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COVID-19 Town Hall Webinar Series – Session II
6/12/2020 2
Webinar Logistics
6/12/2020 3
• All attendees are muted automatically upon entry.
• This webinar is being recorded and will be posted to our website.
• With your registration to this webinar, your email has been added to our
distribution list. Please add [email protected] to your “safe senders” list.
• To ask a question about a presentation or request technical assistance, please
submit a message to Bonnie Hansen via the chat feature. All questions will be
held until the end.
Zoom features:
MNPQC Operations
6/12/2020 4
Phillip Rauk MD
MNPQC Chair
Maternal & Fetal Medicine
MHealth/Fairview
Susan Boehm RN, MS
MNPQC Co-Lead
MPO Executive Director
Bonnie Hansen
MNPQC Program
Coordinator
MPO Business Manager
Anne Walaszek, MPH
MNPQC Co-Lead
MDH Quality Advisor
https://minnesotaperinatal.org/mnpqc
Agenda
6/12/2020 5
COVID-19 resources
Telemedicine & Neonatology
Transitioning to home with newborn and COVID+ parent(s)
PUIs: Visitor Guidelines and Evaluation & Testing of the Neonate
Q&A discussion (submit questions via chat)
MNPQC Response to COVID-19 for moms and newborns
6/12/2020 6
• Town Hall webinars designed for Minnesota healthcare professionals
(every 2 weeks),
• COVID-19 resources available via MPO/MNPQC webpage:
https://minnesotaperinatal.org/covid_19_updates,
• Network and share best practice protocols via our Basecamp forum (available to all perinatal/neonatal healthcare and allied professionals, please
contact [email protected] or leave a message for Bonnie Hansen in
the chat box with your preferred email address for an invite to join).
COVID-19 Updates Page
6/12/2020 7COVID-19 Resource Page on the MPO website: https://www.minnesotaperinatal.org/covid_19_updates
MNPQC COVID-19 Basecamp
6/12/2020 8
Telemedicine & Neonatology
6/12/2020 9
Beth Kreofsky, MBA
Operations Manager, Teleneonatology
Mayo Health System
USING TELEMEDICINE TO SUPPORT NEONATAL RESUSCITATION
‟THE NEEDS OF THE PATIENT COME FIRST.”
MAYO CLINIC TODAY
Academic Medical Center
• 400,000 patients/yr.
• 2,380 Physicians & Scientists
• Including 125 Primary
Care Providers
R O C H E S T E R
Community & Regional Health
System
• 4 Regions
• 18 hospitals
• 75 communities in MN, IA& WI
• 525,000 patients/year
• 1,140 Physicians
H E A L T H S Y S T E M
F L O R I D A
• 110,000 patients/year
• 559 Physicians & Scientists
• 115,000 patients/year
• 621 Physicians & Scientists
A R I Z O N A
CENTER FOR
CONNECTED CARE
• Extend Mayo Clinicknowledge and expertiseto people in the right placeat the right time through theright channel
• Increase patient accessto clinical care services at a distance
• Assist in delivering care in more efficient and convenient ways
• Assist in decreasing overall cost of care
Live Video
Asynchronous
Remote Monitoring
mHealth
MCCN
OtherPartners
Mayo Practice
Acuity
Future
Current
CONNECTED CAREAT MAYO CLINIC
Home
WellnessCenter
Urgent Care/Express Care
Ambulatory Care
OutpatientClinic
Facility Care – Video Outreach20+ subspecialties
AmbulatoryProcedure Center
Video to Home
Hospital
Air/GroundTransport
Acute Care
Pre-hospital
Other specialties
Pharmacy
Emergency Medicine
Obstetrics
NeonatologyEnhanced Critical Care
Stroke
SkilledNursing Facility
OutpatientClinic
Post-Acute Care
Tele-Transitional Care
Skilled Nursing Care
InpatientRehab
Dialysis
Remote Monitoring
eConsultsExpress Care Online
Patient Online ServicesSecure Messaging
eConsultsBedside App
InteractiveCare Plans
Check in Kiosksand Tablets
Self Triage
TELENEONATOLOGY AT MAYO CLINIC
• A telemedicine network that allows
neonatologists to be at the bedside
of critically ill neonates exactly when
needed
• Established MARCH OF 2013
• Over 475 consults
• Program development and expansion
in partnership with CENTER FOR
CONNECTED CARE
©2020 MFMER | 3936671-15
32 BED Level IV regional NICU
24 BED Level III NICU
Staffed by 9
NEONATOLOGISTS
2,500 deliveries per year
>800 admissions per year
50% are out-born
SETTINGTHE HUB
146
1500
200
2400
102
1012
943
424393
310
69237
BEFORE TELENEONATOLOGY
43% of newborns at MAYO MIDWEST HOSPITALS
had immediate access to a Neonatologist
AS OF OCTOBER 2016
100% of newborns in the MAYO CLINIC MIDWEST REGION
have immediate access to a Neonatologist
SETTINGTHE SPOKES
• Staffed by PEDIATRICIANS and/or
FAMILY MEDICINE PHYSICIANS
18 Mayo Clinic
Health System sites
7 – Level I nurseries
2 – Level II nurseries
9 – Emergency rooms
2 External hospital
Level I nurseries
6,000 deliveries per year
©2020 MFMER | 3936671-18
Activations by Gestational Age
Program data from 2017-2019
Preterm Fullterm
%
31
69
Program data from 2017-2019
1931
50
221
0
50
100
150
200
250
≤28 weeks 29-33 weeks 34-36 weeks ≥37 weeks
Number of Consults by GA Category (n=321)
INDICATION FOR CONSULTATION
33
17
21
32
47
52
115
173
0 20 40 60 80 100 120 140 160 180
Other
Congenital anomalies
Encephalopathy
Fetal distress
Advanced resuscitation
Physical exam finding
Prematurity
Respiratory distress
Program data from inception to Jan 2020
Number of Cases
PATIENT DISPOSITION
Transferred
Remained Local
Died
Fang et al, Mayo Clin Proc 2016
% 6334
2
CONCLUSIONS• Telemedicine can:
• Improve access to resuscitation expertise
• Enhance patient safety
• Improve the quality of high-risk newborn resuscitations
During COVID:
• Reduce the risk of exposure for the transport and care teams
• Reduce the need to relocate a family
• Conserve PPE
Transitioning to home with newborn and COVID+ parent(s)
6/12/2020 23
Jordan Marmet, MD
MHealth Fairview
Pediatric Hospital Medicine
Transitioning to home with newborn and COVID+ parent(s)
6/12/2020 24
TESTING
Per CDC:
• SARS-CoV2 PCR is recommended for all neonates of COVID+ or suspected moms, regardless of symptoms
• Timing: at ~24 hrs age. If initial test results negative, or not available, repeat at 48 hrs
• Serologic testing is not recommended at this time
• Caveats
• For asymptomatic neonates with expected DC <48 hrs, a single test can be performed prior to discharge
• In areas with limited testing capacity, prioritize testing for symptomatic neonates or longer anticipated LOS
Per AAP:
• “If testing capacity is available, testing well newborns will facilitate plans for care after hospital discharge; will
determine the need for ongoing precautions and use of personal protective equipment for care of hospitalized
infants; and will contribute to our understanding of viral transmission and newborn illness.”
https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/clinical-guidance/faqs-management-of-infants-born-to-covid-19-mothers/
https://www.cdc.gov/coronavirus/2019-ncov/hcp/caring-for-newborns.html
Transitioning to home with newborn and COVID+ parent(s)
6/12/2020 25
COHORTING, FEEDING
• Currently, no clear evidence supports transplacental viral transmission from mother to newborn.
• CDC stance: Although ideal setting for hospital care of a healthy term newborn is within the mother’s room, should strongly
consider temporary separation of the newborn from confirmed or suspected COVID+ mom to reduce the risk of transmission.
Considerations include:
• Clinical condition of mom and baby
• Testing availability
• Space
• PPE
• AAP: Rooming-in is controversial; experts are divided. The risk to the infant is simply unknown at this time. The safest course of
action to minimize risk to baby is to separate mom and baby, at least temporarily.
• The AAP strongly supports breastfeeding as the best choice for infant feeding.
Transitioning to home with newborn and COVID+ parent(s)
6/12/2020 26
ADDITIONAL CONSIDERATIONS
• Prenatal huddle, discussions on cohorting
• Newborns should be bathed shortly after birth
• Symptomatic baby – NICU has different considerations
• Visitor policy
• Newborn screening unchanged
• Circumcision
• Follow-up plans
PUIs: Visitor Guidelines, Evaluation and Testing in Neonates
6/12/2020 27
Erin Plummer, MD
Neonatologist
Children’s Hospital
PUIs: Visitor Guidelines, Evaluation and Testing in Neonates
6/12/2020 28
Objectives
1. Discuss COVID-19 illness in neonates
2. Discuss testing in neonates
3. Review recommended and practiced precautions
4. Discuss parent/visitor restrictions
COVID-19 in Neonates
6/12/2020 29
“Transmission of SARS-CoV-2, the virus that causes COVID-19, to
neonates is thought to occur primarily through respiratory droplets
during the postnatal period when neonates are exposed to mothers,
other caregivers, visitors, or healthcare personnel with COVID-19.
Limited reports have raised concern of possible intrapartum or
peripartum transmission, but the extent and clinical significance of
vertical transmission by these routes is unclear.”
COVID-19 in Neonates
6/12/2020 30
Zeng L, Xia S, Yuan W, et al. Neonatal Early-Onset
Infection With SARS-CoV-2 in 33 Neonates Born to
Mothers With COVID-19 in Wuhan, China. JAMA
Pediatr. March 26, 2020.
33 neonates born to COVID + mothers in China
3 infants tested positive
1 born at 31 weeks with bacterial sepsis
2 born at term with mild symptoms including shortness of breath, fever, lethargy, vomiting, PNA
Zimmerman P, Curtis N. COVID-19 in Children,
Pregnancy and Neonates: A Review of
Epidemiologic and Clinical Features. The Pediatric
Infectious Disease Journal: June 2020 - Volume 39 -
Issue 6 - p 469-477.
9 case series + 2 case reports described outcomes of COVID-19 in 65 mothers and 67 neonates in Australia
30% fetal distress was reported
37% of women delivered preterm
Neonatal complications included RDS/PNA (18%), DIC (3%), asphyxia (2%), 2 perinatal deaths.
4 neonates (3 with PNA) have been reported to be SARS-CoV-2 positive despite strict infection control during
delivery and separation of mother and neonates, meaning vertical transmission could not be excluded
Jeng MJ. Coronavirus disease 2019 in children:
Current status. J Chin Med Assoc. June
2020;83(6):527-533.
Early-onset (<7 days) neonatal COVID-19 was found in 3 neonates born to SARS-CoV-2–positive mothers; all were
symptomatic, including fever, lethargy, respiratory distress, and pneumonia. Nasopharyngeal and anal swabs were
positive on days 2 and 4 and negative on day 6 or 7
Late-onset (≥7 days) neonatal COVID-19 was reported in 3 neonates between the ages of 15 and 19 days;
infectious sources included their infected mothers (n = 2) and a housemaid.
Close contact with infected persons after birth is the most probable transmission route of these late-onset
neonatal COVID-19 cases
All of these reported SARS-CoV-2–positive neonates recovered after management
White A, Mukherjee P, Stremming J, et al.
Neonates Hospitalized with Community-Acquired
SARS-CoV-2 in a Colorado Neonatal Intensive Care
Unit [published online ahead of print, 2020 Jun
4]. Neonatology. 2020;1-5.
3 patients who required admission to the NICU in Colorado between the ages of 17 and 33 days old.
All 3 had ill contacts in the home or had been to the pediatrician and presented with mild to moderate symptoms
including fever, rhinorrhea, and hypoxia, requiring supplemental oxygen during their hospital stay
1 patient was admitted with neutropenia, and the other 2 patients became neutropenic during hospitalization
None of the patients had meningitis or multiorgan failure.
Evaluation & Testing of Neonatal PUIs
6/12/2020 31
• Data to describing COVID-19 illness among neonates
is limited; based on case reports and small case series
• We tend to think of the NICU population as immune
compromised and at higher risk for severe illness
• Unclear whether signs of illness are due to COVID-19
or prematurity:
• Fever, lethargy, rhinorrhea, cough, tachypnea,
increased work of breathing, vomiting, diarrhea,
and feeding intolerance/decreased intakehttps://www.verywellfamily.com
Evaluation & Testing of Neonatal PUIs
6/12/2020 32
At Children’s Minnesota:
• Infants whose mothers are COVID-19 + or are PUIs are also considered PUIs
• Infants who have a known exposure are also considered PUIs
CDC & AAP Recommendations for Testing of Neonatal PUIs
6/12/2020 33
• Testing is recommended if testing capacity is available
• Facilitates plans for care after hospital discharge
• Determines the need for ongoing precautions
• Contributes to our understanding of viral transmission and newborn illness
• Newborns should be bathed after birth to remove virus potentially present on skin surfaces
• Testing for SARS-CoV-2 RNA by reverse transcription polymerase chain reaction (RT-PCR) should be done first
at ~24 hours of age and again at ~48 hours of age
• Optimal timing remains unknown
• For asymptomatic neonates expected to be discharged <48 hours of age, a single test can be performed
• For infants who are positive on their initial testing, consider follow-up testing at 48-72-hour intervals until two
consecutive negative tests are obtained 24 hours apart to establish that the infant has cleared the virus
• Most important for infants cared for in the NICU and less so for those discharged to home
6/12/2020 34
May 28, 2020
SARS-CoV-2 (COVID-19) RT-PCR In-House Testing Options
Option Cepheid SARS-CoV-2 Assay
Platform Cepheid, GeneXpert
Random access or Batch Random access: 16 modules (Mpls); 8 modules (STP)
FDA Clearance Status Emergency Use Authorization
Sensitivity/Specificity Percent Agreement (95% CI) – AccuPlex Reference Material Positive Percent Agreement (sensitivity) (n=20): 100% (83.9% - 100%) Negative Percent Agreement (specificity) (n=35): 100% (90.1% - 100%) Percent Agreement (95% CI) – Live Virus Positive Percent Agreement (sensitivity) (n=20): 100% (83.9% - 100%) Negative Percent Agreement (specificity) (n=30): 100% (88.7% - 100%) Percent Agreement (95% CI) – In House Test Verification Study, Children’s MN Positive Percent Agreement (sensitivity) (n=50): 100% (92.89% - 100%) Negative Percent Agreement (specificity) (n=50): 100% (92.89% - 100%)
Limit of Detection 250 copies/mL (AccuPlex Reference Material)
0.0100 PFU/mL (Live Virus)
Daily Capacity Current Capacity: ~40/day
Capacity dependent upon following factors:
Availability of NP swabs and VTM
Test kit allocation by Cepheid (not guaranteed and subject to change)
Instrument run time 45 min
Test run times 24/7
Turnaround time ~60 minutes from receipt in laboratory Go-live date April 14, 2020
Testing of Neonatal PUIs
6/12/2020 35
At Children’s Minnesota:
• Universal testing of all infants admitted through the ED; initiated on 5/13/2020
• Universal testing of all pregnant mothers prior to delivery; initiated on 5/21/2020
• For patients less than 1 month old:
• 80 infants tested
• 3 positive (3.8%)
• 2 infants admitted through the ED; length of stay 2 days
Precautions
6/12/2020 36
NICU Admission of PUIs:
• If infant is receiving aerosol-generating procedures place in airborne, contact,
and eye protection precautions
• If infant is not receiving aerosol-generating procedures place in contact,
droplet, and eye protection precautions
Visitor Restrictions/Precautions
6/12/2020 37
At Children’s Minnesota:
• Two healthy visitors at the bedside only (parents and support person) in the NICU
• Universal masking of all persons within the hospital
• Temperature screening of all healthcare providers and parents upon entering the NICU
• Universal use of masks and face shields with patient interactions for healthcare providers
PUI Visitation Guidelines
6/12/2020 38
• Most NICUs have limited visitation at a baseline
• Mothers and partners who are COVID-19 PUIs should not enter the NICU until their status is resolved
• Mothers (and partners) with confirmed COVID-19 should not visit NICU infants while able to transmit virus
• CDC recommends two different approaches to help define when a person becomes non-infectious:
1. Symptom/time-based strategy, mother can visit if (a) she has been afebrile for 72 hours without use of
antipyretics with improving respiratory symptoms and (b) at least 10 days have passed since her symptoms
first appeared (or, in the case of asymptomatic women identified only by obstetric screening tests, at least
10 days have passed since the positive test)
2. Test-based strategy requires the mother to have negative results of a SARS-CoV-2 test from at least two
consecutive specimens collected ≥24 hours apart
Poll Question
6/12/2020 39
1. Can asymptomatic mothers with confirmed or suspected COVID-19 and well newborns
room-in?
a. Always yes
b. Always no
c. It depends following a conversation with the mother
2. Can symptomatic mothers with confirmed or suspected COVID-19 and well newborns
room-in?
a. Always yes
b. Always no
c. It depends following a conversation with the mother
Poll Responses
6/12/2020 40
1. Can asymptomatic mothers with confirmed or suspected COVID-19 and well newborns
room-in?
a. Always yes = 1
b. Always no = 2
c. It depends following a conversation with the mother = 15
2. Can symptomatic mothers with confirmed or suspected COVID-19 and well newborns
room-in?
a. Always yes = 2
b. Always no = 1
c. It depends following a conversation with the mother = 15
6/12/2020 41
PROS CONS
• May provide time for the mother to become less
infectious and reduce transmission
• Most newborns who are exposed to mothers who
have COVID-19 do well
• Reduces ability to promote mother/infant bonding
and breast feeding during the critical days following
birth
• May be missing an opportunity to teach mother
recommended hand/breast hygiene when caring for
her infant
COVID + Mother/Infant Dyad SeparationPROS & CONS
AAP & CDC Recommendations for Mother/Infant Dyad Rooming
6/12/2020 42
• Controversial question; experts are divided on the best course of action
• Knowledge Gap: Risk to the infant in this situation is unknown at this time
• While difficult, the safest course of action from the perspective of minimizing the likelihood of the infant becoming
infected is to separate mother and infant, at least temporarily
• Temporary separation may be accomplished by admitting the infant to an area separate from mother and separate from
unaffected infants
• If after discussion with the clinical care team, the mother chooses to room-in, or if rooming-in is necessary, specific
steps should be taken to minimize the risk of the newborn acquiring postnatal SARS-CoV-2 infection:
• Mother should maintain a distance of at least 6 feet from her infant when possible
• A non-infected caregiver should help provide hands-on care to the infant whenever possible
• When the mother provides hands-on care, she should wear a mask and perform hand-hygiene
• Use of an isolette may facilitate distancing and provide the infant an added measure of protection
Q & A Discussion
6/12/2020 43
• Thoughts?
• Questions?
• Discussion Points?
• Please share via the chat feature at the
bottom of your screen…
Mark your calendars
6/12/2020 44
Future MNPQC COVID-19 Town Hall Webinars:
Tuesday, June 23rd
5:00pm-6:00pm
Watch for registration details via email and/or visit our website:
https://minnesotaperinatal.org/covid_19_updates.
Thank you!
Contact information:
Phillip N. Rauk, MD | MNPQC Chair | [email protected]
Susan Boehm, RN, MS | 612.201.0708 | [email protected]
Anne Walaszek, MPH | 651.201.3625 | [email protected]
Bonnie Hansen | [email protected]
6/12/2020 45
