Hospitals have been forced to cancel elective surgeries due to the COVID-19 pandemic, which has not only had a tremendous impact on perioperative operations and revenue, but has also created a large backlog of cases. I recently hosted a leadership roundtable with experts on the clinical and business side to discuss the strategies that are being used as facilities work to reschedule the backlog of cases and restore their elective surgery caseload.
Joining me for this discussion were:
Dr. Mauricio Gonzalez – Vice Chair of the Clinical Affairs Department of Anesthesiology at Boston Medical Center
Dan Towarnicke – Vice President, Perioperative Services at University Hospitals
Thad Wadsworth – Vice President, Operations, Providers and Surgical, ProMedica
Patricia Hoch – Senior Sourcing Director & Value Analysis, Inova Health System
This is an edited and condensed version of our conversation. You can watch a full replay of the webinar here.
Thad, what is your organization doing to prioritize procedures and resume cases?
Thad Wadsworth: We really wanted to look at a couple of things. What is our actual backlog and what is our surgical capacity? And then from there, how many existing cases will come back when we reopen, due to perhaps a change in insurance status or an unwillingness to come into a hospital right now? For prioritization, we’re aware of different methodologies or scoring methods, but at ProMedica we wanted to rely on the patient-physician relationship for what was determined as essential or not. We thought that was very important with disease progression.
And what about labor resourcing? What are some of the considerations there that have to go into reopening or starting to ramp up again?
TW: A lot of talks that we’re having about labor resourcing right now are around what does the new norm look like when we need to be expanding services, when we go above 100% capacity? We’d like to go down the incentive-based program route, maybe some payroll practices of people going right into time and a half after their normal shift instead of having to wait to get to 40 hours. Or try to come up with some incentive programs for X amount of bonus dollars if you pick up so many extra hours over a certain timeframe to help us increase our capacity so that we can recover the volume before the end of the year.
Dr. Gonzalez, what are you doing in your organization to turn surgeons and staff away from triaging urgent cases to reopening the OR?
Dr. Mauricio Gonzalez: Based on our state (Massachusetts) guidelines, we’re far from that now, but the inflow has slowed enough to allow us to start thinking about how we’re going to pull people back from crisis scheduling to regular scheduling. And trying to do that in a mindful way where we can provide the services for both the residual COVID side of the operation and for reopening surgery, and also not burn people out because they’ve been working pretty hard.
We are also leading into the summer where traditionally we grant a little bit more PTO. And we’re an academic program, so we get new residents who need one-on-one supervision throughout the whole summer. It’s going to be pretty challenging to us.
I understand your organization deployed anesthesia machines to the ICU. What will it be like trying to get those back?
MG: We ended up deploying 12 anesthesia machines, the most sophisticated ventilators we had in the ICU, and we followed the ASA guidelines of staffing them with either resident anesthesiologists or CRNAs. We stripped them of all the OR necessary equipment that was not necessary in the ICU like monitors, computers, etc.
But now we need to start pulling them back to deploy them and there’s the question of decontaminating these machines. We did strictly follow the guidelines of using two high-efficiency viral filters in the breathing circuits, and we are fairly confident that there were no breaches, but we cannot say 100%. I think we have a plan. As our situation in the ICUs of ventilated patients improves, we’ll start taking one or two machines at a time and follow manufacturer’s guidelines for sterilizing the internal components of the breathing circuit that may have come into contact with the patient exhaled gas.
Closing the OR certainly affects the revenue for organizations and, in some cases, that could mean the mission, right? No revenue, no mission. What is University Hospitals doing to prioritize cases from the business perspective?
Dan Towarnicke: We saw a decrease in our surgical volume across our 15 operating locations down to about 30% of what we would normally do. Our process for this started back in March as well, when we were initially ordered to only work and take care of the essential surgeries. We had a cancelation code of COVID-19 entered into our EHR, and the way we’ve been planning is we’ve aggregated all of the COVID-related cancelations.
What we’re focused on trying to understand, what do those 6,000 canceled cases really equate to in OR time? It’s nice to know the number of cases, but for us to be able to effectively manage our schedules, staff, added blocks, weekends, extended shifts, and whatnot, we really dug into how much block time is going to be needed to make up for all of this demand.
One of our tactics and strategies is to open block as much as possible and have the service lines dedicate a larger portion of their block time to open so that we can make the best use of the existing capacity because we certainly know that that will help us dig out of this backlog of cases that we know we’re starting to take on now. We are also, in our ambulatory surgery centers and the Cleveland Medical Center, going to be expanding block hours from 8 to 10 hours to 10 to 12-hour blocks, and adjusting release policies to our blocks. That’s one thing that also immediately creates access. We have variable release policies, but what we’re going to do is extend the block release from 72 hours to 1 week or 2 weeks depending on the need and the demand.
What are the surgeons saying? Are they onboard?
DT: We’ve had a fantastic response from our surgeons, and I think the key to that is having the surgeons part of this governance. We have a surgical operations executive committee all communicating what our proposed recommendations are for improving access and capacity across the system. These decisions are made as a multidisciplinary team. The surgeons are open to all strategies that we have to make sure that they have easy access to the ORs.
A key consideration to reopening an operating room really is supply chain. How are supply chain committees taking this production pressure now?
Patricia Hoch: Many of the supply chains just melted down over demand, so I get a little nervous when I hear everyone else talking about how they want to get as quickly as they can all the cases back on the schedule, and get moving forward again because all of the pent up demand of cases equals pent up demand of supply. And, as everyone flips the switch back on, all this stuff that’s been sitting idle is going to disappear quickly.
We haven’t necessarily run out of anything, but now you’re flipping on a switch that doubles demand, specifically around testing. Everyone knows we have, nationally, a swab issue. Are you going to strategically move that swab volume to the OR, or continue with whatever your testing program was befor e that? Everyone in the supply chain would agree there’s not swab volume to do both simultaneously right away. The same thing with your protocol for N95.
I think that supply chain is going to, at some point, be the limiting factor to whether or not you can run cases. I’ve learned that even suppliers have very cloudy visibility with what’s in their own pipeline. Even something as simple as disinfectant. Oxivir, that’s pretty much gone.
One of the things we’ve been trying to do is have open dialog with the clinical teams planning reopening and what the strategies are. We have a more acute awareness of what the clinical schedule is now than in the past, because we normally would have most of the things that we need. So we wouldn’t need to be following it case by case by case, including our tests and pack volume.
What about the sterile processing department?
PH: I’m assuming, because we have the idea from other people, is that people are reprocessing masks or sterilizing their own swabs. We gave these other super important duties to our SPD team to work through and figure out. Now they’re doing it and to reopen volume, you have to say, “Okay, are you going to be able to still continue to do these functions of COVID response and getting them up to speed with getting instrument return and these sorts of things?” That’s one of the conversations we’ve been having, is how do we keep that work going, especially with the swab sterilization? With the swabs that we’ve been sterilizing ourselves, and that procedure, and still start the normal business of SPD.
Dr. Gonzalez, Thad, and Dan, is supply chain at the table with you during your meetings now?
MG: Absolutely. They’ve been from the get-go, basically. We have been experiencing shortages and supply problems with disposable airway equipment, in particular. I actually applied to the FDA for Emergency Use Authorization so we can re-sterilize those.
The other concern I had was blood. We’re okay, but I hear that the Red Cross, at least locally, was able to spread out the donation system enough to keep social distancing and maintain some supply, but we’ve also been buying a very low amount. We need to give them a heads up so they can bulk up.
TW: We adopted the Hospital Incident Command System in our structure at all levels. We have a system team, and then we have regional teams that are hospital specific. Supply chain, staffing, pharmaceuticals, those inventories are addressed each and every day on those calls.
DT: Our supply chain team has been phenomenal. Ever since January, where we had the down shortage, I think many hospitals across the country have been highly engaged on a daily basis with our teams providing great data, the burn rates of some of our critical supplies, so we don’t have any days on hand, so to speak. We have masks, gowns, and other critical supplies that we’re using to take care of our patients. I mean they’ve been phenomenal.
How many of your organizations are going to demand or insist that testing be done on the patients prior to surgery so that we know their COVID status?
MG: We’re going to test 48 hours before and rapid test in the morning after, with the surgeon insisting that the patient self-isolates 2 weeks in advance.
TW: ProMedica acquired the ability to do testing for all of our asymptomatic surgical and endo patients. It is mandatory and we’re doing it three days prior so we have the results the day before.
DT: Mandatory testing for all surgical, endo, cath, and EP procedures starting with tomorrow’s patients. We’re doing the 72-hour pre-test, and then also the rapid test the day of for patients that either couldn’t get the test or have some sort of urgent or add-on status.
PH: Yes, mandatory testing for all the surgical cases and procedural cases.
For the final question, how are you planning for a potential second wave of cases in the fall or winter?
PH: I absolutely am planning, from a supply chain perspective, that there would be a second wave. One of the things that I’m looking at is what can we get that is a reusable resource, because I feel like the disposable market is about as depleted as it possibly can be. If there’s a second wave any time in 2020, I’m not convinced that we will be able to recover from it by then.
I think it’s probably 18 months for the supply chain to recover, even if things stay relatively normal volume. Just for us to get back to where we were pre-COVID for manufacturing. Manufacturing is not nimble, so I suspect a second wave will be brutal on the supply chain.
DT: I think this is the tricky part, right? Our hospital still has units and beds available for that second wave if that does occur. From an OR perspective, I think the processes we put in place to validate that there are essential surgeries happening and whatnot are still easy to turn back on. We’ve kind of adjusted our operations and our processes, so knowing that, if there is a spike and another surge, we could quickly revert back to what we’ve been doing since March.
TW: We will try to get back to our normal levels, reassess what our disaster reserves should be, and those numbers should probably go up a little bit. And I agree 100% with Dan. I think we’ve learned a lot from this. If the second wave comes here in the fall, it’s fresh our minds. We could only do better than how we did now, and I don’t think we’d have any doubts that we’d go back down fairly quickly and serve our communities and their needs.
MG: Our overall census is still pretty high. Our ICU census is about 20 beds above the original capacity, way below what we set for crisis maximum, but we’re still nowhere close to being stable. That’s why we’re still waiting on the curve to decrease a little bit more before we can start thinking of doing a lot of inpatients. If we start doing inpatients right now, we get hit by a second curve with the current status, we will be in trouble.
I want to again thank our esteemed panelists for a terrific webinar. Your insights were incredible helpful as hospitals across the country navigate through these uncertain times.