The Independent Source of News for Operating Room Managers, Supply Chain Professionals & C-Suite Volume 12 • Summer 2020
www.ormanagement.net
Regaining OR Capacity After COVID-19 Predicting Mortality in Necrotizing Infections Guidelines for Preventing COVID-19 Transmission Brought to you by the publisher of
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TABLE OF CONT ENTS
4
Key Steps to Regain OR Capacity After COVID-19
6
7 Tips for Managing Stress, Burnout During the COVID-19 Crisis
8
COVID-19 Further Complicates Existing Sterilization Problems
10 Many U.S. Hospitals Already in the Red— Then COVID-19 Hit
14 ERAS Surprise: Protocol Falls Short on
BULLETIN BOARD Trending Articles Online Read the most-viewed articles last month on ormanagement.net. 1. Steps to Manage OR Use and Safety During PPE Shortages 2. Abnormal Clotting and COVID-19 3. What Is the Significance of GI COVID-19 Symptoms? Heard Here First
Outcomes, Cost for Colon Resection
16 Updated Guidelines for Preventing Transmission of COVID-19
18 Necrotizing Soft Tissue Infection: Predicting Mortality and Limb Loss
20 Study Quantifies Time Spent on Electronic Health Records
The total cost if 20% of the U.S. population becomes infected with COVID-19. It would also result in a median of 11.2 million hospitalizations, 62.3 million hospital bed–days, and the use of 1.6 million ventilators.
21 Summer Buyers Guide EDITORIAL STAFF Paul Bufano Managing Editor pbufano@mcmahonmed.com Kevin Horty Group Publication Editor khorty@mcmahonmed.com
McMAHON GROUP James Prudden Group Editorial Director
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ADVISORY BOARD Wanda Lane, RN, MaED, CVAHP Senior Advisor VP, Client Management, Broad Jump LLC
Lina Tan, MSN, RN, CGRN Associate Director of Nursing Perioperative Services
Bruce Ramshaw, General Surgeon
David Taylor III, MSN, RN, CNOR Principal Resolute Advisory Group, LLC
MD
SALES STAFF Michael Enright Group Publication Director (212) 957-5300, ext. 272 menright@mcmahonmed.com
PAGE 10
Joe Malichio Director, Medical Education (212) 957-5300, ext. 286 jmalichio@mcmahonmed.com
Lauren Smith Michael McMahon Michele McMahon Velle Partners
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The Independent Source of News for Operating Room Managers, Supply Chain Professionals & C-Suite
OR Management News • Summer 2020
3
BUSIN E SS M A NAG E M E N T
Key Steps to Regain OR Capacity After COVID-19
O
ver the past few months, hospitals and ambulatory surgery centers have postponed thousands of surgeries due to the COVID-19 pandemic. Rough estimates indicate that approximately 70% of elective surgeries in the United States have been put on pause. This decision has not only affected patients; it has also created remarkable complexities for hospitals that want or need their biggest revenue generator—the OR—to function at capacity. As COVID-19 cases across the United States move closer to anticipated peaks, hospitals are beginning to consider when and how they should resume elective surgeries. While various medical societies have issued guidelines to plan for the resumption of elective surgeries, many hospitals remain overwhelmed by the actual tactics that should be executed in preparation for OR recovery. The following seven steps may aid in that effort: 1. Estimate Backlog The first step is to gain clarity about the size of the backlog you have as a result of COVID-19 and how much time it may take to recover. To wade through the complexity and data involved in providing an estimate, free online tools are emerging that can calculate volume and dates that will align with when you can expect to return to capacity. Alternatively, you can pull data from existing systems and work with your data science team to create dynamic predictive models that you will revisit daily. Consider the following factors: • baseline monthly surgery volume before COVID-19; • the percentage of baseline cases you are seeing during COVID-19; • the date when you started postponing elective surgeries; • the date when you expect to reach 50% capacity, 75% capacity and 100% capacity; • levers to accommodate surge volume; • the volume of new cases that you anticipate based on COVID-19 (e.g., surgeries resulting from car accidents have likely decreased because of fewer cars on the road); and • the volume of cases you expect to lose based on people losing their jobs and/or health insurance. 2. Identify Real Surgical Capacity Think about potential constraints in terms of staffing and available beds. When doing so, factor in what is actually possible: 4
OR Management News • Summer 2020
Can you open up more rooms? Can you stay open longer hours or stay open on the weekends? Can you divert some procedures to other types of rooms? When you look at which levers to pull, it is vital to consider your staffing model and all of the people it must accommodate, from the surgeons and nurses to the anesthesiology, support and supply teams. A good way to gauge what is realistic is to survey the people involved (Figure). 70 60
N=425
50
Percent
By ASHLEY WALSH, MHA
40 30 20 10 0
Staffing
Bed Availability
Surgeon Cooperation
Ancillary Services
PPE
Figure. Biggest obstacles to restoring elective surgery caseload post COVID-19. In a recent survey by LeanTaaS of 425 respondents from the country’s top hospitals and health systems, staffing was the biggest concern for restoring elective surgery caseloads after COVID-19.
Once you understand staffing, you have to factor in bed availability. For example, how many standard versus surge/overflow beds do you have, and how many can you use? How many beds are “off-limits” because they are needed for other demand? Are there low-acuity/high length-of-stay patients who can be safely transferred to other facilities to free up beds? These are just some of the options to consider. 3. Rethink the Block Schedule The goal is to maximize utilization. As such, reconsider a temporary and/or partial redo of the block schedule to put the ORs in a better position to catch up with your backlog. In doing so, think about the service lines or surgeons that are of strategic continued on page 22
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PE RSP ECTIVE
7 Tips for Managing Stress, Burnout During the COVID-19 Crisis By DAWN E. SHEDRICK, LCSW-R
W
e are navigating uncharted waters in the COVID-19 It’s important to be pandemic. Health care professionals mindful of any internal face increased risk for compoundchatter that may try to ed stress and burnout in the wake of this global crisis. Although inforconvince you that you mation about the novel coronavirus develops at a don’t have enough time rapid pace daily, the need to monitor and manage for a break or don’t stress remains paramount. The health and well-being of all health care professionals is integral to ensuring deserve it. Ignore the health care systems can keep up with the needs of chatter and take a COVID-19 patients. break anyway. Burnout is defined as a syndrome of emotional exhaustion, depersonalization of others and a feeling of reduced personal accomplishment. A 2009 study of members of the American College of Surgeons found that 40% of surgeons experienced burnout. It appears safe to assume that many 2. Engage in consistent self-reflection to identify the emotional and mental signs of stress. surgeons working on the front lines of the COVID-19 pandemic Take a few moments at different points throughout the day were at high risk for burnout before the beginning of the outbreak. for a personal mental health check-in. It may feel as if there’s Signs of burnout include sadness, depression, irritability, frustrano time to spare, but this is a critical aspect of managing stress. tion, isolation, poor hygiene, social isolation, feelings of hopelessSome emotional signs of stress include the persistence of fear, ness and low job satisfaction. irritability, anger, deep sadness and overwhelmed feeling. Mental Health care professionals working in this pandemic are also at signs include loss of concentration, local memory loss, inability to higher risk for secondary traumatic stress. Secondary traumatmake decisions, disorientation and confusion. ic stress is stress reactions resulting from exposure to another Stress arousal occurs as physical, mental and emotional reacperson’s traumatic experiences, rather than from direct exposure tions to stressors. Try incorporating breathing exercises in your to a traumatic event. Signs of secondary traumatic stress mimic daily self-care routine to help calm the body’s reactions to the those of post-traumatic stress disorder, but the most common are stressors you encounter throughout the day. excessive fear or worry, startle response, ruminations about the traumatic event, and sleep disturbance. Self-care can be challenging for health care workers, many of 3. Prioritize your basic needs. In times of crisis, we tend to ignore our basic needs, includwhom are conditioned to prioritize the needs and care of patients ing food, water, exercise and sleep. To reduce stress and prevent over their own. It is important to keep personal well-being in burnout, try as best as possible to eat at least three balanced meals mind and manage stress to prevent physical, mental and emoevery day while avoiding inflammatory ingredients such as sugar, tional exhaustion. Here are seven tips for managing stress and trans fats, saturated fats and alcohol. Drink water throughout the fostering emotional resilience to prevent burnout while providday to stay hydrated. Exercise or take walks for at least a few mining critical health services during the pandemic. utes daily to maximize the release of endorphins. As far as possi1. Know that what you’re feeling is a normal stress ble, set a routine time for bed to gain the benefits of quality sleep. response. Health care professionals are encountering stressors that may 4. Take brief mental breaks throughout the day. Health care professionals often urge patients to prioritize selfinclude direct exposure to COVID-19 while treating patients, care while dismissing the need for their own. It’s important to loss of patients to death, deciding how to allocate sparse resources, working longer hours, and extended periods away take scheduled breaks to rest your mind and reset. Find a quiet from loved ones. As a result, physicians are experiencing an space during your work breaks or at home when off-duty. It’s increased frequency of stress responses throughout the course important to be mindful of any internal chatter that may try to of a day. Exercise self-compassion and give yourself grace, as all convince you that you don’t have enough time for a break or don’t medical professionals working during this crisis are experienc- deserve it. Ignore the chatter and take a break anyway. ing distress. continued on page 22 6
OR Management News • Summer 2020
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C LIN IC A L NE WS
COVID-19 Further Complicates Existing Sterilization Problems By ALISON McCOOK
F
or months, officials have been warning of a looming shortage in the supply of a gas used in the sterilization of medical equipment. Now, that already stressed system has taken another massive hit from the new coronavirus infection, COVID-19. At the heart of the issue is ethylene oxide (ETO). Across the country, states have been shutting down plants that produce ETO in response to concerns from local communities that the chemical, a known carcinogen, could contaminate the local environment. These closures have raised fears of shortages of necessary equipment for many medical procedures. Now, the onslaught of COVID-19 is placing additional strain on the system, as medical providers ask for more protective gear and single-use instruments, which are often sterilized by ETO before initial use. “Everyone approves of eliminating the emissions to keep people safe,” said Lawrence Muscarella, PhD, the president of LFM Healthcare Solutions LLC, an independent safety and quality improvement company in Lansdale, Pa. “Taking ETO factories offline until enhanced safety goals could be achieved may have seemed smart at the time, but in hindsight with this pandemic, it may have inadvertently contributed to equipment shortages.” To Use or Not to Use The medical industry has been relying on ETO since the 1950s, as one of a handful of ways to sterilize medical devices and instruments that contain delicate materials, such as plastic, which can degrade in high heat. According to AdvaMed, the medical technology trade association, more than half of all medical devices—over 20 billion per year—are sterilized using ETO. These devices include gowns and drapes, syringes, surgical kits, catheters and ventilators. However, exposure to ETO can lead to a host of health problems, such as cancer and neurologic issues. This, along with reports of leaks and explosions at ETO sterilization
8
OR Management News • Summer 2020
facilities, has put residents in areas close to ETO manufacturers on high alert, and facilities have been closing their doors. In October, before the COVID-19 pandemic, the FDA warned that the recent closures of facilities in Georgia and Illinois could affect the supply of sterile medical devices. When the health care system became engulfed by the pandemic, demand for sterilized medical equipment soared. Fortunately, in many fields, providers have rescheduled elective procedures, which eases the strain on the system, Dr. Muscarella said. But the demand for personal protective equipment (PPE) and single-use medical instruments—required to be sterile before first use, often by ETO— will remain high as long as the pandemic continues, he said. Responding to a Crisis In late March, the EPA said Georgia and the medical device company BD had reached an agreement to temporarily increase the number of items the company can sterilize during the pandemic at two ETO sterilization facilities. According to the agency, the company is installing new air emission controls to protect the local environment. Subsequently, the Illinois Environmental Protection Agency announced that Medline Industries could resume full commercial sterilization operations using ETO, after showing it had complied with local environmental regulations. According to Medline, the facility in Waukegan, Ill., produces and sterilizes more than 16,000 sterile surgical packs every day, which supply nearly 80% of the state’s urban and rural hospitals. Soumi Saha, PharmD, JD, the senior director of advocacy at Premier, a group purchasing organization for health facilities and providers, said the company was immediately “concerned about ETO sterilization capacity” once the COVID-19 pandemic hit. Seeing facilities open up and ramp up production has been a big relief, she said. “That’s opened up tremendous
Medline’s Waukegan, Ill., employees pack surgical kits prior to sterilization.
capacity in the U.S. to help sterilize PPE and other medical supplies that are being used to care for COVID-19 patients.” Ideally, that will continue, she added. Long term, the FDA is working to reduce the system’s reliance on ETO to sterilize equipment. Last year, the agency issued two challenges, designed to encourage innovators to develop alternative sterilization techniques and new ways to reduce ETO emissions. “We stand steadfast in our commitment to reduce overreliance on ethylene oxide for medical device sterilization.” For providers who are seeking to reuse filtering facepiece respirators such as N95 masks to address shortages, the CDC has recommended the use of other techniques, such as vaporous hydrogen peroxide and ultraviolet germicidal irradiation (https:// bit.ly/3bqTCLT). A group at Duke University, in Durham, N.C., has reported safely decontaminating N95 face masks using vaporized hydrogen peroxide. “There was a whole science behind reprocessing multiuse instruments, and now there’s a science developing around reprocessing PPE for front-line medical staff to wear during this pandemic,” Dr. Muscarella said. And there is much still to work out, he noted. “This is the big elephant in the room: If you’re reprocessing a single-use device, how many times can you safely reuse it?” Dr. Muscarella is uncertain how the sterilization landscape might be permanently changed by what happens during the pandemic. If providers are able to find ways to reuse single-use devices, why not keep doing it? “What I’m concerned about is that when this crisis ends, we may be incentivized to rewrite our policies in a way that tolerates lax practices,” he said. “We can’t let this become the new clinical norm. We need to assure we revert back ■ when the crisis is resolved.”
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FE ATURE
Many U.S. Hospitals Already In the Red—Then COVID-19 Hit Government Allocates $105 Billion for Hospital Relief, But Efforts Must Continue to Keep Providers Afloat Long Term By ALISON McCOOK
C
OVID-19 has created a financial crisis for many U.S. hospitals, with no easy way out. The math is simple: During the pandemic, hospitals lost a huge source of revenue from elective surgeries while experiencing a dramatic uptick in costs, as facilities purchase more gear to cope with the surge of infected patients, some of whom are uninsured. “They are increasing unanticipated costs and decreasing any revenue you have to offset it,” said Halee Fischer-Wright, MD, MMM, the president and CEO of the Medical Group Management Association, one of the marquis health care associations in the United States. “I think this is the definition of the perfect storm.” Although the federal government has taken some early actions to flood the health care system with financial relief, experts worry about the long term. “No hospital is going to come through this unscathed,” said Jacqueline Barton True, MSW, MPH, the vice president of rural health programs at the Washington State Hospital Association. “I have a lot of concern about our ability to weather this, and what we look like on the other side. I think it is very possible that without significant help from the federal government, there will be closures.”
identified more than 450 additional facilities in rural areas that are at risk for closure.1 One of the hardest-hit states is Texas, where 20 rural hospitals have been forced to shut down since 2010, and 50% of the remaining facilities are vulnerable to closure, according to the Chartis report. Thankfully, small and rural facilities in the state haven’t been hit by a surge of COVID-19 patients and some elective surgeries are starting to resume,2 but they lost a huge source of income from the prolonged pause on those procedures, as well as the usual influx of post-acute care from larger urban facilities, according to Nancy Dickey, MD, the executive director of the Texas A&M Rural and Community Health Institute. “Many continued on page 12
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Bad Timing Even before COVID-19 hit, many hospitals were struggling, particularly those in rural areas. According to a February 2020 report from the Chartis Center for Rural Health, 19 rural hospitals had to shut their doors in 2019, the largest number of closures in a year since tracking began in 2010 (Figure 1). The analysis 10
OR Management News • Summer 2020
0
2010
2011
2012
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Figure 1. Rural hospital closure. Source: The Chartis Center for Rural Health.
2016
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FE ATURE
Hospital Finances continued from page 10
rural facilities are, in fact, extraordinarily challenged right now,” she told OR Management News. Caring for patients in rural areas is often more challenging because they are generally older, have a lower socioeconomic status, and have more chronic diseases than people living in urban areas, according to a report from the Kaiser Family Foundation.3 What’s more, they are more likely to be uninsured,4 and that disparity will likely increase, Dr. Dickey said. “When people lose their jobs, they tend to lose their health insurance. So the number of people who are uninsured is probably going to go up across the country.” “What we’re seeing now in this crisis is that 50% of our rural health care centers were already operating in the red. This is probably the thing that’s going to push them to close,” Dr. Fischer-Wright said. Even larger urban facilities are struggling, said Kerry McKean Kelly, the vice president of communications and member services at the New Jersey Hospital Association. Northern New Jersey has been a “true hot spot” in the nation for COVID-19 patients, and unexpected costs have risen substantially, as hospitals struggle to purchase more—and more expensive—personal protective equipment and add per-diem staff. “Both of those line items have increased significantly,” she noted. Although there now is a billing code for COVID-19, “I don’t think anybody fully understands reimbursement for those patients,” Ms. Kelly said. “Right now, hospitals are just providing the care.” According to one estimate, each infection results in a median of $3,045 direct medical costs (Health Aff 2020 Apr 23. [Epub ahead of print]. doi: 10.1377/hlthaff.2020.00426); another suggests the cost of hospitalization to private insurers could reach $20,0005 (Figure 2). The larger the hospital, the more likely it is to survive the pandemic, as well as any other waves of cases that appear in the coming months, as stay-at-home orders begin to ease, Dr. Fischer-Wright 25,000 20,000 15,000 10,000 5,000 0
With major complications or comorbidity
With complications or comorbidity
Without complications
Figure 2. The cost of inpatient admissions for COVID-19 treatment. Source: KFF analysis of IBM MarketScan Commercial Claims and Encounters Database, 2018.
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OR Management News • Summer 2020
said. Large facilities likely have bigger cash reserves, and can sell off assets or redistribute costs in a way that isn’t possible at small hospitals, many of which only keep 45 days of cash on hand, she said. “And that is not enough to get through this crisis.” Some Help, but Not Enough? By the end of April, hospitals were starting to get some relief from the federal government. Starting April 10, hospitals and other providers fighting the pandemic began receiving $30 billion, 30% of the total amount allocated under the $2.2 trillion coronavirus relief bill, to provide them with an immediate influx of cash. To calculate the payments, Congress considered Medicare payments and gave each hospital its portion of that total. (Medicare reimbursements for 2019 were an estimated $484 billion; if a hospital represented 0.5% of all billings, it would receive 0.5% of $484 billion.6) More recently on April 23, the government passed an additional $484 billion bill, which includes $75 billion for hospitals.7 However, Medicare payments are typically half of what providers receive from private insurance. The formula for the first round of payments under the bill also disadvantaged small and rural hospitals, which don’t have the same volume of Medicare patients as larger facilities but still have fixed costs, Ms. True said. One hospital in Washington state told her the funding they received only covered six days of operation. “It was good to get the cash, but it isn’t enough.” The first round of funding also didn’t take into consideration a state’s burden of COVID-19 patients, Ms. Kelly said. New Jersey has the second-highest case count in the nation,8 and the payment formula applied equally to the state with the lowest case count. The rest of the funding allocated to health providers by the end of April—the remaining $70 billion in the bill and the $75 billion from the second bill—aims to help fill the gaps in coverage, focusing for instance on hard-hit areas, uninsured patients and rural areas,6 but the larger goal of the bailout should be finding ways to make hospitals “whole” enough to survive the crisis over the long term, Ms. True said. “These initial rounds of funding provided just enough to help hospitals limp along. But if each one is just barely making it, what does that do to our viability as a health system and our ability to respond to a future crisis? That’s the concern.” Dr. Fischer-Wright agreed. “The federal support during the initial weeks of the pandemic is certainly laudable, but it will need to continue throughout the remainder of and beyond the pandemic to help our nation’s providers recover and meet patient needs.” “I’m hoping the urgency of the pandemic may help hospitals look at health care as a system, rather than a silo,” Dr. Dickey told OR Management News. “We need to be better at saying this part of your care can be done at hospital A, and then your rehabilitation or post-acute care can be done at hospital B.” For instance, larger tertiary centers could get patients through the worst of COVID-19, then transfer them to smaller facilities once their needs diminish, but they still need hospital convalescence time. continued on page 14
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CLIN IC A L NE WS
ERAS Surprise: Protocol Falls Short on Outcomes, Cost for Colon Resection By MONICA J. SMITH
Enhanced recovery after surgery protocols are associated with reduced hospital length of stay, fewer complications and lower costs, but one institution found no improvement in outcomes and higher costs after implementing an ERAS protocol. “ERAS has been widely studied and accepted; however, more recent data have contradictory findings, calling into question the true impact of the protocol’s benefit,” said Miles Landry, MBBS, the academic chief resident at the University of Tennessee Medical Center, in Knoxville. “We wanted to look at the impact on outcomes and cost, and to further investigate if site of resection had an influence on these results.” Dr. Landry and his colleagues evaluated data on 598 patients undergoing elective colon resection, 100 before the implementation of an ERAS protocol in 2014, and 498 between implementation and 2017. Before implementation, the most frequently performed surgery was right colectomy; after implementation, sigmoidectomy was most commonly performed. (Less commonly performed were
left colectomy, transverse colectomy and low anterior resection). They found a general cost increase that was statistically significant for every site of resection except transverse colectomy. “That did have a more than $2,000 increase, but with the low number of procedures, it failed to reach statistical significance,” Dr. Landry said. There was a smaller difference in the cost increase with the frequently performed right colectomy and sigmoidectomy procedures, “which suggests we’re gaining some level of efficiency from doing those more regularly,” Dr. Landry said. Hospital length of stay, averaging 4.5 days for open procedures and 3.5 days for minimally invasive procedures prior to the protocol, improved initially in the laparoscopic surgery cohort, but then returned to average. “Is this a worthwhile thing to do? I think if we can truly establish the preoperative and perioperative factors that identify patients who would be in the hospital for five to seven days rather than two to three, we’ll be able to see the real benefit of the
Hospital Finances continued from page 12
This would free up space at larger facilities and provide smaller hospitals with sources of revenue. “If we can demonstrate the importance of working together during the pandemic, you may be able to carry it forward when the worst is over,” she said. “There is a possibility that post-pandemic we can take a deep breath and say we’ve learned some lessons that can be useful down the road.” ■ References 1. The Chartis Center for Rural Health. The rural health safety net under pressure: rural hospital vulnerability. February 20, 2020. www.ivantageindex. com/wp-content/uploads/2020/02/CCRH_Vulnerability-Research_FiNAL02.14.20.pdf. Accessed May 7, 2020. 2. Rickard S. Elective surgeries resume as Texas governor loosens restrictions. https://spectrumlocalnews.com/tx/san-antonio/news/2020/04/22/electivesurgeries-resume-as-texas-governor-loosens-restrictions. April 22, 2020. Accessed May 7, 2020.
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OR Management News • Summer 2020
ERAS protocol,” Dr. Landry said. He presented his study at the 2020 Southeastern Surgical Congress (abstract 67). Russell Farmer, MD, an assistant professor of colon and rectal surgery at the University of Louisville, in Kentucky, congratulated the authors for examining a topic that is becoming a standard of care in minimally invasive colectomy. “Many accrediting bodies outside the [United States] include ERAS protocol components as a mandatory part of their board examination,” he said. Dr. Farmer asked if the shift from right colectomy to sigmoidectomy might have affected the researchers’ findings. “I do think that hints at the idea that the expected outcomes for patients would have been different as we included more difficult patients, but we didn’t design the database that way. That’s a key component that we’ll include in future evaluations,” Dr. Landry said. “I do think there is a population that will benefit from this protocol; being able to customize our medical care is a goal of this process,” he added. ■
3. The Kaiser Commission on Medicaid and the Uninsured. https://www.kff. org/wp-content/uploads/2013/01/the-uninsured-in-rural-america-updatepdf.pdf. April 2003. Accessed May 7, 2020. 4. Cheeseman Day J. Rates of uninsured fall in rural counties, remain higher than urban counties. www.census.gov/library/stories/2019/04/health-insurance-rural-america.html. April 9, 2019. Accessed May 7, 2020. 5. Rae M, Claxton G, Kurani N, et al. Potential costs of COVID-19 treatment for people with employer coverage. www.healthsystemtracker.org/brief/ potential-costs-of-coronavirus-treatment-for-people-with-employer-coverage/. March 13, 2020. Accessed May 7, 2020. 6. CARES Act Provider Relief Fund. www.hhs.gov/provider-relief/index.html. Accessed May 7, 2020. 7. Pramuk J. House passes $484 billion bill to boost small businesses and hospitals, sends it to Trump. www.cnbc.com/2020/04/23/coronavirus-updateshouse-passes-bill-to-aid-small-business-hospitals.html. April 23, 2020. Accessed May 7, 2020. 8. Graphic: coronavirus deaths in the U.S., per day. www.nbcnews.com/health/ health-news/coronavirus-deaths-united-states-each-day-2020-n1177936. April 7, 2020. Accessed May 7, 2020.
Disclosures: None of the sources reported any relevant financial conflicts of interest.
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Updated Guidelines for Preventing Transmission Of COVID-19 Preserving the Health and Safety of Surgical Teams By CHASE DOYLE
T
hese days, misinformation about COVID-19 can be as virulent as the virus itself. Thankfully, several medical and professional associations have published living documents that provide physicians with up-to-date and accurate information on the novel coronavirus and its treatment. In this roundup, we cover the latest recommendations for preventing transmission so surgeons can continue to protect themselves while treating patients with COVID-19. Minimally Invasive or Open Procedure? Regarding the SARS-CoV-2 virus, Jonathan Dort, MD, cautioned that the available evidence is still too limited to make strong recommendations or establish standards of practice in a surgical environment. However, because COVID-19 is mainly a respiratory disease, data from previous studies that have demonstrated the presence of viral particles in surgical smoke should be taken into account. “Although these are different viruses that have distinct modes of transmission and cause other diseases, we must assume that the novel coronavirus has similar properties and make subsequent precautions based on that assumption in order to minimize the possibility of transmission,” Dr. Dort said. Even with the assumption that the virus can live in surgical smoke and be transmitted through that mode, he emphasized the difficulty of deciding whether to offer minimally invasive surgery. “Surgical smoke and a pressurized pneumoperitoneum certainly would increase the risk for transmission with its uncontrolled release into the room under velocity,” Dr. Dort said. “However, an equal argument could be made that the sealed abdomen allows better control of the smoke with utilization of evacuation considerations.” In addition, he said, if a minimally invasive procedure turns a one-week hospital stay into a one-day stay, the decreased length of stay and resource utilization should be factored into the decision. According to Dr. Dort, the Society of American Gastrointestinal and Endoscopic Surgeons recommends minimally invasive surgery procedures under the right clinical conditions, but only if proper precautions for smoke evacuation have been taken. SARS-CoV-2 and Filtration Although no evidence of COVID-19 aerosolization currently exists, according to Dean Mikami, MD, the use of devices to filter released carbon dioxide for aerosolized particles should be strongly considered. Dr. Mikami, an associate professor of surgery and 16
OR Management News • Summer 2020
the division chief of general surgery at the University of Hawaii at Manoa, reported that SARS-CoV-2 has been found in the nasopharynx, upper respiratory tract and lower respiratory tract; the entire gastrointestinal tract from the mouth to the rectum; saliva, sputum, throat and nasal swabs; and blood, bile and feces. Filtration may be an effective means of protection from the release of the virus during minimally invasive surgery and endoscopy, he said. Although N95 respirators are designed to filter out 95% of particles that are 0.3 microns and larger, high-efficiency particulate air filters have a minimum 99.97% efficiency rating for removing particles of the same size. Furthermore, ultralow particulate air filters have a minimum 99.999% efficiency rating for removing particles 0.12 microns or larger in diameter. Dr. Mikami said the current best practice for mitigating possible infectious transmission during open laparoscopic and endoscopic procedures is to use a multifaceted approach, which includes proper room filtration and ventilation, appropriate personal protective equipment (PPE), and smoke evacuation devices with a suction and filtration system, as available. N95 Mask Use, Reuse, Decontamination Due to the shortage of PPE around the world, much effort has been made to extend the life of N95 masks (www.sages.org/n-95re-use-instructions). Viola Huang, MD, a general surgery specialist in Stony Brook, N.Y., noted that surgical N95s are designed for one-time use, but the CDC has approved “extended use,” meaning they can be used with several patients and for up to eight hours. Per the CDC, expired N95s meeting the following criteria are acceptable to reuse: • not exposed to aerosolizing procedures; • no extended contact with a COVID-19–positive patient; • stored properly (breathable container, allowed to fully dry); • not soiled (no bodily fluids); • fit is still intact (perform user seal check before each use); and • consider wearing face shield and surgical mask over it. Additionally, Dr. Huang said providers who reuse N95s should have a mask rotation strategy and allow each one to dry for at least 72 hours before re-donning. With this strategy, the CDC recommends that N95s be extended up to five days maximum. Dr. Huang also advised caution when implementing decontamination because each version of N95 differs in appropriate decontamination method. “Decontamination will always be inferior to obtaining a new continued on page 18
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Necrotizing Soft Tissue Infection: Predicting Mortality and Limb Loss By CHASE DOYLE
K
nown colloquially as “flesh-eating bacteria,” necrotizing soft tissue infections carry significant morbidity and mortality, but the risk for death is dropping, according to data presented at the 2020 Eastern Association for the Surgery of Trauma Annual Scientific Assembly. While historical rates of mortality have approached 50%, a new study of necrotizing soft tissue infections at a single Level I trauma center between 2013 and 2018 found an overall mortality of 14%. The prospective analysis also identified several distinct patient and disease characteristics associated with mortality and limb loss. “With earlier recognition, rapid debridement and good critical care, we’ve definitely made improvements in mortality over time,” said Dara Horn, MD, a general surgery resident at the University of Washington Medical Center, in Seattle. “For patients who do survive, however, there is still a high risk of amputation and discharge to a skilled nursing facility.” For this prospective study, researchers analyzed demographic variables, disease characteristics and microbiology, and
outcomes of 430 infections identified at a single institution. As Dr. Horn reported, risk factors for mortality included older age, a high white blood cell count, high creatinine levels and involvement of Clostridioides, while limb loss was associated with old age, male sex, a history of diabetes and chronic wounds. Conversely, patients with Fournier’s gangrene, a necrotizing soft tissue infection of the perineum, had significantly better outcomes. “I think this literature could be informative in helping guide goals of care discussion with patients and families,” Dr. Horn said. “Patients can use this information to make truly informed decisions about how they want to proceed with what is often a prolonged hospital course with many debridements, wound care and lots of pain.” According to Dr. Horn, the most interesting finding was that patients who were transferred from an outside facility (89%) had seven times greater odds of requiring an amputation.
COVID-19 Guidelines continued from page 16
mask because of many variables that are difficult to control,” she explained. “Sweat, saliva, makeup, etc., can impact the efficacy of decontamination, and the viral load on the mask will differ based on your work conditions.” As Dr. Huang reported, the FDA has now approved at least two systems for sterilization of N95 masks that will “likely be of significant impact while we wait for a larger production of new masks.” Both systems use vaporized hydrogen peroxide. In contrast, the use of microwaves, autoclaves, soapy water, alcohol, bleach immersion and storage for less than 72 hours are not approved by the FDA, she added. A Role for Telemedicine Kevin Wasco, MD, a general surgery specialist in Neenah, Wis., reported that use of telehealth services has been facilitated by recent policy changes related to the COVID-19 pandemic. “Medicare will now pay physicians for telehealth services at the same rate as in-person visits for all diagnoses, and patients can receive telehealth services in all areas of the country and at any 18
OR Management News • Summer 2020
“Only 40% of patients transferred to our facility had debridement prior to being transferred, which may be contributing to increased odds of amputation,” Dr. Horn said. “That delay between initial presentation at another facility and receipt of adequate source control may be associated with worse outcomes.” Elliott R. Haut, MD, PhD, at the Johns Hopkins School of Medicine and Bloomberg School of Public Health, in Baltimore, noted that these data raise an important question of whether emergency general surgery should be regionalized into specialized centers or whether all facilities should be equipped to handle the basics. “It is really important to get these operations done quickly, but it’s also important to get them done well in a place that takes care of the patient, even for those few hours,” Dr. Haut said. “I think it’s a tough balance, and there is no cut-and-dry answer. There are a lot of hospitals that are not ready to handle critically ill patients with a necrotizing soft tissue infection.” ■
point of service including home,” said Dr. Wasco, who noted that the list of eligible services is not necessarily the same for all state or private insurance plans. According to Dr. Wasco, since transmission is all about exposure, nonessential staff, which can include administrative staff, research staff, education staff, quality staff and clerical staff, should be allowed and encouraged to telework from home. However, the review of how best to utilize manpower with telehealth visits should be done by each department and each hospital. Some hospitals rotate teams between inpatient and outpatient services to allow breaks from the constant intensity of the inpatient service, while other hospitals factor the age or medical conditions of health care providers into deployment decisions. Dr. Wasco said all outpatient clinics should be converted to video or audio visits, and only patients with urgent issues that require a physical exam should be seen in the office. The same goes for nonessential activities, including surgical education. Many academic programs have successfully changed the didactic sessions to a virtual format, and many organizations and groups offer online education through webinars, videos and social media platforms. Multidisciplinary meetings also should be transitioned to a virtual format, he concluded. ■
OR Management News Summer 2020
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Study Quantifies Time Spent on Electronic Health Records In Findings That Will Surprise No Physician, It’s a Lot; Studies Link Time Spent to Burnout By CHRISTINA FRANGOU
A
sk any surgeon how much time they spend on their hospital’s electronic health record and the answer is likely to be the same: too much. For the first time, researchers have looked at how many hours per day that general surgeons spend dealing with their hospital’s EHR. The number is an average of 1.95 hours every day of the week, with some surgeons regularly spending nearly five hours daily. The heaviest EHR use by surgeons occurred on clinic days, and the lightest was on Saturdays. All surgeons took EHR work home with them, with a measurable increase in remote use occurring on nights and weekends. “We hope to raise more awareness about how our time is spent as we care for patients,” said Morgan Cox, MD, a general surgery resident at Duke University Medical Center, in Durham, N.C. Dr. Cox and her colleagues studied 20 female and 31 male surgeons working in the Department of Surgery at the center between 2016 and 2017. They did not capture EHR use at Veterans Affairs hospitals or physician logins from portable devices, so the study underestimates overall EHR use. Investigators tracked surgeon login and logout time stamps from the Epic EHR (Epic Systems) and compared them with time schedules from the department. Results showed the following: • Surgeons spent a mean of 1.96 hours per day on the EHR. • This duration rose to 2.47 hours on workdays and fell to 0.70 hours daily on weekends. • The top 15% of EHR users logged nearly twice as much time as other surgeons, spending a mean of 4.6 hours on workdays and 1.49 hours on Saturdays and Sundays. • All surgeons spent time on the EHR after leaving the hospital. Of all EHR use, 13% occurred after hospital work hours and 35% was done remotely. 20
OR Management News • Summer 2020
Even though the study is the first to look specifically at EHR use by practicing surgeons, the results are not surprising. Physicians across specialties say they spend hours each day, even after work hours, on the records. A 2017 study found that family physicians spent nearly six hours in an 11.4-hour workday—more than half their working time—dealing with documentation (Ann Fam Med 2017;15[5]:419-426). Physicians say they are frustrated that the time dedicated to the EHR often feels like time wasted because of poorly designed technology that prioritizes billing over patient care or physician time. Doctors voiced their dissatisfaction loudly in a survey of 30,000 physicians, published in Mayo Clinical Proceedings (2020;95[3]:476-487). They gave EHRs an overall grade of F for usability. “That is not shocking to me, but it should be a cause of alarm. Why are we accepting something in health care with F-level performance?” said Lillian Erdahl, MD, a clinical assistant professor of surgery at the University of Iowa Carver College of Medicine, in Iowa City. She was not affiliated with the study. Dr. Erdahl and other surgeons pointed out many design flaws in EHRs, including frequent alerts that are not relevant to a patient’s care, leading to “alert fatigue”; inaccuracies in patient histories that are repeated by using the copy-and-paste function throughout a chart; and crucial information that is locked behind dozens of clicks. These frustrations exacerbate physician stress levels and burnout, research has shown. Another study looked at physicians in a multispecialty practice and found that doctors who received a higher number of in-basket messages by the EHR were
more likely to experience burnout and had an increased intention to reduce their clinical workload (Health Aff [Millwood] 2019;38[7]:1073-1078). The rapid adoption of EHRs in the United States occurred despite the technology and not because of it. Today, EHR systems are present in more than 95% of hospitals, up from about 9% in 2008. This uptake was spurred by policy changes, such as the American Recovery and Reinvestment Act, which poured $49 billion into adoption of EHRs, and the monetary penalties instituted in 2015 via the Medicare EHR Incentive Program. Despite this mass adoption, usability remains low. Physicians and other health care workers are burning out, leaving their practices, and taking their own lives at alarming rates. “This is a crisis in our practice, and resources must be put in place to address it,” Dr. Erdahl said. Health care organizations need to commit more time, money and personnel to reducing the burdens on physicians, she said. Efforts are underway to improve technology to support EHRs. Amazon recently introduced a virtual medical scribe, Amazon Transcribe Medical, which can transcribe doctor–patient interactions and upload the text straight into the medical record. Nuance Communications Inc., together with Microsoft, and Google also are working on developing their own “digital scribes.” “Whatever they are, changes cannot come soon enough,” ■ Dr. Erdahl said.
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OR Capacity
Managing Stress
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importance. You may want to prioritize their needs, or you might become stricter in terms of enforcing policies regarding room usage or robots. Many facilities simply can’t change their block schedule, however. In these cases, increasing the auto-release lead time could be a way to free up more time sooner for others. Consider shifting to auto-release two-plus weeks out for as many blocks as possible, and use a waiting list to fairly allocate unblocked time.
5. Incorporate sensory-soothing techniques to facilitate calm and relaxation. Research supports the effectiveness of embracing sensorysoothing activities to calm the nervous system and promote healing from trauma. Be intentional in taking time throughout the day to engage in sensory-soothing techniques, such as listening to your favorite calming music, visualizing the places where you tend to feel at peace, and imagining your favorite culinary aromas that trigger meaningful memories.
4. Make It Easy for Clinics To get back on track, providers need to know what is available to them. Clear communication is a must. You want to make it as simple as possible to understand what they can and cannot use, and what the rules are regarding space and time in this new normal. Provide easy access to the right time for the right providers. Make it simple to request and gain approval for open times or release blocks that are not full. Also be sure to configure around your constraints. 5. Execute as One Team Execution is as important as your strategy. Therefore, teamwork is a requirement within the perioperative team, across the hospital, and even with ancillary services and payors. Communicate the urgency and rally the team around a common goal. You may need a “war-room” mentality with multiple huddles to make decisions based on your constraints and changing daily dynamic, with those decisions clearly conveyed to all relevant parties. On top of consistent huddles, making data available and transparent across departments can help increase the visibility and communication around surge needs. 6. Continuously Measure and Iterate While you will likely be checking and updating key metrics daily, it’s important to review volume and the state of your backlog every few weeks to assess progress. You want to see the effect of the measures you are taking and determine whether they need to be adapted. One thing you’ll want to pay particular attention to is staff morale. How are people doing? Are strategies such as extending the workday having a detrimental effect? You might need to reduce some extra shifts to preserve the quality of care. 7. Be Prepared for the Next Wave No one knows what exactly will happen with COVID-19. Once social distancing restrictions ease, we may see additional surges, in which case plans will be reinstituted. The important thing is to learn from what your hospital has done. Execute ■ plans and adapt as needed. —Ashley Walsh is the senior director of Client Services for LeanTaaS. 22
OR Management News • Summer 2020
6. Create and nurture supportive connections with your colleagues. Check in with your colleagues and remain open to receiving support in return. Talk to them about your feelings, experiences and accomplishments each day. The validation will help normalize your experiences and prevent feelings of isolation and moral distress. Consistent focus on the harsh realities of the pandemic can often overshadow the bright side, such as patient recovery and discharge and reductions in new COVID-19 diagnoses on a given day. Be sure to talk about the positive things occurring within your facility and personally during this crisis. 7. Seek professional support to cope with moral distress and grief. Many health care professionals are encountering unprecedented circumstances that may cause moral injury. Decisions such as which patient is placed on a ventilator or prioritizing the treatment of COVID-19 over other chronic illnesses can result in moral distress. Symptoms of moral distress include self-criticism and excessive feelings of shame, guilt and regret. This moral distress and anticipatory grief can be difficult to cope with, and additional support is needed to address their harmful effects. Early support is key for addressing trauma from moral distress. Seek peer, supervisory and external professional support to cope with moral distress. If you have access to an employee assistance program through your employer, you can receive confidential support and referrals to help you cope with moral distress. You can also contact your health insurance provider for referrals to mental health professionals who provide video and audio teletherapy. ■ Suggested Reading A list of references and resources for this article can be found in the online version at www.ormanagement.net. —Dawn Shedrick, LCSW-R, is the founder and CEO of JenTex Training & Consulting, a professional development company for social workers and health care professionals. She is a licensed clinical social worker, trainer, consultant and certified life/business coach, and a lecturer at the Columbia University School of Social Work in New York City, and St. Joseph’s College Department of Human Services in Patchogue, N.Y.
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New International Consensus Guidelines on Orthopedic Infections Recommendation
93% of delegates agree
There is No Evidence to Prove Sealants Reduce Surgical Site Infections Without the Use of a Dressing1
The Guidelines recommend the use of silver, occlusive dressings to help prevent SSIs. THREE OUT OF FOUR of the clinical studies supporting this recommendation used
To find out more,
visit www.convatec.com 1. General Assembly, Prevention, Wound Management: Proceedings of International Consensus on Orthopedic Infections. Al-Hourabi, Reema K. et al. The Journal of Arthoplasty, Volume 34, Issue 2, S157 - S168. ©2019 ConvaTec Inc. ™/® indicates a trademark of ConvaTec Inc. AP-020606-US