The Independent Source of News for Operating Room Managers, Supply Chain Professionals & C-Suite Volume 13 • Fall 2020
COVID-19 Fuels Explosion In PPE and Tech Innovation
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BULLETIN BOARD
4 Surgical Smoke: A Risk Too Real to Ignore 6 Consulting Physicians Can Have Clinical, Financial Drawbacks
8 Novel Technique Could Minimize COVID-19 Risk During Tracheostomy
Trending Articles Online Read the most-viewed articles last month on ormanagement.net. 1. Is Surgery Ready For Telemedicine? . 2. Fixing Health Care: What Is the First Step?
10 IV Vitamin C, Ozone Shown Effective Against COVID-19
12 Key Steps for Infection Prevention in Ambulatory
3. Even After Reprocessing, Many Scopes Stay Dirty
Surgery Centers
14 Pandemic Puts Pressure on Innovators to Speed Up AI, ‘Smart’ PPE and Other Medical Tools
16 Most Incisional Hernia Readmissions Occur After 30 Days
18 Are the Towels in Your Hospital Really Clean? 20 Value Over Volume: Reimagining Health Care Through The Lens of Systems Science
Heard Here First ‘One study to quantify exposure found that a single day in the OR is the equivalent of smoking up to 30 unfiltered cigarettes, and another showed that perioperative nurses reported twice as many respiratory issues as the general population.’ PAGE 4
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OR Management News • Fall 2020
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CLIN ICA L NE WS
Surgical Smoke: A Risk Too Real to Ignore By CHASE DOYLE
T
he price for saving lives in the OR could be the healthy lungs of surgical teams. Mounting evidence indicates that surgical smoke, the byproduct of procedures using electrocautery and other heat-producing devices, may pose a serious risk to health care workers. One study to quantify exposure found that a single day in the OR is the equivalent of smoking up to 30 unfiltered cigarettes,1 and another showed that perioperative nurses reported twice as many respiratory issues as the general population.2 It’s not just exposure to carcinogens that has providers worried. Biological substances considered to be mutagenic and possibly infectious, including malignant cells and viruses, also have been detected in surgical smoke.3 Although the long-term consequences of exposure remain unclear, in the age of COVID-19, many health care workers are finally starting to heed the signal. It is estimated that 90% of all endoscopic and surgical procedures produce plume, and approximately a half-million health care workers are exposed to laser or electrosurgical smoke each year.4
Laws on Smoke Evacuation Despite the potential dangers, only two states—Colorado and Rhode Island—have laws requiring that hospitals and ambulatory surgery centers adopt policies to use a smoke evacuation system for surgical procedures that generate surgical smoke. Rhode Island’s law went into effect Jan. 1, 2019, and Colorado’s will take effect May 2021. During the 2020 Association of periOperative Registered Nurses Virtual Global Surgical Conference, Jennifer Pennock, MS, the senior manager of governmental affairs for AORN, provided an update on surgical smoke evacuation legislation in the rest of the United States.5 This year, legislation has been introduced in eight states: Connecticut, Georgia, Illinois, Iowa, Kentucky, Oregon, Tennessee and Utah. Unfortunately, Ms. Pennock said, COVID-19 had a negative impact on many of these bills, including legislation in New Jersey that was not yet introduced this year but was anticipated. The pandemic may have delayed legislative efforts in several states, but there are lessons to be learned from the few sessions that have taken place so far, said Ms. Pennock, who noted that 4
OR Management News • Fall 2020
the primary opposition to legislation has come from state hospital associations and state chapters of the American College of Surgeons. “One misconception expressed by policymakers and others is that surgical smoke is not a problem because they were not aware of it before,” Ms. Pennock said. “It’s difficult to introduce a solution to a problem when it’s the first time that legislators are hearing that there even is a problem, and when no complaints have previously been made.”
COVID-19 and Surgical Smoke Although COVID-19 may have impeded surgical smoke legislation, reducing exposure to surgical smoke has become an even more pressing issue during the pandemic. Mark K. Soliman, MD, a consultant surgeon of the Florida Hospital Cancer Institute and the UF Health Cancer Center, in Gainesville, told OR Management News that although aerosolized SARS-CoV-2 has not yet been isolated in cauterized tissue or surgical smoke, the virus has been detected in peritoneal fluid. Using appropriate protection therefore is imperative until proven otherwise. “There’s no doubt that COVID-19 [virus] has been detected in ascites, which is a big deal,” Dr. Soliman said. “A lot of this remains speculative, but for minimally invasive surgery, you have to maintain a closed circuit with proper filtrations. If you don’t have proper filtration, then you are putting people theoretically at risk.” That does not mean minimally invasive surgery is more hazardous than traditional surgery amid the current crisis. In fact, because the operations are performed within a confined space, minimally invasive surgery may be the safer option if surgery cannot be delayed, according to Dr. Soliman. “When a closed circuit is maintained within the intraabdominal environment, there is a chamber in which all the smoke is contained, and there are only a few points of exit called the trocar sites,” Dr. Soliman explained. “If the surgical team controls smoke evacuation, minimally invasive surgery may be the way to go.” Although it may have taken surgeons a long time to recognize and acknowledge the risks associated with surgical smoke, the pandemic is finally giving the issue the attention it deserves, according to Dr. Soliman. continued on page 6
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Consulting Physicians Can Have Clinical, Financial Drawbacks Research Shows Longer Length of Stay, Greater Mortality, and Higher Cost in Surgical Patients By MONICA J. SMITH
A
s the population of surgical patients with complex comorbidities continues to grow, so does the practice of involving consulting physicians in their care. While the use of consultants may be beneficial in some areas, there could be clinical and financial downsides, according to new research. The study, presented at the 2020 Southeastern Surgical Congress (abstract 13), found the use of consulting physicians was associated with longer length of stay, higher readmission rates, greater in-hospital mortality and higher cost. “We had noted that nonsurgeon physicians often are used as consultants in the care of surgical patients,” said Elliott Toy, MD, a surgical resident with AdventHealth in Orlando, Fla. “As care is coordinated among these consultants, patients frequently experience delays in the progression of their care, often waiting for input from a consultant regarding elements of care surgeons could easily manage.” Evaluations of the effect of consultants on surgical patients tend to be limited and
based on low-quality data, Dr. Toy said, noting that many of these studies report conflicting results on the impact of several important outcomes; there are even less data about patient satisfaction. “Patients often ask, ‘Are you my doctor?,’ which we believe is a surrogate for, ‘Are you the doctor in charge of my care?’ It seems to be a common theme that patients are often not sure who their doctor is.” Hypothesizing that nonsurgical physicians managing surgical patients might overuse consulting physicians with negative effect, researchers at AdventHealth, led by Sebastian G. de la Fuente, MD, a surgical oncologist and the program director of the advanced upper GI surgery fellowship, looked at LOS, in-hospital mortality, 30-day readmission rates, and costs and contribution margins. The study included 11,274 patients aged 18 years and older (mean age, 51.4 years) undergoing more than 90 elective and emergent surgical procedures ranging from cholecystectomy to total pancreatectomy. The patients were hospitalized for at least 24 hours; the
Surgical Smoke continued from page 4
“Surgical smoke is one of those things that surgeons, myself included, have been completely blind to,” he noted. “I didn’t even consider it, truthfully. It wasn’t until COVID-19 that we actually started doing more research, discussing the issue, and being more thoughtful about the problem.” Now, Dr. Soliman and his colleagues are taking all the necessary precautions. “The days of casually walking into an OR as a buddy of mine is operating and chatting with a mask on are gone,” he concluded. “Until we have better data and more robust clinical trials looking at this, I think we need to proceed with maximal caution as opposed to ignorance.” ■ 6
OR Management News • Fall 2020
average LOS was six days; and the readmission rate was 11.6%. An average of 2.5 consultants were involved in each patient’s care, at a cost of more than $1,300 per consultant; the most common consultants were gastroenterologists, infectious disease specialists and pulmonologists. For each consulting physician used, the total and variable cost per case increased by $1,347 and $592, respectively. “We also saw a decrease in the contribution margin per consultant by $350,” Dr. Toy said. “In addition, we noticed a significant increase in the odds ratio of in-hospital mortality rates and readmissions, at 3% and 5%, respectively, and an increase in LOS by 0.7 days per consult, which demonstrates the delays in care we anecdotally observed for these patients,” he said. The authors acknowledged that they could not detect the specific charges incurred as professional fees per consultant or the charges generated by the resources used by consultants, but stand by their conviction that consultants be used as judiciously as possible. “Surgeons should relinquish the care of surgical patients to nonsurgeons only in exceptional circumstances,” Dr. Toy said. ■
References 1. Hills DS, O’Neill JK, Powell RJ. Surgical smoke a health hazard in the operating theatre: a study to quantify exposure and a survey of the use of smoke extractor systems in UK plastic surgery units. J Plast Reconstr Aesthet Surg. 2012;65(7):911-916. 2. Ball K. Compliance with surgical smoke evacuation guidelines: implications for practice. ORNAC J. 2012;30(1):14-16, 18-19, 35-37. 3. Liu Y, Song Y, Hu X, et al. Awareness of surgical smoke hazards and enhancement of surgical smoke prevention among the gynecologists. J Cancer. 2019;10(12):2788-2799. 4. Steege AL, Boiano JM, Sweeney MH. Secondhand smoke in the operating room? Precautionary practices lacking for surgical smoke. Am J Ind Med. 2016;59(11):1020-1031. 5. Pennock J. When the smoke clears: advocating for surgical smoke evacuation policy. 2020 Virtual AORN Global Surgical Conference & Expo.
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Novel Technique Could Minimize COVID-19 Risk During Tracheostomy By NAVEED SALEH, MD, MS
S
urgeons at Berkshire Medical Center developed a novel barrier to potentially decrease the risk for COVID-19 transmission during tracheostomy. Details were published in a recent issue of the Journal of American College of Surgeons (2020; 230[6]:1102-1104). “In addition to all the PPE gear, we wanted to create a means to contain COVID-19 as much as possible to minimize exposure,” said Michael DiSiena, DO, the lead author and a surgeon at Berkshire Medical Center, in Pittsfield, Mass. Dr. DiSiena said the technique is functional and easy to assemble, and it could be useful for other operations that entail aerosolization risk or droplet exposure to OR personnel. “We used a table retractor, a device called the Omni-Tract [Integra Lifesciences],” he said. “It allowed us to create a frame, … a plastic barrier similar to a tent, that allowed us to minimize respiratory secretions from being expelled from the trachea when you perform the tracheostomy. “If the patient has COVID-19 and you perform a tracheostomy, a gush of air is released, and that air can obviously contain respiratory droplets and viruses,” Dr. DiSiena said. “So, we developed almost a sterile tent that allowed us to see through the clear plastic drape, which is sterile. We could put our hands underneath this tent and work in an operative field.” To further minimize the risk for contamination due to aerosolization, the team used a novel filtration system. “We then used a suction apparatus that allowed us to evacuate the air so it would be filtered almost like an N95 mask filter system,” Dr. DiSiena added. The team also used a simple, yet novel method for testing this filtration system. While testing the air to detect respiratory droplets was outside the capabilities of their institution, the team lit a cigarette and had a smoker on staff take a puff in the field to test whether the smoke cleared. “We could not detect the cigarette smoke,” Dr. DiSiena said. Nevertheless, Dr. DiSiena readily acknowledges that the technique lacks experimental validation. “We do not have any experimental data to prove the efficacy of it, but intuitively it seems to work out well,” he said. “Whether it ultimately translates into decreased exposure, I am unsure.”
Immediate Potential, Immediate Need To date, the staff at Berkshire Medical Center has employed the novel tracheostomy technique on two COVID-19 patients with positive outcomes. Dr. DiSiena also explained that the intervention requires approximately five to eight minutes of setup, and it did not render surgery unsafe in any way. Looking forward, Dr. DiSiena anticipates that other surgeons and anesthesiologists could adopt the technique for improved 8
OR Management News • Fall 2020
‘If the patient has COVID-19 and you perform a tracheostomy, a gush of air is released, and that air can obviously contain respiratory droplets and viruses. So, we developed almost a sterile tent that allowed us to see through the clear plastic drape, which is sterile.’ —Michael DiSiena, DO
safety. “We felt we came up with a great idea. We wanted to promote this technique as soon as possible given the crisis, and allow others to adapt to the technique, modify or improve upon it.” He also hopes that industry could use the idea to develop a commercial product with greater applicability. In a separate interview, Jingping Wang, MD, PhD, an associate professor in the Department of Anesthesia, Critical Care and Pain Medicine at Massachusetts General Hospital, in Boston, provided his perspective. “This instrument can be used as a physical shield, like wearing a mask. But we don’t know whether it functions like a surgical mask or N95 mask,” he said. “It may or may not be a source of control for aerosols, unless supported by a validation test. Ideally, a device should be developed to function as not only a physical barrier but also a source of control for aerosol transmission, without interrupting surgery,” Dr. Wang said. We need better-designed devices to meet our clinical demands, not only in the OR but also in the ICU, ED, on the floor and during patient transportation.” ■
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IV Vitamin C, Ozone Shown Effective Against COVID-19 By BOB KRONEMYER
I
ntravenous vitamin C and intravenous ozone are two simple, synergistic and low-cost adjuvant therapies that have been found to be effective for managing COVID-19 in patients who have just been hospitalized, according to an article in Revista Espanola de Anestesiologia y Reanimacion (2020 Apr 14. [Epub ahead of print]. S0034-9356(20)30075X). There are virtually no side effects with this approach. “Vitamin C has a long track record,” said co-author Peter Papadakos, MD, FCCM, FAARC, the director of critical care medicine at the University of Rochester Medical Center and a professor of anesthesiology, surgery, neurosurgery and neurology at the University of Rochester, in New York. As an example, he and his colleagues have been using vitamin C for its anti-inflammatory effects and for fluid modulating purposes in severe burn patients for many years. Others have used vitamin C to treat sepsis and acute respiratory distress syndrome. “With the global pandemic of COVID19, we thought vitamin C would be an ideal agent to use in these patients,” Dr. Papadakos said. “Vitamin C has immunomodulating activity and reduces alveolar epithelial water in burns. It also has a very good safety profile.” For IV administration of vitamin C, Dr. Papadakos recommended doses typically ranging from 0.2 to 0.5 g/kg, whereas central venous access is preferred for very high doses, sometimes over 50 g/kg (Table 1). Other components are added to the IV solution, if possible: zinc sulfate (200 mg over 24 hours), thiamine (400 mg daily), vitamin D (5,000-10,000 IU over 24 hours), and vitamin E (1,600 IU over 48 hours). “All of these elements have been shown to be helpful,” Dr. Papadakos said. Treatment can also be supplemented with calcium and magnesium by IV, if necessary.
disrupts viral proteins, lipoproteins, lipids and glycolipids in the actual virus. As a result, ozone creates a dysfunctional virus, which cannot replicate.” Ozone therapy also affects certain coagulation parameters. To prepare ozone for IV, the patient’s blood is saturated with ozone from a medically approved ozone Peter Papadakos, machine, then the patient’s MD, FCCM, FAARC
blood containing the ozone molecule is infused into the patient (Table 2). Peripheral venous access is favored, using a butterfly infusion set or cannula. The ozone/ oxygen mixture is adjusted to a 1:1 ratio, with a starting dose of 25 mcg/mL of blood, followed in subsequent days by up to 80 mcg/mL. continued on page 12
Table 1. Protocol for IV Vitamin C Administration for COVID-19 Infection • Central venous access preferable for very high doses (>50 g) • Check: blood count, renal function,1 electrolytes and G6PD • Check IL-6; ferritin levels may be a useful indicator of therapeutic response and prognosis • Use sterile water, PlasmaLyte or Lactated Ringer’s for mixture, or dextrose 5%-10% • Doses: 0.2-0.5 g/kg vitamin C2 • Administer daily until improvement, then every 2 days • Infusion rate: adjust for 0.25-0.5 g/min (usually 1 to 4 h according to dose) • Supplement with calcium and/or magnesium IV, if necessary • If possible add zinc sulfate 220 mg/24 h,3 thiamine 400 mg/d, vitamin D 5,000-10,000 IU/24 h,4 vitamin E 1600 IU/48 h oral/NG, melatonin 6 mg/24 h oral at night 1
Caution with doses and frequency of administration.
2
If patient is in critical condition, suggest dose administration twice a day (every 12 hours).
3
220 mg of zinc sulfate contains 50 mg of elemental zinc.
4
Aim for 25(OH) level of 80-90 nmol/L.
Table 2. Ozone Autohemotherapy Protocol For COVID-19 Infection • Exclusive venous access for ozone administration. Peripheral venous access is preferable on the ward; use a central line for ICU patients • Blood removal: 150-200 mL • Anticoagulant to add in the sterile bottle or bag: - Heparin sodium: 1,000 IU for each 100 mL of blood removed; or - Sodium citrate 3.13%: 10 mL for each 100 mL of blood removed; or - ACD-A (Anticoagulant Citrate Dextrose A): 14 mL for each 100 mL blood removed • Initial dose: 40 mcg/mL of ozone. Increasing dose is acceptable in ensuing days to a maximum of 70 mcg/mL • Volume of gas O2/O3 200 mL
Ozone Disrupts Coronavirus
• Shake the bottle gently once ozone is mixed with the blood and every 2 minutes during administration
As a treatment, ozone attacks the envelope of coronaviruses, according to Dr. Papadakos. “By affecting cysteine, ozone
• 2 sessions per day in non-critically ill patients and 4 sessions per day in critically ill patients until improvement
10
OR Management News • Fall 2020
EVIDENCE-BASED MEDICINE
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A Data-Driven, Evidence-Based Methodology for Achieving Best Practices in Blood Management and Hemostatic Resource Utilization in Surgery
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Key Steps for Infection Prevention In Ambulatory Surgery Centers this template along with their potential impact (health, financial, legal and regulatory). The template should also assess preparedness (good, fair or poor).
By CHASE DOYLE
T
he global coronavirus pandemic has spotlighted the need for infection prevention programs that minimize communicable diseases while providing functional environments for surgical services. At the 2020 Association of periOperative Registered Nurses Virtual Global Surgical Conference, Terri Link, MPH, BSN, CNOR, discussed the Centers for Medicare & Medicaid Services requirements for ambulatory surgery centers, including proper risk assessment, prioritizing infection risks and using outcomes for internal benchmarking. According to Ms. Link, an ambulatory education specialist at AORN, because infection rates may differ for each facility, surveillance is needed to determine where efforts should be concentrated during risk assessment. This can be accomplished by checking laboratory results, sending out emails to physicians, and performing chart reviews to produce baseline and endemic rates of infection.
➍
Identify risks, problems and concerns based on your facility’s characteristics. These issues may be classified as patient care risks, health care personnel risks, environmental risks, sitespecific risks and emergency management.
➎
List a description of the risk as part of the risk assessment tool (e.g., safe injection practices, environmental cleaning, new procedure). For new procedures, surveillance should be used to establish a benchmark. “It’s very important to have a standardized, objective way of prioritizing risks,” Ms. Link said, who added that construction projects should also be part of risk assessment. “A construction risk assessment tool should be used in determining how patients and staff will be protected from harm due to air contaminants from construction, such as Aspergillus.”
➏
Prioritize by score those risks that will be part of your plan. Establish baseline data from an internal benchmark or a national benchmark, and identify regulatory requirements that must be included in an infection prevention plan. “It’s really important to limit your scope at first because you can’t do everything,” Ms. Link said. “Prioritize according to regulatory requirements and then the highest score and highest impact.”
➐
Choose goals and measurable objectives. Once risks have been prioritized, select three or four major goals to start with (e.g., improve hand hygiene or decrease an antibiotic-resistant infection). The outcome must be a measurable objective to assess the program’s effectiveness, said Ms. Link, who noted that having some “quick fixes” is a good place to start. ■
Step-By-Step Guide As Ms. Link reported, once this information is obtained, developing an infection control program based on a risk assessment requires several steps:
➊
Form an infection prevention committee composed of an interdisciplinary team of nurses (pre- and postoperative), physicians, scrub personnel, environmental service, sterile processing and front desk.
➋
List services provided by your facility (e.g., number of rooms, specialties, number of surgeons, staff, hours open). Agreements with referring hospitals, patient population analysis, risk for natural disasters, role in emergency preparedness in the community and underlying endemics should also be taken into consideration.
➌
Find a template or develop your own. Potential risks/problems and the likelihood they may occur should be included on
IV Vitamin C continued from page 10
The combination IV therapy begins with vitamin C at an intermittent infusion time of usually one to four hours, depending on the dose, followed by one to four hours of ozone, and then repeating the protocol over a few days. “Because many COVID-19 patients require intubation, anything we can do to prevent intubation will greatly lessen the 12
OR Management News • Fall 2020
‘Anything we can do to try to decrease that initial inflammatory response and prevent the patient from being intubated in the first place helps not only the patient, but mitigates the surge as well.’ —Peter Papadakos, MD, FCCM, FAARC
health care burden,” Dr. Papadakos said. “Part of the surge that hospitals are experiencing is from patients being intubated, which leads to mechanical ventilation for 10 to 15 days. That ties up the technology. Thus, anything we can do to try to decrease that initial inflammatory response and prevent the patient from being intubated in the first place helps not only the patient, but mitigates the surge as well. Our proposed synergistic therapy allows COVID19 to become a more treatable disease.” ■
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LumCheck™ The LumCheck™ is designed as an independent check on the cleaning ƉĞƌĨŽƌŵĂŶĐĞ ŽĨ ƉƵůƐĞͲŇŽǁ ůƵŵĞŶ ǁĂƐŚĞƌƐ͘ ŵďĞĚĚĞĚ ŽŶ ƚŚĞ ƐƚĂŝŶůĞƐƐ ƐƚĞĞů ƉůĂƚĞ ŝƐ Ă ƐƉĞĐŝĂůůLJ ĨŽƌŵƵůĂƚĞĚ ďůŽŽĚ ƐŽŝů ǁŚŝĐŚ ŝŶĐůƵĚĞƐ ƚŚĞ ƚŽƵŐŚĞƐƚ ĐŽŵƉŽŶĞŶƚƐ ŽĨ ďůŽŽĚ ƚŽ ĐůĞĂŶ͘
FlexiCheck™ dŚŝƐ Ŭŝƚ ƐŝŵƵůĂƚĞƐ Ă ŇĞdžŝďůĞ ĞŶĚŽƐĐŽƉĞ ĐŚĂŶŶĞů ƚŽ ĐŚĂůůĞŶŐĞ ƚŚĞ ĐůĞĂŶŝŶŐ ĞĸĐŝĞŶĐLJ ŽĨ ĞŶĚŽƐĐŽƉĞ ǁĂƐŚĞƌƐ ǁŝƚŚ ĐŚĂŶŶĞů ŝƌƌŝŐĂƟŽŶ ĂƉƉĂƌĂƚƵƐ͘ ĐůĞĂƌ ŇĞdžŝďůĞ ƚƵďĞ ŝƐ ĂƩĂĐŚĞĚ ƚŽ Ă ůƵŵĞŶ ĚĞǀŝĐĞ ǁŝƚŚ Ă ƚĞƐƚ ĐŽƵƉŽŶ ƉůĂĐĞĚ ŝŶƐŝĚĞ͖ ƚŚĞ ĞŶƟƌĞ ĚĞǀŝĐĞ ŝƐ ŚŽŽŬĞĚ ƵƉ ƚŽ ƚŚĞ ŝƌƌŝŐĂƟŽŶ ƉŽƌƚ ŽĨ ƚŚĞ ĞŶĚŽƐĐŽƉĞ ǁĂƐŚĞƌ͘
HemoCheck™/ProChek-II™ 'Ž ďĞLJŽŶĚ ǁŚĂƚ LJŽƵ ĐĂŶ ƐĞĞ ǁŝƚŚ ĂůůͲŝŶͲŽŶĞ ĚĞƚĞĐƟŽŶ ŬŝƚƐ ĨŽƌ ďůŽŽĚ Žƌ ƉƌŽƚĞŝŶ ƌĞƐŝĚƵĞ͘ ,ĞŵŽ ŚĞĐŬΡ ŝƐ ƐŝŵƉůĞ ƚŽ ŝŶƚĞƌƉƌĞƚ ĂŶĚ ŝŶĚŝĐĂƚĞƐ ďůŽŽĚ ƌĞƐŝĚƵĞ ĚŽǁŶ ƚŽ Ϭ͘ϭʅŐ͘ dŚĞ WƌŽ ŚĞŬͲ//Ρ ŵĞĂƐƵƌĞƐ ĨŽƌ ƌĞƐŝĚƵĂů ƉƌŽƚĞŝŶ ŽŶ ƐƵƌĨĂĐĞƐ ĚŽǁŶ ƚŽ Ϭ͘ϭʅŐ͘
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FE ATURE
Pandemic Puts Pressure on Innovators to Speed Up AI, ‘Smart’ PPE and Other Medical Tools By ALISON McCOOK
S
omething was happening. Nearly 20 years ago, David Bray, PhD, was working as the information technology chief for the CDC’s Bioterrorism Preparedness and Response Program, when he noticed a strange anomaly: In China, the price of garlic had risen nearly 10-fold. Since garlic is considered medicinal by many people in China, Dr. Bray and his team knew something had to be amiss. Working with people on the ground, they learned the country was experiencing a wave of an atypical febrile illness. Months later, China revealed it had been struck by a new coronavirus, SARS-CoV-1, also known as severe acute respiratory syndrome (SARS). “We knew about it five and a half months before the Chinese government said anything,” Dr. Bray said. Today, as the world reels from the effects of another novel coronavirus, SARS-CoV-2 (COVID19), Dr. Bray has been tracking innovations that rely on more than just garlic prices to quickly spot outbreaks, such as low-cost tools that analyze viral levels in wastewater. Other exciting developments that could help protect from and prevent future pandemics include medical devices that use artificial intelligence to guide treatment decisions and “smart” personal protective equipment (PPE). The possibilities are endless, said Dr. Bray, now the director of the Atlantic Council GeoTech Center, a think tank based in Washington, D.C. The pandemic is forcing innovators to work hard – and quickly, Dr. Bray said. Most of the new ideas he encounters are one to three years away, “if not already here,” he told OR Management News. “Things will change. We won’t go back to ‘normal.’”
New Ideas for a New World To get a sense of what’s happening, the Atlantic Council recently surveyed more than 100 technology experts regarding their predictions of the effect of COVID-19 on innovation. Not surprisingly, respondents agreed that the pandemic will significantly accelerate innovation in data and AI, as well as the medical and bioengineering fields (Figure). Examples already abound. Recently, M-Sparc, a science park in Wales, held a “Hack COVID-19” event, 14
OR Management News • Fall 2020
in which it challenged innovators to find new w ways to help patients; one winner developed d a microphone that lets surgeons and otherr health care workers hear better when wearingg ee FFP3 masks. Another creation was a hands-free door opener for hospital settings, which the designer has made free to anyone with a 3D printer. And when it comes to PPE, the future is smart—smart garments specifically, which David Bray, PhD transmit information about the environment or the clothing itself. Such clothing may adjust the temperature in response to outward conditions, emit light in the dark, or even alert wearers of environmental dangers. Further, smart shoes could alert workers when someone is approaching, so they can don a mask.
FEAT URE
AI to the Rescue There is no end to what computer learning can do to help during a pandemic: AI can sift through the mass of research pouring in about COVID-19 and identify promising areas to pursue, accelerate the discovery of therapies that block the virus, identify early warning signs of new outbreaks, and provide insight about when it’s safe to return to work and school. Other benefits include identifying new risk factors for severe disease, such as genetic markers or blood types, which can guide resource distribution, said Stewart Scott, a program assistant with Atlantic. One such device that uses AI to monitor patients—including, most recently, those diagnosed with COVID-19—is Emerald, a wireless system developed by a team led by Dina Katabi, PhD, the Andrew and Erna Viterbi Professor of Electrical Engineering and Computer Science at Massachusetts Institute of Technology, in Cambridge. The device passively monitors patients’ vital signs, activity, sleep quality/stages and respiration, and then transmits that information to their health care providers. It does so by analyzing the wireless signals in the room without any physical contact with the patient’s body. Since it’s already been tested in a variety of diseases such
(Accelerate)
10.0 8.0 6.0 Average Rate
Other innovators are focusing on improving the materials themselves, such as Canadian company Texavie, which is developing PPE with interwoven antiviral and antibacterial biocides for superior protection. Protection works best when it has a personalized fit, said Dr. Bray, so future garments may scan or use photos to produce something on demand that’s tailored to the specific wearer. Some COVID-19–inspired innovations involve tweaks to existing tools to fit the needs of a new world. For instance, the “smart mirror” Miaza Mirror—meant to display email and news—now plays an animated video about proper handwashing. Makers of the Ava bracelet are claiming it can both track ovulation and alert users to the early signs of COVID-19 via changes in breathing rate, pulse rate and skin temperature. Drones are being used to broadcast public health messages about social distancing, as well as monitor fevers and spray streets with sanitizers. One company that Atlantic has partnered with, Valence Medical, is tackling supply chain logjams, such as when pandemichit nations scramble for PPE and other supplies. The technology would create a virtual middleman that links reliable suppliers to reliable buyers, sorts out fair pricing, and facilitates the monetary transaction. Another Atlantic partner is applying computer vision to the manufacturing process, to ensure that items produced from different manufacturers have similar quality. The technology was originally expected in 10 to 15 years, but the pandemic has significantly accelerated the time line, Dr. Bray noted.
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Q1.Future of Work
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Figure. Technology experts’ predictions on how COVID-19 will affect tech and innovation efforts.
as Alzheimer’s and Parkinson’s (Digit Biomark 2019;3:22-30), “when COVID-19 became the problem, the Emerald was just a natural fit,” Dr. Katabi told OR Management News. The company Dr. Katabi co-founded is now collaborating with Mayo Clinic, McLean Hospital and Washington University School of Medicine in St. Louis. “By having these records of the evolution of symptoms of different patients, one could develop machine learning models to predict the risk that a particular patient may experience a difficult recovery journey,” she said. “Retrospective analysis of this data along with patients’ medical history could be useful in guiding hospital admission and discharge decisions.”
There is no end to what computer learning can do to help during a pandemic: AI can sift through the mass of research pouring in about COVID-19 and identify promising areas to pursue, accelerate the discovery of therapies that block the virus, identify early warning signs of new outbreaks, and provide insight about when it’s safe to return to work and school. Necessity is the mother of invention, and right now, COVID19 has created the need for tools to treat the current pandemic and mitigate the effects of future outbreaks, Dr. Bray said. The situation reminds him of how the risk from house fires prompted innovators to design a system to warn occupants before it was too late. “Can we instrument the planet in such a way that we’ll have earlier warning signs about new viruses and infections, analogous to smoke detectors?” ■ Disclosures: Dr. Katabi co-founded the company behind the Emerald device. The Atlantic Council GeoTech Center is partnered with two companies in the medical industry; one is Nanotronics and another is SICPA, a Swiss company involved with the economy of trust in medical supply chains. OR Management News • Fall 2020
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C LIN IC A L NE WS
Most Incisional Hernia Readmissions Occur After 30 Days Scale of Untracked Complications Potentially Enormous; Investigators Recommend Extending Post-Discharge Tracking Period By CHRISTINA FRANGOU
O
ne of every five patients who underwent an incisional hernia repair in the United States was readmitted to the hospital within a year, with most readmissions occurring after the 30-day benchmark commonly used to track health care utilization, according to a new study of hospital admissions between 2010 and 2014. Additionally, one-fourth of readmitted patients did not return to the same hospital where they were operated on, making their complications and readmissions even harder to track in most databases. The analysis, published in the Journal of Surgical Research (2020;255:267-276), indicates many patients who are readmitted with complications following incisional hernia repair are overlooked, leading to consistent underreporting of complications. “Patients, and some clinicians, may not be aware of how prevalent readmissions are after incisional hernia repair and that most readmissions are related to postoperative complications,” said study author Arturo J. Rios-Diaz, a fourth-year general surgery resident at Thomas Jefferson University, in Philadelphia. Many of the readmitted patients required substantial treatment. One-third of them underwent a subsequent major procedure during their return stay and 4.1% experienced a recurrence requiring an inpatient revision of their repair. The study confirmed what some surgeons and patients have long suspected: Many complications and events related to quality of care in hernia, especially ventral hernia, occur well beyond the 30-day postoperative time point, said Benjamin Poulose, MD, a professor of surgery at The Ohio State University, in Columbus. This is especially important given that surgeons implant meshes in patients, expecting them to stay in place for years. “This should be another wake-up call—not only to hernia surgeons, but also to hospitals, payors and those funding quality improvement and research efforts,” Dr. Poulose said. With more than 350,000 incisional hernia repairs performed in the United States annually, the scale of overlooked complications is potentially enormous, with tens of thousands of patients requiring readmission for infections more than 30 days after surgery. There is too little understanding in the field about why, how and in whom complications are occurring long term, and these uncertainties are driving massive legal actions in hernia repair, Dr. Poulose said. “We, as surgeons, can no longer just accept the status quo.” Surgeons should follow their patients long term and develop targeted strategies to reduce complications, including appropriate
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OR Management News • Fall 2020
patient selection, prehabilitation when needed, and good surgical judgment during the performance of the procedure, he said. The researchers used the Nationwide Readmissions Database to study readmission rates of patients who underwent elective incisional hernia repair between 2010 and 2014. In that period, 15,935 patients underwent incisional hernia repair and 19.35% were readmitted within one year. Only 39.3% of readmissions happened in the first 30 days after surgery. Complications were the leading cause of readmission, accounting for 50%, with half of them due to infectious complications. Of all patients readmitted for infection, 91.8% were initially discharged within a record to indicate infection. Readmission for bowel obstruction was found in 5% of patients, which is higher than previously reported rates and may be explained by the broad definition used by investigators. Reoperations were performed in 35% of readmitted patients and 5% had revisions to their repair. The results highlight the need for national policies that require physicians to follow patients and collect data beyond 30 days, the investigators said. Most data on health care utilization after incisional hernia repair are only carried out to 30 days after surgery and are not nationally representative. Dr. Rios-Diaz and his colleagues believe the readmission benchmark for incisional hernia repair should be extended to at least 60 days in the Centers for Medicare & Medicaid Services’ Hospital Readmissions Reductions Program, which reduces reimbursement by up to 3% to hospitals with excessive readmissions within 30 days of discharge. The investigators estimate that the annual cost of unplanned readmissions totaled more than $90 million per year. After controlling for confounders, the predicted mean difference in cumulative costs and length of stay (index admission plus readmissions) were $12,189.70 higher and 6.1 days longer for patients readmitted within one year. Generally, patients were between the ages of 45 and 65 years (49.1%) and most were female (58.8%), nondiabetic (80.81%) and not obese (77.54%). One-fourth of the initial hernia repairs were done laparoscopically and mesh was used in 88% of cases. Readmitted patients did not differ in age, sex, income quarter, ■ obesity and hospital characteristics.
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CLIN IC A L NE WS
Are the Towels in Your Hospital Really Clean? Investigators Find Dangerous Microbes By ALISON McCOOK
C
lean towels are clean, right? Several years ago, a group of investigators set out to answer that question. They collected three cleaned towels from 10 Arizona hospitals, submerging each towel in buffered peptone water to extract microbes. They wrung out each towel, collected the broth and examined it for signs of potentially dangerous microbes. The investigators found them. More than 90% of the towels contained viable microbes, including 3% with the potentially dangerous bacteria Escherichia coli. Furthermore, more than half of the buckets used to soak towels in disinfectants—the very containers designed to clean the towels—harbored viable bacteria, including those that form spores (Am J Infect Control 2013;41[10]:912-915). The results are among a body of research that points to a troubling trend: The products used to clean medical facilities may be contributing to their contamination. Now, researchers are asking themselves how to do a better job of cleaning hospital cleaning products.
‘We’re cleaning up after people, and people leave behind a lot of stuff—everything from small bits of human skin and hair to bacteria, fungi and viruses ... In some cases, the contamination level was too high to count with the traditional and molecular methods we were using.’ —K. Mark Wiencek, PhD In the 2013 study, the researchers examined reusable cloths made of cotton and of microfiber, common materials used in cleaning products. Both were contaminated. Roughly 10 years ago, microfibers came onto the market, promising to do a better job of picking up soil and weighing less than cotton, the typical material of cleaning products such as mops and rags (Am J Infect Control 2007;35[9]:569-573).
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Since then, hospitals rapidly added them to their roster of cleaning products. But then they came across a dilemma: The laundry techniques that kill microbes—bleach and hot water— also destroy the delicate microfibers. The gentle cleaning process that microfibers need doesn’t always destroy the contamination on the surface of used cleaning products. Now that the world is dealing with an ongoing COVID-19 pandemic, adopting the best products and practices for cleaning has become even more crucial. The situation has left facilities scrambling for solutions. “We’re finding lots of contamination in the very tools we are using to clean,” said K. Mark Wiencek, PhD, the lead microbiologist at Contec, Inc., a company headquartered in Spartanburg, S.C., that manufactures cleaning supplies. “As a result, we are faced with this conundrum of how to properly decontaminate these towels and mops without destroying the textile.”
A Fine Mess A microfiber mop that’s been used to clean a hospital floor is, simply put, pretty gross. “We’re cleaning up after people, and people leave behind a lot of stuff—everything from small bits of human skin and hair to bacteria, fungi and viruses,” Dr. Wiencek said. He and his colleagues have repeated the 2013 experiment, testing mops and towels from hospitals after laundering. “In some cases, the contamination level was too high to count with the traditional and molecular methods we were using,” he said. Microfiber initially works better than cotton, but after multiple washes and if laundered improperly microfiber may not perform as well (Am J Infect Control 2010;38[4]:289-292), noted Karen deKay, MSN, RN, CNOR, CIC, a perioperative practice specialist at the Association of periOperative Registered Nurses. Most facilities likely use a variety of materials to clean between patients, she said. In the perioperative environment, for instance, most places employ single-use disinfectant cloths made of continued on page 22
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PE RSP ECTIVE
Value Over Volume
Reimagining Health Care Through The Lens of Systems Science By BRUCE RAMSHAW, MD B
predictable because our health care system is designed around financial growth rather than patient care. Our health care system, particularly hospitals and academic medical centers, may be in the most complex of all industries and organizations in our world. But these organizations are designed in a reductionist system structure that leads to increased fragmentation when complexity is increased. The current reductionist organizational structure in health care evolved with no attention to the vast diversity of patient populations and increasing complexity of problems that are seen in a typical medical center. The result is more fragmentation manifested by an everincreasing number of department silos that are not designed around each definable patient care process. It would be like a car manufacturing plant that functioned in department silos: one department for tires, one for engines, one for steering wheels, etc.
W
hen the parts of our health care system are motivated by volume and revenue growth, the result of the whole system is represented in the figure (below). Every country in the developed world has an unsustainable slope of increasing per capita spending on health care. Each part of the system is successfully hitting revenue and growth targets, guaranteeing the unsustainability of the system as a whole. If private insurers raise rates and decrease benefits each year, hospitals continue to increase revenue and volume, physicians continue to hit increasing relative value unit targets, and pharmaceutical and device companies continue to hit increasing quarterly Wall Street revenue targets, what else do you think would happen at the whole system level? An unsustainable increase in global per capita spending is
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Figure. Average spending per capita by country, adjusted for the cost of living. Source: Organisation of Economic Cooperation and Development Health Data, June 2011
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OR Management News • Fall 2020
These department silos would not communicate well with each other, yet they would be expected to make flawless automobiles. The first automobile on the manufacturing line is intended to be a sports car; the next is a school bus, the next is a tow truck, the next is an SUV, and so on. It would be a disaster. By continuing to address increasing complexity with reductionist structural solutions, the harm and waste we see in health care are guaranteed. This fragmentation also leads to system tools being designed inappropriately into the fragments of care rather than for whole patient care processes. For example, electronic health record systems are designed for the fragments of care, primarily with the purpose of documentation for coding and billing. By only collecting data for a fragment of care, it’s not possible to measure the outcomes for any whole patient process. This prohibits the appropriate measurement of value-based outcomes and the appropriate analysis that could be applied to learn how to better measure and improve outcomes. So, if volume is an unsustainable strategy, what is a sustainable strategy? Value. The language about the transformation of health care from volume to value is all over the place. But the understanding of how to do this and the science behind why we should do this are still not well understood. Sadly, no hospital that I know of has made this transition yet. For the good of our patients and our physicians and clinical teams, this transition is essential. The continued focus on volume (an extrinsic continued on page 22
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OR Management News •Fall 2020 21
Dirty Towels continued from page 18
polyester to clean and disinfect the surfaces after each patient. At the end of the day, a facility will do a “complete clean” using disposable cotton or microfiber cloths, Ms. deKay said. The mops, too, could consist of cotton mop heads, or reusable and/or single-use microfiber. Dr. Wiencek agreed that most hospitals still use laundered products, but more facilities are adding disposable products to their supply closet. The use of disposable cleaning products “has really exploded in the last five years,” he said. Unfortunately, some evidence indicates that contamination of cleaning products is causing infections. More than a decade ago, researchers in Japan linked five cases of infection by spore-forming Bacillus cereus bacteria to reused towels that had been dried and steamed (J Hosp Infect 2008;69[4]:361-367). In 2015, six immunosuppressed patients developed infections from a sporeforming mold, Rhizopus microsporus, by inhaling and touching contaminated linens supplied by a designated laundry (Clin Infect Dis 2016;62[6]:714-721). A 2015 literature review uncovered 12 outbreaks of infectious diseases associated with laundered health care textiles over the previous four decades (Infect Control Hosp Epidemiol 2015;36[9]:1073-1088). These reports might only scratch the surface, according to Ms. deKay, who said other cases of infections related to laundered cleaning products likely haven’t been documented.
a solution, Dr. Wiencek said. As a natural fiber, cotton can biodegrade; that’s good for the environment, but not for the sterile hospital room, where fibers break apart and cause lint. Some facilities also may want to consider including more disposable products with their cleaning materials, Dr. Wiencek said. Cost could become an issue, as facilities would have to replace each mop pad after every use. But single-use pads are lighter and less expensive than reusable pads, which may not be effective after hundreds of washes. Plus “laundry isn’t free,” he added. “Cost is part of the story, but organizations have to look into their laundry contract to figure out how much they’re paying per use of the product.” So how can facilities clean microfiber materials properly? The best advice, Ms. deKay said, is to follow the manufacturer’s instructions. Even if the instructions eschew bleach and high heat, the laundry industry’s bug-killers of choice, “instructions from the manufacturers have been validated to show they will get rid of organisms,” she said. Another tip: Separate microfiber cloths from mops because contamination can spread from one to the other. For now, no additional technology exists that can replace the physical action of rubbing a surface with a chemical disinfectant, but some facilities may want to consider adjunct technologies, Ms. deKay said. Among those, ultraviolet radiation and hydrogen peroxide mist can kill microorganisms and add another layer of protection, she said. However, they can be expensive and can’t do the job alone. “You can’t just use that technology without doing the cleaning, which is why it’s so important that we’re getting the cleaning materials clean.” ■
Let’s Clean It Up However, switching back to all-cotton towels and mops is not
Value Over Volume continued from page 20
motivator) instead of value (an intrinsic motivator) is having a significant negative impact on patients and the front-line clinicians who care for them.
Contec, Inc., sells disposable microfibers and other textiles.
of care—lowering costs while improving patient outcomes. Basically, our prime motivation comes from autonomy, having control over what we do and how we do it; mastery, getting good at what we enjoy doing; and purpose, having a goal in life that is bigger than just serving ourselves.
By incentivizing physicians with money for seeing more patients in clinic and doing more procedures and operations, we guarantee poorer outcomes than if intrinsic motivators were used. —Bruce Ramshaw, MD In his book “Drive: The Surprising Truth About What Motivates Us,” Daniel Pink presents a compelling argument based on decades of research about what motivates us as human beings and the differences between extrinsic motivators, like money for doing tasks, and intrinsic motivators, like improving the value 22
OR Management News • Fall 2020
One interesting thing about this body of research is that extrinsic motivators work well to incentivize people to improve the output of simple mechanical tasks, like hammering a nail. But these same extrinsic motivators, when used to incentivize people performing complex work, as in health care, lead to poorer performance.
These structural changes to allow the transformation of health care from volume to value will require a deep knowledge of systems science tools, including the appropriate application of data science, learning to lead and work in small teams, and developing an evolved mindset to allow this transformation to happen. This is our challenge, and our opportunity to transform to an economically sustainable global health care system. When will it happen? I don’t know. When will we have the courage to consciously reject the status quo and embrace the discomfort of change that unifies all parts of the system around value for the patient? Soon, I hope. ■
—Dr. Ramshaw is a surgeon and data scientist in Knoxville, Tenn., and a managing partner at CQ Insights. He is an editorial advisory board member of ORM. Visit his blog at: www.bruceramshaw.com/blog.
Fall 2020
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