COVID – 19 CRISIS

WORKING TOGETHER

Town Hall Meeting:

May 6, 2020 5:00pm PDT | 7 PM CDT | 8 PM EDT

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Presenters

Mina Larson, M.S., MBA, CAE Chief Executive Officer

National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM) )®

Dr. Guangxi Li, MD (China), Dipl. Ac. (NCCAOM)®

Medical Director, Department of Respiratory Medicine,

Guang An Men Hospital of China Academy of Chinese Medical Sciences

Assistant Professor, Department of Respiratory and Intensive Medicine, Mayo Medical Center

President, Computational Medicine Committee of the World Federation of Chinese Medicine

Valerie Hobbs, DAOM, Dipl. O.M. (NCCAOM)®, L.Ac.CNT Committee, CCAOM

Director of Postgraduate Doctoral Programs,

American College of Traditional Chinese Medicine @ CIIS

Steve Shomo, DAOM, L.Ac., AP, GCDMH, CSCS, ERYT, WFRDAOM Faculty, Emperor’s College of Traditional Medicine and

American College of Traditional Chinese Medicine @ CIIS

The information presented by guests on the ASA/NCCAOM Town Hall meetings is for

educational purposes only, and is not meant to direct specific patient

treatments. Any information presented by guests should be evaluated by each

practitioner individually, and ASA/NCCAOM cannot and does not endorse any

specific treatment regimens (herbal, acupuncture, or other). Practitioners are

cautioned to avoid any advertising or other outreach that would lead consumers to

believe the direct treatment of Covid-19 is offered in any form. Such statements do

violate FDA regulations on health claims. All treatments using integrative/Chinese

medicine in the care of patients with Covid-19, whether originating from studies in or

outside of the U.S., should be considered experimental at this time. For more

information https://www.asacu.org/2020/03/best-practices-for-prescribing-herbal-

medicine-during-the-covid-19-crisis/

PRC’s Expert Insight for Patients with

COVID-19

——Essentials of COVID-19 Treatment

Guangxi Li MD/P

CLINICAL PRESENTATION

• Fever, cough, shortness of breath, fatigue

• Mild（85%） to severe（15%） cases

• Death mostly in patients with underlying health

conditions

Encounter COVID19

Why we need worry about

“novel influenza”

•Easy to be ill Pandemic

•Mortality Pandemic

•Psychology Pandemic

•Long term carry-on Pandemic

•Work Discrimination Pandemic

Lung Injury Prediction Factors

• Male

• Overweight

• Diabetes

• Baseline Comorbidities

Methods

Study design and participants:

• a retrospective , multi-center, large samples study with 50 hospitals in 10 provinces , ten regions.

• All consecutive patients(aged≥18) and above confirmed with COVID-19 were enrolled from January

28 to March 6.

Definitions: BMI was classified three groups according to the Criteria of weight for adults, health

industry standard of the People’s Republic of China, definition was as following.

➢ Underweight：BMI<18.5

➢ Normal weight：18.5 ≤ BMI < 24

➢ Overweight：BMI ≥24

The illness severity of COVID-19: mild cases, ordinary cases, severe cases , which was defined

according to the Chinese management guideline for COVID-19.

Clinical Classification

Comorbidities(Any)

Table 2. BMI was associated with poorer of clinical course of patients a

VariablesModel1

OR (95% CI)b P Model 2

OR (95% CI) cP

Model 3 OR (95% CI)d

Ordinary(vs Mild)

BMI* 1.146(1.065-1.234) <0.0001 1.124(1.043-1.210) 0.002 1.099(1.004-1.202)

Underweight vs

normal weight0.785(0.329-1.874) 0.586 0.938(0.387-2.274) 0.887 0.720(0.261-1.985)

Overweight vs

normal weight1.825(1.114-2.991) 0.017 1.688(1.025-2.881) 0.04 1.359(0.768-2.405)

Severe vs Mild

BMI* 1.307(1.187-1.440) <0.0001 1.267(1.145-1.402) <0.0001 1.214(1.077-1.366)

Underweight vs

normal weight0.841(0.201-3.522) 0.812 1.507(0.339-6.707) 0.59 1.811(0.343-9.571)

Overweight vs

normal weight4.577(2.382-8.793) <0.0001 3.853(1.967-7.544) <0.0001 3.168(1.456-6.896)

Time Series Clinical Presentation

• Incubation period 1-14 days(mostly 3-7 days)

• Fever period(D1 to D7): Golden window to prevent ALI

• ALI Period （D8 to D14): Delayed treatment and prolonged fever could trigger ALI

• Recovering Period (D14 thereafter):

Time Series Data and Golden Window

BadOutcome

GoodOutcome

Failure to Rescue

High TemperatureDry CoughDyspnea

Whole Map of Treatment

Home IsolationEmergency Room

Hospital Ward ICU

Very Early Stage: Control Transmission

• TEST TEST TEST

• Mild patients(they may not even know they got disease)

isolation

• Lockdown the whole country(China lockdown 53 days)

and now back to normal

• Treat early: Leverage patients according to different

disease level

Fever Window

• Transmission stage

No confirmed any antiviral drug work

Patients may fall off cliff right after fever

Steroids, NSAIDS……..

Best: Chinese Medicine

ALI Prevention

• The only medication recommended in China is Chinese

Medicine(Most effective)

• Ginseng 12g Poria 20g Glycyrrhizae 6g Peucedani 10g Chuanxiong 12g

Notopterygii 12g Angelicae pubescentis 12g Platycodonis 10g Bupleuri

12g Fructus Aurantii 10g Ginger 6g Herba Menthae 6g

• NSAIDS(if Chinese Medicine not available) plus Ginseng(Korea

Ginseng, Chinese Ginseng, American Ginseng)

ALI Prevention

• Monitoring patients fever progression closely

• Monitoring oxygen saturation with pulse oximeter closely

• Monitoring Cough and Shortness of breath

WE SHOULD NOT WAIT

ARDS Treatment

• Invasive mechanical ventilation: Lung protective ventilation

strategy, namely low tidal volume (6-8ml/kg of ideal body

weight) and low level of airway platform pressure (<30cmH2O)

should be used to perform mechanical ventilation to reduce

ventilator-related lung injury. While the airway platform pressure

maintained ≤30cmH2O, high PEEP can be used to keep the

airway warm and moist; avoid long sedation and wake the

patient early for lung rehabilitation. There are many cases of

human-machine asynchronization, therefore sedation and

muscle relaxants should be used in a timely manner.

Persistent Fever——Early ALI

• Male, 52y, Marathon runner

• Moxifloxacin iv. 10 days

• Methylprednisolone iv 10 days

• Fever increase from 38.8 to 39.8

• Coughing, shortness of breath

• Desaturation SPO2 90%

Early ALI

Early ARDS -----Coughing & Dyspnea

• Male, 52y, DM, OSAS

• Moxifloxacin iv. 8 days

• Methylprednisolone iv 8 days

• Fever increase from 37.8 to 39.5

• Coughing, shortness of breath RR 32

DO NOT MOVE PATIENTS----REDUCE OXYGEN CONSUMTION

ALI Case Report------Coughing

Coughing-----Transdermal Therapy

CT Scan on Discharge

One Month After Discharge

One Month After Discharge

Treatment Summary

• Only Chinese Medicine was given with HFNC support and stop all antiviral drug, steroids, antibiotic

• Fever gone after one day on Chinese Medicine

• Cough gone after 5 days on Transdermal Therapy

• Rest patient on bed

ARDS Rehabilitation

• Male, 57y, DM, OSAS

• Day 21 in hospital after NIV & remaining low fever

• Persistent low-grade fever

• Coughing, shortness of breath RR desaturation

MUST MOVE PATIENTS----EARLY REHABILITATION

Late Stage after ARDS

Late Stage ARDS Rehabilitation

Classification of COVID-19 disease

Siddiqi, H.K. and M.R. Mehra, COVID-19 Illness in Native and Immunosuppressed States: A Clinical-Therapeutic Staging Proposal. The Journal

of Heart and Lung Transplantation, 2020.

Classification of COVID-19 disease

[1]Kim, J.H., et al., Role of ginsenosides, the main active components of Panax ginseng, in inflammatory responses and

diseases. Journal of Ginseng Research, 2016: p. S1226845316301282.

• Classification of COVID-19 disease states the potential

therapeutic targets.

• It shows the direction of our treatment.

• Ginseng(ginsenosides), the soul of Ginseng Defeat Toxin

Powder Formula, could be used to prevent and treat a

variety of inflammatory diseases via anti-inflammatory

functions.[1]

• TCM practice suggests the key mechanism of

immunoregulation.

TCM practice observation about 95 cases

• The youngest patient was 58yrs，the oldest patient was 78yrs，average age of 63yrs

• Male patient tend to be worse

• Total of 95 cases: USA 10 ，Russia 10，UK 15，Italy 5，Wuhan,

Hunan Province, China, 29，Henan Province, China 22

UK & ItalyAmerica

China

TCM practice observation about 95 cases

• One died(China, run out of oxygen unexpected)

• One intubated (London, survived)

• Most of them reduced fever after one dose or two.

• Most of them stopped progression before stage IIB.

• After fever reduced, other symptoms persisted for some time,

and now all survivors get full recovery.

• Lack of blood markers to test, need more research.

History of Ren Shen Bai Du San

• Ren Shen Bai Du San (Ginseng Defeat Toxin Powder Formula)

was originally recorded in the Prescriptions of the Bureau of

Taiping People’s Welfare Pharmacy

[compiled in several editions from 1078-1110].

• The later commentary by Yu Lin [note: a Qing Dynasty

physician (1723-1795 CE) famous for authoring Insights from

Treating Epidemic Diseases] stating that it is “the best

formula for treating epidemic diseases” .

History of Ren Shen Bai Du San

• The history of ancient Chinese people fighting against epidemic diseases is a reminder to us that seasons and time periods have common characteristics, and therefore if we correctly identify the disease mechanism [a technical term in Chinese medicine], then the majority of patients will be effectively cured using the treatment principles and the formulas targeted at that disease mechanism.

• At such times, it’s not necessary for the treating physician to be highly skilled; they can modify the basic formulas slightly or even give the original version, and this will be efficacious, saving many lives.

Take Home Message

• ALI prevention is the key

• Prolonged fever is the most important predictor for ALI

• Chinese Medicine & Acupuncture/Moxibustion/Cupping should be considered as the first line therapy----fever & cough

• Early Intubation and Early ECMO for critically ill patients

Valerie Hobbs, DAOM, L.Ac. CNT Committee, CCAOM

Director of Postgraduate Doctoral Programs,

American College of Traditional Chinese Medicine @ CIIS

Steve Shomo, DAOM, L.Ac., AP, GCDMH,

CSCS, ERYT, WFRDAOM Faculty, Emperor’s College of Traditional Medicine

and

American College of Traditional Chinese Medicine @ CIIS

BEST PRACTICE

COVID-19: Practice Guidelines

For Acupuncturists

Going Back To Work

May 2020

Acu Provider Return

• Economic

• Provide care to existing patients

• Provide care for those on the front lines

• Our own physical, mental, emotional &

spiritual well being

Primum Non Nocere – DO NO HARM

Who Governs?

Local Health Department

State/Province

Federal/Nation

LATE

R O

PEN

ING

DA

TES

Public Health Authority

• What governmental authorities make return to

practice orders in your community?

• Your nation, province or state may follow one set

of dates and regulations, and your local, tribal,

county, parish, or city may follow another.

• In most areas LOCAL authority has the final say

Key Resources

World Health Organization

https://www.who.int/emergencies/diseases/novel-coronavirus-

2019/technical-guidance

CDC: https://www.coronavirus.gov

USA State Guide

https://www.huschblackwell.com/state-by-state-covid-19-

guidance

USA NACCHO county health departments:

https://www.naccho.org/membership/lhd-directory

What We Know

• Nature of infection prevention or virus has not changed just because we are reopening

• Duty of a health care provider is to keep their community safe and follow directives of local public health and medical facilities

• Primum Non Nocere – DO NO HARM

• CNT Advisory: Safety Plan

– Facility settings, Availability of PPEs, Disinfection Procedures

• Use good clinic judgment – practitioners are accountable for decisions

• Consider mental emotional health as we come back from trauma

Requirements to Reopen

Open only

• On officially announced date

• When requirements CAN be fully implemented

• When you can safely re-open

• When you choose to re-open

CNT Advisory - Facts

• SARS-CoV-2 virus is shed in high

concentration before symptoms appear.

• Shedding is from upper respiratory (nose)

• Screening by temperature and symptom

tracking alone is INADEQUATE (NEJM)

• Facemasks are required

What To Do

• Hold a Safety Meeting: document!!

• Assess your clinic SETTING and PROTOCOLS

• Use PPE

• Implement and/or maintain infection controls: document!!

• Stay informed

• CMS guidelines for re-opening

https://www.cms.gov/files/document/covid-flexibility-reopen-

essential-non-covid-services.pdf

Office Space

• Analyze your own setting: entry, treatment

space, dispensary, staff area

–Screening

–Social distancing

–Hand hygiene

–Cough hygiene

–Surface decontamination

Office Space – Screening

• Begins with visual and audio alerts on website,

voicemail, posters

–Alert that COVID-19 symptomatic or positive

patients may not be treated on site

–Alert to social distancing procedures

–Reminder to bring face mask, pen

Office Space – Social Distancing

• Analyze entry to your clinic for distancing during

screening

• Analyze treatment spaces

– Minimum 6 ft distance between patients

• Analyze staff spaces

– Minimum 6 ft distance/barriers

• Enact procedures to ensure distancing

– Physically mark 6 ft distance in queue

Office Space –

Social Distancing Procedures

• Utilize telehealth or phone intake as much as

possible

• Patients wait in car until taken directly to

treatment room

• People accompanying patient wait in car (no

kids alone!)

• Curbside delivery of herbs

Office Space –

Hand Hygiene

• Provide posters on hand hygiene

• Must be carried out by each person upon entry

to clinic

• Provide hand sanitizer (min. 60% alcohol)

throughout space or immediate access to soap

and water

• Practice hand hygiene per CNT

Office Space –

Cough Hygiene

• Provide posters on cough hygiene

• Provide tissues and no-touch waste receptacles

• Assess ventilation https://www.osha.gov/Publications/OSHA3990.pdf

– High-efficiency air filters

– Increase ventilation and outdoor air rate*

– Ensure smooth operation and maintenance of HVAC

– Install sneeze guards

*HVAC recommendation

Office Space –

Surface Decontamination

• Analyze setting

–Minimize furnishings with cloth coverings

–Minimize non-essential objects in treatment rooms, remove decorative items

–Place clean laundry in cabinet or sealed storage container

–Create checklist for cleaning all items in a treatment room

Office Space –

Surface Decontamination

• All hard surfaces: clean and disinfect with EPA

registered disinfectant for Corona virus

according to label

https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-

against-sars-cov-2

To kill virus, surface must remain wet for entire time specified

on label. Look for “contact time” or “dwell time”

Office Space –

Surface Decontamination

• Establish frequency of cleaning according to

how often surface is contacted

https://www.cdc.gov/coronavirus/2019-ncov/community/disinfecting-

building-facility.html

https://www1.nyc.gov/assets/doh/downloads/pdf/imm/disinfection-

guidance-for-businesses-covid19.pdf

Office Space –

Surface Decontamination

• Treatment table and any surface touched by

patient: after each patient

– Doorknobs, check out counters, sinks, handles of hand sanitizer

dispensers

• All surfaces in treatment room, including floor: daily

• All frequently touched surfaces by staff: daily

• Office/dispensary surfaces and floors: weekly

Office Space – Laundry

• Nothing may be used for multiple patients

– Table liners/pads, blankets, sheets, gowns, pillowcases

• Hanging cloth room dividers

– See manufacturer label for frequency of washing

Office Space – Checklist

• Create a checklist for cleaning after each patient

• Create a checklist for daily/weekly cleaning

• Use checklist to create a grid with spaces to initial and record dates of cleaning, post on inside of cabinet in treatment room and initial and date when completed. File sheet when completed.

Office Space –

Surface Decontamination

PPE

• Eye Protection*

• Facemask

• Gloves

• Clinic apparel

* watches/jewelry

PPE - Facemasks

• Patients may wear DIY cloth mask

• Surgical masks are for HCP

• N95 for HCP treating COVID-19

N95/KN95

• HCP are fit tested with N95

• 3M research* (KN95 = <8% leakage)

• Provider response – Unable to get a good

seal

PPE - Facemask

• Can be worn for a day if (currently HCP are

reusing for up to 7 days)*

– They are clean and dry

– There is no visible defect

–You don’t touch them

PPE - Facemask

• Can be “donned and duffed” between

patients

• Wash hands before putting mask on

• Don’t touch interior

• Wash hands before taking mask off

• Place mask in a paper bag

• Wash hands before re-donning mask

PPE - Gloves

• Gloves are not usually required for acupuncture

• Best advice is that gloves should be worn now, and

changed between patients

• Hands should be washed whenever gloves are removed

• Gloves should be worn whenever handling patient

laundry and disposables

• Gloves should be worn to clean and disinfect treatment

rooms

PPE - Clinic apparel

• Use a clinic coat or

• Strongly recommend wearing scrubs

• Keep change of clothes/scrubs on hand; change if

exposed to patient droplets

• Laundering of clinic apparel: daily

• Isolation Gowns used for treating Covid19 pts

Before Opening - Protocols

• START WITH UNIVERSAL PRECAUTIONS – assume every

patient is a carrier and asymptomatic

• Is your facility cleaned and equipped (safety meeting)

• Do you have enough PPE for you and your staff

– is it sustainable

• Access to wash and/or sanitize station for providers and

patients*

• Contactless payment exchange procedures

Pre-Screening Protocols

Phone screening recommended 24 prior to

appointment;

• Fever or respiratory issues (SOB/Cough/Difficulty)

• Chills

• Muscle Pain

• HA

• Sore Throat

• Loss of smell or taste

DOS Screening Protocols

Day of Service

• Any changes since pre-screen

• Temperature (>100.4)

• Wash/sanitize hands before entering clinic

• Direct to exam room (no waiting area)

• Does pt have a mask

– What happens if patient doesn’t bring mask to the clinic?

TX & Schedule - Protocols

• Analyze treatment protocols for increased infection

by droplet

– Patient positioning (prone/supine)

– Patient removes their mask*

• Stager appointment times

• Allow minimum of 30 min. between appointments to

disinfect exam/treatment room.

– If you run multiple rooms; limit to ONE room to minimize risk

Treatment - Protocols

• Contactless payment

• Follow the above described disinfection procedures

(Treatment and Daily)

• Contact and prescreen next days patients if back to

back days

Resources

• PPE Supplies are low and difficult to acquire

–Acupuncture and medical supply vendors

Traumatic Stress

• COVID19 Patients

• Providers

• At Home

• Coming back from a place of trauma

– Transform FEAR into Calm, Clarity, and Creativity

• Self Care practices

Referrals

• Refer to Western provider for any emerging sign of

potential infection

• Self quarantine (14 days)

• Active COVID-19 nasal swab testing available with

physician referral

–Current testing has been to those patients with

symptoms that require hospitalization

–Healthcare providers

CCAOM CNT Advisory

• https://www.ccaom.org/images/ccaom/Documents/COVID-

19/CCAOM%20Clinic%20Infection%20Control%20Advisory%20(

Updated%204.30.2020).pdf

COVID – 19

HELPFUL RESOURCES

COVID – 19

HELPFUL RESOURCES

CERTIFICATES OF COMPLETION FOR TOWN HALL

MEETINGS ARE DISTRIBUTED WITHIN

TWO (2) WEEKS OF THE EVENT DATE

Thank you!Questions and Answers

townhall@thenccaom.org