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No, we're not hearing you. I apologize for this to, to both to uh Professor mcwhinnie and to uh to everyone attending. But while the first video is on, I will try and ensure that we get Professor mcwhinnie back on uh so that we can hear him. Uh So the first presentation is from Professor mcwhinnie and uh it is about uh the new normal for the ambulatory surgery pathway. Yeah, I'd like to talk today about the new normal for the ambulatory pathway. Uh and give you some thoughts and ideas of how I think the pathway has changed in this COVID pandemic. Now, it's a few short months since the director General who ted risk every uses announced that could hold 19 was a global pandemic. At that point, many countries were in their first wave of infections and now many are in the second wave. And it's interesting to compare COVID with the Spanish flu epidemic of 1918, 1919. You can see in this graph that the initial wave was quite small, but it was a second wave which was greater and more deadly than the first, probably due to troops and soldiers returning from all over the world to their homelands. At the end of World War One and spreading the disease. There may also be some evidence there was a degree of antigenic shift at that time. The other thing you see in this graft is that there's a third wave and I hope this doesn't happen to us today. Now, the effect on ambulatory surgery is interesting in the first wave, we were creating capacity for COVID patient's in our hospitals. And in many cases, we converted ambulate treatments into makeshift itus. We stopped and reduced elective surgery when we restarted surgery as a standalone units that were best placed to start again. And of course, you could actually keep COVID three with appropriate triage in uh integrated units. There was a great driver because Cobra was present in the hospital to push for more ambulatory surgery. And this also has been seen in many countries. Now, we're probably in the middle of the second way of the time and I hope that we can add it with COVID protection, please. And that our ambulatory surgery is contained. So let's look at the pathway we know and love. This is our ambition pathway, the three domains, pre assessment period, operative discharge domains coming divided into each into three components. And I'd like to look at each of the components and turn and see what's changed in the pathway. So major change in the patient referral and pre assessment, almost all of this can now be brought online, streamline the pathway considerably and it's all remote by phone pad or top. Now, the remote consultation pathway can be successful if you don't require an examination and the patient has got capacity to make a decision, then the remote consultation is fine. If you do require an examination and many surgical patient's require this or you're not sure of the patient's capacity to make a decision, then a face to face consultations required to ensure safe and accurate clinical decision making. So what's changed in patient selection? Well, before COVID, as we all know, we looked at biological age, we looked at body mass index, perhaps a universal policy for your unit or procedure specific. So for example, in my own unit, we wouldn't operate on an incisional hernia if the patient had a BMI a great and 35 because we know there's great recurrences after that. And of course, the comorbidities as shown by a SC status. So after COVID is patient selection, but well, of course, it has, we've now got to consider not only the risk factors for ambulatory surgery, but the risk factors for COVID. And we also have to test for COVID and the risk factors with we're finding worldwide is age, male, sex, ethnicity, obesity and the core mobilities especially from the heart lung, endocrine systems, blood and then the urine a compromised in cancer. Patient's age is a major risk factor for COVID. And in these data from the Chinese Center for Disease Control and Prevention. You can see that once you get the age of 60 your chances of dying rise exponentially in the UK. Well, got quite a large ethnic minority. And in this bar chart, you can see the predicted death rate and blue in the actual death rate and orange and in each of these ethnic minorities, the actual death rate, pharynxes, the predicted death rate. The question is why now I'm not going to get to any political arguments, but suffice to say it's either genetic, socioeconomic, environmental or a combination of all. And there are ongoing studies to try and see which is which now when it comes to obesity. Another great factor. I'm not talking about the few pounds that we all put down during lockdown. I'm talking about the major worldwide obesity epidemic. And as we all know, the who classified obesity is a BM I of greater than 30. And this is the obesity map of the world in dark blue. You can see with 40% obesity, Saudi Arabia and USA and the normal blues and greens. You've got Europe, South America, South Africa and Australia. And the light green yellow is middle Africa and Asia. And the OECD published these charts again in the United States top and Korea and Japan and China at the bottom. And why are we have a BC epidemic is most likely due to the wide availability of cheap fast food, high calorific content. Now, if our populations are continuing to get fatter, we need to continually review our BM I limitations. If you think back to 1992. Well, my goodness, we wouldn't operate at anyone with a BM I, more than 30 we then got a bit more knowledgeable and decided that perhaps we should look at the individual patient and not look at arbitrary limits. And then nowadays, we're actually with experience, we can now successfully manage many patient's that with BM I of up to 40 more now for ambulatory surgery, we really concentrate patient's with communities of A S A one and two and two B's, the main risk for COVID diseases to three's. And so there's a bit of overlap here. We are going to get patient's who are at risk for COVID uh military surgery. And that means we really have to enhance our shared decision making policies. We need to talk the patient at length about the benefits of the operation, the risks of the operation. And if there are any alternative options, and we also have to discuss the risks of going ahead with surgery versus the risk of delaying the surgery. And in order to do this, we got to consider the risk factors, both COVID and ambulatory risk factors. We've got to consider the working or living conditions of the patient density, for example of the living conditions, the local COVID prevalence. And if we can optimise health beforehand. As we always do an ambulatory surgery. When we're preparing our patient's for surgery, we now have to consider uh what we do beforehand and many local policies enforce it might be double COVID tests. It may be up to the indigenous tests and so on. In England, we've got nice guidelines and we divided the risk factors into those who got COVID risk factors and those who do not have COVID risk factors. So if you're not any major risk factors for COVID, we suggest social distances for 14 days. A COVID test 72 hours before then lockdown. If you are at risk of COVID, remember all over sixties and noted obese, then you decide if I sleep for 14 days beforehand and have a COVID test 72 hours before surgery. As I said, it varies from country to country and unit to unit. And this is our own COVID testing station at a private clinic and Milton Keynes, as you can see, it's a summer, nice, clear blue skies and the station is outside the main hospital. So we can actually perform the COVID test without the patient even getting out of the car. Now, what about procedures? Well, have they changed in any way? We know there is no definitive list of ambulatory procedures in the world but different countries have their own lists usually for required for patient safety or for the purposes of reimbursement. But what I would say when it comes to procedure selection is that most ambulatory procedures are actually life enhancing rather than lifesaving. And if you do get COVID, when you're in your operating, you've got a 50% chance of having permanent complications afterwards. And it's also highlighted the COVID pandemic that we don't need to do surgery, which is necessary. And again, it makes you think very carefully if you really do need to do the surgery. And I'm talking mainly about plastic surgery. And I always tell my own medical students that there's only three surgical operations, you either do open, you do it minimally invasively or you don't do it at all. And that third option perhaps is relevant this COVID pandemic when it comes to scheduling, then normally we would six weeks before plan our list, arrange p assessment, confirm the list four weeks before and two weeks before lockdown. The list with no changes. The problem with COVID is that it's no longer possible to replace late unavoidable cancellation with substitute patient's. They may not have had the COVID test and they may not have fulfilled their in their self isolation period. Remember that COVID can take up to 14 days to become apparent and you can be asymptomatic for up to 72 hours. Hence the 14 days and 72 hour fixed when it comes to admission. Yes, things have changed also in my own unit. We don't allow patient's in without a friend or relative except a parent child or somebody educating for a vulnerable adult and both healthcare worker and the patient. We are loose fitting surgical masks to provide one way protection. Now, for surgery itself, we have to address this new term. We all know about aerosol generating procedures. A GPS and of course, general anesthetic has got a number of ways of creating aerosol generation. Uh largely mask anesthesia isn't quite as bad as ett and for surgery, the high risk operation or ent endoscopy, the jury at the moment is out with laparoscopy. So far, there's not much evidence to suggest that COVID will come out in the smoke or the CO2 from the abdominal cavity. After insufflation have an anesthetic point of view. The non aerosol generating aesthetics are spinal regional and local. And for surgery that's surgery. Now, if we're going to wear proper surgical respirators in case patient's got COVID, then we really do need to have a filter capacity of minimum 99% and that means FFP CNN 99 and above. So in theater, if there's a great risk of COVID, we need the FFP respirator, high protection, fluid resistant gowns and double gloves, certainly for the high risk and needs. It is not quite such a risk for the surgeon and this governors, but whether the circulating team needs such protection or they can downgrade a little bit is entirely up to local policy and local risk. We still do RWHR team briefing all the team are involved. The only difference is that we now have to wear our surgical face masks, but we still discuss the order of the list of what equipment required and any changes to ensure surgical safety. The surgical safety checklist remains as it was with one edition and that we checked the COVID results of asserted to our swab beforehand. And indeed, in many units, the patient won't even get into the unit. And let's the swab result is negative. Far, let's get to theater. Now, what about turnaround times? Turnaround time is important in ambulatory surgery because we're doing lots of cases in the day. And this is an old slide of show many times before, but in green is operating time and read is turnaround time. And you'll see that sometimes the turnaround time exceeds the operating time. So what time do you actually need in this COVID? Well, let's look at the science. If we're going to replace the air in the theater, one air exchange will replace 63% of the air. And that means the same amount of potential virus bearing aerosol, that means 37% of the air is left. So after N eight exchanges, 0.37 to the power N remains. So after two, that's 0.37 squared which is 40% and so on. Now, the average theater in terms of air changes per hour has between 15 and 20. Uh consider laminar flow which is sometimes nation of 300. So ignore that just now, the average theater 15 to 20 you want to have 99.9% efficiency of airborne contamination. Then you can see you need around about a 20 minute gap between the cases and that is about the normal time it takes to change around at the present time and ambulatory surgery. So there should be no delay which you call it when it comes to discharge from the the unit, then we still use protocol is discharge. And if you fulfill the criteria, you get home again, a doctor does not need to discharge, you discharge itself is slightly changed. We don't allow the relative, a friend into the unit to meet the patient. We actually go to the waiting area and uh discharge the patient, the friends and relatives again wearing face back when the patient gets home. We know it's a good idea to an adult available to help at home from these 24 hours after surgery. However, many patient's falsely claimed to have help at home the first night after surgery, especially if they don't have this modern term, a social bubble whereby to households can get together with impunity and not worry about the risk of COVID. However, I would suggest that in the elderly, it's essential to have help at home because they have often confused if you've undergone invasive surgery, you may be at risk of covert and overt bleeding. And if your airway is at risk, then you have to make sure perhaps after thyroid and translate to me that you've actually got somebody at the bedside in case something goes wrong. But for the rest of non invasive surgery such as open her knee and so on, we take a pragmatic approach and I don't think you need help. Follow up again. Good practice in many units is to the next day your phone call. If you need a surgical follow up several weeks later, then this can be done remote. So, ladies and gentlemen, there you are. There are some thoughts on the post COVID ambulatory pathway. I'm sure you're gonna hear many of these topics amplified and expanded in the list of talks of this online conference today. Thank you very much dog for that. And I'm going to try once more to see if we can bring dog to uh to chat. Uh Doug can you clear us? I can hear you loud and clear. Well, look, the important thing is that unfortunately, we're here because of COVID and it is prevented us from meeting together to share all our practice and experiences. And of course, most importantly, our friendship with each other. And I actually, in a serious note, I really would like to dedicate the meeting today to all our healthcare colleagues and their families throughout the world who have worked through this pandemic, many of whom have suffered severe illness. And some who have paid the ultimate price. But today, let's be optimistic. We've got around 100 delegates from about 25 countries and it was selected a starting time and not just so that Ian and I can be in the middle of the day, but uh so that everyone can participate at a reasonably sociable time. So it's quite clear that our American colleagues are enjoying breakfast. Those of us in Europe are having lunch while those in the Subcontinent Asia and Australasia are getting ready for an evening meal. And don't forget we're gonna meet again next Saturday at the same time for the high quality free paper presentations. Now keep reminding everybody that the I WS was founded in 1995. And today we have got 20 member organizations from 50 18 countries and we are very proud to be a multidisciplinary organization. We welcome their cities and East is surgeons and of course, our managers and our primary aim as always is to promote the worldwide development of high quality ambulatory surgery. And our core objectives are to enhance uh the international exchange of knowledge and experience through meetings, network incentive, you search, but it's education which underpins these objectives. And we hope that today this meeting will stimulate your thoughts and ideas to incorporate in your own units. So no matter how experienced we all think we are, there's always new things to learn. Now, many people have worked hard to make things happen today. Yes, we're having some technical problems here and there, but hopefully it will be successful. We've got to thank the officers of the Iws, the scientific committee chaired by President elect Carlos Me Alice, the guest presenters. And we also have to thank Ian are former present, my good friend uh for running and being the web mastered today. So let's carry on with the presentations and I'll hand you back to Ian. Second talk of this session is from Marianne Aland, from Norway. And she's going to talk to us about nursing and nursing processes post COVID. So I will uh start Marianne's talk. No changes to the nurses and nursing process post COVID 19. Welcome to my presentation. My aim with this presentation is to make reflections about what is the chance. Uh what is the change of need in taking care of and being taken care of post COVID. My name is Marion Holland. I'm an intensive care nurse. I'm head of today's surgery unit at a key issues, University Hospital Presidente of the Norwegian Association of Ambulatory Surgery and member of the community in the EIIS. I'm also the host of the International Congress in 2024. And as you can see on the small mark on the, on the map I come from Norway, which is a small country up north in Scandinavia. My background uh talking to you now is with the background of my experience from our University Hospital in Norway. It's also the experience of other members of the Norwegian Association of Day Surgery and also input from Alcoholic's in Denmark. Our hospital have had the biggest day surgery unit. We have the biggest day surgery unit in Norway with 12 operating theaters. Our hospital have had the biggest amount of COVID. 19 patient's in Norway are intensive care unit. Normally have 8 to 10 patient's on a respiratory or, and on the top, we had 20 ICU COVID 19 patient's in addition to the ordinary ICU patient's. And also, in addition, we have the intensive light without the respiratory or on the nib and so on. And the number of Kuwait patient's isolated in the in bed units. Our hospital has one of the best figures of surviving the virus after I see treatment Norway, as I said, it's a small country with about 5.4 million inhabitants and this is some key figures from our Norwegian Institute for Public Health. We have tested about 1.5 million people. The reported cases is about 17,000 admit thems to the hospital until uh now is about 1200 admitted to the ICU in total is 253 and 279. That's all together the restrictions after the COVID situation started seems to be quite similar in many countries, Denmark, our neighbor country, practical er testing all before admittance to the DC you. So it's also the case in several DC use in Norway or all the patient with the aerosol exposed intervention are tested before arrival. Even a symptomatic relatives are not allowed in the DC you and they are hardly allowed to come inside the hospital. Of course, one parent might join the child. There is a checkpoint at entering the hospital. I think most of the hospitals do that. All patients' will get an SMS to be told not to travel abroad 10 days before admittance and even to go to green countries is not allowed. Regulations are changing according to the present national restriction. As I guess it is uh continuously changing in a many countries at our hospital. We have the checklist. We actually has that as a routine since 2010. But in this checklist, we now included the questions about COVID 19 known positive COVID 19 acute air race problem with or without close contact with anybody with confirmed COVID 19, Karen tell or traveling abroad the last 10 days. If yes, in any of the above, the surgery will be postponed or planned and performed in the in bed unit at the COVID 19 area. The questions will also be repeated on the day of admittance. The acute great soul patient's which need to to be uh at the surgery quite fast uh or defined negative as the next 24 hours after a negative COVID test. And most most of the units I have contacted do the same or even have longer checklists. So the patient's experience host COVID, I think the patient would say that the hospital feel less welcoming. They have experienced cancellations because of capacity or COVID 19 suspicions more mosques on both patient's and healthcare providers. The checkpoint at entering the hospital, the patient's are afraid to come to the hospital due to the COVID 19. They are afraid to bring the virus uh with them to the hospital and they are also afraid that they could be affected by the virus at the hospital. It is very difficult for many to be without the relative at the hospital in Norway. We do the handshake as a polite way to to treat each other and now the handshake does not exist anymore. So there is the nurses experience, the nurses say that a lot of following up and checking accord to the COVID 19 could lead to lose focus on other important issues. And we are very, very busy about that point because we don't want this to uh to have any influence at the patient safety. The pathways Timewise might be less effective because cause there are extra checking. Also the more physical distance auto automatically feels it makes a sense of distance between the career receive. Er, and the caregiver. The possibility to comfort to patient is limited the support by close holding a hand to hug a scare mother who gave a child to us to perform anesthetics and surgery does not exist anymore. We lose parts of the nonverbal communication due to varying the masks. There are tools to elevate the stress. The most important is the information uh and the written or information is the key also the oral, but the written is also important because the relatives are not longer present to receive the oral information from the doctor or nurse together with the patient's. We need to have the predictable path where based tell the patient's about those focus on the challenge challenge to, to keep the patient's giving the the feeling of trust that we know about the problems and we were doing something about it. So they don't feel that uh there will be an infected and so on at the hospital. Uh the eye contact is important because some of the other nonverbal communication is uh it's not easy to make anymore and the physical and mental presence and also the clinical communication. I would like to tell you a story. Uh This is Ricca, she's working at my day surgery unit and this is her story from expert and back to beginner. She's a nurse since two, since 2002. She is an operating theater nurse since 2009. She has been working in the day surgery unit since uh 2012. She's clever, intelligent, reflected, she's grown up. And in Venice five steps from novice to expert, she is definitive an expert and you can see the steps under a picture to the right in the day surgery unit. Erica has totally control in the operating theater. She has control over the instruments. She has nice and familiar colleagues. She is, uh, she, the type of surgery is well known, uh, procedures are predictable and the patient's is also one more two in the satellite unit where Eric A is working. She is free from work, holidays and weekends, nights and evenings. And she planned our life in uh due to that. So the COVID 19 appeared for our hospital. It was um the critical situation happens uh in March, uh not close to, to Easter RDCU unit was closed the 12th of March the next morning, the intensive care nurses and an anesthetic nurses uh in the DC, you will move to to the intensive care unit after a few days of an anxiety, some tears, a lot of news, reading, two days of training, Erica and her surgical nurse colleagues are also transferred to the intensive care unit. But nurses, doctors, other healthcare providers always ready to help. No uh no matter what. And Rica was scared but she was ready and she was proud to contribute when she arrived. The intensive care unit, the patient group was totally knew it was also four and five and this patient were really sick. The new virus was new and unpredictable. The colleagues were new, new working environment, totally different procedures. Rica has never been to nice to see you before staying in the patient room. The whole shift except by uh maybe by lunch break, even alone, she was working shift, Easter and weekends, the nurses were also very scared to bring the virus home to the loved ones. There was lack of infection control equipment that was also why they had to stay in the in the patient room the whole day. Uh And the total unpredictable time perspective concerning how things would escalate and went to end was also a stress moment. So what changes we did we do at the out day surgery unit, they're all the day surgery, nurses were relocated located to the ICU, the DC, you changed into a big COVID 19 cohort. We were planning four iceu patient's per operating theater, the skate DCU specialist, nurses specialist, especially the surgical nurses felt terrible to stand in a situation where they felt like beginners. Uh and also the EC you, they need help. Uh There was a very limited time to train, the nurses were afraid to do something wrong. And they were also asking the question, who would behold responsible if they did something wrong? The rest of Norway and then the other countries was closed down, the nurses and the doctors were working double. So what we did did we as leaders at the hospital due to support. Uh We did, we made deep briefing teams with psychologists. We had repeating telephone contact with, with our staff, sometimes every day, we were talking to them in the telephone, we were trying to keep things predictable. Of course, information, information, things were changing very, very fast from days, from day to day and sometimes from hour to hour, we made the, what's up, what's up groups. And we also make talking groups with colleagues uh where they could talk together about their experiences. That was very well. Uh They like that were much, it was important. And also we did more of the training classes. Uh We made stress coping classes because the situation was new at work, but it was also new in life. Uh We were trying our best. So what are the changes? 15% of our experts are now back in the day, not back in the day surgery unit, Hana. Our Danish colleagues said five of my nurses are now gone. If another peak is coming up, probably the rest of them will also become they quit because they don't want to do this again. They don't want to go from expert back to beginners in 48 hours. Again, the day surgery unit rams would reduce capacity. The waiting list are increasing. The remaining personal is running even faster. The COVID 19 situation will not end yet. Ryka, she's now a college teacher. She's not back up to work at the day surgery unit, but she will voluntarily be back to help if needed. How can we make our skilled professionals stay. I do certainly not have all the answer. The biggest change for the nurses and nursing processes is that we now live with constant anxiety. This anxiety is constant for all health workers around the world. I think we need to tell the politicians and the public what a tremendous job our colleagues performed, performed and still are performing. And I am quite sure that the nurses from the day surgery surgery units uh did a better job than they thought themselves that they were doing because they are so used to have control. And in this situation, they felt that it was not good enough. We have to make areas where the healthcare providers can talk together, the process, feelings and experience experiences and maybe some professional help. Of course, the cultures and countries are not similar and they solve the challenges differently. And uh so it has to be, but I think the basic is quite uh similar for all of us. So at least what we have to do is acknowledge that this is a problem and reflect on the South. Thank you for paying attention. I wish you welcome to Norway for the 15th EIS Congress in Oslo 2024. Thank you very much Marianne. Uh We will take questions at the end of this session. Sorry, I'm telling my, my screen so I can, you can see me. Um We will take questions at the end of this session. Um So we will now move on to the next speaker who is a professor Beverley Philip from uh the US. And she's going to talk to us about multi special specialty roadmaps for resuming and maintaining ambulatory surgery in the post COVID 19 era. A US. A perspective. One moment. Hello, I'm Beverly Philip and I'm honored to be able to join you for the 2020 IAS virtual meeting. And I'd like to share with you some perspectives on ambulatory surgical care and COVID from the United States. Let me start with us. Timeline. We had our first confirmed case in January and by mid February, our first come earned community transmission. By early March, it became clear that COVID was becoming a nationwide epidemic and our government acted, the presidente declared a state of emergency and CMS which is the national government health care for the elderly. Issued guidance to limit all non essential plan surgeries and procedures until further notice. And the professional organizations responded first, the American College of Surgeons issued guidance about managing electra procedures. And because this is a multidisciplinary need. A S A, the American Society of Anesthesiologists joined the surgeons and the operating of nurses to issue guidance about a surgical review committee to conserve surgical resources. Well, this is a graph of the COVID resource needs in the United States real time. As of mid April, we all expected there to be a surge of cases and then we'd be done with the disease So by mid April we saw we were passing the peak and because of the impact on patient's who needed deferred care, as well as the impact on the health care economy. Many thought about how to resume non essential, non essential but needed surgery, but we needed to do this safely. So by mid April working in parallel, the federal government and major professional organizations offered a series of expert recommendations and this is what I'm going to be going through with you today. I think the biggest and first of these was a road map about resuming elective surgery after the COVID pandemic. And this was a joint collaboration of the American College of Surgeons, the Society of Anesthesiologists Operating Nurses and American Hospital Association. And I have to say this cross disciplinary collaboration simply had not been happening before COVID. But this is what working together we came up with. We should be res guidance a roadmap to resume elective surgery when there were sufficient personnel and resources to avoid a crisis standard of care and what a crisis standard of care means when you can't do what you would usually do where you are deviating from. What is your usual best practice that to resume elective surgery, we need to consider testing if it were available for patient's and staff. We needed personal protective equipment PPE adequate for the planned types and numbers of operations and we needed a prioritization policy committee consisting of multidisciplinary leaders with object of criteria. We recommended that institutions need to develop policies on how to address address the entire arc of perioperative care. Free to post with issues specific to COVID reassessing health standard directives, postacute care. We needed to address data collection and management safety and risk mitigation, healthcare worker well being and all of the I want to point out take a pause that all of these documents are available from the American Society of Anesthesiologists are publicly available on the A Sahq website. Just search there now in parallel or uh CMS National Health Insurance for the Elder Me offer their recommendations and they would have had a series of very high goals of very low local COVID coincidence, setting up non COVID separate care zones, having everyone wear uh face masks at all the time of conserved them facility, decreasing patient volumes to allow distancing and testing as well as for patient's and staff. These were really high goals, but none of this was actually possible because we did not have the supplies or the physical ability to follow these guidelines. So instead our professional organizations provided more real world guidance. This is from ambulatory community, the Society for ambulatory Anesthesia that issued a document about resuming ambulatory anesthesia care as our nation recovers from COVID. And they overheard some real important pointers that in ambulatory care, we needed to develop a stepped approach for reopening A SCS and other outpatient facilities when there was a low incidence of COVID missions to regional hospitals, trending decrease in cases and adequate PPE. And they specifically warned be cautious in performing surgeries that have the potential for patient's needing to transfer to a higher level of care, start with lower risk, shorter procedures and then go to more advanced ones. And I think lead the this organization led the movement to point out we now had new options that we could and needed to explore for remote preoperative evaluation by anesthesiologists using telemedicine platforms. Ask, uh is the allegory Surgery Association? And they are the industry group representing a sc interest to government regulators and payers and they were proactive going into the epidemic. They issued a statement recommending encouraging their member ambulatory surgery centers postponed elective surgery to be prepared to take on cases from hospitals or volunteer their facilities to contribute to the community health care. And they provided concrete guidance tools for a SS to record the resources and capacity they add including items such as what staff, what equipment, what capacity as we started to resume elective surgery? Ask issued another guidance to guide that a sc should resume, deferred electric surgery, elected but necessary surgery if the community prevalence of disease was low or declining and the community had sufficient bed capacity and PPE for the care of the COVID patient's that was still needed. And that a SS as a second major point, a SS can provide safe care. They have to consider screening patients and staff following government recommendations, distancing, masking and adequate disinfection. And I think from even a larger sense, provide a great guidance, looking to the community guidance about surgical care, looking to patient prioritization, starting with patient's with lower comorbidities and surgical risk procedure prioritization. Starting with procedures that have less risk of airborne transmission, less risk of hospital admission and testing where feasible. And as they again here to provided concrete checklists about helping to reopen your A sc and about emergency response expansion. Another problem we had during the pandemic was an issue of drug shortages. This is a chronic issue in the United States but was greatly worsened during the pandemic because of drugs largely needed for the intensive care and also disruption of our international supply chains. So the American Society of Anesthesiologist work together with the Organization for Health Systems Pharmacist, provide a multidisciplinary guidance document several major points, infection prevention and the control that well. We need to be continue to emphasize infection prevention, don't discard unused and open medications, especially those a short supply. There are other ways to do it. Put these drugs uh separated aside, for example, in plastic bags that you disinfect the outside of the bag and then conserve the drugs for another patient. They issued, we issued guidance on medication storage policies to use of literature to support longer dates before exploration beyond what is on the vials and to allow compounding pharmacies and other facilities to prepare other drugs if they are needed in shortage and for hospitalized COVID patient's another ongoing issue during COVID was the availability of PPE for antiseizure professionals. This has uh abated somewhat but continued to be a problem throughout the pandemic. And in fact consist today, this is an updated document first in April now here in June because the problem still existed. The issue is that hospitals were not providing adequate PPE for their anesthesia providers. Uh they didn't have it, but what they did was tell the providers that they didn't need it. And the anesthesia professionals who were working in the airway bought their own approved PPE and some facilities forbade them from using it because it might frighten the patient's. Some anesthesia providers were disciplined. A few were fired. So our organizations came together to promote patient safety. And here we have an organization across the spectrum of anesthesia providers in the US, the American Society of Anesthesiologists, the organization for Anesthesiologist Assistance and for nurse anesthetist and the Anesthesia Patient Safety Foundation. The points we made were that the safety of anesthesia professionals is of utmost importance to developing policies related to PPE. If you don't have a healthy workforce, the work will not get done. Our recommendation was that all professionals had now a document to support, they needed to utilize appropriate PPE during aerosol generating procedures for all patient's endotrachial intubation. Any work in the airway is going to be an aerosol generating procedure. Next point that the facilities should issue and 95 masks or equivalent equipment for all anesthesia professionals as a facility priority. And that, that understanding that conservation is important, health care facilities may wish to implement extended use or limited reuse practices even before shortages are are observed so that adequate supplies will be available when people need and demand occurs. And of course, using these uh 95 masks in unusual crisis care modes should follow the best safety guidelines. No, over Maine and June, we organizations developed experience working in the COVID well world and it became clear to all of us as it did to you that COVID is not going away. So we need to reframe our approach to the care of the COVID patient. Now we are talking about maintaining essential surgery during an ongoing COVID pandemic. This is we're going to be for quite a while. And here this document again, unusual collaboration between the American Society of Anesthesiologists was we actually were the organizer of these events and I was the drafter of them and is the American Society of Anesthesiologists with the surgeons, the operating room Nurses and the Hospital association. What we had learned about our pandemic was two major overriding issues that regional cooperation was critical to providing essential surgery, tying in with supply chain issues. And this regional cooperation needed the hospitals, the medical professional societies and the government agencies to make it work. And we need to consider the breadth of everything that we needed to care, patient's correctly. So we needed hospital facilities. Uh I see you and non ICU beds, PPE testing, re agents and supplies vital equipment, medication. And again, to emphasize, sufficient trained staff on a more concrete level. Beyond these two umbrella issues, we addressed that facilities need to have developed guidances about COVID testing within the facility. We now this new as a matter of patient safety, we already had seen all the reports that have patient's have surgery during undiagnosed COVID disease. They have, they have bad surgical outcomes. So testing was a patient priority and now as uh as testing equipment was becoming more widely available, many facilities now are testing all patient's uh before they're surgical care, we also needed to address uh testing of hospital staff because staff are exposed in the community and we need to prevent transmission within the health care facilities. This joint statement promoted consideration about PPE because there's still shortages of PPE roving shortages with policies for conservation, extended use and reuse policies for case prioritization and scheduling and timing. When are we going to do these extra surgeries? Uh evenings, weekends and specific detailed policies for the care of patient's during all phases of surgical care. Now, we specifically addressed the need for pre assessment because we had become aware all of us that COVID was uh not only a lung disease but affect every major organ system uh from uh kidneys and heart and brain. And the and the effects are not only acute but can be long term and chronic pre assessment as a major factor. And we also recommended that facilities address policies surrounding surgical care for the patient's for the personnel about or turnover, about cleaning and sterilization about facility management. We emphasize the facilities need to collect data about COVID, so they know how to plan for their care and COVID related safety and risk mitigation. And that brings us to one last point, all of the multi specialties documents and all the societies were increasingly aware that the large issue here was healthcare worker. Well being in many of these documents, not only were we seeing increases in stresses and anxiety and burnout but um increases on how healthcare workers were coping with the stress is not in the best way. Uh community wide, not just healthcare worker we have seen in the US increase in alcohol and drug, drug use increase in domestic violence and child abuse and even more tragically increases in suicide and especially healthcare workers suicide. So to conclude, uh these have been some ways, the way the United States has approached resuming and maintaining obligatory surgery as we realize that this is going to be a long term COVID era. What we learned was that system wide planning is critical and we need to develop facility policies based on sciences more than on business interests and use the best available data. And that means that we're going to need to revise what we do based on new incoming available data. And the last major point that we really emphasized is that communication is key. We need to communicate to the public because they are all potential patient's to policymakers and payers to industry partners and suppliers, two and specifically to the healthcare workforce, all of us because it is we who make the care of COVID patient's possible in this difficult time. Thank you very much uh for, for that Beverly excellent overview of uh the approach in in the United States to end this first session. I I will now show uh the talk from Dr Naresh Row uh from Mumbai. As I said, we've changed the order so that one of our speakers who's busy dealing with COVID 19 patient's in the Netherlands, it has time to be able to attend at the end. So I will start the video now and hand over to nourish. Hi everyone. I hope everyone is safe, including your families in this COVID era. I'm going to talk on can technology help in the COVID era? Let us see what we have come up with. I did a bit of a research the past few days before making this presentation and we all know that necessity is the mother of invention and the innovative minds are from anywhere, every uh continent, every place and they are watched very carefully is using syringes and IV sets a dozen. There you go. So what is expected of technology? It cannot prevent the pandemic. However, it can help you prevent the spread. Educate, warn empower those on the ground to be aware of the situation and thereby noticeably lessening the impact physicians and health systems all over the world are racing to adopt a system which is virtual, which can treat with the least physical meetings between the patient's and the health providers. But many doctors are watching verily the pandemic has affected every industry all over the world, including healthcare. They're all interrelated. We have been trying to avoid the infection and it's spread, find a vaccine. It has impacted on trade, it is impacted on travel and on the financial market. So it is an all around issue. Now, innovations in a daily life are something which we all come across online shopping, digital and contact lessons, contact less payment's work from home, distance learning, online entertainment supply chain is the fourth industrial revolution globally. Three D printing five G internet robos drones and the most important for us telemedicine. So there are opportunities everywhere even from work from home collection as you can see. So what is telemedicine? It's a combination of internet and help. It's e consult e prescription, e medicine purchase and E payment. Basically, our services were oriented around the position with the doctors. The Sergent concern. From here, we have to change our orientation towards the patient by the use of gadgets, internet and the apps that are there, which is used for the benefit of uh advancing the technology attendance face official reading apps are available now which does not require your thumb impression. There are apps for digital consultations. Every hospital is coming up with their own apps to help their own physicians, staff and the patient's remote monitoring has become the norm. You have gadgets which are there on the wrist which can transmit and record your vitals as well as advanced monitoring system, which I'm sure will be available for everyone very soon. During the pandemic, several innovations have come up and here you can see the IV set which has been attached to a electrical tree, um pen uh basic ideas to suck out the smoke that comes out. This was the initially additional days of the pandemic when there was a lot of confusion about the air filtration of circulation and so on and so forth. And you have the face shield if you have the shield, patient shield for intubation and excavation. So these, this is how it all started then went on to create a transport system where a COVID positive patient could be transported from one place to the other without infecting lot. Many people. You already have a pre op kiosk where you can punch in all your details before your pre op assessment. On a daily basis. You have drones delivering. You have got robots delivering your stuff at home, contact lists as well as you have restaurants which require you to pay without touching without manpower anywhere. You will not see anyone. Classes have started. The schools are all going on. We are on a web, we are on a webinar and so are the classes. So it is the human adaptability that is at its full play. We can adapt to the changing situation. Very fast. Robots have been pressed into work where the staff, the healthcare workers is afraid to go. These provo's talk to you, help record the vitals and transmit them. So what has digital health done so far? We have artificial intelligence powered city scan interpretation which reduces the reading time and the radiologist can sit in the comfort of his office or home and do the reading without any problem. We have automated mask machines for N 95 masks. We have indigenously produced ventilators which are far less expensive and low cost PPS which are now being extensively used everywhere. Machines are being operated by foot. We have COVID safe transporting patient's systems. We have sanitizer channels which have, which are controversial things on its own. But a safe swab phone booth testing apparatus where the patient, the patient is sitting outside and you are inside the phone booth and doing the swab test without getting, without risking your uh self to the contamination. So how has data science and technology come together to fight the pandemic. We have been able to use artificial intelligence to identify track and forecast the outbreak, diagnose the virus process. Healthcare claims, drones delivering medical supplies, robots sterilize, deliver food and supplies. We developed newer drugs. We have developed advanced fabric for extra protection artificial intelligence to identify noncompliance of infected individuals, which is very important for contact tracing chatbots to share this information. And now the super computers are working on a vaccine which is soon to be released. The amazing part that I notice is that is the creation of dashboards. This was not heard of in many cities, especially in India. But now every city has its own dashboard. It basically gives you the whole uh different types of beds with ventilator without ventilators in the ICU, the ordinary oxygen beds. And they are updated every day of different hospitals. As you can see the names of different hospitals. Now you don't have to call up each and every hospital to know where the beds are awakened on this dashboard, which is updated every day, you know exactly where to go. This has got tremendous, tremendous type of opportunity and we have um the ability to continue this the way it is payment apps and contact tracing apps on your mobile is already there. Six examples of innovation is the simple that we use everyday scan, pay and go dynamic digital signage, camera scanning of people. QR Court, virtual fitting rooms, click and collect and virtual queuing contact tracing apps. Every country has developed their own. India has Arab Gazzetto trace together from Singapore, COVID Safe in Australia COVID 19 app in UK. So what is its application in day surgery pathways? We have these pathways that we all use in our daily practice. And as you can see the pre op assessment consultations, part of investigations, three, preparations, admission surgery, most of it can be done remotely except maybe the investigation, some part of it, you may have to go into the, to the hospital and the admission and surgery with part of pre op POSTOP assessment and discharge, of course can be done uh in the hospital and the rest followed up remotely. They have found that globally across all the industries that have been tremendous rise in the utilization of tele intelligence as your eczema, call it to contact, communicate and keep track of each other. So the future is something like this. Imagine a new reality where you don't have to travel to work because you could just teleport there where you could shake your teammates hand and feel together even if you are continents apart where the rules of physics don't exist and everything is designed to make your meetings more productive than ever where the whole space around you is your blanket campus. And you can use your superpowers to create three dimensional mind maps a reality created for agile meetings, presentations and brainstorming sessions. And it's application is in, in your medicine is something called as Hollow Lands. I'm a surgeon and I'm the Chief medical Officer of Medical Realities. So you just showed me the most in credible video that I've ever seen. It is a bit of the future. Can you tell me a little bit about this operation that you did it with the Holland? And it went across three different countries, three different continents actually. Uh Oh my God. Exciting. So this is real science fi so one thing we're trying to do is think about how we change the way we communicate uh from doctor, doctor or doctor the patient, for example. So we use the whole lens um yesterday to connect four people in three continents. That was the US India and the UK London. And what we did we during the operation that was performing on a patient with cancer, we took some time out, put hot lens on and we connected into a virtual space. We could share the scans, the images of the patient interact with them, discuss the case in more detail, much like a multidiscipline team meeting that we do normally in the healthcare practice. This was obviously quite different. It's a virtual people around the world connecting and you know, it was an incredible experience. It's the way I think healthcare in the future should progress. So the future is amazing. And to sum it up, there's a review from the Harvard Business Review. See it says that while there is no doubt that the pandemic is amplifying the adaptation of newer technologies, technological advancements are already changing the world over in the past two decades, from living standards to the very nature of our work. But there is a fear that the robo or artificial induced may cause unemployment. Therefore, we need to ramp up the the investments in human capital, which is as they call it to increase our knowledge, skills and health, create social protection for the safety of the net coverage, affordable access to internet, upgrading the taxation systems, reduce disincentives in loss of formal jobs. With this, I come to an end and I will leave you with a small clip to see what our future will be. It's a bird, it's a plane. No, it's actually something much closer to Superman or at least Iron Man. This is a jet suit developed by UK based gravity industries. And while in the past, the suit has been on display more is a proof of concept. Now they're showing up the jet suits real world applications as a means of fast response and rescue. So just how much faster can first responders arrive using a jet suit rather than can additional cars? Well, in its first test stimulation, the jet suit responder was tasked with raising another team in a traditional rescue vehicle to a 10 year old girl who had fallen from a cliff. It took the conventional motor vehicle 25 minutes to arrive and signal the chopper. It took gravity industries jet pilot just 90 seconds. So how to first responders feel about the suit flight in Cumbria uh for a jet suit that's going to save lives and he's suffering so incredible moment. Truly, truly incredible moment. Amazing, amazing. Thanks. Thank you very much, Naresh. So that's our first four speakers. Um And what I would like the speakers to do uh on their screens, they should have a hand up request to speak. If they could click on that, uh then it will make me much easier for me to pick them out to answer any questions. Uh Doug, do you want to start with any questions you might have? Oh, no doc you're, you've not turned your microphone. Can hear me now? All right. OK, perfect. We'll just go in order actually. Can I talk to Maryann actually? Because I thought that was quite an emotional little vignette. I enjoyed it very much. And now Marianne, that we're hitting the second wave, you clearly have had some of your yes you nurses leaving. And do you think this will be easier for the nurses because some have left? But those who are left are even more efficient because they know what's going to happen or do you think it's another crisis? What do you think? Hopefully you can speak now? Marianne. Marianne. Can you hear us? I can hear you. Yeah. Can you hear me? Yes. We can doug, did you have a question for Mary? I didn't Marianne. That was a lovely little presentation. And I thought it was, it was quite as it were from the heart. And you were mentioning that many of your dsedsu nurses or Dieser, the nurses are trying to find alternative forms of employment, but those who are left will clearly be more efficient and well trained to hit a second wave. What's your feeling of what's going to happen with the second wave in Norway? I think we are going to be there if necessary. As I already told you, uh I think now until now some hospitals, they did not have any COVID patient's because it is uh Oslo in the main city. There are more than other places. Uh I think now it is more or less all over the place. I think some will now face their first wave but for us who are facing our second wave, I think yes, we are in, in somehow we are more prepared. Uh The other way, I would say we are more prepared prepared, but also a little scan because it was a tough situation. I think people will uh will help. The problem is the the respiratory and the ventilators because in the day surgery unit, we don't use those. So when you go to the inter care using it and you're supposed to handle the restaurateur, it's a problem. So I think what is we just need to stick together somehow and try to help each other. That's the only way. And are you still managing to maintain some form of ambulatory surgery at the moment? Yes, we have some extra people coming in. And so the the intensive care unit nurses working in my place and also the anesthetic, the nurses are still working there. But most of the surgical nurses describe nurses have been moving around but they are working other places in other hospitals. And of course, we get some from those hospitals again. So I think there is just a movement, people are now moving around. But I think also in the day surgery unit, people who need to have uh you know, the day work, you might have a disease migraine for example. And if you start to, to work in the night and in the evening you will have a health problem. So I think people also try to avoid that to, to stay at the daytime. So I think one of the problems for the day surgery nurses in total is that they have to work all around and they actually don't they get sick out of it. That's the problem. And their domestic situations were such that they went into day surgery for a reason. So yes, again, very difficult, very difficult, so great at the job they're doing at the day surgery unit. So, so they're, that is no problem there but to, to be moved when you don't want to go. That's a problem. Yes. Okay. Right. Then I think that ends our first session. Thank you. Thank you too, Marianne and all our speakers. Uh We will have a 15 minute break. Uh Then we'll restart. I will, I will stop this recording. Uh Now, uh because the room is being recorded for future use so that you can come back and view the talks again if any of them interest you and there's a maximum time for that recording function. So I will end this session and the screen should go back to the original joining screen. If you have any problems joining, just use the uh the original uh uh entrance, the shortcut that, that you had, but it should automatically allow us to reconnect to you. Uh Thank you for all your forbearance with uh this first session. Thank you.