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I would like to welcome everybody to our second online conference. Um We held our very first successful conference last October. And at that time, you were all learning to accommodate COVID and a ribbon, a routine surgical procedures. And this was reflected in the program at that time. Now, vaccines for COVID was still only a wish and not a reality. And with the new year came hope and the introduction of vaccination programs worldwide. And I know there's discrepancies in vaccination rates from country to country, but the rollout does continue at a pace now, while many of us feel a little bit more safe and secure than we did a few months ago. Let's not forget those in the poorer countries where vaccines are not yet available even to the most vulnerable. Our hope is that the World Health Organization's co back facility will ensure that COVID treatments and vaccines are shared equitably across all countries. But until then, we're all prisoners in our homelands. Remember no one is safe until everyone is safe. So for today's conference, our theme is strategically coming out of the pandemic and we have some interesting thoughts used and presentations on the program, what do we have to change going forward? What are the strategies in different parts of the world? And of course, let us not forget the value of ambulatory surgery for the patient definition and the hospital in the post COVID era. Remember too that the second part of the conferences at the same time next week when we will enjoy the free paper presentation. Now, as ever in organizing the I WS Program of Education, there are many from the General Assembly and Exco who have worked tirelessly to make it happen. And I must thank in particular Arnie valid in at the Ent Vieira who have taken on the main organizing tasks with enthusiasm, skill and diplomacy. And of course, in Jackson, our web masters who has taken time out of his volunteer vaccinate er role to run the it today to let us all link up remotely from our safe locations. So whether it's morning, noon or night, whatever you are, let us open the conference, enjoy the presentations and I'll hand over to Arne and the Gente. Thank you. Well, good morning everyone and welcome to Albert Spring meeting for I double A S. Uh I really hope you are all safe wherever you are in the world. And first and foremost, I would like to thank the speakers for their contributions and their effort. Uh We're looking forward to having a heavy discussions with all of you. Uh Doc mentioned, we've had some challenging months uh in the past. And certainly uh ahead of us as we take care of our patient's, we learn more about COVID 19 and how to best deal with uh prior to infection protocols and post infection protocols in our lives and have no transportation. There is a lot to learn and we certainly hope that we can learn from each other. Uh from around the day. You tend to, if you'd like to say a few words, yes. Uh introducing words. Uh I'd like to uh say hi to everyone all over the world wherever we are and telling everyone that ambulatory surgery as uh emerge as a solution to most of the uh non COVID surgeries that need to be performed. And this came as a challenge because we have now to operate more complex procedures and operate on more complex patient's and still preserve the safety and efficiency that is so uh typical for ambulatory surgery. So these strategies are the ones that we are going to discuss. And as you said, Arnie, we can learn from each other. Very mark very much and come out of this day richer and bring to our unit's, bring to our hospitals, new solutions and maybe new ways of coming out of this pandemic without leaving anyone behind. Well, thank you. Thank you. Thank you very much. Present to our first session today is the impact of COVID 19 on ambulatory surgery development where we stand and future recovery strategies. What we wanted to achieve with this session was to have a view literally from around the world, Australia, uh Europe, the United States and Asia. And again, have a lively discussion as to where things stand uh went through going. That being said, I would like to introduce John Napoli. Um and Karen mcmillan from Australia, thank you, Doctor Napoli and Karen for agreeing to speak and we look forward to your presentation. I would like to thank the organisers for the invitation to speak at the spring online Congress, Karen macmillan. And I will present our talk on our experiences in Australia. We've been very fortunate in Australia to not have the extent of the problems faced in many parts of the world. We were able to close down both our international and internal state borders early and effectively, this included all travelers having to quarantine for 14 days. A very rigorous contact tracing system to track down and isolated outbreaks was developed quickly since the start of COVID Australia has had 29,218 cases in total of the cases. Now, classes closed, 90% 7% have recovered and there's been a 3% death rate of cases still classes active. We've had no further deaths when we stratify our numbers by age and sex. We see that the majority of cases occurred in the ages from the late teens to the late sixties with a further peak in the over 85. As seen around the world. The majority of our deaths occurred in patient's over 70 with death rates increasing significantly in the over eighties. From this slide, we can see that our numbers peaked in July 2020. But then we had a dramatic fall after August and the consequences of all the strict measures that were put in place materialist in 2021. Most of our cases have been travelers in hotel quarantine in hotel quarantine and any community outbreaks have been quickly shut down by meticulous contact tracing measures and isolations. One of the hallmarks of our response in Australia was a coordinated bipartisan approach by government to dealing with COVID with respect that private hospital system which includes our day surgery hospitals. There was a national partnership agreement by federal and state governments where private facilities were conscripted by government to help in any way needed. In the national response against COVID, all elective surgery was canceled on April 1st 2020 and individual private facilities agreed to use their facility in accordance with their state government. The payoff of private facilities would be that once all the disruption due to COVID past, they will still be viable and quickly be able to return to normal. The formal arrangement between government and private facilities including day surgeries was called the private Hospital Viability Agreement which included the financial viability payment. This was a commitment by the Australian government to ensure the viability of the private hospital sector. The financial viability payment would cover operation operating costs including all staff wages for all overnight and date hospitals. This package which would contribute to the ongoing viability by private facilities but not to profits or loan or debt repayments. In addition to disagreement between government and private hospitals, there was a national job keeper allowance scheme for all Australian employees to help employers pay and retain their staff. During COVID this help facilities who did not sign up for the private hospital viability agreement with the private hospital viability agreement, private hit facilities would not necessarily be asked to perform any activities. In which case, operational costs including staff costs would be covered by the commonwealth government guarantee. However, ways that the government could ask private facilities to assist in the COVID 19 response included, the private hospital could become a COVID 19 hospital. They could be asked to provide additional capacity for public hospital overflow of either COVID 19 or general patient's. The private hostile could be asked to provide equipment including ventilators and anesthetic machines. They're skilled staff could be deployed anywhere in the hospital system to where they were needed. Most the private hospital could become a quarantine facility for cruise or flight COVID 19 passengers and finally, they could become COVID 19 testing or potential vaccination centers. Thank you John. At this point, I'd like to say that in Australia, there has been a high level of compliance to the numerous strategies that have been put in place to protect our society from COVID 19. I dare to say that this is in part and may well be due to the fact that that we saw so many images and heard so many devastating stories from Europe and other countries around the world lockdown did happen in Australia and continues to happen occasionally. So not all states have undertaken lockdowns. The longest lockdown was in Melbourne from the seventh of July to the 28th of October. And this was a total of 112 days. Most day hospitals were able to remain operational, supported by the government viability agreement and job keeper. So strict screening protocols are and have and will continue to be in in place to ensure safety and confidence. The patient's doctors and staff, temperature checks are done with noncontact temperature scanners, screening questions are required for all patient's carer. Staff, doctors and critical technicians and delivery drivers, statutory declarations are filled out by patient's that are admission and QR codes have become preferable carers are asked to remain on site if high risk of transmission is assessed, then preoperative PCR testing is undertaken within four days of admission. Negative test results of course are required before admission's allowed transmission. Risk management procedures include socially distancing patient's in waiting areas and preoperative areas mask can be worn by everyone in the facility when the risk is high contact as well as droplet precautions are taken for aerosol generating procedures. High risk HPV. EPS are booked last on our operating lists to ensure adequate air changes. After aerosol generating procedures, theaters stand empty for 20 to 30 minutes between procedures particularly where air flows or are unknown or HEPA filters are not installed. Now to minimize risk exposure to key staff, noncritical management and non facing patient facing staff work offsite wherever it's possible. And of course, we avoid face to face meetings where possible. We exclude staff, clinical and non clinical who work in high risk settings such as aged care or with COVID positive patient's manage risk of transmission by a third party contractors also became very important. So no company representatives are on site unless it's absolutely required. Delivery drivers are requested not to enter premises and staff meet the drivers at the door, contact high risk delivery transmission sources such as laundry and food services and waste. Our contacted to confirm that there are no high risk sources of transmission that are on the same delivery routes. So looking at future um strategies, vaccination of all staff has already started to take place. There's five phases in the rollout in Australia, the vaccines free, the vaccine's not mandatory. And currently we're in the second stage which includes all healthcare workers, which of course is day hospital workers. Australia does have a laboratory that is producing the immunization. On the 24th of March, it produced, it produced 830,000 doses and hoping to release 1 million every week. So we'll use QR codes and checking temperatures in the future. And patient's will be contacted before the day of surgery and screen potential symptoms. And of course, if they're symptomatic, then they'll be tested and will be rescheduled once they're negative or a symptomatic potential geographic hotspots are identified daily with patient staff and visitors required to declare they have not been in a hot spot and patient's are screened on the day of surgery and deferred if they are symptomatic, the level of PPS is dependent on current COVID status in the community. As are a lot of our strategies that we have mentioned. So during COVID, there was a significant increase in the amount of public and private day hospital partnerships. With this, it increase the government's awareness of the high quality and standards that day hospitals have their efficiencies and the cost effectiveness. Um and also they're high patient satisfaction. So an opportunity to consolidate and increase the level of day hospital activity has come out of this pandemic. And just to say again, you know, Australia has been very lucky and we will continue to use these strategies in the coming months and possibly use. Thank you. Thank you so much. Uh John and uh and Karen uh very, very interesting network and apologize for the the order feedback. As I mentioned on the chat, if we could all keep our microphones on mute that that will really help us with the feedback. Our uh second speaker today is a probably Philip uh Doctor Phillip is well known uh internationally. She is the current Presidente of the American Society of Anesthesiologist. She is a professor of anesthesiology at the Brigham and Women's Hospital in Boston, which is part of the harvest system. She is also a past presidente for uh a Yes, Beverly. Welcome back and hope you're safe in Boston. Hello and welcome from Boston. I'm honored to be able to join you for the 2021 ias virtual meeting. And I'd like to share some perspectives on ambulatory surgical care and recovery strategies from COVID in the US. Now, the COVID pandemic had a dramatic effect on surgical volume in the US. Compared to the same month in 2019, surgical volume dropped 38% in March, 59% in April gradually came back into the summer but has not yet returned fully to normal, but it's not only been the effect on the also on physicians, physicians have considered career changes after the experiences with COVID 25% are retiring earlier than previously planned. Different work settings, different work situations, different specialties, career changes away from patient care and distressingly leaving medicine entirely. Also, there's been an increase in poor health care worker well being increased documented increases in anxiety, burnout substance abuse. Domestic violence also worst of all increases in suicide rates among physicians. The pandemic has also had effects on patients' in terms of meeting missing needed healthcare. In this recently published survey, 41% of patient's reporting this care and among those who thought they needed care, half of them missed what they needed. 60% declined to go through with scheduled electrosurgical procedures, preventive care, mental health visits, general medical care, 50% of patient's who thought they thought they had a new severe mental or physical health issue did not go for care. Why some medical practices were closed and it's estimated 10% have not reopened. About 60% of patient's feared COVID exposure while getting care. And there are the financial effects of the pandemic, loss of jobs, loss of employer based insurance. And many of us think this percentage is underestimated. Now, how do we go about addressing the challenges during recovery? The first set of challenges of financial, as we know, we have mandates to suspend non essential surgeries, there was an estimated 70% drop in surgical revenue in the US leading to facility closures, work our decreases and staff furloughs and that means uh mandatory time off without pay. What were the actions ongoing? The need to encourage patient to have confidence to have surgery. There was financial assistance to the entire healthcare system from the federal federal government but specific incentives related to ambulatory surgery center care, the hospitals without walls initiative that allowed patient's to stay overnight without the usual regulatory requirements for the duration of the pandemic and regulatory incentives that are driving cases from the hospital inpatient to outpatient, the ambulatory surgery center setting. Now there are staffing challenges for reopening. The need is to right size staff for the addressing the backlogs of delayed cases and the variable effect of COVID on capacity need to keep staff safe from COVID exposure COVID disease has come in from the community. But one positive case in the facility can lead to a domino effect of staff quarantine and then insufficient staff to do the work. Temporary closures employees need to be assured, reassured to be comfortable to coming to work. But some workers for their reasons had to scale back hours. Many needed to take care of Children who are now at home and attending school. Virtually. Also uh workers had a personal uh increased vulnerability to COVID and did not want to work. Their COVID also drove a need for developing new protocols, ongoing evolving protocols to address the evolving knowledge, a need for increase infection control measures, new, putting up plastic shields around interaction areas, sanitizer stations addressing the COVID screening testing and protocols that do change regularly as knowledge appears visitor restrictions and particularly for the or additional infection control prevention needed and especially the management of aerosol generating procedures that requires greater time, uh greater staff time and greater investment in single use supplies above budget. One of the bright spots of addressing the COVID pandemic has been the opportunity and adoption of new technology in joint replacements. There are three D printed patient specific devices that make surgery and recovery easier in spine surgery, new devices for minimally invasive surgery that allows this to be done in surgery center settings. Gynecology, the new Da Vinci surgical system that is designed to work in the A sc setting. And I think most exciting telemedicine, our surgical colleagues are identifying prospective patient's by telemedicine Are anaesthetic colleagues doing their pre procedural evaluation and uh post care follow up and also tele rehabilitation for our procedures at home. Now, our member organizations have responded to this in a gratifying way. I represent the society for ambulatory anesthesia. And they, we have put a a large amount of resources out for our physician colleagues, statements on the timing of elective surgery uh developing the concept of a so COVID safe environment that checklists that we can use to assess our facility. And we also use it as relations to the patient's to show them that is safe to come in. Uh We've had a series of COVID webinars and COVID status updates, the ambulatory center center, uh Ambulatory Surgery Center Association, NASCA also an is member, their statements related to uh their audience emergency response checklists and a dedicated resource center as well. The American Society of Anesthesiologists is working on the national level to create multidisciplinary roadmaps, college of surgeons, working anesthesiologists, working with the College of Surgeons, the or nurses. The Hospital Association to develop national guidance is on how to work during the ongoing pandemic. And of course, a host of statements and other resources. The last point is that we found that we really do need to reach out to patient's better. Uh Last month was Patient Safety Awareness Week in the United States. And this is the A SAS outreach to patient's. And this is what and what I found doing so many media interviews, the points that patient's were most interested in was that it was safe for surgeries to go forward with appropriate precautions. And that vaccines have no effect on anesthesia or surgery. What we need to tell the patient's is that that patient's will be required to have negative preoperative COVID tests for their safety. Patient has had COVID disease, have to wait a variable amount of time after they recover and the length depending on how severe illness they had vaccinated. Patient should wait two weeks after their final dose. So they are optimally safe. Also, families cannot remain with patient's for the surgical day. This is a burden but it is necessary for the family's safety. And I think the biggest point is that preoperative evaluation is more important than ever. We are learning that over a third of patient's who've had COVID disease, have a chronic and possibly permanent long term illness. So where do we conclude? What have we learned in terms of recovery that we've learned that COVID is likely to be with us long term. So what we're going to need to do is ongoing, learn what is new and adjust to the ongoing new environment. Thank you very much. Thank you so much for having me. I really appreciate your uh your thoughts and uh insights and concisely relate closely to what we've been going through. Our next speaker today is uh Matt's uh Moxleys. He is a senior researcher uh in the Department of Medicine at the Norwegian University of Science and Technology. And he has done put a bit of work on sleep Africa. Doctor Martinez Martinez, excuse me. Hello to everybody. My name is Smuts Hendricks tremulousness and I am newly elected chairman of the Norwegian Association of Ambulatory surgery taking over for Marion. Oh Alum, who has done a superb job the last few years. Uh I'm gonna give a short talk on the impact of COVID 19 on ambulatory surgery development where we stand and future recovery strategies. And um obviously going to do that from the Norwegian point of view. Um The added numbers as of March 31st 2021. Um The number tested is well above 4.5 million. We have 95,208 confirmed cases uh and only 673 fatalities, uh which is in stark contrast to our neighbors to the east in Sweden, close to 3.5 1000 people are hospitalized during this uh during this time period and there are some 650,000 plus being vaccinated. And that is the first vaccine, not the second. When we break the numbers down, we can look at the confirmed COVID 19 cases by age and sex and we can see that the the younger age groups are in the lead, especially 20 to 29 and 30 to 39. There also seems to be somewhat more men than women having confirmed COVID 19. When we look at new patient's admitted with COVID 19, as the main reason for admission, we can hear uh clearly see the three waves, the first one back in March and April of last year. And then we had a relatively long period during the summer where there were almost no admission's at all to the hospitals. We had the second wave in October last year and now we are well into the third wave. And on a positive note, it seems that we are over the top and there's a slight decrease in the uh admission's to hospital in the third wave. The number of COVID 19 associated deaths by sex and age. Um Here, we can see that the the elderly are at risk, especially the age group, 80 to 89. Um And also here, we can see that men are more at risk than uh women. Uh not so in the plus 90 age group. And the reason for that is that in that age group, there are mainly women, they still live longer than men. Um Varying histories and democratic traditions are perhaps some of the reasons why Denmark Finland and Norway have reacted differently to COVID 19. And why Sweden has had a completely distinctive approach. Politicians have been more directly in charge in Norway and Denmark while health authorities and state epidemiologists have a more advisory role in these, these two countries. Um Now this is before the Corona hit Norway. Uh were we were already before the Corona hit us quite good at social distancing. Uh There are relative, relatively large variations within Norway. The black areas to the uh Southeast are areas where you have confirmed. Uh That's the red areas are uh confirmed cases but no deaths and the gray areas are no confirmed cases at all. This has of course led to an uneven distribution of the COVID workload in hospitals. Large hospitals in the southeastern part of Norway have been more affected than others. Uh Some smaller hospitals in Ruhr allay areas have not had any COVID 19 patient's admitted at all. Um The strain on healthcare workers in selected areas are probably due to both high percentage of COVID 19 admission's and reduced workforce due to quarantines and or infections among health workers. And there's a need for reading redistribution of workload by a nationwide relocation of healthcare personal, for instance, intensive care nurses and uh an ethicists. There is also an uneven distribution of the backlog of elective and military surgery. Um The greatest decrease in non emergent surgery surgeries are mainly in the large hospitals in the southeastern part of the country and probably due to the higher COVID 19 prevalence in that area. Uh university hospitals in the middle part of Norway and uh smaller community hospitals have had a smaller impact on their uh ambulatory surgery, product production. And some regional health trusts have made arrangements for private or ideal institutions to reduce the backlog of done emergent surgeries. Also in Norway, there's a renewed focus on so called aerosol generating procedures or a GPS. Um There are some discrepancies as to what constitutes in a GP. There's no uh worldwide consensus on the matter. The World Health Organization's as that intubations, positive pressure ventilations, tracheotomies, cardiopulmonary resuscitation, bronchoscopies and sputum inductions are backed by epidemiologic studies. However, other studies and I've put up the reference here can document that controlled intubations and controlled excavations in a symptomatic patient's generate a very small amount of aerosols and only a fraction or that generated by ordinary coughing. So we need to take a look at the risks during medical procedures. Uh We believe that these four factors may be important where you have forced air over moist respiratory mucosa. It will generate more virus laden aerosols. Uh the disease severity, um symptomatic patient's are more likely to have active infection than a symptomatic patient's the distance you're from the patient, the further away from the source you are and the better the ventilation in the room is the smaller the chance for aerosol transmission. Uh the duration, the more time one is exposed to virus aerosols, the greater the chance for infection. So back to aerosol generating procedures, I think we need to add on to the World Health Organization's view on the matter and include noncontrolled intubation and non controlled ventilation. The use of high power drills in the oral cavity and nasal sinus cavities procedures in which oral pharyngeal track your mucosa are involved pulmonary procedures and upper digestive tract procedures. The way ahead um early detection of infection outside the ambulatory surgical center is probably important. The use of rapid antigen tests or PCR testing outside of hospital to minimize any risk of spread of infection inside the hospital. Uh to optimize the use of existing resources that might be extending operating room hours. The use of private or ideal hospitals to cut down the backlog. Um predicting future surgical volumes accurately is probably uh something we have to deal with in the future and to transform operational efficiency using new technology. For instance A I based algorithms to predict case length allocate block times or automation to address workforce shortages, flexibility of workforce uh in some areas, there is a reduction in um billitteri surgery of 50% or more and the workforce is uh redirect relocated to other areas. Um for instance, intensive care units and doing exercises and training um using medical simulation programs to provide education and training against the spread of COVID 19 will also probably be something we have to look at in the future. Now that concludes my small lecture on the situation in Norway. Thank you for your time and I hope sincerely that we will meet again soon in the post COVID era. Goodbye from Nor wake. Thank you so much, Matt. Very, very interesting what we're seeing so far in terms of numbers and statistics among the country's very much looking forward to our discussion. Uh Please feel free to put in your questions and comments on the chat walks and we will get to as many as we can in the discussion. Uh Our next Panelist is Professor Chang who joins us from China and he is the lead surgeon appointed by the state to expand ambulatory surgery uh in China. It is an honor to have you and we're looking forward to your views um on the management of COVID in Asia. Professor Chang, usually gentlemen, uh Dubai Lucia Vamping Fango only the go to change your ankle. She uh check your emails. You go e by what your your your sender third one, you're Bintan by, by Buster. There are key one drawn Cheney and General. Uh he 200 ni entry under natural are they're blue. So, so the, the usual pin humane, Ian Chen Lian past R one D Toyo pinch in the 300 steak Yoda. It can. Giraudo Arlene, Arlene, me and the Sharif ent. Uh So I don't want to 800. So your sandal washer, you don't uh washer uh Guanglie. Um uh So uh uh through the uh when uh retention uh simulator, uh why uh 500 mother is on China by Fender are uh who's uh number uh our union that send you essentially how you can center. If I change your central suggestion, should uh do you eat, you know, fashion the children's uh Children that you need to send that uh Children, you need some by uh shouldn't be only from. Well, that's Regio August um should treat you you Benedict to uh woman uh with uh uh so through the uh usually a woman your fight yet. Uh Yeah. Gee uh fashion Lucian uh 500 easily cancer. Guangzhou. Uh you are uh your uh dollar, Arlene, Arlene and Anandhi uh uh lineu. Sure. Being the Children dot Xiujun Juan service uh quite so uh gentle for the uh uh she uh has changed uh the function from that uh woman uh woman that uh woman to eat all the moisture to be real gentle through the merger, tually hear from being the Eagle Drive. You should require sued by two Hou Chan tickle in general for the Green more Changcheng while I can three of the uh effect that a lot are uh quite so far. And uh they are uh so she uh woman called uh then why not woman? Do you value tongue uh aggression. She uh the uh E Salma and uh uh user woman uh kind of uh kind of uh maintain the movement, the maintainable uh Children uh quite to the uh uh so, so uh either and five and the independent woman, Tiaan tree on the gluten Treaties sensation truly. Meanwhile, the regionals has been found, they turned down the uh remember 55 really gentle. So is uh so uh uh huh uh Guang Financial uh about region show through Gyn 3000 newly three shoulder. So she uh she developed she uh to the drug woman that uh to uh to uh to actually each other found sir, uh Children uh by uh uh function uh woman, uh woman, uh uh 55 woman that uh user the whole uh maybe your shoulder issue. Uh truth drag woman. You can hold a granny about uh uh use uh uh RG you on uh uh woman uh uh two further ready. She died young. Thank you so much. Uh Very, very interesting. Again, uh our perspective uh around the world really uh on how uh the pandemic is gonna being handled. Uh dog. Do you have a comments? And I know we have several questions posted on the, on the chat and would like to um uh move along with them dug. You need to turn your audio back on. Right. So what, what I want to see our knee is that there's good themes coming through, isn't there? Um We're seeing how um everyone has had to take drastic Axion, the pathways change we're bringing in telemedicine. I'm going to repeat a little bit more about that later from Madu. Um But the other theme I'm seeing is that we're all trying to get rid of the backlog. Now, bearing in mind that a lot of ambulatory surgery is life enhancing rather than lifesaving. There is a reluctance of many people in the population to have surgery. And how do we now convince them that ambulatory surgery is now safer than ever and you know, address this with Beverly's there or, or Mads or Karen or John or Professor Xining? Any thoughts on that? Just make sure that your mix are on. Can I just interject here? They, to have one of the other speakers speaking? I would need to uh invite them to the podium. So if they put their hands up, I can find them and uh I can invite them up. So, Arne, while we're waiting. Yes, your sister needs an ambulatory procedure. Yes. What would you tell her to reassure her that it's safe? What would you say to her? What I, what I would tell her first and foremost is to, to make sure that she is careful. Uh So if at all possible uh to uh to get enlisted to get vaccinated. It is assuming that this is a purely electric procedure. But also I would tell her that the measures that are being taken right now. Uh not only in our fertility for many, many facilities around the world are probably about the most exhaustive what I have seen in my lifetime. Not that it was 1 30 before, but now that the processes of the cleaning and the screening that is being done, it is being done to the t So just like you mentioned, uh personally, I feel that this is probably one of the safest uh times two to have surgery. Uh We're really paying a lot of attention as to how patient's are doing cooperatively with respect to uh they're comorbid conditions, how, how well they're being controlled. And we're also looking in a lot of details cooperatively after how they're dealing, we're gonna be hearing a little more about what happens after surgery uh later on from the local Antonia's. And also, uh in terms of the preoperative evaluation point, I know there's a question about uh from a Dallas in Portugal if patient's were positive in the past and are now cured to go for a survey. How do we can have a preoperative evaluation? And Carlos, I can tell you that uh Doctor Sweitzer, uh Bobby Jones pfizer will be talking about this uh in detail. Um And I was with that lovely, that discussion really for, for that session since I'm sure we'll be hearing some interesting thought from her butt doctor. Back to your question. I think this is the safest that you have. Ok, just very quickly. Um, the wh show checklist and briefing has been a great revelation over the last decade really. And there was, it was becoming a little bit passe, people were not really taking it as seriously as they should. And I think COVID has made as look even more carefully at the wh show briefing and checklist. And I think that's one of the reasons we're now safer than ever. And the Soviet Gente wants to come on there. I do apologize. We change. I just want to make that common. Yeah, I just wanted to add a small comment in the way that uh these COVID 19 precautions were having now they are also taking care of other infectious diseases. So hospital acquired infections are really smaller now. So I think Britain's should feel safer now than ever because all the other infections are also coming down. Absolutely. Absolutely. Beverly has joined us. I have so I morning I was listening while I was trying to get the rest of this just have to wear. It's by scrutinized. I was just adding another screen. That's what the hiccup was the. Um So I've been doing a lot of interviews about having surgery during COVID. You've probably seen half of them are knee the and the questions that people ask me. First of all the uh not just as they say, but the details they want to know they want to know about is, is the vaccine going to affect my honesty, too big surgery. And so that's an easy question. That's a no. Um And the other thing they wanted to insurance on why they need to be tested beforehand, why they're family campaign. So those have been the really big, really big issues. Um I mean, the answer, the answer is, uh, you need to be tested is for your safety because if you have COVID, you're having surgery. Um, the data a little better, there's a small study from the inventory, um, already, but it's, uh, people that have certain don't, don't usually do it. And so the quizzes bad outcomes. So that's why we do encourage people get vaccinated if they can cause pretty much around here. It's, uh, you have to, everybody is eligible. It's just a matter of finding an appointment. So, and we also talked about family not waiting is that, that's again for their safety. Imagine the whole family's sitting in a room with a lot of other, whole family's for a few hours. So, uh, those are the, uh, so the crowd is what, what, what the people been asking the reporters come with specific questions, but it always comes down to these. Very good. Thank you so much, Beverly. Uh, I know we had several questions in the chat. Uh, and I, uh, we have noted all the questions down. Uh We need to move on to our back in session of the day. Rest assure we're gonna inter lace the questions that we have uh, further um into the chat. So Ian, uh if you'd be so, so kind, we're gonna move on to the second session. Hidalgo Hidalgo Ground will be joining as a co moderator. Hello, from the pain and hello from the United States uh to all of you. Uh Our segment today is COVID induced adjustments on the usual pathway for ambulatory surgery. Would you like to say a few comments? Iran's? Oh, thank you very much. Uh And it's a great pleasure for me to share discoloration with you learning and I hope it will be very useful for all of us. Thank you very good. So, our first speaker today is Doctor Bobbi Jean uh slicer colleague and friend uh from Samba. She is a Presidente elect for the Society of Ambulatory Anesthesia. She is a professor of Anesthesiology at the Northwestern University, Feinberg School of Medicine. She's double boarded in anesthesiology and internal medicine. She is an international author with multiple publications including uh several uh in the property management of patient's Doctor Spicer. Thank you for being with us today. Hello, I'm Bobby Gene Sweitzer, professor of Anesthesiology, an Associate chair for Perioperative Clinical Practice at Northwestern University and I'm going to uh speak about preoperative evaluation lessons learned and suggested changes in the COVID era. So my disclosures are that receives the research funding for American region and Daiichi Zenko as well as from the IARS. So the challenge is due to COVID 19 have been numerous. Um but I believe ambulatory surgical centers um have been asked um to perform procedures of higher complexity than they typically may have done before COVID. They also, I may be asked to take care of higher risk patients'. And it's typical for any given facility. I think during these challenging times, it's very important to remember that we need to be conscientious about preserving personal protective equipment and maintaining hospital and ICU capacity to manage COVID 19 patient's. We also want to be sure that we are managing the personnel uh affect personnel as well because many times uh as ambulatory surgery centers closed where they were short staffed in hospitals, people who traditionally worked in the inventory setting were asked to provide care in the acute care settings. Um or that those individuals were also getting exposed to the virus and getting ill themselves and we're not available. So there have been various guidances on um advising how long uh one needs to isolate um after a diagnosis of COVID. And so during the period of infectivity, it is recommended that only absolutely emergency surgery be performed. So we wouldn't typically be doing the those kinds of procedures in ambulatory surgery center. So these decisions should be made in a case by case basis but it includes um uh considering all of the following uh that has been at least 10 days since the onset of illness. And um the patient has been free from fever without any fever, reducing medications or at least 24 hours. And the COVID 19 symptoms are improving um or have mitigated uh with the exception of the loss of taste and smell, which can persist for um weeks, two months after an infection and typically should not be a reason to delay um the time to uh and isolations. So I've included a couple important urls there um from nice in the UK and from the CDC in the United States for more information that typically is updated on a weekly to monthly basis. So it is important to remember that um it is that um infection and reinfection or persistent infectivity um is probably better based on symptoms, it is on testing um because we know that these patient's may test positive for the SARS COV two virus for weeks, two months after an an acute infection. And most of these patient's are felt to be non infectious. Um again after the resolution of symptoms and after typically 10 days, particularly if they are immuno competent patient's, the patient's are immunocompromised may take longer to actually clear the infection at least in the United States. The recommendation is is that we do not do repeat testing for someone within 90 days after a positive test. Uh it's unclear though how long patients' truly have immunity to SARS COV two. This is both uh the situation for patients who have been infected and had an illness as well as those who are now receiving vaccines. Uh We do know that reinfection does occur variably over time for other human Coronavirus is so it would not be surprising to find that the immunity does wane with time. Um So COVID, COVID 19, COVID 19 does have various um symptomatology and complications. Most of these are secondary to an overarching problem with um diffuse inflammation. Uh the patient's who do the worst are those who have this cytokine storm. Um and hypercoagulability with um venous thromboembolism which can affect everything from um the heart, the kidney to the lungs. Um and many patient's um do have pulmonary symptomatology. Almost all of them do have some degree of pulmonary symptomatology. But then some patient suffer from cardiomyopathies, heart failure, inflammation of the heart muscle, um and cute kidney injury, which can lead to chronic kidney injury, even acute kidney failure requiring dialysis strokes. Um and then various complaints including difficulty concentrating memory problems, depression, anxiety, mood swings, um and a decrease overall a functional capacity and decreased quality of life. Um Some of these patient's end up with a significant restrictive lung disease, um acutely hypoxia ARDS and long term um restrictive lung disease. So, I'm not sure that anyone knows what the risk of surgery is for patient's who have had COVID 19. Um but I'm going to go over with some information that um different uh entities have published as guidance. So this was once a day that was done very early in the pandemic, it was done. Uh They enrolled patient's between January 1st 2020 the end of March 2020 they had just over 1100 patient's who were diagnosed with SARS COV two, only about 1/4 of those patients were diagnosed preoperatively. Um, the other 75% were diagnosed post operatively. Um, and um, most of these patients actually were having emergency surgery. So at baseline, this is going to be a very high risk group of patient's. Um, because we do know that patient's having emergency surgery do worse than patients who are having elective surgery and the mortality was quite high. It was about 24%. Um, a little over half of the patient's actually had pulmonary complications and then those who did have pulmonary complications. The mortality was 38%. Um, the, uh many of these patient's um, had uh acute respiratory distress syndrome pneumonia or required ventilation. In this group of patients, they broke down the risk of patient's under the age of 70 over the age of 70. Um, and they broke the surgeries down into minor or major surgeries and then to emergency or elective procedures. You can see if the patient's younger than 70 years of age, having minor surgical procedures. If they were elective, there was a slightly increased risk of mortality in the men but no increased risk of mortality in women. Um But when the surgeries were emergency minor procedures, you can see that risk was further increased in men about almost double that. And now they saw some increased risk in women. Um, for those uh major surgeries, the risk was even higher but not substantially higher, particularly for elective, major versus emergency minor surgeries. The risk was about the same in men, somewhat higher in women, which is quite different, usually emergency surgeries or have carry significantly higher risk than elective surgeries. And major surgeries typically carry uh significantly higher risk than minor surgeries for patient's that were old over the age of 70. You can see that the risk was significantly greater about twice that. Um, and men and now even women had a higher risk when undergoing elective minor surgery and in fact, was equal to them men and you can see all the rest of those as well, um, were increased. Um So it's worse to be older, worse to have emergency or major surgeries. Um The patient's who had cull morbidities did more poorly. Those were at A S A three through five, had a worse outcome and men compared to women had worse outcomes. This was an interesting study. It was a study done that was just published as, as a research letter. It was never published as a full manuscript, but it was quite a um interesting study. They looked at the surgeries that occurred during one week. Um They had over 1300 centers so quite multidisciplinary in about 100 and five different countries. So quite diverse. Um It covered all surgical specialties and they looked at patient's who um were having surgery, who had SARS COV two infections and this was the outcomes um both pulmonary outcomes of those mortality. You can see um the 30 day POSTOP outcomes for pulmonary complications in pain who had surgery within 1 to 2 weeks after a positive SARS COV two swab, they did not even have to have a COVID. Just a positive swab was almost 20%. Um If they waited 2 to 4 weeks after a positive swab, that risk was still about 12%. Um But once they waited a month or more, the risk was down to zero. Um Similarly, if you looked at mortality, the risk was highest within that 1 to 2 week period after a positive uh SARS uh swab and was relatively high at 8%. Um not as high as that previous one I showed you. But again, these patient's had simply a positive SARS COV to swab. The previous patient's actually um had much higher risk of having actually COVID symptomatology. Um At 2 to 4 weeks, the mortality was down to um just over 3%. And again, after four weeks, the mortality was zero So they did, you know, uh published a sort of a caveat saying that there were significant limitations to the data. Um Perhaps patient's were selected. Um uh you know, uh it was in a randomized control trial or anything like that and that this data should be considered more exploratory than definitive. So, we'll talk a little bit about patient's who have post COVID syndrome or what they used to refer to as long haulers. Um These are patients who have seem to have symptoms that linger much uh longer than they, their, their initial illness and long after they should have recovered otherwise, I mean, these patient's have muscle atrophy. Some of that is you as from, you know, being hospitalized from disuse. Um but they comply kind of weakness, fatigue, dyspnea, chest pain, um chronic joint pains, uh sleep disturbances. Um they can seem to have continuing ongoing inflammation, diminished quality of life and complain of this, you know, brain fog, difficulty concentrating memory problems and a relatively small percentage can have ongoing cardiomyopathies. So this is one protocol that was published by one university here in the United States, but it's actually one of the few uh universities or protocols that have been published on how to evaluate patient's prior to uh surgery who have had a episode of COVID 19. Um This was based on a lot of uh review of very small studies, um not robust randomized control dot data and a lot of it from, from their own um institutions experience. But they did, uh, recommend that for patient's who have had a symptomatic COVID 19, they had their surgery that laid for four weeks to recover if they were symptomatic with COVID. They recommended a 6 to 8 week recovery period. Before embarking on elective surgery. They did say that you should focus primarily on the history and the physical examination to both rule out any COVID 19 complications or residual problems and to try to determine if the patient's were back to their pre COVID baseline health. They did recommend frailty assessments in those over the age of 65. Now, that's being recommended for most patient's over the age of 65 whether they had COVID or not. But they also recommended that a frailty assessment be done in anyone who was hospitalized during the COVID 19 illness. Um and they did say that additional tests should be based on both the COVID um 19 illness severity as well as the organs that were actually affected. But they did highlight, you know, evaluating cardiopulmonary function, coagulation status, inflammation and other kinds of organs, um organ dysfunction. This was a table that was published within that document. I'm not going to go over it in detail, but I just want to point out that on the far left, there's various tests, you can see their chest X ray, electrocardiogram, echocardiogram, and various blood tests and basic things like the CMP. The CBC coagulation studies. Um But then some more specialized test that we don't routinely do such as D dimer and fibrinogen. Um and then uh bnap or NT PRO BNP. And then some assessments both for chronic inflammation as well as nutrition with ferritin LDH and Prealbumin. They divided these into minor procedures, um and major procedures and within those then minor on the left or major on the right, they divided it into patient's who had either had a symptomatic disease or symptomatic COVID disease. Um And then you can see there, they, they, they broke it down into recommendations of whether the recommended these tests are not. Again, I want to say this is, I think far from definitive. Um but it is a least one protocol that you can start to use to do to determine if that suits your patient population. So, the American Society of Anesthesiologists and the Anesthesia Patient Safety Foundation here in the United States did published a joint statement um several weeks ago now, um on when to um proceed with elective surgery in patient's after COVID 19. Um again, this was based on some very, very small studies, very limited data. Um but they suggested that one should wait four weeks for asymptomatic patient's or those who had only mild or non respiratory symptoms. Um Wait six weeks for patient's with symptoms such as of cough for dyspnea, but that did not require hospitalization. Um excuse me. And um for 8 to 10 weeks for those with who were symptomatic with diabetes, who are immunocompromised or patient's who had to be hospitalized. And they recommended waiting for at least three weeks for, I mean, sorry for at least 12 weeks or three months for patients who required an ICU admission. This is just a nice sort of demonstration of patient's who are frail compared to those who are healthy and the predicted surgical risk. And we know that frail patient's do carry a higher risk. This was pre pandemic, pre COVID um that compared to healthy patient's, but it also appears that, you know, um both frail and healthy patient's will have an increased risk post um infection. Um some of and even increased risk when they haven't had COVID, but just simply been um you know, at home, unable to be out and able to go to the gym or exercise, um or get regular healthcare and the patient's who are frail to begin with, they have even a greater uh decker um int in their baseline function and have higher risk when undergoing surgeries. So, there's been a lot of um you know, emphasis on pre habilitating over the last few years. Pre habilitating is kind of the concept of what we do after surgery. But before surgery to get patient's in better shape, um a lot of the early focus was on simply, you know, improve functional capacity, exercise capacity, but more complex and more beneficial pre habilitating in um centers around, you know, a holistic approach, getting patient's to stop smoking, lose weight, eat healthier, um dealing with their chronic pain, wean them off opioids per her. Perhaps a man needs their depression anxiety um and sort of prepare them for um the stress of surgery and what surgery requires. Some of this is physical, some of this is as medical, you know, optimizing their co morbid conditions, getting their diabetes under control, their hypertension control, etcetera. And some of it's psychological um and emotional and it often involves, you know, including uh patient as well as family and friends. So I think if you want more information about this, I urge you to go to the Society for Ambulatory Anesthesia website at Samba HQ dot org. It's there in the lower right hand corner. Um Over the last year, we've uh published several different recommendations and guidelines to assist individuals in um managing ambulatory surgery and ambulatory surgery, patient's and procedures. In the COVID era. We've also staged um several webinars um that have been quite well received. Um Over the last year, most of the webinars or many of them were focused on COVID some um on other um aspects of ambulatory surgery. But I think the overarching goals should be to provide necessary and safe elective care to patient's um at ambulatory surgery centers and to be cognizant to avoid transfer an admission of patient's to a hospital due to either poor patient selection or preventable surgical complications. So I put my email down there. My Twitter handles their um please contact me if I can be of a further assistance or if you have any questions. Thank you very much. Mhm. Apologies there. I think we've got slightly out of sync with the audio. I think Arnie A UK there. I am. Somehow I got uh I got uh I don't know what happened. My my apologies. The era of zoom. Okay. Um So we're everybody back on. Yeah, because I know some people got, also got kicked off. It looks like we have uh 40 people. Uh Carlos uh Castoro, he is the head of the upper gi unit um uh in uh Italy uh for his hospital, the uh instituto. Uh He has also a long standing member of ali double A s with many, many contributions uh to us, Carlo Cloris. Good afternoon to everybody. And thank you very much again for inviting me to participate. So these is spring meeting. Unfortunately, the a close spring meeting, I have no disclosures. So I work in the Note of Italy in Milano and Humanities Research Hospital that is a tertiary referral center for cancer Patient's Milano is a historic city with many monuments and museums and work of arts and full of tourists in all seasons. This was the appearance of the main square of the city and the cathedral one year ago in March and April. So everything has changed very quickly. Yes, as you may know, global numbers are quite different from uh country to country and epidemics is worsening again in many, many countries around the world that moment. So we learned a lot of lessons from the very early phase of the pandemic. Italy was the first country to be hit by what the epidemic in Europe, we did well for the first four or five months. But after summertime, when we thought everything was finishing, the number of new positive COVID 19 cases was rapidly increasing. In the experience first the second wave and are now in the midst of a third wave, we were not prepared, but we have learned a lot from the first epidemic outbreak starting a few days or weeks. From the beginning of the epidemic, many scientific societies have published suggestions and guidelines but at the beginning, not always consistent. And I remember that that who at the beginning did not recommend the use of facemasks say, please remember that when sciences lacking common sense should prevail, we also enjoyed a lot sharing knowledge and experiences and participating too meetings such as the meeting of today, of promoting international collaboration in this field. Immediate a long term impact of the COVID 19 epidemic on the liberal surgical services has been extensively studied pandemic burden is the determinant of the disruption of surgical services in the hospitals. There are in the center of the most effective Aritz in the first phase that pressure capacity of healthcare system is overwhelmed and almost no strategy is possible. In this phase, only life saving, emergency surgeries maintain. And we unfortunately experiencing a number of deaths from pandemic and a high risk of non pandemic deaths due to lack of surgical services. Or I see you bet in the second phase together with initial control of the academic and the reorganization of health services, we will be able to provide emergency surgery and some cancer surgery of transplants but still fighting with delays and cancellations. And this yellow phase there is still a high number of deaths from the pandemic and some risk of death from lack surgical services. And some concern on short and long term effects of the late surgery on prognoses of patient's in the first in the third phase of the pandemic. And that's the green wave. It is under control in the green phase risk of undated debt shift with time. And there is a lower risk of non pandemic debt from lack lack of surgical services but still concern on long term effect related to delayed surgery. Our cancellations and this phase maintenance of electives, cancer surgery as possible. And all elective surgery is again possible and that should be considered like a phase of new normal. This slide shows what we did in humanities, University Hospital in Milan in the early disrupted phase of the epidemic. In March, we all work in teams starting with separation of patient flows to keep safety. First dedicated errands for positive patient were identified. All low priority activities were closed, released critical resources and in this early phase, all ember to the surgery activity was obviously stuffed and delayed. Yeah, here has some data from a collaborative international studies that study that involved many hospitals and also hours hospital, 37% of cancer surgery was cancelled and 81% of benign planned surgery was cancelled. The tremendous impact on surgical services. Similar experience uh we was that Alaba of my country, we conducted a study that was recently published in the annals of surgery showing that reduction of hospital deaths was experienced by overall 70% of the hospitals in Italy and reduction of surgical activity was more than 50% was experiencing almost 80% for the hospitals in my country. This um this new uh shortage of resources stimulated us to create a new prioritizing prioritizing model for cancer depression. But a similar model can be adapted to all elective surgery, reconsidering, urgent, near urgent, non urgent and Differin ble cases in planning new surgical services. So okay, what is most interesting is that as you can see here, age sex and age. American surgeon, anesthesiologist rate are significantly related to post operative mortality. So, so thresholds from surgery during the COVID 19 pandemic should be higher than new normal practice, particularly men, age 70 years for older. What's interesting is that strict adherence to safety protocols allows a safe surgical environment. So surgery is safe if we applied strictly applying safety protocols, what is to me a lot most importances patient perspective, anxiety, paying treatment delays, long waiting lists and certain anything are affecting many patient during this phase of the pandemic. Also, if we are now in a green stable phase, so it's really necessary to rethink the patient pathways. Patient refer a pre assessment, barely open care, discharge procedures and follow up procedures. In order to minimize hospitals, they minimize face to face interaction and again, promote day surgeon. That is really uh the right answer to this reorganization of surgical services. Safe from selection and reassessment. We need to introduce COVID antigen test 48 70 72 hours before admission. Health, question of periodic contacts at risk and tracing self isolations, social distancing, patient information should be changed. And what is most interesting to me is we need to try to optimize patient health health status and invest in pre habilitating in. But last but not least avoid unnecessary surgery. When, when possible recommendation for systems to consider after the peak of the epidemic, I don't want to go through all these items, but just to show you that ambulatory surgery has been considering this publication, the owners of surgery and the role of ambulatory centers could also help to address the burden of delay prior or addressing less urgent operation. So it's interesting, it's it's changing possible, changing role. I'm going to research in the base of the pandemic way. So now how can we go on? Obviously, we need to base our choices on priorities with the gradual recovery of surgical volumes play attention to stuff stress, organizational flexibility is mandatory, adopt the diagnostic therapeutic path, dedicated path for college 19 patient. Even the number of researchers setting new working models such as team rotation, for example, Lambie spoke center say change the referral of patient's. So what can we do in the ambulatory surgery settings and informed decision to proceed with ambulatory researchers should be in my, you know, the first step. And if I also need to focus on follow up procedures, I'm and really convinced that correct follow ocracy to start at the very beginning in the process of patient selection. So discuss risk and benefits with patient considered delay surgery. If possible, discuss alternative options more than ever confirm constant including COVID 19. Risks, agree with a new treatment plan, agree on admission discharge and follow up plans and prevent of COVID 19 related possible complications. According to individual risk stratification, age, patient mail previous illnesses such as respiratory illnesses and so on. Prepare infection for surgery. We suggest to develop a rehabilitation strategy strategy was main aim is to optimize help the health status of of our patient's inform the patient of COVID 19 prevention guideline. Arrange practical arrangements on the day of surgery should be well known by the patient. The caregiver, social distancing a hospital journey uh changed accordingly plan COVID 19 testing, 48 72 hours before admission, we choose to do it quick 48 hours before nation self isolation. After testing, when test is negative hygiene measures very strict social distance since and caregiver involved in the treatment plan and if if available rapidly in hospital COVID 19 testing in case of name. So preparing patient for surgery, pre assessment process, reduce patient healthcare professional interactions. Obviously, it's mandatory develop a remote consultation strategy that could also be really helpful in the follow up period. Reassessment redesign according to local organization of your hospital, consider patient capacity and conditions. But if if you're not confident, never give up and promote the face to face consultation. When appropriate, this includes new selection criteria obviously and consider really again, it's a mandatory importance respiratory disease and other factors such with COVID 19, security and risks, age and COVID 19 is a is an issue. Are now who's a positive uh new issue that is the effect of vaccination that is particularly clear and evident in the UK. And I really hope we will follow soon your experience. Yeah, something about the day of surgery, redesign the day unit to obtain spacing between patient's promote stagger. The admission's reducing number of proceed er sometimes is uh it is mandatory single room available. If yes use it use it reduced number of beds in the same room. Obviously plan admission and discharge accordingly. Train the unit, staff to the new normal the day of surgery risks, uh staff risk and prevention strategy in each area or function. There are different areas. Well, risks that risk stratification is quite different. Air change and procedures and risk of uh stabilization of the virus. So consider the area where stuff works and where patient's stay. First stage recovery is, for example, in Irish, carrying an immediate post operative period session are more exposed and the staff is more exposed than in other recovery areas. Discharge to second stage recovery as soon as possible. Obviously, uh this reduces the context with patient, patient to patient, to patient, to healthcare professions, minimize stay in the unit. So early promoting early discharge, strict patient behavior monitoring inside the unit wearing mask, for example, some DPI up hand eye gene, keep patient information and advice continuously and start planning discharge quite early at the beginning of the journey risk associated with with surgery. So choice of anesthesia and sedation, choice of surgical techniques should be discussed. Minimize the need in order to minimize the risk of post operative face to face follower discharge procedures and safety. Remind the greed treatment plan to the patient and the caregiver informed patient again and again, what to do in case of suspected complications should be absolutely clear. Reassure patient of minimal real risk. That's that's the truth. And whenever possible use uh tele monitoring or uh tele consultation to avoid patient coming back to the hospital for known uh unnecessary, unnecessary controlled again, discharge procedures and follow up simple plan and direct contact in case of doubts of symptoms. So the hospital should be open to phone calls or to solve any doubts. Follow up by telephone or tele consultation will become east to die. The new normal, we reduced greatly the number of context with the hospital by the patient plan for our contact. Also, if not strictly needed better, one more telephone call that uh that one less informal, simple actions and contact number if developed problems, these are two question mark. So the GP involvement whenever possible and oncale services involvement if they are available available, but please remember that not only the patient but also the caregiver should be informed, contacted, inductive lee involved in the treatment plan. In conclusion, I really believe Ambrotose surgery is safest and best quality treatment. You leak COVID 19 epidemic. Whenever possible, redesign the day unit for the new normal redesign, the patient journey, minimize patient, patient and patient to staff interactions, leadership should take advantage from the emergency situation because we nearly we it's a great chance to rethink the world system. We think what patient really need involves stuff and the designing of the new pathways and develop new tasks and I hope new opportunities. So thank you very much for your attention. I really hope we will be back to our traditional meetings soon and hope to welcome you and Milan in the next few years. Thank you very much. Well, thank you so much, Carlo. Uh, we really appreciate, uh, we do know that Italy has been, has been hit hard with the, uh, with the pandemic. Please be safe. Our next speaker, uh, today is, uh, Carmody. Uh, she's a consulting anaesthetist, uh, and lead for the surgery and pre assessment, uh, part of the Royal Wolverhampton Hospitals as part of the NHS, uh, in the UK Maru. Good after. I would like to thank the is scientific committee for inviting me to share my thoughts on the road of telehealth in ambulatory surgery. I have no conflicts in interest. This is my hospital in the Midlands and like the majority of other healthcare systems are trust to has been tested as never before by the COVID pandemic. The national lockdown led to a rapid adoption of technology to provide the necessary clinical care to patient's in order to minimize the risk of COVID transmission. Telemedicine. A term point in the 19 seventies means healing at a distance. In 2007, the World Health Organization defined telemedicine as the provision of healthcare services. While the use of communication technology for diagnosis and treatment of diseases and for education of healthcare providers, although used interchangeably, telehealth refers to healthcare services involving all healthcare professions, including their education. Whereas telemedicine refers to services delivered by physicians only telehealth can be delivered in different ways. It can be synchronous, which is real time, telephone or live audiovisual consultations with a patient using a smartphone, a tablet or computer asynchronous mode includes store and forward technology where messages images or data are collected at one point in time and interpreted or responded to later patient potent can facilitate this type of communication. The third modality is remote patient monitoring which allows patient's vitals to be monitored remotely and be shared with the healthcare professions, professionals in real time or reported by the patient telephonically or electronically SMS is still the most commonly used modality as it does not require the patient's to have a smart for those can facilitate this type of communication areas in the ambulatory surgery pathway that can be considered for telehealth delivery that I shall be discussing today. Our patient referral, pre operative assessment, remote monitoring and post operative follow up. I undertook a short survey prior to this talk and I would like to share it with you. Thank you to the eyes and bads members who kindly filled out the survey. It was a quick poll to ascertain the use of telehealth and take a surgeon pathway. Only 30% of the responders are currently using any uh overall based system and 10% of these have been set up boost COVID. Majority of the units carry out the telephoning pre assessment and patient information is given out mainly in Britain form as is the discharge and follow of information. Majority carry out POSTOP follower telephonically remote patient monitoring is still relatively under used with only one unit offering variables to patient's and a few units getting the patient's to telephone or feed the data electronically using their own measuring devices. On a positive note, more units were currently trialling various telehealth modalities for a remote consultation to happen. The patient should be billing and have capacity face to face appointments are a preferred option for the first time appointments and those that require a physical examination. The General Medical Council states that doctors must maintain the same standards of care when treating a patient through telemedicine as they would when face to face. It also stresses on taking consent from the patient for providing clinical care by telehealth as well as maintaining patient records and confidentiality. During the first COVID search to facilitate remote consultations, my hospital implemented a web based software that allowed clinicians to set up virtual clinics by logging in via their hospital inject patient's are sent to the clinic appointment. Ling why SMS or um you therefore having a smartphone is not a prerequisite for healthcare professionals signing in via the email, makes it user friendly one list, password to remember. And at the same time, it fulfills the security and confidentiality related requirements that need to be addressed such as data encryption and robust authentication with elected activity. Now ramping up healthcare facilities are keen on exploring avenues that can reduce wait times. My trust in the last month has piloted a patient digital photo for outpatient appointments for patient's on cancer pathway. The plan is to eventually rule it out to all occupations appointments. The processes that admin staff get the patient's consent to sign up for this mode of communication. Once signed up, the patient's then have the option to manage their appointments and get the letters electronically. Though it is still early days, the future aspiration would be to have a patient digital photo. That is an interactive platform for the patient's to engage with the healthcare professionals in managing their care. Whilst from the ambulatory pathway, they should have the option to arrange for a pre assessment appointment at their own convenience. Be able to access patient information as well as discharge advice, complex patient's having major surgery should have access to remote monitoring to allow early detection and timely management of any complications. Does avoiding pre admission's, the patient engagement leads to enhance patient satisfaction as well as improved quality of care. There is a white variation in the use of tele Gance consultation for pre operative assessment. Some units currently offer it to only select patient such as A S A one and two prison patient's or patient's living in remote locations. Once other units pre assess majority of the patient's either online or telephonically barring the very complex patient's having major surgery who get seen in person. The online pre assessment to allows patient's to submit their health assessment in their own time without the need for a hospital appointment with tele consultation, patient save time and money on transportation. They do not need to take significant time off of work or arrange for childcare in order to attend the appointment. The downside of a tele consultation is not being able to record vital signs or do a physical examination. Many patient's now have their own devices at home and are able to record their own vitals before the virtual consultation. Use of smartphones for video consultation can allow a reassessment if indicated. Rehabilitation is now routinely being offered to patient's for improved surgical outcomes. Telehealth can facilitate pre operative remote patient monitoring by any status. It could be remote optimization of anti coagulation, glucose control fluid status, weight management or increasing functional capacity before surgery. This can be achieved by using data from variable sensors, continuous glucose monitors, bluetooth connected smart home devices and cardiopulmonary sensors. The data is transmitted into electronic medical record voters and gets stored in data clouds for an s sadistic review, taking very operative medicine. One step further, mobile apps can be used by patient's to record daily post operative mind stones after having major surgery within an enhanced recovery program. Also, patient's with complex home abilities on the ambulatory surgery pathway can seek advice on matters such as went to restart. Anti habitants is or anti prevalence. Anesthetist can use telehealth to implement hospital at home and reduce hospital readmissions. Remote patient monitoring is collecting and interpreting patient data such as BP, pulse oximetry and heart rate. This can be transmitted in real time or reporting visitation, telephonically for elementary classical actuations, patient's can use their own devices or be provided with variables by the hospital. As mentioned in my previous night, it can be used for pre habilitating in as well as to improve post operative anesthetic care, especially for the high risk patients' or patient's having complex surgery. Surgeons have been using routine monitoring of specific objective clinical data for early detection of POSTOP complications such as ileostomy output or surgical drained output. Telehealth. For POSTOP follower gained popularity when excellent clinical art forms and high patient satisfaction were achieved in a large pilot study conducted in 2013 that explode whether her telephone visit would safely substitute an in person visit for POSTOP cases for elective surgeries such as that fully or open hernia repair telehealth in post offices, post operative setting can be routine post of discharge assessment and evaluation of acute post of issues or a routine POSTOP follow appointment. Both SMS messaging and mobile health applications have been used successfully to reduce the length of stay, reduce readmissions and improve patient satisfaction. Telehealth for POSTOP follower can generate substantial number of additional clinic slots for new patient assessment who can then be offered elective surgery. The most obvious benefit of telehealth adoption has been the reduced exposure to COVID for both patient's as well. As healthcare professionals because the patient's are more engaged with their care team. There are fewer DNA is there are few readmissions as remote patient monitoring and remote consultations, health patient's manage their health conditions more effectively. Tele consultations extend access to care beyond normal clinic. Cars, let's turn around time and clinics helps improve efficiency and better patient engagement, enhances patient satisfaction. Moving on to limitations. There can be situations where in person visits are more appropriate due to urgency or underlying health conditions. Telethons consultation is also not appropriate if there is a need to petrus sensitive issues, especially if there is concern for privacy. One of the barriers to telehealth is limited access to technological devices or there are connectivity issues. Staff may offer resistance to change, wanting to continue to work in their own traditional set ways. There can be cultural or language barriers, not so much as NHS, but in countries with private healthcare providers, barriers to telehealth can be an inconsistent reimbursement, interstate license Shal challenges and other regulatory issues concerns over security. Privacy and confidentiality can be a barrier when there is a requirement for initial capital investment to introduce telehealth. A lack of evidence about impact on healthcare costs, utilization or outcomes can be a limiting factor. In order to implement telehealth. It is important to align with organizational priorities. One can start with identifying gaps in care in ambulatory surgery pathway where you lose efficiency where your staff encounter pinch points or where patient's health or satisfaction suffers. It could be a high DNA rate in pre assessment clinics long waiting times for anesthetic consultant, appointments or consideration to allow complex cases to be discharged safely by the establishing by establishing remote monitoring to summarize during the pandemic, telehealth has supported social distancing by minimizing the need for patient's and clinicians to travel to hospitals post COVID. It is anticipated that a substantial proportion of out wishing visits will continue to be virtual. This change would eventually reduce overall health care costs while the reduced need for staff and space, looking ahead, it would be useful for institutions to share knowledge, successes and pitfalls of telehealth in order to improve the delivery of patient care. Thank you for listening. Thank you so much madam being a user of telehealth, I can tell you it certainly has, has saved those quite, quite a few issues. Uh And the patient's are loving it uh so far. So I saved them a visit. Uh It's more convenient. I mean, again in an era of COVID 19, trying to keep everybody in the distance. It's been well received. Uh I'll go, do you have any any commerce that's part of the discussion for our Panelist, any questions you might want to post? I think it has been a very useful uh round table and I hope all the people who is with us have been enjoying us. Like, like, like I have, I have done Yeah, very good. So, we, uh, we, we do have a question, uh, that was sent to me, uh, for the blood Sweitzer. And that has to do, uh, specifically with a cardiac evaluation preoperatively, uh, for patient's who have had COVID and common in for a surgery. We do know based on autopsies that even patient's who are asymptomatic post COVID can have a significant amount of virus in the myocardium. The early patient's who have passed have been infections. But um are you aware of any, any data currently uh that would point us toward doing a more in depth cardiac evaluation? Anything again, we have moved away from doing EKGs routinely gone patient's. But what are your thoughts? Yeah. And if you could uh invite doc advisor to the podium, that would be great. If uh if she could highlight herself, I can invite her to the podium, I can't see her amongst our delegates at the moment. Well, while we're waiting uh descente, if you, what is, how is your unit dealing with the preoperative evaluation of patient's who have had COVID in the past? Well, uh at the beginning, there was a little bit of confusion because COVID 19 patient's were patient's who have, who have had uh pulmonary illness. And we didn't know how uh that illness was affecting our anesthetic and surgical outcomes. So we felt more prudent who if possible delay surgery. But nowadays, if the COVID infection was not a serious one, we wait for as much as the flu for uh 14 days and then we proceed with surgery very different. We have a question for, uh, for Madu. Uh Madou would respect to uh, the literature that you, um, that you review. Were there any, uh any actual negative outcomes? Uh, even if there were no statistical significant that you could identify again, Madou, if you could click on the speak button, I can invite you forward and while we're waiting, she, she's just joining us now. Thank you. Thank you. Right. Hopefully she should appear in a moment. Thank you, William and thank you for navigating the challenges in the background here. Welcome, Madu. Can you speak? Uh the tele consultations are using telehealth in the delivery of services? I think there were barriers rather than negatives. So it was all um better patient satisfaction, better patient engagement, reduced costs. And I think this is the way forward. So we have to identify the barriers and the uh physicians who are working with traditional set ways to engage them and get the telehealth in place. So, while we have been using telehealth during COVID times, what we don't want is reverting back to traditional set ways, we want it to continue and in fact, um widen the scope of it. Right. Thank you so much. So we do, we did have a couple of questions for uh for Carlo. However, in the interest of time, uh we're hoping that at the end, we have a few minutes to get two questions that we have not gone to. Uh, so, um, moving right along, we, uh, would like to go to our next session. Uh, and I'd like to welcome uh, Doctor Presente Vater and it, I'll go to bed, um, cold moderator for the session. Thank you very much. Thank you, Barney. Um I think it will be necessary to introduce you within TB area at least well known, but Vicente anyway, but then to is Ansi ologist and is the director of the ambulatory surgery unit at Braga Hospital and also is a member of the International Association for Ambulatory Surgery Executive Committee. Um and uh defensive. Do you want to introduce uh the next speaker, please? I again, good evening, good evening, everyone. Uh This table is about Tempra Torrey Surgery as a dynamic and versatile strategy for vertical paintings in the post pandemic area. And we have young his house and Kirsty Lehtonen uh share ing the first session, Jan his house is an anesthesiologist. He is the founder and former director of the ASU in University Hospital of Answer. Damn is our long secretary of is and now presidente of the Royal Choir propriety in answered them. Kirsty Lehtonen is a registered nurse. She specialized in Perioperative nursing and a matter of health scientists, a sciences. She is currently nurse manager at children's and women's operating room at Turku University Hospital. She's also the Presidente of the finished Association for ambulatory surgery. Welcome both of you. Ladies and gentlemen, a warm salute from Amsterdam. Uh In this very, very short presentation, we will take a look at the future where we see a complete vaccination far on the horizon. And as you know, horizon as if line imaginary line, far away that receipt as you get closer, my country, like many other countries has been affected by COVID from nine, from March 2020 out of a population of 17.3 million inhabitants, 1.2 million have been infected with the virus and uh around 16,300 has died. So far. On an annual basis, we usually perform 1.3 million operations. Around 65% of elective cases of which is is on an ambulatory or short state basis. Here, you can see the impact on hospital capacity of the admission's during the 1st and 2nd wave and the early possibly third wave, especially in the first wave, we reached the limit of intensive care capacity and patient's had to be spread all over the country. Here is the I see um coverage due to the large influx of severely ill. Um COVID patient's the regular care for. I see care in protection early the operations for which and I see admission was indicated, postop quickly flee was severely hampered as a consequence of uh the influx of COVID patient's a shortage of I see you that came to light operating room. Personnel were withdrawn from the operation theatre and the process because they were deployed to strengthen the I see colleagues. Colleagues initially, they went into it with enthusiasm. But soon the heavy duties in the heavy services took their toll. There was a significant drop out because of illness due to start becoming infected or over tired. Holidays could not be included. In addition, and there was no prospect of rapid vaccination for a long time. Many patient's have had their needed but not essential surgeries postponed you to the pandemic. In the first wave, we had 1150 ICU bits usually 75% 75% of which were occupied but now imminent overflooded with COVID patient's regular care was reduced operations, prioritized hospital, ambulatory hospital, ambulatory care virtually blocked and other beds in the hospital were upgraded to I see uh level with personal without full intensive care, education, patient's were distributed among I see beds nationwide and even a few cases to Germany. Later during the year. During the second wave, the personnel was not yet fully recovered and sick leave reached about 8% in health staff. Yeah, are some examples of reduced regular care. A dramatic drop in referrals from GP uh to hospitals drop in orthopedic operations on knee and hip and also in decrease in cancer diagnosis compared to normal years. Former years, uh reference spoken the result of uh COVID in 2020 was a backlog of 100,000 operations in all kinds of surgical specialties and a persistent persisting non recovered sick leave among healthcare personnel. All this was against a backlog in uh back all this against the backdrop of a impending third wave. Here, you can see uh the uh new cases are rising and however not uh more recovered uh health care uh graft. But anyway, uh there is clearly an increase in hospital and in intensive care admission's. While the COVID 19 vaccination is beginning to be rolled out, it will take time for all patient's and staff to be protected. Health authorities have developed a sophisticated vaccination system uh to first vaccinate vulnerable elderly people from old to young and there's not overburden the hospitals. However, interest groups like we as healthcare professionals, teachers, education, staff, police police staff claim all priority for vaccination from policy makers, which means that strategy is constantly being changed, resulting in delays. The faltering delivery of the vaccine doesn't help either. So my country where a rather bureaucratic strategy is rolled out. Uh to my regret is not the best example of efficient vaccination progress. Although many Europe here you can see in the Netherlands, 14 per ones of people and uh the rest of Europe is around 5 15 60 people, uh vaccinations per 100 people. Well, what should be the strategy to over what is the strategy to overcome the backlog of 100,000 operations on the one side, you see planning and logistics where regional planning of surgical services, the installation of a multidisciplinary prioritizing of Operations Committee uh and referral from hospitals too, ambulatory surgery where light cases will be day cases. And we're uh by extending court hours of service, uh we get additional capacity and by flexible planning of briefly basis and use of independent clinics. We hope to uh increase our operative capacity. On the other side, Very important. The uh flexible personal management is a cornerstone of getting this uh backlog overcome education of recovery, theater and general nursing staff for operative tasks leads to mix it competences. And uh when they give the possibility to have a light of team for simpler procedures together with flexible working uh schedules, we hope to have more time in the operating theater. Well, ladies and gentlemen sufficient vaccination coverage will certainly stimulate the surgery again. But it is not possible to say how long it will take before add additional 100,000 patient's uh surgeries are eliminated in the normal given daily program. Given the overload of staff, sick leave will gradually decrease. And my expectation is that ambulatory surgery will get off the ground fossil than the larger clinical surgery, especially in the clinics. Thank you very much for your attention. Thank you A IIS for your invitation to speak about expected role of COVID 19 vaccination and ambulatory surgery. I believe that the goal of every country's COVID 19 vaccination strategy is to lower the disease burden of COVID 19. That is severe cases permits the debts and years of potential life lost and to maintain functioning the healthcare system. That is also the case in Finland. The selected vaccination order supports these goals and it's based on the medical risk assessment. Finland has decided that COVID 19 vaccination will be offered to all persons 8, 16 or older who are willing to take the vaccine because the number of available vaccines is limited. They are first offered to people with higher risk of severe COVID 90 disease or being exposed to the virus. At work. For example, the Finnish Institute for Health and Welfare recommends that COVID 19 vaccinations are offered to different groups. In following order, vaccinations started in December from the healthcare, personal caring for Coronavirus. Patient's, this includes, for example, personal in intensive care units, personal inpatient wards and emergency wards, treating, diagnosed or suspected COVID 19 patient's and emergency care. Personal, also personal in infectious disease clinics, treating diagnosis or suspected COVID 19 patient's and also testing personal and laboratory involved with COVID 19 diagnose diagnostics. What high risk groups? The COVID 19 vaccine recommended for H is the most important risk factor for serious corner virus disease. For that reason, the vaccine is recommended for the elderly, elderly residents will be vaccinated in age groups starting from the oldest one and elderly is living in the same household vaccinations in round the clock care facilities started at the same time with the healthcare, personal caring for corner virus, patient's both personal residents got the vaccine. Highly predisposing conditions for severe COVID 90 disease include for example, severe chronic kidney disease, severe immunosuppressive condition and severe chronic pulmonary disease. Predisposing conditions. Uh disease include for example, coronary artery disease and care osis for liver. The number of available vaccines has been so limited that vaccinations of new healthcare personal groups had to be halted. Older persons and persons in risk groups are now primary recipients of the vaccines. Once a number of vaccines arriving in Finland is cynically cynically into the higher, the vaccinations will be extended to entire adult population. The first preliminary research results on the effectiveness of Coronavirus vaccines have been received in Finland. The results are based on a Ritish study. Vaccination reduces the number of severe Coronavirus disease is requiring hospital treatment by an average 74% in the elderly and 84% in the risk groups. Vaccination data have been included. Uh all people who have received at least one dose of corner virus vaccine. A new international prospective cohort study about COVID 19 vaccination. Modeling for safe surgery, say to save lives was published now in February 2021. Uh The aim of this study was to inform vaccination prioritization by modeling the impact of vaccination on mortality in patient's undergoing any type of inpatient elective surgery. The primary outcome was the number needed to vaccinate and envy to prevent one COVID 90 related death in one year. Assuming that surgical patient's would receive the vaccination before operation N MVS were more favorable in surgical patient's than in general population. The most favorable NVS were inpatient, 8, 70 years or more needing cancer surgery or not cancer surgery both exceeded the envies in the general population. And then these four surgical patient remained vulnerable at the range of COVID 19 incidence rates. Insensitively, anna loses modeling. Globally, prioritizing pre operative vaccination of patient's needing elective surgery ahead of the general population could prevent at least uh additional almost 60,000 COVID 19 related deaths in one year. So patient's needing elective surgery should be prioritized ahead of the general population. I think it looks like that we are on the right path in Finland vaccinations has started from the old ones and risk groups. Uh We heard that COVID 19 vaccination, uh it's best to get at least one week before surgery if that is not possible. The COVID 19 vaccination is best to take at least one week after elective operation because of the possibility of side effects. However, vaccination is not the barrier for emergency operation operation during COVID 19 infection causes senior countries of death or lung damage. Elective operations should be postponed at least seven weeks from the first positive COVID 19 result, test result or wait so long that the symptoms have disappeared. So far, the vaccination has not changed our life in hospital. And you know, our we have to continue to avoid close contacts, maintained with hand and coughing hygiene and use mask. Try to limit the number of persons in the same room when having bunch etcetera. At the moment, we are trying to get ready to move on uh to a new building, a new wing of Turku University Hospital which you see in a picture will be the only hospital in the Nordic countries to be built above railway tracks based on the public naming competition. The name of the new hospital is Mucus Iraola, the Lighthouse Hospital. Therefore, different ors are going to unite and form a large one and we have now less than one year time to wait for the move and thank you for your attention. Thank you very much Janan in Christie. Uh Next speaker will be uh Professor Corinne Bones. Uh Professor Bones is a surgeon in uh Paris and also member of the General Assembly of the International Association for Ambulatory Surgery. Please screen uh Mr Presidente. Dear more directors. Do your collects and friends for um letter surgery. It was a very hard question that there was asked to me and I did my best to answer hit surgery was directly impacted by the COVID pandemic depending on the country, ambulatory surgery. What must consult surgery during the pandemic in order to transfer person? It's there will be a hug backlog of and inversion to be clear at the end of the dynamic. So what strategy we're considered under what role was given to the increased of ambulatory surgery activity particularly for mature Proscar. So uh uh look to all data from the church. Er and uh I collect the old studi and then I will present you for the the evolution of the petition bad plugs. Uh In front, we have an estimation from the French Hospital Federation which is uh for public hospital. And uh well then, uh during the COVID 2300 million hospital stay, uh were not carried out uh for uh the surgery. Um it was a decrease of 900 thousands compared to 2019 and the most. Well, during the first week and clustering the wagon and between the two waves for ambulatory surgery, there were 500,000 fever stays. And so, uh how is the same? The ambulatory surgery was uh very impact by canceling that cancellation during the first week, but less afterwards. Uh but we are now in the third where and it has been canceled again here. You can see the decrease of uh surgery uh in traditional hospitalization with degrees is uh five and 8 50%. But there uh for the surgery, uh ambulatory surgery, it's 80% uh dropped and I found one other paper but in that means that open from, from Greg Virgin, but it's what's in the uh news, uh the uh reform think tank, uh, said that waiting list for hospital treatment could be more than doubled by Apria and hit a 10 million in England. However, Chris Opsin, uh, Jeff Executive of NHS providers say that, uh, there was yes, a significant problem but, uh, not so much. Uh, they already made a similar Mettetal logic that the, it previously said it would hit 10 millions by December last year, but that there were currently only, uh, 5.5 million. So it's uh let's, but it's still uh so what side uh model ization of resuming their surgery? Uh I found five form from model ization. One from uh you ca uh about only carotids and doctorate, doctorate to me. Um the construct range of scenario and 40 74 cases per week where uh necessary. And uh for the total, it was 7000 700 patient that will require courage in and atherectomy in the two years for the following the startup station of surgery. But uh if uh surgical capacity immediately recruiter to the pre COVID capacity of uh 74 cases a week, therefore, the least remain constant and uh was of 962 case after the uh resumption of surgical service. Uh The message was that there were no reduction in the between the list. Uh So the there were not to addiction in the waiting list. Uh And even if the surgical capacity was doubled after one month, it was in track of a C month to clear the waiting list. And so 31% of patient will know under got surgery within the two weeks started and 11% will wait more than 12 weeks for surgery resisting in about 100 to 350 additional strokes. So it's a really uh big problem. Um I found out of the model coming from Candida, um, admitted to the administrative was used and they tried to calculate the size of the back block for surgery and the time clearance for uh 10% scenario. And there're, is, it was, except that the uh estimated block for, for four months of uh, interruption was, uh, one, under that 50,000 surgery and average weekly increase is on 11,000 surgery. That was estimated Black Luck Clarence time was 21 months. Uh, with this estimated work throughput requiring seven and grade 19 operating rooms, 250 under 65 watt beds and so much I see you that, that week, um, there conclusion what the, uh, the magnitude of this impact was unprecedented and uh, that the health system surgical trigger could not get back to business as usual and they should employ, employ innovative system, that solution, but they did not describe it. Uh There is a last, uh, third model of coming from us a for cardiac surgery and they are also alarming. Uh I think that uh, if only the prep clinic capacity is is available. Bad luck will never clear. So, the purpose Tribe Trish in, we're coming from floor paper, American College of Surgeons with not emotion of uh ambulatory surgery. Um ought appendix. We are mentioned revision of uh length of uh little state and but no direct mention of uh ambulatory uh surgery again, orthopedic surgery. Uh That's Targhee was in Enron's recovery after surgery. I'm trying to proactively pasta proactively. But again, no mention of uh ambulatory surgery. I found this uh Canadian uh talking about just uh um resuming the surgical back block. And uh is uh proposition was to get help from, from the liberal Tron decal professional and uh to a lower additional at our operative room shift in the evening or the weekend. Uh no mention of an ambulatory solution. So, is there any paper talking about our meritage surgery? Yes, but I'm not really coming from uh medical staff. One is from uh the hardwood business surgery um to resume the backlog. Uh They then they the 45 strategy tips. It just say that we should expand surgical capacity by transitioning to al patient care. Has this letter to produce uh paper about modernization. And uh it's uh two anesthesiologist and uh one ought to pick and one scientific as you said, we, we uh it's true. It's a modular surgery. They say that we need to hospital, to need to pivot to toward outpatient total join altruistic and the third, what, what coming from consultants from Avenza, uh there were six presents to be optimised during and after COVID uh for the military surgery centers. And uh uh they think that COVID will uh continue to push procedure too. Ambulatory surgery center question will seek out ambulatory surgery center for safety and cost saving and the ambulatory surgery center can easily expand capacity. So at the conclusion, I could say that all the models have demonstrated but resuming the bad block in surgery is going to be very difficult, almost for firm impossible using similar clinical packs where capacity for surgical care. So strategy mentioned the need to increase the capacity of to park in theater works and staff dosing required people to increase daily walking out and the walking day paid per week. But for most of them, if only the pre pandemic capacities ever would probably never clear. And in most paper, there was no motion of uh ambulatory surgery. Uh So uh the massive transferred to um battery surgery was however mentioned in fewer by fugitive uh three paper and uh one's about total joint a tra proces or it's a module surgery. Yeah, so it leaks, it looks like a missed opportunity. However, I think that currently no country is really on the postcode post post COVID state. There there are no true report on resuming the back blogging surgery. Everything is still possible. Thank you for your attention. Thank you, Professor Corinne. Very interesting. Presentations. And I'm sure these, these very relevant issues will cause an impact on our all our national societies that uh care for ambulatory surgery and want the best for ambulatory surgery patient's. I'm sure we will go to get to some consensus statement issuing that those same worries that you have will be the concerns of many other associations in the world. And I think it was very useful to hear you. Our next topic is postdischarge monitoring for ambulatory surgery, uh ambulatory surgery, patient's and benchmarking of outcomes. Our speaker is Professor Eric Glytone Ius. He's an anesthesiologist is a visiting, he was a visiting assistant professor at the University of California between 22 14 and 2017 and he's the Chief, chief medical Officer of the largest private provider of operating room staff in Finland, Eric. Hello everyone. My name is Eric Let Tony's. I'm currently the Chief of Trawl Man Aesthesia at Helsinki University Hospital in Finland. And I'm here today to talk to you about postdischarge monitoring and benchmarking from the ambulatory surgery perspective. I have no disclosures for this talk to shortly go through what I'm going to talk to you about today. I will start with a helicopter view of what is a very big topic that is auditing and benchmarking your performance. Then I'll segue into the topic of postdischarge monitoring. This is an important component of a high quality ambulatory surgery service. I'll end the talk with a short discussion or what to do if you're patient gets COVID after surgery. Okay. So let's take a look at auditing and benchmarking. First, you can measure all kinds of things regarding your performance. But I'd roughly divide these into four categories. You have measures of productivity. For example, on time starts or room turnover times your measures of safety. For example, unplanned post operative hospital admissions or visits to the emergency department for complications. You can also look at important concepts such as patient and the provider satisfaction. When choosing what to measure. It's important to keep in mind that you need data that you can make decisions on. It should be easy to collect in a timely fashion while remaining accurate. The result of your analysis should be easy to interpret. You should only measure things you can affect and what you measure and you're set objectives should be aligned with your goals. If you only compare your current performance to your own previous performance, you have no way of knowing whether you're actually better or worse than everyone else. And this is where benchmarking comes in. Benchmark it against your peers will help you set reasonable goals for improvement. Let's say you measure room on time starts and currently 20% of your rooms have a start delay over 15 minutes on average. Is this good or bad? Last year? 30% of your rooms were delayed this badly. So you've improved, right? But then you find out the benchmark is only 2% of rooms have a delay over 15 minutes. So you realize you still have a lot to improve when benchmarking. You do need to remember your comparisons need to be valid. Especially on an international level. There will be significant differences in healthcare systems that will affect your results. For instance, if you wanted to compare costs per hour of or time, you will get totally different results in the US and Finland do two different salary levels. As many as I mentioned earlier, you do need to be careful about what you measure metrics should be aligned with your larger goals. And you should also be aware the metrics make maybe contrary to one another. Let's say you only measure efficiency and managed to streamline all your processes. But this means you end up rushing the patient in the dor with no time to answer questions or take care of specific needs. You end up reducing both patient satisfaction and safety in the process. So you should always measure performance from many different perspectives and said metric goals at levels were effectively a reasonable balance between aspects of patient's care. Also, remember especially when basing conversational performance that any metric can be gamed. The moment you choose to manage by metric, you invite your providers to gain it. Next, let's take a closer look at postdischarge monitoring the patient's recovery after surgery can be divided into three stages. Stage one is when you wake up and recovery your vital reflexes. This typically happens in the pack you which continues monitoring of vital signs with nursing staff and anesthesiologist immediately available. Once you're stable, you can go to stage two, which in our ambulatory center is a lounge area with coffee chairs and drinks and snacks available with the nurse on hand to help patients' with issues like nausea, pain. During their stage two, recovery, patient's get discharged instructions and when ready they're discharged home accompanied by an adult. Stage three occurs at home. That means the patient fully recovers and is able to assume all of their regular activities depending on the surgery. This can even take several months up two years and what can happen after the patient goes home and before they're fully recovered. Of course, every procedure has a specific spectrum of complications procedures and anaesthetic techniques suitable, suitable for ambulatory surgery in general, carry a low risk of significant complications. But before discharge, any sign of complications have to be reviewed and either treated until a resolution, patient gets submitted to a hospital or you give them instructions for how to take care of themselves at home. Now, before the patient leaves the hospital, they should receive both verbal and written instructions on what to expect and how and when to seek help, there should be 24 hour coverage of post surgical complications to ensure the patient receives prompt assistance regardless of when these complications occur. And to facilitate this, the surgical anesthetic notes should be available to all involved parties before the end of the day. It's recommended that all patients receive a 24 hour follow up phone call the day following surgery. In addition to detecting complications is also a good opportunity to make sure the patient's have understood their follow up instructions. Issues around patient satisfaction can also be discussed. Uh In addition, many centers send the patient's a separate survey concerning patient satisfaction. But I find that the 24 hour follow up phone call is a good opportunity to get more detailed feedback. No, let's go into the specific problem of post operative COVID. There are only a few studies on this subject and I'll try to summarize a couple of them for you and give you my impression of what conclusions you can draw from the literature. Probably the first and scariest paper you're going to run into when you start researching. This is this large retrospective study published in the Lancet last spring. The COVID search collaborative report a extremely high mortality rate in patient's testing positive for COVID either right before or within a month after surgery. Now, unfortunately, from the ambulatory surgery perspective, the analysis in this paper doesn't really group the patient's into an ambulatory subgroup, but based on what they report, I've tried to sort of extrapolate what the ambulatory group might look like. In general. Amateur patient's tend to be younger or at least healthier and procedures are typically miners, intermediate in invasiveness and elective. So as you can see from this figure, patient's younger than 70 having minor to intermediate elective surgery had a much lower mortality than the 24% reported for the entire cohort and much lower mortality. They have their age cut off for 70 years. But I'm sure that if they divided into smaller subgroups, they would see even lower mortality in these groups. There's some second paper published in BMJ Quality and safety. I'd say some perhaps closer to, to the amateur situation. This is a patient also patient cohort from last spring and this cohort were patient's having upper extremity surgery at the peak of the British British epidemic at that point. And as you can see from even this some large cohort over over 1000 patient's only 19 confirmed COVID cases of which one of the patient's died from COVID pneumonia to be noticed, they, they go into more detail about the patient that died and uh say that this patient had baseline comorbidities bad enough for the patient to be precluded from critical care. So they're passing from, from COVID doesn't seem so surprising to me at least. So when judging the data, we should keep in mind that what's currently published stems from the situation we had last spring and back then, we didn't really know how to treat COVID patient's. And um now that we, we have better schemes in place our results have improved significantly. Also when the cohorts for these, these papers were gathered, testing was fairly limited and concentrated to the more severely symptomatic patient's. So this probably lead to an overestimation of the mortality rate as asymptomatic carriers and patient's with only mild symptoms were left out of the denominator when calculating the mortality rate. However, it has been theorized. Um, and in my opinion, reasonably that surgery and uh, proinflammatory state following might make the patient's susceptible to having more severe COVID symptoms and also the reduced mobility often following surgery. In combination with the pro thrombotic state induced by COVID will probably raise the patient's risk of embolic events. So, based on the limited evidence and experience, we have my best suggestion is that uh these patient's contracting COVID postoperatively should probably be closely followed. I'm wouldn't admit everyone to the hospital, but I would definitely give them clear instructions to seek help if any symptoms of more severe COVID develop. Also when feasible. I would uh consider a higher than normal uh dose of trauma, pro flexes with the loan liquor with heparin or even starting thromboprophylaxis in patient's typically not having trouble prophylaxis. But this of course, depends on the surgery, your institutional guidelines and so on. I'll conclude my talk by stating that I think this exceptional year has shown us that a well run a sc is both safe and efficient even during the pandemic. Thank you very much for your attention. Yeah, I think, I think Korean was very um pragmatic when she said we had a missed opportunity. I would like to ask you, Corinne, who do you think was responsible for this? And what do you think that we could do to change that, please? Um uh The responsibility is on earth. It's just because we are going on COVID and don't look after COVID in uh early and uh we should really uh read the paper too. Yeah, to explain the image, the urgency of the fact of this backlog. It's uh in France. Uh authorities think that uh it's not so bad because maybe we operate on uh some pathology that they don't need to. And I think that they will uh you, you mean do a treat that separate real thing needed charity, think not needing charity. That's what they think. And if we don't elect them about uh the number of people we are, but nobody is counting how many people are to be operative now. For important bedding disease are important cancer. There is no real uh very much estimation of the, the volume of the backlog. And as you see, I see some allusion to ambulatory surgery only from the consultant or uh not medical people. I think Roger in the cavity. Do you think our National Associations or even the International Association for Ambulatory Surgery can have a role uh showing authorities that we can do better surgery and we can maybe solve not all but some of the problem by encouraging doctors to perform more ambulatory surgery. Yes. It, uh, need the, uh, editorial, uh, in a medical, uh, journal. Uh, I'm going to do a news later for France, but it's only after the work you asked me to do, I did not realize before. Okay. I've got, I'm glad to see that. We also lay the role, uh, giving you this topic and then can you probably cause the answer to the question about the question on adult? Thank you for uh evacuation. Uh But 20 can I come in there just for seconds with Corin? It's a, it's a topic which I've been texting on, on the chat line and uh we're suggesting that we should put out a statement from all the national associations with Iwas. And the question is how could we quickly get agreement with all the associations and how could we get our position statement publicized? I think we could all do it. But how can we get it in the right media format? I think that's the question but well done. Mhm. Has anyone got any ideas gratefully accepted? I have also found Eric uh let Tony's to invited him to come to the podium if you want to ask him a question. Uh is John Hayes house out of the podium? Yes, unfortunately, still having trouble with his microphone. We're buying him a new computer for Christmas. Okay. Well, let me, let me tell you how I think we could publicize this. The only way I think that we can publicize this is by having uh lobbies inside the National health systems. We should organize the lobby to work uh as a mole inside the health, national National Health System. And maybe that's the only way we can influence politicians to create uh laws uh create incentives for ambulatory surgeries. Because I think there is no other way than through financial incentives to get hospitals to produce more and more complex procedures in ambulatory surgery. Yeah, and I get that we clearly have got a crisis on our hands with every country having a backlog. But we all, what we have to publicize is that the way out of this problem is to use ambulatory surgery, which we're all doing. But Corin in her studies has demonstrated that it's not happening. And I don't think any of us realized just how much people are ignoring ambulatory surgery in the middle of this crisis. So that's the key point I think, and that has to be addressed. But I think we'll put an email round to everybody after this conference related to this fact. And I think maybe I'd like to get a position statement that all the national associations agree to. Perhaps. Now, at least we can put it out website if nothing else. And if anyone has got any other thoughts apart from that and how we can publicize that I'd be very grateful. Sorry to take some time but well done. Thank you. Mhm. Well, I have to say that in a spain is not the situation. So personally, there is a uh recognizing of uh the Ministry of Health, even the Spanish Association for uh Spanish Association uh surgeons for the role of uh ambulatory surgery in the pandemia, even in the post pandemic era. Yes. And I think there is an enhancement of the, of the ambulatory surgery promoted by the Ministry of Health. This is very surprising for me because it's the first time they do that, but they do. Okay. Let me thank to all the presenters and let me thank you. It'll go for co chairing this session with me. I must call now the next speaker. But before before that, I would like to present uh Carlos Meghalaya ish. I don't know if he is already on board with us. Uh Carlos Meghalaya is, is the elected presidente of IAS. You will shortly play a key role on the, on the issue that we were just talking about. We will have to, to seek for a way to, to make ambulatory surgery more visible for managers and politicians as a strategic partner to getting out of the COVID uh pandemic. And for that, I think we need uh different strategies. Of course, we need to get out of the box. We need to think differently and we need to go further on how we think about ambulatory surgery. And this is the topic of our next uh presentation that we will be led by Professor Gerry Shashi. I don't know if we have Carlos Magallanes onboard Ian. Do we have cargo seen? I think he's joining us. I've, I've clicked him to come to the panel, so I'm hoping that he will be joining us shortly. Okay, then I will be presenting uh Professor Gerry Shashi is the professor in the Department of Anesthesiology at the University of Texas Southwestern Medical Center, is the edit er of anesthesia and analgesia and also on up to date uh magazines is the past presidente of Samba and has been the distinguished with the Price for service. Uh Sorry, he has received the distinguished service award winner. He was distinguished service award winner in 2018. So let's see what uh Professor Gerry Shasha has to tell us about out of the box ambulatory century. Thank you. I will like play that now and I will try and get Carlos onto the podium. My name is Chris Joshi. I'm a professor of anesthesiology and Pain management at the University of Texas Southwestern Medical Center in Dallas Texas. I want to thank the meeting planners for inviting me to speak. These are my disclosures I received on the radio from Baxter and Pass era from circles in the US. Uh Approximately 60 to 65% of all surgical procedures are performed on an outpatient basis. Implementation of a national curry after surgery pathways has further facilitated migration of complex surgical procedures in high risk patient population from the inpatient to the outpatient setting day surgery has been associated with lower cost and improved outcomes. Even in these high risk patients' undergoing complex surgical procedures. Nevertheless, patient selection is critical for maintaining safety after ambulatory surgery. In appropriate patient selection can increase perioperative mobility can delay discharge home and does reduce the military surgery facilities efficiency as well as increase emergency room visits and hospitalization after surgery and increase unplanned readmission rates. These could further increase the cost associated with ambulatory surgery. Overall, it could decrease patient and family dis uh satisfaction. Yeah, patient selection is a complex and dynamic process which involves consideration of the type of surgical procedure. Patient characteristics, the proposed anesthetic technique, the type of surgical facility, as well as social considerations such as availability of a caregiver at home. Example of such complexity is a patient whose under scheduled to undergo cataract surgery on the topical or local anesthesia can be of a higher S a physical status even S A four and can undergo this procedure in a freestanding ambulatory surgery center. In contrast, a patient undergoing cavi surgery or a major uh such a good procedure should have their co morbid conditions stabilized and the procedure may be better performed in a hospital based facility. What I'm going to discuss our, the calm, different complex aspects to patient selection. It starts with prestigious considerations. The procedure appropriate for ambulatory surgery should have a low risk for severe periodic blood loss and need for blood transfusion. Also, postdischarge pain should be easily controlled with oral medications. There should be no need for intensive or prolonged process, operative care, hour duration of procedure remains controversial. There is no good data to allow us to determine the optimal duration or the car off duration for ambulatory surgical procedures. Nevertheless, it is most common to use a six our car off for the duration of surgery. It has also been shown that surgeon's expertise influences period active outcome. So a surgeon performing a procedure in ambulatory surgery center should have good ex expertise with low complication rate in the hospitals facility before they start operating in an ambulatory surgical facility. As far as patient characters are concerned, there are several factors that can influence patient selection. What I'm going to discuss our the controversial patient characteristics in the interest of time. Age is one of the biggest controversy for patient selection. Typically, it's been suggested that elderly population, patient's who are older than 80 should not undergo a surgical procedure in an ambulatory setting. However, more recent data suggests that age should not be used for patient selection or there should be no car off age for selection of the patient for ambulatory surgery. In fact, all the patient's benefit from ambulatory surgery and may have improved outcomes because they're recovering in a more familiar environment However, in this patient population, post discharge discharge issues need to be considered, there needs to be good supervision at home or particularly if the patient's have older and debilitated partners. Also, it is suggested that patient function or frailty should be considered, not just the age frailty has been associated with increased periodically of mobility, which is independent of age, the ancestor type and co morbid co mobilities. In fact, combining S A physical status with the frailty scoring system improves the sensitivity and specificity of the ace A physical status as well as A C physical status is concerned. Although it is subjective, it is a valid indicator of overall patient health. It suggested that patient's with controlled stable coexisting medical conditions are suitable for ambulatory searching. These are typically patient's with acid physical status of three or less and patient's with physical status of four are usually not suitable for ambulatory surgery. The essay has recommended specific patient characteristics that would define an ace a fiscal status for these are patient with recent that is less than three months of MITIRCV A or patient with significant cornea trick disease and stents. Patient's with ongoing cardiac ischemia, severe valve dysfunction and civilian reduced ejection fraction as well as patient's with end stage renal disease who are not undergoing regular dialysis as far as obesity and sleep apnea's concern the society for a military anesthesia. Samba several years ago, developed guidelines are recommendations for patient selection in the obese population as well as the sleep apnea population. These were further corroborated by the society for an season sleep medicine. More recently, there's data which confirms that the recommendation by Samba and SSM are still valid. A recent study in patient's undergoing joint are arthroscopy showed that age BM I alone is does not influence 30 day readmission rates. However, patient's with BM I of more than 50 had increased odds of same day hospital admission, even with optimized comorbid conditions. Another study which looked at the American College of Surgeons New Script database in patient's and going open hernia repair also found that BM I alone should not be used as a car off. And in fact, 24 hour readmission rate was influenced more by the S A physical status, patient's functional status age and the duration of surgery. Overall. The general principles for patient selection with regards to obesity and sleep apnea is that obesity and sleep apnea are a part of a spectrum of diseases such as hypertension atrial fibrillation or heart failure, COPD or diabetes and does obesity and sleep apnea per se does not influence outcomes. It is obesity and os a related comorbid conditions that influence outcome and therefore, obesity and sleep apnea should not be considered in isolations, but in relation with the severity of the associated comorbid conditions. Also, it has been emphasized that mild sleep apnea has a very low risk of uh periactin complications. It has been also emphasized that all patient's undergoing surgical procedures including ambulatory surgery should have screening done for presence of sleep apnea. The stop bank criteria or stop bank questionnaire has been recommended for screening of OS A. However, in contrast to what was suggested by the original study published by Frances Cheung of three or more positive responses to be considered as a risk of Os A Samba as well as society for anesthesia in sleep medicine has recommended that a cut off of five should be used as for diagnosis of possible risk of OS A. And that's based on correlation of a score of five or more with moderate to severe sleep apnea. This is an algorithm which I've developed based on the Samba guidelines. All patients' undergoing ambulatory surgery should have their co morbid conditions optimized. We then divide the patient's to three broad groups. Those with the PMI of less than 40 in this patient population. There's no further need for any testing and the patient's can proceed for surgery. Patient's who have a bmir 50 are typically not suitable for ambulatory surgery or caution needs to be taken before scheduling surgical procedure on an outpatient basis for patient's who have a PMI between 40 50 they need to be uh considered for sleep apnea. And we can further divide this patient population into non sleep apnea versus presume sleep apnea. Those patient's who have known sleep apnea and that means they've had a sleep study done. So typically, they would be prescribed a CPAP machine. If this patient are able to use CPAP after discharge, they may proceed for ambulatory surgery. With regards to patient's who could not use CPAP after surgery or refused to use CPAP after surgery, they would then be put into the so called presumptive sleep apnea group where the diagnosis of sleep apnea is made on screening such as the stop bank criteria. In this patient population, POSTOP opioid use needs to be considered. If the POSTOP opioid use can be limited, then this patient may undergo surgical procedure on an outpatient basis. Let me give you an example if a patient who's scheduled for ambulatory ACL repair, which is well known to be fairly painful and require significant opioid doses. If regional sees has not used in this patient population, if the patient refuses regional anesthesia, then the OPI a requirement would be higher and thus this patient may not be suitable for ambulatory surgery. The same guidelines was silent with regards to patient selection for area surgery because at that time, there was not much data to provide any recommendations. However, recently a consensus recommendation from E ent surgeons suggested that ambulatory surgery may be appropriate for nasal surgery for minimally invasive palate or tongues based surgery or hipaa glossal nerve stimulation. In contrast, overnight stay is recommended for patient's ongoing invasive palatal surgery unless it's determined appropriate by the surgeon and the anesthesiologist together also invasive lower forenza surgery such as midland glass ectomy, genio glasses, admire and advancement, etcetera are not suitable for ambulatory surgery. Also, maxillofacial surgery is not suitable for ambulatory surgery. We recently performed analysis of the American College of Surgeons New script database which had the 3200 patient's undergoing area surgery for OS A. Between 2011 and 2017 of these 3200 patient's 32% we're outpatients and 67% were in patience envelope. Palatoplasty was performed in 96% of the patient's and was typically combined with either nasal surgery and our base of tongue surgery. Not surprisingly in patient's were older and had her calm. A big burden also had higher BM I and multilevel surgical procedures. When we looked at the composite of readmission rate, re operation and complication rates, they were similar in the in patient population and the out patient population before they did a so called propensity matching where a patient who had undergone an outpatient procedure was matched with the inpatient procedure. These patient's were matched for every aspect including the patient characteristics, their overall health except for the surgical setting, that means inpatient versus outpatient. And we found that after matching the composite outcome was similar in the two patient population or the two settings, the inpatient and outpatient setting 30 day readmission rate as well as the operation rate was also similar between the two groups. We found that the acid physical status of more than three and tongue based surgery. We're associated with higher 30 day readmission rates while diabetes and increased operating times were associated with higher complication rates. We also found that 42% of impatience that was almost 50% of in patient's had similar characteristics as outpatients. In other words, these patient's could have safely undergone the procedure on an outpatient basis. The take home a message from this analysis is that ambulatory surgery in patience with sleep apnea, undergoing area surgery is safe. Assuming that patient selection is done appropriately, that means the patient's come up with conditions adequately treated and the duration of surgery is limited, multiple surgical procedures are not performed and the patient's who had the tongue based surgery had the worst outcome or readmission rates. And so that should be avoided for the work obviously is needed. But we have now some guidance with regards to selection of patient's with sleep apnea, undergoing ambulatory surgery. As far as cardiac status is considered a patient with cardiacs core mobilities. It's well described that ambulatory surgery is not suitable for patient's who are a safe for that. That is, these are patient's who have less than 30 days of acute M I decompensated or new onset or untreated heart failure patient who are symptomatic with low left ventricle ejection fraction, new onset atrial fibrillation or severe valuable disease. These are all so called A PSA for patient's. There is a so called risk calculator which is available on this website, which can be used to calculate appropriate risk and patient selection. What I've done here is given an example, let's have patient's patient who's 65 years old with the a safe physical status of three and the normal creatinine level and a normal functional status is a scheduled for hernia surgery on an art patient basis. Based on this risk calculator, the possibility of this patient having POSTOP cardiac complication is less than 1%. And does this patient is suitable for ambulatory searching? I also want to emphasize that surgical procedure should not be postponed solely based on system systemic BP values. The only time one could should delay surgery in patient with hypertension, particularly patient's with diastolic BP. More than 1 10 is if they have acute an organ damage with symptoms, that is they have malignant hypertension with symptoms. Another complex patient population that is increasingly being scheduled for ambulatory surgery. Our patient's with implantable cardio defibrillators or icds. This is the algorithm which have to develop based on the publication or consensus recommendation published in the heart rhythm and it's basically by the Heart Society Rhythm Society. The essay has an advisory recently published on the same topic. First, we need to confirm if the EMR electromagnetic interference is likely if it's not likely, then one can proceed with surgery in the patient with ICD or any other cardiac electronic implantable device. If Emma is likely if the procedure is below the umbilicus, 1 may proceed with the surgical procedure an outpatient basis. If the surgical procedure is about the umbilicus, that we need to determine if the patient's pacemaker dependent. If the patient's pacemaker dependent, then it's necessary to reprogram the ICD prior to surgical procedure. If the patient is not pacemaker dependent, 1 may use a magnet to deactivate the defibrillator are function prior to searching. The most important part is to minimize em I and that can be achieved by placing the grounding pad which is the plate as close to a surgical procedure site as possible. And to use monopoly Doctor Me if possible, another complex surgical population. Uh the patient's with Coronary stents. Recently, the American Heart Association and the American College of Cardiology came up with recommendations for newer generation coronary stents. They recommend that patient's with a bare metal stent should not undergo an elective surgical procedure within 30 days. Patient's with newer drug eluding stent should not go undergo electrosurgical procedure within six months. And those with older drug eluding stents should not undergo such electrosurgical procedure within 12 months. And that is because these are the durations for dual anti platelet therapy that have been recommended. Once the dual anti platelet therapy has been discontinued, patient's may proceed for elective surgical procedures including ambulatory surgery. However, certain surgical procedures such as Catterick surgery under topical anesthesia may be performed even while the patient is on dual anti platelet therapy. And therefore, in this patient population for cataract surgery, ambulatory surgery can be performed within after 30 days of PCI or placement of coronary stents as far as other comorbid conditions are concerned. For example, patient with COPD, it's prudent exclude patient's who have severe disease. Also those with mild tomorrow disease, it would be prudent to optimise bronchodilator therapy, treat patient's respiratory infection of present and encourage patient to stop smoking. As far as diabetes is concerned, it would be appropriate to exclude patient's who have unstable metabolic conditions such as diabetic ketoacidosis of non kit arctic states. Also, it's recommended and there's a Samba guideline for this, that patient's who have diabetes should continue anti diabetic oral medications as appropriate and resume oral intake as a hypoglycemic regiment as soon as possible. After surgery, with regards to patient with end stage renal disease, they should be excluded from ambulatory surgery if they are not on dialysis. However, if they are on dialysis, then it's still necessary to optimize the coma with conditions accepting that they may be anemic and may have hypochelemia, which is a symptomatic patient with ti a stroke, surgery should be delayed for at least three months after T I or stroke. Also, in this patient population, there's a need to manage anti platelet therapy. Another controversial patient population is patient with them. Itch patient with malignant hypothermia susceptibility may safely undergo ambulatory surgery using non triggering anesthetic. However, it's important that the anesthesia workstation is appropriately prepared. These are recommendations from Samba and the A C Ambulatory Surgical Care Committee published in 2019. These recommendations also emphasize that preoperative controlling proof Lexus is not indicated. However, Dantrolene should be available within 10 minutes in case necessary. Also, it's been recommended that point of care, blood gas analysis is not necessary as well as extended post optical observation is not necessary in this patient population. Nevertheless, there should be transfer arrangements between the ambulatory surgery center in the hospital in case of occurrence of image in this patient population. Just a couple of months ago, a consensus guidelines was published from the European malignant hypothermia group which basically went along with the Samba and the A C recommendations. This group also suggested that image population or image susceptible patient may be anesthetized in an outpatient setting. Prophylaxes with controlling is not necessary and use of trigger free. And Caesar's is mandatory preop management, interrupt monitoring and recovery PSU care should not be unaltered. In other words, the care period optic care should be the same as any other patient and specific pre op and post our blood tests are not necessary. This document goes into details of ancestor workstation preparation which is critical in this patient population. Overall, the European malignant hypothermia group confirms the recommendations from Samba and the S and Military Surgical Care Committee. I also want to emphasize that recently there've been attempts to look at different surgical procedures and patient comorbidities and develop a grading or a score ing system. This recent paper looked at large databases both in academic settings as well as private practice settings and confirmed previous studies that the comorbid conditions that are associated with high unplanned admission rates after ambulatory surgery include COPD, heart failure, diabetes, chronic renal failure, liver disease, perfect vascular disease, anemia, drug abuse and depression. Interestingly enough patient's undergoing surgical procedure or procedures outside the are such as ERCP Bronco stents had a higher incidence of readmission. These surgical procedures were typically performed in a hospital based uh setting rather than a freestanding ambulatory surgery settings. The authors developed a score ing system that obviously needs validation but can give some guidance as to the type of procedure and the patient population that could be scheduled for ambulatory surgery. We wrote an editorial to go along with this article again, discussing the limitations of the study as well as how the information from the study could be used to guide appropriate patient selection. I would like to emphasize that the best approach for safe patient selection for ambulatory surgery is to develop procedure specific clinical recommendations or clinical pathways such as attempted by these authors for shoulder arthroplasty or Tyrod ectomy. These procedures specific clinical pathways allow us to safely determine the appropriate patient selection. And does there are no controversies or challenges on the day of surgery between the surgeon and the anesthesiologist? No conflicts. And so patient safety's mention. Maintained to summarize patient selection is complex and dynamic process. The first step in determining appropriate patient selection includes preoperative identification and optimization of comorbid conditions, then developing and implementing clinical pathways. And finally, one needs to keep asking the question, why is this patient in the hospital and his hospitalization? Really going to improve outcome? Thank you for your attention. Well, thank you very much. Uh all the speakers uh for their work uh and very, very enlightening uh facts about how we have dealt with the pandemic in different countries. Uh I definitely agree uh with the sentiment, some readings with the chat regarding uh ambulatory surgery and uh at least in some countries truly being underutilized. Well, we just heard from Girish again. Very interesting. Uh No, we both practice in the States but certainly we, that those boundaries that are perceived and that's really what it is. There's more of a perception of the reality uh can be overcome. So, Gary, I don't know if we have you on camera or not, but we're not seeing you, but hopefully we'll have you. I lived on audio. Uh we can see you but we cannot hear you. Can you hear me? Yes. Okay. Thank you, honey. So, um I think one of the uh listening to cap uh for you, Garish has to do with maybe a clarification uh when you were talking about uh always a and obesity and comorbidities, maybe I, I understood it correctly. But I believe you mentioned that they were not independent variables for worse outcomes after surgery. It was the common abilities if you could just go over that pelvic. Great. Okay. Thank you for the question. And yes. Uh more and more data, I have now shown that sleep apnea per se and weight of the patient per se actually have no relation with POSTOP outcomes are bad outcomes after ambulatory surgery, I have to be very specific. It is after ambulatory surgery, including the more uh intensive surgical procedures. Uh And it is the comorbid conditions that influence post up outcomes. Chest readmission rates are admission on the same day we er, visits, etcetera. Um So one can I can fairly confidently say that uh it is not the weight of the patient or the sleep apnea status of the patient. Obviously, there are limitations in a busy free, a military uh freestanding ambulatory setting where we should know that the beds, the our tables may not take a certain weight and the face that uh in day to day practice or these patient's may have difficult IV starts so that may delay uh efficiency or uh those kind of aspects. So it's more of a administrative aspects rather than the patient characteristic per se that should be considered. And Girish, let me, let me ask you something because on the on the anesthesiologist perspective of things, sometimes we have the, the evidence that shows that one thing is safe that we, we, we work in places that don't have the, we work in facilities that don't have the material or the, or the drugs or the experience stuff. We need to deal with those so special patient's. And I think it's important as well to emphasize that you, you don't have to be blind to the, what the, the evidence tells you, you have to be aware of the conditions you work in. Absolutely yes. Um But I'm assuming that at least in the uh basic and military uh facility, there are abilities to say uh address difficult airway uh which could be a problem in the s a patient but not in in the obese population um as well as well as address uh problems in the family room suggest potential hypoxia or, or desaturation. But I do want to emphasize that when you look at all these studies and I have really looked into details of large amount of studies and, and large amount of data, any study that just tells me that there is higher incidence of hypoxia in the sleep apnea population, obese population is trash. I just throw it away because we all know how to manage what I want to know. And that's why I feel these studies which are looked at are, are really, you know, clinically relevant. Is, was this hypoxia which occurs very commonly in this patient population population lead to did this hypoxic lead to any further difficult problems. So we look at the studies appropriately and, and obviously we need hands in the A sc um That's why I do not even address office based surgery because that's a whole different animal and that's not formally done in most of the other countries. It's the ambulatory surgery center where you have enough number of people, appropriate early management and appropriate management for POSTOP potential complications, mainly it's respiratory complications. Okay. Another question I would like to ask you is the role of telehealth in post operative situations of complex patient's. As those you mentioned, having for example, uh remote oximetry monitored with help and the expand the scope of of intervention in OS A patient's, for example. So I have actually done a very small study where we sent patient's home with pulse ox is after uh OS a patient's patient's with OS A uh diagnosed based on stop bank criteria. We send the patient's home, we monitored their POSTOP pulse ox and it was all basically recorded and then post operatively, we downloaded the data. And sure enough, there were significant hypoxic episodes in this patient population. What we learned from this is appropriate patient education and our Samba guidelines in fact, had those. And my study was based on to look at the Samba guidelines that was published in 2012. Um Just to confirm and what we realized is telling the patient that if they're just even sitting in a chair, postoperatively, they make those off and therefore it's critical that they, they are aware of that and, and that somebody is looking after them also, if they are going to sleep, propped them up themselves up a little bit. So patient education is very critical having somebody at home not being alone. Um So if you look at our Samba guidelines, I won't go into details assuming there are other questions, but please have a look at the Samba guidelines. The patient education part is the most important for patient safety. Um So it is not our clinical management. It is basically the other stuff associated with patient care. Uh the efficiency of the A C patient education which really matters to improve safety. She can I make a question? Sure, please. Uh Sorry for not being on the beginning here. We have a very interesting talk on the shot. And my question is this one, imagine that you are invited for to be the director or responsible for an international marketing promotional of a motorist surgery. What do you think we should focus this these um marketing campaign on surgeons and ethicists, nurses, patient's health managers or politicians who will do select first? Oh, first, I would select just one, just one. Yes, first. That's why I said surgeons obviously the best answer is all and that's why I ask er comes into play because they are basically encompassing all. Um but first surgeons, I tell you why, at least in our experience in the US experience. And I have been in Ireland, I vote there for five years. Um, um, is that the certain's are the ones who are scaling these patient's, uh, in the, um, military surgery setting. They're the ones who are trying to convince the patient it's appropriate to do, uh, do so. And, and that's why the first one should be the surgeon and after that everybody else, I totally agree with you. So, any more questions? You got to limit. Well, I, I do have a quick question. So you brought up the study about post of hypoxia uh garish uh in that even in that small, that mute and doug got muted as well. Dog can speak. No. Yeah. No. All right. OK. Anything else? Yeah, I've got your Irish. Okay. Go ahead. Duck. No, no, you go ahead. It's fine. You're more important than me. No, no, I couldn't hear Elonis question. Uh No, no, it, it all comes back to how we go forward. We're, we are struggling to get our message across as we discussed this afternoon and it's just an ongoing saga. And I was interested to see that you do identify the surgeon as key. But yes, and it is because we are the interface, the first interface with the patient and it is so critical for us to get it right. But the second most important is actually the pre assessment team and if they're on your side, then that's fine. And the third most important then is the anesthetist, be honest. So there's, there's my order, there's my pecking order. Does anyone want to put them in a different order? It's up to you. So, again, yeah, once you have, because Carlos put me on a spot, I have to say one but a best approach like anything else in life is a multi pronged approach. You know, uh I can tell you one thing about the US. Um uh there are 5500 ambulatory surgery centers in the US, of which majority of the centers, the director, medical director, our anesthesiologists and yes, they are key, but they're the ones who will talk to the surgeons and, and that kind of stuff. So multi pronged approach is best but given, you know, put in this part outset surgeons, uh that's, that's two different issues. The first issue is from the patient's point of view. The surgeon, number one is most important to convert. But running a system, the anesthetist has got the overview and they need to be in charge of the whole system, correct. And that's why. So once the surgeon can convince the patient and, and get the patient uh to the A sc we then take over and then we will have algorithms. That's what I've done at my place. We'll have algorithms because keep in mind in the US majority of the patient's coming in for a sec. Don't have the pre op done prior to surgery. They may get a phone call prior to surgery that, hey, you know, a quick talk about what their conditions are, but they're seen on the day of surgery. So, having a triaging system where, which patient's, it has become more and more curriculum now with COVID because at Rascs now we are doing, which was never happening before. Are doing these semi trauma. I'm in a trauma major trauma center and we have two freestanding ambulatory surgery centers away from the hospital. But we are doing these trauma patient's ankles fractures, etcetera, which we never did before in the A SC because of COVID. Um so triaging becomes very critical and that scoring system which I was presenting is what I am using right now. So we need to validate that scoring system. So I'm combining the score ing system which requires patient characteristics and procedure characteristics together. So, so I think that's what COVID has really taught us is that we are going to do these more complex patient's in the sc and actually we are going to be safer than the hospital, but we want the surgeons or whoever decides dissipation is going to have surgery in the A C and sees all just take over and we develop algorithms. That's why eras protocols are very much important uh here in the acs as well. OK. Everyone I think we have only 10 minutes left. So we'll allow another last question, Arnie and then we kind of know, you know what that means. But in reality, we don't have a formal definitional, low risk. More importantly, intermediate risk, we know of course, a thoracic aneurysm is going to be very different than upon you and which we know that it is that intermediate range. So I'm very glad to hear that there is a, some, some work going on in that area. Um The other question that I have for you have to do with uh a diabetics. Can you just rehash real quick about the management? Um I just wasn't sure how, what, what came across from that. Okay. So uh in 2010, Samba came up with guidelines for diabetic management. In fact, I'm proud to say that nice guidelines which was subsequently published in 2011 has identical. Literally, they stole our approach to the management of diabetic patients' where we recommend we look at preop the day before management day of management. And this was more specific to what which drugs should be continued or dis discontinued. And so we emphasize that Metformin should be continued. So optimal management of a diabetic patient basically is optimal management of the pre diabetic drugs. And if you do so you won't have problems on the day of surgery. We also addressed um uh patient's coming in with high blood sugar levels. So in interest of time, I would say uh you know, please review the 2010 Sama guidelines and I also want to emphasize that we are updating those. I'm in the process of updating those. Um And, and I'm so infused with COVID that ambulatory surgery will shine in, in the process and it will be the safest for all our patient's okay. Thank you to everyone, Yan and dig. I think it is time to finish. I think we are almost on the limit of our time, isn't it, Jan? So yes, please. So uh I would like to thank on behalf of myself and is for the presence of everyone. It is is spring meeting. This is a very hot topic and it was for sure, an excellent time to share experience and learn from each other from all over the world. I think that the presidente of is and uh my friends. Yeah, uh isn't and darn for this excellent organizations. It was really very, very good. As I said, it is very important that we discussed the different problems that we are facing in our different countries and we, the way we are trying to solve all these problems, the scientific quality of these meeting, for sure, at a great, great contribution for helping all of us to solve our old problems in our own hospitals. In my opinion, as some of you already said, uh this is a moment of great opportunity for the field of mandatory surgery. It will be a great challenge to all of us to respond to all the problems. We have to solve the main problems in the health area. Overcoming the waiting list, resolving delay starting new protocols, new ways of addressing infection disease, how to expand the surgical capacity of the hospitals, etcetera, etcetera. And I only see one way and the way is through the ambulatory surgery field. And I think we should all push to go this way. I think, I think all the delegates for the presence. I hope it was nice meeting my opinion. It was a very, very good one and I invite all of you to be with us on next Saturday on the 17 for the session of the best papers. We hope it will be possible to meet together in the near future and please keep safe and make it simple, as I always say, through inventory surgery, uh pathway. Thank you very much.