to reach out to me,
01:12:42I could potentially get it out to you sooner.
01:12:45Um again, if you want to add
01:12:47to the research survey,
01:12:48I did put the link in the chat
01:12:51function and again, here is, uh.
01:12:53For May shun if you need that. So, um,
01:12:56I don't believe Doctor Thomas ever joined us,
01:12:59but the rest of the panelists are here.
01:13:02You per for both of them.
01:13:05So one main person you haven't
01:13:07heard from his doctor Sullivan,
01:13:09who adds a sort of pediatric
01:13:11sleep background to our mix.
01:13:13An is also active on the Public
01:13:16Safety Committee.
01:13:16It, as you heard,
01:13:18the task force that's coming up.
01:13:20So I am going to.
01:13:22Leave us back on on this slide,
01:13:24but I'm going to hand us over to
01:13:27Doctor Krieger to help moderate any
01:13:29questions and other people want to
01:13:31join in with any comments they've seen
01:13:33from the questions that are coming.
01:13:36OK, so the waivers that came out the
01:13:39see Ms waivers I thought were terrific.
01:13:42How did they know about what
01:13:45they needed to have on waiver?
01:13:48Uh, and I'd like to give this to the
01:13:51Academy because these are things that
01:13:54they must have known about it in advance.
01:13:59Yes, I I'm not sure I have a good
01:14:02answer for that Doctor Krieger,
01:14:04the as we all very well no.
01:14:07I think uh, the ASM has been trying to
01:14:10push for this for the last few years and
01:14:13something needed to tip the balance.
01:14:15And unfortunately we
01:14:17have had to be recovered.
01:14:1819 that tipped in favor in terms
01:14:21of relaxing all these things.
01:14:23I mean, of course from a
01:14:26practical practice perspective.
01:14:27It makes complete sense in
01:14:30terms of what they did.
01:14:32Um, uh, that way I think access becomes easy.
01:14:36However, what prompted them in the
01:14:381st place might be more related
01:14:41to what's being pushed onto
01:14:42them for a period of time.
01:14:45For the last few years,
01:14:47and I think they probably.
01:14:49Had that in place,
01:14:51which subsequently helped,
01:14:52uh, when the situation came
01:14:55before. OK so I have a question that
01:14:58came up in the question and answer
01:15:02section from a couple of people.
01:15:05So right now the IT is recommended
01:15:09that there be a 72 hour.
01:15:12If I'm machine comes back,
01:15:14you know if ends home sleep testing
01:15:17device comes back and it's not be used
01:15:21for three days for some labs that might
01:15:24be a really big sort of financial hit.
01:15:28The is is it not recommended that
01:15:31one can use something else to
01:15:34disinfect the device except for time?
01:15:41So in in Barrow. Do you
01:15:45think? Well, the recommendation came?
01:15:47We had sort of.
01:15:49Two different recommendations and the 72
01:15:51hours for devices that are being reused
01:15:54and recycled throughout the community,
01:15:56and the recommendation to wait 72 hours
01:15:58was at a time during the height of the
01:16:01pandemic when there were substantial
01:16:02community transmission and the risk
01:16:05of potential transmission through it.
01:16:07Because there are areas of the
01:16:09device that just cannot be cleaned.
01:16:11And there's 72 hours.
01:16:13That's a room been following where
01:16:15we don't even handle the package
01:16:17because of the possibility that
01:16:19viable virus can persist on certain
01:16:21surfaces for up to 72 hours,
01:16:22and so really was following
01:16:24one of the principles.
01:16:26One of the guiding principles
01:16:27we established early on,
01:16:29which is first do no harm and air
01:16:31on the side of caution, basically.
01:16:34Um, so so that was that was the main, uhm.
01:16:38The guiding force behind saying
01:16:4072 hours so the other option is
01:16:43then to use disposable parts or.
01:16:45Units that are entirely disposable.
01:16:48I mean that would be ideal.
01:16:50But it is cost prohibitive
01:16:52for most centers to do that.
01:16:54Yeah so but I agree with you and I think
01:16:58that that's something that we need to
01:17:02ask the the device representatives.
01:17:04That that sell these devices to us?
01:17:06Is there a way to come up with a model?
01:17:09Where large numbers of studies can
01:17:12be done and become accessible.
01:17:15No, at at at a more viable cost.
01:17:18Yeah, you know,
01:17:20like a like a loan program or
01:17:23something. Yeah so indera,
01:17:24I have another question kind of
01:17:27related to that is from what I
01:17:30can tell the reimbursement for
01:17:32Tele Health isn't fabulous.
01:17:34An and and a lot of places.
01:17:37A lot of centers are going to be doing
01:17:41a lot of Telehealth going forwards
01:17:44an do you do you think that that's
01:17:48a sustainable financial model in
01:17:50terms of reimbursement right now?
01:17:53That's a great question, uhm?
01:17:57From from my understanding,
01:17:58many pairs followed what Medicare suggested.
01:18:01See Ms suggested, which is that there
01:18:03be parody with face to face visits,
01:18:06at least for right now.
01:18:08What they'll do moving
01:18:09forward is anyone's guess.
01:18:11It would be great if they would
01:18:13maintain that so that we can
01:18:15continue physical distancing,
01:18:17but it's really not known.
01:18:19And uh, and there is this difference
01:18:22for some pairs between a video
01:18:24visit versus a telephone visit,
01:18:26and a lot of infrastructure is required,
01:18:29and personnel are required to
01:18:31prepare patients for video.
01:18:33You need the right platform
01:18:35and some of the ones that were
01:18:37mentioned earlier by our dentist.
01:18:40Dental of input Doctor D Gardy.
01:18:42Was very helpful,
01:18:43so you know using easily accessible apps.
01:18:45So doximity is one,
01:18:47but different health centers are using
01:18:48different different software platforms
01:18:50to to accommodate these visits.
01:18:52An LG centers have done
01:18:53this very successfully,
01:18:54but even smaller practices through
01:18:56the use of some of the freeware that's
01:18:59out there have been able to do it.
01:19:01But there's definitely going to be a
01:19:04population that's going to be hard to reach,
01:19:06and that's one of our concerns.
01:19:08How do we reach everybody,
01:19:10and how do we not make disparities worse?
01:19:12In the pandemic,
01:19:13with the solutions that we
01:19:15are potentially offering.
01:19:16So we need to work together to to
01:19:20get through this.
01:19:21OK so a couple of people had a
01:19:25question that had to do this
01:19:27again is gonna be for Indera
01:19:30can you define what is meant by
01:19:33substantial versus minimal versus
01:19:34moderate versus non versus minimal?
01:19:37A couple of people ask that question.
01:19:41Yeah, that's a That's a really important
01:19:44question, and it's really based on um,
01:19:46what the, uh? the CDC says, right?
01:19:49So there's widespread community transmission.
01:19:51There are many cases of Comunal Transmission,
01:19:54and staffing is significantly impacted,
01:19:56and that's the that's what we
01:19:58use for substantial and none or
01:20:01minimal is almost self explanatory.
01:20:03And then we have what's in between and
01:20:06many places now along the East Coast,
01:20:09or sort of in that in between area.
01:20:12Where the risk is more than minimal,
01:20:15but not quite substantial.
01:20:16A man and again, this is dynamic.
01:20:19There's no specific number an as I said,
01:20:21regionally,
01:20:22lokoli things can vary within the same
01:20:24zip code as to how many cases you're seeing.
01:20:27So, uhm, you know it behooves
01:20:29us to be connected to what local
01:20:32health departments are saying
01:20:33and what our state guidance and
01:20:36water health systems are doing.
01:20:38To determine,
01:20:38like how quickly do we open
01:20:41up and and when do we?
01:20:43When do
01:20:43we scale back? Yeah, so again,
01:20:46it turns out and arrow that this is for you.
01:20:49Uh, several people asked the question
01:20:51about negative pressure rooms.
01:20:53What are your thoughts about it
01:20:55and what if some or you know what?
01:20:58If a clinic can't do it?
01:21:01Yeah, I think that's a great question.
01:21:04I think the first and foremost thing
01:21:06to remember is that this is still a
01:21:09droplet spread that the primary mode
01:21:11of transmission is still contacting
01:21:13droplet spread and so using the basic
01:21:16hand washing don't touch your face.
01:21:18Maintain physical distancing is really
01:21:20important and minimizing contact face
01:21:22to face contact time with patients.
01:21:24So all of those other things we talked
01:21:26about are still going to be primary and
01:21:29foundational in reducing transmission.
01:21:31So this the the question of negative
01:21:34pressure rooms really becomes an issue
01:21:36when you look at the possibility
01:21:37of error civilization.
01:21:39And uh, and there's so many different
01:21:42factors involved when it comes to
01:21:44efficient Aircel ization enough to
01:21:46cause infection in another person.
01:21:49And so air exchange rates are important.
01:21:52Is there sunlight in the room?
01:21:54Is there adequate UV light?
01:21:56Is there a ventilation?
01:21:58And definitely is there affective
01:22:01negative pressure so we don't
01:22:03have data on any of this.
01:22:05And unfortunately lot of labs
01:22:07don't have windows there closed.
01:22:09There's not a lot of ventilation,
01:22:11and some of the freestanding centers don't
01:22:13have the air exchange rates of six per hour.
01:22:16That hospital grade rooms have,
01:22:18so that just poses a lot of challenges,
01:22:21and I acknowledge that.
01:22:22So we advise that if you're going
01:22:24to do something potentially Aircel
01:22:26Ising like positive airway pressure
01:22:27administration in a lab setting that,
01:22:30then you consider using
01:22:31negative pressure rooms.
01:22:32OK,
01:22:32so
01:22:32I'm gonna ask you one final
01:22:35question that somebody asked.
01:22:36Uh room cleaning between patients.
01:22:41It's recommend for
01:22:43that. Come and look at the CDC guidelines.
01:22:46We lick linked those in our document online.
01:22:49So is it an and they they're very
01:22:52specific about how to clean everything
01:22:54all the surfaces but high touch
01:22:56surfaces definitely need to be.
01:22:58You know there's cleaning.
01:22:59And then there's this infection and
01:23:01the protocols are very specific
01:23:03about dwell time and what percentage
01:23:05bleaches affective and so forth.
01:23:07And it's unfortunate that at
01:23:09times during the pandemic that
01:23:10were actually shortages of these
01:23:12of these agents that we needed.
01:23:14So maintaining an adequate supply
01:23:17is going to be really important at
01:23:20supply of pbe of cleaning materials
01:23:24and also of masks and.
01:23:26Gowns and gloves and so forth.
01:23:28It is going to be going to go and
01:23:30testing supplies is going to go
01:23:32hand in hand with reopening an
01:23:34offering services in which volume of
01:23:36services is appropriate to offer.
01:23:39OK, so another question which is gonna
01:23:41be going to Doctor Amar. So tell me so.
01:23:46A person asked about insurance companies
01:23:48and I know that here in Connecticut
01:23:51every insurance company ends up doing
01:23:53their own thing even though they're
01:23:56pretending that they're following.
01:23:58See Ms guidelines. So the so how?
01:24:01How are you going to be advocating?
01:24:05Kind of at the local level?
01:24:07Like how would you advocate,
01:24:09for example for?
01:24:11Connecticut Blue Cross Blue Shield
01:24:15or Connecticut Oxford and so forth.
01:24:18'cause it sounds like that's gonna be
01:24:21a really big task.
01:24:23That's a good question and difficult one's
01:24:26you pretty well known doctor krieger too.
01:24:29So I think from an advocacy POV at the
01:24:32folks that we really want to target.
01:24:35Of course, other legislators who
01:24:37will hopefully influence EMS.
01:24:39You're hoping that by influencing CMS that
01:24:42the other players would follow through,
01:24:44which includes the local state players.
01:24:48And this is where I think that stayed.
01:24:52Sleep societies and other drastic grassroot
01:24:55level folks becomes really important
01:24:57to make sure that they are engaged and.
01:25:01And I think there are some local
01:25:03advocacy groups that we may want
01:25:05to figure out ways to engage them
01:25:08with the at the national level.
01:25:10And then I think it goes back to the
01:25:13point that has been made so far.
01:25:16We're all in this together and we
01:25:18want to make sure that whatever
01:25:20effort that's being put in at the
01:25:22national level against disseminated
01:25:24to the local level and whether that's
01:25:27through the state sleep societies,
01:25:29other grassroot level folks,
01:25:30that's what I think we need
01:25:32to continue to explore an.
01:25:34And making sure that those advocacy
01:25:37efforts continue to happen
01:25:40so I don't have any other
01:25:43questions here.
01:25:44I want to follow up on on that comment.
01:25:48Uhm, So what one experience
01:25:49I had recently was so mass.
01:25:52How, um, recently, um,
01:25:53higher Debbie court to do
01:25:55their their sleep management,
01:25:57and so they you know basically
01:26:00assume that every Corps doing
01:26:02doing a great job for them.
01:26:04So I actually reached out to their
01:26:07mass health people to find out who was
01:26:10sort of in charge of of, you know,
01:26:13having the contract with every core.
01:26:16And so I had an hour conversation with
01:26:18them explaining different ways that
01:26:20that things weren't weren't going well.
01:26:22So one of the things now that
01:26:24we're reopening our lab or trying
01:26:26to get people's cross again.
01:26:28So we have patients that were approved for
01:26:30prior off before and now are, you know,
01:26:33we were on the phone for an hour.
01:26:36For two, you know,
01:26:37each time for two different patients just
01:26:39to get an off that was previously approved.
01:26:42So you know, she thought it was a
01:26:44very reasonable idea that you know.
01:26:46There should be a grandfathering
01:26:48end of a prior authorizations.
01:26:50Uh, uh,
01:26:51and you know.
01:26:52And and then other issues that have
01:26:55come up related to kovid in terms of,
01:26:59you know,
01:26:59when we can't get testing or
01:27:01the issues related to follow up
01:27:04and getting on going supplies.
01:27:06So I think you know if all of us
01:27:09can specially reach out to those
01:27:11insurers that have decided to use
01:27:14these other companies, you know.
01:27:17Sometimes the insurers are are actually
01:27:19more willing to to hear the stories and and,
01:27:21and you know,
01:27:22and bring them back to the every course
01:27:25through the aims and really say you
01:27:27know the service you're providing
01:27:29for our patients is making you know,
01:27:31is making us look bad.
01:27:32You know you shouldn't, you know.
01:27:34I mean,
01:27:35maybe you still have to have these things,
01:27:37but you should make it so we don't have
01:27:40to spend an hour on the phone to get there.
01:27:43Or you know so.
01:27:44So really letting them know what
01:27:46the reality of what's happening.
01:27:48With these services and then
01:27:50you know the other.
01:27:51The other way is a lot of um,
01:27:54specially big companies do self
01:27:56and ensure so you know if if,
01:27:58let's say,
01:27:59my hospital,
01:28:00you know we all of us get insurance
01:28:02through Health New England so I may not
01:28:06get anywhere talking to help New England.
01:28:08But I might get,
01:28:10you know,
01:28:11somewhere talking to my people
01:28:12at the hospital we're paying
01:28:14health New England or mass mutual?
01:28:17Who's paying Cigna?
01:28:18You know, so if you go to some of these,
01:28:21uh, these companies that are self insurers,
01:28:23it's in their self interest to,
01:28:24you know, make these insurers do
01:28:26do things right by them.
01:28:28So I think there are some.
01:28:30You know some ways that we can
01:28:32get the stories out and you know
01:28:34not what I would love is to have
01:28:36a collection of patient stories
01:28:37to be able
01:28:38to use. and I think those are the most
01:28:41telling an you know if we can get
01:28:43those out in the main media of some
01:28:46of the struggles patients are having,
01:28:48I think that's the.
01:28:49You know some of the best ways to advocate,
01:28:51so I think really working with those
01:28:52patient advocates is going to be important.
01:28:54Yeah, so I'd like to change
01:28:57the subject very, very briefly.
01:28:59We've been talking as though sleep
01:29:02apnea is like the only problem that is
01:29:06related that we need to be talking about.
01:29:09So several of the patients
01:29:11that I've had recently,
01:29:13I've had nightmares symptoms
01:29:14that I think will progress into
01:29:17post traumatic stress disorder.
01:29:19I've had patients who I think have
01:29:22developed central apnea because of
01:29:24something going on in their nervous system.
01:29:27Related to Kovid and I think we need to
01:29:30pay attention to to the to the nightmares.
01:29:34The pandemic insomnia's out there,
01:29:36and because I think we're going to be
01:29:39seeing a lot of patients like that in
01:29:42the future and maybe for a very long time.
01:29:46I mean, today I had a patient who
01:29:49is actually a psychiatry resident
01:29:52here at the ale who had insomnia.
01:29:55That started with the pandemic.
01:29:58You know and and that's we're
01:30:00going to be seeing a lot
01:30:03of that. That's
01:30:04a great point. I completely agree.
01:30:06I don't think we should definitely
01:30:08not forget the other disorders either.
01:30:11I mean, there's definitely.
01:30:12And if all, as you rightly point out,
01:30:15they might be on the rise at this
01:30:18stage compared to be covered error.
01:30:20So your point is
01:30:21very important, IP alright,
01:30:23so Karen should we.
01:30:24Should we adjourn?
01:30:25This has been a great
01:30:27session that you organized.
01:30:29Uhm, well I wanted to, uh my.
01:30:33I have one other question a friend era.
01:30:36So for those centers that do have access
01:30:40to Dekoven testing prior to coming in.
01:30:44You know the what's up on
01:30:46the website really says,
01:30:48you know, using, uhm, uh,
01:30:50the negative pressure rooms and
01:30:51using the N 95 if you're using path.
01:30:55But what if it is a presumed negative
01:30:57or not more beyond presume negative?
01:31:00A tested negative patient?
01:31:02Do you feel that that puts people in
01:31:05that sort of different basket from the
01:31:07others where you can safely feel that
01:31:10that you don't use those precautions?
01:31:12I will catch this and saying.
01:31:15The idea experts in my institution,
01:31:17uhm, you know,
01:31:18feel feel that's true an in the conversation
01:31:20that we basically had with them is,
01:31:23you know,
01:31:24they acknowledge you know that
01:31:26there's always the what if?
01:31:27What if the patient who we've
01:31:29already screened for symptoms that
01:31:31we've checked their temperature,
01:31:33that they've had a negative task?
01:31:35What if you know they picked it
01:31:37up in the last three days where
01:31:40there are false a false negative
01:31:42test and they said yes,
01:31:43you know that can happen.
01:31:45However, we can't ever present prevent.
01:31:47All the what ifs.
01:31:49So we have to think reasonably about,
01:31:51you know,
01:31:52supplies about you know how we're going
01:31:54to use our resources and if you know
01:31:57there there is that slight chance,
01:31:59but it's lower risk than someone you know
01:32:02going to the grocery store or you know,
01:32:04having having you know,
01:32:06meeting with a friend you know
01:32:08is that is that is that except
01:32:10you know exactly acceptable and
01:32:12and what to do with
01:32:14that. I think that we gotta look
01:32:16at the totality of the picture.
01:32:18And it really is going to
01:32:20vary based on the time point,
01:32:22the region, what happened locally
01:32:24in the last couple of weeks.
01:32:26And could this be a presymptomatic
01:32:28Renee symptomatic patients and
01:32:30testing may not pick it up,
01:32:32and we know there the rates of false
01:32:34positive iti with antibody tests and
01:32:37the rates of false negativity with
01:32:39PCR testing an antigen testing is
01:32:41just unacceptably high right now,
01:32:43and you know,
01:32:44and even temperature testing
01:32:46I've heard about patient saying I
01:32:48have a fever and then you check
01:32:50and they absolutely completely
01:32:52afebrile and vice versa,
01:32:54and then we don't know who has.
01:32:56Anti pyretic use or happens to
01:32:58be on an sets for some of the
01:33:01reasons so it mastiff you were.
01:33:03So I think you got to look at
01:33:05the whole picture of what's going
01:33:07on and really look at background
01:33:10prevalence in that locale.
01:33:12And make your best gas.
01:33:14So a man I would say if you're
01:33:16gonna start doing pap titrations,
01:33:18it's gotta happen in a in an orderly way.
01:33:22So the ones that absolutely cannot
01:33:24wait like I have a few people now who
01:33:27are completely recovered from coded.
01:33:29They clearly had it.
01:33:30They tested positive that symptoms are gone,
01:33:33their positive tests are negative,
01:33:34and they really need to come in.
01:33:37So someone like that I feel more
01:33:39comfortable sending forward.
01:33:40We don't know how long the immunity lasts.
01:33:43But imagine it you know in the
01:33:46first initial week.
01:33:47So far we haven't heard of every
01:33:49infections in the first few
01:33:51weeks after recovery,
01:33:52and so that might actually be a safer window.
01:33:55No?
01:33:55It's you know,
01:33:56providing tears of which patients need
01:33:58to go up first and who needs to wait.
01:34:01So probably the emergency patients
01:34:02and the ones that are recently
01:34:04recovered that you're very confident.
01:34:06Or F cleared their virus.
01:34:08The ones that are clearly negative
01:34:10and low risk,
01:34:11local regional transmission rates.
01:34:12And then look at the other ones
01:34:15that are if they were to get cold,
01:34:17but are they going to get severe disease?
01:34:20And unfortunately,
01:34:20that's a lot of our patient panels
01:34:23look that way because of obesity and
01:34:25hypertension and diabetes and so forth.
01:34:27Um?
01:34:28Yeah,
01:34:28I I've uh, so sort of following those
01:34:31sort of guidelines that that uh is
01:34:34I'm did put out I I've taken all our
01:34:37patients probably have about 500
01:34:39patients that have been studied to
01:34:42get rescheduled and reviewed all
01:34:43of them for those high risk states
01:34:46for sort of their urgency level.
01:34:48And you know there is a.
01:34:50You know a small percentage that are
01:34:53sort of in that hitting that more
01:34:55emergent state, but but yeah, I mean,
01:34:57you know, probably over half I
01:34:59kind of teared his level 4. So my
01:35:02you know I did on the wonder for scale and
01:35:05so you know those patients have high risk.
01:35:08Conditions are going to use path and so
01:35:10you know put them sort of after. You've
01:35:13done a really great point.
01:35:14You have come up with a way to strategize.
01:35:17I think we should have a form
01:35:19where we share these strategies
01:35:20with each other and how well are
01:35:22they working now we're working
01:35:24in sort of an information boy.
01:35:25I have too many tears. I
01:35:27just wanted to add on to that.
01:35:29I agree with that.
01:35:30I think if you were I've been reading
01:35:32through the comments and I think if
01:35:34you're into practice where you're able to
01:35:36Cove in test everybody before coming in.
01:35:38I mean, that's fantastic. Kudos to you.
01:35:40I don't think it's available
01:35:42everywhere and these issues especially
01:35:43come up with the pep titrations.
01:35:45I mean, it's great if you're testing
01:35:47everybody coming in, but the The
01:35:48real concern is around titrations.
01:35:50I think that's a special category, Karen.
01:35:51We saw that with your data
01:35:53when you ask the question,
01:35:55are you resuming services OK?
01:35:56Which ones?
01:35:57You had twice as many uhm responding,
01:36:00saying that they were planning to
01:36:02get restarted on diagnostic testing
01:36:03as compared to past studies and
01:36:05especially if your patient population
01:36:07you have special populations
01:36:08weather very chronically ill,
01:36:10special needs, Pediatrics, whatever.
01:36:12It happens to be,
01:36:13you have to consider that
01:36:15and the health of your staff.
01:36:17So that was a point I wanted to bring
01:36:20up that you know it may be the case
01:36:23that your staff member is someone
01:36:25who stands to be a special risk.
01:36:28They were to contract COVID-19 because
01:36:30of other risk factors that they have
01:36:33and we have to consider that as well.
01:36:35So I can't imagine I don't know.
01:36:38It's a question for the rest of the panel.
01:36:41In what circumstances would you be
01:36:43comfortable not having airborne and
01:36:45aerosol precautions in place during a
01:36:47titration for the pattern in the titration,
01:36:50knowing that there's no way
01:36:51they can stay the safe 1 meter.
01:36:54Just say for 1 meter distance away?
01:36:57I like to make a make a point so much
01:37:01over discussion is about process. We're
01:37:04kind of forgetting. In part
01:37:07location. Occasions experiences
01:37:09has been of course very
01:37:12different. During this a pandemic.
01:37:16We have a lot of patience waiting.
01:37:18It means that a lot of
01:37:19patients were bumped. So
01:37:21they care has got
01:37:23delayed in many instances.
01:37:25Yeah, more to help they get from their home.
01:37:28Care companies has dramatically
01:37:29dropped. Uh, at least
01:37:31in our area, no
01:37:32ones doing home visits. An
01:37:34patients, uh, have
01:37:35to do a bit more
01:37:37DIY. Uh, with the mask mask fitting so much
01:37:41harder now they pretty much have to go
01:37:43to the home care
01:37:44company. Well, of course they meet
01:37:46someone in a rubber suit. Um?
01:37:50If it is delay,
01:37:51we all of us have patients who
01:37:53are fairly complicated. And,
01:37:56uh. You know the past. We simply got
01:37:59into the lab and go the data and
01:38:01send them on their way with water. Treatment
01:38:03was right. I will have to do I think
01:38:07much more empiric treatments and.
01:38:09Uh, put us, uh? I mean, if we
01:38:11all just go back if it all target
01:38:13in going back to baseline.
01:38:16Think they're Lawson opportunity?
01:38:18Uh, this disruptive hopefully will. Change
01:38:21things I worry the see Ms is just
01:38:23gonna go back to doing what they were
01:38:25doing before and so will Blue Cross
01:38:26over how the program. And it'll be
01:38:29good at the pandemic is gone, but will
01:38:31be pretty much doing what
01:38:32you were doing in the
01:38:34past. I'm not sure exactly
01:38:36how we can avoid that.
01:38:39I agree with that and, um,
01:38:41you know the other place where
01:38:43I practice the VA hospital has
01:38:45not been bound by a lot of these.
01:38:47These rules that players have had,
01:38:49and so in terms of empiric see path.
01:38:52I think Mary, You said you had done this
01:38:55before 2 but offering C Pap based on on
01:38:58clinical criteria and so far they haven't
01:39:00been refused. Yeah they've done great.
01:39:02I've had probably in the last
01:39:0410 years a couple 100 patients.
01:39:06I've done that before
01:39:07and I don't believe that.
01:39:09Adherence rates are worse than they
01:39:10would be in the veteran population.
01:39:12They tend to be low to begin with,
01:39:15so yeah, yeah, that's true,
01:39:17but I don't believe they were worse.
01:39:19And what there is to do is to put the
01:39:22data together and put it out in press.
01:39:25Well, one thing and let's
01:39:27not forget.
01:39:28There's also nasal dilator therapy.
01:39:29There's position therapy and you
01:39:31know good old weight loss and
01:39:33addressing nasal issues there.
01:39:34There are other things that we could
01:39:37be doing in the meantime as well,
01:39:39and I find that my patients are
01:39:42actually very motivated to do those
01:39:44things when they hear that sleep is
01:39:46important for immunity and well being.
01:39:48They actually are interested. And
01:39:52when one experiences having been on
01:39:54the ASM care Policy Committee when
01:39:57we were writing up are sort of.
01:40:00Cards to rate how insurance companies
01:40:02were doing with their policies.
01:40:05We were reflecting it on the ASM policy
01:40:08statements and all those policy statements
01:40:11are based on what the data is out there
01:40:15and sort of the best case scenario.
01:40:18So a lot of all these scenarios there's not
01:40:22studied data on doesn't mean they don't work,
01:40:26so it is. How do we get? You know the.
01:40:30These things that we've had to do out
01:40:33of necessity, and either, you know,
01:40:35say you know we was expert consensus to
01:40:38say that these are are potentially options.
01:40:41Whether there are ways that the SM
01:40:44could so sort of help fund, you know,
01:40:47these sort of research projects on.
01:40:50Facility of care which I know you
01:40:52know when when I talk to um, uh,
01:40:55some of the NIH folks about sort
01:40:57of you know how about this idea
01:41:00for product and they're like?
01:41:02Well, that's not science,
01:41:04so I've been really shut down about. Well,
01:41:07this is what really impacts our patients.
01:41:09We need to know,
01:41:11you know whether 3% criteria
01:41:13for percent creature is better.
01:41:14We need to know if we set up a
01:41:17home sleep tasks with attack.
01:41:20I don't showing them how to use it up
01:41:22over a video is acceptable to doing a
01:41:25face to face set up because those are
01:41:28the things that affect the guidelines,
01:41:30which then a fact.
01:41:32Tell the insurance policies to do so,
01:41:34I think you know there needs to
01:41:36be this change from, you know,
01:41:38sort of the guidelines to to
01:41:40what the players should do.
01:41:42and I think when you just follow the
01:41:45guidelines it may work for 70% of cases,
01:41:47but it doesn't work for 30.
01:41:49And now that we're going to go visit,
01:41:52it probably works for 30% of
01:41:54the cases and 70% it doesn't.
01:41:56You know it's not not working for,
01:41:58so I think those are some other
01:42:01things to think about and.
01:42:02And maybe it's time does have some
01:42:05ways to help get people to do this.
01:42:08Little,
01:42:08you know,
01:42:09sort of tests and provide data
01:42:11based on sort of their experiences.
01:42:13I know I was thinking of a project
01:42:15now that we removed from having all
01:42:18the patients come in and do home sleep
01:42:21studies settings in person to mailing
01:42:23out the devices and doing it over the
01:42:26phone when it is looking at what is our.
01:42:29You know what?
01:42:30What is our rates of technical failure?
01:42:33And it actually sort of quick quick look.
01:42:35Adam,
01:42:36it seems to be that we actually
01:42:38have less favor failure,
01:42:39probably because the person's right
01:42:41there watching a video at home
01:42:43and then sort of focusing in on
01:42:45it right then rather than rushing
01:42:47in through the day and getting
01:42:49annoyed about parking and timing.
01:42:51So I think you know,
01:42:53I think there's a lot of data
01:42:55we can gather
01:42:56about these practices of
01:42:57care that were sort of.
01:42:59Worst part is that we need to
01:43:03really inform future guidelines in
01:43:06future changes.
01:43:07It is very well taken.
01:43:09You're absolutely right, the the policies.
01:43:11Usually, as you rightly point out,
01:43:14come out of clinical practice guidelines in
01:43:16the clinical practice guidelines through a.
01:43:19Some are usually data driven,
01:43:21and so that's how you come up with
01:43:23these strong and weak recommendations.
01:43:26Using great mythology.
01:43:27And so there's a science to how
01:43:30that ends up being used to get
01:43:33to the data points as well as.
01:43:35Helping out with a policy point of things,
01:43:39there are other two types of papers
01:43:42that they some puts out the best
01:43:45practices as well as the position
01:43:47statements and so those are based on.
01:43:51And studies that may not be up to the
01:43:53level of the clinical practice guidelines,
01:43:57for example,
01:43:57and so if it's a retrospective study case,
01:44:01reports K series and our expert consensus,
01:44:04then they might come under one of these
01:44:07other two paper formats through the SM.
01:44:10They don't carry as much weight as a CP G,
01:44:14the clinical practice guidelines do from,
01:44:16uh, from a paper policy point of things,
01:44:19but they still might help.
01:44:2122 Fight for things that's needed
01:44:25from a policy change point of things,
01:44:30and so I would take this as.
01:44:34If people are doing studies,
01:44:35I think we need to make sure that
01:44:38that gets published because any data
01:44:40is better than no data cycling.
01:44:43Through webinars and uh,
01:44:44such as these things,
01:44:46if we can come up with some type
01:44:48of a consensus statement,
01:44:50I think those are going to be helpful.
01:44:54And then I'll maybe let a bug of
01:44:56Attila touch upon this as well
01:44:58through the code 19 task force,
01:45:00if she hears these things and
01:45:02puts out a recommendation or a
01:45:04consensus type position statement
01:45:05on things that could be done,
01:45:07which is not going to be easy,
01:45:09because whatever you say right now,
01:45:11she also pointed out things do change,
01:45:13and so that's where we've been
01:45:15caught a little bit in terms of
01:45:18how best to go about doing this.
01:45:20And so without the data
01:45:22to support it when you do.
01:45:24Make a recommendation.
01:45:25It's very likely to change in the
01:45:28next few weeks to months at two,
01:45:31depending on your data,
01:45:32so it's a tricky point,
01:45:33but at the same time your point is very
01:45:36well taken, and I think that's where.
01:45:39Books, researchers doing studies.
01:45:41We want to make sure that they
01:45:43get their data out as soon as
01:45:45a bathroom from a foundation.
01:45:47A some foundation perspective,
01:45:48we thought through this a little bit too.
01:45:51Should we be putting out our
01:45:53face for these things?
01:45:55Answer is of course it would be great.
01:45:58Only downside to it is by the time
01:46:00we get answers through our phase,
01:46:02it's going to take awhile and but
01:46:05that shouldn't preclude us from
01:46:07making sure that the studies that
01:46:09are in place that are ongoing.
01:46:12Hopefully can get their results
01:46:14out pretty soon.
01:46:15So I mean,
01:46:16I think there's more to come on
01:46:18this. I think we just still have to
01:46:21have an open mind and continue to
01:46:23explore other ways of how best to
01:46:26come up with these things that will
01:46:28support a policy changes or support.
01:46:30Pushing from an advocacy point of view,
01:46:32I think all those need to be way inflated. I
01:46:36think I I that is beautifully said.
01:46:38I agree with everything you said.
01:46:40Come and I think the other thing is just
01:46:43really leveraging all the knowledge that
01:46:45our international colleagues have have
01:46:47gathered ahead of us. And you know,
01:46:50origin collaborations and you know.
01:46:52Sharing what they have,
01:46:53I think we're going to have
01:46:55to broaden our platform.
01:46:56Very quickly.
01:46:59Can I pay by parent Pediatrics
01:47:01to change topics a little bit?
01:47:03I see a couple of questions coming in
01:47:06on the chat related to that and the
01:47:09questions are basically you know what
01:47:11about from a Pediatrics perspective,
01:47:14and I think you know there's a
01:47:16few reasons that Pediatrics,
01:47:18while all of the considerations we have
01:47:21discussed are also in play for labs that
01:47:23are in practices that are serving children.
01:47:26There's also unique features.
01:47:28For example,
01:47:29there's really no home diagnostic pathway,
01:47:31at least supported by the Academy right now.
01:47:34Um for for children or for adolescents,
01:47:36and so in many cases pediatric
01:47:39practices have already had very
01:47:41long waiting list to get end long
01:47:43waits for patients to get into,
01:47:45but their studies done and now
01:47:47they have been made even longer,
01:47:49and so I think that's an issue.
01:47:52Another issue is even simple things
01:47:54for children having their health
01:47:56care providers be wearing masks so
01:47:58that their police cannot be seen
01:48:00can change the experience for the
01:48:02child coming in for the study.
01:48:04Can be very frightening,
01:48:06and In addition,
01:48:07of course,
01:48:07when you have a child coming
01:48:09into your clinic or to your lab,
01:48:12you don't have one individual coming in.
01:48:14You have minimum too,
01:48:15so there's also the family member
01:48:17to consider.
01:48:18And when we talk about screening for
01:48:20symptoms or doing testing for individuals
01:48:22before coming in for their studies,
01:48:24for example,
01:48:25we have to think about what is going
01:48:27to be the pathway to be considering
01:48:29that family member who is going
01:48:31to be coming in with the patient.
01:48:34Do we even know who the family?
01:48:36Number is he's coming in and where
01:48:38where do we stand and being able to
01:48:41collect that type of information?
01:48:42And then what do we do once we get the
01:48:45information? So there's a lot there.
01:48:47Another thing to get back to?
01:48:49Mirrors point about 9.
01:48:51Non apnea, non breathing.
01:48:52Related disorders.
01:48:53Young people in particular,
01:48:55oftentimes at this might be the age
01:48:58range where you say hypersomnia central
01:49:00hypersomnia's present, such as narcolepsy.
01:49:03Type one.
01:49:04These individuals are going to are.
01:49:07You know,
01:49:07often worked up with an MSLT,
01:49:09and so in a smaller lab you have to
01:49:12think about what's your protocol for
01:49:14being able to turn over that room in
01:49:17a sanitary way to get it prepared
01:49:19for the next patient coming answers.
01:49:21A lot of unique issues.
01:49:22Again,
01:49:22they're facing all labs,
01:49:24but in particular we have to think
01:49:26about children,
01:49:26and I wouldn't say it's the case.
01:49:29I know early on there was this discussion.
01:49:31Well,
01:49:31children don't seem to be affected
01:49:33by coronavirus,
01:49:34but I you know there are also
01:49:36reports that there is very.
01:49:38A very serious syndromic multi organ
01:49:40system illness that can resolve and
01:49:42we have to be aware of that as well.
01:49:45These kids might not present,
01:49:47typically.
01:49:49Our children having more home
01:49:51studies, now you know.
01:49:53You know there's good question.
01:49:56I'd love to hear from what's happening
01:49:58at the panelists institution for sure.
01:50:01Uhm, in my practice,
01:50:03children are being diagnosed in laboratory.
01:50:06And so if there are suspected to
01:50:08have a sleep related breathing
01:50:10disorder movement disorder,
01:50:11they're coming into the lab
01:50:12and having in lab testing.
01:50:15Agree the same here.
01:50:17Yeah. Yeah, we're we're in lab,
01:50:19although I certainly question
01:50:21for the older kids point.
01:50:23Are they the same as adults? Yeah
01:50:26there uh at shop as well. It's in lab.
01:50:29There was some talk about some of the
01:50:32older kids possibly doing home studies,
01:50:35but that hasn't been formalized.
01:50:39And I think this is again work for the pair
01:50:42Policy Committee as well.
01:50:44Yeah, and I don't believe doctor
01:50:46remark and coming on this,
01:50:47but I don't believe there's any
01:50:49pathway for diagnosis that supported
01:50:51through the Academy via home
01:50:53testing. That's true. You're
01:50:54right, there is none at this point.
01:50:58Yeah, I think through this alone, but in
01:51:00terms of what else can we do to help in
01:51:04the mean time, Yeah?
01:51:05As I've been hearing everybody speak,
01:51:07I think that change happens
01:51:09through drift and through Swift,
01:51:11and this is one of those times
01:51:13were in a shift and so it's an
01:51:16enormous opportunity as a number
01:51:18of people have pointed out,
01:51:20and I hope that we as a field can
01:51:22take advantage of this time of
01:51:25shift to be able to do what we know
01:51:28how to do best and really build
01:51:31on efficiencies for our patients
01:51:32of all ages. Yeah,
01:51:35let's try Colburn, it's hot. And it's
01:51:38the time to collect data.
01:51:40We might not get because we are forced
01:51:42to do things we wouldn't normally do.
01:51:44So you know, I do think if there
01:51:46can be thoughts of what are
01:51:48these practice questions that
01:51:50we can't get in normal times,
01:51:52but might people might have
01:51:53been trying out in these times,
01:51:55can we ask to you know to get
01:51:57that data and let people know
01:51:59what we're interested in and then
01:52:02try to see if it does make sense
01:52:04to change some of the way
01:52:06we're doing things in the long term.
01:52:10So I do as less
01:52:12as anyone else. Have.
01:52:14Any lungs comments? We are at
01:52:16355, just a quick
01:52:18a comment. There were a couple of
01:52:21questions about screening and how do
01:52:23you specifically screen and the ASM
01:52:26document the mitigation strategies
01:52:28document online has details about that.
01:52:31So the questions to ask is what the
01:52:34CDC has specific questions to ask,
01:52:37common symptoms, shortness of breath,
01:52:39cough, fever.
01:52:40Loss of sense of smell and so forth,
01:52:42and an actual testing of testing is
01:52:45available that should be implemented as well.
01:52:47And there's a schedule for when to
01:52:49do patients and also technologists
01:52:51with temperature screens.
01:52:53And the
01:52:54other last comments. Otherwise I
01:52:55want to thank all our panelists.
01:52:58Um, thank you for coming out.
01:53:01And in two hours of time with us today.
01:53:04And thank you, I think
01:53:06we still had almost 200 people
01:53:09at the at the end of this.
01:53:12So thanks to all the participants and
01:53:15till next time. Thank you very much.
01:53:18Bye bye everybody, thank you.