Over the years, a few things have become clear about cyber-attacks in the healthcare industry. Through our own research as well as in the wider industry context, we know the real threat is already in healthcare networks in the form of privileged access misuse — the growth in healthcare internet of things (IoT) devices is overwhelming and dangerous and a majority of attacks occur due to negligence and a lack of security awareness by insiders.

Within the healthcare industry many people have access to patient medical records, making it very easy, and perhaps a bit enticing, for some to take advantage of that privilege. Internal actors — meaning employees who access patient data out of curiosity or to commit identity fraud — are largely responsible for healthcare data loss, and healthcare is the only industry where this occurs at such an alarming rate. Indeed, our own research demonstrated that human error and misuse occurred more frequently in the healthcare industry than external threats such as hacking or ransomware.

Related: Overcoming healthcare’s cybersecurity challenges

While most of us worry about cyber-attacks from someone we’ve never met, security professionals in healthcare mostly worry about the people they talk to in the break room. Even worse, motives seem to be a mix between financial gain — patient records are the most valuable form of digital personal data — and simple curiosity. Those who are curious simply want to know what’s going on with others and the information is there for the taking.

The ongoing proliferation of the IoT in the medical industry doesn’t help either. These medical devices improve clinical care and outcomes but produce massive volumes of data about every patient who comes through the door, and most healthcare organisations don’t have a way to track what or where those devices are, or where they’re connecting to.

Related: Prioritising digital transformation in healthcare

IoT devices might be the easiest target for attackers. There are lots of them, a hospital or other healthcare organisation rarely knows how many exist on their site at any one time, and security is often not seen as a priority, especially over clinical imperatives. However, the risk is one that needs to be taken seriously. We’ve seen cyber-attacks evolve from authenticating through default admin passwords and using IoT for botnets, to the outright destruction of IoT devices by wiping their drives. Wiped devices can be restored, but the impact is greater if those are needed to deliver critical care.

Take connected insulin pumps for example. Just last year, U.S. medical device company, Medtronic, recalled a number of insulin pumps after discovering they had potential cybersecurity risks and were vulnerable to hacks. Furthermore, in October 2019, the U.S. Food and Drug Administration (FDA) warned patients, medical providers and hospitals, that software in some medical devices could allow hackers to take control of items that connect to wireless networks or find a back door into entire hospital networks.

When you factor in how long it takes to discover a data breach, it suggests that healthcare is losing the battle against cyber adversaries. It’s not acceptable to find out weeks, months or years after a breach occurs, but unfortunately, that is what’s happening. So, what can be done?

 The answer lies in 360-degree visibility inside the network. This includes the need to monitor across the cloud, data centre, IoT devices, and enterprise networks, as well as having the ability to carry out real-time attacker detection while prioritising all the detected threats so you know where to start. However, that answer must address the challenges mentioned above, and there are four key parts to it.  

 First, it’s important to eliminate the manual, time-consuming work of security analysts by implementing the capability to automate and prioritise detected threats. Second, look at lowering the skills barrier needed to hunt down cyber threats. Third, consider that everything is connected, which makes for an easy target and a huge attack surface. And finally, and perhaps the most vital aspect, provide visibility inside the network to see attackers — where they are, what they’re doing, and the compromised hosts and workloads they’ve exploited, or could potentially exploit.

This fundamental approach is advocated by a growing number of healthcare security professionals. Many of these are augmenting their security teams with AI-derived machine learning models to automate the early detection of cyber attackers, speed up incident response, investigate conclusively, and hunt for threats efficiently.

It’s a battle that has been won by many healthcare organisations, but the industry still has work to do to ensure the protection of all of its patients, as well as their data.

Ammar Enaya

 

This article appears in the latest issue of Omnia Health Magazine. Read the full issue online today, covering cybersecurity in healthcare, the ongoing rise of telehealth and much more.  

It was recently reported that a series of cyberattacks were aimed at companies and governments that will be distributing COVID-19 vaccines around the world. Pharmaceutical company Pfizer Inc. also recently suffered a data breach with patient information found exposed on unsecured cloud storage.

Healthcare institutions, research companies and drug companies have been under constant attack since the outbreak of the pandemic. These latest headlines warn of a targeted cyberespionage campaign to disrupt the global COVID-19 vaccine distribution network and is, yet another wake-up call to public and private sector companies working around the clock to put an end to this global pandemic.

Related: How to win the cybersecurity battle in healthcare

According to Sam Curry, Chief Security Officer, Cybereason, it has never been a question of if the research companies, pharma companies and hospitals would be targeted, but more about how frequently and how much damage would be caused.

He said: “What the recent Pfizer data breach tells us is that it is extremely difficult for even the largest companies in the world to secure their data every hour, every day and every week. The most important aspect of the distribution of the various vaccines is that it is being done efficiently and safely. Think about the suffering and impact if a threat actor interferes with the distribution of COVID-19 vaccines and launches a successful ransomware campaign against the supply chain responsible for distributing the vaccine in mass; locking down the distribution network and demanding millions of dollars to unlock the networks. It is not that far-fetched.”

Related: How are cyber attackers targeting healthcare sector?

Curry explained that cyberattacks can have a massive impact on hospitals and clinics in many ways, including the hacking of sensitive patient data, medical health records and other proprietary information. In addition, ransomware attacks can have devastating outcomes if IT systems fail and a hospital is unable to treat its patients.

He said: “The security analysts and IT professionals that protect patient data are on call around the clock, keeping nation-state actors and rogue hacking groups from stealing patient data. The healthcare industry is susceptible to hacking because patient data can be monetised or used for identity compromise. In times of this pandemic, anything in critical infrastructure becomes targeted and particularly susceptible. Hospitals and research companies are critical infrastructure. Overall, the healthcare industry is ripe for cyberattacks and fraud because of the volume of patient data that is available across connected networks. In addition, with an increase in the number of connected devices used in hospital emergency rooms, doctor’s offices and minute clinics, security vulnerabilities will continue to be the single biggest risk facing patients.”

Sam Curry

 

Types of attack

The healthcare industry has been stretched in its efforts to accommodate the COVID-19 pandemic. Hospitals have been overwhelmed with patients and several have introduced commercial technology — including baby monitors and even home-based vital monitoring solutions — to monitor patients and ensure temporary field hospitals, as well as overstretched hospital facilities, to adjust to the surge in cases. None of these solutions have good security hygiene, especially for a hospital, and many devices introduce extreme risk when used in bulk to aid patient care.

In addition, many hospitals have strict change control processes when it comes to the information technology used for patient care and medical record storage. This can introduce a lag time in security updates, new devices, and maintenance required to protect against the latest threats.

Morey Haber, CTO & CISO, BeyondTrust, said: “When the risks of the pandemic are merged with the lag in technology updates present in healthcare, the state of cybersecurity in healthcare is in a dire state and prime for an attack.”

Threat actors generally operate using two modes: government, social, and business destabilisation and to create a criminal profit stream. Today, they have ramped up attacks against the COVID-19 vaccine supply chain in order to accomplish several nefarious goals.

One of the most popular attack vectors are phishing emails. Haber shared that some of these attacks also include disrupting nation-state confidence in the vaccine via social media and fake news and compromising (in the form of hacking) refrigeration equipment and technology needed to safely deliver the vaccine through the supply chain. The results could lead to incomplete coverage for inoculation or the delivery of bad product.

There could also be the possibility of introducing faux vaccines into the supply chain for profit. The contents of which could be harmless, highly addictive, or even life-threatening. Or vaccine information could be targeted for an individual manufacturer of a vaccine, in order to adversely affect their reputation, distribution, or stock prices. Cybercriminals could also falsely advertise the availability and registration for vaccination. The goal could be basic credential theft or monetization via payments to reserve placement in a faux queue for inoculation.

Haber stressed: “The COVID-19 pandemic has already proven that phishing attacks and misinformation can easily accomplish these goals. Now, with the release of a vaccine, threat actors have multiple new attack vectors to spread misinformation and monetise the results. The primary vehicles will include phishing attacks (email, voice, and texting) and malicious websites, and will not be limited to one country or region.”

Morey Haber

 

Leaving the front door open

Administrators that are failing to take basic steps to secure cloud services or apps isn’t a new story – there have been many instances that have come to light where private data was inadvertently left exposed to the internet. Whilst cloud computing’s instant provisioning and scale are valuable benefits, the cloud service provider’s features and default configurations are constantly in flux and so administrators must know and adapt what they’re doing and ensure appropriate access controls are in place to protect their data.

“As no system, or person, is ever perfect, the ability to monitor, detect and respond to unauthorised or malicious access to cloud services can make the difference between a contained security incident and a full-blown breach as being reported at Pfizer. For example, in a recent study, we performed analysis on Office 365 — the worlds most used Software and a Service Cloud offering — and identified how attackers are using existing tools and services within the cloud to spy and steal. When administrators inadvertently “leave the front door open” it’s unsurprising that attackers walk straight in and out unnoticed,” emphasised Matt Walmsley, EMEA Director, Vectra.

Matt Walmsley

 

Focus on training

Hackers have a full toolset available to them as they continue to successfully breach hospitals and research companies. One of the most common ways for criminals to gain access to a computer network is through the commonly used phishing emails. To combat this, hospitals need to improve their security hygiene, implement around the clock threat hunting and increase their ability to detect malicious activity. “Security awareness training is also needed, and doctors, nurses and medical professionals should not open attachments from unknown sources and never download content from dubious sources,” Curry said.

Healthcare environments require sensitive information in order to complete their mission of providing health services for an individual. The data collected has monetary value to a threat actor for future attacks. The vast range of attack vectors can cost lives, the loss of data, and prohibit care. The attack vectors themselves almost always — outside of a critical vulnerability — require some form of human interaction in order to exploit. Therefore, education, awareness, and training is the best method to prevent cyber-attacks against healthcare institutions and the results could be branded as “human firewalls”.

Haber highlighted: “Pfizer is a perfect example of what can go wrong in the cloud. It essentially reminds us that everything we do online is being recorded – somewhere. Having spoken with several healthcare CISOs, VPs and Security Professionals, it is interesting that all of them have mentioned one common problem — end-user security awareness and training. The majority of healthcare workers are normally secured within the confines of their brick and motor buildings and networks. But in large part due to the pandemic, several of these workers are now on home or personal networks which are considered unsecured and unmanaged by enterprise standards.

“As a result, users are more exposed to social engineering attacks, phishing attacks, and even social media attacks across numerous devices. This is resulting in more risk and potential for compromise. All the security executives I have spoken to wish they had ramped up security awareness programmes for all remote employees and they plan on making this a priority moving forward.

How can a cyberattack impact a hospital or clinic and how this affects patients?

• The inability for a critical piece of technology to be available during care
• A device periodically malfunctioning or providing incorrect results, affecting the safety of the patient
• Lack of network connectivity to report patient data
• The monitoring of staff and patient information, including the capturing of keystrokes and screen recording, for future inappropriate activity
• The theft of personal healthcare information, including medical records and payment information
• The inability for hospital staff to access or enter patient records
• The inability to access or inventory devices used for the distribution of medication

This article appears in the latest issue of Omnia Health Magazine. Read the full issue online today, covering cybersecurity in healthcare, the ongoing rise of telehealth and much more.  

As the COVID-19 crisis unfolded, health insurance company Aetna was quick to offer support to the community — to businesses, employees, and their loved ones. As early as March, the company extended access to its telehealth service, vHealth, to ensure that all its UAE members had uninterrupted access to sound medical advice. Excerpts from an interview with Catherine Darroue, Senior Director of Customer Proposition, EMEA, Aetna International.

How has Aetna responded to the COVID-19 crisis?

We were acutely aware of the economics of the COVID-19 world and rolled out several initiatives to alleviate the financial burden on members and customers. Any Aetna International member that required diagnostic testing for the coronavirus was subsequently reimbursed in full for both the test and the associated consultation. In early April, Aetna also started waiving all deductibles for inpatient hospital admissions related to COVID-19.

Related: UAE embraces telehealth in battle against COVID-19

Given the impact of COVID-19 on mental health, members also continued to benefit from 24-hour access to clinical counsellors via our Employee Assistance Programme (EAP) and could access WorldAware (red24) to stay informed of any significant travel, safety, or security-related incidents. In addition, they gained free access to myStrength — an interactive, personalised app that helps address depression, anxiety, stress — and Wysa, a well-being app with an AI-driven chat function.

Could you share some highlights from Aetna’s recent digital health dilemma study?

In March 2020, Aetna International conducted an international survey — including over 1,000 respondents from the UAE — to gauge employees’ views on workplace technology and digital health services and their impact on employee health and well-being. The results offer a unique snapshot of a key moment in history.

Related: 2020: The year that telehealth came of age

On the positive side, respondents have clearly bought into technology’s ability to improve connectivity, collaboration and productivity and, as a result, worker health and well-being. 93 per cent of workers in the UAE say technology lets them complete simple tasks quickly, connect with co-workers across different locations and receive job support. 85 per cent say technology lets them manage time better, thus reducing stress levels. And 54 per cent of UAE workers say technology helps them improve physical and mental health overall.

Furthermore, UAE employees clearly believe that technological innovation and digital tools and services could further help them to improve their health. One area of note is mental health — while less than 40 per cent of respondents say they currently use video, text-based or telephonic solutions to help manage their mental health, an equal number said that they might consider these options in future.

That being said, while most employees recognise the advantages of workplace technology, they do acknowledge that it has its drawbacks. For example, 72 per cent of UAE respondents believe that being able to have a company mobile phone to handle work calls and emails remotely helps them better manage their mental health. Yet almost the same percentage (69 per cent) worry that they use their phones too much. That’s probably why 61 per cent try to check their phones less often.

A big concern is that digital technology contributes to an “always-on” mindset. 73 per cent of UAE respondents admit to checking their phones first thing in the morning for work-related messages, whilst nearly an equal number (74 per cent) do the same thing right before going to bed.

Catherine Darroue

 

How has Aetna responded to the increase in demand for telemedicine?

In today’s digital-first world where the likes of Airbnb, Netflix, Uber and Zomato have essentially become verbs, it isn’t surprising that we are seeing consumers demand ease of use, convenience and quality of service from healthcare providers and associated products and services. As a consequence, particularly over the last year, we have seen tremendous uptake, both in the demand for, and the number of telehealth offerings in the market. We’re also seeing healthcare providers start to offer various mental health services via easy-to-access applications or via phone or video chat.

We offer our members access to a telehealth service via vHealth. Launched in 2018, the purpose of vHealth is to provide a high-quality healthcare service that fits in with modern living. Every aspect of vHealth has been designed with the customer in mind. So, in addition to giving patients access to experienced doctors that have been trained in telemedicine to international standards, we have put a major emphasis on making the service convenient and easy to use with the launch of an application and a concierge service for everything from managing appointments and arranging specialist referrals or regular follow-ups, to organising prescriptions delivery or diagnostic tests at the patient’s home or office. We’ve seen a 180 per cent increase in global utilisation between April 2019 and April 2020, with some regions more than doubling their usage during this time.

What, according to you, are the major healthcare market segments that are likely to expand this year, and why is this so?

For one, I believe we are going to see an increase in demand for primary care. Particularly here in the UAE, where people have a choice and immediate access, primary care is sometimes seen as an unwanted gatekeeper — a place you have to go before you can get through to the specialist you think you really need. However, when you break it down, it’s actually primary care that enables the sustainability of health care systems, contains extortionate cost inflation over time, safeguards responsible medical practice and ensures coordination across a range of medical conditions. In fact, it's a crucial first check mechanism before people get into secondary care. That's why we're now seeing a resurgence in primary care.

Closely tied to this is telehealth. Consumer preference for more digital engagement models is a big contributing factor, but so is COVID-19. The social distancing and self-isolation have brought a paradigm shift to many behaviours, particularly when it comes to how we choose to interact with doctors — not many of us want to sit in a waiting room for fear that we might get exposed to the virus. Also, if you cast your mind back twenty years, you may remember that GP appointments were only available Sunday through Thursday, 9am to 5pm. This made life very difficult if you were a full-time employee, a working parent or simply needed a doctor out of hours. Now consider that more than 60 per cent of primary care can be done without physically touching the patient. Taking a good history, getting vital sign readings and/or conducting an examination — prerequisites of an effective consultation — can all be done virtually, so telehealth will definitely see exponential growth over the next few years.

Finally, COVID-19 has shone a light on mental well-being, and the importance of mental resilience. And while the sector has made strides in this area, much is left to be done, whether it be in terms of raising awareness or providing tools and resources to help people improve mental health and well-being. No doubt, this will be an area of significant focus and growth going forward.

This article appears in the latest issue of Omnia Health Magazine. Read the full issue online today, covering cybersecurity in healthcare, the ongoing rise of telehealth and much more.  

In the initial days of COVID-19, there were numerous questions from the public who wanted to know how they could protect themselves from the virus and access treatment. There were also questions from clinical teams about how they could support the members who were infected, support their families, as well as concerns around the risk of contracting the virus themselves.

In an interview with Omnia Health Magazine, Jerome Droesch, Chief Executive Officer, Middle East and Africa (MEA), Cigna, said that as a health service company, Cigna has been able to be at the forefront of the COVID-19 crisis and has strived to support its clients, members and partners.

Related: Health insurance: The golden ticket to dealing with stress

“We are a global company and saw the effects of COVID-19 in China and Asia early on and were prepared for it well in advance here locally. We started working from home before the new regulations came in and were prepared to absorb all the volume of activity from the pandemic,” said Droesch.

When asked about how Cigna responded to the increase in demand for telemedicine during the pandemic, he highlighted: “There are two main pillars in terms of the actual access to care. First and foremost, we do provide telemedicine, and this is part of our terms and condition. Also, single members have access to our global solution that anyone can access 24/7 and get access to care whenever it's needed. This was an absolute must-have, and something that was a real differentiator in the market during this period, enabling any of our members wherever they were in the world to be able to access care. Secondly, we've supported all the local providers to be able to provide virtual care to any of our members.”

Impact on wellness

Related: Impact of Insurance on Healthcare Economics

Recently, Cigna carried out the ‘COVID Global Impact Study’ to understand the impact on wellness, and what could be the consequence of the pandemic, above and beyond immediate treatment.

“We found that thanks to technology, people were able to still keep in touch with each other, probably even more than usual,” shared Droesch. “However, the consequence of this has been the “always-on” culture. So, people are always connected and that has created certain negative side effects. We also observed that to some extent people were struggling to find the right balance between their personal and their professional lives. So, we've seen more and more people working during the weekend.”

According to the study, 64 per cent of employees surveyed said that they were working during the weekends, which is significantly higher than what it was before COVID-19. The good news, he added, is that most people were also able to avoid some of the stress of working in the office and leveraged flexible working hours. The main question, Droesch stressed, is going to be around how people will adjust after many months of working from home.

Jerome Droesch

 

Appetite for insurance

In the early days of the pandemic, emphasised Droesch, the insurance industry was booming because many young people, those that are globally mobile, and were not always purchasing any insurance policy suddenly discovered that it was extremely important for them to get access to the right level of cover.

Furthermore, he said that recently Dubai announced that they will be issuing a five-year visa for retirees. “We are the only international insurance company working with Dubai Tourism. We do see a lot of appetite from people who want to stay back in the UAE as well as get access to an international policy to be covered both when they are living the UAE but also when they travel back either to their home countries or go on holidays across the world,” he added.

He concluded by saying that today everybody understands that access to care is incredibly important. However, there is economic pressure due to the pandemic. “Cigna is working to provide innovative solutions to offer access to care at an affordable price and at the same time give patients access to the best provider in the market, making sure they can access the best doctors and treatment whenever it's needed.”

This article appears in the latest issue of Omnia Health Magazine. Read the full issue online today, covering cybersecurity in healthcare, the ongoing rise of telehealth and much more.  

Since the beginning of the COVID-19 outbreak, it has been widely reported that people who suffer from chronic diseases such as heart diseases, respiratory diseases and diabetes appear to be more susceptible to becoming severely ill due to the virus.

According to a new survey commissioned by Gilead Sciences, 52 per cent of UAE respondents highlighted that they have become more anxious about visiting a clinic or going for their regular check-ups due to the fear of contracting the virus. This is concerning as people who suffer from general ailments, existing chronic diseases and other health issues that require regular monitoring are at risk of delaying treatment and diseases such as Hepatitis C virus (HCV), for example, that requires laboratory testing to identify can go undiagnosed.

Related: World Hepatitis Day: fast-tracking the elimination of hepatitis B among mothers and children

Research shows that 71 million people are infected with HCV worldwide with approximately 21 per cent of them (15 million) reportedly in the Middle East and North Africa region, making it one of the most affected regions globally. However, the prevalence rate in the UAE is low (0.24 to 1.64 per cent).

In an interview with Omnia Health Magazine, Dr. Sameer Al Awadhi, President of the Emirates Gastroenterology and Hepatology Society, explained: “HCV is a serious liver disease, often with no symptoms, that can cause both acute and chronic hepatitis ranging in severity from a mild illness lasting a few weeks to a serious lifelong illness and is a major cause of liver cancer. While the prevalence of HCV is low in the UAE, early detection and treatment are essential in preventing health problems that may result from infection, as well as preventing the transmission of the virus.”

Related: New Care Models Offer Potential for Eradication of Hepatitis C

According to the Journal of Hepatology, Al Awadhi highlighted, a one-year delay in HCV programmes due to COVID-19 could cause excess HCV morbidity and mortality, with as much as 72,000 excess deaths predicted.

The survey further highlighted that close to 90 per cent of respondents admitted to not knowing what the symptoms are (tiredness/depression), 11 per cent know that it can be asymptomatic and only 20 per cent believe that it can lead to serious health complications. Moreover, just 13 per cent are aware of how the virus can be transmitted (mother to child, possibly shared razors, toothbrushes, etc.) and 15 per cent know how it can be prevented.

He shared: “From the Gilead survey, we can see there is a lack of awareness about HCV among the general public in the UAE, with only 17 per cent of respondents being aware of the virus. We have previously worked on several campaigns with the Ministry of Health and Prevention (MOHAP), including the ‘Ready to be Hepatitis C Cured’ which was launched in 2018. We continue to work closely with key stakeholders to increase awareness about HCV, as well as provide patients and their families with support throughout the treatment journey.”

A targeted approach to elimination

The UAE has focused on micro-elimination to target high-risk populations across the country. Micro-elimination is the process in which the most vulnerable populations within local communities, such as those who are incarcerated, patients who frequently receive blood transfusions or regions with relatively higher HCV prevalence, are targeted through multi-stakeholder initiatives. It has proven to be an effective strategy to achieve the elimination of the virus in various parts of the world, as it allows for the appropriate allocation of resources and support to local medical professionals who can tailor interventions to suit the need of a particular segment.

He added: “Micro-elimination is proving to be an effective strategy and we believe that the UAE is on track to eliminate HCV by 2030 in line with the World Health Organization’s (WHO) target. However, it is crucial for both the public and private sector to remain proactive in this domain, despite the ongoing pandemic, to achieve both national and global elimination targets.

“If we look at it more simply – at an individual level, the Gilead survey highlights that the majority of UAE respondents (80 per cent) are more likely to take action for their health if healthcare communications apply specifically to their health needs. The same concept applies to micro-elimination but is applied at an institutional level in the UAE.”

Furthermore, Al Awadhi stressed that technology has brought in a massive change to the way the healthcare industry operates, and the applications are vast.

“COVID-19 has accelerated the adoption of telehealth. This has made primary healthcare more accessible to those who are hesitant to visit healthcare providers for general ailments and routine check-ups whilst the pandemic is still active. It also offers healthcare stakeholders and providers the opportunity to simplify models of care and maintain micro-elimination efforts to enhance step by step HCV elimination efforts,” he concluded.

Advancing the science of digestive diseases

The Emirates Gastroenterology & Hepatology Society was formed in 1995 as a sub-speciality of the Emirates Medical Association (EMA) to advance the science and practice of digestive diseases through mutual professional interaction among doctors in the UAE with an active interest in this field. Currently, this forum has around 160 active members from various specialities like Medical and Surgical Gastroenterology, Paediatrics, Radiology, Pathology, General Medicine and Surgery. There are ongoing plans to do epidemiological studies, clinical trials and basic research to have authentic data on the common and relevant clinical problems in the UAE.

This article appears in the latest issue of Omnia Health Magazine. Read the full issue online today, covering cybersecurity in healthcare, the ongoing rise of telehealth and much more.  

Recently, at Latifa Hospital for Women and Children, a tiny little foetus, a brave mother and a team of highly specialised doctors created history when they performed the first-ever intrauterine foetal surgery for a spinal cord defect in the Arab region.

The extremely delicate six-hour surgery was performed on a 25-week-old foetus that was diagnosed to have myelomeningocele (my-uh-lo-meh-NIN-guh-seal) a type of spina bifida (spinal cord defect). The foetus weighed only 700 grams.

Related: DHA becomes first healthcare authority in the UAE to integrate UpToDate within an electronic medical record

As the surgery was performed at this stage and not after the baby was born (which is typically still the standard medical procedure) the foetus’ defect was corrected, giving the baby a chance for improving cognitive function, lower limb function and deformities.

Spina bifida is a neural tube defect that occurs during the first month of pregnancy when the spinal cord does not develop or close properly. In its most severe form, the defect leaves a section of the spinal cord and nerves exposed in a sac on the patient’s back.

Related: DHA and Indian health officials host webinar to discuss public and mental health

Spina bifida can lead to many physical disabilities, including problems with walking and mobility, bowel and bladder function, wounds healing and fluid accumulating in the brain (hydrocephalus) requiring shunt surgery.

Transforming Dubai’s medical sector

DHA doctors highlighted this historic medical achievement for the Arab region at a press conference held recently at the DHA headquarters.

 H.E. Humaid Al Qutami, Director-General of the Dubai Health Authority said, “The DHA dedicates this great achievement to the wise leadership of the UAE, who always direct us to implement everything that achieves security, health and safety of community members.”

He said on his behalf and on behalf of all DHA employees; he expresses his thanks and gratitude to His Highness Sheikh Khalifa bin Zayed Al Nahyan, President of the UAE; His Highness Sheikh Mohammed bin Rashid Al Maktoum, Vice President and Prime Minister of the UAE and Ruler of Dubai; His Highness Sheikh Mohamed bin Zayed Al Nahyan, Crown Prince of Abu Dhabi and Deputy Supreme Commander of the UAE Armed Forces; Their Highnesses the Members of the Supreme Council and Rulers of the Emirates.

Al Qutami thanked His Highness Sheikh Hamdan bin Mohammed bin Rashid Al Maktoum, Crown Prince of Dubai and Chairman of the Executive Council for His Highness’s continued support for the health sector in Dubai.

He also thanked His Highness Sheikh Hamdan bin Rashid Al Maktoum, Deputy Ruler of Dubai, UAE Minister of Finance and Chairman of the Dubai Health Authority for His Highness’s direction and guidance to develop and transform the medical sector in Dubai.

Al Qutami said the DHA is proud of the medical team and their achievement and that the authority tirelessly strives to provide the highest level of accessible medical care to community members.

H.E. Humaid Al Qutami and DHA doctors highlighted this historic medical achievement recently at the DHA headquarters

Extreme precision

Dr Muna AbdulRazzaq Tahlak, Consultant in Obstetrics and Gynecology and CEO of Latifa Women and Children Hospital performed this surgery jointly with Dr Mohammad Sultan Al Olama, Consultant Neurosurgeon with Pediatric and Functional Neurosurgery Specialty at Rashid Hospital & President of the Emirates Society of Neurological Surgeons in the UAE.

A highly specialised team (20 multidisciplinary medical professionals) from Latifa Women and Children Hospital and Rashid Hospital accompanied them during the surgery. The team comprised maternal and foetal medicine experts, obstetricians, anaesthesiologists, clinical pharmacologist, NICU nurses, scrub nurses from both hospitals, nurse coordinators and a radiographer.

Dr Tahlak said, “The patient was referred to us when she was 24 weeks pregnant after her condition was diagnosed in an ultrasound. We immediately conducted a full workup which included a complete foetal evaluation including ultrasound, foetal echocardiogram and foetal MRI to understand the type and depth of the lesion and to completely evaluate the case to determine whether the patient is eligible for this kind of an intrauterine procedure.

 “Upon analysis, the patient underwent comprehensive counselling to understand the situation at hand, the medical options and to prepare her for the surgery.”

The young 24-year-old Emirati patient, F.A. is a third-time mom-to-be and has two healthy children. She said she wanted to do everything possible for her baby’s well-being. “I want him to be a healthy boy and lead a healthy and happy life. As complicated and as difficult the procedure was, I never hesitated even for a second coming to Latifa Hospital and I am very thankful to the full team for everything they have done for my little boy and me.”

Dr Tahlak said, “A multidisciplinary team was present for the surgery. This kind of surgery requires extreme precision and is a very delicate surgery. It requires opening the uterus but not the way it is done for C-Section. In this particular case, the incision was done from the back of the uterus because her placenta was anterior. A minor incision was performed delicately – it had to be done in layers without opening the membrane that has the amniotic fluid and the foetus inside. We meticulously eventually opened the membrane. We then used certain tools to extend the incision as the baby had a 6 cm lesion in the spinal cord that needed to the fixed. We then gently positioned the baby in a way that the lesion was facing the incision so that Dr Mohammad Sultan Al Olama, the Neurosurgeon, could correct the spinal cord defect. All through this time, the baby and the mother were being monitored with regular foetal heart rate monitoring.”

Dr Al Olama said: “I first gave the foetus anaesthesia. Then, under the microscope, I started to repair the defect. There was an extra sac that I removed and then preserved the spinal cord and the nerves. Then I covered it delicately using micro instruments with layers of different membranes sealed and then covered that by the skin so that amniotic fluid does not touch the foetus’ spinal cord and this step is essential to prevent leakage of spinal fluid. I used 6.0 sutures to close this delicate defect. These sutures are considered one of the finest sutures used in surgery. It took me less than 50 minutes to correct the defect and achieve the normal anatomical form for the foetus.”

 Dr Tahlak said, “Once Dr Al Olama finished his part, I gently filled up the uterus with a special solution with antibiotics and saline. I filled the fluid according to the amount of amniotic fluid lost during this procedure. We then closed the uterus again and tightly sealed it to prevent any leak of amniotic fluid. This procedure is also crucial as the uterus will expand in size as the foetus grows”.

Dr Tahlak added, “The procedure was a success. Both mother and foetus recovered in the Intensive Care Unit (ICU) in the immediate post-operative period.

“Currently, the patient is well and stable and out of ICU care. The future follow-up plan is to closely monitor the mother in our clinic until the day of the C-section. Post-delivery, the child will be followed-up by a multidisciplinary team led by Dr Al Olama.”

 Dr Tahlak highlighted that since 2018, DHA has actively been involved with training and preparation for this kind of surgery and a DHA team underwent training in the U.S. in November 2018 under Dr Samer K. ElBabaa, Pediatric Neurosurgeon and Dr Cole Douglas Greves, Maternal and Fetal Medicine Specialist, who are pioneers in this kind of delicate surgery.

He further added: “Moreover, Dr Samer and Dr Cole even travelled to Dubai and were present in the surgery room with us as we carried out this historic surgery for the first time in the Arab region.

“This is a true example of advancement in medicine. We are now able to stop the pathology of the disease halfway. Previously we had to wait until the baby is born and then do the surgery. So, this is really a huge breakthrough in medicine, and we are extremely proud to be one of the few centres in the world to perform this kind of complex surgery.”

 Dr Al Olama mentioned that there are only 12 countries in the world performing this type of surgery.

He said: “This is an extremely delicate but important procedure since we can correct existing deformity, prevent further deformity and help the baby grow and develop organs inside the womb without any complications so that the baby can be as healthy as possible when the baby is born. With the intrauterine foetal procedure, we can eliminate chiary malformation, which is a condition in which brain tissue extends into your spinal canal and this causes several complications. While this can be totally eliminated, other complications can be reduced largely offering the baby a high chance to walk and be independent.

“Traditionally, the defect is repaired during first days after birth, but studies have shown that repairing the defect between 22-25 weeks of gestation when the foetus is still in his mother’s tummy, will increase the chance for the child to walk and to avoid shunt surgeries for hydrocephalus and many other complications. When the procedure is done after the baby is born, usually the baby does not have a chance to walk as the damage is too late to rectify.”

Dr Al Olama added, “Immediately after the baby is born, we will thoroughly assess the baby neurologically.”

He added, “There are very few foetal surgery centres in the world and to have such a kind of advanced surgery in Dubai makes us very grateful and proud.”

Dr. Tahlak added, “His Highness Sheikh Mohammed bin Rashid Al Maktoum, Vice President and Prime Minister of the UAE and Ruler of Dubai said that despite the COVID-19 pandemic challenge, nothing is impossible to hinder us to advance. Over the last few months, UAE successfully launched its Mars-bound Hope Probe, marking the Arab world’s first interplanetary mission. In terms of medicine, we achieved this historic surgery, we feel a deep sense of gratitude and pride as we pledge to continue providing our patients with excellence in healthcare.

This article appears in the latest issue of Omnia Health Magazine. Read the full issue online today, covering cybersecurity in healthcare, the ongoing rise of telehealth and much more.  

Clinicians have had to be very strategic in their use of critical life-saving equipment, such as ventilators, as well as basic supplies during the COVID-19 outbreak. However, healthcare administrators have been thinking about ways to improve asset and inventory management for some time now. COVID-19 simply fast-tracked planned efforts to enhance track and trace capabilities within the four walls of acute and non-acute facilities.

Zebra Technologies Rikki Jennings, Zebra’s Chief Nursing Informatics Officer, and Elizabeth Miller, Zebra’s Healthcare Lead in the Australian and New Zealand market, have been working closely with healthcare systems to address this very issue. Below they provide key insights into all the progress being made, as well as the best practices, process enhancements and technology platforms that have proven most effective in improving inventory management capabilities.

COVID-19 depleted many hospitals’ inventories of basic supplies, which caused a simultaneous surge in replenishment orders that ultimately strained the supply chain. How can we learn from this and be better positioned to manage inventory moving forward, as well as in an emergency response situation?

Related: Smart tech boosts UAE’s healthcare market to US$21 billion by 2021

Rikki Jennings: There is a saying that you can’t manage what you can’t measure. Without visibility and insight into the materials and use of the stock levels in general status, as well as the location of vital equipment, there is a strong likelihood that clinicians in patient care could resort to stockpiling, or worse yet be left without the key assets they require to provide the utmost quality patient care.

There is an opportunity here to learn from this experience and more widely adopt technologies that bring visibility to the required resources, such as stock levels to those departments who are responsible for ensuring that there are adequate supplies at the patient’s bedside.

Related: Download: Accelerated healthcare technology & trends in the age of COVID-19

Rikki Jennings

What would you recommend to hospitals and clinics that want to improve their inventories and asset management capabilities? What’s it going to take to eliminate these types of issues once and for all?

Elizabeth Miller: At the moment what we’re seeing is society’s adoption of technology, which is driving the utilisation of technology in hospitals and in healthcare around the globe. And some of those hospitals are at different levels, depending on whether they’re public or private. Finances are always a challenge, but if hospitals could invest in clinical mobility, that’s going to create workflow efficiency and also better utilise the limited resources that they have. I also think they should provide software solutions for inventory management because many of them currently don’t have it.

For example, providing barcode items with scanning capabilities, so that they can scan medicines, prosthetics equipment, consumables, loaned equipment, etc. But most importantly they need to ensure that they have constant real-time visibility of assets and of their people, both in terms of staff and patients. Looking for equipment is really challenging, so to have this technology available moving forward would be a blessing. I think embracing digital technology would be advantageous for a hospital moving forward.

Elizabeth Miller

Real-time location systems may take some time to deploy in healthcare settings. Are there tools that hospitals and clinics have in place today that could be configured to better support inventory management and asset tracking?

Rikki Jennings: Absolutely. Today’s clinical environment has really changed, most recently having reduced foot traffic and less disruption, which is vital to patient care. Clinicians need to remain focused on caring for patients. During this discussion, we have mentioned technologies that are in place today, and those can carry over and start to be utilised immediately to automate tasks and bring visibility to solutions. These include solutions for barcoding and scanning, as well as clinical mobility, which has so many actionable use cases that can support automation and bring visibility to asset management moving forward.

The lack of automated technologies today that alert to the needs of the status and location certainly can lead to disruption in patient care without the technologies that are in place. Our clinicians can be reliant on manual processes for notifying other areas and departments that are responsible for servicing this equipment. Using clinical mobility across the entire enterprise, mobilising all staff members, both clinical and ancillary to communicate with one another can greatly provide impact.

Could these same technologies or applications help healthcare systems comply with regulations such as the falsified medicines directive or European Union medical device regulation?

Elizabeth Miller: Yes. The scanner is always 100 per cent correct. In fact, there are regulatory bodies (TGA and the FDA) that require medical device packaging, whether it be consumables or hardware, have a UDI in the form of plain text and barcoding. So, the scanning of the information eliminates the risk of human error, which is normally the information that is manually entered into a computer system. By scanning it, you are eliminating that risk and ultimately maintaining a patient’s safety.

For example – if there was a recall or an event, having that technology available directly in the system and therefore removing human error for incorrect numbers or letters means that you can do that recall immediately. And ultimately that’s going to impact the safety of the patient.

Is inventory management also critical for acting quickly on device or drug recalls?

Rikki Jennings: Definitely. Being aware of the recall is really the first step, and it’s a critical step. The next most important step is to assure the timely removal of these recalled items, whether they are a device or a medication, so you’re ensuring its use is stopped immediately.

Today’s processes without utilising scanning technology or UDI, however, are very manual and they’re labour intensive. They take quite a bit of time to execute and the longer it takes to execute and remove these items from the care areas, the more increased risk our patients and our clinicians are at for utilising this device during a recalled time.

Some training would be needed to ensure doctors, nurses and other staff know how to use their clinical smartphones or scanners. In some instances, to report the use of supplies or devices. Would you agree?

Rikki Jennings: Yes, training and user support are vital to technology adoption. Executing a training methodology that ensures clinicians and all staff are comfortable and aware of both how to use the technologies, as well as its capabilities to influence their day-to-day work, is critically important.

Look at multiple modalities to do that training, whether that be in classroom learning or follow-up. Have additional champions or super-users nearby physically present in the care environment to support technology, both at the additional deployment and then routinely in an ongoing basis moving forward.

The clinical environment is changing and having that reduced traffic in fewer individuals in the environment is certainly creating some challenges with technology adoption. Looking at solutions such as video on-device learning, which put learning educational videos directly on the device that a clinician or a staff member is using, can absolutely influence adoption and then directly relate to the impact of the technology implementation going forward.

Elizabeth Miller: I think in our current situation globally, healthcare has changed forever. It’s changed in the way of how we have done things in the past. And I think it’s embracing and fast-tracking the use of digital technology – how we do that and what’s that going to look like.

This article appears in the latest issue of Omnia Health Magazine. Read the full issue online today, covering cybersecurity in healthcare, the ongoing rise of telehealth and much more.  

Arab Health, the largest exhibition for healthcare and trade professionals in the MENA region, has announced that the 2021 edition of the annual showcase will include a four-day live event taking place at the Dubai World Trade Centre from 21-24 June, and a two-month-long series of online events from 23 May to 22 July.

Medlab Middle East’s live show will run at the Dubai World Trade Centre from 28 June to 1 July 2021, while the online element of the show will take place from 31 May until 18 June, bringing together key medical laboratory and trade professionals from across the region.

Related: New technological advancements in cataract surgery to benefit UAE patients

The online and live event formats have been specifically designed to allow participants to engage and utilise their time more effectively and efficiently through Arab Health and Medlab Middle East’s Connections Experience (CX). The new digital tool enables healthcare businesses to make meaningful connections and contacts, network and secure deals via a tailored timetable.

Wouter Molman, Executive Vice President, EMEA – Healthcare, Informa Markets, said: “As part of our commitment to facilitating business in the healthcare industry we have developed a carefully configured series of online and live events to enable and optimise connections, while maximising the time available to attendees.

Related: Smart tech boosts UAE’s healthcare market to US$21 billion by 2021

“From a digital perspective, healthcare professionals can search, discover, and connect at their own pace, making the most of their valuable time. At our live events in June, we are encouraging people to attend to safeguard partnerships, strengthen relationships, see products and demos in real life, as well as develop those chance encounters only found at live events.”

In the month preceding the live event in Dubai, both Arab Health and Medlab Middle East will host a series of dedicated online focus days to allow participants to find the correct person to meet and do business.

These will include online trade focus days, which will allow participants to showcase their latest products and technical advancements, while connecting them directly to the most relevant people interested in their range of products.

A series of medical speciality days have also been scheduled, with a host of experts presenting the latest advancements in a range of medical specialities, including obs & gyne, emergency medicine & ICU, paediatrics, and oncology.

From a laboratory perspective, vaccines, infectious diseases, and virology will take centre stage, with a host of experts presenting the latest advancements in these specific clinical specialities.

Meanwhile, the live events at the Dubai World Trade Centre will feature a range of keynote speeches and roundtable discussions, industry briefings, product demos and networking opportunities, as well as a series of pre-arranged one-to-one meetings, with an emphasis on creating lasting relationships.

In the month after the live event, the online platform will remain available for all participants to continue to make connections and secure deals.

“As the leading business platform in the healthcare and medical laboratory sector, Arab Health and Medlab Middle East have consistently brought together the key decision-makers and provided the highest-quality learning opportunities,” said Molman.

“To ensure we continue to deliver an event that is representative of the success of previous years, we have adapted and created a reinvigorated format which ensures we attract the right audience, and their time is being utilised to its fullest capacity,” he concluded.

Cataract, an opacification of the eye lens, which leads to a decrease in vision quality, is the leading cause of blindness in the world. Cataracts affect roughly 25 per cent of the population living in the MENA region.

Fortunately, cataracts can be treated through a simple yet highly effective surgery that has become extremely common and successfully performed worldwide. Ophthalmologists around the world have performed this technique since the early 1990s, as it has proven successful for millions of patients.

A tailored approach to cataract surgery

Related: Early-onset cataracts: Experts urge not to delay essential treatment

According to Dr Luisa Sastre, who is a specialist ophthalmologist in medical retina and cataract surgery at Moorfields Eye Hospital Dubai, the “gold standard” technique for cataract extraction is still small incision phacoemulsification, which involves the use of ultrasound energy to dissolve and extract the cataract. However, recent advancements in cataract surgery such as, Femtosecond Laser-assisted cataract surgery and Extended Depth of Focus lenses (EDOF lenses) are proving to be beneficial alternatives for patients who require a more tailored approach.

“Femtosecond Laser-assisted cataract surgery has been used to perform certain parts of the cataract surgery (e.g., incisions, capsulotomy and softening the nucleus) offering a smoother removal,” Sastre explains. “This procedure can provide a greater level of precision for patients that are in need or willing to correct their astigmatism at the time of cataract surgery and can improve patient outcomes for those that will have intraocular lenses correcting near and distant vision.”

Related: Diabetic eye diseases make up 2 of the top 5 eye problems affecting UAE patients

“Additionally, the procedure can be safer for patients suffering from certain medical conditions including Fuchs corneal dystrophy, subluxed crystaline lens, and mature/advanced cataract,” she adds.

In spite of these benefits, Femtosecond Laser-assisted cataract surgery remains a secondary method for cataracts extraction because of its limited availability through standard insurance and the perceived amount of improvement it yields in comparison to similar more cost-effective procedures.

According to Sastre, Extended Depth of Focus lenses is a relatively new development to correct both near and distance vision when performing cataract surgery, with the aim of minimising the dependence on reading glasses after surgery.

Classically, monofocal lenses are implanted during cataract surgery to correct distant vision impairments and so the patient will rely on reading glasses after their surgery. Multifocal lenses, a solution to correct both near and far vision, have gained widespread popularity in the last decade.

Patient outcomes

However, Sastre highlights that monofocal lenses can have some downsides like the fact that few patients may notice halos or glare around lights at night. EDOF lenses, an alternative that eliminates some of the downsides of both monofocal and multifocal lenses, have a unique design that creates a single elongated focal point to enhance the range of vision or depth of focus for patients.

“Several studies have found that EDOF lenses performed similarly to monofocal and multifocal lenses when correcting distance vision, (e.g., driving, watching TV, and walking around) and showed a trend toward superior correction of intermediate vision (e.g. reading on a computer),” Sastre says. “On the other hand, multifocal lenses have trended toward giving better outcomes for near vision (e.g., reading a book, reading on a mobile phone, reading ingredients on an tag from an item in supermarket).

“When patients are appropriately selected, both multifocal and EDOF lenses are related to very high levels of patient satisfaction,” she adds.

The following article is available in full, including figures and data, on Cleveland Clinic Journal of Medicine August 2020 as part of its COVID-19 Curbside Consults.

The worldwide COVID-19 pandemic has required healthcare systems to implement strategies for effective healthcare delivery while managing blood supply chain disruptions and shortages created by infection-limiting practices that have reduced blood donations. At Cleveland Clinic, we have made multiple synchronous efforts: a call for increased blood collection, alignment of efforts among transfusion medicine departments (blood banks), enhanced monitoring and triage of blood product use, and increased education on patient blood management practices regarding blood utilization and anemia management. In addition, we created an algorithm to assess anemia risks in patients whose elective surgery was cancelled to optimize preoperative hemoglobin levels.

Introduction

Related: Evolution of blood transfusion medicine

The worldwide COVID-19 pandemic has created a need for healthcare providers to respond, innovate, and adapt quickly to address the continued demand for emergency care and necessary healthcare services amid this pandemic. Thus, healthcare systems have had to determine how best to care for patients, keep caregivers safe, and manage supply chain disruptions and shortages, including shortages in blood products.

In March 2020, states began issuing social distancing guidelines and escalated school and business closures. In response, healthcare facilities cancelled all elective surgical procedures and nonessential care. These measures also caused cancellation of blood drives and reduced the number of blood donors who could be at a collection site, which severely affected the availability of blood products. Blood centers and hospitals have had to collaborate to ensure continued blood collections.

Related: Experts underline need for early detection of blood cancers in UAE

At the start of the COVID-19 pandemic in Ohio, blood suppliers for the Cleveland Clinic informed us of the potential for blood shortages and a possible 25% cutback of standard inventory orders, creating a need to adjust inventory and blood utilization. Blood utilization services include transfusion medicine (blood bank) and patient blood management (PBM) departments. Plans were instituted to actively monitor and triage blood product orders. Electronic health record blood orders were modified to enhance and facilitate triaging efforts. PBM amplified its educational efforts regarding restrictive blood utilization and anemia management. In addition, PBM took a proactive approach in reviewing cancelled elective surgical cases to identify opportunities for preoperative hemoglobin optimization once these surgeries were restarted.

Background on patient blood management

PBM practices have existed for decades, but have not been fully integrated as a universal standard of care. PBM is defined as an evidence-based medical and surgical approach to minimize the need for and use of blood transfusion in patients as a means to improve their clinical outcomes. It encompasses a comprehensive integration of a patient-centric, multidisciplinary standard of care centralized on blood health, which involves all functions of maintaining blood volume, anemia management, coagulation management, and surgical technique, not just blood transfusion therapy.

To achieve optimal patient outcomes, PBM implements a variety of treatment strategies to minimize or reduce the use of blood products as well as decrease overall healthcare costs. The practice and standards of PBM are universal across specialties as well as inpatient, outpatient, surgical, and medical disciplines.

The pillars of PBM prove valuable in both normal daily patient care as well as during a global pandemic. They focus on optimizing hemoglobin values, minimizing blood losses (eg, frequent phlebotomy, intra operative), managing coagulopathy, and enhancing tolerance to anemia.

Practitioners of PBM consistently consider the hypothetical situation of caring for patients without the availability of blood products when describing its relevance and value. The US blood supply depends on volunteer donors. The stay-at-home orders created unprecedented cancellations of blood drives, placing the blood supply at risk for shortages. Blood suppliers began notifying hospitals of these shortages, which led to preparations and actions to address the shortages while maintaining care delivery.

Patient blood management and COVID-19: Cleveland Clinic experience

The COVID-19 pandemic highlighted the need for PBM guidelines to be mainstream practice. First, there is the immediate risk that blood shortages impose on acutely ill patients. Second, there is the surge of need for innovation in delivery of PBM services given new opportunities to optimize patients such as after cancellation of elective surgeries.

In the event of blood shortage, the most meaningful areas of concern are the decreased availability of O-negative red blood cells (RBCs) and platelets. These require a well-structured and formal system that triages orders for blood products to ensure allocation to patients at greatest need. This system needs to outline specific triaging criteria as well as implementing workflows that can be adapted for each individual organization.

At Cleveland Clinic, the following efforts occurred simultaneously:

• Transfusion medicine established guidelines for issuing all Rh (D)-negative RBC units, not just O-negative, and issuing Rh (D)-negative platelets. Transfusion medicine had a well-established process in place for triaging all platelets when the inventory fell below a prescribed level. In addition, transfusion medicine personnel alerted institutes to the potential for blood shortages and the plans to curtail blood use.
• PBM implemented guidelines for RBC use and anemia management. These guidelines strongly support a consistent blood management strategy regardless of blood product supply. Restrictive trigger and target thresholds are supported by evidence-based literature.

Anemia management is a vital pillar of PBM. It is not uncommon for our PBM program to have presurgical referrals of patients with a longstanding history of moderate anemia, which may have not been formally addressed. The assessment of anemia focuses on immediate hematinic supplementation, especially parenteral iron, as iron deficiency is the most common hematinic deficiency, and noncorrected preoperative iron deficiency has been strongly associated with poor perioperative patient outcomes.

PBM personnel worked collaboratively with pharmacy to ensure availability of intravenous iron formulations and monitored the operational aspects of infusion centers that could potentially disrupt the ability to treat patients, such as ease of access and appointment availability. In addition, to minimize the risk of virus exposure, more patients were prescribed oral iron formulations to help them avoid visits to infusion centers, with follow up on tolerance and clinical response. We advocate administering oral iron every other day in a single nighttime dose to maximize enteral absorption.

In normal operations, our PBM program has a referral system for preoperative anemia management. However, the cancellation of elective surgeries and transition to virtual patient visits decreased referrals by 70% during April and May 2020. The PBM team discussed the best approach to continue anemia care for patients whose surgeries were postponed and created a workflow management plan for assessing these cases. Surgical services were notified that the PBM team would assess these patients without the need for a formal referral.

This process provides us with additional time to optimize patients’ hemoglobin values, time that was not previously available. Once regular surgical services are restored, patients will be re-screened for anemia, including measurement of iron stores.

Efforts in the inpatient and surgical arena have not been changed. There is still intraoperative optimization of coagulation using monitoring with thromboelastography, use of tranexamic acid, as well as cell-saver use. For critical care patients, the current approaches support restrictive over liberal fluid management, reinforcing the use of a restrictive transfusion approach to minimize the risk of transfusion-associated circulatory overload.

Impact of COVID-19 on blood donations

The COVID-19 pandemic has had a major impact on blood donations, both in cancellation of blood drives and in social distancing rules that affect the number of donors allowed at blood drives and blood centers. Hospitals, such as ours, continue to collaborate with blood centers to hold blood drives in large spaces to minimize donor contact and maximize collections. The criteria for regular blood donations remained the same until the Food and Drug Administration (FDA), in an effort to increase blood donations, modified some of their more stringent criteria. For example, the deferral period for accidental needle stick or a blood transfusion is now 3 months instead of the previous 12 months. Individuals diagnosed with COVID-19 (symptomatic or asymptomatic) and those suspected of having COVID-19 should not donate for at least 14 days after complete resolution of symptoms or the date of the positive diagnostic test, whichever is longer. Blood centers may be more stringent, so blood donors need to register on-line with the blood collection facility to determine eligibility.

Convalescent plasma utilization for COVID-19 survivors

Patients who have recovered from COVID-19 have helped patients with COVID-19 by donating plasma. This plasma, called COVID-19 convalescent plasma (CCP), is considered an investigational new drug by the FDA and can only be administered under an approved Institutional Review Board (IRB). The FDA has introduced two IRBs, an emergency investigational new drug, which requires FDA registration for each patient, and an extended access program under the Mayo Clinic IRB, which allows registered hospitals to request CCP for any qualified patient. The FDA also approves randomized controlled trials using CCP.

Hospitals must place orders for CCP through their blood banks, which then request the plasma from their blood suppliers. Blood suppliers use apheresis machines to collect CCP from qualified blood donors, which has resulted in a balancing act between collection of apheresis platelets and CCP, both of which are collected on the same apheresis instruments.

Patient blood management and COVID-19: What happens next?

PBM practices must continue reinforcing best practices for patient-centric anemia optimization as well as decreasing the risk for blood losses. There must be stringent criteria to triage blood utilization and pursue parsimonious transfusion practices. Among patients with COVID-19, there should be growing evidence on best ways to manage anemia, ideally with a nontransfusional approach, especially as fluid administration strategies are focusing on a restrictive approach, especially among critically ill patients.

The duration of the pandemic is still unknown and the challenges for blood availability will remain present for an unknown duration. Efforts to correct anemia in the general population as well as implementation of safe blood drive protocols must remain in place, aiming to mitigate the risk of viral exposure.

Conclusions

Pandemics and active crises act as a catalyst for innovation and implementation of novel strategies to overcome barriers for effective healthcare delivery. Blood management also is affected as it plays a crucial role for enhanced patient optimization, especially before surgical interventions. Clinicians must balance the need to optimize anemia while minimizing the risk for patient blood loss in order to mitigate the need for blood transfusion. In our experience, blood use by patients with COVID-19 is no different from other patients. Also of note, there have been no documented cases of transfusion-transmitted respiratory viruses, such as the coronaviruses, including SARS-CoV-2.

Read the full article.