Healthcare professionals are putting their lives on the line to provide critical care

Not since 1918 has a global pandemic caused so much disruption to society. Soldiers returning home from the trenches of The Great War ensured that what quickly became known as Spanish Flu, (an influenza pandemic caused by a new strain of bird flu) spread quickly, resulting in global pandemic and an unprecedented death toll. How could it be, that after 'the war to end all wars', a simple flu outbreak could cause the deaths of between 50 and 100 million people?

Whole towns and villages were forcibly isolated to contain the outbreak, and complete families wiped out by the flu, it took at least 18 months for the pandemic to run its course before life could start to resume. Today, more or less everyone in the United States and Europe is under a stay at home order to abate the spread of the latest coronavirus, allowed out only for essential supplies and exercise as health experts attempt to flatten the infection curve. Many nations in fact, have adopted even stricter measures with movement tightly controlled and enforced by armed police and permits needed to leave the home with strict penalties for those that break quarantine. Unless the rate of infections can be brought under control, the 1918 flu pandemic will look like a walk in the park by comparison to the damage caused by COVID-19.

The Front Lines:

Today, our hospitals and clinical staff are stretched to breaking point as patient numbers continue to surge. Additional hospital beds are being setup in conference centers and inside tents in former parking lots just to cope with the influx. But there are a finite number of medical devices, like ventilators, to keep patients alive when they can no longer breath and an even more limited number of clinical staff trained to operate them or to deal with highly infectious disease like this. But the extreme measures that nurses and doctors have to go to protect themselves and the risks they take to their own health and that of their families is enormous. The infection and mortality rates for doctors and nurses is already way above that of the population as a whole, and their sacrifice to save many of us, has not gone un-noticed globally. These front line medical staff and the epidemiologists that race to develop a vaccine and other drugs to impede the effects or the spread of the disease are indeed the new hero's of 21 century.

We asked one of our senior solutions engineers at Cylera, Mark Elliott, who has over 20 years in healthcare on both the clinical and technical side, to tell us what it is currently like on the front lines. This is what he told us:

As an IT professional working within the Healthcare space for the last 20 years and being the husband and father to a nurse practitioner and ICU nurse, I have enjoyed seeing how our worlds have become integral to each other over time and how we help each other to improve patient care and outcomes while ensuring their privacy and security.

Never has this been truer than during our national and regional response to the COVID-19 pandemic. The changes in required medical infrastructure, medical protocols and procedures, and acceptable drug regimens are rapidly and constantly in flux.

As of today, our front line healthcare workers are placing their own health and their families’ health at risk to provide care to their patients, with many of them contracting the virus themselves. Besides the physical aspects of this disease and the extraordinary precautions they must take several times a shift, these healthcare professionals are having to watch these patients and their families cope with the new normal of their family member dying alone in isolation.

Healthcare Professionals:

Be it in daily routine or disasters, these healthcare professionals are on the frontlines of the epidemic. As COVID cases only increase with time, it is important to understand what healthcare professionals are dealing with today as well as how HDOs become prime targets for cyber attacks while dealing with disasters. 

The following is a description of what ICU professionals are dealing with today. As the number of hospitalized victims drastically increases over the next 8 weeks, these stated conditions might only get worse.

Patient Care:

Each patient in the ICU is assigned a specific nurse for direct care for that shift, that nurse can only work on two or more dedicated patients per shift to ensure no cross contamination.
Runner nurses from other departments are assigned to service the direct care nurses to ensure they don't contaminate other spaces in the hospital.

Protective Measures:

All of the technology added to adapt to caring for COVID-19 patients faces one crucial question - how hard is it to initiate using the technology in full PPE - two to three layers of gloves, plastic gown, N95 or higher filtration mask that has been appropriately fitted (Droplet or surgical masks do not filter viruses, only bacteria). While being completely soaked in sweat, hands shaking with the adrenaline from entering a room full of highly contagious virus.

General Medical Devices for COVID-19 Patients:

1. Littman Electronic Stethoscope - nurses can record breath and heart sounds electronically and save the audio to a file that can be accessed by the health care team outside of the room. This is used when donning the PAPR mask since white noise of the fan makes a traditional stethoscope useless
2. Periodic peroxide swifter mopping - to clean virus droplets off the patient room floor.
3. Microsoft Teams - iPhones are in all patient rooms and can be used to message, call and video-call other team members including charge nurse, other nurses, and physicians/providers; utilizes hospital emails.
4. The nurses are also using the "chat" function in Epic to message each other asking for help throughout the shift with doffing gear, sending labs, or acquiring supplies once we have entered a "dirty" room.
5. Most patients coding from the virus will be suffering from hypoxia. If these patients are not already on a ventilator, then they will not be manually bagged to avoid aerosolization of virus droplets.
6. At this point only 3 staff members are allowed in a patient's room to work a code: Primary Nurse, Respiratory Therapist, and Anesthesiologist.
7. Lucas device - allows hands-free compressions once placed on a patient, reducing the need for extra staff members in the room and reducing proximity of nurses to patient's face/source of virus. Typically, anywhere from 5-10 people alternate giving compressions in an ICU code, now none are exposed.
8. Utilizing 5-lead EKG (versus a 12 -lead EKG that would require staff to enter the patient's room) and electronic calipers on patient monitors to track patient's QTc length, as QTc prolongation is a common and dangerous side effect of several medications being used to treat COVID-19.
9. IV pumps and ventilator screens are placed outside of patient rooms using extension cords and tubing to allow titration of medications and ventilator settings without donning full PPE.
10. Infusion pumps have additional ports to allow code meds to be pushed outside the room, reducing the need additional exposure during a code.
11. Patient Rooms are maintained at negative air pressure to reduce airborne contamination.
12. II possible medical device controls have been run into the hallways to reduce the amount of times a nurse must put on (Burn through PPE resources) protective clothing and devices.

In an effort to reduce personal protective equipment, a suggestion has been provided to move IV pumps outside of the patient room as shown below and extend the tubing to the patient. This will help staff tend to the IV pump without the need of personal protective equipment. This checklist may help hospital facilities professionals assist in relocating patient equipment from negative pressure rooms to avoid repeated entry into the room to check on patient equipment.

Medical loT Devices per patient bed: Patient monitor - Located outside the patient room.

1. Blood pressure at the bed side with cables to the patient monitor outside of patient room.
2. Temperature sensor at the bed side with cables to the patient monitor outside of patient room.
3. Ventilator with controls outside of patient room.
4. Bi-Spectral Index Sensor at the bed side with cables to the patient monitor outside of patient room. This is similar to EEG and measures the state of sedation in medically paralyzed patients that would otherwise fight the ventilator.
5. Glucometers are the one medical device that still requires a nurse to bring it into the patient's room to get a blood sugar several times per shift.

IT Can Help with Healthcare loT Management:

How can IT monitor and manage Healthcare loT in this chaotic environment where new devices will be pressed into service before they can be cataloged correctly and verified in your healthcare infrastructure?

1. With passive monitoring of the network traffic, IT staff should be able to identify each medical device on the network in real time:
   1. Vendor
   2. Model
   3. Serial Number
   4. Hardware Version
   5. Firmware Version
   6. Software/OS Version
   7. Location: Campus/Building/Floor /Department/Room
   8. Switch/Port
   9. Access Point/ SSID/ Band/RSSI
   10. Status: On/Off
   11. Actively being used on patient
   12. Last Seen and Where
   13. First Seen
   14. AV Client Software
   15. Desktop Management
   16. FDA Type
   17. Impact of Data Stored
   18. Impact of Data Transmitted
   19. Known NIST CVE Vulnerabilities or known attack vectors
   20. Known FDA Recalls
2. Update legacy CMMS database systems with real time device inventory information.
3. Monitor devices for abnormal communications between other internal devices.
4. Monitor devices for abnormal communications to unauthorized or malicious intranet or internet sites.
5. Monitor for the use of default passwords or compromised passwords ensuring proper on-boarding process is completed.
6. Provide reporting on firmware patching status across all devices and all fleets.
7. Auto generate work tickets in applications like ServiceNow for Helathcare IoT devices experiencing alerts, vulnerabilities or threats as they are identified.
8. Integrate with existing Network Security systems (Firewall, NAC, SIEM) to enforce Zero Trust policies proactively or on alert notification.
9. Provide intelligence to existing Firewall, NAC, Vulnerability Scanners, SIEM, Ticketing and CMMS systems where a device's entire profile is know not just its MAC and IP address.
10. Track operational use of devices and provide reporting to allow location tracking, hardware/software version control and optimized usage of critical medical equipment through operational analytics of individual devices or fleets of devices to better maintain and utilize critical care equipment.

As IT professionals, we must stand up and implement solutions that will provide the front-line workers with the tools needed to deal with this global pandemic and reduce the negative impact of the new devices and procedures thrust on them.

Mark Elliott is a Senior Solutions Engineer with Cylera. Not only is he a technologist, but also a clinician having worked in war-torn Africa for 7 years providing free surgeries and surgical training while consulting with UN, EU, USAID, AU, and National Ministries of Health. He has over 20 years working in the Healthcare space and is married to a nurse practitioner while his daughter is an ICU nurse, both at very busy Texas hospitals.