OR Management Digital Edition - June 2021

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The Iron Intern® PAGE 12

Management News The Independent Source of News for Operating Room Managers, Supply Chain Professionals & C Suite

Volume 16 • June 2021

www.ormanagement.net

Pulling Back The Curtain No Surprises Act Passes, Targeting Unexpected Bills

Warming Devices Contamination Risk Cybersecurity Attacks on the Rise Clear Masks Benefit Communication Brought to you by the publisher of

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TABLE OF CONT ENTS

BULLETIN BOARD 4 Warming Devices May Be Source of Airborne Microbial Contamination, but Fix Is Possible 6 Clear Surgical Masks Lead to Higher Patient Satisfaction 8 Hospitals Urged to Strengthen Cybersecurity Systems With Attacks on the Rise 10 Pulling Back the Curtain: No Surprises Act Passes, Targeting Unexpected Bills 12 Why Surgeons Should Partner With Their Central Sterile Processing Department 14 Harassment of Docs on Social Media A Growing Problem 15 Overnight Telemedicine Services Reduce Mortality in ICU Patients 16 COVID-19 Registry Reveals Factors Leading To Increased Mortality 18 Futile Trauma Transfers Uncommon but Costly 20 Readmission Adds to Necrotizing Soft Tissue Infection Disease Burden

Trending Articles Online Read the most-viewed articles last month on ormanagement.net.

1. AI Tool Can Predict Post-op Hernia Complications 2. Lifelong Financial Planning: A Road Map 3. Court Ruling Alters Informed Consent Process 4. Emerging Biophysical Approaches to Advanced Wound Care

Heard Here First “Surgical site infections are the third most expensive type of health care–acquired infection, costing nearly $21,000 per patient case.

Some estimates raise that cost to $90,000. It’s estimated that the total cost of SSIs to the U.S. health care system ranges from $3.5 billion to $10 billion annually.”

PAGE 12

In the Next Issue AI for Surgeons: Current Realities, Future Possibilities “AI is there to make us better. It should run quietly in the background, catching our blind spots and helping us make more informed decisions about patient care.”

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The Independent Source of News for Operating Room Managers, Supply Chain Professionals & C-Suite

OR Management News • June 2021

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IN FECTIO N CO NTRO L

Photo courtesy of the investigators

Warming Devices May Be Source of Airborne Microbial Contamination, but Fix Is Possible

By MICHAEL VLESSIDES

N

ew research has identified an unexpected source of airborne microbial contamination in the OR as the Neptune (Stryker) surgical suction system or the Bair Hugger (3M) forcedair warming device, both of which discharge exhaust into the OR environment.

These sources of contamination, the researchers noted, may be mitigated by changing the devices’ HEPA filters more regularly, or adding a high-efficiency filter at the end of the Bair Hugger’s exhaust hose.

“The CDC recognizes operating room air as a potential source of surgical site infections, and has published several strategies to limit infections resulting from airborne microbes,” said Justin Ward, MD, the chief resident, Department of Anesthesiology, at Stanford University, in California. “Both the Neptune surgical suction system and the Bair Hugger forced-air warmer have been staples in operating rooms for many years, and both emit HEPAfiltered air into the OR environment from their exhaust ports.

“We know that HEPA-filtered air should capture at least 99.97% of particles greater than 0.3 microns in size. But it’s also true that time and particulate loading can degrade the efficiency of these filters. So we wanted to see if these devices might be contributing airborne microbes to operating room air,” Dr. Ward said.

To do so, Dr. Ward and his colleagues collected 200-L air samples from each device and from OR air inlets in 12 randomly selected ORs, using an industry-standard portable microbial air sampler.

Sample plates were incubated at 30° C to 35° C for three days, followed by four days at 20° C to 25° C, and then interpreted for colony counts. The researchers identified colony organisms using DNA sequencing technology.

The study found that the total colony counts (colony-forming units per m3) from the exhaust of the Neptune device were not significantly different from those obtained from room air. In contrast, colony counts obtained from the Bair Hugger’s output hose were significantly higher (P=0.0005) than in room air.

“The Bair Hugger emitted over twice the number of colony-forming units as did the Neptune, and four times as many colony-forming units as room air,” Dr. Ward said (Figure).

The study also found extreme variation in colony counts between the two devices. This finding, the investigators said, indicates that some individual Neptune and Bair Hugger units may be significant sources of contamination.

“The samples from the Neptune and the Bair Hugger were notably more variable than those from room air,” Dr. Ward said.

“This is important because if all the HEPA filters are performing at the same efficiency, we would expect no difference in variability.

But that isn’t what we found.”

In total, four organisms identified as human pathogens were common to all sources and assumed to be present in room air.

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OR Management News • June 2021

Figure. Colony counts from room air (left) and the Neptune system’s exhaust port, sampled from one OR in the study.

Three human pathogens were unique to only the Neptune or Bair Hugger, and not isolated from the OR air inlet.

Manufacturer Disputes Findings A spokesman for 3M, Sean Lynch, disagreed with the findings. “For 30 years, the 3M Bair Hugger system has been a safe and effective method of keeping patients warm before, during and after surgery,” he said. “There is no legitimate scientific support for claims that the Bair Hugger system can cause infection. The U.S. FDA, independent institutions including Duke University’s Infection Control Outreach Network (DICON), and federal and state courts that have examined claims of whether the Bair Hugger can cause infection have consistently rejected them.

“Scientific research supports the conclusion that the Bair Hugger system helps patients by maintaining normothermia, which is associated with reducing the risk of infection, shortening recovery time and improving patient comfort,” Mr. Lynch said.

The good news, however, is that the investigators proposed a fix: Change the HEPA filters in both devices based on usage instead of time.

“This could look something like a meter on the machine that shows hours of use,” Dr. Ward said. “Then those machines being used more often would be identified before their filters lost efficiency.” Institutions should also consider placing a high-efficiency filter at the end of the Bair Hugger’s exhaust hose, he said.

“Since the Bair Hugger’s HEPA filter is located at the air intake on the bottom of the machine, that leaves the remainder of the machine and the hose open to the OR air and able to collect particulate matter in the corrugated tubing. This is supported by swab studies of that tubing showing several species of Staphylococcus,” Dr. Ward explained.

The researchers also suggested that the Neptune system’s exhaust could be routed outside the hospital, via an existing suction system.

“The infrastructure is there, and it would obviate any concern for OR contamination from these devices,” Dr. Ward added. Stryker was asked to comment but did not reply to our request.

■

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CLIN IC A L NE WS

Clear Surgical Masks Lead to Higher Patient Satisfaction “Therefore, it is important to identify mask technology that allows this urgeons who wear clear surgical visibility, while maintaining safety masks during patient encounters standards and providing a comfortreceive significantly higher marks for able mask-wearing experience.” communication and trustworthiness, Margaret L. (Gretchen) Schwarze, compared with colleagues who wear MD, an associate professor of surtraditional surgical masks, according gery at the University of Wisconsin– to a new study.

Madison School of Medicine and The report, which is the first study Public Health, who authored a corto evaluate differences in patients’ responding commentary, agreed. perceptions of surgeon communica“We do a lot of things to try to tion based on their mask type, may improve patient care,” she said. “This have additional implications as the study clearly shows that patients COVID-19 pandemic recasts the Figure. A standard covered mask (left) and a report much higher communication clear mask (right). need for mask wearing during physcores when the surgeon is wearing sician–patient interactions (JAMA Image Courtesy of JAMA Network® a clear mask. This seems incredibly © 2021 American Medical Association Surg 2021 Mar 11. doi:10.1001/ valuable for our patients, and somejamasurg.2021.0836). thing we should probably do to sup“With the changing health care land- and qualitative impressions regarding the port them in their surgical care.” scape due to the pandemic, masks have two mask options.

However, surgeons themselves were less become an even more important aspect Across the board, patient rankings were positive in their reviews of clear masks. of surgeon PPE,” said Ian M. Kratz- more positive for surgeons who wore clear Only 47% indicated they were likely to ke, MD, a physician in the Department masks. choose clear masks for future patient of Surgery at the University of North Surgeons wearing clear masks were encounters.

Carolina (UNC) at Chapel Hill School rated higher for providing understandable In addition, since the COVID-19 panof Medicine, and lead author of the explanations (95% clear vs. 78% standard), demic has increased use of masks, patients study. “The findings speak to the impor- demonstrating empathy (99% vs. 85%) have grown more accustomed to them tance for surgeons and OR personnel to and building trust (94% vs. 72%). Over- being worn during all interactions. Dr. recognize the barriers that masks create all, patients preferred clear over standard Kratzke noted that while it is difficult to in effectively communicating and build- masks (100% to 72%), expressed greater estimate the long-term effect of the paning trust with patients.” excitement for clear masks, and had more demic on mask wearing, the study provides A total of 200 patients were enrolled frequent complaints regarding interactions key information regarding ways health care in the study, recruited from 15 surgeons’ with doctors wearing standard masks. professionals may adapt mask usage to satclinics spanning seven surgical subspe“This study demonstrates that patients isfy patients. “While the scope of this study cialties. Clinic visits were conducted at a prefer to see their surgeons’ faces,” said did not involve evaluating the situations single academic medical center, with the senior author of the study, Muneera R. that masks should be worn moving forpatients rating the surgeons on communi- Kapadia, MD, an associate professor of wards, masks have and will always serve a cation, trust, and a number of quantitative surgery at UNC School of Medicine. role in the health care setting,” he said. ■

By ETHAN COVEY

S

NE W P R OD UC T A NNOUNC EM ENT

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OR Management News • June 2021

FE ATURE

Hospitals Urged to Strengthen Cybersecurity Systems With Attacks on the Rise

By CHRISTINA FRANGOU

A

s the SARS-CoV-2 virus spread globally over the last year, health care institutions became increasingly vulnerable to another kind of dangerous viral attack—this time, at the hands of cybercriminals.

During the 2021 Critical Care Congress Virtual Event, a panel of physicians urged attendees to take steps to protect their hospitals’ cybersecurity systems, pointing out that the health care sector is now the most targeted industry by ransomware in the United States.

These attacks can significantly affect patient care, harm patients and providers and carry an enormous price tag. Medical data breaches alone cost the health care industry more than $5.6 billion annually.

“Hacking in health care is a major problem, with estimated millions of records being breached every year in the U.S. alone,”

Erie County Medical Center, the Buffalo trauma center attacked by a variant of ransomware named SamSam. Credit: D-Day/Wikimedia Commons

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OR Management News • June 2021

said L. Nelson Sanchez-Pinto, MD, MBI, a specialist in pediatric critical care medicine and informatics at Ann & Robert H. Lurie Children’s Hospital of Chicago.

This past fall, federal agencies issued a warning that cybercriminals were targeting U.S. health care institutions. The wave of ongoing attacks was designed to lock up hospital health information systems (HISs) as COVID-19 cases were spiking. Cybersecurity firm Check Point reported that ransomware attacks against American hospitals rose 71% from September to October 2020.

Cyberattacks on health systems come in three forms—phishing, malware and medical data breaches—said Dr. SanchezPinto, who moderated the panel. Phishing attacks are the most common; they arrive disguised as legitimate-appearing emails that trick the recipient into opening a link or document with malware or into providing personal information.

Malware is software that users inadvertently download onto their devices, which infects the system with a virus. Malware can take control of a computer until a user pays a sum of money, a version known as ransomware; or it silently spies on a computer, sends data or gives access to a hacker.

Medical data breaches have become more frequent in recent years; hackers steal medical records and sell them on the dark web.

They can fetch up to $1,000 per patient because of the breadth of information in medical records. Information contained in these files can be used for fraud or identity theft, as well as blackmail or extortion. Provider data can also be accessed and used for fraudulent insurance claims or prescription drug fraud.

Dr. Sanchez-Pinto said physicians and their colleagues must create a culture focused on cybersecurity, although it means some tasks require more time.

“Taking extra security steps online can be annoying because it can seem like they are slowing our workflow, but we owe it to our patients to be safe with their data because it’s extremely vulnerable,” he said.

On April 9, 2017, the Level I trauma center at the University continued on page 22

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Natural is the new normal.

w w w.telabio.com OviTex Reinforced Tissue Matrices are intended for use as a surgical mesh to reinforce and/or repair soft tissue where weakness exists. Indications for use include the repair of hernias and/or abdominal wall defects that require the use of reinforcing or bridging material to obtain the desired surgical outcome.

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BU SIN E SS M A NAG E M E N T

Pulling Back The Curtain No Surprises Act Passes, Targeting Unexpected Bills

By VICTORIA STERN

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OR Management News • June 2021

BUSI N ESS MA NAGEMENT

I

n December 2020, after years of heated debate and mounting anxiety from patients, Congress passed legislation to ban surprise medical bills.

The No Surprises Act provides sweeping protections for patients from these unexpected charges, which reportedly accompany 20% to 44% of elective surgeries or hospital visits, and can range from a few hundred dollars to more than $100,000 (JAMA Intern Med 2019;179[11]:15431550; JAMA 2020;323[6]:538-547).

Surprise bills typically occur when a patient with commercial insurance unknowingly receives care at an out-of-network facility or from an out-of-network provider. That facility or provider can bill outside the limits of in-network rates, but if the insurer refuses to cover the charge in full, patients are often on the hook for the balance.

The No Surprises Act goes into effect on Jan. 1, 2022. It prohibits out-of-network providers or facilities from balance billing patients in both emergency and nonemergency settings, including out-ofnetwork air ambulances but not ground

These unexpected charges, which reportedly accompany 20% to 44% of elective surgeries or hospital visits, ... can range from a few hundred dollars to more than $100,000.

Sources: JAMA Intern Med 2019;179(11):1543-1550; JAMA 2020;323(6):538-547.

What We Know Ultimately, the No Surprises Act will protect more than 135 million Americans in employer-based plans regulated under the federal law known as the Employee Retirement Income Security Act (ERISA), and millions more in stateregulated plans in areas with no surprise billing legislation.

However, insurers and providers need a forum to settle payment disputes for out-of-network bills. The law maps out an independent dispute resolution process called “baseball-style arbitration”— an approach that only comes into play when insurers and providers fail to reach a voluntary agreement about a charge after 30 days.

In baseball-style arbitration, each party makes a payment offer and the arbitrator must select one of the two amounts. The

‘Arbitration and consent waivers will have the biggest impact on income, but it will be a while before we know the nuts and bolts of the legislation and the specific details of those regulations.’

—Patrick Bailey, MD, FACS ambulance transport. In other words, patients will no longer be responsible for paying more than the in-network costsharing rate, which may include a commercial plan’s deductibles, coinsurance and copayments.

“Essentially, the new law takes patients out of the middle of insurers and health care providers—an outcome everyone can support,” said Patrick Bailey, MD, FACS, the medical director of the American College of Surgeons.

Although the legislation lays out a framework for banning surprise bills, several key details remain unwritten. These unknowns, and their potential consequences to providers’ income, have left some physicians on edge.

losing party subsequently will pay the administrative costs of arbitration.

No payment standard exists, but an arbitrator can weigh a host of factors, including median in-network rates, a surgeon’s training, experience and quality, as well as the complexity of services provided. But the arbitrator cannot consider billed charges or Medicare and Medicaid rates.

The idea here, Dr. Bailey explained, is to encourage insurers and providers to come to an agreement before arbitration and dissuade excessively high or low payment offers during the process.

The No Surprises Act does include an exception to the

balance billing protections, called a notice and consent waiver. In specific circumstances, certain out-of-network providers can ask patients for written consent to send balance bills in the nonemergency setting. The notice must include details such as a good faith estimate of the charges, the fact that the provider or facility does not participate in the patient’s health plan, and a list of in-network physicians or facilities where the patient can receive care instead. The law also bars specialties with a history of balance billing from using these waivers.

“These two categories—arbitration and consent waivers—will have the biggest impact on income, but it will be a while before we know the nuts and bolts of the legislation and the specific details of those regulations,” Dr. Bailey said.

What We Don’t Know Physicians don’t yet know how two key aspects of the legislation will play out in real time.

The first one is arbitration decisions. If arbitrators base their payment picks on the insurer’s median in-network rates— the amount an insurer pays other local doctors for the same service—health care costs will likely decline, as will physician income.

Calculating median in-network rates depends on many variables, including what constitutes a geographic region and how to deal with newly covered services or providers. Some providers argue that relying on median in-network rates as a benchmark will give health plans an incentive to reduce these rates, for example, by terminating in-network contracts that raise the average rate.

For venture capital‒backed physician groups, which are responsible for the lion’s share of surprise bills, relying on median innetwork rates will likely continued on page 20

OR Management News • June 2021

11

PE RSP ECTIVE

Why Surgeons Should Partner With Their Central Sterile Processing Department Redefining the Relationship to Decrease Surgical Site Infections

By DAVID TAYLOR III, MSN, RN, CNOR

Over the past decade, hospitals have spent a great deal of time, resources and money to prevent surgical site infections (SSIs).

Properly timed antibiotics, nasal decolonization, skin antisepsis, appropriate hair removal, preoperative bathing and hand hygiene have been some of the measures taken to reduce infection rates. But one critical dimension of infection safety has received comparatively much less attention, and that is the role of the central sterile processing department (CSPD).

Central sterile processing is the first link in the chain of infection prevention. Its role is to decontaminate, clean, inspect and sterilize instrumentation for future use. However, failure to do so can introduce pathogens into the OR, increasing the risk for SSIs. The major problem is a lack of awareness of the importance of this step.

In U.S. hospitals, SSIs are a major problem and a significant patient safety issue. They affect a significant number of the patients and can have devastating consequences, including longterm disability (http://bit.ly/2OfAsSJ) and worse outcomes (BMJ Open 2016;6[2]:e007224). Most hospitals have made substantial process changes to improve intraoperative safety, but these gains are vulnerable to weaknesses in the CSPD.

The Financial Issue Nearly 1.5 million surgical procedures were performed in 2019.

Cases declined in 2020 because of COVID-19, but experts are predicting a spike this year, with further growth in the surgical market from 2022 to 2025 (http://bit.ly/30uwTe2).

Surgical site infections are the third most expensive type of

health care‒acquired infection, costing nearly $21,000 per patient case. Some estimates raise that cost to $90,000. It’s estimated that the total cost of SSIs to the U.S. health care system ranges from $3.5 billion to $10 billion annually (bit.ly/3cfPbVB).

In addition, in 2015, the Centers for Medicare & Medicaid Services began to penalize hospitals for high rates of SSIs along with other health care‒acquired conditions. Because these SSIs dramatically increase the risk for rehospitalization, hospitals are more vulnerable to readmission penalties (Table, page 22).

These safety and financial issues make a very compelling argument for timely preventive action (Langenbecks Arch Surg 2011;396[4]:453-459). A surgeon who knows more about CSPD can have a positive effect on their own practice. When surgeons engage directly with hospital leaders to create a strong process for preventing SSIs, patient safety surely will increase.

Going Behind Closed Doors A CSPD orientation program designed to educate surgeons represents a low-cost, high-impact opportunity that not only drives the alignment between key customers of the OR, but can improve safety and efficiency.

Individual and small group tours are an important start, and can give the surgeon a general overview of the inner workings of the CSPD and how it may affect their practice. To increase the return on investment, a more robust program can be created by taking this concept further and allowing the leaders to present at a department of surgery meeting. Once established, the leaders can grow the orientation program and combine it with the introduction of a quarterly surgeon satisfaction survey. continued on page 22

NE W P R OD UC T A NNOUNC EM ENT

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OR Management News • June 2021

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7KH 0RVW 9HUVDWLOH DQG $GDSWDEOH 6XUJLFDO 5HWUDFWRU The Iron Intern® is an articulated surgical retractor designed to mimic the human arm. With wrist, elbow, and shoulderlike movements, it delivers WRWDO PDQHXYHUDELOLW\ ɠH[LELOLW\ and versatility for multiple procedures. The Iron Intern® provides greater autonomy, UHGXFLQJ 25 VWDɞ and contamination.

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FE ATURE

Harassment of Docs on Social Media A Growing Problem or religion. Sexual harassment frequently included receipt of inappropriate and sexually explicit messages or comments. ne-fourth of physicians report being personally attacked on “The thing that was most surprising for me was the intensisocial media, with many experiencing death threats, verbal ty of the attacks and sexual harassment incidents described that abuse and sharing of personally identifying information, accord- included things like death threats and threats of rape,” Dr. Arora ing to a new study. said. “I also think it’s important to note that women physicians, Additionally, one in six female physicians reported online in particular, face a double hit: They could be attacked and also sexual harassment. face the risk of being sexually harassed.”

“It is important that in an era when physicians are engaging The authors noted that their research was completed before in advocacy and education on publicc health on the outbreak of COVID-19, but the pandemic makes the social media that they risk being attacked,” d,” said finding even more relevant. findings Vineet M. Arora, MD, a Herbert T. Abelson elson “O “Over the last year, we have truly seen the professor of medicine at the University of im importance of disseminating evidence-based Chicago Pritzker School of Medicine. f factual information founded in science,” Dr. Arora and her colleagues conductDr. Jain said. “Physicians and other health ed the study as a way to test a hypothecare workers have been using social media sis that harassment and personal attacks effectively to disseminate facts and science, were prevalent among physicians engagbut unfortunately there has also been a paring with social media (JAMA Intern Med allel ‘infodemic’ where we have seen misin2021;181[4]:550-552). f formation and false information spread. We “I have been an active social mediaa h have seen our scientific leaders attacked and user for years with the primary focus of bu bullied for advocating for public health meadisseminating evidence-based informamasu that would save lives. Now more than ever, sures tion so patients can make informed decieciwe need to trust our scientists and public health sions,” said co-author Shikha Jain, MD, an ffi officials, and this is one of the first studies to assistant professor of medicine in the Divishow conclusively that those individuals who use sion of Hematology and Oncology, Unitheir platforms to disseminate information are versity of Illinois at Chicago. “With more targeted, bullied and harassed.” health care workers and physicians utilizing In an effort to increase social media advocasocial media in this manner over the years, cy, Drs. Arora and Jain founded an organization we conceptualized this study to get a betcalled IMPACT4HC (Illinois Medical Profester understanding of how other physicians sionals Action Collaborative Team), a group of across the country used social media, and health care workers with social media presence what their experiences were in the digital who are actively advocating and educating as part space.” of a team.

The team developed a survey that was disThey have also created a tool kit to help health —Shikha Jain, MD tributed via Twitter from Feb. 6 to March care professionals navigate how to properly and 20, 2019. Respondents were asked to answer safely use social media. yes or no to two questions: Have you ever been personally tar“We have found that having others to support you and your geted or attacked on social media? Have you ever been sexual- messaging can be very helpful in the social media space,” Dr. Jain ly harassed on social media? A comment box was included for said. “When engaging on social media, I remind people that the respondents to describe such incidents. amount of energy you expend is up to you. While having a spirA total of 464 participants who self-reported as U.S.-based ited discussion with someone who thinks differently than you can physicians completed the questionnaire. Of the respondents, result in a productive exchange of ideas, if the person is simply 57.8% were women or nonbinary, and 42.2% were men. The attacking you or trying to get a rise out of you, there is no need ■ median age was 39 years. to continue to engage.”

Reports of attacks on social media were widespread, with 23.3% acknowledging abuse. Common themes for harassment Dr. Arora reported funding from the Journal of Hospital Medicine as a included anti-vaccination, anti-gun control and anti-abortion social media editor, the American Board of Internal Medicine and the Joint comments, as well as personal attacks based on physicians’ race Commission, and is a founding member of TIME’S UP Healthcare.

BY ETHAN COVEY

O

‘We have seen our scientific leaders attacked and bullied for advocating for public health measures that would save lives.’

14

OR Management News • June 2021

C LINICA L NEWS

Overnight Telemedicine Services Reduce Mortality in ICU Patients

By CHRISTINA FRANGOU

P

atients in the ICU who received telemedicine services overnight were less likely to die, and were more likely to be discharged quicker than patients receiving traditional ICU care with no on-site intensivist overnight, according to a study presented at the 2021 Critical Care Congress Virtual Event.

The retrospective study ended just before the COVID-19 pandemic began, but the results underscore the value of ICU telemedicine at a time when critical care specialists are in short supply, according to the investigators.

“In an ideal world, patients would have an intensivist at the bedside 24/7, but the reality is that even if we had all of the money in the world, we don’t have enough trained professionals to do the job,” said Chiedozie I. Udeh, MD, a critical care anesthesiologist at the Cleveland Clinic Foundation and lead author of the study.

Dr. Udeh and his colleagues reviewed the cases of 153,987 patients who received ICU care at one of nine Cleveland Clinic hospitals between Jan. 1, 2010, and Dec. 31, 2019. Overall, 70% of ICU patients (108,482) received telemedicine care when an intensivist wasn’t on-site between 7 p.m. and 7 a.m. An offsite team of intensivists, acute care nurse practitioners and critical care nurses monitored and assessed patients remotely.

Analysis showed that ICU patients who received telemedicine care were about 18% less likely to die, and spent 1.6 fewer days in the ICU and 2.1 fewer days in the hospital. In this study, researchers found that patients who were admitted on a weekend were no more likely to die than those who were admitted on a weekday, despite weekend admission being a known risk factor for death in an ICU. “Telemedicine offers an excellent means for providing a high level of care, allowing health issues to be discovered earlier and care moved along more quickly so that recovery can be as smooth and as swift as possible,” Dr. Udeh said.

Today, about 15% to 20% of hospitals throughout the United States offer ICU telemedicine through an off-site command center. In some cases, ICU telemedicine is provided by an

independent company or a different hospital system.

From the telemedicine command center, tele-intensivists monitor a dashboard of patients at distant hospitals. Using realtime audiovisual two-way communication, the intensivist can see and speak to the bedside nurse and patient, and can observe various monitors tracking patients’ vitals. They can also call up medical records, x-rays and other test results.

The software often includes decision support tools to help identify patients who may be sicker or are deteriorating.

ICU medicine is particularly well suited to telemedicine because it’s physiologically based rather than requiring substantial hands-on provider–patient interaction, said Omar Danner, MD, an adjunct professor of surgery and the former chief of surgery at Grady Memorial Hospital for the Morehouse School of Medicine, in Atlanta.

“It’s very plausible with critical care that you can access 95% to 99% of the information you need remotely and can guide

Analysis showed that ICU patients who received telemedicine care were about 18% less likely to die, and spent 1.6 fewer days in the ICU and 2.1 fewer days in the hospital. the person who is at the bedside,” he said. As such, he was not surprised by the positive results reported in this study.

Other studies are underway that examine outcomes for ICU patients with COVID-19 who received ICU telemedicine. Dr. Danner expects the studies will also show a benefit for telemedicine, including a reduction in nosocomial infection rates.

Telemedicine means fewer people are required to be in the room with patients with highly contagious infection.

“The COVID-19 pandemic has challenged systems and now allowed us to also test telemedicine in the ICU. Telemedicine ■ does have its place,” he said.

OR Management News • June 2021

15

C LIN IC A L NE WS

COVID-19 Registry Reveals Factors Leading To Increased Mortality Age, Need for Organ Support, Hospital of Admission Play Large Roles

By CHRISTINA FRANGOU

H

ospitals around the world report wide variations in mortality rates for patients admitted with COVID-19, with a consistent pattern: Risk for mortality increases with age and need for organ support, according to results from a global registry.

In February 2020, the Society of Critical Care Medicine and the Critical Care Research Network launched VIRUS (Viral Infection and Respiratory Illness Universal Study) to track hospital care patterns in near real time. Since then, 298 hospitals in 26 countries have joined, with data collected on 64,182 hospital admissions and 12,130 ICU admissions.

This is one of the first large studies to evaluate outcomes among patients with COVID-19 according to a major prognostic factor: organ support required by patients.

The hospital where patients were admitted made a difference to their outcomes. The risk-adjusted mortality rates for 4,749 patients who received invasive mechanical ventilation (IMV) ranged from 27.7% to 77.9%; a patient presenting to a hospital with poorer outcomes had a 1.69 odds of dying compared with a similar patient at a hospital with lower mortality.

Amos Lal, MBBS, a critical care fellow at Mayo Clinic in Rochester, Minn., presented results at the 2021 Critical Care Congress Virtual Event. The paper was published in March in Critical Care Medicine (2021;49[3]:437-448).

Approximately 10% of the variation in mortality is explained by the hospitals of admission, Dr. Lal said.

“This presents an opportunity for quality improvement and for future studies to learn from practices at hospitals that achieved low adjusted mortality rates,” he said.

Many hospitals in the United States had lower mortality than other countries, but even within this country, mortality differed between hospitals. The effect of country was “a likely minor contributor” to mortality variation, he said.

Dr. Lal and his colleagues studied patients admitted with COVID-19 at participating hospitals between February and November 2020. At the time, the registry included data from 179 institutions and 49,058 patients. Of these, 20,608 patients had complete outcomes data and were included in the analysis.

Patients had a mean age of 60.5 years, 54.3% were men, and 50.4% of patients were white, 25.9% Black and 5.6% Hispanic; 85% had at least one comorbid condition and 42.4% required ICU admission.

Overall, 19% of patients died. Patients younger than 45 years of age who did not receive organ support therapies were the least likely to die, with a mortality rate of less than 1%. Patients with the highest risk for death were those older than 74 who received

16

OR Management News • June 2021

‘Remarkably, the mortality for those critically ill patients receiving ECMO is lower than some of the other subgroups, which probably reflects the selection of patients most likely to benefit from ECMO.’ —Greg Martin, MD IMV, vasoactive drugs and renal replacement therapy (RRT).

In this group, 78.3% of patients died.

At all ages, patients were more likely to die as they needed more organ support. Among patients placed on IMV alone, 40.8% died. Mortality rose to 71.6% for those who received IMV, vasoactive drugs and RRT. Only 2% of patients in the registry received extracorporeal membrane oxygenation (ECMO). In this group, 35% died.

“Remarkably, the mortality for those critically ill patients receiving ECMO is lower than some of the other subgroups, which probably reflects the selection of patients most likely to benefit from ECMO,” said Greg Martin, MD, the president of SCCM and a professor of medicine at Emory University, in Atlanta.

Three-fourths of patients received no organ support. Of those who did, IMV was the most common method, used in 24.3%, either alone or in combination with other organ support therapies. Only 2.9% of patients (n=602) received vasoactive drugs and/or acute RRT without IMV. The VIRUS registry helps researchers and clinicians get a better understanding of what people and hospitals around the world continued on page 18

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C LIN IC A L NE WS

Futile Trauma Transfers Uncommon but Costly

By JENNA BASSETT, PhD

D

espite making up less than 2% of trauma transfers, unsalvageable patients present a significant cost burden to the health care system, researchers report.

Researchers at the University of Kansas Medical Center (KUMC) investigated the rates and costs of futile transfers within their organization between June 2017 and June 2019. Futility was defined as a patient who had a stay that was no more than 48 hours that resulted in death, implementation of hospice care or discharge with no major operative, endoscopic or radiological intervention.

Within the study period, there were 1,241 trauma transfers.

Among the 407 trauma transfers with hospitalization time less than 48 hours, 18 patients (1.5% of the study population) were deemed futile. In both the futile and nonfutile groups, the majority of patients were transferred for traumatic brain injury and the need for neurosurgical consultation or intervention.

The researchers evaluated injury severity among transferred

COVID Mortality continued from page 16

are doing. They can share knowledge to improve quality of care, Dr. Lal said.

It also helps answer questions from families concerning patients who present with an acute COVID-19 infection about expected outcomes, based on the organ support required, he said.

18

OR Management News • June 2021

patients using the Injury Severity Score (ISS), a validated score that correlates with morbidity, mortality and hospitalization time after trauma. Scores above 15 indicate severe injury.

Futile transfers were older, with more severe injuries as indicated by a median ISS of 21 versus 8 in nonfutile patients. Specifically, futile patients had more severe injuries to the head and torso.

The median cost of treating futile patients was $56,396, and the total cost to the health care system exceeded $1.7 million during the two-year study period. The authors estimated that elimination of futile transfers would result in a cost savings of over $27 million annually in the United States.

“Our study clearly has limitations in that our data represents the retrospective experience of a single institution serving a large network of rural referral facilities,” explained presenting author Craig Follette, DO, a general surgery resident at KUMC, in Kansas City.

“The data may not be able to be generalized to other trauma networks but could be compared to similar regional networks.”

Dr. Follette also added that the study definition of futile was conservative, which may affect study conclusions, and the data do not show the intricacies of what occurs in the period surrounding a trauma transfer.

“It is possible that patients received therapies not available at referral centers, although, in our experience, this would be extremely unlikely in the absence of ongoing consultant care.”

To optimize trauma transfer, the researchers propose a new trauma transfer paradigm that incorporates a telehealth support component that could be used to extend specialist support to critical access hospitals.

“While beyond the scope of this paper, we believe that this future state will involve enhanced means of communication through telehealth/tele-trauma, and the overall sharing of Level I trauma center expertise beyond the walls of the center itself,” Dr. Follette said. “I believe the next step is collaboration with other centers in multicenter studies to truly define this special patient population and guide further resource utilization region by region.”

The authors concluded that additional work is needed to avoid futile care and ensure appropriate allocation of health care resources to patients who will benefit.

■

“Our findings provide novel prognostic estimates for important patient-centered outcomes of survival and probability of discharge home across a wide range of ages and types of organ supportive therapies commonly required for patients with severe COVID-19,” he said.

To date, of the nearly 48,000 patients included in the registry, 28% received IMV, while 13% and 2%, respectively,

had noninvasive ventilation and ECMO. One in five received highflow nasal oxygen and 10% were placed on dialysis. The median length of time that patients receive IMV is nine days; ICU stays last a median of seven days.

Just over half (56%) of patients are discharged alive.

The real-time dashboard of the VIRUS registry is available at sccmcovid19.org. ■

Summer 2021

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Readmission Adds to Necrotizing Soft Tissue Infection Disease Burden

By JENNA BASSETT, PhD

P

atients with necrotizing soft tissue infections (NSTIs) experience greater disease burden with hospital readmissions, according to the results of a new analysis.

Patients with NSTIs have a high risk for unplanned hospital readmission, but the factors that influence readmission are poorly understood. Researchers from Tulane University School of Medicine, in New Orleans, retrospectively investigated the incidence and factors associated with unscheduled readmission among patients with NSTIs. Of the 82,738 patients diagnosed with necrotizing fasciitis, gas gangrene or Fournier’s syndrome, 30.3% were readmitted within 90 days. Of the readmitted patients, 79.8% had unscheduled readmission. The most common causes of readmission were septicemia, cellulitis, abscess and postoperative infection.

Patients with unplanned readmission were generally older, female, more likely to be diabetic, had higher Charlson Comorbidity Index scores and were less likely to be obese.

In a multivariate analysis, factors associated with readmission were prolonged versus short length of stay, Medicaid versus Medicare as the primary payor, and leaving against medical advice. No demographic variables, clinical characteristics or interventions were associated with readmission.

Of the readmitted patients, 3.8% died during their hospitalization. Age older than 65 years and fragmentation of care caused by readmission to a different hospital were independently associated with mortality, while being obese favored survival.

Presenting author Eman Toraih, MD, an associate professor of medical genetics at Tulane University School of Medicine, said clinicians need to ensure that discharged patients have the resources they need so they will not require readmission. “This may mean ensuring that they do not only have a prescription for antibiotics, but also the means and resources to obtain antibiotics

No Surprises continued from page 11

minimize inflated charges. But for the private practice surgeons who have faced declining reimbursement rates for years, a further reduction in reimbursement may mean a death sentence for their business.

The outcomes of arbitration also may affect health insurance premiums, but it’s unclear in which direction. The Congressional Budget Office estimates that the federal law will reduce commercial insurance premiums by between 0.5% and 1%, 20

OR Management News • June 2021

and take them as directed. In addition, these patients often have complicated wound care needs, and we must ensure that those needs are met after discharge.”

In the future, Dr. Toraih envisions the implementation of formalized protocols for patients being discharged after NSTIs. “These protocols may need to be directed toward patients that are at high risk of readmission, such as those that had a prolonged hospital stay. These protocols may help with access to antibiotics and wound care needs. In addition, these protocols should provide clear lines of communication to the discharging care team in case the patient has questions or problems after discharge. This may help prevent fragmentation of care in another hospital.”

Dr. Toraih added: “Our vision is to apply artificial intelligence to design mobile application or online risk assessment tools to predict the probability of readmission and complications for each ■ patient.”

if insurers win in arbitration. Alternatively, some experts worry that premium costs could rise if insurers lose in arbitration.

The second uncertainty is how exactly the federal law will interact with existing state laws. The answer, Dr. Bailey said, depends on whether a person has a federalregulated plan or a fully insured state-regulated plan.

For the 18 states that have comprehensive surprise billing legislation, the federal law defers to the state regulations for fully insured plans. However, because states cannot regulate employer-based plans,

which fall under ERISA, the federal regulations take precedence. State laws will also remain primary when state-level requirements extend beyond those detailed in the new federal law.

“In states with their own laws, there is a potential for very different outcomes on claims for similar services depending on whether the patient’s plan is subject to state or federal regulations,” Dr. Bailey said. “This could create confusion for the out-of-network surgeon when determining what steps can be taken regarding a payment from an insurer.”

■

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OR Management News • June 2021 21

Cybersecurity

Central Sterile Processing

Continued from page 8

Continued from page 12

of Buffalo was hit by a variant of ransomware named SamSam. The attack shut down the hospital’s HIS, including all electronic clinical applications, billing and scheduling services, and communication tools. The hospital decided not to pay the ransom and turned to old-fashioned paper charts and face-to-face communication for two months while the HIS was restored.

In that time, staff lost access to the electronic medical record (EMR), the picture-archiving and communication system, and even the internet.

Physicians could access patients’ historical data, including medical records and imaging, through HealtheLink, an electronic clinical information exchange among hospitals in Western New York. Otherwise, patient information was communicated only in writing, by phone and in person.

W. Alan Guo, MD, an acute care surgeon and a surgical intensivist at the University of Buffalo, said trainees struggled with the abrupt switch to a paper-based system as they came to medicine in the era of the EMR. In a study published in 2018, Dr. Guo and his colleagues reported that residents were very stressed by the lack of online resources in the aftermath of the attack (J Surg Res 2018;232:389397). Some surgical residents said they had less hands-on experience in the OR because limited imaging made cases more difficult.

He urged hospitals to treat ransomware attacks like other disasters and prepare for them as part of disaster planning.

Training in paper-based documentation should be included as part of hospital in-service and the graduate medical education curriculum, he said.

“Everything is digital now. So, younger generations need to learn about paper-based documentation in case something happens, because the cyberattack rate is getting higher and higher in this world.”

Program components can consist of the following: • Walk through each area of the department.

• Detail the time it takes for accomplishing each step.

• Explain the equipment used in the process.

• Introduce surgeons to the staff responsible for their instruments.

Reliance on Telemedicine During the pandemic, health systems have become more dependent on smart devices and telemedicine. This reliance makes hospitals more vulnerable to major attacks, according to Piyush Mathur, MD, a staff anesthesiologist and critical care physician at Cleveland Clinic in Cleveland. He chairs Cleveland Clinic’s Anesthesiology Institute compliance committee.

“We need to understand that despite telemedicine providing access to a lot of different patient care areas, it has vulnerabilities and we need to be prepared for that,” he said.

Telemedicine systems rely on a network of products that are built in one country, used in another and perhaps serviced in yet another. These systems can be accessed by a global network of people working at multiple points in the chain, including human resources programs, audiovisual intersections and even IV pumps at the bedside.

“These, across the entire nation, are all vulnerable to attack,” Dr. Mathur said.

■ 22

OR Management News • June 2021

Inpatient surgery patients who develop an SSI:

2% to 5%

Number of SSIs that occur in the U.S. each year:

160 to 300K

Increase in average length of stay as a result of an SSI:

7 to 11 days

Increase in chance of death associated with SSIs:

2 to 11✕ greater

Estimated percentage of preventable SSIs:

Up to 60%

Sources: Infect Control Hosp Epidemiol 2014;35(6):605-627; World J Emerg Surg 2019;14:50.

What’s There to Learn?

Efficient turnover of instrumentation can help ensure the surgical team has the necessary equipment to perform its procedures. However, far too often when instrumentation is missing, the CSPD gets the blame. When surgeons have a better understanding of the department and its inner workings, they can begin to truly understand where the issues lie.

First and foremost, knowing your set inventory is critical.

When a surgeon schedules five procedures for the day and the hospital has only three instrument sets, delays are inevitable.

Most organizations require loaner instrumentation to arrive 24 to 48 hours before the surgery to ensure it has been properly inventoried, inspected, decontaminated, reassembled, sterilized and packaged. Also important to note, it takes on average three to four hours for an instrument set to be properly processed, and that’s a low estimate. In this scenario, it’s called an instrument turnover.

So, when the surgeon asks why their case is delayed and the circulating nurse says the instruments are not ready, it’s easy to see why the CSPD would be blamed. The truth is the department most likely had requested additional instrumentation to improve processes; however, due to the high cost of instrumentation, the request probably was denied.

Finally, consistent turnover of instrumentation can result in corners being cut and a greater possibility that something was missed, which can have devastating consequences.

■ —David L. Taylor III, MSN, RN, CNOR, is the principal of Resolute Advisory Group LLC, a health care consulting firm in San Antonio. Mr. Taylor is a board member of OR Management News.

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