Minnesota Physician • June 2020 by Minnesota Physician Publishing

MINNESOTA

JUNE 2020

PHYSICIAN

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Volume XXXIV, No. 03

Elective Surgery Defining what is “essential” BY JOLEEN HARRISON, RN, BSN, PHN, CASC

rior to Gov. Tim Walz’s May 5 Emergency Executive Order (EO) 20-51 to “open up” elective surgery procedures across the state, health care centers had struggled to interpret what had been temporarily banned as “elective” under his previous orders in early March. Those EOs had been intended to conserve supplies of personal protective equipment (PPE), respirators, and anesthesia equipment, and to ensure safety and adequate resources for both physicians and patients, but offered little specific information or guidance. The earlier orders produced confusion among providers—as well as concerns about potential government overreach in defining health care decisions.

When elective procedures aren’t elective Planning for future emergencies BY SCOTT R. KETOVER, MD, AGAF, FASGE

innesota has always set a high bar for innovation, quality outcomes, and delivery of health care, consistently ranking high among all the other states. Even so, the COVID-19 pandemic has provided policy leaders, public health officials, and the medical community with an opportunity to do better. On March 19, 2020, Minnesota Gov. Tim Walz signed Executive Order 20-09, which directed the delay of inpatient and outpatient elective surgery and procedural cases. Guidance was provided and included this language: When elective procedures aren’t elective to page 104

The Governor’s EO 20-51 acknowledged that “[n] on-essential or elective procedures are often clinically necessary, for example, to treat chronic pain and conditions or to prevent, cure, or slow the progression of diseases,” and noted that Minnesota had made significant headway in securing PPE, improving testing, and building hospital surge capacity. Citing guidance from public health officials, he ordered that surgical facilities could “reopen,” subject to six requirements (see https://tinyurl.com/mp-order-20-51).

Elective Surgery to page 124

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REQUEST FOR NOMINATION

Volume XXXIV, Number 3

COVER FEATURES When elective procedures aren’t elective Planning for future emergencies

By Scott R. Ketover, MD, AGAF, FASGE

Elective Surgery Defining what is “essential” By Joleen Harrison, RN, BSN, PHN, CASC

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L RS EA IN F L L T H U E N T I AA D E C A R E LE

Publication Date: November 2020

Nominate the 100 Most Influential Health Care Leaders In our November 2020 edition, Minnesota Physician will profile 100 of our state’s most influential health care leaders. In a format featuring photos, bios, and quotes, we will highlight the men and women most responsible for making Minnesota a global model for health care delivery.

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These individuals will represent every aspect of the industry: physicians,

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business executives, political leaders, policy analysts, etc.

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you know anyone within your organization you feel should be considered,

We invite you, our readers, to participate in this recognition process. If please fill out the form below and mail it or submit online (www.mppub.

Person-centered care environments

com/top100.html) or via e-mail (comments@mppub.com) prior to

New trends in assisted living facilities

September 25. We welcome your input and participation in making this

By Gaius Nelson, MA ARCHITECTURE........................................................................... 28

list as comprehensive and meaningful as possible.

COVID-19’s influence on facility design Considering patient and provider safety

I would like to nominate the following individual(s):

By Stacy L. Collins and Dave Moga, AIA

NEUROLOGY.............................................................................. 30 The coronovirus pandemic

Nominee’s name (please include all advanced degrees):

Assessing neurological complication

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By Irfan Altafullah, MD

Nominee’s affiliation:

HEALTH CARE ARCHITECTURE HONOR ROLL 2020

Brief description of the nominee’s work and influence:

Recognizing outstanding achievement in new facilities design ..... 18 By Richard Ericson

Nominator information (strictly confidential):

Name: Phone #:

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Mike Starnes, mstarnes@mppub.com

EDITOR___________________________________________________________Richard Ericson, rericson@mppub.com ART DIRECTOR______________________________________________________ Scotty Town, stown@mppub.com Minnesota Physician is published once a month by Minnesota Physician Publishing, Inc. Our address is PO Box 6674, Minneapolis, MN 55406; email comments@mppub.com; phone 612.728.8600;. We welcome the submission of manuscripts and letters for possible publication. All views and opinions expressed by authors of published articles are solely those of the authors and do not necessarily represent or express the views of Minnesota Physician Publishing, Inc. or this publication. The contents herein are believed accurate but are not intended to replace medical, legal, tax, business, or other professional advice and counsel. No part of the publication may be reprinted or reproduced without written permission of the publisher. Annual subscriptions (12 copies) are $48.00/ Individual copies are $5.00.

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State updates law on prior authorization A bill modifying the utilization review and prior authorization requirements used by Minnesota’s health insurance companies to medically manage health care benefits has been signed into law by Gov. Tim Walz. The revised Chapter 114 (https://tinyurl.com/hcn-chapter-114) follows passage of House File 3398, authored by Rep. Kelly Morrison, MD, and Senate File 3204, authored by Sen. Julie Rosen. Most sections of the new law are effective Jan. 1, 2021. Highlights: • Standard review authorizing decisions will be due within five business days for electronic submissions and six business days for paper submissions (previously 10 business days). Expedited review decisions will be due within 48 hours,

including at least one business day (previously 72 hours). Standard review determination on all requests for utilization review must be communicated to the provider and enrollee within five days for requests received electronically or within six days for requests received nonelectronically (previously 10 days). • Utilization review organizations will not be able to revoke or change a prior authorization, unless there is evidence that the prior authorization was authorized based on fraud or misinformation or a previously approved prior authorization conflicts with state or federal law. Application of a deductible, coinsurance, or other

Reports show continued disparities in health care

cost-sharing requirement does not constitute a limit, condition, or restriction. • The new law also requires the review to be done by a physician within the same or similar specialty; online posting of prior authorization criteria; a 45day notice of all new prior authorization requirements; a continuity of care of 60 days if the individual changes health plans; and an annual posting on the health plans’ public website of the number of prior authorizations that were authorized or denied. For a summary of the issues and recent legislative history, see “Prior authorization: We need a better law” by Sheldon Berkowitz, MD, FAAP in the April 2020 edition of Minnesota Physician: https://tinyurl.com/ mp-berkowitz.

MN Community Measurement (MNCM) has released two new reports highlighting disparities in health care quality in Minnesota. The reports examine disparities in quality measures for preventive care and care for chronic conditions such diabetes, heart disease, and depression. MNCM expressed concerns that disruptions to health care services and access will affect future health for groups that are already at risk for worse outcomes. “2019 Minnesota Health Care Disparities by Insurance Type” examines differences in nine quality indicators between patients covered by Minnesota Health Care Programs (MHCP) managed care plans and other types of health insurance. Although large gaps exist between quality measures for MHCP enrollees and other types of insurance,

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Ryan Ellis

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performance improved in 2019 for six of the nine measures included in the analysis. In addition, the gap between MCHP and other insurance types has narrowed over time for seven of the nine measures, but the report documents wide disparities by race and ethnicity within MHCP, especially for American Indian/Alaska Natives and for Black/African American MHCP enrollees. There is significant variation across health care providers in quality measures for MHCP enrollees. The report recognizes eight medical groups that achieved performance above the MHCP average on at least five of the nine measures included in the report: Allina Health, Essentia Health, Fairview Health Services, HealthEast Clinics, HealthPartners Clinics, Lakewood Health System, Mankato Clinic, and Park Nicollet Health Services. “Minnesota Health Care Disparities by Race, Ethnicity, Language and Country of Origin” analyzes disparities in quality measures for colorectal cancer screening, diabetes, vascular care, asthma, and depression. It includes summary information on separate components of the diabetes and vascular care measures, and more in-depth analysis within race/ethnicity/language/country of origin categories (for example, combinations of race and language or race and sex). Across all measures included in the report, American Indian/Alaska Native, Black/African American, and Hispanic Minnesotans experienced the largest disparities. Results by language and country of origin are more mixed, with non-English speaking patients and patients born outside of the U.S. sometimes experiencing better outcomes.

Stay-at-home orders may decrease COVID-19 hospitalizations New research from the University of Minnesota’s Carlson School of Management illustrates an

association between the implementation of statewide stay-at-home orders and a reduction in the number of people hospitalized for COVID-19. The research, published in JAMA, analyzed hospitalization rates before and after stay-at-home orders were issued in Colorado, Minnesota, Ohio, and Virginia. “What we found is that about 12 days after the stay-at-home order was implemented, the growth in hospitalizations began to deviate favorably from the initial, projected trajectory,” said Soumya Sen, PhD, MS, associate professor in the Carlson School and the study’s lead author. “In all the states we examined, growth in the total number of patients being hospitalized due to COVID-19 symptoms appeared to slow down from the initial, exponential trend.” The four states examined were the only states that met the study criteria:

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• Issuance of a statewide stayat-home order; • At least seven consecutive days of cumulative hospitalization data for COVID-19 patients (i.e., those currently hospitalized and those released) before the stay-at-home order was implemented; and • At least 17 days of cumulative hospitalization data following the order date. Researchers estimated how many total Minnesota hospitalizations might have occurred if the initial growth trend continued in the absence of a stay-at-home order. By April 13, 2020, five days after the end of the incubation period, projected hospitalizations were 988 while the actual hospitalizations were 361. Similar results were found in the other states. A variety of additional factors may have contributed to the slowing hospitalization rate, including a declaration of national emergency; school closures; a growing, general awareness about social distancing;

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and good hand hygiene practices. However, some of these measures were already in place before the study’s designated period.

Essentia Health trims staff due to pandemic Some 900 Essentia employees—about 6% of the health care system’s workforce—will be laid off due to the financial impacts of the COVID-19 pandemic. Essentia will continue to provide health insurance for non-contract employees for the next three months. Staff covered by collective bargaining agreements have other protections, including the right of recall. Additionally, there are about 850 Essentia colleagues on administrative leave with benefits through July 31, with the intention of being called back to work as needed. Minnesota hospitals and health systems expect to lose almost $3 billion in the first three months

responding to COVID-19. In Essentia’s case, operational losses due to pandemic-related declines in patient volumes since the beginning of March have totaled nearly $100 million, with more losses on the horizon. To offset its significant decline in revenue while prioritizing patient and staff safety, Essentia has placed some employees on administrative leave, offered flexible hours, reduced physician and executive leader compensation, restructured and eliminated leadership roles, limited capital expenditures, and reduced services and discretionary spending. “Despite our best efforts, the many cost-reduction measures we’ve taken over the last several weeks are not sufficient to preserve our mission and the health of the organization,” Essentia Health CEO David C. Herman, MD, said in a message posted at the Essentia website. “This has prompted our leadership team to carefully consider the most difficult decision we’ve faced.”

State’s COVID-19 cases in skilled nursing facilities lower than national average, data shows Minnesota’s rates of COVID-19 cases and deaths in skilled nursing facilities are lower than the national average, according to a state-bystate comparison from the Centers for Medicare and Medicaid Services (CMS) presented by Minnesota Department of Health (MDH) Commissioner Jan Malcolm before a recent House Health and Human Services Finance Division hearing. The CMS data shows the national rate of COVID-19 cases at 62 per 1,000 residents in skilled nursing facilities, compared to 39.9 cases per 1,000 residents in Minnesota. Across the nation, deaths total 27.5 per 1,000 skilled nursing residents, compared to 12.7 in Minnesota. Previous reports issued by MDH and reported in the media included

all senior congregate living settings, not just skilled nursing facilities. Case rates and death rates are higher when these additional types of facilities are included. Larger facility sizes and higher prevalence rates within a county are primary drivers of higher infection rates, according to national studies. In her presentation, Malcolm updated legislators on progress in COVID-19 testing of long-term care residents and workers, efforts to provide PPE to long-term care settings, and onsite visits to provide technical support addressing infection control improvements. Malcom also discussed hospital discharges and transfers to long-term care. “We are not aware of any facilities whose outbreak started because they accepted a COVID positive patient from a hospital,” she said. “It is much more likely transmission from workers and others coming and going from facilities.”

V Alzheimer’s is now an approved condition V

HAVE YOU REGISTERED WITH THE MINNESOTA MEDICAL CANNABIS PROGRAM? Registration can be done online; there is no fee and it takes only a few minutes. Visit the registry website: mn.gov/medicalcannabis Your account will provide access to medical cannabis purchasing information from patients you certify. Once you are registered, you will be able to certify patients with a variety of conditions, including: • Cancer, Glaucoma, Tourette Syndrome, HIV/AIDS, and ALS

• Inflammatory bowel disease, including Crohn’s disease

• Seizures, including those characteristic of Epilepsy

• Terminal illness, with a probable life expectancy of less than one year

• Severe and persistent muscle spasms, including those characteristic of MS

• Intractable Pain

• Obstructive sleep apnea

• Post-Traumatic Stress Disorder

• Alzheimer’s

• Autism

Cannabis Patient Centers are now open to approved patients in Minneapolis, Eagan, Rochester, St. Cloud, Moorhead, Bloomington, Hibbing, and St. Paul.

OFFICE OF MEDICAL CANNABIS (651) 201-5598: Metro (844) 879-3381: Non-metro P.O. Box 64882, St. Paul, MN 55164-0882 health.cannabis@state.mn.us

Many patients have reported improvement in their health status from medical cannabis — some describing dramatic improvements. Smoking cannabis is not allowed under the program. Visit our website for educational resources about cannabinoids and the endocannabinoid system and for scientific literature on the efficacy of medical cannabis in treating certain conditions.

See our website for a detailed first year report. mn.gov/medicalcannabis

JUNE 2020 MINNESOTA PHYSICIAN

MEDICUS

Timothy A. Lander, MD, is the new medical director for the ENT and facial plastic surgery program at Children’s Minnesota. Dr. Landers had previously served as vice chief of surgery and as a member at large on the credentials committee. He is an assistant professor of pediatric otolaryngology at the University of Minnesota.

St. Luke’s Advanced Wound Care & Hyperbaric Center, directed by Tania McVean, has received the President’s Circle award from Healogics. The award cited exceptional clinical outcomes for 12 consecutive months, patient satisfaction higher than 92 percent, and a minimum wound healing rate of at least 91 percent within 28 median days.

David Boulware, MD, professor of medicine at the University of Minnesota, recently led the nation’s first randomized trial testing the effectiveness of hydroxychloroquine in preventing COVID-19. The study showed little difference between those who took hydroxychloroquine and a comparison group who took only folic acid vitamins.

Minnesota Orchestra at Home watch. listen. learn. Minnesota Orchestra at Home features content created by our musicians. Enjoy listening, learning and watching as they present mini-concerts from their home to yours.

Steve Wigginton has joined NovuHealth, succeeding company co-founder Tom Wicka, who will move to the role of executive chairman. Before joining the health care industry consumer engagement company, Wigginton had served in leadership roles in both payer and provider markets, including Sutter Health|Aetna, Sutter Health, and Evolent Health.

Scott Stayner, MD, has joined Nura Pain Clinic. Board-certified in anesthesiology and pain management, he previously served as a member of the Montana Medical Association’s committee addressing the state’s opioid crisis, educating primary care physicians on best practices for managing chronic pain, as well as the role of opioid medications. Dr. Stayner has published book chapters and journal articles on safe practices for opioid prescribing.

Principal Cello Anthony Ross and his mother-in-law, Mary Rapier, perform Solveig’s Song by Grieg.

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MINNESOTA PHYSICIAN JUNE 2020

INTERVIEW

Preserving independent practice Owen O’Neill, MD Infinite Health Collaborative Please tell us about Infinite Health Collaborative (i-Health).

checkup tests that cannot be done virtually: blood pressure, baby’s heartbeat, position of the baby, and vaccines. Similarly, Twin Cities Orthopedics (TCO) launched virtual care in under seven days, going from zero telemedicine infrastructure to providing over 1,000 virtual care visits per week. The best part is we did so without sacrificing the patient experience. Niney-nine percent of TCO’s virtual care patients say they would recommend this service to family and friends.

We like to say that i-Health is a modern approach to a timeless idea. We’re an independent practice of like-minded physicians representing several unique specialties, including cardiology, colon and rectal conditions, family medicine, orthopedics, and women’s health. All of us believe that independence in health care enables physicians to focus on each patient’s individual goals without limitations, and that’s the inspiration behind i-Health. By empowering patient choice—arming patients with the tools to make their own educated health care decisions—we are earning their trust and keeping health care personal. In a nutshell, we deliver valuebased care, enable physician autonomy, and preserve patient choice.

Revo Health, a management services organization, helps practices develop value-based care services and provides support across several departments often referred to as “back of house.” These include revenue cycle, finance and accounting, human resources, information technology, quality, marketing, and more. Sharing these resources creates efficiencies and cost savings, fosters collaboration, and consolidates our expertise. Revo takes care of the business side, so physicians can focus on taking care of patients. What kind of framework for growth and sustainability of independent physician practices does i-Health provide?

There’s power in numbers. By banding together, we preserve our independence and strengthen our voice in the industry. These days, many small practices are getting squeezed out or bought up by large systems, and transition to becoming employed by the system. i-Health is physician-owned and led, however, so every new physician to join becomes a fellow partner and retains ownership stake in the business. Another major advantage for our operating divisions is collaborative learning. Innovative operational initiatives such as developing prospective care bundles and collecting outcomes data takes time to develop. We’ve all experienced different

JUNE 2020 MINNESOTA PHYSICIAN

“...” patient-physician We believe relationships are the heartbeat of health care. “...”

Please tell us about Revo Health and the services it provides for i-Health physician groups.

What can you tell recent medical school graduates about the opportunities and benefits presented by the independent practice of medicine?

stages of growing pains, so we help each other avoid re-inventing the wheel. How can independent physicians be the drivers of the industry’s improvement?

We believe patient-physician relationships are the heartbeat of health care, and we intend to keep it that way. Independent physicians have autonomy to guide patients without the limitations of larger systems, and ultimately enable patients to make their own educated health care decisions. Getting back to basics and putting the power back in patient’s hands is how we believe the industry moves forward. What are some examples of how independent physician practice contributes to innovation in the health care industry?

Our independence enables us to mobilize and test new ideas quickly without the red tape of many larger systems. In the past couple of months, for example, OB-GYN specialists from our women’s health operating division launched curbside obstetric care in response to COVID-19, performing routine

Our model, which centers around the patientphysician relationship, is the original health care model. Many physicians are attracted to independent practice because it reminds them why they got into medicine in the first place. i-Health provides immediate and long-term financial stability, and independence puts you in control of your own destiny. By building a strong reputation, and delivering exceptional care day in and day out, the sky’s the limit to your potential. What are some of the ways i-Health members encourage patients to be active participants in their health care decisions?

It sounds so simple to do this, but it’s not our job to tell patients what to do. We encourage patients to be in control of their own health, and it’s our job to guide patients to make the best decisions for themselves. We accomplish this by clearly explaining diagnoses, walking them through options, listening to their concerns, and answering their questions. We also use anonymous clinical outcomes data from over one million survey submissions to set realistic expectations. For example, we can tell patients considering a hip replacement that six months after surgery, 97.93% of total hip arthroplasty patients reported little to no pain lying in bed and turning over. What benefits can i-Health provide to self-insured employers?

It’s amazing how many employers are simply unaware of the freedoms they have when it comes

to customizing their benefits plans. For example, they can partner with us tomorrow to give their employees more surgical care options and better outcomes via our TCO EXCEL Surgery & Recovery program, without changing anything else about their existing plan. It’s a simple add-on model, and the best part is it actually reduces costs across the board. In fact, some local employers have already identified i-Health as a preferred tier inside of their health plans, effectively encouraging their employees/patients to consider value-based care options. New health care legislation is informed by considerable input from health plans, hospitals, and the pharmaceutical industry, but very little from physicians. How can i-Health help address this inequity?

This is a big reason why we were inspired to band together in the first place: to grow our shared voice in the industry. A voice that is focused on patient care and the delivery of innovation in the market. We deliver value-based care, which means we have actual data to prove how we can improve outcomes and patient satisfaction, while also reducing costs. We’re putting the data to good use in these conversations.

What can you tell independent physicians who may want to become part of i-Health?

We live and succeed on our own reputation, and often take the road less traveled, which isn’t for everyone. We were founded upon the promise that no matter what, the care of our patients would always come first. It’s in our DNA, and it’s what drives us every single day. The freedom we are granted as an independent practice allows us to be innovative, create meaningful solutions to complex problems, and deliver on that fundamental promise. And, ultimately, it’s how we provide value. If your core motivation as a health care provider aligns with our core principles, and you share our vision for the future of value-based care, then we would love to get to know you better. The recent government response to cancel “elective” surgeries brings up several important issues. What are your thoughts on this?

On the orthopedics side in particular, we have seen many patients suffering as a result of elective surgery restrictions. We have observed increased opioid drug use and suicide attempts from patients dealing with severe pain and immobility, in addition

to prolonged pain leading to poor long-term outcomes. Prolonged waiting causes stress physically, mentally, emotionally, and financially. Treatment for many of these patients was initially categorized as elective or non-essential when the COVID-19 pandemic began. The good news is that we have developed comprehensive safety protocols that have enabled us to perform more surgeries in a safe, COVID-free environment within ambulatory surgery centers. We are using a clinical risk stratification tool to determine which surgeries can be performed first, we’re testing patients and employees for the virus, we’re screening at entrances, and much more. Our patients and their families have high expectations for their care, and we want our safety standards to exceed those expectations. Owen O’Neill, MD, is a board-certified orthopedic surgeon with fellowship training and subspecialty certification in sports medicine. He is a board member for both Infinite Health Collaborative and Twin Cities Orthopedics.

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3When elective procedures aren’t elective from cover A non-essential surgery or procedure is a surgery or procedure that can be delayed without undue risk to the current or future health of a patient. Examples of criteria to consider in making this determination include:

the overall health care system. Safe outpatient care is not a “nice to have” option, but rather a significant part in providing continued services and allowing hospitals and the rest of our health care system to focus on other emerging priorities.

Defining elective

a. Threat to the patient’s life if surgery or procedure is not performed. b. Threat of permanent dysfunction of an extremity or organ system, including teeth and jaws. c. Risk of metastasis or progression of staging. While the guidance was helpful for triaging in the short term, several significant matters were not considered, and delays in necessary care developed as the duration of the executive order continued.

We owe it to patients to establish clinically based definitions on what is urgent/ emergent versus elective.

Physicians clearly understood the need for an immediate shutdown to evaluate the crisis and be in “survival” mode, making assessments and recommendations for reducing the spread of the virus, response capacity, personal protective equipment (PPE) supply levels, etc. But there needed to be a next step after that. Deferring care for one to two weeks for some patients was acceptable but was ultimately harmful when those same patients had to be deferred for four weeks or more. Additionally, Minnesota failed to seize upon the opportunity to recognize that free-standing ambulatory surgery centers (ASCs) play a critical role in

Surgery is defined under Minnesota Statute 144.7063, subdivision 5z as follows: “Surgery means the treatment of disease, injury, or deformity by manual or operative methods. Surgery includes endoscopies and other invasive procedures.”

While there are mentions of “elective outpatient surgery” under Minnesota statute, that term or related terms are not defined. That undoubtedly presented a problem when the Governor and public health officials were considering the executive order. In fact, when Executive Order 20-09 was issued, the supporting documents made it clear that Minnesota does not have its own definition of “elective surgery or procedure.” The Minnesota Department of Health attempted to clarify the issue with its “FAQ: Executive Order Delaying Elective Medical Procedures” (https://tinyurl.com/mp-mdh-faq). That document explained the reasoning behind the order and provided direction from professional and academic organizations, but did not reflect a Minnesota perspective. It is unfortunate that conversations about what constitutes “elective” have never taken place, but now we have that opportunity. Additionally, it would be nearly impossible to determine when and where the term “elective” first took hold and became a catch-all for any procedure or surgery that wasn’t performed as the result of an emergency, but it is terminology that needs a fresh look. The term may have become commonplace for the purposes of reimbursements, insurance, and coverage. We can’t turn back the clock, but we owe it to patients to establish clinically based definitions on what is urgent/emergent versus elective with medical necessity versus purely elective for screening or cosmetic reasons. In Minnesota, we can do better. Now is the time to focus on what “elective” means for the higher purpose of patient health and providing care.

Not all elective procedures are the same By general definition, “elective” means chosen by the patient rather than urgently necessary; one that it is open for choice, is optional, voluntary, discretionary, and not required. However, while the patient might have some flexibility or control in scheduling that procedure, the actual procedure is often not discretionary or a matter of choice in terms of their health. Additionally, not all procedures are the same in their immediacy, and deferment can mean different things for different patients. Without a proper understanding of how different procedures affect a patient’s current or future health, it isn’t possible to make well-informed decisions that are included in a broad executive order. Three scenarios demonstrating the various interpretations of “elective” with regard to medical urgency: 1. Patient A has a positive stool hemoccult as a screening test for colorectal cancer. Patient B has occasional gross blood in his stool

JUNE 2020 MINNESOTA PHYSICIAN

and a 5-pound weight loss. Both are not emergencies, and delays in care can have long-term consequences, but Patient B should be assessed with colonoscopy as soon as possible.

or more. While there is an obligation to public health, there is also a need to focus on the needs of patients. Identifying steps would allow for some elective procedures to resume following an immediate shutdown.

2. Patient A can no longer play tennis and needs a right knee replacement. She has gained 10 pounds while not being able to exercise. Patient B has significant right knee arthritis and can no longer walk up a flight of stairs. She lives in a two-story home. Again, neither case is an emergency, both need knee replacements, and Patient B Free-standing surgery centers should be minimally delayed from surgery. 3. Patient A cracks a crown on his second molar which needs dental repair. Patient B bites into an apple and cracks off a crown on his front tooth. He works as a television anchorman. Both can still eat, neither has a medical emergency, yet there are different degrees of urgency for their respective dental care.

do not pose a threat to inpatient care or ICU beds.

A better solution for Minnesota While I am not advocating for every term to be defined in Minnesota statute, it has become increasingly clear that before there is another surge or the next health pandemic strikes, there should be meaningful discussions between those who govern and those who provide direct patient care.

Conclusion COVID-19 has presented Minnesota with an opportunity to do better for patient care, especially in times of crisis. Now is the time to have discussions that will lead to better solutions for the future. Scott R. Ketover, MD, AGAF, FASGE, is a practicing gastroenterologist and President and CEO of MNGI Digestive Health (previously Minnesota Gastroenterology), one of the largest independent gastroenterology practices in the country. He completed his medical degree, residency, and

GI Fellowship at the University of Minnesota. Dr. Ketover also serves as the Chairman of the 3,000-physician member Allina Integrated Medical Network, a Minnesota Accountable Care Organization (ACO). He is a Fellow of the AGA and the ASGE.

Ultimately, the goal would be a mutually accepted and agreed-upon process for leaders and physicians to follow when executive orders are issued in the future. Here is my prescription for those leadership discussions and a roadmap for the future: • Work to acknowledge the value of ASCs and the critical role they can play in an overwhelmed health care system. Free-standing surgery centers do not pose a threat to inpatient care or ICU beds and provide an important method to deliver high-quality care that does not require an overnight stay in a hospital. Safe outpatient care is not a “nice to have” option, but rather a significant part of the overall solution. • Work to establish clinically based and mutually accepted definitions of “elective,” acknowledging there are differences between what is urgent or emergent versus elective with medical necessity versus purely elective for screening or cosmetic reasons. Come to an understanding that “elective” refers to timing and scheduling of a procedure, but it does not mean the procedure isn’t needed. There could also be conversation about PPE use for various procedures, so hospital supplies do not feel unnecessarily threatened in time of crisis. • Work to identify interim steps between “survival” shutdown mode and “all clear” that can be activated during future executive orders. Interim steps would recognize that there are dangers to postponing all procedures within a broad category. Deferring care for one to two weeks might be acceptable for some patients, but a continued postponement can ultimately be harmful when those same patients are deferred for four weeks

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3Elective Surgery from cover The lessons learned to date could help to ensure that elected officials understand and consider the impacts on patient care, and craft sound decisions that serve both physicians and the public during the current pandemic and in the future.

One practice group’s experience Mankato Surgery Center is one of many providers across the state that struggled to define “essential.” With ownership split evenly between Mankato Clinic, a multispecialty facility, and the Orthopaedic and Fracture Clinic of Mankato, Mankato Surgery Center provides a safe, low-risk alternative to hospital surgical suites, where patients might have had broader exposure to the coronavirus. Ambulatory Surgery Centers (ASCs) such as ours offer outpatient, same-day procedures that allow hospitals to free up bed space and focus on their potential COVID influx. The Governor’s earlier orders had included three criteria for essential procedures: “a. Threat to the patient’s life if surgery or procedure is not performed; b. Threat of permanent dysfunction of an extremity or organ system, including teeth and jaws; and c. Risk of metastasis or progression of staging.” Our Board of Directors and surgeons had questions about what to do with patients that did not fall into category a, b, or c. For example, patients whose pain tolerance did not meet the criteria outlined, or those who needed to be mobile and working with a torn meniscus, did not qualify under this definition. Was this type of patient treatment “essential”?

Under EO 20-03 and the state’s Peace Time Emergency, we could have been fined and charged with a misdemeanor if the procedures we continued to perform were not “essential,” even though we did not know the definition of that term. The order was more robust than we had seen in other states with similar orders. We struggled from March 23 to April 9 to find a definition, all the time striving to balance patient’s surgical needs, business changes, and the daily demands under a changing health care environment. As we began looking for detailed information and guidance, our first thought was what needed to be done with regard to documentation in the event of a state inspection and risk perspective based on a surgeon’s decision, and how we would “defend” cases we had scheduled as essential. The surgery center board ultimately decided to accept our surgeons’ medical judgement in determining which cases fell into the Governor’s new order. “Essential only” had been described as loss of limb, organ failure, or permanent nerve damage, but our center’s orthopaedic owners decided to have a group of physicians review each surgery case to determine if it was necessary. That process assisted in the defending of “essential” cases to be allowed during the Governor’s order. Speaking as the center’s administrator, I believe that this approach represented good risk coverage in the event we are audited in the future by the state during a retrospective COVID-19 review. The multispecialty clinic and the orthopaedic clinic also reviewed essential cases with some of the specialty associations, including the Association of Ophthalmology. On March 18, they had already published what they considered to be “urgent and non-urgent” cases. We looked for each specialty to do the same until we started to see information in the surgery centers on what they were doing, to allow for a comparison with industry standards.

Collaborating with outside resources After learning that some ASCs had closed sites and others had slowed cases, as we did, we decided to collaborate with the Minnesota Ambulatory Surgery Center Association (MNASCA). By collaborating with this association, we believed we could reach Gov. Walz to explain our positions and concerns about defining “essential cases only,” and could send a united ASC message.

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The initial MNASCA contact was a letter to Gov. Walz’s office, followed by an in-person visit with the Governor’s staff, in which we explained our PPE and ventilator usage and offered to assist potentially strained hospital systems. We also explained the differences between ASCs and hospitals, which include separate PPE and ventilator needs. Mankato Surgery Center does not have the same supplies required in the hospital or among COVID19 front-line workers. We have special packs for specialties, with all our supplies in a surgical pack, along with a few surgical gowns outside of the pre-made surgical packs. We have our own glove supply and we use surgical masks on hand, and did not intend to ask for additional supplies. Tom Poul, MNASCA’s legal legislative counsel, and MNASCA President Tom Stevens initiated weekly calls with their members, and invited the Minnesota Department of Health (MDH) team to collectively hear from association members who had been affected by the “shut down” order. A number of ASC administrators have been part of these ongoing calls to help the ASC members navigate through the perils of the pandemic, and are looking to both influence and to assist in changes to impact any future MDH or Governor’s directives. Following these contacts—which also included metro-area surgery centers—the Governor’s office gave MNASCA the option to follow less restrictive MDH guidelines for surgery until Gov. Walz could make an announcement to resume elective cases.

In the literature On April 9, the Journal of the American College of Surgeons published an article outlining a stratification system intended to help surgeons determine when to proceed with medically necessary operations. This Medically Necessary Time-Sensitive Prioritization (MeNTS) tool was developed to define necessary surgeries and to reduce the burden on the health system. In addition, on April 17, four medical associations issued a “Joint Statement: Roadmap for Resuming Elective Surgery after COVID-19 Pandemic.” Both of these resources helped validate the choices we had made previously to remain open as a relatively low-risk Covid-19 facility option for patients. It is an ongoing balancing act for our board to feel confident we are making choices for the best interest of patients and employees. Outside resources to “hang our hat on” is always to preferable to paving our own way.

centers to see what space was available for use if ventilator patient overflow options made sense, and to use the center if space was needed.

We are not over the pandemic yet, but lessons learned to date could help us assess what went well and what needs more work in the future. During this pandemic, some providers sought approval to sterilize and reuse N95 masks. The FDA moved quickly on approving some sterilizing units to re-sterilize N95 masks and to help facilities slow the rapid depletion of PPE supplies. While rapidly approving equipment or products may produce unexpected consequences in the future, this We could have been fined and is one example of public officials responding quickly.

charged with a misdemeanor.

Feedback, concerns, and responses

The policies unfolding now during the pandemic—both in government and within health care organizations—have and will most certainly affect future policy in the face of continuous changes. Policymaking is a moving target. Mankato Surgery Center will continue to follow guidelines from the CDC and other specialty resources to adapt to changing circumstances.

Some of our Board members and surgeons believed that the restrictive order could harm patients who did not fit the Governor’s profile of “loss of limb, organ or cause permanent nerve damage.” In addition, they were concerned about patients in constant pain, as well as essential workers who are in need of a shoulder repair or knee surgery. Those types of patients just fell out of the executive order into a holding pattern.

Closing thoughts

Jesse Botker, MD, FAAOS, who practices at The Orthopaedic and Fracture Clinic of Mankato, said this about the order’s directives:

Mankato Surgery Center.

As we move forward, we must ensure that elected officials understand the impact of their decisions on physicians and patients, ensure physician autonomy, and recognize the unique needs of patients across the state. Joleen Harrison, RN, BSN, PHN, CASC, is administrative director at

“I would say that the ban is going to have down the road effects due to delays in care such as higher opioid use which may lead to dependence, increased disease progression that could lead to decreased function and loss of work. Surgery centers are ideal spots to allow patients to receive much needed procedures in an environment that can reduce COVID transmission risk.” Throughout this period, physicians also struggled to determine how to serve patients who relied on opioids to manage chronic pain that fell outside of the order’s description. The solution should not have been to prescribe additional pain medications to carry them over until an unknown date. We felt as a surgical center that we could put new practices in place with what we knew at the time, to create a relatively low COVID-19 symptomatic facility to remain open as part of the solution. In the wake of the EO to prioritize surgical cases, we have put in place new processes, policies, and procedures based on guidance from the CDC and MDH. These include mask requirements for patients and staff, COVID swab testing or no COVID testing for patients and staff, airborne precautions with N95 masks if needed, and recommendations for extended PPE use. The goal is to increase patient service under a systematic approach. We are prioritizing patients that have been waiting or taken off the surgery schedule for more than a month. The surgeons decide which patients to put in the new surgical line-up. We inform all patients on these COVID-19 issues, and have explored changes in telemedicine services, developing new policy and payment services.

Looking ahead Legislators and policymakers should understand what ambulatory surgery centers are and how they can play a role in any future pandemic. Some ASCs in the metro area are affiliated with a hospital system and had reviewed their

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ARCHITECTURE

Person-centered care environments New trends in assisted living facilities BY GAIUS NELSON, MA

hysical or cognitive difficulties often make living at home impractical or unsafe for older adults. Multiple home care options provide support for those wishing to remain in the familiarity of their own home, but this can be an expensive proposition, and one that could limit the social interactions or the sense of community and belonging that are available in congregate long-term care settings. Choosing the right facility can be overwhelming. Several long-term care communities stress their “chef-driven” menus and beautifully appointed entrance lobbies to prospective residents and their loved ones. Architecture clients often wish to present a “Wow” experience for those entering the facility. First impressions are important, but it is even more important to be sure that the same careful design and execution of the physical environment occurs throughout the long-term care facility.

Telephone Equipment Distribution (TED) Program

Whether it is the availability of appropriate types of services, accepted payer sources, or cultural affinity groups, sorting through the various settings and organizations is a difficult task. Decisions can produce even more anxiety during the current pandemic. Some family members may

Guidance for consumers and physicians Minnesota’s Assisted Living Report Card—now under development—may help consumers and physicians sort through a variety of quality measures for long-term care settings (see recent Minnesota Physician article at http:// mppub.com/mp-s4-0320.html). Building on the experience of the state’s Nursing Home Report Card (http://nhreportcard.dhs.mn.gov/), planners have developed a list of nine quality domains based on national literature, reports, and experts. Among the nine domains, Quality of Life; Safety; and Physical and Social Environment most directly correlate to and can be impacted by the architecture and design of long-term care settings. Individuals who have lived within congregate settings rate the quality of the physical and social environment as being more important than those who have not done so, but a review of data from the Nursing Home Report Card shows a discrepancy in satisfaction ratings between residents and their family members. In one cohort of facilities, resident and family ratings on the quality of the environment correlate closely, but in a separate cohort, residents rate the environment much higher, often twice that of family members. This diversity of opinions points to the difficulty that people have in describing which physical attributes of the environment are important, or to a lack of understanding of how these attributes can affect residents, family, and staff.

Physical environment contributes to therapy

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contemplate “rescuing” loved ones from congregate living settings, believing this is the safest alternative—but very few loved ones have the training or ability to practice infection control as effectively as long-term care providers.

JUNE 2020 MINNESOTA PHYSICIAN

The late David Green, former CEO of the Evergreen Retirement Community in Oshkosh, always explained to visitors that the built environment was the most important therapeutic tool available to caregivers. Subsequent research confirms this observation, demonstrating that the environment has a significant impact on the well-being and quality of life experienced by its occupants. These “person-environment” studies led to the development of new types of environments for aging after the passage of the Federal Nursing Home Reform Act, created under the 1987 Omnibus Budget Reconciliation Act. New regulations mandated that quality-of-life measures be integrated into the life of nursing home residents on an equal or greater footing to quality of care. Person-centered care that looked at each person as an individual became the new standard. The proliferation of assisted living centers as an alternative to traditional nursing homes pushed the concept of personalized, non-institutional care environments throughout the longterm care industry. There are a wide variety of care setting typologies available, ranging from independent living, assisted living, memory care, and nursing homes. In many cases it is difficult to distinguish one type of setting from another. For example, assisted living may offer two-bedroom apartments with full-unit kitchens, while nursing home care suites may provide studio-like

living quarters and tea kitchens with mini-bars. The service needs of each individual—and the license level of the operator—should determine the type of setting to be selected.

Focusing on the physical environment A number of common attributes of the physical environment that should be considered by physicians and consumers appear in the Facilities Guidelines Institute (FGI)’s Guidelines for the Design and Construction of Residential Health, Care and Support Facilities (https://tinyurl.com/mp-selectcare-2020). Part 4.1 of that document, “Specific Requirements for Assisted Living Facilities,” has been adopted as the governing standard for the design and licensure of assisted living facilities in Minnesota, beginning in August 2021.

Key concepts

Major physical environmental contributors to quality of life appear below. Many of these person-centered care concepts are in place throughout the country, and Minnesota regulators have been at the forefront of encouraging movement toward person-centered care environments. With the recent concerns over COVID-19 transmission, greater attention has been given to protection of older and vulnerable populations. Based on early indications, personEnvironment has a significant centered design models have performed well in impact on well-being helping to control transmission of the disease, and quality of life. thanks in great part to the courageous efforts of direct care staff.

These concepts and attributes have been integral to the work of architects across the nation as they strive to provide person-centered care environments focused on quality of life for all occupants. Two local Twin Cities examples of my firm’s work include the Shaller Family Sholom Home East Campus in Saint Paul and the Minnesota State Veterans Home Building 22 in Minneapolis. The Shaller campus includes affordable independent living, assisted living, memory care (assisted living), nursing home, and hospice care services, whereas the Veterans Home is a 100-resident nursing facility designed as the final phase of a 300-resident campus reconfiguration within a historic setting.

Private accommodations. An early and devastating COVID-19 outbreak in the Twin Cities occurred at a well-respected suburban campus where most residents lived in semi-private rooms with a toilet room shared by four residents from two adjoining rooms. Thousands of older U.S. nursing homes still fit this description. In the past 15 years, nearly all new and renovated resident rooms our firm has designed have been private rooms with individual bathrooms. In 2006, the FGI adopted private rooms as the standard for all new hospital construction, noting that it represents a best practice for infection control. Person-centered care environments to page 164

MINNESOTA PHYSICIAN JUNE 2020

3Person-centered care environments from page 15 that provide opportunities to fulfill these desires, and then communicate Size of dining and social groups. Household model facilities are this information to future caregivers. designed as small family-sized settings of 8–20 residents. Each household is Access to the outdoors. Spending time outdoors benefits both psychological envisioned as a self-contained living environment, and physical health—activating all of our senses, with all of the normal spaces found in a home boosting vitamin D through sunlight, and improving alongside required care support areas for staff. circadian cycles. Ease of access to the outdoors is Compared to institutional model nursing homes, particularly important for those with limited mobility. smaller living groups provide a family-sized social Minnesota regulators have been In multi-story structures, exterior roof terraces and group and dedicated direct care staff, who gain at the forefront of encouraging balconies on each floor can help. These smaller an intimate understanding of the care needs movement toward person-centered outdoor features can allow community members to and desires of residents. This model can limit care environments. interact while maintaining social distance. contact with outside groups if necessary, creating Changing design aesthetics. Many recent what some call a “COVID Bubble.” Similar retirement housing units and long-term care household designs are often used in memory care developments, particularly within urban environments. In other settings, activity lounges locations, are being designed with contemporary European-style interior make it possible to create small groups, using social distancing for dining design elements that feature easier maintenance and sanitation, as well as and activities. antimicrobial surfaces. The challenge in designing for infection control Variety of activities and experiences. Psychologist Mihaly will be to retain a residential look and feel without reverting back to Csikszentmihalyi’s “Flow” concept states that life entails what we like to institutional patterns. do, how we feel about it, and whom we do it with. He stressed that quality of life can be found in everyday experiences. The challenge is to increase the time we spend doing activities that maximize the experience of Flow—a difficulty for caregivers, since these activities and experiences are unique to each individual. Physicians and family members should look for settings

Accessibility standards. While the Americans with Disabilities Act (ADA) includes requirements for accessibility, these standards were not developed with older, frailer individuals receiving assistance from caregivers in mind. Many facility designers go beyond the ADA to provide additional

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space to accommodate assisted transfers. In assisted living facilities, the Fair Housing Act—with less stringent requirements and smaller spaces—is allowed as the minimum standard. Look for bathroom arrangements that go beyond minimum standards and support aging-in-place, allowing the environment to adapt as a resident’s needs change.

Gaius Nelson, MA, is president of Nelson Tremain Partnership, a nationally

Hand-washing stations. A hands-free sink, cleaning agents, and towel-free hand drying can limit the spread of disease. Soap and water are more effective than the ubiquitous alcohol-based hand sanitation dispensers. We have designed hand-washing stations within or near dining areas for both ceremonial and hygiene purposes. In higher acuity environments, additional hand-washing stations should be provided within—or just outside of—resident rooms, to eliminate staff use of bathroom facilities for hand-washing. Bedpan sprayers in resident rooms and toilets without seat covers should no longer be allowed due to their potential to aerosolize pathogens.

Building and Design Codes & Regulations as they are applied to facilities for

Ventilation systems. Centralized fresh air and continuous exhaust systems are critical to limit exposure to the coronavirus. The main concept is to maintain a negative pressure within resident rooms to avoid spread of contamination. Proper filtration of room air is also key. Typical recirculating ventilation equipment, often found in older nursing homes and assisted living units, has little capacity to filter contaminants, especially those as small as a virus. HEPA filters are the suggested means for capturing these types of pathogens. The Association of Healthcare Engineers (ASHE) has developed white papers and standards regarding the creation of settings for COVID-positive patients, although most of their efforts have centered on COVID-19 wards for patients with confirmed cases. Multi-level campuses or care systems. One key factor in selecting an assisted living setting for a family member is the desire to make a single move to a setting where future needs could be accommodated. My family selected a single campus containing a full, interconnected continuum of care for our loved one. Other options may include the selection of a care network, or a health care system that offers a variety of settings from which to choose, all managed by an umbrella organization. Changes in health and cognitive capabilities can occur quickly, so planning for the future is a valuable exercise.

Conclusion The physical environment is an important part of the long-term care milieu that is often overlooked in choosing suitable long-term care settings for patients or family members. The current Nursing Home Report Card provides little specific information in this area beyond a broad measure of the proportion of private rooms available, and the domains evaluated for inclusion in the upcoming Assisted Living Report Card appear to downplay the direct effect of the environment on resident well-being and quality of life. Physicians and family members can help to ensure a successful transition by understanding the aspects of life—whether physical, emotional, intellectual, or spiritual—that are most important to the patient or loved one, and then comparing potential settings against the concepts discussed above to see if there is a congruence between the desired quality of life and the physical environment.

recognized architecture firm in the field of Design for Aging. He earned a Master of Science degree in Architectural Studies from the Massachusetts Institute of Technology, focusing on person-environment research in long-term care settings. Mr. Nelson has been instrumental in working toward change in older adults.

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HEALTH CARE ARCHITECTURE

PrairieCare Medical Group Type of facility: Medical Office Building: Outpatient Behavioral Health Location: Rochester Ownership organization: PrairieCare Medical Group –Southern Minnesota Architect/interior design: HGA Engineer: HGA Contractor: Knutson Construction Completion date: September 2019 Total cost: $10,650,000 Square feet: 37,029

rairieCare’s new Rochester facility provides Intensive Outpatient Programming (IOP) to children, adolescents, and adults struggling with mental illness within an uplifting, light-filled environment. This model divides patients’ time between public school education and individual or group therapy. Most treatment occurs within four “pod” units, which consist of therapist offices, classrooms, group rooms, and activity spaces organized around a

JUNE 2020 MINNESOTA PHYSICIAN

central milieu space. Additional multi-purpose space encourages children to expend excess energy, with community functions held during nonbusiness hours. Connection to nature is reinforced through abundant glass, which minimizes the barrier between interior and exterior space. Finishes feature warm, natural materials and color palettes inspired by natural elements. Patients are encouraged to explore secure, semi-private outdoor spaces that integrate nature into the healing process.

Minnesota Physician’s Health Care Architecture Honor Roll recognizes outstanding achievement in new facilities design. Each year we present an overview of the widely varied work that creates the brick and mortar of patient care. The 11 projects featured in 2020 will serve patients of all ages in the areas of behavioral health, orthopedics, surgery, physical therapy, neurosocience, birthing and fetal care, primary care, and more, at sites throughout the state. We thank all those who participated in this year’s Honor Roll. By Richard Ericson

Twin Cities Orthopedics Type of facility: Ambulatory Surgery Center and Physical Therapy Clinic Location: Eagan Ownership organization: Twin Cities Orthopedics Architect/interior design: Sperides Reiners Architects, Inc.; Crawford Architects (shell building) Engineer: Dunham Contractor: Kraus-Anderson Construction Completion date: June 2017 Total cost: $9.5 million Square feet: 70,000

perides Reiners Architects, Inc. (SRa)’s previous projects for Twin Cities Orthopedics include orthopedic clinics, imaging suites, physical therapy clinics, and athletic training facilities. SRa has also provided TCO with development and design services for outpatient surgery centers that focused both on orthopedics and multi-specialty services. TCO has found great efficiencies and synergies in their surgery centers by bringing all of their services

under one roof. This collaborative relationship between TCO and SRa has provided the opportunity for SRa to become a trusted advisor to TCO, allowing for helpful discussions on projects and opportunities to develop relevant solutions. In the Eagan project, SRa teamed up with Vikings Lake Development, TCO, and Crawford Architects (shell building designer) to create a facility that captures the essence of TCO’s core orthopedic care mission. MINNESOTA PHYSICIAN JUNE 2020

HEALTH CARE ARCHITECTURE

Abbott Northwestern Hospital Richard M. Schulze Center of Excellence in Neurological Care Type of facility: Inpatient Renovation Location: Minneapolis Ownership organization: Allina Health System Architect/Interior design: HGA Engineer: HGA Contractor: Mortenson Construction Completion date: November 2019 Total cost: $30 million Square Feet: 43,000

he Richard M. Schulze Family Foundation’s Center of Excellence in Neurological Care provides state-of-the-art care for patients with complex conditions such as brain tumors, sleep disorders, strokes, concussions, Alzheimer’s disease, and seizures. The project co-locates 12 ICU and 42 medical/surgical beds with shared rehab and imaging. Prefabricated interior walls offered a faster construction schedule and minimal construction staging space; future

flexibility for layout changes; and flexibility for changes to utility systems, all without the dust associated with traditional gypsum board construction. Best practices and technologies to support patient safety are deployed throughout the unit, while natural materials and imagery promote a sense of calm. Accent colors and patterns assist patients and their families with wayfinding, and numerous respite spaces welcome family members and staff.

Allina Health, Mercy Hospital Expansion Type of facility: Hospital Location: Coon Rapids Ownership organization: Allina Health System Architect/Interior design: HDR Engineers: Loucks; Dunham Contractor: Knutson Construction Completion date: March 2020 Total Cost: $68 million Square Feet: 168,000

ercy Hospital was bursting at the seams and needed to relocate its front entrance to the opposite side of the facility to create a connection between its new parking garage and existing campus, forming a grand and intuitive means to draw people in. The garage façade, adjacent to the Mississippi River, draws inspiration from river sediments and is wrapped with a perforated metal panel skin composed of five custom perforation types

JUNE 2020 MINNESOTA PHYSICIAN

derived from and image of rock sediment. The result helps bring visitors, patients, and staff steps away from a new main entrance tower. The hospital’s interior forms guide and direct visitors to various key connections, taking cues from the winding river landscape to their destination. On the interior side of the project, the team used a custom computation tool to accurately predict sight lines within the design of clinical spaces, ensuring optimal solutions for staff and users.

HONOR ROLL 2020

Child and Adolescent Behavioral Health Services Hospital Type of facility: Inpatient Facility Location: Willmar Ownership organization: DHS Architect/Interior design: Mohagen Hansen Architecture | Interiors Engineer: Dunham Contractor: Knutson Construction Completion date: May 2020 Total cost: $8,983,589 Square feet: 18,100

his 16-bed hospital provides inpatient services to children and adolescents aged 6â&#x20AC;&#x201C;18 who suffer with behavioral health issues. It includes quiet lounges, seclusion rooms, private patient rooms, consult rooms, a family lounge, a large commons area, day lounge, comfort sensory room, and exterior courtyards. This facility responds to a critical need for sensory stimulation and offers feelings of safety and comfort. Patient rooms are planned as three

containable zones that allow for patient oversight in a dignified manner. Ligature-resistant fixtures and finishes are delicately incorporated into the design concept for this at-risk population. Circular clouds with pops of color hang from the ceiling in the main commons area, while varying height soffits serve to lower the ceiling heights to enhance comfort and provide a sense of security. Large, vibrant murals of nature serve as art to provide calming connections to nature.

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HEALTH CARE ARCHITECTURE

Woodbury Medical Building Type of facility: Multi-tenant Medical Office and Ambulatory Surgery Center Location: Woodbury Ownership organization: MSP Commercial Architect/Interior design: BDH Engineer: Civil Site Group Contractor: Welsh Construction Completion date: September 2019 Total cost: $9.2 million Square feet: 40,989

haring a 7-acre plot with Minnesota Eye Consultants, the exteriors use similar designs and materials to create a cohesive feel. The two-story building has a contemporary faรงade with a mix of natural stone and brick, architectural metals, and large vision glass paneling. Interiors feature crisp whites and variegated grays along with geometric designs and textures. Tenant spaces include detailed wood accents, stylish use of glass accents, and

beautiful pops of bright and inviting colors. The building houses multiple specialty care providers, including VitreoRetinal Surgery, PA, and The Urgency Room. Anchoring tenant Summit Orthopedics encompasses the second floor with an Ambulatory Surgery Center (ASC) and clinic. Summit Orthopedics relocated its Landmark Center of Excellence to this location. State-ofthe-art systems allow for innovative regenerative medicine therapies and spine injection services.

EAPC PROVIDES A WELCOMING DESIGN GIVING PATIENTS THE COMFORTS OF HOME

Patients visiting the new Sanford Health dialysis clinic in Detroit Lakes are welcomed with an abundance of natural lighting into each treatment bay, providing a relaxing and healing environment.

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HONOR ROLL 2020

Saint Marys Children’s Hospital Atrium Lobby Renovation Type of facility: Children’s Hospital/Pediatrics Location: Rochester Ownership organization: Mayo Clinic Architect/Interior design: HGA Engineer: HGA Contractor: Weis Builders Completion date: October 2019 Total cost: $1.25 million Square feet: 3,460

he Mayo Clinic Children’s Center at Saint Marys Campus in Rochester provides care to children and adolescents from around the United States and countries throughout the world. As part of this project, the two-level lobby was redesigned to act as a special harbor for children, utilizing the healing powers of nature to inspire hope and contribute to health and well-being—and to provide the best care to every child every day. The reimagined lobby

functions as a waiting space and respite for Children’s Center patients and their families. The space is animated with the sights and sounds of nature, from “forested” areas featuring a soothing diorama wall to the dynamic atrium and waterfall. Throughout the day, the lively space encourages exploration and discovery, while colorful lighting and twinkling stars create a soft glow at night. The hospital serves infants, children, and teenagers.

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HEALTH CARE ARCHITECTURE

Midwest Fetal Care Center/ Minnesota Perinatal Physicians Type of facility: Fetal Care Clinic Location: Minneapolis Ownership organization: Allina Health System and Children’s Minnesota Architect/Interior design: HDR Engineer: Paulson & Clark Engineering, Inc. Contractor: Knutson Construction Completion date: March 2016 Total cost: $2.8 million Square feet: 6,300

esigners of the Midwest Fetal Care Center’s “clinic of the future” considered scenarios that could arise now and well into the future. Consultation rooms and exam rooms are similarly sized, providing flexibility and adaptability. A large teaming room at the core of the clinic is enclosed with glass walls, allowing acoustical privacy while encouraging transparency and collaboration. A state-of-theart conference room allows live communication

with OR teams, as well as with fetal care experts around the globe. The exterior blends seamlessly with the Mother Baby Center, located directly above. Waiting and registration space is designed with the future mother in mind, providing comfort and privacy while allowing for interaction. Tall ceilings, carefully crafted soffit and wall details, soothing and artful graphics, and creative lighting design create a sense of calm and provide positive distraction for families.

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JUNE 2020 MINNESOTA PHYSICIAN

HONOR ROLL 2020

The Mother Baby Center at United Hospital Type of facility: Hospital Birthing Center Location: St. Paul Ownership Organization: Allina Health System and Children’s Minnesota Architect/Interior design: HDR Engineer: Palanisami & Associates, Inc. Contractor: McGough Construction Co., Inc. Completion date: February 2018 Total cost: $24.6 million Square feet: 62,000

he Mother Baby Center answers the question, “what does every mother and baby deserve?” The center offers the comforts of home, 5-star hotel amenities, positive distractions, and state-of-the-art care from first arrival to departure. The brand for this Mother Baby Service Center service line, created by Allina Health and Children’s Minnesota, carries through each of three Twin Cities facilities while staying unique to location and relevant to

community. Four design elements were created to reinforce the interior and exterior architecture in each Mother Baby facility: iconic-exterior, supergraphics, sculptural-ribbons, and lighting. For this project, we focused on the gardens of St. Paul, with flowering trees dominant, and delivered art through architecture. The sculptural-ribbons, applied to represent the flower shape, mimic the Mother Baby logo. Soft indirect lighting enhances the space and the patient experience.

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PrairieCare Medical Center Type of facility: Intensive Outpatient Mental Health Programming Location: Mankato Ownership organization: Tailwind Group, Inc. Architect/Interior design: ISG Engineer: ISG Contractor: DeMars Construction Completion date: September 2019 Total cost: $5.3 million Square feet: 22,000

rairieCare Medical Group of Southern Minnesota provides intensive outpatient mental health programming for children, adolescents, and adults. To establish flexible spaces for therapy, education, and supervisory activities, each of the Mankato site’s four floors was designed for a different age group, reducing the need for patients to move from one level to the next and crafting spaces customized to their needs and abilities. The design team focused

on providing as much daylighting as possible, including all group therapy rooms, classrooms (for school age-patients), patient care areas, and gross motor activity spaces. The design includes clear and controlled public and private spaces. Interior design utilizes finishes and colors to provide a calm, warm, and welcoming environment, while also acting as wayfinding. It also includes carpet seating patterns to get patients and providers on the same level and promote equity and inclusion.

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JUNE 2020 MINNESOTA PHYSICIAN

HONOR ROLL 2020

Voyage Healthcare Clinic Type of facility: Primary Care Clinic Location: Crystal Ownership Organization: MSP Commercial Architect/Interior design: Mohagen Hansen Architecture | Interiors Engineer: Innovative Structural Solutions, PA Contractor: RJM Construction Completion date: May 2019 Total cost: N/A Square feet: 13,842

oyage Healthcare (formerly North Clinic PA) has repurposed the former Chalet Liquor store in Crystal into a primary care clinic. The siteâ&#x20AC;&#x2122;s convenient retail surroundings and proximity to Highway 100 was ideal for relocation and expansion of their nearby Robbinsdale Clinic, minimizing disruptions to current staff and patients. An expansion of 3,000 square feet was added to the buildingâ&#x20AC;&#x2122;s south side. Significant structural, electrical, and mechanical

updates were completed to get the building up to medical office standards. With an original exterior building shell of bland, painted concrete blocks, additional windows, architectural metals, and sleek longboard siding was added to provide natural light. The interior design conveys a clean and fresh atmosphere with pops of blues, teals, and gold throughout. Attractive textures and abstract patterns are used throughout the space, creating a comforting and calming aesthetic.

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ARCHITECTURE

COVID-19’s influence on facility design Considering patient and provider safety BY STACY L. COLLINS AND DAVE MOGA, AIA

here is no denying that the world is a different place than it was a few short months ago. A seemingly healthy economy has been leveled to its knees and daily patterns and behaviors have changed dramatically. There is not a single industry that has been unaffected by the COVID-19 pandemic—some positively, most negatively. As we emerge from the pandemic, many positive changes will follow. Some of these will involve rethinking health care facility design. These changes will vary based on specialties and where the care is provided. What will the new health care environment look like? Changes in health care facility design will likely follow a three-stage process. There will undoubtedly be short, mid-term, and long-term modifications required as the health care industry moves to a new normal. One thing is certain: planning principles associated with the layout and design of medical buildings and clinical environments will change in a variety of ways.

Short-term solutions—emotionally driven Social distancing, stringent hygiene practices, and isolation will be part of the new normal in clinics and hospitals. The importance and

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emphasis placed on these behaviors will require a needs assessment of each facility to identify potential gaps and vulnerabilities. Walking through existing spaces and viewing each area through the eyes of a patient or staff member will present the need for one or many of the following solutions: Create spatial barriers between the patient and staff at the check-in desk. Expand use of electronic check-in and self-check-in kiosks. Reconfigure waiting areas to incorporate spacing and back-to-back seating arrangements versus those facing one another. Implement cleaning stations in the public areas. Plan for one-way traffic flow of patients into and out of the exam areas. Adjust procedure schedules to allow time for room disinfecting between patients. This may require that clinic hours be extended with split shifts of staff to accommodate more visits per day. Reconfigure existing underutilized exam space to accommodate telehealth capabilities. When executed properly, these examples of proactive planning offer a comforting, safe, and welcoming environment that instills confidence in patients and staff alike.

Mid-term solutions—research influenced As more research is gathered surrounding this pandemic, we will begin to see more complex solutions put in place that will provide comfort and confidence to health care administrators as they invest in modifying their facilities. These solutions may include: Space plan modifications that create larger, more flexible waiting areas to meet distancing requirements while compressing other spaces to maintain the same footprint. Medical Office Buildings may seek to develop accessible exterior locations to provide a canopy for drive-up testing. Enclosing open patient treatment spaces such as infusion bays for control of airborne particulates.

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An upgrade of materials and finishes may be required throughout to incorporate bleach-cleanable fabrics and surfaces. A recent Johns Hopkins report states: “So far, evidence suggests that the virus does not survive as well on a soft surface (such as fabric) as it does on frequently touched hard surfaces like elevator buttons and door handles.” Ventilation, purification, and humidification play a key role in mitigating the spread of infections. Additional research will likely change requirements in this area and an assessment by a qualified HVAC partner will become necessary. Facilities will look to make modifications to the existing HVAC systems to improve air flow and filtration. Research will continue to drive modifications that health care facilities will seek in the next 12 to 18 months. Rest assured, patients beginning to

JUNE 2020 MINNESOTA PHYSICIAN

make their way back to their normal well-patient visit schedule, and even those who seek specialty care, will approach that care and ultimately make a provider selection based on emotional and intellectual information gained as a result of the COVID-19 experience.

Long-term solutions—yet to be defined As research and models continue to be developed and assessed, changes are on the horizon. The health care industry will look to advancements in technology that may change the level of interaction between the patients and care providers at different times during a patient visit.

Changes to the flow of patients throughout the facility. Although it is unlikely that flow in a building would be formally codified, the building code may require that facilities be able to identify separate routes for suspected infectious patients that limit cross contamination.

Medical buildings and clinical environments will change in a variety of ways.

We have noticed a change in the preregistration process, with fillable forms being sent via email and submitted prior to a visit to reduce wait times and interaction. This will most likely become commonplace as facilities seek to reduce the number of patients in the facility at one time. The ability to check in for an appointment with a smart phone or at a self-check-in kiosk will also reduce interactions as the six-foot social distancing does not offer a great deal of privacy during the check-in process. We anticipate future building code modifications may impact all building types and functions but will directly impact health care environments in response to the need for surge capacity and overall infection control measures. These potentially could include:

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Requirements to develop multiple and controlled building entries which may be identified for “well patients” and “potentially infectious patients” to be utilized based on the reason for a visit.

Waiting room size requirements may be altered to accommodate social distancing and include sub-divided spaces to segment the patient population.

Modifications to HVAC system requirements to address humidity control, increase ventilation, and improve exhaust air from high-risk environments will aid in infection control. This may be a significant challenge for some existing buildings, since many mechanical systems do not lend themselves to changing functionality or control without replacing the entire mechanical system. It is more likely that newly designed buildings would be required to have more controllable HVAC systems to account for isolating and exhausting air from critical spaces. COVID-19’s influence on facility design to page 344

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MINNESOTA PHYSICIAN JUNE 2020

NEUROLOGY

The coronovirus pandemic Assessing neurological complications BY IRFAN ALTAFULLAH, MD

oronaviruses are a large family of viruses that are believed to cause between 15–30% of common colds. SARS-CoV2 is one member of this family. Until recently, it was known to be endemic only in bats and is believed to have jumped species to infect humans, probably through an as yet unidentified intermediate host. The first human cluster was identified in December 2019 in Wuhan, China and, within a matter of months, rapidly spread across the globe. As of June 10, 2020, there have been over 7.3 million cases reported worldwide, with over 400,000 deaths.

About the virus SARS-CoV2 is a relatively large single-strand RNA virus with about 30k nucleotides that code for several non-structural and four structural proteins, of which the best known is the spike protein located on the outer surface of the viral envelope, giving it a crown-like appearance. SARS-Cov2 shares approximately 80% genetic commonality with the SARS-Cov1 virus (responsible for the SARS epidemic in 2003) and the MERS (Middle Eastern Respiratory Syndrome) virus. The Coronavirus

genome is remarkably stable probably due to a robust proofreading mechanism. Isolates of the OC43 strain (which can cause “common cold”) from 1961 and 2000, show only two amino acid differences. Nonetheless, mutations do occur and three major strains of SARS-Cov2 have been identified; the clinical significance of the mutants is uncertain. The primary method of human-to-human spread is through airborne transmission. The primary target of the virus is the respiratory tract where the spike protein binds with the Angiotensin Converting Enzyme 2 (ACE2) receptor. The virus then enters the cell and hijacks the host cell protein synthesis machinery. The viral RNA is translated and various subgenomes direct the synthesis and post-translational modification of viral proteins, eventually producing copies of the virus that are released from the host cell by exocytosis. While SARS-Cov2 primarily causes respiratory illness of varying severity in most symptomatic individuals, the virus can have widespread effects on the body. In the initial patient cluster in Wuhan, neurological symptoms were reported by 36% of individuals hospitalized with COVID19. Several reported symptoms were non-specific (e.g. headache, depressed level of consciousness, dizziness, or seizure), while others were more specific such as loss of smell (anosmia), loss of taste (ageusia), or myopathy.

The nervous system

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There are several known mechanisms of viral involvement of the nervous system such as direct infection (West Nile Virus–WNV), reactivation of latent infection (Varicella Zoster Virus–VZV), or immune-mediated, where antibodies produced in response to viral infection can attack the brain (Acute Disseminated Encephalomyelitis–ADEM), spinal cord (transverse myelitis) or peripheral nerves (Guillain-Barré syndrome). Recently, an unusual mechanism has been described where Herpes Simplex Virus 1 (HSV-1) encephalitis can be followed a few months later by an anti-NMDA receptor antibody encephalitis. It is believed that the HSV-1 virus alters the NMDA receptor making it antigenic. Viral infections of the nervous system can occur in immunocompetent (e.g. HSV-1, WNV) or immunocompromised hosts (Cytomegalovirus, JC Virus, Epstein-Barr Virus). Interestingly, viruses can sometimes produce neurological disease years or decades after the primary infection, for e.g., SSPE in adolescence following measles infection in childhood. Viruses can be highly neurotropic and affect very specific cell types or groups, such as Polio virus, which predominantly attacks anterior horn cells in the spinal cord and various nuclear groups in the brain stem.

SARS-CoV2 and neurological diseases There may be several potential mechanisms by which the SARS-CoV2 virus produces neurological disease including direct invasion possibly through the hematogenous route or through the cribriform plate of the ethmoid bone with invasion of the olfactory nerves and transsynaptic spread, or indirect mechanisms via proinflammatory cytokines (e.g. IL6) or antibodies that cross-react with neural antigens.

thromboses. Many centers are now routinely treating patients hospitalized with severe SARS-CoV2 with anticoagulants, such as lovenox or heparin.

Over the past several months there have been numerous case reports and series describing various neurological complications of SARS-CoV2 infection. Our knowledge is evolving very rapidly, almost week to week. Some of the major clinical syndromes associated with SARS-CoV2 are described below:

Acute Disseminated Encephalomyelitis (ADEM). There have been many reports of patients infected with SARS-CoV2 demonstrating symptoms and signs consistent with ADEM, an immune-mediated Strokes. Strokes due to viral brain infections inflammatory condition affecting the brain and are distinctly rare though have been previously spinal cord. My colleagues and I have personally described with VZV infection. There have been seen several cases in our inpatient practice. Clinical several short case series reporting the occurrence presentation includes altered mental status, of ischemic strokes in patients infected with multifocal weakness and sensory disturbance, SARS-CoV2. Many affected patients were Knowledge of these syndromes will help in earlier recognition as well as seizures. Brain MRI may reflect young, without the traditional risk factors for diffusion-weighted imaging abnormalities along stroke such as hypertension, diabetes mellitus, with multiple T2/FLAIR sequence hyperintense, hyperlipidemia, or history of smoking. Further, the bilateral, asymmetric, patchy and poorly defined strokes were large and were caused by thrombosis lesions typically involving the subcortical cerebral of intracranial vessels such as the internal carotid white matter and cortical gray–white matter or middle cerebral arteries. Eligible patients were junction, thalami, basal ganglia, cerebellum, and brainstem. CSF often shows treated with intravenous alteplase and mechanical thrombectomy but despite elevated protein and mild pleocytosis consistent with inflammation. Highinterventions, many had significant residual disability. Unfortunately, there dose corticosteroids are used as first-line therapy and intravenous immune were significant delays in seeking medical care after stroke symptoms had globulin or plasma exchange are used in steroid-unresponsive cases. ADEM is developed, which generally translates to a worse prognosis for recovery. The typically a monophasic illness with favorable clinical recovery in most cases, clinical manifestations of stroke caused by SARS-CoV2 are not unique and as well as complete or partial resolution of MRI signal abnormalities. We do depend upon the size and location of the affected area of the brain. Although not have enough data at this time to know the prognosis of ADEM caused by the precise mechanism causing strokes is elusive thus far, it is believed that severe SARS-CoV2 infections produce a systemic prothrombotic state, with endothelial dysfunction and hypercoagulability leading to arterial and venous The coronovirus pandemic to page 324

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3The coronovirus pandemic from page 31 SARS-CoV2. A rare variant of ADEM has also been described with SARSCoV2—acute hemorrhagic leucoencephalitis, which is a more fulminant condition with significantly higher morbidity and mortality due to petechial hemorrhages, necrotizing vasculitis and diffuse cerebral edema. Thus far, it is not certain whether SARS-CoV2 causes encephalitis by direct invasion. Guillain-Barré syndrome (GBS). Several cases of GBS in patients with SARS-CoV2 have been reported. In most cases, the onset of GBS was preceded by respiratory symptoms by 5–10 days. In at least one reported case, the patient did not report preceding fever or respiratory symptoms but had transient loss of smell and taste and had a positive RT-PCR test for SARSCoV2. GBS typically presents with gradually progressive sensory symptoms, motor weakness or both, beginning distally and ascending over a few days. In severe cases of GBS, patients can develop bulbar weakness and/or respiratory failure that requires intubation and mechanical ventilation. Autonomic nerve involvement can result in arrythmias and labile blood pressure. Initial diagnostic suspicion is based on clinical presentation; CSF examination often shows elevated protein with normal cell count and cases may be confirmed by EMG. Nerve conduction studies typically show slowed peripheral nerve conduction (due to demyelination), but can also demonstrate denervation due to axonal destruction in more severe cases. In early stages the diagnosis can be quite challenging when various tests can be normal. GBS is believed to occur due to antibodies produced against the SARS-CoV2 virus that cross-react with various antigens in the peripheral nerves. Treatment involves a five-day

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course of IVIG or plasmapheresis. Corticosteroids are contraindicated in GBS. Recovery, while generally good, can be slow and incomplete dependent largely on the extent of axonal involvement. Patients may require prolonged rehabilitation, as well as extended respiratory and nutritional support. In addition to these well-defined syndromes, there have been isolated reports of cranial neuropathies and myopathy with muscle aches, weakness, and elevated CK enzymes in patients infected with SARS-CoV2. Many patients with existing neurological diseases such as multiple sclerosis, myasthenia gravis, inflammatory neuropathies, or polymyositis are therapeutically immune suppressed with corticosteroids or monoclonal antibodies. This group of patients are at high risk for severe disease if they contract SARS-CoV2 and need to be especially vigilant to minimize potential exposure. Health care providers should take extra precautions when dealing with these (and other) vulnerable populations during clinic visits. In our relatively short experience with SARS-CoV2, it is evident that the entire neuraxis—brain, spinal cord, cranial and peripheral nerves, and muscles—can be affected, directly or indirectly, by the virus. Knowledge of these syndromes will help in earlier recognition and thus better care of patients affected by COVID-19. Irfan Altafullah, MD, is Medical Director of the Comprehensive Stroke Program at North Memorial Health Care, President of the Minneapolis Clinic of Neurology, and Adjunct Clinical Professor of Neurology at the U of M.

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3COVID-19’s influence on facility design from page 29 facility. This design could easily be modified and adopted for hospital and Planning for areas within the current footprint to provide telehealth. clinical settings to account for airborne contagion cases. Telehealth typically takes place where an onsite patient has access to a remote Summing up provider. The new model is one in which the patient There is no doubt that the delivery of health-related is at home and the services could be delivered services is going to change as we continue to gain from a local or a national health provider. The insight and research from the current pandemic. difference between the two models is that homeHealth care spaces will be designed with flexibility based patients would not have access to testing, and functionality at the forefront of the planning blood pressure, temperature checks, and other Waiting room size requirements and conceptual design process. We must begin basic functions that take place during a traditional may be altered. thinking about worst-case scenarios and develop visit. It is likely this model of care will be expanded solutions that respond to those scenarios while and become more sophisticated moving forward as implementing design principles that meet the an alternative for remotely diagnosing infectious current and future programmatic needs of the patients and eliminating cross contamination. practice. If there is one thing that we have learned Building design to accommodate exterior about the health care industry, it is that medical testing and triage bays. During the COVID-19 outbreak, we have seen personnel are dedicated, resilient, and innovative. As health care designers, an influx of exterior testing stations and drive-through services. This may we continue to seek unique design solutions that respond to the needs of become common for hospitals, clinics, and outpatient centers as drive-up patients while addressing the challenges providers face to confidently and service care delivery may become a better alternative for potentially infectious safely deliver high quality care to their patients. patients to reduce the risk of introducing them to non-infected patients and staff. This type of design is already used in emergency departments Stacy L. Collins is Project Manager/Medical Planner at Mohagen Hansen near hazardous chemical and nuclear facilities with a decontamination room that is isolated from the rest of the facility, allowing the initial care for contaminated patients until they can be safely admitted to a medical

Architecture | Interiors, a full-service planning, architecture, and interior design firm. Dave Moga, AIA, is Project Manager/Architect at the firm.

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Minnesota Physician • June 2020

Articles inside

ARCHITECTURE COVID-19’s influence on facility design

ARCHITECTURE Person-centered care environments

INTERVIEW