SUGGESTED SAFETY GUIDELINES FOR MEDICAL OFFICES

Copyright © 2020- IntermediaWorx Inc. Educational Publications & NY Cancer Resource Alliance

As essential health and medical service providers, our community looks to us to set the standards when it comes to implementing safety measures, risk prevention strategies and sanitizing efforts.  We are all in the same fight to control the spread of pathogens and to preserve the health of our patients and our staff.  These same priorities align with our commitment to share these top recommended protocols for HEALTH & SAFETY which we assembled from a wide survey of safety‐minded colleagues. We urge you to review and consider these safety measures for your office.  Only together can we continue 'flattening the curve' and win this global health crisis- one office at a time!

1) BY APPOINTMENT ONLY:    As private practices are now beginning to re-open on a cautiously limited and adjusted schedule, communicate with your patients that you are officially open for in-person patient care and your new office hours. Adjusted scheduling allows you to better spread out all appointments for better crowd control and allows your staff time to disinfect and clean between patients. Also, emphasize NO WALK-INS.

2) TEMPERATURE CHECKS AT THE DOOR: More and more businesses and professional practices are now requiring temporal temperature checks at the door as an essential public safety measure.  The doorway is a major point of contact with the public at large- and one of your first lines of defense, starting with temperature screenings. Also, you can suggest all patients to check their temperature prior to traveling to your office - and stay home if they have above 100 degree reading (recommendation by the CDC). 

3) PATIENTS ANNOUNCE THEMSELVES UPON ARRIVAL: When the patient reaches your facility for their appointment, request that they announce themselves via phone from outside. This gives your staff a chance to adjust in case the office is backed up- or if you can see them earlier. If possible, encourage patients to wait outside the building until their time is ready.

4) THE "NEW" WAITING ROOM: More and more doctors’ offices are now reducing the number of seats, and others are even eliminating their waiting rooms altogether.  Waiting rooms have been recognized as a potential ground for sharing bacteria and viral pathogens.  Reducing the wait capacity to the least number of patients (ONE or TWO max) is crowd-control and supports social distancing. 

5) (NEW) REMOVE MAGAZINES & NEWSPAPERS: Take away any materials in the waiting room that may land on a patient's hands.  Reading material is a potential breeding ground for traveled viruses from others.

6) MASKS & OTHER PPE: The current law of “NO MASK = NO SERVICE” applies to all indoor professional or commercial settings where masks (nose & mouth covering) are required AT ALL TIMES. And when working with patients under treatment, make sure to wear clinical-grade protective gear such as gloves, protective gowns and face shields as standard precaution. 

7) HAND SANITIZING: Regular hand-washing (20 seconds) is highly advised for reducing contamination from pathogens both for the public and your staff. In addition, your office should have visible & easy access to hand sanitizers in every room especially for all office occupants. 

8) REDUCE IN-PERSON TALKING: As viruses are widely recognized to be transported by one’s BREATH and atomized saliva, a major part of Prevention means limiting verbal exchange between patients and medical staff to the absolute essential minimum. A safe alternative is discussing anything administrative BY PHONE prior to the appointment.   

9)  PAPERLESS OFFICE:  Another means of reducing person-to-person contact and minimizing physical engagement with patients. Transmitting and receiving patient forms and payment processing via email before the visit is a proven and safe office solution (PAPERLESS OFFICE) that streamlines workflow and reduces patient time spent in the office. 

10) TELEMEDICINE: A sustainable tech option that is spiking in popularity, TeleMedicine is a nationally billable alternative to the (now risky) face-to-face consultation and post-procedure doctors’ visit.  Digital and video communication with patients is an intelligent use of our existing web & video technology.  Telemedicne supports the elimination of the patient's travel time and is a completely SAFE preventive measure from any possible exposure from a waiting room or public contact.

11) OFFICE DISINFECTING REGIMEN: Stock up on disinfectant wipes and sprays for your staff’s daily maintenance.  Upgrade your office cleaning routine to include a regular hospital-grade sanitizing regimen.  This includes use of industrial rated anti-microbial products. Offices and hospitals can hire outside disinfecting companies to come in and conduct disinfecting services. Research the many available products and sanitizing vendors in your area. Also, explore the many new disinfecting technologies (their efficacy and pros and cons) - including liquid sprays, electrostatic applications, UV-C (Ultraviolet) Lamps and Negative Air Ionizing Filters.  [CDC also recommends increasing the frequency of disinfecting surfaces.]

12) (NEW) QUESTIONNAIRE / PATIENT'S CURRENT CONDITION
Sometimes, clerical measures can be a preventive tool.  Many doctors offices are requiring patients to fill out and sign a form asking about the patient's health condition and history with Covid-19. By their signature, they are attesting legally to the validity of their responses, committing them on record as to their level of risk to others and to themselves.

..............................................................................................................................................................

THE DAILY SELF-CHECK KIT

In keeping with daily maintenance in our current pandemic, "knowing is half the battle" and is a useful weapon against an invisible enemy. According to the NYS.gov site, PREVENTION protocols include MATILDA'S LAW which includes:

- Remaining indoors

- Going outside for solitary exercise

- Pre-screening all visitors by taking their temperature

- Wearing a mask in the company of others

- Staying at least 6 feet from others

- Do not take public transportation unless urgent and absolutely necessary in addition to washing your hands and wearing a cloth face covering or a mask around others. 

As we all agree that illnesses can be unpredictable (and even SNEAKY), to know your body requires a few essential tools.to use daily to check your current state of health. (see graphic INSERT) This includes a PULSE OXIMETER to check your daily oxygen saturation of your blood. This helps identify if there is something wrong with your lung functions. Next, check your temperature at least once a day. If it is possible to have more than one thermometer, this allows you to get a confirmation reading as you should never trust any thermometer to always be accurate. Lastly, a blood pressure monitor to track high BP or irregularities - considering the coronavirus hs a cardio-pulmonary disorder (that means lungs and heart).

..............................................................................................................................................................

TALK ABOUT SAFETY... See what other docs are saying

NO-TOUCH TECHNIQUE

“Without a doubt, this pandemic has awakened much change in the way we do just about anything, and thinking SAFETY is a big part of that! Our patients appreciate our converting to an ONLINE platform for all patient registration forms... once we went completely digital,  you have a true “no touch” and "no talking"  technique where patients walk directly in to an exam room and no stopping at the front desk and no MA’s or techs needed.  It’s a direct walk into treatment then out the door.”  
– Dr. Stephen Chagares, Breast Cancer Surgeon- NJ (drchagares.com)

A TIMELY REVOLUTION IN METHODS

“- I’ve always felt that there are many areas in patient care that could use an upgrade... this  pandemic made us re-evaluate every part of our work process for better safety and cost efficiency. This  includes our current resources like TeleMedicine- where remote consults and digital file have become such a blessing as it saves patients travel time and $$ while keeping everyone safe from unnecessary risk and exposure." 
– Dr.Robert  L. Bard, Cancer Diagnostic Imaging- NYC (Cancerscan.com | TelemedScans.com)



LEADING BY EXAMPLE
"It is imperative to institute good safety measures in medical office settings as we begin to navigate this COVID-19 pandemic and help guide the country through the reopening phases.  As healthcare professionals- it is our duty to set the example for others to follow.  We can provide a framework and high standards of health and safety ideas that can be mirrored in all office settings, stores, schools , banks and other industries." 
- Juanita Mora, MD, Volunteer National Spokesperson, American Lung Association

PREVENTIVE ADJUSTMENTS

“The landscape for treatment has changed…Patient visits are spaced so that no one is in the waiting room. Patients  must wear a mask upon entrance and throughout the course of the visit and so does the caregiver or attendant. After each visit, the room is wiped down with appropriate sanitizers; careful to not overdo it which might cause respiratory problems. Common surfaces (doorknobs etc) are also wiped” 
– Dr. Richard Kushner, Podiatrist - NYC

PATIENT CONFIDENCE
"It is critical that every patient “touch point” is educational and science based. Examples include; the first email sent out announcing your practice re-opening, the screening questions that are asked prior to the patient’s first visit,  the patient’s greeting/screening at your entrance, the handwashing station, the waiting and patient areas. Take the time to make sure your staff is comfortable with the procedures implemented."
- Dr. Carol Stillman Physical Therapist and owner of Sutton Place Physical and Aquatic Therapy.

SMART SYSTEM UPGRADE

"Promoting SAFETY GUIDELINES in any health practice (especially during this Pandemic) is everyone's duty in our community-- where we all need to do our part to help minimize the risk of contamination. Policies like checking temperatures at the door and having maintaining sanitizers and PPE's for the staff gives the patients peace of mind knowing they are walking into a safety conscious office.  It's an opportunity for providers to lead by example!" 
– Jessica Glynn, Licensed clinical social worker/psychotherapist- NYC (jagtheracoach.com)  

For  the  latest  CDC updates,  additional  information  and  safety  recommendations  for  your  medical  office,  visit:  PREVENTION101.ORG and review our CDC SAFETY LINKS.  This list of suggested Safety Guidelines for healthcare offices  is published by The Advocacy for Professional Safety‐ a branch of the NY Cancer Resource Alliance and IntermediaWorx  Educational Publishing. (c) Copyright, 2020‐ All Rights Reserved. 

..............................................................................................................................................................

VIDEO EXTRA:
"The Power of Prevention of Covid-19 is in YOUR HANDS"
Source: MD Anderson Cancer Center

You have the power to reduce your risk of infection by washing your hands often. Watch how a blacklight reveals what improper hand washing can leave behind. According to Dr. Christina Le-Short of MD Anderson Cancer Center, "Cancer patients are at greater risk of developing complications from respiratory viruses... Effective hand-washing is your best defense against germs that cause the flu or Covid-19".

----------------------------------------------------------------------------------------------------------------------

A WORD FROM THE TOP

As the country aims at opening more and more areas of business, the concern for safety is at its highest.  Commercial business and health centers alike are following the many safety protocols recommended by city, state and federal leaders with the hopes of quelling the threat of a Covid recurrence, bringing us all back to another shut-down.

In a NY State press conference on 5/12, Governor Andrew Cuomo presented his goals for reopening lower New York with safety conditions, starting with a push to maintain social distancing and valuing the importance of continued face covering.  "Out of respect to you," he started, "I wear this mask.  The mask says I respect the nurses and the doctors who killed themselves through this virus to save other people- all essential workers who get up every day to do their job so I can stay safe... it's not about ME-- it's about WE!" ( see complete video LINK)

A recent CDC report about Screening Patients for COVID-19 at Intake stated, "If there is widespread community transmission of COVID-19, facilities can consider instituting active temperature monitoring by having a staff member check the patient’s temperature immediately upon arrival at the door and when the patient is first asked about symptoms".  (ref. link: CDC Screening Patients) In addition,  masks, social distancing and disinfecting work areas are part of this new critical infrastructure.  (See complete CDC Interim Guidance)

In addition, the NYS Dept of Health also published Covid-19 Guidance for Medical Providers about infection control.   "...When engaging a client (patient), staff should use alcohol-based sanitizer with at least 60% alcohol prior to entering the home and should wear a face mask, if available.  Staff should attempt to keep at least six (6) feet away-- [and] should also remind everyone to practice appropriate hand hygiene and to avoid touching their face".  From a May 2020 update, the DOH also encourages Telemedicine and TeleHealth technologies whenever possible. (link).- Also see Managed Care Organization Contracting and Surveillance Relief.  (DOH link) 

Also see: Senator Biaggi’s 6/4 COVID-19 Update: NYC has Zero Confirmed COVID-19 Deaths for first time since March 11

Disclaimer & Copyright Notice:  Any materials (article links, video links etc) shared or reposted from outside sources are acquired by express permission from the source publisher who are independent sources not associated with this publication nor are related in any way with other sources published herein. All content sourced in this section have been selected on the merit of the scientific, technical or relevant information they provide. Any views and opinions expressed by the authors or speakers in the entries of this section may not necessarily reflect those of our publishers and producers.  The original materials provided on this page are copyrighted and are intellectual properties of the publishers/producers (The NY Cancer Resource Alliance/IntermediaWorx inc. Educational Programs). It is provided publicly and strictly for informational purposes within non-commercial use and not for purposes of resale, distribution, public display or performance. Unless otherwise indicated on this web based page, sharing, re-posting, re-publishing of this work is strictly prohibited without due permission from the publishers.  Also, certain content may be licensed from third-parties. The licenses for some of this Content may contain additional terms. When such Content licenses contain additional terms, we will make these terms available to you on those pages (which his incorporated herein by reference).The publishers/producers of this site and its contents such as videos, graphics, text, and other materials published are not intended to be a substitute for professional medical advice, diagnosis, or treatment. For any questions you may have regarding a medical condition, please always seek the advice of your physician or a qualified health provider. Do not postpone or disregard any professional medical advice over something you may have seen or read on this website. If you think you may have a medical emergency, call your doctor or 9-1-1 immediately.  This website does not support, endorse or recommend any specific products, tests, physicians, procedures, treatment opinions or other information that may be mentioned on this site. Referencing any content or information seen or published in this website or shared by other visitors of this website is solely at your own risk. The publishers/producers of this Internet web site reserves the right, at its sole discretion, to modify, disable access to, or discontinue, temporarily or permanently, all or any part of this Internet web site or any information contained thereon without liability or notice to you.

©Copyright Intermedia Worx Inc./Prevention 101. All Rights Reserved.

GERMOPHOBE'S PARADISE & THE BOOM OF THE SANITIZING MARKET

by: Robert L. Bard, MD

In the era of Covid, where fighting invisible airborne killers are recognized as our new global reality, we call on the scientific community to offer logical innovations to thwart the pandemic issue.  While a vaccine for the Coronavirus remains in research phase, our battle leans heaviest in targeting prevention, safety and protection protocols.

As we continue to reach new levels of "the curve", businesses and industries continue to suffer the economic downturn while a select group are receiving the BOOM of a lifetime.  Such is the case for web-based technologies (temporarily replacing social gathering), PPE manufacturers, pharmaceuticals and the many marketers of SANITIZING PRODUCTS.

As market trends are aligned with consumer behavior, the March lock-down prompted panic-shopping and premature hording frenzy.  This led to empty shelves nationwide, further raising the level of desperate consumer activity.  But recent signs are showing a strong rebound of fulfillment activity in stores with a re-growing supply of many health essentials.

Manufacturers old and new are fast responding to the consumer's emotion-based reactive shopping behavior.  Domestic popular brands and generic house brand producers (white label manufacturers) are now showing increased presence in retail store shelves with more stores finding little need to limit customers from over-buying. The War Powers Resolution Act has been said to help motivate new American suppliers and producers by expanding their product lines to include creating PPE's and other health & sanitizing products.

...BUT WHAT ARE THEY SELLING US?
In the case of marketing sanitizers, a phrase like "Kills 99.9% of bacteria " is one of the most common sell-phrase used to describe antimicrobial or antiseptic products. Others brandish even more pointed descriptions like germicidal, fungicidal, virucidal, or (even) tuberculocidal to paint an even higher scientific picture to lure buyers.   A wise word of caution to consumers is to READ the active ingredient in all these packages as part of recognizing exactly what we are exposing ourselves to-  and knowing how they can affect us.

Fact: Not all sanitizers are the same!  Types of  ANTIMICROBIAL SANITIZERS on the market fall into one of five base categories: alcohol, chlorine (bleach), phenol, quarternary amine and quarternary amine + alcohol. (The effects of these chemicals and their potential health effects will be discussed in part 2 of this report.)

* Benzalkonium Chloride
* Isopropyl Alcohol
* Ethyl Alcohol (ethanol)
* sodium hypochlorite
* Didecyldimethylammonium Chloride
* Alkyl Dimethyl Benzyl Ammonium Saccharinate

COMMERCIAL SANITIZING: PREVENTION OR MAINTENANCE

Entering the warmer months of 2020, we are all (by now) programmed by prevention to wash our hands incessantly, mask up in all public and shared areas and "think contagion" when touching just about anything.  Where health means supporting our immune system to fight off any bacteria or virus,  this fight also means stepping up our cleaning practices to stricter measures like sanitizing , disinfecting and sterilizing of our homes and work areas.

For commercial areas, an influx of cleaning companies are majorly promoting "disinfecting services for covid".  The industry term HAI (healthcare-associated infections) is often used in healthcare and hospitals to apply to disinfecting solutions and sanitizing standards.  Upon review of some of the top advertised service providers, certain products and sanitizing protocols are offered to manage HAI rates.

These products are either "fogged" in an enclosed space, sprayed on contact with an "electrostatic applicator" or wiped on surfaces.  One common product is called Noroxycdiff - a hospital grade, EPA registered disinfectant for use against SARS-CoV-2. The main active ingredient in our chemical is Hydrogen Peroxide. Another is BIOCIDE 100, a product used for remediating mold. Meanwhile other companies offer applying VITAL OXIDE through an Electrostatic Sprayer or hospital grade wipes like CLOROX HEALTHCARE VERSASURE or OXIVIR wipes.  

Other products are also trending on the market like Nano-wipes including the common brand "Bio-Kil" used in high-demand areas such as ICU. "After application of Bio-Kil, the bacterial burden declined in both groups, although the reduction was greater in the study rooms as compared with the control rooms (p = 0.001). During the pre-intervention period, 16 patients were admitted to control rooms and 18 patients to study rooms. After the intervention, 22 patients were admitted to control rooms and 21 patients to study rooms. The number of cases of new-onset sepsis declined in the intervention group (from 33% to 23.8%), but increased in the control group (from 25% to 40.9%); however, there was no significant difference in incidence of new-onset sepsis between the study and control rooms after intervention. Application of Bio-Kil reduced the environmental bacterial burden and MDROs in ICUs. Further studies are needed to evaluate the efficacy of this nanotechnology-based disinfectant in reducing HAIs. [2]|

.................................................................................................................................................................

SANITIZING WITH UV-C LIGHT
In a recent interview with American Health Supply Co. (a PPE supplier), a unique concept of using ultraviolet light to disinfect surgical and respiratory masks for repeated use extends the life of what is currently a rare, life-saving commodity.

Hospitals that use UV-light disinfection after cleaning and disinfection standard protocol have actually significantly mitigated infection risks associated with environmentally mediated transmission routes. [6]  Investigations of the bactericidal effect of sunlight in the late 19th century planted the seed of air disinfection by UV radiation. First to nurture this seed was William F. Wells, who both discovered the spread of airborne infection by droplet nuclei and demonstrated the ability of UVGI to prevent such spread. Despite early successes in applying UVGI, its use would soon wane due to a variety of reasons that will be discussed in this article. However, with the enduring research of Riley and others, and an increase in tuberculosis (TB) during the 1980s, interest in UVGI was revitalized. With modern concerns regarding multi- and extensive drug-resistant TB, bioterrorism, influenza pandemics, and severe acute respiratory syndrome, interest in UVGI continues to grow. Research is ongoing, and there is much evidence on the efficacy of UVGI and the proper way to use it, though the technology has yet to fully mature. [5]

Dr. Christopher Centeno of Regenexx, a prominent stem cell therapy center in Boulder, Colorado subscribes to the benefits of UV-C disinfectant lighting. “Our clinic began researching UVC light sterilizers about two months ago, but they were very expensive and hard to get. Hence, I decided to build my own. This project cost $400 with parts from Amazon that took a week to get. The average commercial price of an exam room sterilizer is about $5,000 and these take months to be delivered after ordering.  I’ve tested our DIY unit with standard UV dosimeter cards used in hospitals and it pumps out enough UVC light to kill MRSA.”

An early study showed that NAIs caused a significant amount of biological decay of the bacterium Serratia marcescens. Exposure to NAIs showed inactivation or growth inhibition of the bacteria E. coli, Candida albicans, Staphylococcus aureus, P. fluorescens [96,97,98,99,100] and has a lethal effect on starved Pseudomonas veronii cells. NAIs prevented 60% of tuberculosis (TB) infection and 51% of TB disease. Except for the inhibition effect of NAIs on bacteria, reports also showed that NAIs inhibited the growth of fungi and viruses. (Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6213340/)

.................................................................................................................................................................

PREVENTION 1: IMMUNE SYSTEM SUPPORT
By: Dr. Jesse A. Stoff

Basic biology attributes any contracted sickness or disease to a WEAKENED and COMPROMISED IMMUNE SYSTEM.   Our body's immune system accounts for approximately 1% of the body's 100 trillion cells.  The different cell lineages that develop all share one common objective: to identify and destroy all substances (living or inert) which are recognized as not being part of what "should be in the body.” Whether it is an abnormal cell or what are perceived as dangerous or damaged cells, they are actively hunted down and destroyed by effector cells of the immune system.

Imagine having your own personal army of cells in your highly advanced defense system, working against outside invaders or abnormal cells where each cell type (over one hundred and eighty-seven recorded) carries their own dedicated function. This specialized team of cells work together to fulfill the complex mission of protecting the body from infection or illness each day.

During this (and any) pandemic, supporting and boosting the immune system is priority 1. Improving the health of the immune system means your body will become more resistant to incoming diseases. Making your immune system stronger is not a linear program, because you are dealing with a complex network of factors in your body that needs to be addressed. However, there are certain measures you can take to boost the immune system.  If you have to do one thing to boost your immune system, it should be maintaining a healthy lifestyle because there is no better and natural way for the improvement of the immune system. Avoid smoking, eat healthy, limit your alcohol consumption, maintain your weight and blood pressure, and get enough sleep.

Make sure that you are consuming all those important micronutrients which are important for bolstering the immune system. If you can’t manage this through your diet alone, go for supplements.  Vitamin D is often referred to as the sunshine vitamin because our body can actually manufacture vitamin D. It's a fat-soluble vitamin, and it's metabolized in our body from various fat-soluble steroid complexes, as they're referred to. And vitamin D is then metabolized in the skin and split from some of these molecules into the active form of vitamin D- which then has a wide range of effects on basically every single cell in our body. Vitamin D isn't just about having strong bones and strong teeth; vitamin D also has some really wonderful effects from a preventative medical point of view.
(For complete articles on the immune system, visit Dr. Stoff's Immunology Today blogsite: http://immunologysmarts.com/)


Ref: 
1) A Comparison of Commonly Used Surface Disinfectants
https://www.infectioncontroltoday.com/environmental-hygiene/comparison-commonly-used-surface-disinfectants

2) Bio-Kil, a nano-based disinfectant, reduces environmental bacterial burden and multidrug-resistant organisms in intensive care units-  Journal of Microbiology, Immunology and Infection https://www.sciencedirect.com/science/article/pii/S168411821630038X

3) Silver nanoparticles as an effective disinfectant: A review (Pub med)
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7127744/


4) Top ten disinfectants to control HAIs
https://www.hospitalmanagement.net/features/featureppc-disinfectants-hai-globaldata/

5) The History of Ultraviolet Germicidal Irradiation for Air Disinfection 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2789813/

6) Evaluation of an Ultraviolet C (UVC) Light-Emitting Device for Disinfection of High Touch Surfaces in Hospital Critical Areas https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6801766/


Disclaimer & Copyright Notice: The materials provided on this website are copyrighted and the intellectual property of the publishers/producers (The NY Cancer Resource Alliance/IntermediaWorx inc. and Bard Diagnostic Research & Educational Programs). It is provided publicly strictly for informational purposes within non-commercial use and not for purposes of resale, distribution, public display or performance. Unless otherwise indicated on this web based page, sharing, re-posting, re-publishing of this work is strictly prohibited without due permission from the publishers.  Also, certain content may be licensed from third-parties. The licenses for some of this Content may contain additional terms. When such Content licenses contain additional terms, we will make these terms available to you on those pages (which his incorporated herein by reference).The publishers/producers of this site and its contents such as videos, graphics, text, and other materials published are not intended to be a substitute for professional medical advice, diagnosis, or treatment. For any questions you may have regarding a medical condition, please always seek the advice of your physician or a qualified health provider. Do not postpone or disregard any professional medical advice over something you may have seen or read on this website. If you think you may have a medical emergency, call your doctor or 9-1-1 immediately.  This website does not support, endorse or recommend any specific products, tests, physicians, procedures, treatment opinions or other information that may be mentioned on this site. Referencing any content or information seen or published in this website or shared by other visitors of this website is solely at your own risk. The publishers/producers of this Internet web site reserves the right, at its sole discretion, to modify, disable access to, or discontinue, temporarily or permanently, all or any part of this Internet web site or any information contained thereon without liability or notice to you.


©Copyright Intermedia Worx Inc./Prevention 101. All Rights Reserved.

The "SalScan" Procedural Research Project: Ultrasound Chest Monitoring of Covid+ Patient

Program credits: Lennard Gettz (chief strategist/coordinator), Michael Thury (Remote instructor), Dr. Robert Bard (Imaging Overreader/Radiologist), Carmen Regallo-Dewitt (Editor), Sal Banchitta (Patient), Elizabeth Banchitta (Patient coordinator) & Terason Ultrasound Inc.* Copyright©2020- IntermediaWorx /NY Cancer Resource Alliance /CPS- Coalition for Professional Safety- All rights reserved.

VIDEOS OF SAL BANCHITTA UNDER THE SALSCAN REMOTE CHEST ULTRASOUND PROJECT

ABSTRACT
In response to the many health concerns of the current Covid-19 pandemic, radiologists and imaging technicians worldwide have presented significant demand for portable imaging in “the front lines” -including pandemic treatment centers, emergency care centers and triage facilities.  As a result of this demand, hospital bedside ultrasound screening of respiratory & cardiovascular disorders are now expanding in popularity to identify disorders that may be related to Coronavirus pathogen response.
Renamed "the modern stethoscope",  the handheld ultrasound provides visual evidence of many organs in their current state or condition.  Matching the many field advantages of the portable nature of ultrasound devices with the surge of tele-health/telemedicine solutions, remote training procedures and e-file sharing capabilities supports the future of immediate data access and diagnostic accuracy.  This report provides a practical overview of the entire remote screening process while providing a full breakdown on each element of the testing process.

1. INTRODUCTION
In April of 2020, a collaborative research project to explore (and design) a working model for remote ultrasound training and diagnostic evaluation was formed with the hopes of formalizing a future strategy of "virtualizing" technology-based health assessments.  Code named "SALSCAN", this concept was formulated between a research strategist & process analyst, a NYC based radiologist, a volunteer patient who tested Covid-19, a portable ultrasound manufacturer* (donor of current portable ultrasound device) and a remote/virtual training specialist to conduct imaging guidance to ensure the patient's proper use of the device.  The developers hoped to formalize this protocol as a nationwide scanning alternative during Covid times, as it was first launched in European triage centers to identify covid-related respiratory disorders [1]

The SALSCAN test program was established to review, record and build conclusive evidence of any/all useful information that may lead to, or reflect the strategic paradigms of real-life applications pertaining to the use of remote personal & portable ultrasound.

2. TESTING PARAMETERS
Objectives of the SalScan test program include:
1) Creating a synergistic work model of the 3 integral participants (the patient, the trainer and the overreader/radiologist) to support a future work plan for any and all remote diagnostic scenarios
2) Blueprinting and monitoring the progress of a working model of a medically monitored self-scanning paradigm (including scan diagrams on the torso, selected probes and frequency settings)
3) Developing any and all instructional guidelines to duplicate the process of this plan
4) Selecting and reviewing portable ultrasound technology with easy-to-use controls for ANY patient
5) Tracking the feasibility of a patient-induced tele-training program to capture ultrasound images for medical diagnosis via tele-medicine
6) Challenging the current web-based communication solutions, including conferencing, file sharing, privacy protocols, media player applications and collaboration (group) reporting capabilities
7) Developing a fully-functioning remote training program (through the use of web-based teleconferencing) to guide the patient on the proper/effective use of ultrasound transducers or probes
8) Assessing the actual ‘learning curve’ of the patient to confirm a formatted lesson plan
9) Evaluating the UI (user interface) of the current technology controls to identify patient’s learning success
10) Reviewing, overcoming and problem-solving all obstacles of the remote connection
11) Develop a fully streamlined data transferring/file sharing portal with the overreader (radiologist) to assess and submit a full report of the patient’s condition
12) Producing a quantitative data-gathering screening program from a home-based unit
13) Exploring and confirming the effectiveness of a portable ultrasound as a screening option for any field (non-hospital) situation- ie. battlefields, the ER, ocean liners, ambulances, space programs, natural disasters, etc.
14) Promoting a safety-conscious program to test for contagious pathogens in the safely & comforts of one's own home without health risks from travel
15) Developing a solid 3-point communication system for a real-time remote diagnostic protocol; synergy between patient, trainer and radiologist
16) Opening many more potential patient types, disorders and scenarios for this level of remote scanning access and telemedicine

This self screening program is an opportunity to beta-test key elements of the remote instructional functions and medical  diagnostic intervention whereby the project planner can successfully track and explore all procedural responses and the many findings set by the dynamics between the 3 parties: the patient, the radiologist and the remote trainer.

The obstacles of zero physical contact and the scenario of conducting a scan training to the a non-medically familiar individual aimed to draw valuable conclusions dedicated to reproducing this remote screening plan for countless emergency and non-urgent care situations worldwide.

The volunteer patient (Mr. Sal Banchitta) offered his own Covid-test results, his experiences and his complete participation to this technical process research. The program directors were successfully able to conduct a real-time beta test that drafts a complete staging plan on a future of remote virtual ultrasound screening.

click to enlarge

2.5 WHY ULTRASOUND: TESTING FOR "B LINES"
According to Dr Philippe Kory (critical care physician) "When we use an ultrasound on the lungs, we look for something called B LINES. Compare with a base line, the worse your lung ultrasound score was, the higher risk you had of deterioration. It's another type of exam where you could identify the trajectory of a patient, leading to a possible need for an escalation in therapy."


3. ADVANCING THE REMOTE SCAN MOVEMENT & PRE-HOSPITAL ULTRASOUND:
Before Covid-19, TeleMedicine, TeleHospital and other web-based 'tech med' solutions have existed for decades. Teleradiology has been used for over 60 years since film was being passed through a digitizer for direct digital capturing and transmitting globally overnight.  [2] This allowed faster response when it comes to head injuries in rural areas and other trauma events where teleradiology vastly improved other applications in diagnosis and treatment planning.  Today, expanded evidence of remote imaging appear in areas like space travel, emergency response, military deployments- and pandemics.

Emergency response units rely on
remote / portable innovations for 
on-site calls

Pre-hospital ultrasound has many clinical applications that may reduce morbidity and potentially improve outcomes for patients with life-threating conditions.  Remote ultrasound telemedical services were developed nationally by the author (Dr Bard) in 1980 and military field hospital application by Dr Ted Harcke for the US Armed Services in the in the 1990’s for imaged guided removal of foreign bodies. Worldwide, responders have adopted the use of a portable non-invasive, non-radiation ultrasound in their rescue rig.  Remote   For example, in Germany, the use of ultrasound in the field has focused on the FAST exam and cardiac sonography for non-traumatic patients since 2002–2003.  French prehospital clinicians have adopted ultrasound in certain areas as well, including SAMU (Service d'Aide Médicale d'Urgence). The Italian EMS system began incorporating ultrasound into prehospital care in 2005. [3]

Pre-hospital ultrasound is employed in this setting to differentiate reversible causes of pulseless electrical activity (PEA), assess for pericardial, intraperitoneal, and pleural fluid in trauma, and to differentiate between pulmonary edema and emphysema. In the USA, the focus on rapid transport and limiting on-scene time may have contributed to slower adoption of prehospital ultrasound [3]

4. INITIALIZING THE REMOTE SELF-SCREENING CONCEPT AND PROCESS
The patient volunteered himself to be the first test case and self-scanning trainee for a regimen of chest ultrasound scans under the beta-tested REMOTE HOME-SCAN & TELE-RADIOLOGY program. This program adapted key elements of lung ultrasound for a wider set of uses at the safety and comfort of the patient's home for regular ultrasound screening and continued monitoring.
Targets:  Provide the patient and overreader and designated radiologist immediate access to a reliable high-frequency PORTABLE ultrasound scans of LUNGS, HEART, LIVER and KIDNEYS (image- R) - the major organs that may show signs of Covid related disorders.

The "Body Map" followed by the patient (Sal) marking scan target
points of organs as directed by the remote trainer (Mike)

Predictions:  Imaging results are collected from the test subject (Sal) who is assigned to scan himself regularly within a given window of time (6 consecutive days).  In this case, Sal happens to be Covid + but has been recorded to NOT show symptoms.  Use of the ultrasound can either confirm that he is in fact asymptomatic, or may identify any hidden anomalies.

Virtual (web) access:  Through complete remote access, the professional ultrasound trainer (Mike Thury) operates the scanning software (via Teamviewer™) while instructing the patient via video conferencing (Zoom™) on how to properly operate the hand held probes and the ultrasound.

Data Collection Routine:  After each scanning session, the patient and trainer shall save all daily scan images collected- both on the portable device and on a cloud-based backup. Once a given number of days has been satisfied, the designated medical radiologist (Dr. Robert L. Bard, NYC) shall access the device to collect & review all image files for a through analysis.

Communication between the three parties (Image below): Through the use of TeleMedicine and online access of the device's controls and its saved files, the patient has unlimited personal use of a high frequency portable ultrasound while being remotely guided by a certified ultrasound instructor to scan specific organs of concern.  The remote Chest Ultrasound test puts the patient in the drivers seat to safely monitor and receive diagnoses of their own condition.






























5. REMOTE ULTRASOUND BENEFITS FOR ALL PATIENT TYPES
The constant evolution and upgrades in portable ultrasound innovations has made it possible for any patient undergoing treatment to track their own progress on a regular schedule (from home) without the hindrance of traveling to a doctors office.   For patients suffering chronic conditions, personal access to a portable ultrasound with remote access to a designated clinical team represents the next generation of patient diagnostic care. [4]

During his training and scanning period, the patient's participation provided the SALSCAN program with important procedural data toward the foundation for this upcoming national screening initiative. Our program developers' goals aim to support the global use of ultrasound imaging devices for the many non-hospital applications where access to large-format devices are simply not available.  Use of the ultrasound can either confirm the patient is in fact asymptomatic, or may prove to be useful as an early detection device by identifying any hidden anomalies.

5.1 Covid-19 is a multifocal, multiorgan disease meaning that a unit would require variable probes and equipment settings. The settings used in this scan series that included the lungs, liver, kidneys and heart utilized safety protocols for mechanical index (MI) and thermal index (TIS) employing curved array probe for lung, liver and kidneys and sector scanner for heart and lungs. Different transducers are available on many units but this study did not involve the application of the linear probe since the regions insonated were appropriately covered by the sector and curved array, or linear transducer if necessary.


5.1.1MI: The Mechanical Index
MI is of possible clinical interest if the beam focus is close to the surface of lung tissue. MI has the following characteristics:

• Potential bioeffect: Any possible mechanical or non-thermal mechanisms - although the likelihood of adverse consequences from these causes is not well understood, such risk may be highest in the presence of gas-saturated structures such as lung tissue.
• Mode type: Calculated for all modes of operation.
• Tissue type and location: Soft tissue at all locations in the scan field.
• Acoustic parameter: Maximum negative (rarefactional) ultrasound pressure at focus.

5.1.2 TIS: The Soft Tissue Thermal Index
TIS is of interest in the absence of bone, either at the tissue surface or near the beam focus. Applications of clinical interest include general abdominal examinations, first-trimester scanning before fetal bone has ossified, and cardiology. TIS has the following characteristics.
• Potential bioeffect: Thermal heating of soft tissue due to absorption of ultrasound. The TIS value is the ratio of the current probe power to the reference level that would cause
a 1ºC temperature rise in soft tissue.
• Mode type: Relevant for all modes, in both scanned and non-scanned modes.
• Tissue type and location: In scanned modes, soft tissue at the surface is of concern. In non-scanned modes, heating of soft tissue along the beam axis between the surface and focus is considered.
• Acoustic parameters: For scanned modes, the associated intensity at the surface is usually related to surface tissue heating. For unscanned modes, the maximum derated power through a 1-cm2 area anywhere along the beam axis is the basis for estimating tissue heating: unscanned beams less than 1cm2 in area at the surface are assumed to contribute only to surface heating, and the calculated effects are combined with those of scanned modes to estimate total soft-tissue heating at the surface. Unscanned beams larger than 1 cm2 at the surface are assumed to heat tissue only near the focus. Total heating effects at the surface and focus are compiled separately, and the larger value is
reported as TIS.

5.2 the role of the patient includes turning on the unit and applying gel to the areas to be scanned.  Wifi internet is activated for real time connectivity. The sonogram unit activated by the patient will then be used by the remote trainer through video or audio/video conferencing to guide the procedure
5.3 the role of the remote trainer/technician is to view the probe position on the patient and adjust the perpendicularity of the sound beam on the televised image VIDEO ?????  Breathing and other respiratory maneuvers may be adjusted at this time such as investigation of the inferior vena cava when pericardial effusion is discovered or aberrant ventricular wall motion is present.  All imaging functions of the probe such as patient ID input, M mode, Doppler, video are remotely carried out by the trainer during the live scanning session. Routinely 2-5 second videos are recorded for review and verification of the event.

5.4 The role of the physician radiologist is to verify the image quality, probe placement, depth of penetration and confer with the trainer if adjustments are necessary. Ideally this interaction occurs at the initial or second visit. Most patients will have normal findings therefore 12 hour intervals is adequate for observation.  Any aggravation of the symptoms (dypnea, palpitation, oxygen concentration decrease) calls for 4 hour scan intervals and real time physician input. Adverse outcomes may occur at any time and in any organ system. It is recommended that the heart, liver and renal structures be interrogated daily as well since delayed onset of ventricular inflammation (myositis) or large vessel thromboembolic phenomena are increasingly common. If neurologic sequelae occur the linear probe may image the carotid artery in the neck and the ophthalmic artery/vein complex. The sector or phased array cardiac probe has sufficient penetration to assess the intracranial arteries (transcranial Doppler ultrasound) and check for impending stroke or venous thrombosis.

5.5 Overall pulmonary function clinical assessment relates to the A-lines and B-lines. The high percentage of normal pleural A-line appearance implies that there is no significant pleuro-pulmonary pathology as is expected in patients on bedrest. B-line increase may call for hospitalization while the conversion of B-lines to A-lines highlights improvement. Bedside point of care remote diagnostic criteria are not available for non pulmonary organs. In the “sal scan” project A-line pattern was uniform for 14 days and our patient returned to normal activity. He is currently donating his plasma for the benefit of others.



6 REMOTE CT AND SONOGRAM FUSION DIAGNOSTICS
After initial experience with the outpatient remote ultrasound program, the scope moved to remote CT reviews and finally, combined reporting of lung ultrasound with lung CT with the option of image guided treatment using fusion of both modalities (fusion is covered in chapters 3 and 8) at distant locations throughout the United State on inpatients. On one encounter during the month of June, remote CT review by a radiologist supported the clinical impressions by overworked clinical colleagues.

Below are the pertinent data:
6/24/20                                               CT INITIAL FILM         FOLLOW UP
THICKENED PLEURA                               5/5                               1/5
GROUND GLASS OPACITY (GGO)         5/5                               2/5
SUBPLEURAL CONSOLIDATON            5/5                               1/5
TRANSLOBAR CONSOLIDATION          5/5                               0/5
MULTILOBAR CONSOLIDATION           5/5                               0/5
PLEURAL EFFUSION                                N/A                             0/5


KORY #5 BEFORE AFTERDATE REPORT
Kory arrows traction bronchiectasis

...................................................................................................................................................................
SALSCAN PROJECT- STATEMENT OF CONCLUSION
1) The SalScan Remote Screening project started on April 15, 2020 for six (6) consecutive days.  It collected complete ultrasound video images of the patient's Lungs (from various angles), heart, liver and kidneys each day.

2) As of June 1, 2020, the SalScan project concluded its imaging, multi-testing and research efforts showing a non-symptomatic Covid Positive case.  This supports conclusive data available in current medical reports from nationwide testing.

3) The SalScan project integrated the results of the patient's (1) original Covid test and (2) an independent AntiBody test.
* The Covid Positive test result assumed the connection with the patient's heavy Flu-like and respiratory symptoms in early January-Feb. and may have functionally recovered by April as our imaging scans have indicated no present physical traces of pathogen response in the major organs scanned
* The patient's recent antibody test indicated positive (+) results, suggesting the validity of the initial Covid test and its diagnostic result.  Based on current scientific reports, this presence of antibodies suggest a likelihood of infection by Covid-19 pathogens in the recent past and that the patient's immune system has built up a protein defense to fight the virus. (image below)

* Our 6-day scan series recognizes his path to recovery (from his noted symptoms from earlier months) as images gathered on April, 2020 have concluded NO visual trace of pathogen response or infections.

4) The SalScan Program was designed as a PILOT to beta-test the blueprint of future Chest Ultrasound Screening, Remote Personal Screening and Virtual Overreading programs.

5) The SalScan Pilot successfully supported the comprehensive breakdown of the 3-member virtual/remote diagnostic paradigm, whereby this test proves the ease of use of the device and its comprehensive application of web-based communication and file sharing technology.

6) As the SalScan volunteer patient continued to maintain a non-symptomatic state (after July) under a twice confirmed Covid Positive test diagnoses, initiating the use of a personal ultrasound screening helped validate the patient's recovery and/or non-critical status.  This also provided necessary peace of mind to the patient seeking to affirm the direction of his clinical test results.

7) Additional imaging studies, medical (lab) reports and peer-reviewed data shall continue on a quarterly basis due to any possible recurrence that may arise.  Probability of recurrence has been clearly documented in recent medical journals and news reports.

8) The current pandemic and the growing list of treatment communities are poised to receive this report as part of Dr. Robert Bard's global advocacy to expand the medical use of portable ultrasound in "the front lines" of health responders community.

9) The SalScan virtual remote self-screening protocol, its staging plans, chest ultrasound mapping, scheduling and training process is a comprehensive program design that can be translated to serve any individual undergoing critical care, patients who are recovering from treatments at home or are in remote areas where regular radiology visits may prove to be a hardship to the patient.

"Remote Personal Imaging" (L-R): Sal Banchitta,  Actual heart
scan image | Mike Thury (remote technical trainer,  Terason Ultrasound)
 Len Gettz- program dir. |  Dr. Robert Bard- monitoring radiologist

The "SalScan program" is a research project developed by Dr. Robert L. Bard, IntermediaWorx Inc, The New York Cancer Resource Alliance, AngioFoundation (501c3) Research Group under strict partnership guidelines and each reserve exclusive copyrights to the program.  Publishing rights are granted exclusively to: Prevention101.org in perpetuity. No part of this publication, its contents, graphic assets or concepts may be reproduced, distributed, or transmitted in any form or by any means, including photocopying, recording, or other electronic or mechanical methods, without the prior written permission of the producers and publishers aforementioned, except in the case of brief quotations embodied in critical reviews and certain other noncommercial uses permitted by copyright law.


Resources:
1) Global Medical Allies Share Lung Ultrasound Solution for COVID-19 Triage |  ITN Imaging Technology news (April 6, 2020) https://www.itnonline.com/content/global-medical-allies-share-lung-ultrasound-solution-covid-19-triage
2) The Evolution of Telehealth: Where Have We Been and Where Are We Going? - https://www.ncbi.nlm.nih.gov/books/NBK207141/    Copyright 2012 by the National Academy of Sciences. All rights reserved.
3) Use of ultrasound by emergency medical services: a review | US Natl. Library of Medicine (PMC)- Nov, 2011: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2657261/
4) Recent Developments in Tele-Ultrasonography | US Natl. Library of Medicine (PMC) Apr-Jun, 2018 : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6320468/

TECHNICAL CONTRIBUTORS

ROBERT L. BARD, MD, PC, DABR, FASLMS

Project Overreader- Advanced Imaging & Diagnostic Specialist

Dr. Bard received the 2020 nationally acclaimed Ellis Island Award for his lifetime achievement in advanced cancer diagnostic imaging. He co-founded the 9/11 CancerScan program to bring additional diagnostic support to all first responders from Ground Zero. His main practice in midtown, NYC (Bard Diagnostic Imaging- www.CancerScan.com) uses the latest in digital imaging technology and has been also used to help guide biopsies and in many cases, even replicate much of the same reports of a clinical invasive biopsy. Imaging solutions such as high-powered sonograms, Power Doppler Histogram, sonofluoroscopy, 3D/4D image reconstruction and the Power Doppler Histogram  are safe, noninvasive, and do not use ionizing radiation. 

MICHAEL THURY, RDCS, RVT, FASE

Michael is the current Global Product Manager for Terason Ultrasound (Burlington, MA). Commercially he has spent the last 19 years training physicians, clinicians and distribution partners around the world on the uses and benefits of ultrasound. He has been recognized numerous times for outstanding clinical and sales excellence both at Terason and GE Healthcare. Michael holds a AAS in Cardiovascular Technology from Southeast Technical College and is a South Dakota native.

PIERRE KORY, M.D., M.P.A.

Technical Advisor- Bd. Certified Internal Medicine/Critical Care & Pulmonary Medicine. 

He served as the Medical Director of the Trauma and Life Support Center at the University of Wisconsin where he was an Associate Professor and the Chief of the Critical Care Service. He is considered a pioneer and national/international expert in the field of Critical Care Ultrasound and is the senior editor of the widely read textbook “Point-of-Care Ultrasound” (winner of the President’s Choice Award for Medical Textbooks from the British Medical Association in 2015).  Most recently, Dr. Kory joined the emergency volunteer team during the early COVID-19 pandemic in NYC at Mount Sinai Beth Israel Medical Center. He is also a founding member of the Front Line COVID-19 Critical Working Group (flccc.net) composed of 5 critical care experts that devised the COVID-19 treatment protocol called MATH+. (www.covid19criticalcare.com/)

* TERASON ULTRASOUND: donor of the 3200T remote / portable ultrasound device used in this beta test.

The "SalScan program" is a research project developed by Dr. Robert L. Bard, IntermediaWorx Inc, The New York Cancer Resource Alliance, AngioFoundation (501c3) Research Group under strict partnership guidelines and each reserve exclusive copyrights ©2020 to the program.  Publishing rights are granted exclusively to: Prevention101.org and Awareness for a Cure in perpetuity. No part of this publication, its contents, graphic assets or concepts may be reproduced, distributed, or transmitted in any form or by any means, including photocopying, recording, or other electronic or mechanical methods, without the prior written permission of the producers and publishers aforementioned, except in the case of brief quotations embodied in critical reviews and certain other noncommercial uses permitted by copyright law. For permission requests, write to the publisher, addressed “Attention: Permissions Coordinator,” to: nycralliance@gmail.com

Disclaimer & Copyright Notice: The materials provided on this website are copyrighted and the intellectual property of the publishers/producers (The NY Cancer Resource Alliance/IntermediaWorx inc. and Bard Diagnostic Research & Educational Programs). It is provided publicly strictly for informational purposes within non-commercial use and not for purposes of resale, distribution, public display or performance. Unless otherwise indicated on this web based page, sharing, re-posting, re-publishing of this work is strictly prohibited without due permission from the publishers.  Also, certain content may be licensed from third-parties. The licenses for some of this Content may contain additional terms. When such Content licenses contain additional terms, we will make these terms available to you on those pages (which his incorporated herein by reference).The publishers/producers of this site and its contents such as videos, graphics, text, and other materials published are not intended to be a substitute for professional medical advice, diagnosis, or treatment. For any questions you may have regarding a medical condition, please always seek the advice of your physician or a qualified health provider. Do not postpone or disregard any professional medical advice over something you may have seen or read on this website. If you think you may have a medical emergency, call your doctor or 9-1-1 immediately.  This website does not support, endorse or recommend any specific products, tests, physicians, procedures, treatment opinions or other information that may be mentioned on this site. Referencing any content or information seen or published in this website or shared by other visitors of this website is solely at your own risk. The publishers/producers of this Internet web site reserves the right, at its sole discretion, to modify, disable access to, or discontinue, temporarily or permanently, all or any part of this Internet web site or any information contained thereon without liability or notice to you.

©Copyright Intermedia Worx Inc./Prevention 101. All Rights Reserved.