Fourteen hospital and health system leaders shared the most challenging aspects of resuming elective surgeries, the first steps they are taking to reschedule elective procedures that were canceled last month, and how they are collaborating with health officials.
All respondents shared their insights with Becker's via email April 20-22. Responses were lightly edited for clarity and length. They are presented alphabetically.
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What is most challenging about deciding when to resume or ramp up in-person care?
Kathy Bailey, President and CEO, Carolinas HealthCare System Blue Ridge (Morganton, N.C.)
We want to make absolutely sure that we ramp up in-person care at the right time — early enough to start getting people seen again, but late enough to prevent a second surge of COVID-19 cases. We will need to rely on trending data to help drive that decision, which should be compiled based on testing data.
Peter Banko, President and CEO, Centura Health (Centennial, Colo.)
The biggest challenge in deciding when to resume or ramp up in-person care is the willingness of our communities to come back in person. Our neighbors now know that touching things, being with other people and breathing the air in an enclosed space can be risky. And they have been purposely avoiding hospitals and other care settings to, in turn, avoid the virus. For example, a recent article in The New York Times reported that cardiologists across the country are seeing a 40 to 60 percent reduction in admissions for heart attacks. We need to be able to assure our communities we are doing everything we possibly can to keep them safe.
Paul Beaupre, MD, CEO, St. John’s Health (Jackson, Wyo.)
I think restarting elective procedures is actually simple, however it is predicated on our ability to obtain the appropriate amount of rapid COVID-19 RT-PCR testing. If we had the appropriate amount of test kits, we would test everyone who is scheduled for an elective procedure on the day of their procedure. If the test is negative, they could come in and be treated like any patient prior to the COVID-19 outbreak. If they tested positive, we would inform public health and quarantine them for 14 days and then retest and provide the elective procedure. Without testing availability, we will go through inordinate amounts of PPE.
Ralph Castillo, CEO, Morgan Medical Center (Madison, Ga.)
Probably the most challenging thing is getting people to trust seeking care in the ED again (understanding that they will not catch COVID-19 by seeking ER care). The second is the mitigation steps that have been put in place. When is it time to start phasing them out?
Michael Dorsey, CEO, Johnson Regional Medical Center (Clarksville, Ark.)
It is challenging coordinating with local, state and federal guidelines. There are differences at each level, and not all the guidelines make sense, like antibody testing, when they are not reliable.
Steve Edwards, President and CEO, CoxHealth (Springfield, Mo.)
The variables and risk factors of this decision are well beyond our normal margin of error. It is a calculus that requires factoring in perceived versus real burn rate, the R0 [reproduction ratio] versus the impacted R0 due to social distancing, and any political adjustments to social distancing, the gradual effect of civil disobedience, the financial impact and the risk of life and limb. It becomes a decision that must be based upon our highest ethical thinking.
Will Ferniany, PhD, CEO, UAB Medicine (Birmingham, Ala.)
What makes this challenging are changes to governor’s order and all hospitals in the area working in concert.
Kiley Floyd, CEO, Nemaha Valley Community Hospital (Seneca, Kan.)
As of April 20, we have not had any cases in our county (yet). It is hard to sit by and wait, knowing it is the right decision to protect our staff and conserve PPE, while our cash is drained.
Steve Goeser, President and CEO, Nebraska Methodist Health System (Omaha, Neb.)
I am not concerned about the safety of elective procedures and our ability to test patients prior to surgery. The rub is that there is not enough PPE in the supply chain, and we are now getting about 30 percent of our propofol and fentanyl supplies. If we open up to all the private ASCs and GI labs, we could quickly create an unsafe environment if there is a second wave. We have plans on how and who would be brought back, but the supply chain is the key!
Ken Johnson, President and CEO, Hutchinson (Kan.) Regional Medical Center
The toughest part is making decisions with conflicting medical advice on the national front as well as locally. Some experts say it is still too soon to reopen significant avenues to surgical care, while others advise that we are simply not going to see the large influx that everyone feared two or three weeks ago.
Also, Kansas has not received needed test kits to do widespread testing, which will allow us more confidence in opening up the clinic and hospital to needed healthcare services that are building up rapidly due to COVID-19. The shortfall is not in the diligent effort to advocate and solicit needed testing kits, it’s in the number supplied to Kansas as a whole and the dismal amount of supplies that reach us in Hutchinson. We are poised to have a significant impact on the testing shortfall in Kansas. We are fortunate to have robust labs, experienced staff and capacity to meet a significant need. We just need testing kits.
Michael Layfield, Interim CEO, Carlinville (Ill.) Area Hospital
Two things are most challenging about deciding when to resume or ramp up in-person care: 1) The recommendation of social distancing and knowing the only way to stop coronavirus conversion is stay at home. 2) Testing of patients. There is no way to test for those who have the virus but show no symptoms yet.
Robb Linafelter, CEO, Lincoln (Neb.) Surgical Hospital
Our biggest concern is making sure we have enough PPE to meet the demand going forward with the increased need to meet additional PPE requirements. We would not want to stop doing surgeries after we started because we do not have enough PPE.
Tony Slonim, President and CEO, Renown Health (Reno, Nev.)
For Renown Health, this is all about risk assessment, given that we have not yet hit the peak in our region. We need to balance the ongoing health risks from further delaying important but elective surgeries with the ongoing limitations in PPE, COVID-19-related exposure to those who may be carriers and a lack of population-based testing that prevents us from knowing who may have the virus but be asymptomatic.
Matt Walker, PharmD, CEO, William Bee Ririe Hospital (Ely, Nev.)
Most challenging is the potential risk to patients given that you are bringing them out of their homes to a healthcare facility.
Where does one begin in rescheduling elective procedures that were canceled last month? How are you collaborating with local/state health officials?
Kathy Bailey, President and CEO, Carolinas HealthCare System Blue Ridge (Morganton, N.C.)
As we did with canceling procedures, we will rely on our providers to help determine which cases need to be scheduled first. They will look at patients who have urgent issues, and based on condition and COVID test results, determine when to do their procedures.
We’ve had a seat at the county unified incident command table since the pandemic was first identified and will be a part of the unified collaboration and discussion in determining when and how to begin to open businesses again. We are also part of the chamber of commerce discussions with businesses in our community on when and how to begin opening again.
Peter Banko, President and CEO, Centura Health (Centennial, Colo.)
We started with a 22-member multidisciplinary physician- and clinician-driven team across our 17 ministries for Centura, like we have for testing, PPE and other aspects of managing this efficiently effective virus. This "return to normal" group has provided standard recommendations and considerations in four key areas — resources, patient selection, critical nature of the patient and capacity. They also directed the formation of individual hospital committees to make the final determination of the prioritization of patients based on their unique needs, impact of COVID-19, geography, acuity and availability of support.
Ralph Castillo, CEO, Morgan Medical Center (Madison, Ga.)
As with most things, this begins with the surgeon and the patient. Those two entities have to agree that these items are necessary going forward, and they both are comfortable with the hospital. The key first step is the surgeon, followed by the patient, and then the regulatory restriction satisfactions.
Rick Davis, President and CEO, Central Peninsula Hospital (Soldotna, Alaska)
Protecting our employees is our No. 1 objective as we bring elective cases back into the OR. To help achieve that goal, we’ve converted four of our pre-op bays into negative pressure intubation/extubation rooms so we can keep everyone safe during the most dangerous parts of the surgical case. We also formed a cross-specialty surgeon committee to help triage the schedule to make sure that the more urgent cases don’t get delayed and pushed out because the ORs are backed up with less urgent cases.
We are working alongside the local borough within their incident command structure to help guide them as they look toward developing alternative care locations. We provide some guidance to the state through our state association.
Michael Dorsey, CEO, Johnson Regional Medical Center (Clarksville, Ark.)
Our hospital used the surgery section meeting, made up of surgeons, anesthetists and nursing, to cease performing elective surgeries and monitor emergency surgeries during the active COVID-19 phase. This group has decided what cases to begin after certain criteria at the hospital and county level have been met.
We are in constant contact with local, regional and state representatives regarding the opportunity to safely begin elective surgery.
Steve Edwards, President and CEO, CoxHealth (Springfield, Mo.)
We have appointed a group of highly regarded informal and formal physician leaders to establish the criteria to guide the prioritization of cases. They are evaluating cases in a new category that we call "time-sensitive medically necessary." These are cases that might have been elective one month ago, but have or will likely grow more acute. Due to the degree of subjectivity, the final decisions are made by this physician panel. We have a three-stage revamping, which may be stepped back or advanced based upon readiness metrics and risks of outbreaks. Each stage is based upon completing two cycles with a flat number of new cases per day. Each stage is liberalizing qualifying criteria.
Will Ferniany, PhD, CEO, UAB Medicine (Birmingham, Ala.)
The first step is sufficient testing of surgery patients and OR staff.
Kiley Floyd, CEO, Nemaha Valley Community Hospital (Seneca, Kan.)
We will begin with our most urgent needs and add from there. We have weekly calls within our county with our peer hospital, as well as county health. Statewide calls are under two different entities — our hospital association and the department of health.
Ken Johnson, President and CEO, Hutchinson (Kan.) Regional Medical Center
As you know, Kansas has not been nearly as hard hit as many other states with a more dense population, especially in larger urban settings. We are working closely with local and state health officials. We are currently following the CMS guideline for elective procedures and asking our medical staff to consider the procedure and its necessity during this time. The hospital leadership team sponsored a community medical collaborative about four or five weeks ago before much was being discussed in Kansas. This weekly call is attended by about 40-50 or so physicians, APPs, nursing, ancillary technicians and administrative colleagues representing many organizations within the community. We have found this to be very effective in discussing strategies and tactics as we continue to address the changing patient needs in our community. We have a favorable relationship with our state health department and are well represented by state and national legislative colleagues.
Michael Layfield, Interim CEO, Carlinville (Ill.) Area Hospital
The key first steps: Access physician availability, schedule the patient via online preregistration (helpful to reflect the absence of the human touch) and ask the COVID-19 screening questions. Once the patient arrives at hospital, we will need to rescreen the patient in person, then have them wait in their parked car in the parking lot. We’ll place a call to the patient's cellphone while they wait in their car (no waiting in the lobby) to go straight to the surgery department. We’ll also coordinate with family to pick up patient and return back home.
Robb Linafelter, CEO, Lincoln (Neb.) Surgical Hospital
We were looking to the governor of Nebraska to give us the go-ahead on opening up elective surgeries and we received that May 4. One concept is to have a phased-in approach of limiting the number of cases you do per day to make sure you have enough PPE. This will be difficult once the "floodgates" are open. We will keep a continuous count of PPE to make sure we have enough to meet the demand.
The hospitals of the county meet daily with the county health department to plan for the patient surge as well as PPE inventory. We also worked together to plan when to shut down elective surgeries. Hopefully, we will work together to plan the opening of elective surgeries.
Tony Slonim, President and CEO, Renown Health (Reno, Nev.)
As we transition from a public health model, where the public health infrastructure has jurisdiction, back to a medical model where the doctor-patient relationship has jurisdiction, we are relying on our physicians to help us establish guidelines for prioritizing which patients get scheduled first and how to tier the other patients whose care might have been postponed because of concerns related to COVID-19.
We believe that in the context of a state and national emergency, the public health infrastructure has jurisdiction with managing the event. We look to and follow guidance from the CDC, state department of health and local health district. As contributors to the dialogue, we are active participants in the emerging recommendations and challenge them, in a collegial way, if we do not agree, so that the work product can be improved.
Matt Walker, PharmD, CEO, William Bee Ririe Hospital (Ely, Nev.)
We have begun rescheduling as of this week by reaching out to patients, explaining the risk/benefit and allowing the patient to decide. We are doing registration over the phone to allow less time and contact within the facility, and we will now bring the patient directly back to the pre-op/post-op area to reduce exposure and time in the facility. We had canceled orthopedic cases, cath-lab cases, urology, etc. We are starting with the more urgent cases and allowing more time for the case so the potential for getting behind and making patients wait in the facility is reduced.
We have shared our plan with the local [emergency operations center] and health officer. Everyone is in agreement that the steps taken are prudent, and given the limited cases here, it seems low-risk. We also have a contingency plan to stop all cases if we see an increase in cases locally or have admissions that increase risk for patients coming through the facility.