May 29, 2020

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On May 13, 2020, Caravan Health hosted a webinar to share ideas about how facilities are working toward reopening a broader range of services. The following is a summary of that discussion.
 
Presenters:
  • Moderator and Host John Findley, MD, Caravan Health
  • Chris Solaro, MD, Blessing Health Systems, Illinois
  • Renee Diamond, MD, Iowa Specialty, Iowa
  • Scott Smith, MD, Central Montana Medical Center, Montana 
Planning topics include:
  • Using Community Data vs State Declaration
  • Anticipating a Potential Tsunami of Chronic Disease
  • Foundations for ReopeningReopening Governance
  • Medical/Staff Communication and Program Development
  • Ideas from Sweden and South Korea
  • Multiple Uses for Telemedicine
  • COVID and non-COVID Workflows and Locations
  • Special Strategies for Surgery
Foundations for Reopening
John Findley, MD
Using Community Data vs State Declaration
With the prevalence of COVID varying greatly throughout the country, health care providers find themselves at different points along this pandemic journey. Some have experienced significant surges in COVID related care while others have seen little to no impact. Although some health systems have not reached their peak of cases, there are urgent reasons to rapidly plan for reopening. Shutting down services has created a severe financial impact on providers and patient backlogs in surgeries, procedures and routine care are mounting.
 
While state government declarations may influence the timing of reopening health care services, facilities need to first explore multiple internal and community interdependencies before proceeding safely. With community spread now occurring across the nation, exposure risk is even higher, and a repeat surge could potentially create hospital capacity issues in the ensuing months.
 
Anticipating a Potential Tsunami of Chronic Disease
Although necessary to prevent exposure to at-risk populations, such as those over 65 or with common chronic diseases like hypertension, sheltering in place has led to many vulnerable patients avoiding services altogether. A Commonwealth Fund study showed a 45 to 65% reduction in outpatient visits since the start of the pandemic, with those over 65 leading all age groups in care avoidance. This simply isn't sustainable as halting routine care will result in avoidable exacerbations and associated morbidity and mortality if virtual solutions are not implemented.
 
The consequences of this delayed care are not insignificant. The American Heart Association and the American College of Cardiology has been vocal about encouraging patients to seek care when necessary. Stories abound of individuals that stayed at home with symptoms of a stroke, afraid to go into the hospital. This may be out of fear of COVID or hearing a strong message that there are no beds available. As a consequence, patients are suffering significant sequelae of disease that could have been rapidly and readily treated had they sought care. Patients need to know that their providers and hospitals are available to take care of them virtually or in person as this pandemic plays out over the next few years.
 
Three Key Points for Reopening
 
"Maximum use of all telehealth modalities is strongly encouraged. However, for care that cannot be accomplished virtually… these recommendations may guide health care systems and facilities as they consider resuming in-person care of non-COVID-19 patients in regions with low incidence of COVID-19 disease.”
Opening Up America Again, CMS
1. Telemedicine for vulnerable patients: Multiple recent Public Health Emergency policy recommendations from the Centers for Medicare and Medicaid Services (CMS) clearly articulate that telemedicine must be a central strategy to keep vulnerable patients at home when reopening America through the duration of this novel pandemic. With many remaining unknowns there is a strong message to ramp up telehealth capabilities as step one or a foundation for future care delivery.  

2. Gating criteria: The much-anticipated CMS guidance document Opening Up American Again Centers for Medicare & Medicaid Services (CMS) Recommendations Re-opening Facilities to Provide Non-emergent Non-COVID-19 Health care: Phase I included specific language about gating criteria to be considered before communities open. The first gate is that before resuming in-person care, regions would have declining rates of COVID 19 cases for a 14-day period. This is an essential first step to make sure that people aren't unknowingly being exposed to COVID-19 while seeking needed care. Many states are proceeding with reopening businesses without taking this 14-day decline into consideration. Given that nearly 20% of patients are asymptomatic carriers and community spread is now occurring in both metro and rural communities, the potential for a significant increase in new cases in the ensuing weeks demands continued incident command preparedness. Before resuming operations too swiftly, a potential resurgence of COVID related illness and the resulting potential impact and stress on health systems must be considered using data to drive best practice decisions.
 
3. Adequate testing: The third point is the need for adequate testing that is readily available. Testing is part of the tools needed to approach and assist communities in tracking current prevalence and guiding decisions for reclosure. There is wide variation between states in available testing, turn-around times, and general approaches to both acute diagnosis and community surveillance. Working with local and adjacent communities to establish needs and approaches should be one of the first orders of business.
 
Opening as a System
For the facility itself, service lines have many interdependencies that must be considered, and handoffs must be contemplated.  As one line is opened, are you prepared for the ripple effect that it might have on the other ancillary and support services within your own system? How will you manage transitions from high to low acuity settings to avoid post-operative complications? Systems must consider the entire continuum of care as they approach reopening.
 

The good news, as per the most recent interim fee schedule updates, there are ways that you can accomplish this goal by reopening service lines virtually. Now with expanded services and eligible providers in PT, OT, post-acute, home health, and SNF, there is recognition that pre-operative or post-operative patent care needs can be managed in a virtual environment. With the added emphasis on removing barriers to virtual services in primary care, the care continuum is now complete.
 
This new pathway to your health system’s virtual front door must be easily navigated and highly coordinated between care settings in order to provide the quality of care patients are accustomed to.
 
Before resuming normal operations, facilities will also need to have clearly defined criteria for when to close back down in the event of a resurgence. What will your circuit breaker be? What are the conditions that close services again in the event of local community spread? What will the leading indicators be and how will you make the difficult decision of closing back down if that day comes?
 
A Call to Action
There are many steps to contemplate as you approach reopening in your communities. Despite economic pressures, health systems must be at the table actively advising and advocating for the safety of their own communities.

Although New York City is seeing a decline in new cases, the rest of the country is not. If that trend continues to increase, communities must be prepared. Rural or non-metro areas are seeing dramatically higher rate increases, not only in new cases, but in deaths. The CDC has shown eight out of 10 of these patients are over 65, vulnerable elderly. What are we doing to protect them the most?
 
History has a tendency to repeat itself, if one does not take heed of its lessons. The second wave of the Spanish Flu was dramatically greater. Many causative variables have been debated, but the consensus seems to be that a quick move back to a return to normal from a social distancing standpoint and troops traveling about the country resulted in an unexpected and even more deadly second wave. Health experts agree there is a high probability that COVID is likely to have a much greater impact on rural if precautionary measures are not continued. A simple truth due to capacity and scare resources in many if not most rural communities. An issue likely exasperated due to furloughed staff, continued PPE shortages, and a lack of adequate testing. Health systems must work closely with community partners, adjacent rural and metro health systems, and local and regional public health departments in order to have a successful reopen and recovery.
 
Blessing Health Systems, Illinois
Chris Solaro, MD

Emergency medicine physician Chris Solaro, MD, serves as chief in medicine for Blessing Health Systems and leads their clinically integrated network. Located in Quincy, Illinois, Blessing Health System is a three-hospital, regional health system that serves an area of about 250,000 people. Blessing hospital is a 300-bed, acute care hospital with two associated multi-specialty medical groups and two affiliated critical access hospitals. The emergency department sees around 50,000 patients per year.
 
Time spent strategizing and organizing at the beginning of the pandemic has proven helpful as they work to reopen. The process and structure used to develop their COVID response is being used to restart and recover and are based on five main concepts: organize, engage, delegate, communicate and respond.
 
Reopening Governance and Planning
Early on, Blessing Health Systems set up an Incident Command System to provide a system wide structure and assemble key stakeholders around the table. Key stakeholders in the room were virtually connected to about 40 stakeholders throughout the health system. This includes everyone from the CEO in the room to purchasing, virtual health, IT, and anyone else who might have information to report.
 
Meetings were held twice a day, led by the incident commander, and lasted 15-20 minutes or longer if necessary. Each stakeholder provided an update on what they were working on; what they needed; and pain points or areas for further exploration. It was an efficient way to share information and get things done.
Out of this group, small groups developed to get work done on projects. There was accountability and expectations that things would get done quickly because they were meeting twice a day and on weekends. The structure worked well and continues now with once a day meeting.

Medical/Staff Communications and Program Development
Solaro works closely with several other physician leaders, namely the chief of quality and safety and the lab director. These physicians met daily and found this a great opportunity to engage medical staff.
Staff wanted to know more about the disease itself, how the hospital was responding, and what the implications were for their practices. These physicians engaged medical staff, who were then able to design several new committees. And from these committees, other aspects of response were addressed.

Non-COVID Care Locations: An ED triage was redesigned and an off-site COVID testing facility was developed to get COVID testing away from the hospital and to preserve the community's understanding that the hospital was still a safe place to come.

COVID 19 Physician Work Group: A COVID 19 physician work group was developed with about 15 hospital-based physicians. They developed a shared knowledge base, so everyone knew how the Blessing Health System would care for COVID 19 patients from a treatment and management standpoint and for assembling best evidence.
An Airway Response Team was developed to address how to get the most expert airway management physician for patients who needed an airway. Would it be the usual code response team or someone else?

A physician leader and leaders from infection control educated not only physicians, but also nurses on how best to use isolation.

An OR review committee was developed initially to look prospectively out about a week or two to determine if cases need to be cancelled and, if so, which cases. The committee was chaired by a lead surgeon, but is multi-disciplinary group. It includes surgery anesthesia, nursing, and pharmacy, and other proceduralists, like GI, for example. This started at the beginning to recast the surgical caseload and, when the time came, elective surgeries were shut down. This committee met weekly and is now in a position to decide how to reopen surgery. This same group, who developed a workflow and trust, is now reopening elective surgeries in a very careful way with proper testing and adequate PPE, etc.

Overall, physicians and other providers were kept informed every day. Daily email briefs summarized new information. Twice a week, there were virtual updates and Q & As for about 15 or 20 minutes. It provided information through a different medium and an opportunity for dialogue.

Responding to and Supporting Staff: Physicians and other staff and providers needed leaders who were available and supportive. There are a lot of emotions when the workload goes down 50%, people worry about their patients and income. Supporting people through change invited constructive feedback and kept leaders open to new ideas. Most of the good ideas came from medical staff because they know what the acute problems are. The medical staff talks to each other now more than they ever have. Change is hard and that must be acknowledged, but everyone had to face it and become more of a support network.
 
Factors for Reopening
One development from incident command was IT developing a dashboard to watch key indicators to monitor how the system has been doing. It is now being used to help determine when it’s safe to return to doing regular work in the hospital.
Blessing Health hasn’t had a lot of COVID cases. They tested about 1600 people, with about 53 positive cases. Most of those have not been hospitalized. While they haven’t had the surge they prepared for, they still want to open up safely. They are tracking:
  • Positive case rates.
  • The community hotline used for COVID related questions.
  • The volume of calls is tracked per 24 hours to see if there's an uptick and whether people are just interested or if they have more symptoms.
  • The volume at their outpatient flu-like illness center where COVID testing is provided.
  • If more patients are seeking COVID testing, it may indicate a surge in cases.
  • The hospital census with COVID potential patients and ICU volumes.
  • Testing at nursing homes in the region, which is provided by the county department of health.
  • PPE inventory.  
Patient Communication & Coordination
The Blessing Health marketing and public relations team are part of incident command and help interface with the community and the public health department. A number of physicians provide media interviews for the community. Now, not so much to talk about social distancing but to say it's safe to come into the hospital and get care.

Iowa Specialty Hospital & Clinics, Iowa
Renee Diamond, MD
 
Renee Diamond, MD, is a family medicine physician at Iowa Specialty, a small health care system with two hospitals in Clearing and Belmont. Each of those communities has about 3000 residents. Iowa Specialty has a large primary care presence and also serves as a regional health care provider having a high number of specialists. Last year they did 519 total joints, about 400 deliveries, and 300 bariatric surgeries. They have nine mental health counselors and also have pain management, ENT, and urology.
 
Reopening Governance and Planning
On March 17, the Iowa governor shut down elective services. During that time, the COVID team (about 20 people) developed information and disseminated company-wide summaries. On April 24, the governor announced that elective or less essential procedures would be allowed. Their team discussed how to return to some normalcy and included versions of the Sweden and South Korea plans. The caveats that the governor put on opening was to have at least 30% of beds open at all times. 30% of ventilators available, and a willingness and ability to accept COVID patients in the event of a surge. They weren’t allowed to use state PPE sources and needed their own sources before opening.

Lesson That Underscored Plan Development: Iowa Specialty was asked to swab workers from a pork processing plant who were bussed to Wright County from a county with a high prevalence of COVID. Of the 62 initial swabs, 16 were positive. They partnered with public health and others to swap the rest of the company, 805 more people, and found nine additional cases. All of those positive had mild or no symptoms, which revealed the presence of asymptomatic infection within their communities and the threat this posed. This finding underscored the processes the team developed.

Sweden Plan: Iowa Specialty’s take of the Sweden plan opened the system for younger, healthier patients and allowed practitioners to work down the backlog. This applied not only to surgeries, but also ambulatory services, clinic radiology, and some other therapies. It emphasizes the use of telemedicine as feasible. The plan also asked older individuals and those with chronic illnesses to remain at home.
Social distancing without congregating continues and both patients and staff are encouraged to limit their footprint within the facility. Visitors are not allowed except in the cases of minors or disabled persons. Practitioners limit their caseloads so there are fewer people in the waiting room. Waiting room chairs are moved away from one another and visitors wear cloth masks.

Telemedicine: Telehealth has been one of their silver linings from COVID. Telehealth legislation had been passed, but it wasn't set to take effect until next January. COVID put it on the fast track. Using multiple platforms in the first five weeks, they had 3,200 visits, including patients from nursing homes. They did annual wellness visits with telehealth as well as postpartum lactation visits, physical therapy, speech therapy, diabetic education, and dietitian consults. Patients have ranged from 18 days to 100 years old. The team had used the initial downtime to prepare for their virtual office.
Currently, they have a survey monkey questionnaire out to the medical, registration, and nursing staff to discover which systems or platforms work well, which don’t, and where the kinks need to be worked out. Once identified, best practices will be used throughout the system.

Elective Surgeries: All patients sign a consent to acknowledge the risks that may be associated with having surgery during a pandemic. They also have a swab done 48 hours prior to their procedure. Using this method, they are operating at about 50% their usual surgical case level.

South Korea Plan: Iowa Specialty’s version of the South Korea plan includes doing low risk inpatient cases, and based on surveillance of the disease, proceeding with some patients who are at higher risk for morbidity and mortality from COVID infection. This strategy uses aggressive testing to provide reasonable assurance that COVID cases are found and contact tracing will help contain the spread.

Contact tracing is assisted by local public health departments. While tracing is often done to household contacts and people who were within six feet of someone positive for 30 minutes, Diamond said their population density and the paucity of cases allows them to be more aggressive. Their method includes household contacts and interviews to find anyone patients been exposed to for more than 10 minutes within six feet in the last 48 hours prior to their positive test or 48 hours prior to their onset of symptoms.
 
COVID and Non-COVID Workflows and Locations
Medical & Staff Communication A triage bank of nurses are in direct communication with physicians so that as resources are rearranged and clinics or entrances change, providers know exactly how to route patients through the system. The goal is to make sure patients are evaluated in the safest setting for both patients and health care workers.

COVID Testing: Iowa Specialty does all nasal pharyngeal swabs at their curbside clinic. This takes the work off the public health department, but also ensures swabs get funneled through their system and results get to providers. Public health conducts epidemiology tasks with positive cases. Almost 1000 people have been swabbed with only 11 positives. None of those have been hospitalized to date.

Adult Respiratory Clinic: This clinic focuses on patients with uncontrolled diabetes, CKD, CHF, COPD who have a new fever or cough. It has a separate entrance, separate air flow and a different path through the building. It allows the team to do labs, radiology, and swabs.

Non-COVID Care: When allowed to start elective cases, a separate entrance was created to minimize COVID exposure for patients and health care staff.

Telehealth and Lab Work: If a patient seen via telehealth needs lab work done, they can avoid coming into the facility. Iowa Specialty is using the Wright County Emergency Preparedness trailer as a portable lab. Patients are given a time to arrive and directions for which slot to drive into. Patients provide the make and model of their cars and the lab team draws labs car side.
 
Outreach to Neighboring Counties
Iowa Specialty realized that while they don't have the supplies or staff to swab 5% of Wright County and the eight bordering counties, they still wanted to help neighboring counties and protect their ability to expand services. They arranged a neighborhood county call and invited public health directors and the administrators from care centers. The goal was to share their process and let others know they are happy to help. If they use similar processes, they can help others and others could help them. The team also had a call with local businesses to raise awareness about their services.
That outreach opened up avenues for the team make things happen quickly and efficiently. The day after their neighborhood call, they received a request for assistance at 7:30 a.m. A team with nursing and lab was assembled. Registration staff worked remotely. The team showed up 10 hours later and swabbed the facility and residents that evening. The Public Health Department there wouldn’t have been able to do that for eight days.
 
Central Montana Medical Center, Montana
Scott Smith, MD
Scott Smith, MD, is a general surgeon at Central Montana Medical Center (CMMC), a 20-bed critical access hospital that serves a large geographic area with low population density. They closely partner with tertiary centers and rely on their resources when patients exceed their level of care. CMMC focuses not only on their capabilities, but also tertiary or receiving facilities capacities and patient caseloads.

Smith shared their approach to restarting operating rooms and elective procedures. In March, the American College of Surgeons recommended the cessation of elective procedures. They shut down elective operations at CMMC within 24 hours of that recommendation. This was part of an overall plan to flatten the epidemiologic curve of COVID 19 and to prevent overwhelming the medical community’s resources that may be needed in the event of a COVID surge.
 
Reopening Governance and Surgery Planning
Montana has had a low burden of disease so far. While they have one of the lower rates of testing, they have just 16 active cases in the state. Three of those required hospitalization. On April 27, the governor allowed some phased reopening of activities, including elective procedures. CMMC wasn't ready to restart at that point and took about week or so to prepare. While there has been a significant financial burden from not doing elective procedures, they wanted to reinstitute procedures safely.
The American College of Surgeons issued another statement outlining plans to reinstitute elective procedures throughout the country. CMMC expanded upon that guidance based on their local situation. They took into consideration three key points: disease prevalence, hospital capacity, and supply availability. They also searched for an objective scoring system to help identify patients who were suitable candidates for the first phase of reopening their facility. They wanted a plan to “dip our toes in the water, rather than cannonball back in.”

Disease Prevalence: It was important to consider multiple aspects in their system and within their community and county. In Fergus County, which is a county the geographic size of Connecticut, they currently don't have any cases of COVID and have not had any positive tests. The county was credited with one patient diagnosed in Seattle but who has not been in their county for about five months. They also monitor the state’s and surrounding region’s prevalence data. CMMC is surrounded by a number of states with sparse populations and large land masses, which create natural socially distancing. There has been a low incidence of COVID in Wyoming, North Dakota, and South Dakota.

Testing: Their COVID testing swabs are sent via courier to a lab in Helena. The average turnaround is about 48 hours. It's important for them to understand the capacity to test and the turnaround times for results. Turnaround times may increase as facilities ramp up elective procedures and include mandatory swabbing prior to elective procedures.

Plan for Complications: CMMC planned for normal post-operative outcomes and complicated post-operative courses. If there is a complication that they are unable to provide care for as a critical access hospital, they need to ensure receiving facilities have capacity as well. CMMC also collaborated with referral centers when planning the timing of reopening elective procedures.

Staffing Capacity: Staffing issues were an important part of their plan since OR staff had been repurposed to assist with ICU care or with acute care management of patients on the floor. They made sure that hospital acute care and ICU wards had staffing capacity so OR staff members could return to their original positions, cover call, and do a full OR schedule.

PPE and Other Surgical Supplies: One challenge was their supply chain. It was critical to make sure supplies are available to move forward with elective procedures without putting undue burden on ICU management. CMMC encountered a challenge when a major manufacturer of surgical gowns issued a nationwide recall just prior to the spread of COVID. On top of that shortage, there was the increase for gowns in the treatment of COVID patients. They were faced with waiting until July before resupplying. They had to consider workaround options, such as using cloth reusable surgical gowns and other options. Not having surgical gowns also affected the manufacturing of surgical packs, which usually include surgical drapes and other supplies. Three gowns are included in those surgical pack, so when surgical gowns were unavailable, the manufacturer quit producing surgical packs.

Telemedicine, Social Distancing and Restrictions: CMMC restricted visitors and drivers in the operating room area and used telemedicine or the phone to talk with the families before and after the procedure. Telemedicine was also used for pre-operative and post-operative evaluations to limit traffic through outpatient clinic settings.

Starting Elective Procedures: For preventive procedures like colonoscopies, only patients under age 65 without significant comorbidities were allowed in the initial phase of reopening. CMMC continues to push back patients in higher risk categories until later phases of the reopening process.

There has been a transition in the language used. Traditionally, elective procedures in surgery means that they can elect the time at which those procedures are done. It's not to indicate that the procedure itself can or cannot be done. Now, there has been a transition to say medically necessary, time-sensitive procedures to minimize confusion about what elective procedure means.

Scoring System: Smith noted an article in the Journal of the American College of Surgeons (see reference link below) that highlighted a novel scoring system developed by a team of physician investigators at the University of Chicago called the Medically Necessary Time-Sensitive (MeNTS) Prioritization process. This tool identifies 21 factors related to outcome, risk of viral transmission to health care professional, and use of resources. Each of the 21 factors is scored on a scale of 1 to 5, and the total score, ranging from 21 to 105, is computed for each case. The higher the score, the greater the risk to the patient, the higher the utilization of health care resources, and the higher the chance of viral exposure to the health care team. 

It helps to remove biases when determining which cases should be prioritized. There are multiple specialists that do outreach at their facility, including ophthalmology, orthopedics, ENT, and urology. If a patient’s score meets the criteria, then the procedure is scheduled within the limited capacity. CMMC controls the number of procedures to limit traffic through the pre-operative and post-operative areas and maintains social distancing principles.

There are some flaws with the scoring system such factors are weighted equally when maybe they shouldn't be, and there's subjectivity to a substantial portion of the scoring. It’s also dependent on the professional integrity of the surgeon scoring patients. If there is abuse of the system, CMMC has a plan in place to police that and to speak with the surgeon who is abusing the situation.

There is no mandated scoring for urgent or emergency cases. The definition of that is largely is left up to the surgeon’s discretion. If the surgeon declares that is cases emerging or urgent, it moves forward. Cases such as C sections, appendectomies and other emergent surgeries forego the scoring system.

Choosing the Circuit Breaker: Each facility and community has to look at its own situation and circumstances to determine the criteria to back off a little or reverse direction. CMMC uses the concept of community transmission of the disease as criteria for putting the brakes on or backpedaling a little if COVID cases rise. If they can be contact traced and appropriately quarantined and contained, they will not necessarily stop the progress. However, if they encounter community transmission, that’s a different scenario.
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