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Triage OR capacity amid COVID-19: lessons from the field

This article originally appeared on OR Manager.

As COVID-19 cases escalate nationwide, health systems across the country are determining policies and procedures related to their resources, staffing, scheduling and more to prepare for anticipated patient surges. This week, I talked with perioperative physicians and administrators from two health systems located on opposite coasts that have seen their numbers of COVID-positive cases rapidly increase, prompting significant changes in operating room management.

The panel, Triaging OR Capacity During the COVID-19 Crisis, included representatives from Washington’s Tacoma General Hospital, its parent organization, MultiCare Health, and New Jersey’s Saint Peter’s University Hospital. Each facility is located near a COVID-19 hotspot, yet neither local area has reached its projected peak. Still, ICUs are at capacity.

Given the situation, we discussed some of the biggest issues they face and how they are responding in order to help other hospitals around the country get their own environments ready. Here are the key takeaways.

PPE preservation triggers operational changes

For both Tacoma General and Saint Peter’s, the decision to cease all elective surgery was executed in mid-March, before government guidelines were issued. It was imperative for each organization to act quickly because they were already dangerously close to running out of PPE.

Providers initially were given significant leeway to determine which cases were deemed urgent versus emergent, which then underwent executive review. On the surface, this seems like a relatively straightforward process, yet there are a lot of gray lines. Procedures related to oncology cases are one example. mmediate action might not be, but if surgery was postponed for long, it would require a much more aggressive treatment plan or the procedure would shift into the emergency category (perhaps closer to COVID-19’s peak). Similarly, orthopedic surgeries typically would be considered elective, but if not addressed in a timely manner, outcomes would be poor.

Over the course of a week, however, as cases began to surge, guidelines around what was considered urgent became stricter. Review teams had to drill down into cases in order to figure out what was considered appropriate and necessary, often relying on the American College of Surgeons’ recommendations as a guide, in addition to considering the surgeon’s opinion.

There were some irate patients initially whose surgeries were canceled that were truly elective, and there were some difficult calls on potentially emergent cases. Neither hospital’s practice of canceling all “elective” procedures has been optimal, but it has been a necessary precaution for patients and staff.

New communications are in order

As the need to move surgeries off the schedule continues to increase, new communications challenges have arisen. Clinics and providers need clear guidelines about what should be canceled and which procedures can proceed. At Tacoma General, these guidelines were sent and are updated via email to physicians on staff as well as community doctors. Spreadsheets have been routinely circulated, which make it clear that the cases remaining on the schedule fit the criteria. A high level of direct communication with specialty perioperative teams has also been instituted over the past two weeks, beyond the typical hospital-wide distributions, in order to update teams about what is happening inside the surgery world.

Additionally, teams have to communicate with patients, existing and new, regarding the status of their surgeries. This involves proactive calls and notifications to scheduled patients as well as clear communications to incoming patients — although this number has dropped considerably due to the fact that most diagnostic centers are currently closed. Neither hospital is currently rescheduling appointments for future dates as they don’t know what the coming weeks will hold or what scheduling policies will be instituted.

Staffing assignments transition accordingly

Given the decision to cease any non-essential surgeries and the concurrent need of assistance in emergency departments and ICU units, perioperative staff are being redeployed to these areas. Staff can be understandably nervous to move to one of these departments. As such, Tacoma General spent a week educating and training staff on how they could assist in new positions, particularly in the ICU, where perioperative nurses work as secondary nurses unless they have previous experience in that area. Training has provided a lot of the hands-on skills to assist the primary nurses; perioperative nurses are not placed in medication passing roles however.

Tacoma General has also created its own intubation teams, with an anesthesiologist and an operating room nurse, in order to offer a highly efficient pair when COVID-positive patients require it. This team can get in and out of patients’ rooms very fast while limiting close contact. Other perioperative staff are being deployed to help with activities like tracking coded patients throughout the hospital system and alerting areas that they’ve visited as well as coordinating beds, becoming part of a high touch surface wiping staff, or monitoring social distancing in open spaces like corridors and break rooms.

There are many tasks that must be completed in the present environment for which there are a number of ways for personnel to be useful and still get the hours they need to support their families.

Space and equipment are repurposed to meet needs

As hospitals continue to fill, there is an increasing shortage of rooms and equipment. At the top of everyone’s mind is what to do about the lack of ventilators. Saint Peter’s currently is safely converting anesthesia machines from the hospital as well as those from local outpatient facilities to increase supply as needed. Converting anesthesia machines is one of the fastest ways to have access to a ventilator while leveraging equipment that is not used as frequently under the current circumstances. Every facility should look into whether the supply of oxygen is sufficient and confirmed for the future — and log it — in order to convert machines in time but not go through the process unnecessarily.

In terms of available beds, because Saint Peter’s ICU is already at capacity, it has emptied its pediatric ICU as much as possible as well to accommodate adult COVID-positive patients. It is also designating floors within the hospital as COVID-units and converting regular rooms to negative pressure environments. Tacoma General has planned to follow similar procedures, though it is not at this point yet. With multiple hospitals within its system, some are being designated as COVID hospitals to attempt to separate populations as much as possible. As scale demands, it is also looking into the process of bringing two patients into an operating room converted to an ICU.

Converting ambulatory centers is another option for hospitals to attain much needed bed space. Saint Peter’s, for example, has a large ambulatory surgery center next to the hospital. It is currently discussing the potential of repurposing it for COVID patients, as they have in New York City under Governor Cuomo’s mandate to increase capacity. Or it may consider moving specialties such as labor and delivery to the ambulatory center in order to create more separation between COVID-positive environments and new mothers and their babies.

Amid the shortages of essential equipment and space, particularly negative pressure environments, it is clear that hospitals are becoming more creative and resourceful in their quest to treat as many patients as possible. They are exploring every option for safe, quality care.

The future Is wrought with new challenges

With so many changes underway in this moment, it begs the question of what post-pandemic care looks like when a whole new set of challenges arise. Chief among them, when and how do you resume scheduling? In addition to transitioning rooms and floors back to their previous configurations, and moving staff back to their designated line of care, there will come a time, hopefully, when existing surgery appointments will no longer have to be canceled. Yet, there is a tremendous backlog of cases to work back into a queue that is already full. To complicate matters further, new cases will emerge as diagnostic centers resume testing.

Existing OR schedules are commonly broken into physician blocks, where times were assigned to and reserved for a specific provider long before COVID-19 struck. Changes to block schedules are almost a given, as providers may be asked to release time further in advance than usual to make room for community physician needs. New rules might go into effect, and facilities could expand hours, adding postponed surgeries to nights and weekends, which would open new blocks of time. Intelligent, real-time scheduling software will become indispensable in identifying gaps and optimizing resources to right the OR schedule.

Executives have yet to solidify plans as they attempt to manage through the current crisis, but many are questioning how they ask personnel mentally and physically exhausted from working on the front lines of COVID-19 to take on extra shifts.

Incentives are considered the chief motivator, yet many hospitals are not in a position to offer substantial pay increases due to the financial strain the virus has placed on them. Grants and additional state and federal funding could help, but right now, the focus remains on getting through an unfathomable crisis as quickly and painlessly as possible.

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