ERIN MCCLURE: Good morning and happy Thursday to each of you. My name is Erin McClure and I'm a medical education manager with 3M and I'd like to welcome you to today's webinar Continuing with Optimal Wound Care in United States Outpatient Settings during Uncertain Times. We're excited to bring this program to you. Our presenters will be sharing a lot of their day-to-day challenges in identifying solutions for the way that they manage their wound care patients and their practices.

I'm going to go over some important information with each of you. Any opinions, findings, and conclusions or recommendations expressed in this presentation are those of our faculty and not necessarily those of 3M and its affiliates. Also, any photographs in the slide deck are the presenters, unless otherwise indicated.

This presentation is also based on current United States federal requirements as of May 2020. US state or other country requirements may be different and always consult user instructions and follow local laws and regulations. This is some disclosures of our faculty and then we're going to move on really quick to some of the important housekeeping information which is vital.

As you note on your presentation, at the bottom there is a Q&A widget which you can go to type in questions throughout the program, which we highly encourage. At the end of our three faculty going over their presentations, we're going to have a virtual roundtable with them with questions and answers that come in from you all, which again, is very important. You will get some pop-up reminders to submit your questions. Again, you can never have too many and that's why we have this expert faculty here with us today.

We also have, if you scroll down to the bottom of your page, you will see a resource widget as well. In there, we'll have some upcoming medical education events for 3M, as well as some educational materials that you can utilize and implement in your practice. The last piece of information I want to share with you is that this program is going to be on demand and it will be available in the next few weeks. So utilize the link that you pre-registered with to access the webinar once it's available on demand.

I'd like to introduce each of our speakers at this time beginning, in the East part of our United States with Dr. Christopher Barrett in Springfield, Pennsylvania who is a DPM certified wound specialist and fellow of the American Professional Wound Care Association. He is the director at the Centers for Wound Healing at Crozier Keystone Health System.

We'll then we'll take a trip over to the West part of the United States, ending up in Oakland, California with Dr. Colin Traynor, DPM, who practices currently at Highland Hospital, a Level 1 trauma center in Oakland, California.

Our final destination will land us over to Louisiana-- Hammond, Louisiana that is-- with Amanda Estapa who is a board certified Acute Care Nurse Practitioner, Certified Wound Care Specialist, and Fellow at the American College of Certified Wound Specialists. And she is the vice president of clinical services for MedCentris.

So Dr. Barrett, Dr. Traynor, and Amanda, I'd like to take this time to welcome you to today's presentation. We're going to begin with Dr. Barrett, who I'm going to hand over at this time so he can begin. Thank you, Dr. Barrett.

CHRISTOPHER BARRETT: Thank you, Erin. I appreciate it. So first hello everyone and thank you and welcome to our presentation. I appreciate everyone taking time from their busy day to have this discussion. And I know with everything that's going on in this world right now, a lot of us aren't traveling. OK, so we have to-- if you're like me, you're getting inundated every day with requests, advertisements for webinars, so a lot of information being exchanged this way. We can't get out, unfortunately, and meet together.

So what know what I find interesting about our group today, my two colleagues, we each practice in a different care setting. OK, so I'll give you a little bit of background on my practice setting. So I work for a management company, RestorixHealth. I've been specializing in wound care for the last 18 years. So 18 years ago, I kind of jumped into this new concept of wound care and hyperbaric oxygen therapy.

And so I kind of have an interesting role, in that I'm an administrator. I'm a clinician. Some days I'm a front desk coordinator. Some days I'm a wound care nurse. So I kind of do it all in the center. And I charge entry and coding and billing, so I've kind of seen all aspects of wound care.

My situation here in Springfield, Pennsylvania-- and again this is kind of one of the interesting things about our panel-- some of my other two panelists, Amanda and Dr. Traynor, are in kind of busier, high-risk areas. Amanda is kind of seeing multiple care settings. I'm strictly in an outpatient wound center in a hospital that's now closed to inpatient care. And for the last month and a half, my wound care center-- we're in a basement just outside of pretty much an empty parking garage-- and so I kind of have a unique perspective in that I've been dealing with mainly a lower risk, lower volume population.

So I'll give you my perspective on my patients and how our hospital's dealing with the pandemic. And then you're going to kind of hear two different-- a couple of different perspectives-- on maybe a different type of practice, whether it's in inpatient side and outpatient, skilled nursing facilities, home care. So this is kind of one of the interesting aspects of this discussion is it's really going to cover really all the care settings that we have in wound care.

So at this time, I'm going to switch over to my deck. Let me share that. OK, and we will get started. OK. So again, just some housekeeping-- and I think we went over the disclosures-- so this global pandemic that we're dealing with right now, very, very-- it's a very, very difficult situation for everybody. These numbers change every day, so I think these numbers that I've put up-- and I've had to kind of chase this on a daily basis to keep the slide up to date-- but these are four days old. So what's amazing is the number of cases worldwide, the number of deaths growing. Here in the US, we know that this depends on what side of the political spectrum you're on. But the unemployed-- this number jumped from seven million to 23 million just in the last few days so pretty amazing. Very difficult time for everybody.

Certainly health care has been impacted dramatically. And it's not just finding physicians and health care providers to manage the volume of patients, ill patients. But how about shortages in PPE, shortages in space to treat patients? So a lot of things have happened to kind of accommodate this outbreak, this public health emergency, and I'll kind of talk about that, but wound care-- it hasn't escaped this.

Wound care has been impacted, but differently. Again, impacted differently in different parts of the country and different practices. So I'll talk about how I've been impacted, my wound care practice in my location here on the suburbs of Philadelphia, and then you'll hear our other two speakers, presenters, talk about how their health systems and their own practices have been impacted by the pandemic.

So this is a question that kind of popped up-- when? Probably late March and it really-- there was a discussion going on. Again, I look at the wound care family. OK, and this started to become a concern, because while it didn't impact me, what I was hearing is certainly from our management company was the hospitals, health systems, were they were mobilizing for the pandemic and trying to mobilize providers and also protect their patients so they started looking at non-essential service lines, and unfortunately, wound care came into the discussion.

So many health systems started to say, well, women care probably isn't that important. And we need the resources for other sick patients, more at-risk patients, so many wound centers started closing. OK, without really any discussion about the impact that it would have on our patient.

So what happened was, the Alliance of Wound Care Stakeholders kind of took the lead in this issue and put out a position statement. And I remember this discussion coming through, not only RestorixHealth, but the American Professional Wound Care Association and some of the other societies. We all kind of mobilized and we kind of follow this statement and what was great was, not only how quickly and effectively the Alliance worked, but it's how quickly CMS and the government responded to our need.

So the Alliance went out and first put out the position statement that wound care is essential, and while we're trying to protect our high-risk fragile patients the impact on some of our-- especially our diabetic patients-- would have foot ulcers or veinous leg ulcers, pressure ulcers, our patients with many co-morbidities. What the hospitals are trying to prevent may actually happen if we don't really continue care on this high-risk population.

And once the Alliance got out there with the physician statement, we started to see a lot of other key opinion leaders, other wound care professionals kind of stepping up and providing information for all of us that we could use, not only to support our position, but to help us in our practices and help us with our hospital administrators.

And one of the first guidance documents to emerge after the position statement was this-- and it was led by Dr. Lee Rogers and three other-- probably four, of the most influential DPM's in the world, I'll say. So we all know David Armstrong, Dr. Warren Joseph, who was one of my instructors in school, Dr. Lavery from Texas, and obviously Lee Rogers. And Lee Rogers has really kind of become the authority on developing systems of excellence for wound care. And they're being adopted by other health systems and other wound care centers.

This article that was put out in the Journal of the American Podiatric Medical Association, it was really geared towards podiatry, or at least it was meant for the podiatric crowd in dealing with the highest risk patient population we have-- and that's the diabetic with the foot ulcer-- but really, this pandemic triage system is not just meant for podiatry. It really crosses over to other care settings and other specialties.

And in fact, last night, I watched another webinar which was just published in "Wounds." There was an article led by Lee Rogers, Dr. Lee Rogers, in another group. In fact, our CMO from Restorix was also part of that article. And it was the Wound Care Center without walls. OK, and it's really taking this podiatric center, all-feet-on-deck triage system and really expanding it to all places of care.

And that the point of this triage system is to kind of address the Alliance's statement where certain patients of ours, depending on their co-morbidities and the urgency of their problem-- whether it's a diabetic foot ulcer, a venous leg ulcer, a pressure ulcer-- many of these patients are-- they need to be seen. They need to be treated for their wound care. We can't just kind of forget about them and close our center.

This is why we need to really be open and available for them, but we need to triage patients because the less critical patients really don't need to come into the Wound Center and be put at risk. So these triage systems, these guidelines, were really to shift less critical patients away from the hospital-- and whether that's, as you can see in Dr. Rogers in this model, whether it's the ambulatory surgery centers or office space laboratories. Maybe a vascular laboratory, a radiology laboratory, private practices, home health care.

OK, there are places that we can take care of our patients and not put them at risk and bringing them into the hospital, but there is that subset of patients who meet-- many patients are going to need to be admitted. They're going to have to have surgery if they're infected and they need to go into the hospital and those critical patients cannot be denied that service because the point of all this is obviously to prevent amputation. So this guideline, really the focus here is utilizing telehealth, telemedicine, remote patient monitoring. These are things that, prior to the pandemic, we really weren't focusing on.

But I think now-- I can tell you truthfully. I'm not using these tools, not yet. Actually I had my first telehealth visit with one of the home health nurses yesterday. But I think these are going to become more routine because this pandemic isn't going away. And this triage model is going to be with us for months and, potentially, years. So remote patient monitoring, there are devices and technologies that exist today that can be utilized to monitor your patients at home. And certainly using home health care.

But how do we do this? How were we able to start utilizing all these new technologies and these new ideas? Well, what happened was-- and this is where the Alliance really working with CMS, and really health care working with CMS, in saying we need to mobilize. OK and we need to be able to do that without barriers.

So CMS-- and kudos to the government-- we know sometimes it moves very slowly and the bureaucracy can be pretty frustrating, but you know it really stepped in and these waivers and flexibilities-- really they did two things. They ensured beneficiaries could get safe and effective care during this emergency, but they also kind of took away the impediments to make sure Medicare payments and coverage policies didn't interfere with these patients and the ability of health care clinicians to see patients.

OK, so it allowed us to see more patients and really use technologies and methods that we really weren't using prior to pandemic and, here's the other part, to get paid for them. OK. To be able to bill for services. So and we'll kind of if we go to the slide to the right, I can't spend too much time on this, but if you kind of look at these flexibilities and waivers, here's what it did.

Number one, telehealth. It expanded coverage. So now providers could use telehealth and telemedicine phone visits and get paid for it like they were using it like they were seeing the patients in the hospital or in the office and that didn't exist prior to the pandemic. Or I should say nobody was doing it. It was very difficult. There were a lot of barriers.

How about expanding the workforce? Patients had to be moved from other locations, sometimes to other states. Physicians needed to-- if they're working in Pennsylvania-- some of our physicians needed to go to New Jersey to be able to see patients, to be able to follow patients, because we needed health care physicians and clinicians to be able to see the volume of patients that were ill. And so these waivers and flexibilities took down those barriers. Clinicians now didn't have to get a new license to go to New Jersey. You know how long that would have taken?

So it took down the barrier to allow the health force, the workforce, to get out and see patients without barriers and address this pandemic. We have one here in Philadelphia, it allowed us to take a hotel and turn it into a COVID hospital. And not just turn it into a COVID hospital and not have to jump through a bunch of hoops to do that, but it allowed our physicians to go into that hotel, that motel, and get paid like they're working in the hospital. So they're still actually able to practice and there's no barriers. We don't have to jump through all those hoops.

Removing the waivers for reporting deadlines, for audits, for prior authorizations that are really just made it so difficult for us to respond to the volume of patients coming into-- whether it's our clinic, whether it's our hospital, or whether it's a convention center that we've now turned into a triage center. That's what the flexibilities and the waivers did and it allowed us to mobilize, to deal with this health care emergency that we're dealing with right now.

So now we know that a certain subset of our patients need to be seen in a clinic, OK Not everyone, but in my clinics-- I'll talk about my Wound Care Center-- we never close. OK, we have a physical therapy department working side-by-side with us and they shut their doors. OK, they were seen as nonessential. We've been seeing patients and we never slowed down-- OK, we had a slowdown and I'll talk a little bit about the impact of the pandemic-- but we've been treating patients so we know patients are going to come in and we know that my staff members and other staff members are going to be working with these patients, these at-risk patients.

So how do we protect ourselves-- my staff-- and our patients? OK, well number one, it really talked about probably the hottest topic. It's masks. OK, so you can't go anywhere. And this is now mandatory everywhere we go, OK. Whether it's in the hospital or outside in the public, we need to have a mask.

And there is a difference and I'm not going to-- we have experts from 3M here that can really dig down deeper into the technology, to different technologies with masks. So we have the N95 respirator-- very popular. We have surgical respirators and then we have surgical masks and I'm not going to belabor the point, but respirators are, in general, are to protect the wearer from the outside versus the surgical mask.

We know that as a surgeon this is what we wear in the operating room. It was to protect our patients. It was to protect the environment from us-- saliva, mucus-- and also protect us from any splashing that could potentially get into our nose and mouth. So there's an important difference to understand between masks and respirators, and depending on the rules in your hospital and what you're doing in your clinic, you may have a combination of both. Or in my situation, we primarily use surgical masks.

OK and again, because I'm a different patient population, we have really nobody in our environment other than us. We're in a basement and patients can walk right in the door and walk right out to a private car, so a little bit different in terms of risk. So this is an important topic and certainly ask questions later. We have experts who can talk to you about that, OK, so

--and that's what I just talked about. So let's talk about my clinic. So this is how my health system reacted. And this is a month old, so I can tell you there's been changes. So when I first got the email-- this is the phone triage for a new patient. Now I can tell you, number one, my patients, they're not flying to Luxembourg. OK. I can tell you nobody's flown to Luxembourg or Liechtenstein. So I don't ask my patients if they've gone to all these countries.

What I do, from day one, we ask them, have you traveled? OK, and I can tell you in the last month and a half, nobody's traveled, at least in my group. So we asked them if they've traveled and then we ask them if they had a fever, if they have a cough or shortness of breath, or if they have been exposed. OK, and then depending on the answers, if they've traveled and they have symptoms, we're not seeing them in the outpatient department.

OK, then we're going to make sure that-- and again this has already changed-- so now they're not calling the Pennsylvania Department of Health. We're going to get them if they're sick. We're either going to get them to the emergency department or they might want to see if they're stable enough to see their primary care physician and be evaluated. They might come into the ED. So things have changed.

OK, so we're going to guide them where we think or they get they might go and get a test. OK. And we have drive-through testing centers now and they can certainly get that as well. We document this in the EMR and we maintain a log. And then again if they travelled and have no symptoms, how about if they've traveled. They have no travel history and no symptoms, we're going to see these patients.

Back a month and a half ago, they didn't require a mask. Now everybody requires a mask. So that has changed because we certainly know now, we have better policies in place, and then we have phone reminders. Every patient-- even if we've seen them before-- if we're calling them up to remind them to book an appointment, we're going to ask them those questions.

So make sure we're monitoring our patients, So that anybody has potential symptoms, or maybe there's a potential that they're ill, we're going to direct these patients to the right location. We're taking temperatures now, which we didn't do a month and a half ago. Everybody's walking into the hospital getting their temperature taken.

In the office, if somebody comes in-- and this is a little-- Again, this is from the health system if they're sick and they're not COVID 19. Well that's pretty-- we're not going to know that. So if patients are sick, we're going to not see them, and we're going to have these patients directed to the emergency department or their primary care doctor and be evaluated, get a test.

We have posters and supplies up. We have gowns. For my physicians we have shields, we have masks, we have everything they need to be protected. Some of my physicians like to gown and mask, others just use a surgical mask, but these are-- we do have these stocked because of the requirement.

And then daily setups when patients walk in. Again now, they're getting them-- everybody gets a mask and pretty much everybody comes in now with the mask anyway, so it's pretty common. But then we added general precautions, so what happens is when you walk into any of the hospitals in our system-- we have four hospitals-- every employee, every physician gets their temperature taken and gets handed a mask if they don't have one.

Visitors-- and I think this is probably in every health system in the country for the most part or at least at the beginning. We don't allow any-- only one visitor per patient. OK, so we can't have a family coming in and sitting in the waiting room or going up into the emergency department. We also don't have our vendors. Our reps are not allowed. They haven't been here in a month and a half so unfortunately no free lunches, but these are the rules that the hospital put on.

And social distancing. We took half of our chairs out of our waiting rooms so we have everybody distanced. And we're modifying, in terms of the way we schedule and things like that, so we don't have a lot of people sitting in the waiting room. These are the things, the preventative measures.

Back before a month ago, a month and a half ago, if you were a health care system-- if you were an outpatient ambulatory center-- the CDC put out some guidelines, and very similar-- Again the goal being if you look at wanting to keep sick patients out of the clinic, and healthy patients, keep them safe, then utilize telemedicine. Utilize other methods of triaging patients.

If you think they're sick, OK, then get them to call 9-1-1 one or go to the emergency room with their primary care doctor. Have algorithms that you can screen patients so that they don't come to the clinic to be screened. OK, you want to screen them at home and direct them to the right care location to keep everyone safe.

Home health services. Engage other organizations, but certainly home health has been, for me, it's just been huge just to help us treat our wound care patients and get through this pandemic and still assist those who really need care, they've been invaluable. They're angels. They just do amazing work.

And also health care providers, OK. Take care of them. OK protect them. Be able to have-- Again, they recommend algorithms, so many health care providers are getting ill from COVID. They're on the front lines. Have backup plans for these down times when you're going to need physicians and have backup for your supply of PPE.

I'm fortunate that I haven't had a major problem with getting PPE, but I know this has been a problem, especially in those areas and those hospitals that have been overwhelmed-- New York, New Jersey-- just outside, you know, the state right next to me. One of the worst in the country certainly. Amanda dealing with that in Louisiana, Dr. Traynor out in San Francisco, so different for me than for them and they can kind of really speak to what they're seeing.

There's a website on the bottom. This is a wonderful website provided by 3M. If you can spend an hour going through all of the links and information on, not just PPE, but how to take care of yourself and how to deal with this pandemic. There's so many resources on that website. So certainly utilize that. It's wonderful, wonderful information.

So here's the last thing I'll talk about. Here's how the pandemic affected us. So again we never closed, but as this ramped up, as we saw this getting worse and worse, unfortunately my company had to-- like pretty much every business in the country-- we had to start furloughing some of our part time folks, salary reductions at the corporate level.

Unfortunately for my staff I've had to, when the clinic hours are over they go home. OK. Now the clinic doesn't close. I get to answer the phone the rest of the day, but we're trying to cut down because as a company we've suffered just like every business, so reduced staff hours. We saw about a 40% reduction in patient volume, which is down to about 25%. Now we're starting to ramp back up, thankfully.

Staff flexibility-- that's me. So I pretty much do every job here as needed. OK, and that's how we kind of fill in the gaps. We had a patient volume-to-hours-worked target of 2.0 for the staff, including myself so that was pretty challenging. And then now we close early if we have to and I keep my staff home. It keeps everybody safe, but it also reduces the volume.

So that's the impact that it's had on my program. Physical therapy has opened up here again. The hospital's starting to expand. Although two weeks ago my hospital closed in inpatients, so everybody is being funneled to a couple of the other hospitals in the health system and that's kind of how they're managing the volume, but we're seeing fewer COVID patients in the hospital.

So with that, I'm going to step back and pass on the baton to Dr. Traynor. So I want to say thank you very much for your attention.

COLIN TRAYNOR: Thank you Dr. Barrett, and hello out there, everybody. Thank you for joining us today. I'm a DPM out in Oakland, California as Dr. Barrett introduced me. System professor at the California School of Podiatric Medicine, and an attending at Highland Hospital in Oakland, California, where I practice 100% of the time.

And Highland Hospital is the Level 1 trauma center, not only for the city of Oakland, but also for the county of Alameda. And so of course, a little bit of a contrast to what Dr. Barrett's been dealing with at his wound care center at his clinic.

So I'm going to spend my portion today talking about my practice and how it's changed. In order to know how it's changed, you kind of have to know what it used to be like. As you can imagine, a Level 1 trauma center is a busy institution, especially out in California, in Oakland, California of all places.

So that busy institution typically had an emergency room that was standing room only from noon to 2:00 AM, seven days a week. My clinic, being the same way, we have clinic four days a week and our waiting room typically was always full. Not full with just patients, but of course full with vendors, family members, care providers, to the point where patients were in a crowded room and of course not able to socially distance at all.

And that same waiting room for us is the waiting room that services all the clinics, in addition to our clinic on that floor. When I say that floor-- and I talk about the differences between my practice at Highland and Dr. Barrett's is-- our clinic is on the seventh floor. So how do you get to our clinic on the seventh floor? Well, you have to enter the level of the emergency room, go up from level four to level five, where the OR suites are, up to level six where adult medicine is, and then up to level 7.

So we are in the hotbed as an outpatient clinic when it comes to being an at-risk location for our patients to come and be treated. So our clinic not only is a busy clinic and a busy hospital at a Level 1 trauma center, we are a teaching hospital. So running eight rooms at a time, seeing patients with three to four MAs staffed with an LVN. We also have anywhere from eight to 12 students with us at all times, two to three residents as part of our team, interns as part of our team, and as a attending for the hospital representing the residency program, we get visiting students from all over the country that wanted a sneak peek at what life would be like as a resident at our hospital.

And we'd have students visiting that would be interested in podiatry in undergrad coming to look at the hospital and to look to see what their education and their training would be like. As you can imagine this is an institution that was always buzzing, always busy, and of course my head sometimes spinning, being able to try to balance it all.

Well that's not the experience anymore. That's not the practice we have now obviously with COVID 19. Our hospital has had over 120 positive COVID 19 tests I think we currently have about 12 inpatients at our institution and we've had several employees test positive for COVID 19 so it's very serious and very real where we are in the hospital.

So as I suggested, what does my practice look like now? Well, the waiting room is empty. Waiting room has to be empty. We have to be able to socially distance our patients, decrease volume as Dr. Barrett was talking about, which also meant that we had to significantly reduce our staff to decrease their contact, decrease their risk, and so it does mean flexing individuals off, furloughing individuals.

We talked about using eight exam rooms in a typical clinic, sometimes even overflowing to add additional rooms-- stealing rooms-- from other clinics. Well now we only run four rooms. Three private rooms and one minor procedure room is always left available for us now at the clinic. The exam rooms selected are those rooms that are closest to the waiting room so we can decrease the traffic of patients going through our clinic.

Resident coverage has been minimized. Our team isn't always a full resident team, which of course, means that not only are we now losing some of those helpful hands, but residents are losing some of those experiences that are so important in their education. They have such a brief moment with us and the brief time of a residency and so education is getting affected on the resident level to the point where the national organizations have decreased the required numbers of contact hours required, numbers of cases, to make sure that these residents can actually qualify for graduation, which is coming up soon for senior residents.

Well we talked about education being affected for the residents, well all of our students have been dismissed. So students were dismissed nine weeks ago from rotation and haven't been back. And we don't know when we're going to allow students to come back. It was a mutual agreement between the hospital system and the University to not expose, unnecessarily, individuals. And so the students have been left at home and students now are getting a different type of education. They're doing Zoom meetings, similar to doing the webinar that we're doing today, and they're learning about that telemedicine. How to do Zoom visits and telephone visits in simulation labs, so the students get exposed to something that's obviously changing right before our eyes, as Dr. Barrett suggested. This is new to us, and of course some clinics have been doing this for some time, but not on this scale. And not with reimbursement, the way it's changed just over the last few weeks. And so they're getting a different type of education, but still getting that education, so they too can graduate and go on to residency. And of course, we have no recruits coming to look at our hospital. No recruits from undergrad and no recruits from other doctoral programs.

So it's difficult to give you the perfect algorithm to which patient needs to come into this setting-- this high-risk setting and be seen-- and this particular patient doesn't. It really truly comes down to the individual and we as providers make that decision.

So what types of dressings are we doing? It's important to think about. I have less staff available, vendors and reps aren't available to us in clinic, and skin substitutes are considered, by our hospital, as elective procedures. So the decision was made to finish out anyone that was being treated with a skin substitute in the first few weeks of shelter in place back in March. And then we did not elect to start any new wounds or new patients on skin substitutes and we have not, to this date, started the use of skin substitutes on new patients, on new wounds.

We're putting on dressings ourselves with the lack of MAs, the lack of interns, and the lack of resident coverage, so these dressings need to be cost-effective, available dressings that are on the shelf. And the dressings that either can be changed by the patient, the patient's family, or home health agencies, are dressings that are available and can be made available to them. And dressings that hopefully can stay on for a prolonged period of time and still manage the bioburdens of the wounds, still manage the drainage.

Total contact casts, I'm a big believer offloading is key. We are still doing total contact casts, so not only patients that were currently being treated with TCCs, but patients with new diabetic foot also is that need to be offloaded are being seen weekly with TCCs, because we can't heal these wounds without the help of that TCC. And again, these patients are at risk and I do not feel comfortable leaving a total contact cast on for greater than seven days. There's too many additional risks associated with that, so we're continuing to see those patients on a weekly basis.

As I mentioned as providers, we're responsible for putting on the dressings. We're responsible for taking off the dressings. We're doing the photo documentation. We're measuring wounds. We're doing it all, similar to what Dr. Barrett is having to do at his clinic, but we are a lot more involved with our patients as far as doing the actual dressing changes and the documentation for the patients.

Within the dictation room, we are making sure to socially distance ourselves. We leave a computer station open between every provider and we are responsible for cleaning each station before and after use at the beginning and the end of each clinic. Highland Hospital has been really good about making sure on the hour, every hour, they're cleaning all the high contact, high risk, surface areas-- doorknobs, door handles-- so everyone's being very responsible there. And it makes it feel like a safer environment than maybe it is.

As far as the PPE goes, we in the beginning had a little bit of a shortage that we don't see that anymore. Thank goodness. We are permitted as providers to wear N95 respirators in clinic if we elect to do so. We are mandated to wear a face covering or a surgical mask at all times. Everybody that comes into our facility gets screened-- staff and patients alike. You have to answer a short survey. You get a temperature scan and you are provided a mask if one is not already with the patient or with the staff member. And you're expected to leave that mask on at all times.

So what's happening with these patients? Are they doing well? Are they completely falling apart with some of the changes, some of these restrictions? Well now we've actually seen, especially with a diabetic foot ulcer, with a DFU, and improved compliance. It's much easier for patients in California that are sheltering in place now for nine weeks going on 10 weeks it's much easier to offload if you're not allowed out of the house. And so these patients actually are doing a much better job than the traditional patient had been doing prior to this at keeping off of these wounds.

Now it hasn't been on a long enough period of time to know how poor patients are doing with glycemic control. I think in a few more weeks we'll have a better picture of what's happening there. I know myself I'm not doing a great job at home with what I'm eating, so I'm sure that's true for a lot of my diabetic patients and other co-morbid patients that are stuck at home and probably not doing as good of a job and of course probably not exercising. But we are seeing an improvement in the offloading of these ones.

So when do we get back to normal? What is normal anymore? Will we ever truly go back to the way we were in December or January of this year? We don't know. It just got announced earlier this week that Los Angeles is extending their shelter in place by another three months.

We had word from Gavin Newsom, the governor in California, that we were going to start to be allowed to do elective procedures again. That's true more so at small facilities, smaller hospitals. That's a big revenue source and maybe hospitals that aren't currently treating COVID 19 patients, but as we are the hospital for the city of Oakland and Alameda County, I have the feeling that we're going to be one of the last to start opening up our operating rooms to all elective procedures.

So it's going to be some time and I think we're going to see some long term changes, as Dr. Barrett suggested. Some long term changes for the positive with the improvement in telemedicine and leaning on home health agencies. So thank you. And with that, I will send everybody to Louisiana to speak with Amanda. Hi Amanda.

AMANDA ESTAPA: Hi, everyone. Thank you for joining us. I'm going to talk to you a little bit about our practice. We are a company-- I'm a nurse practitioner first and foremost. I work for a company called MedCentris. We're a wound medicine company out of Louisiana-- based out of Hammond, Louisiana-- and we cover over 60 facilities in the states of Louisiana and Mississippi.

We provide services throughout the care continuum, so we are in the acute hospital all the way to the home. So I see patients and have tried to manage the challenges of COVID and all of the barriers we've had to seeing our patients in almost every care setting throughout all of this. So that's what I'm going to talk to you about today.

And we'll start with how do we empower our providers to continue providing quality wound medicine during this time? Like I said, I am a nurse practitioner, first and foremost. I'm also vice president of clinical services for MedCentris. I've been a nurse practitioner for 16 years. I'm acute care by training, but really narrowed my focus on medicine in 2010, about 10 years ago.

Our home office is in Hammond, Louisiana as I mentioned, and we service patients throughout the entire care continuum. So what are the preventative care measures that we are taking? Of course, protecting our patients, staff, and their families is of highest priority-- in all care settings-- whether it be in one of our private office clinics or sending our providers into a facility that we actually partner with.

We are following recommendations from each health care facility that we partnered with, whether it be an acute hospital, a long term acute care, skilled nursing facility, or rehab. We're seeing checkpoints at entrances of all locations. We, as a company, have mimicked the other care facilities that we work with and placed checkpoints at the entrance of every building to check temperatures, provide brief screening and questionnaire regarding symptoms, travel, and any recent exposure before anyone is allowed to enter the buildings.

All clinical staff are provided N95 respirators, as well as cloth masks, to cover those N95 respirators. In the beginning of all this, we had a lot of challenges getting our hands on the respirators for all of our providers and clinical staff. So we opted to start making cloth masks to cover those respirators, to prevent soiling throughout the day time, to limit replacing the mask throughout the day.

Of course, we followed standard PPE and infection control measures. As always-- in every location-- that's standard health care. And cloth mask are also provided to all administrative staff. Here in Hammond is our home office, so half of our building is administrative offices. We have coding, billing, denials, human resources, et cetera, and all of those departments for the staff that is actually physically coming to the office, we have them wear cloth masks.

So to talk a little bit about the difference. I know Dr. Barrett touched on this, the surgical mask versus the respirator-- and like I tell friends, family, neighbors, and co-workers-- the difference between the mask and the respirator is very simple. The mask protects you from me, whereas the respirator protects me from you.

The surgical masks prevent any bodily fluid or anything from exiting my mouth and going into the air or airborne particles. It is not fool proof. That surgical mask is really just to prevent transmission of fluids. And there's some data out there that suggests that it reduces transmission rate of 50% just wearing a mask in public, which is why most people are. The CDC has recommended wearing masks in public.

The respirators, on the other hand, really need to be fit-tested. Most hospitals fit-test medical personnel when they're hired and that fit-testing-- I'm not going to get in great detail, but essentially you would try the different size mask, though differentiating between COVID-19 guidelines. Being we are in all care settings, like I mentioned, we carefully monitor guidelines as directed by the CDC and the Louisiana Department of Health.

As individual facilities or institutions offer guidance daily, we follow those directions as well whether they have differences in their screening processes or their accessibility for our patients. Most of our hospital partners have been great about those daily updates and really sending out blasts on number of cases in each building and how many patients have been discharged-- of course we celebrate that-- how many patients have actually beat this virus and actually on the way home or just go outside the hospital.

Guidelines for private offices have also been modeled after the CDC and the Louisiana Department of Health and partnering institutional guidelines. These guidelines are reviewed daily and reported to what we have is a COVID-19 task force. That task force for our organization meets regularly and then reviews all the information, evaluates it, and disseminates it throughout the organization so that everyone is kept up to date on the latest guidelines and where we're moving, where and how we're moving, forward.