COVID-19 Physician Advisory Group

COVID-19 Physician Advisory Group

The ND Dept. of Health Physician Advisory Group (PAG) is diligently working on improving the COVID-19 systems throughout North Dakota. The group is chaired by Dr. Joan Connell.

JULY 16, 2020 - UPDATE

Summarized Minutes for 7-16-20 Physician Advisory Group

Long Term Care Facilities (LTCF)
Augusta Place Pilot: working to formulate data and are targeting to review the information next week. So far, testing has revealed no positive cases. See pilot program outline here.

Treatments
Vitamin D update: Dr. McLean will present available scientific data at LTCA meeting within next few weeks.
Remdesivir update: biweekly, the US Dept. of Health & Human Services (HHS) will contact ND to inform us on allocation of Remdesivir. NDDoH will then allocate to hospitals based on number of hospitalizations. The hospital will then get onto their Amerisource Bergen account to order and pay, then inventory will be sent directly to the hospital.

Allocations will begin with submitted data by 7/22 to expect allocation information within 2 weeks.

Inventory: approximately 50 liquid and 500 powder vials are in the state cache. The state will hold 10-20 percent of that in inventory, but will likely release the remaining supply. This is to assure inventory is available for hospitals in need. Trinity and Altru have been utilizing Remdesivir and inventory is running low and need to replenish supply.

Interim ND State Health Officer Dr. Stahl would like to expand Remdesivir access to as many hospitals as are willing to participate. This will require a change to the current policy regarding Remdesivir distribution criteria.

ND has been selected to have further interaction for data analysis with genomic sequencing to see how various strains respond to the drug through three clinical sites. Dr. Stahl will keep the group informed when more data is available.

Testing
See COVID-19 Diagnostic Testing Guidance here.

Elective surgeries: most require pre-op tests a few days in advance of elective surgery

Physician Advisory Group agrees that state and local public health need to work together to optimize their processes while optimizing service capabilities.

Emergent surgeries: everyone is using POINT OF CARE (POC) test.

Surveillance statistics: ND Health Information Network (HIN) - the lab is updating the system. The Physician Advisory Group recommends that processes be put in place so that specimens can be categorized as diagnostic, surveillance, or preoperative.

Messaging - Masks/Social Distancing
Videos have done a great job of spreading the word on social media

Dr. Stahl is requesting funds for implementing an awareness campaign on use of masks and social distancing

School Restart - Needs for Local Public Health Leaders
Lots of disparity in various schools’ approaches to policy.

School nurses say no guidance is available.

Green light for school sporting events now opens up new points of exposure.

Dr. Stahl said that two executive orders are being considered, ranging from local public health departments being completely decentralized versus everyone operating as NDDoH employees.

Dr. Stahl says students are asymptomatic spreaders and school will likely need to be shut down- at 2 weeks then need to reassess.

Vaccination Strategy
Dr. Stahl is working to increase vaccination in ND by limitations in philosophical and religious exemptions. In summary, those who contributed to discussion expressed much concern for current lack of guidance standard and lack of ability to formulate solid guidance on the local level due to limited expertise and time constraints. Dr. Stahl has advised that we will (continue to) make public health recommendations, which is (the limit of) our role in school restart, and other aspects of this pandemic.

Long Term Care Facility
Augusta Place will follow Phase 2 guidelines in conjunction with the current guidelines being followed as a Pilot Study for accelerated testing and visitation. The facility will continue to follow the parameters approved by North Dakota VP3 guidance, to allow increased resident/visitor engagement in a controlled environment.

  • Visits between a Resident and up to two visitors can take place at scheduled times, in resident rooms only, per the facility’s visitation appointment calendar.
    • Visitors will arrange for their own COVID-19 testing. All visitors must present written documentation to the facility of negative results within the past 7 days prior to visitation.
      • Visitors are limited to immediate family, i.e. spouse, children to include step-children, siblings and grandchildren 13 and over.
      • All visits must be scheduled and approved a day in advance of each visit.
  • All visitors will be screened per facility protocol prior to each visit.
  • Visitors must wear a face mask while in the facility. Residents must wear a face mask as tolerated (facility provided). Proper hand hygiene, (i.e. hand sanitizer) must be observed before each visit.
  • Facility staff will escort visitors to and from the resident’s room without contacting adjacent surfaces. Other areas within the facility may not be utilized or accessed by visitors.
  • If guidelines are not followed by the resident and/or visitor, the visit will be stopped and visitation rights revoked.
  • Entry of limited non-essential healthcare personnel, to include beauticians, will be allowed as determined necessary by the facility while exercising universal source control.
  • Communal dining will increase to normal capacity with tables spaced by six feet.
  • Non-medically necessary trips outside the building may be scheduled. Face masks and hand hygiene will be observed. Potential 14 day isolation or enhanced infection control monitoring may occur if universal source control is not followed.
  • Group activities will occur for COVID-19 negative residents. Chapel services and other activities may occur with groups of ten or less. Face masks and appropriate hand hygiene will be observed for groups of less than ten.
  • 100% screening will continue for all individuals entering the facility, including facility staff prior to the beginning of their shift.
  • Residents will continue to be screened daily.
  • Universal source control measures will be followed per current CDC guidance by everyone within the facility.
  • End of life guidelines will be as follows:
    • No more than two immediate family.
    • Must remain in the room.
    • No time limit.
    • Screening will observed per facility protocol.
    • Visitation will be re-evaluated should the resident’s condition improve.
  • Outdoor visitations managed by facility staff will continue per protocol.
  • Therapeutic leave from the facility, to include outings off campus other than with staff, will require a 14 day quarantine upon return to the facility to mitigate exposure to other residents.
    • Residents and persons accompanying residents will be provided education on the risks of exposure.
    • Staff will remind residents and persons accompanying residents to utilize universal source control i.e. masking and hand hygiene to assist in keeping residents safe.
    • These practices will allow for keeping all residents safe and recognizing resident rights through choice.
  • A dedicated space in the facility is set up for cohorting and managing care for residents with COVID-19 as identified within the facilities Emergency Preparedness Plan.
  • The facility will reserve the right to discontinue this program at any time.
Note that this is a summary. Read complete details of the 7-16-2020 meeting minutes here.
 

JULY 9, 2020 - UPDATE

Summarized Minutes for 7-09-20 Physician Advisory Group

Long Term Care Facilities (LTCF) (see attached ND guidance and draft Augusta plan printed below)
Dashboard report from Dr. Paul Carson: LTCF where he sees patients, cases decreased from 30% +ds to 21%; numbers are down after initial surge, but are now increasing again: 6 residents and 5 staff are infected; the LTCF was in phase 2 with some communal dining, outdoor visits and 1:1 visits preceding this outbreak and feels it is infected staff bringing it in; facility is moving back to phase 1 and considering recommending (voluntary) testing policy for visitors; recommends that we continue lots of testing of LTCF staff >=1x/week of staff.

Augusta Place pilot update- Dr. Field, Kathy Greff, Alena Goergen: Kathy (Augusta)  and Alena (Miller Point) are on board with opening.

Concerns are poor public compliance and the need for lots of monitoring. Surveyors found 2 visitors with masks below nose. Kathy says families have been extremely compliant at Augusta Place. 

Kathy’s concern is family showing up at clinic appointments and the clinics allowing families to be present during appointments; Kathy shares that when a resident requires a support crew, it is provided by the LTCF and no family member is necessary for appointment.

Support issues for family members of LTCF who are struggling with lack of contact with resident: Alena reported few residents are struggling; however, family members are those who are struggling; Dr. McLean mentioned the possibility of having support groups for those family members.

Physician Advisory Group recommends that we follow facilities that are piloting different approaches to decreasing exposure to COVID-19 (ie: Augusta) and compare those facilities with other facilities in the same community following standard VP3 guidelines to develop best practice approaches; monitoring will begin and data will be shared on numbers of staff and residents infected as well as hospitalizations.

Testing gap: staff is doing testing in LTCFs and other health care workers are not getting tested; ND Dept. of Health is working on getting staff testing personnel tested in same manner as LTCF health care workers.  

Treatments
Hospitalization is required to receive Remdesivir and convalescent plasma.

Vitamin D update: NATL Institute of Care reports no evidence of effectiveness, but still recommends 400 IU/day in fall/winter.

Testing
ID'ing more cases in young adults and more resistance for isolation/quarantine.

Physician Advisory Group recommends that videos promoting mask use and social distancing are placed on the NDDoH Coronavirus website and that press conferences show people wearing masks when they are not at podium.

Co-infection syndromic testing: FDA approved FluA and Covid multiplex: https://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(20)30342-6/pdf

Proposal to develop a daycare and school guidance allowing for kids to return to daycare/school sooner if they have alternative dx that has resolved in light of this paper and recent evidence of coinfection with Sars CoV2.

Personal Protection Equipment (PPE)
Expect glove shortages
PPE supply replacement has still not been received

Vaccination Strategy
https://www.nytimes.com/interactive/2020/science/coronavirus-vaccine-tracker.html

Continue to consider various prioritization schemes but recent information suggests that vaccine supply will be adequate so prioritization will not be necessary.

Vaccine development timeline is suggested by Dr. Field. Learn more about the Coronavirus Vaccine Tracker here: https://nyti.ms/2MHNdRL
 

Note that this is a summary. Read complete details of the 7-09-2020 meeting minutes here.

 

 

JULY 2, 2020 - UPDATE
Summarized Minutes for 7-01-20 Physician Advisory Group

Long Term Care Facilities
Compassionate Care guidelines were updated by Drs. Winston, Field, and McLean; the Physician Advisory Group agrees with the recommendations to allow for “therapeutic visits” written into the care plan as part of treatment for those with moderate to severe anxiety or depression, dementia, and/or failure to thrive.

Drs. Winston, Field and McLean suggest piloting this policy and following the infection rates. Two Bismarck facilities are suggested as good pilot sites: Miller Point and Augusta Place.

Since some of the facilities are already open to visitors for all patients, Dr. Carson offered to share the dashboard from Fargo/Cass that has nursing homes around the state infection statistics.

Dr. Field will bring the pilot data back from Augusta to assess the consequences of loosening up regulations for nursing home visitation.

Strategy for return for Long Term Care Facilities (LTCF) patients who leave the facility for an outing
Residents are now allowed outings and Dr. Winston reminds us that we are the first in the nation for this.

It is recommended to try the plan, which should be flexible to account for the risk level associated with the outing (graduation party vs intimate family dinner) into the particular LTCF guidance.

LTCF Testing: weekly testing of staff and almost weekly of residents; facilities should plan for allocation of tests. Fargo is not interested in mass testing events. More discussion to follow.

Remdesivir procurement update
Final shipment from Gilead has gone out: 120K doses. This is the last of the free product. U.S. Dept. of Human Services is allocating the medication to states based on Covid burden (hospitalizations) then states ND DoH will base allocations. Gilead will do direct shipments every two weeks to hospitals: $3200/course (6.25 vials) as part of DRG.
 
LTCF treatment update

Dexamethasone treatment is now part of National Institute of Health (NIH) treatment guidelines https://www.covid19treatmentguidelines.nih.gov/dexamethasone/.

PCR Testing
People still being turned away for testing; Physician Advisory Group agrees with Dr. Carson’s recommendation that public testing opportunities be continued with encouragement from the governor etc.- publicly encourage younger age groups.

Turnout of public testing events continues to be good: Bismarck>1000 people today, >250 from BBPH, GF>1000, Minot >500 x 2 with Dickinson/Williston next week[CJM1]; Positive rate is low (13/>1000)-

Co-infection syndromic testing

Covid present with other infections seems to be fairly prevalent and associated with increased morbidity/mortality.

CDC is providing a  flu a, b and covid test that can be sent to state lab. Molly will arrange for lab to attend this meeting within the next few weeks to further discuss this issue

Dr. Connell suggests that it might be useful to understand who is co-infected in anticipation of more aggressive care/follow-up due to the increased morbidity/mortality data (i.e.: use outpatient monitoring protocol on these patients/have closer follow-up etc.).

Personal Protection Equipment (PPE) update
The Battelle crew is still present, but it is expected to downsize.
UV trailers are now available.

Note that this is a summary. Read complete details of the 7-01-2020 meeting minutes here.

 

JUNE 25, 2020 - UPDATE

Summarized Minutes for 6-25-20 Physician Advisory Group

Remdesivir
A Gilead Remdesivir manufacturer representative, Porscha Showers, PharmD, shared information about studies sponsored by Gilead, NIH, and WHO, and reviewed by the U.S. Food and Drug Administration (FDA).

Showers shared that Gilead had just begun the FDA process for intranasal route of administration.

Showers will research questions asked by Dr. Andrew Stahl, interim ND State Health Officer:

Questions:
1) ND has sequenced 30 genomes with 3 specific with variability of the RNA-dependent RNA polymerases (RDRP) component- does this RDRP component variability affect drug efficacy?

2) Has Gilead noted differences in its efficacy in New York vs. Chicago vs. Washington state, given that they had different strains of Covid-19?

Since manufacturing is a lengthy process, Gilead has begun scaling up for several hundred thousand treatment courses with a goal of  one million treatment courses by end of 2020 and several million within the year 2021.

Distribution Plan
Dr. Stahl advocates for distribution to health care facilities with a small reserve in the state medical cache, keeping the most stable form (5-10%): 240 lyophilization vials and 180 solution vials are in the state warehouse for just in time distribution.

The Physician Advisory Group agrees with this recommendation.

COVID-19 Transmission
June 23 - 25 resulted in six travel-related COVID cases from Florida and Arizona, as cases are increasing within these two states. It is suspected that we will need to quarantine if cases continue.

Health Care Worker Testing
Serology testing of health care workers in Fargo update: a group of representatives from Essentia Fargo, Sanford Fargo, and VA Fargo will be developing a plan for mass serology testing of employees from their facilities.

Long Term Care Facilities (LTCF)
Dr. Stahl shared the updated long-term care “compassionate care” guidelines policy. The guidance is available online at www.nd.gov/dhs/info/covid-19/provider-resources.html.

Visits can incorporate social distancing, mask, and outdoors: up to 2 family members per resident.

Dr. Stahl shares his need to make the biopsychosocial balance of all members of congregate situations.

Dr. Connell and Dr. Stahl both agree that those allowed into visit should undergo weekly PCR or antigen testing.

Personal Protective Equipment (PPE)
FEMA wants to right size Battelle- volume is 80K masks/day. ND is processing small quantities, so FEMA would like to reduce staff, which would decrease monthly costs, ultimately prolonging duration of program. More discussion will follow.

Dr. Connell and Dr. Stahl agree that health care facilities must be accountable for use/repurposing agreements tied to accessing supplies from state's medical cache.

Note that this is a summary.

Read complete details of the 6-25-2020 meeting minutes here.

 

JUNE 18, 2020 - UPDATE
Summarized Minutes for 6-18-20 Physician Advisory Group

Remdesivir
Protocol Reassessment - Dr. Nagpal shares that Remdesivir is not being used when it is outside of the 10 day window or if patients are already intubated and feel the criteria does not need to change.

According to Nagpal, Sanford Fargo’s census is down to 15-16 COVID-19 patients per day and patients have been stable within 2 weeks; 12-13 have patients have received Remdesivir with no real change. Extended 10 day Remdesivir treatment was given to 3 people who eventually resulted in intubation. One patient did not get intubated.

Drs. Winston, Field, Carson, McLean will receive a draft of the announcement for Long Term Care Facilities (LTCF) regarding Remdesivir as a hospital option for COVID-19 positive LTCF patients.

Personal Protective Equipment (PPE)-Tim
The chart below shows current supplies and note that the face shield information is inaccurate.

As per Tim Wiedrich, since the COVID-19 Response began, the only inventory received is face shields. All other items are on order with a tentative receipt of 3M N95 masks by late July.

The Physician Advisory Group recommends a conservation policy modification at the time when we begin to replenish our stocks.

Decontamination UV light trailers almost ready; need to complete emergency use authorization to begin utilization.

Serology Mass Testing Strategy Update
There is a big push for mass serology testing, in spite of attempts to educate on questionable benefits with a big risk of lessening of social distancing and hygiene practices, which could lead to increased spread.

Dr. Connell shared info about orthogonal testing in the CDC guidance regarding serology testing https://www.cdc.gov/coronavirus/2019-ncov/lab/resources/antibody-tests-guidelines.html and encourages people to use the calculator with information about Abbott Architect sensitivity at 100% and specificity at 99.6%, assuming a 2% prevalence. This gives you a 83.6% positive predictive value (PPV).

It is recommended to take positives from the first serology test and submit those patients to a second and different serology test (NDDOH also has Diasorin Liaison with sensitivity of 99.3% and specificity of 97.6%). Combining PPV when both tests are positive is 99.9%.

Using Serology Tests
Serology tests are mostly used for epidemiology and donation of convalescent plasma and can also be used for health care workers and long term care facilities.

Dr. Connell points out that CDC states serology testing results information cannot be used to modify policy and to determine congregate and living situations.

Status of Serology testing
Physician Advisory Group recommends that NDDoH limit mass serology testing to strategic sites identified by NDDoH to optimize utilization/interpretation of tests as well as to reduce risk associated with change in social behavior due to positive results.

Holiday Scheduling
PAG Chair, Dr. Connell, will be outside of the Bismarck location from July 10-26 and will have a designee assigned to lead the meetings in case she cannot connect due to questionable internet access.

There will be no meeting on July 2nd.

Note that this is a summary. Read complete details of the 6-18-2020 meeting minutes here.

 

JUNE 11, 2020 - UPDATE

Summarized Minutes for 6-11-20 Physician Advisory Group Meeting

Healthcare Worker Travel Guidance (click in to see current guidance)
Recommended to remove restrictions so that international traveling healthcare workers may return to work, masked and checking symptoms, rather than quarantine.Healthcare Worker Screening Protocol (click in to see current guidance)

Physician Advisory Group recommends accepting this protocol with the following changes:

Change contact time from 10 to 15 minutes (questions 4 & 5)

Add “for an individual answering “yes” to question 3, please follow guidance for health care workers who recently traveled”

Remove (question) “3” and “after they return to North Dakota” from “for an individual answering 'yes' " to question 3 or 5

COVID-19 Vaccine update
Potential to have vaccine by 1/21 with 14 candidates soon to be narrowed to 8.

While in clinical trials, manufacturers are concurrently manufacturing the vaccine to prepare for distribution. The drug manufacturer Majerna is farthest along.

Herd immunity-would need 60-70% vaccine rates and would still have local outbreaks.

Effectiveness will vary with vaccine efficacy and disease prevalence.

CARES act requires 15 days for insurance to cover and will be Medicare part B so will be easier to bill.

Personal Protective Equipment (PPE)
3M is looking at 1860s and evaluated Battelle system (3M) and found that 3 cleaning cycles did well.

Studied UV light:tested several cycles (10-100) without degradation. UV trucks being assembled.

Preventive Care/Screening
Medicaid does not reimburse for preventive visits

Dr. McLean offers option of completion of waivers 1135/1115 for state to consider coverage of well checks via telehealth.

Fargo Testing Protocol Policy Proposal
Capacity for additional testing. Discussion on recommendation to approach Essentia Health and Sanford Fargo as a partner with NDDoH to develop surveillance testing plan involving urgent care centers.

Abbott Architect Serology Tests
Recommend utilizing in long term care facilities.
Recommend using in day cares but down side is blood draw.
Recommend using  leftover serum from patients to do surveillance studies.
North Dakota's Sofia serology testing equipment is still on order.
Note that this is a summary. Read complete details of the 6-11-2020 meeting minutes here.

 

JUNE 4, 2020 - UPDATE

Summarized Minutes for 6-4-20 Physician Advisory Group Meeting  

Remdesivir update

  • Physician Advisory Group shared recommendations to modify current Remdesivir criteria by increasing oxygen saturation from <88 to <=94% and to change comorbidity of age from >75 to >=50 yo with plan to revisit the criteria in 2 weeks to see if we need to remove the comorbidity criteria to increase access/utilization of this research medication.
  • Interim Health Officer Dr. Stahl wants to make sure the medication is accessible.
  • The manufacturer, Gilead, is expecting to start charging for Remdesivir and cost is expected to be $900-1000/course.

Long Term Care Reopening

  • North Dakota is the only state on record that has tested all Long Term Care Facilities.
  • More discussion is needed. 

Behavior Health

  • Physician Advisory Group recommends that NDDoH work with the Center for Rural Health to do mental health COVID-19 modeling project similar to what was done in Washington state.

Telemental Health

  • Physician Advisory Group Recommends that NDDoH works with ND DHS to improve options for access to telemental health in preparation for behavioral health aftermath of COVID-19.

Travel Guidelines

  • Presently there are inconsistencies in the guidance. The Physician Advisory Group is expected to review the guidelines on 6-11-2020.

Medical Cache

  • Medical cache includes many syringes that are technically expired, but have been housed in controlled environment (heated but not cooled). Mr. Tim Wiedrich notes expiration dates set by manufacturers state to not use after expiration date. Tim agreed to ask manufacturing companies for any data they have regarding stability of products after expiration dates.
  • Physician Advisory Group agreed that if there was no stability data from manufacturer and packaging and syringe components appeared to be intact, they could distribute and use in case of syringe shortage. 

Note that this is a summary. Read complete details of the 6-10-2020 meeting minutes here.

 

MAY 28, 2020 - UPDATE
Summarized Minutes for 5-28-20 Physician Advisory Group Meeting  

Update on Battelle system for N95 decontamination

  • System is operationalized yet underutilized to this point.
  • Dr. Sather, Trinity Health, had great service and turnaround time provided for 250 masks, which were cleaned promptly, and returned.
  • North Dakota is allowing three rounds of mask decontamination, per the NIH guideline in response to claims of capacity for 20 cycles of decontamination/N95, which some fear will result in the breakdown of the mask.
  • North Dakota expects that medical facilities will decontaminate N95s if the facility is receiving medical cache supplies.
  • Supplies for both sizes of 3M respirators was sourced and ordered. This will place inventory cache at <800K N95s. The PAG feels confident and expects to obtain 1860s.
  • The group was notified that Battelle will direct MN masks into the ND site due to capacity.

Strong recommendation to the group to encourage their facilities to utilize the Battelle System for mask decontamination.

Reassessment of Remdesivir criteria- who and where 

  • Sanford reports not using as much as they would like due to criteria being too stringent and recommended altering criteria to original EUA.
  • Dr. Nausheen has not had a chance to use it at Altru due to no active patients. Minot has not used any due to no hospitalized patients.

PAG recommends modifying age risk from >75 to >= 50 yo as well as modifying oxygenation criteria from <88% to <94%. 

Outpatient Oxygen Monitoring Protocol update

Mylynn Tufte requested that NDDoH proceed with process of obtaining continuous monitoring devices to utilize with protocol.

Update on  NDDoH Testing criteria
Modifications include recommended testing for any symptoms, close contacts-preferably 7-10 days post exposure, and preop testing option, and pregnant women upon delivery.

Note that this is a summary. Read complete details of the 5-28-2020 meeting minutes here.

 

MAY 21, 2020 - UPDATE
Summarized Minutes for 5-21-20 Physician Advisory Group Meeting  

Management of Remdesivir
CHI Dickinson reported that seven patients were transported to Bismarck CHI St. Alexius to be treated with Remdesivir. If COVID patients are no longer able to be supported with NC or high flow O2. patients will be intubated, stabilized, then transported to Bismarck CHI St. Alexius.

Mylynn Tufte, ND Dept. of Health State Health Officer, reminds the group that Remdesivir can follow the patient AND facilities under same umbrella can share their allotment.

Physician Advisory Group recommends that Dickinson CHI participate in the Remdisivir distribution program through NDDOH.

Physician Advisory Group recommends that additional critical access hospitals desiring access to Remdesivir via the NDDOH distribution program can make a presentation to the PAG for consideration on a case-by-case basis to hospitals for managing patients.

Viral Signs - Dr. Brioche/Barry Hix gave a presentation regarding technology that tests for presymptomatic presence of virus, using Viral Signs thermal cameras. May have some useful application and will be reviewed by PAG.
 
Serology testing
PAG recommends that serology testing be considered for diagnostics ONLY when previously untested close contacts want to donate convalescent plasma.

Businesses requesting serology testing should submit plan, including what will be done with the information.
Note that this is a summary. Read complete details of the 5-21-2020 meeting minutes here.

 

MAY 14, 2020 - UPDATE
Summarized Minutes for 5-14-20 Physician Advisory Group Meeting  

Smart Restart Travel Guidelines and Guidance for Health Care Workers Who Recently Traveled or have Travel Plans
PAG members will review the health care worker travel guideline to determine if guidelines should be continued, modified, or discarded.

Multisystem Inflammatory Syndrome in Children (MIS-C) Associated with Coronavirus Disease 2019
ND Health Alert Network issued advisory on request for reporting. PAG will continue to conduct research on the similarity to Kawaskai.

Remdesivir Guidance/Administration 
Several doses were administered at Sanford Fargo. Altru, Trinity, and Bismarck Sanford have not used any doses yet. Primary goal is to establish a protocol that increases the likelihood that patients at greatest risk for dying have access to the medication and PAG will continue to review the protocols.

Facility Allocation: requests for Remdesivir are coming from more critical access hospitals, such as Dickinson, Williston, Devils Lake & Jamestown

Hydroxychloroquine Inventory 
Given recent negative results in studies and patients discontinuing this medication due to QT prolongation, the PAG recommendation was given to cancel the order for 500,000 doses.

Abbott Rapid COVID-19 Test Results
A study shows up to 48% of Abbott tests showed false negatives with lots of hospitals using it. Altru and Sanford Fargo have had good success with machine (>=85% sensitivity, with false negatives thought maybe due to sample prep). PAG will continue to watch for more information about this and provide guidance if concerns are valid.
Note that this is a summary. Read complete details of the 5-14-2020 meeting minutes here.

 

MAY 7, 2020 - UPDATE

Summarized Minutes for 5-7-20 Physician Advisory Group Meeting

Outpatient Covid Monitoring Protocol: shared with Unified Command for approval

Oxitone/project: tie in of this project with homeless - hotel project and need for nursing/paramedic and physician teams

Pre-op testing: physician concerns that facilities plans are not safe for patient or staff due to insufficient PPE/testing and was forwared to the Unified Command

Personal Protection Equipment (PPE): concerns of having a definitive source for PPE and recommendations were made to limit N95s to providers caring for Covid patients and/or patients requiring essential procedures. Current inventory shows 1 million N95s between hospitals and state cache; surgical masks have 1.6 million in medical cache and 734K in hospitals.

Battelle Critical Care Decontamination System may be ready by May 15th with ability to decontaminate 60K masks/24 hours. Go online to register for services:https://www.health.nd.gov/battelle-critical-care-decontamination

Mass vaccination plan: discussions will be held in June to review potential Covid vaccines and also discuss the need to increase flu vaccination rates.

Travel Recommendations: PAG agrees on recommendations to create Smart Travel guidelines that help people optimize their safety while travelling.

Resource Allocation Strategy: discussions on recommendations to move away from using age cut offs for prioritization of resources and to create a triage committee to separate this from being made by the front line workers.

Separate guidance discussing advanced directives (Covid-e-POLST): see NDDOH Covid website entitled Smart Guidelines for Vulnerable Populations/Smart ACPs.

Distribution of Remdesivir: Cody Schulz from ND Homeland Security contacted FEMA who will be responsible for allocating Remdesivir now that FDA has approved an emergency use authorization (EUA) regarding ND’s interest in acquiring this medication for our hospitalized patients. The Governor assigned the task of distribution to PAG. More information will follow.
Note that this is a summary. Read complete details of the 5-7-2020 meeting minutes here.

 

APRIL 30, 2020 - UPDATE

Testing Priorities & CDC guidance
Physician Advisory Group recommends adopting the current (April 27) guidelines for testing prioritization, with the caveat of including First Responders with direct contact exposure in the Priority Group with recommended PCR testing on day 5-7 post-exposure.

PAG concurred that PCR testing priority should follow the CDC guidelines, particularly targeting symptomatic patients for testing and agree with the Governor’s priority of testing staff and residents of nursing homes in point-prevalence surveys to establish a baseline of current infection and transmission. 

In addition, we would encourage the Governor’s testing strategy group to assist long-term care facilities in developing a plan to allow serial testing of staff to identify healthcare workers that are asymptomatically infected and potentially shedding virus to vulnerable LTCF residents.

Serology testing
While serology testing may be useful in predicting protective factor of herd immunity (starts to take effect when 67% of citizens in a region are immune), current low prevalence indicates we are far away from this (prevalence is 2-4% in CA, up to 20% in some regions of NY).

Roche test is likely the best option, but still not useful due to prevalence.

Preop testing, patient safety and healthcare worker safety were also discussed in detail

Travel quarantine does not have an end date: 
Mylynn Tufte, ND Dept. of Health health officer, is suggesting to release the travel quarantine on May 15. This gives people time to plan and allows for the impact of reopening and supports MN and Canada start dates. The Physician Advisory Group recommends that we observe consequences of reduction of restrictions prior to announcing end date of the travel ban.
Note that this is a summary. Read complete details of the 4-30-2020 meeting minutes here.

 

APRIL 27, 2020 - UPDATE

Personal Protective Equipment (PPE)
Monitoring PPE continues to be a priority as it is identified as a likely rate-limiting step for the ND Smart Restart. The Physician Advisory Group proposes that the state's medical cache is reserved for essential facilities that primarily rely on the cache for their supplies.

Institutional supply and access to PPE varies. Following are some guidelines:

Current supply and prospects for replacement/site-driven repurposing MUST be tied to facility’s smart restart plan

ACS/ASA recommends that elective surgery start decision based on PPE supplies that are adequate for the second wave of a Covid-19 outbreak.

Discussions will be held with institutional leaders to discuss best practice strategies of safety/PPE conservation in the ND Smart Restart of Elective Surgery plans.

Based on limited supplies of PPE in the state's cache and at institutions, PAG recommends aggressive rationing of PPE from medical cache and recommends against availability for non-emergent dental visits, optometrist visits, etc.

Dual (Polymerise Chain Reaction (PCR)/Serology) Antibody Testing Strategy

PAG agreed with the proposal from last week that involves surveillance testing. The ND Dept. of Corrections will determine a baseline measurement for new infection/recurrent infection, similar to surveillance testing in correctional facilities in North Carolina and Ohio. Statistics showed that 2/3 of residents and staff in NC facilities and 78% in Ohio facilities were positive for COVID, but only 10% of these were symptomatic.

Once we have proven that antibodies are protective, we can begin using the antibody test.
 

Additional Proposed Priority Sites for dual-type surveillance testing are as follows:

  • Long Term Care Facility Workers (direct pt contact>no pt contact)
  • Long Term Care Facility patients
  • Hospital Workers (direct pt contact>no pt contact)
  • Essential businesses/Intermediate care facilities
  • Communities with high/medium/low incidence

Proposed Expansion of PCR testing as available:

  • Asymptomatic Contacts (could couple this with serology test)
  • One symptom

Proposed Expansion of Serology Testing-ONCE POSITIVE SEROLOGY IS PROVEN PROTECTIVE:

  • All essential employees
  • Teachers
  • Elderly and other vulnerable
  • General public

Proposal for Location of Care for Long Term Care Facilities for COVID-19 Positive Patients

The State was suggesting to hospitalize all COVID-19 POSITIVE Long Term Care Facility patients, regardless of their criteria for hospitalization. The PAG had many concerns with the plan and how it would impact long term care residents. Through negotiations, PAG, the ND Medical Association, ND Hospital Association, and the ND Long Term Care Association, a satisfactory plan was worked out to form a win-win situation. See plan  details here.
Read complete details of the 4-27-2020 meeting minutes here.

 

APRIL 16, 2020 - UPDATE
Determination of Death
Monitoring the emergence of Coronavirus Disease 2019 (COVID-19) and guiding public health response requires accurate and timely mortality data. The Physician Advisory Group recommended that the CDC Coronavirus Disease (COVID-9) Death Data and Reporting Guidance should be provided to every North Dakota physician and coroner.

Conservation of ND Personal Protective Equipment (PPE) – Tim Wiedrich, Emergency Preparedness & Response Section Chief

If PPE gets to 40% of cache, permit only necessary procedures
 
Inventory in Cache-
N95 respirators- we had 1.6mil, now we have 600K. A great deal of inventory has been distributed

Gowns - estimates about 650-700K gowns

Decontamination Strategy Update
Many hospitals are using the vaporized H2O2 process but recommend against use of ethylene oxide. The Physician Advisory Group is exploring UV light trailers with UV light kitting that should arrive next week to set up six trailers/permanent institution- will process 400 N95/ hr at 24/7.

John Hagan has devised a steam operation in the correction facility’s kitchen for decontaminating masks and can share the process upon request – the Physician Advisory Group will review this proposed policy and respond in favor or against.
 
Advance Care Planning for Managing Acute Respiratory Distress During the Covid 19 Pandemic
There are two documents that outline advanced care planning: The AMDA Advanced Care Plan tool and the Honoring Choices ND document. Either approach could be an option for providing this information. The Physician Advisory Group agreed to review the process and documents, then advise.
 
NDDOH Recommendations to Prevent and Respond to COVID-19 In Long Term Care, Basic Care & Assisted Living Facilities
The document will continue to be discussed by the Physician Advisory Group and will determine acceptance of the guidance. (download here)

Convalescent Plasma Update
Outpatient and inpatient physicians should be discussing and recommending convalescent plasma donation to Covid patients. 

Plasma donations can be made by patient eligible for blood donation at Vitalant.

  • lab-confirmed Covid 19 dx (PCR or antibody) AND
  • completely symptom free for 14-27 days OR >= 28 days AND
  • negative PCR test to prove noninfectious that is attached to the application

NDDOH will be contacting those with positive tests to encourage plasma donation
Download the donation form here.
Read complete details of the 4-16-2020 meeting minutes here.

 

APRIL 9, 2020 - UPDATE

CDC guidance for return to work for essential employees: At this time, ND critical infrastructure workers, excluding first responders and health care workers (HCW) should continue to abide by the ND executive order for two weeks of quarantine if meeting the criteria for close contact with a COVID-19 patient. Exemption considerations will be considered by the ND Dept. of Health on a case-by-case basis when it prevents a critical infrastructure business from functioning due to excessive absence of critical employees.

Health care workers working in multiple facilities and testing: Recommend that ND develop a COVID-19 + Facility List, similar to Minnesota, that could be used by facility administration is aware when a HCW may have been working in another COVID+ environment. Guidance will need to be developed for facilities with cross-working HCWs to come off of the list.

Allocation of medical cache resources: Medical cache resources should be allocated based on need of facilities (considering census of COVID-19 patients/number HCWs in the facility etc., and perhaps using the CDC estimator used during the Ebola crisis, with modification of calculation to account for current personal protective equipment (PPE) conservation practice recommendations). The Physician Advisory Group is interested in participating in the decision-making process.

Convalescent plasma update: Dr. Joan Connell encourages passing relevant email information onto those within this group’s facilities who may be interested in using convalescent plasma, along with contact information, so Dr. Connell can add the contact to the distribution list. She also encourages facilities to share information/progress on this project to meet the goal of the convalescent plasma being available to all patients who may benefit, no matter where they are being hospitalized.

Antibody testing: the ND Dept. of Health State Lab ordered rapid antibody test kits; however, kits are not FDA-approved but are approved in other countries. ND Dept. of Health Officer Mylynn Tufte reports that according to the U.S. Dept. of Health & Human Services tests are not reliable at this time and recommends waiting a few more weeks when tests are expected to be FDA to approved.

This committee continues to meet at a minimum twice weekly or more often as the COVID-19 situation rapidly changes. NDMA extends a huge shout out to the physicians involved in the advisory group.

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