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Triaging OR Capacity During COVID-19 Webinar Transcript

JO QUETSCH: Good morning. Welcome to Triaging OR Capacity. During the COVID-19 Crisis, and I would like to take a minute to introduce our panel. I will be moderating, today, and we’ll do the panel introductions. We’ll go by the order in the slides and have you guys each introduce yourselves and tell your role and responsibility. And I would like to start by thanking you for taking the time, today, to have this discussion with us. We really appreciate it. I think it’s going to be an exciting discussion between two different facilities across the country. Dr. Meyer? Can you introduce yourself? 

MIKE MEYER: Hi, good morning. My name is Michael Meyer. I’m a cardio-thoracic surgeon and Chief Medical Officer of Tacoma General Hospital. We are a seven-hospital system in Washington state with facilities around the West Coast, around Seattle Tacoma area, as well as on the east side of the state in Spokane. We, Tacoma General Hospital’s the flagship of this system, and we are heavily involved in the surge, right now. 

JO QUETSCH: Thank you. Donna? 

DONNA PEDERSON: Hi, my name’s Donna Pederson. I’m the Perioperative. Business Manager for a region within the. MultiCare Health Center that involves Tacoma General. We have five ORs that I oversee for the business part of functionality. 

JO QUETSCH: Welcome, Donna. 


JO QUETSCH: Silje Kennedy? 

SILJE KENNEDY: Good morning. My name is Silje. Kennedy, and I’m the Director of. Perioperative Services in West Pierce of. MultiCare, and I have a total of four operating rooms under me. And I’m excited to speak this morning, thank you. 

JO QUETSCH: Yeah, you’re welcome. And then, from St. Peter’s. University, we have Dr. Kett. 

ATILLA KETT: Hi, my name is Dr. Attila Kett. I am the Chair of the. Department of Anesthesiology at St, Peter’s. University Hospital. We are located in. Central Jersey. We are a 487-bed facility. Our primary focus, in peacetime, taking care of moms and babies. We have a large tertiary care perinatal unit. We have 10 main operating rooms with a good mix of cases. We have and ambulatory surgery center which built right next to the hospital, and we have a five ORs for our labor and delivery. And, right now, we are very heavily involved in the surge. New Jersey cases are increasing very rapidly. Our ICU is full, at this point. 

JO QUETSCH: So we’d like to start– you guys have given a little bit of a hospital location overview, but just like to start talking about, you know, when did you decide to postpone elective surgery? And how was that decision made? I would direct this to. Dr. Meyer and Dr. Kett. 

MIKE MEYER: So this is Mike Meyer. It was a tough decision, and we decided– it would be about two weekends ago, I would say. And much of the hospitals around the country that were hit hard, especially in Seattle, so the hospitals north of us that were already seeing patients had stopped. There was not official guidance yet from the government on doing this. And so– but that weekend, about two weekends ago, as I said, we started to suddenly see a large number of cases, realize that our PPE was at risk of running out, and we got to the point, just prior to stopping elective surgery, where we only had a couple days of PPE left. And that, that was actually the trigger. It wasn’t any official government announcement or other kind of guideline. We finally were able to get a full accounting of all the PPE in our health care system, and saw that we were just at a dangerous level. That was the trigger for us. 

ATILLA KETT: Yeah, on our side, we started pretty much at the same time. I recall, two weeks ago, on Sunday, we had a phone conference with leadership here in St. Peter’s, and we made the decision to postpone elective surgery starting exactly two weeks ago, on a Tuesday. The reasoning was very similar. Personal protective equipment is something which is paramount important in this scenario, and we had limited supplies as well. So we postponed, initially, surgeries. Which surgeries? At the beginning it was less strict. However, soon after, last week, the Governor of New Jersey, Governor. Murphy, came out with an Executive Order to strictly postpone all elective cases. So, right now, it’s not an option any more in New Jersey. 

JO QUETSCH: So, Donna, this question’s directed at you. What was the communication and scripting plan with surgeons and patients? How did that go, and what did that look like? 

DONNA PEDERSON: So we found out, the week of March 9th, that we would be canceling all cases starting March 17 that were elective, and we did a– various methods of communication. We used email. We also called surgeons in person that were community surgeons so that they were on board as to what was going on. And then we created, from the scheduling side, we created spreadsheets, delivered those to the clinics so that they would know what cases we would be calling them about to cancel or not cancel. And then, the next day, after they received the spreadsheets, communicated with their providers what was elective and what was not. We were able to remove those cases from the snap board or schedule and either send the case request back to the office or actually cancel the case. We let the surgeons decide which cases were urgent emergent, and then we made notes of that within the case so everyone would know that the cases that were left on the schedule were actually urgent. 

JO QUETSCH: OK. So looking at determining case criteria for surgical cases, Dr. Meyer, Dr. Kett, how did you decide on protocols or case selection, how to prioritize? Who was involved with the process? 

ATILLA KETT: Well, in our case, we started, again, two weeks ago, first, with a similar process to allow surgeons to make that decision which cases are emergent and which are not, and the process got more strict, probably a week into it, when our operative leadership, chair of our surgery and our chief medical officer, who happens to be a vascular surgeon, reviewed these cases. There was, sometimes, some adjustments had to be made, what’s really truly urgent or emergent, and that’s where we’re standing, right now. So leadership does review it. 

MIKE MEYER: For us, we’ve had a similar process. I would say that we’ve really relied heavily on the surgeons to do the right thing and intervene when necessary. And so, at the start of the elective case cancellation, I would say there was some turbulence there, and probably Silje and. Donna could back that up. But as we started the process, we got very interesting feedback from all areas of, at least, our hospital. So as Chief Medical Officer, you know, not only– and the fact that we have no medical director of the OR, I was doing a bunch of different jobs with regard to this. As Chief Medical Officer,. I was receiving calls from irate patients who couldn’t get things done, such as a fine-needle aspiration of a thyroid nodule, things such as that which truly are elective. 

But, for surgeries, the biggest challenge I’ve had was with my own cardiac surgery partners. And so– and what. I’m getting at is the gray zone cases are really difficult. So and that goes for things like coronary artery disease, cancer surgery, and that’s where. I think a lot of the challenges lie. And then some other cases that we might think of as elective, but if we don’t do them in a timely manner, you know, the outcomes may be poor. And so I’m thinking about things like ACL repairs and other type of reconstructive surgery. So we’ve really– we’ve drilled down to a lot of our different cases to figure out what is appropriate. I’ve used the American. College of Surgeons as a guide for some of these things because they’ve come out with fairly discrete recommendations, and that’s been a big help in talking to the surgeons also. 

JO QUETSCH: This questions is for the group, were any kind of early lessons learned that anybody would like to highlight? 

SILJE KENNEDY: This is Silje Kennedy, and I would say that the biggest lesson that we have learned is to provide a high level of direct communication to perioperative specialties specifically. There’s a lot of communication that comes out from executive level to everybody, including the surgeons, all of the other physicians, all of the staff. However, a lot of that information is very specific to processes around the rest of the hospital. So we’ve developed a way to communicate just with our perioperative team, and the communication is very specific as to what’s going on inside the surgery world. We’ve had a lot of really good feedback from this and have been able to get a lot of the information out. So this includes the surgeons that are employed by MultiCare as well as our community surgeons. So every couple days, we try to do something that’s very specific to the perioperative world. 

JO QUETSCH: That’s great. OK, so we’re going to be moving on to a polling question. [BELL RINGING] And the polling question is, how do you triage in surgery? And leadership review follows specific list procedures or abide by some kind of guidelines to determine urgency, or no, no plans? We’ll just kind of pause here and give people a minute to answer this. 

ATILLA KETT: Well, what we’re using– this is Dr. Kett. So what we are using as a guide is which cases can be postponed safely for an approximately two-month period of time. That was our kind of guiding principle, the distance you will have to put some type of number here, number there. The other thing, what I would like to point out in terms of cancer surgery, what we are experiencing, that at the beginning of this period, there were more and more of those typically breast cases or colorectal cases coming in because they were a result of diagnostic mammograms or colonoscopies, et cetera. Recently, what we are seeing that many of those procedures, like colonoscopies or nearby diagnostic radiology centers have been closed. So, now, we’re seeing a much lower influx of these types of cancer cases. 

JO QUETSCH: OK. So the results from the polling question, 76.7% for leadership review for triaging surgery, and then 20% are following a specific works procedures. And then the other 26% are abiding by guidelines similar to urgency. So we want to talk about workforce challenges and solutions. And, Silje, I would like to direct these questions to you. And have you deployed perioperative staff to other areas of the hospital? If yes, in what kind of capacity?

 SILJE KENNEDY: Yes, we have started redeploying staff. And this has been an area that has made perioperative staff a little bit nervous to go outside of the perioperative world. So we’ve done a lot of education. We spent the entire week, last week, doing hands-on education in combination with LMS education for staff to get skills to be redeployed specifically to the. ICU and a little bit to Emergency Department. And the purpose is to have nursing staff work as a secondary nurse, not primary nurses, unless they have previous experience in that area. So they’ve learned a lot of the hands-on skills to do things to assist the primary nurses. For our hospital, we chose to not put the nurses from the surgery into medication-passing roles. So that’s one area that we have elected to not do. 

We would only have the primary nurse doing that. We have two different branches of areas to deploy our staff. We first start at the local level. And so there’s been a lot of requests throughout the hospital to do things such as assisting with. RT, and we have created our own intubation team. So this is a anesthesiologist with an operating room nurse that is available 24/7 to intubate COVID and suspect-COVID patients around the hospital. So the focus of this is to have a highly efficient team that can get into the room and out of the room very fast, intubating patients, so we’ve deployed staff in this area. There are some things such as data analytics that they’re helping with and tracking the COVID patients throughout our system and alerting the areas that they’ve been to and also some bed coordination. 

At this point, our regional float pool has not opened up as our numbers aren’t as high as we’re expecting them to be, but that’s what we’re getting ready for. So after the local level of staff has been deployed to areas that are needed, then we will open up to a regional float pool. And the staff will be then asked to go to each of the areas that need help. 

JO QUETSCH: Are you implementing other protocols to focus on helping monitor employees? How are you addressing that? 

SILJE KENNEDY: Yeah. So, daily, we talk to the staff. They are quite worried about all of this. They’re not only worried about what’s coming into the operating room that we don’t know, but they’re also worried about going out into the rest of the hospital. So, on a daily basis, we talk to the staff. We make sure that if they do have any symptoms, and this includes mental wellness, that they would stay home. We ask that there’s no more than 10 people in a small space. And we have implemented things such as high-touch surface wiping staff, so staff that are continuously going around the department and wiping all of the high touch areas, and social distancing monitors for open spaces like center corridors and break rooms. 

JO QUETSCH: One other question, too, Silje, are you guys– how are you handling family members in your preoperative space? 

SILJE KENNEDY: At this point, we only allow one family member with the patient. And all family members, all patients, are screened on entrance to any of our hospitals. So if they’re experiencing any of the symptoms or if they have a temperature, they are not allowed in. And each person is only allowed one person in surgery area. 

JO QUETSCH: OK. So I want to move on and talk a little about physical spaces and equipment. And these questions, this set of questions is directed to Dr.. Kett and Silje. But what considerations have either of your organizations made for repurposing OR suites to ICU beds, isolation rooms, COVID units, other types of plans? 

ATILLA KETT: Yes, there is a contingency plan for that. And so we inventoried, in fact, here in New Jersey, the state mandated to inventory all the ventilators which are available. So we have 66 ventilators here in St. Peter’s, right now. And we have an inventory from nearby surgicenters in terms of anesthesia machines which can be used as ventilators. And, as I mentioned that our ICU is full, so right now we’re moving to next step. We emptied out to our pediatric ICU, which will serve as an adult ICU as a next step. And, the same time, converting certain floors into COVID units, we’ve gained a fair number of scrubbers, so these can be placed into windows as units and convert the rooms into a negative pressure environments. So we’re working on that part. We have, first– of course, we are using the traditional ventilators, but as a contingency, we made plans to use our anesthesia machines, or at least the portion of them, as ventilators. 

We had discussions what would be the best location to do that. We considered PACU or operating room. Turns out that most of our new operating rooms can be converted to a negative pressure environment, so probably that will be the final decision. We are also looking into options how can we convert certain areas to cohort patients who will receive non-invasive ventilation modalities. In fact, in Europe, right now, and the original guidelines were recommending to avoid these type of ventilation methods like high-flow nasal oxygen or a CPAP. However, multiple– the Italian critical care guidelines and the British guidelines are starting to change showing better outcomes with these models, so cohorting patients in a unit like that, probably going to have more significance. So these are all kind of in our plans, step by step. 

JO QUETSCH: Silje, do you have anything to add to that? 

SILJE KENNEDY: Yeah. We are doing a similar process. In our main operating rooms, we are fortunate enough to where we’re divided by floors. We have a cardio-thoracic floor and we have a general operating room floor, so we do have a plan. However, we’re a little bit lower on the triage list of where– when we will become a COVID unit. But what we will do, at that point, is use our cardio-thoracic space for all emergent surgeries and convert our standard operating rooms into a COVID unit. So we would do the actual ORs as ICUs to you and our PACU are as Med Surg. Similar process, we have the availability of our anesthesia machines. Our RTs are going through training, right now, to be able to use those machines. We have plans to bring two patients per operating room. And working through the process of what that’s going to look like to actually turn an operating room into an ICU, but those are the plans. 

JO QUETSCH: And roughly, Silje, how many patients would you be able to accommodate in your main operating room, if you have had to do that? 

SILJE KENNEDY: In the operating room, we can accommodate 22 patients. And in our PACU space, we can accommodate 21. 

ATILLA KETT: Regarding that, actually, there is a very helpful guide regarding all the issues converting anesthesia machines into ventilators from the American Society of. Anesthesiology website and a downloadable. PDF regarding that. And it is a guide through how to do that process, what’s important, issues related to that, what to do in case you are running short of the soda lime which is important for the use of these machines. But there are ways around. The problem with ways around is a high need of oxygen flow. And that, I believe, every facility has to look into whether the supply of oxygen is sufficient and confirmed for the future because we will need a lot of that. 

JO QUETSCH: So moving on to a polling question. How much additional bed capacity has your organization planned for? And less than 20%, 20% to 50%, or 75% or greater than 75%? So let’s pause here a minute. Also, just like to mention that the polling questions will be sent out in the summary and available after the end of this webinar. All right, so the results are less than 20% is sitting around 17%. And most people responded that we’re sitting– they’re city at about 20 to– estimating 21% to 50% bed capacity that you’re trying to plan for. And then the other 22% responded 51% to 75%. And then moving on to a second polling question, do you plan to repurpose your ASC, if you are no longer doing elective surgery, to additional inpatient beds, additional space for urgent surgeries, both, or neither? 

Pause a minute and let people get a chance to answer. 

ATILLA KETT: So, as I mentioned, we have a large Ambulatory. Surgery Center right next to our hospital. And we’re discussing whether do a larger number of the urgent emergent cases there. I am aware, in New York City, since Governor Cuomo mandated to increase bed capacity by 50% to 100%, one of the solutions for multiple of these hospitals was to repurpose these ambulatory surgicenters. They did, in some cases, they moved labor and delivery units for the ambulatory surgicenters and do other things. But it’s a big part of the surge plan over there. 

JO QUETSCH: OK. So results of the polling question, do you plan to repurpose your ASC, 21% said of additional inpatient beds, 25% said additional space for urgent surgeries, and then 21% said both, similar what you’re saying, Dr. Kett. 


JO QUETSCH: So we want to talk about future planning and postponed cases and backfill and how are things going to be in the future, and I would like to direct this question to Donna. 

DONNA PEDERSON: So we started looking at that this week, as far as what we’re going to do to prioritize cases when we go back to a semi-normal schedule. We have a lot of surgical block time that exists in all of our ORs, and there’s consideration that you open up that block time all together. Do we expand our hours to be 24/7 or something close to that? Do we work on evenings and weekends to get these backlogs of cases in? And then we were talking about possibly releasing block time earlier. Most of our traditional blocks release a week ahead of time. Would we increase that two weeks out? 

Because we do have a significant percentage of surgeons within the community that don’t have block time, and it’s very difficult to get those cases on if they don’t have traditional block, especially during this wave of patients that we’re trying to do the catch up on. There’s a huge, huge amount. We’re also a Children’s. Hospital, and the smaller ENT cases for ear tubes and tonsillectomies, we’ve canceled upwards of 40 of those per week since we’ve been closing down the ORs on March 17, and sometimes upwards of 60 or 70. So it’s a lot of cases that we need to backfill. 

JO QUETSCH: Donna, what kind of– what are you thinking about for future plans when you have to ramp back up? And, like, what are some early thoughts about that, like how you’ll do you do that? 

DONNA PEDERSON: Well, it’s– to tell you the truth, it’s kind of overwhelming to think about. We definitely will be using our software IQ to do that, and I really don’t have a good feel for how that’s going to look, right now. We’re going to have to take it one day at a time. We’ve closed it down and canceled the cases one week at a time, so should we take that same method to add on cases, one week at a time? I’m not really sure. 

JO QUETSCH: And,. Dr. Kett, you were talking about your organization exploring funds, two federal and state grants. Can you speak to that a little bit? 

ATILLA KETT: Well, yes. I mean, that’s, as you see, that like some of us are employed physicians, some of us are community physicians in private practice. And during this period, it’s not easy to meet payroll and figure out all those things. So we are actively looking at federal and state grants which would help us to get through this difficult period. So there are several options and opportunities grants which start out as loans and convert to grants in case you hold on to your employees. In terms of your previous question, that, you know, all I can say is that like, yes, at this point, it’s just way too overwhelming for us to really plan for that backlog. But I have to say that– you know, I would like to be that optimistic that we will have a huge, huge surge once this epidemic is over. 

But once we’re done with that backlog, don’t forget that surgeons have to get, first, referrals from primary care providers, then have to see those patients, have to schedule those cases. So probably there will be a kind of less of that. So there is a backlog, but less of those new cases. And there are a couple of issues related. We don’t know the exact economic impact of this whole crisis, and sure a lot of people who have elective surgeries thinking about postponing it because they just have to make a living for a while. And a lot of people probably they will end up with a pretty high unemployment rate, so other people will wait because they’ll lose their insurance. And so I think there are way too many factors coming here to be able to see clearly how it’s going to play out at the end. 

JO QUETSCH: OK. So it looks like we’re at the end of Question and Answers. I don’t know if anyone on the panel has anything more you want to add to of things maybe we didn’t cover that you would like to close with? 

ASHLEY WALSH: Hi, everyone, this is Ashley Walsh, also with LeanTaaS. And Jo, panel, thank you so much for your time today. We’ve gotten a number of questions. So we have well over 130 people on the webinar. Thank you, attendees, for joining. We will do our very best to get to all of your questions. If we don’t get to your specific question, or if you have additional questions, we do please hope that you reach out. You will receive information how to do so. If you want to jot it down quickly, you can email info@leantaas– L-E-A-N-T-A-A-S– dot com– and we’ll be happy to forward any additional questions on to the panelists. But I will summarize the questions that everyone has asked and share the results. So let’s start with,. Silje, a question for you. Have you created– and, actually, multiple people can answer, but I thought that this might be good for you. Have you created intubation and extubation rooms in your OR for your general anesthesia cases? 

ATILLA KETT: Yes, we did. We created an intubation team for cases in the ICU or in the Emergency Room. And, in the operating room, because for– most of our ORs were not converted yet to negative pressure rooms, we use another room to do the intubation and the extubation in this negative pressure environment. 

SILJE KENNEDY: We’ve done something very similar. We have a negative pressure room in our PACU area, so we use that to intubate and extubate. We also have an operating room that is dedicated as our COVID operating room, right now, just to try to minimize the number of anesthesia machines that we’re using on. COVID-positive patients. So we do have that process set up. 

ASHLEY WALSH: Excellent, but actually with a follow up question I had to that was with regards to the intubations. Actually, the question read, as we are aware, intubations are supposed to be performed in a negative pressure room. Are you performing surgery on COVID-positive or suspected COVID patients in a negative or a positive pressure room? The second part to that question is, what resources did you use to help make your decision? 

ATILLA KETT: So the answer for that, the intubation is occurring in a negative pressure room. Once the patient is intubated, this is a closed circuit. So, at that point, being in a negative pressure environment is probably less critical. That’s where we are, right now. 

MIKE MEYER: I would just make a comment with that. You know, some of the societies are recommending that if you’re doing thoroscopic surgery on undifferentiated patients, even laparoscopic surgery, that you might consider N95 masks, like you would prepare for any aerosolized procedure. So while the closed circuit anesthesia machine may be protective, as Dr. Kett’s saying, if you’re going to be involved in a procedure that violates the airway, or any part of it, it probably has to be reconsidered. That’s what gets the staff fairly charged-up is that the undifferentiated cases are very difficult to know the right answer. 

ATILLA KETT: Yeah. I would agree with that completely. 

ASHLEY WALSH: Great. Thank you, both. That was another question, how you’re managing those laparoscopic cases. OK, let me see some of our other questions. So let’s start with you, Dr. Kett, on this. What are the staff and anesthesia providers, so OR RNs or other assistants, donning for the intubations as well as throughout the hospital? So whether the intubation is occurring in surgery versus at the bedside, what is the PPE equipment that is being worn?

 ATILLA KETT: So there are three people in the room while we are intubating, and there is a runner at the room outside. The PPE equipment, what we are wearing, is an impermeable gown, and N95 mask, a hat, a surgical mask over the. N95 mask, shoe covers, and double gloves.

 ASHLEY WALSH: Thank you. Silje or Dr. Meyer? 

SILJE KENNEDY: At this point, our operating room staff do not have N95s. So during COVID-positive or suspect-COVID patients, we are using CAPRs. 

ASHLEY WALSH: Excellent. Thank you very much. Let’s see another question here, oh, great question. So I’ll direct this back at you, Silje, and then Dr. Kett. Can perioperative staff operate your anesthesia machines, or does it have to be done by an anesthesiologist if you convert the anesthesia machine to be used as a ventilator? Have you established a plan for that at MultiCare? 

SILJE KENNEDY: No. Our preoperative staff do not run it. It has to be an anesthesiologist or a trained respiratory therapist. 

ATILLA KETT: Yeah, I would agree with that. Like, these machines are pretty specific, so I would say anesthesiologists are very familiar with it and would be best served. Perhaps we cross-train a respiratory therapist, but they are very busy with their events all around the hospital. So we’re thinking anesthesiologist. 

ASHLEY WALSH: I see. Great. Thank you, both, very much. All right, Donna, this question is for you with regard to your reporting and kind of preparing for next steps. Have you done any modeling to anticipate the timing of your disease peak in your organization and/or at what point you would begin to do more elective surgeries? 

DONNA PEDERSON: The latest I’ve heard on that is that they’re expecting a peak in two to three weeks. And I would imagine that it would be quite a while after that before we start doing elective cases again. ASHLEY WALSH: Great. Dr. Kett, anything to add from St. Peter’s? 

ATILLA KETT: Yeah, well, unfortunately, in New Jersey, the curve doesn’t look too flat at all. So we are expected to peak somewhere between April 9th and April 11th. And I expect a pretty significant time period until those cases– first, we’re probably going to be able to extubate patients in the operating room, on the floors, but you will still have probably an ICU full of ventilated patients for quite a while. So I think it’s kind of a little too early to say that, but I think it’s going to be a while. 

ASHLEY WALSH: OK, great. Thank you. I’m just scanning through a lot of these questions. I think we’ve had some repeats. So another question regarding the PPE equipment, any other– anything else being used other than an N95. Silje, I think you answered that for the audience, that you are wearing CAPRs? Let’s see. How are you– how are your staff utilizing PPE? How do you handle. COVID versus unknowns? I think we answered that as well between the N95 and the CAPRs as well as determining what type of procedure, et cetera. Good question here on the anesthesia machines. So, Dr. Kett, any special precautions you’re taking with your anesthesia machines post a positive patient in the OR? 

ATILLA KETT: Well, the key is that you have to use the proper filters. The proper filter has to be placed right at the end of the endotracheal tube so, this way, it’s not beyond– between the elbow and the Y-piece. It’s right on the endotracheal tube. The purpose of that, to protect the [INAUDIBLE] CO2 sampling line. And the anesthesia machine, some suggestions are also to place an [INAUDIBLE]—- place a filter in the expiratorial end as well. So these are the ways to protect the anesthesia machine. If you follow these recommendations, you should be fine. 

ASHLEY WALSH: OK, great. Thank you so much. Let’s see. I think we have a few more questions and a little bit more time. Let’s see, lots of more questions around the elective surgeries and the ICU, the OR to ICUs. So, Dr. Meyer, I’d like to direct this to you. Talk to me more about how you are determining the steps that would need to be taken in order to convert your operating rooms to inpatient units, ICUs, et cetera. So I think the audience would like to hear– because I see multiple questions on this– what type of resources are you using as a guideline to that? And then what types of physical steps will you actually take to make that happen? 

MIKE MEYER: So in order to– so for determining when to pull the trigger on these alternate spaces, particularly the OR turning into the ICU and other spaces, we watch the number of cases nationally and in our state almost on an hourly basis. And so we’ve got some really smart computer geek types, you know, that are doctors that are– they are just into the data, and they are producing these curves for us multiple times a day where we look at conversion. We look at conversion rates for testing. We look at all the statistics that you would need to develop what would be worst case, best case, and expected case scenarios. And so, based on that, and then looking at the number of patients that we are admitting both to the Med Surg, to the ICU, and the number of ventilators being used, we try to make– you know, we’re trying to make these predictive models on when we should convert. You know, that’s kind of the best answer I can give for that. But, as a system, it’s a little more telling what we’ve done. And, in our region, where we said, we’ve got five hospitals that we can put patients into and we’ve designated some of these hospitals to be COVID hospitals specifically. And we– one of our first hospitals with about– in our Phase 1 plan, has about 40 beds that are full of COVID patients already. 

And we are starting to transfer them into our Phase 2 hospital. We developed a kind of a triage and transfer center to help facilitate that transfer of patients. And so, typically, when business is normal, you get– someone needs to transfer to the tertiary facility. There’s multiple phone calls. There’s a transfer center that tries to manage it. It’s a long process. We scaled that down so there’s only two or three calls that have to be made in order to get a patient in place. So there’s system oversight into where patients are going so we know when it’s time to pull the trigger on the next unit that has to spin up. And so, when we talk about– you know, just to make it easy, we talked about these phases of which a hospital, which wards in particular, are going to start accepting patients. You know, we are we are polling. We have triggers for each phase up through about eight phases which, as we get later on into this process, that’s when ORs would come into play into using them. I don’t know if that kind of answers the question. 

But as far as resources go, we’ve taken some of our hospital wards that are newer, that do better air handling, that can become negative pressure, and we are converting them into double rooms, whatever it takes in order to accommodate the volume. We’re especially focused, in some of the hospitals, on acuity adaptable rooms. So if you have someone that is a COVID rule-out, let’s say, and then they rapidly decline as we know that they do– sometimes, they might come in as being unclear, and then in a number of hours to even a day or two, they’re already requiring mechanical ventilation– we have rooms that typically would be like a step-down unit that can handle that array of patients. And in those units, the nursing staff, they are fully protected and, as Silje mentioned, we use CAPRs in our part of the state as the primary method for protection for aerosolized things. And so that’s how our system’s handling that. So we’re looking at it locally, within each hospital. Then we’re looking at coordination across the five hospitals on the west side of the MultiCare Health System. 

ASHLEY WALSH: Great. Thank you so much. Dr. Kett, you talked a little bit about the plans for conversion of your space. Any other– anything else to add along with what Dr. Meyer touched on as far as resources you are using to make that decision, what steps you’d have to take, et cetera? 

ATILLA KETT: Well,. I mean, I can– I wish we would have that option, but I completely agree with that statement that if you’re able to designate some hospitals kind of COVID hospitals here, that’s a huge help trying to keep the COVID patients away from the non-COVID patients. And I had, recently, a conversation– I was lucky enough to participate in a conversation with some ICU physicians from Bergamo, Italy, and as they mentioned that if they would be able to do it again, and if they would say mistakes they have made, that they did not separate these patients. And basically, they destroyed their hospital by mixing COVID and non-COVID patients. So, yeah, I think that, certainly, if you can do it, that’s the right way to go.

ASHLEY WALSH: Donna, there is another question for you. I know that, in your role, you oversee some of these scheduling practices and are involved in the communication with the physicians. And the question came in that was really specifically directing the issue of surgeons posting elective cases and if the administration, or the perioperative administration, questions that, the senior hospital administration seems to be allowing them to continue. How are you handling that, or have you been faced with that challenge? 

DONNA PEDERSON: We have two physicians, Dr. Meyer and Dr. Hart, that are looking at these cases. And they contact the surgeons directly if there’s any question at all on whether it should be urgent. So it’s specifically geared here. 

ASHLEY WALSH: I see, so from the scheduling department, you direct– I see. So you direct all that to be handled by the senior physician leaders?

 DONNA PEDERSON: Correct. ASHLEY WALSH: OK, great. I think we have time for just a few more questions. Let’s see, the last question that came in was is there a merit to performing non-COVID patient surgeries away from primary campuses? I think both Dr. Kett and Dr.. Meyer just both addressed that. Interesting question about what is a reasonable distance for the negative intubation room from the procedural OR room? Any recommendations on that from anyone on the panel? 

ATILLA KETT: Why is the negative pressure recommended for intubation? It’s– 

ASHLEY WALSH: No, the reason– what is a reasonable distance from the room where the intubation would occur to the procedural or OR space? 

ATILLA KETT: What’s the reasonable– well, our on is probably about like less than 50 feet away. So I would certainly minimize it. Again, all I can say that like our one is approximately 15 feet away. And that certainly seems reasonable. 

ASHLEY WALSH: Silje, how about for you? 

SILJE KENNEDY: Like I said, our intubation room, our negative pressure room is in our PACU, so I would say that it’s 20 feet from our operating room. But if the negative pressure is working as it should, that should be enough. So we keep the doors closed. We let it air out for one hour following the procedure, and then do a terminal clean on that. So that, as long as the negative pressure is working, it should be fine. 

ASHLEY WALSH: OK, great. Let’s see, one more question. I’m going to ask Dr.. Kett, Chair of Anesthesia, how will you incentivize anesthesia providers to increase workload post the peak so that they are encouraged to work multiple hours or increased hours of the day as well as weekends? 

ATILLA KETT: Well, if you’re able to get through this difficult period, as I mentioned, it’s not an easy task to hold on to everyone and meet payroll. Certainly, you know, by financial incentives, I believe a lot of folks will be very interested to work longer hours and make up for lost wages. So, yes, I mean, the financial incentives are probably key for working long hours, working weekends, running ORs. Again, I’m hoping that like this surge of elective cases will be as large as we are hoping for. 

ASHLEY WALSH: Any thoughts from the MultiCare team? Has this been a topic of discussion yet at your organization? 

MIKE MEYER: Well,. I think it’s not going to be too tough to motivate the surgeons to work 24/7. You know, I’m thinking more along the lines of our operative staff. We have– we’ve got such fantastic people, and they’re going through such a tough time. To have them work long, long hours afterwards without some kind of incentive,. I think it would be unfair. So I don’t know if Silje has got a thought about that. But, you know, I’m not as concerned about the doctors, really. It’s more about the staff. 

SILJE KENNEDY: Yeah, we’ve certainly thought about that a lot and are preparing for the surge. We know that we can’t train perioperative staff in a fast manner, so planning to utilize travelers as much as possible and really think outside of the box as far as how we can staff this and then obvious pay incentives, if we’re going to use time and a half, double time, for the extended hours. The good part about preoperative staff is there’s a lot of buy-in with their team, and they want to do what’s right for the community and their surgeons that they work with. So I think that we’ll– we’ll get through this. 

ASHLEY WALSH: OK, wonderful. Thank you so much, panel, for your time, for your questions. Jo, I think we’ve reached the end of the questions from the audience. We will summarize them, if we missed any, to send out. But I think that that is all the time we have for questions, today. So we do have one more poll. We’re curious for those that have attended the webinar today and the roundtable discussion, are you interested in finding out the time needed to catch up on your canceled cases during COVID-19? So we’re just taking a very simple poll on this. We are doing some modeling and would love to share some of the opportunities we have for you as attendees. And we’d love to hear from you if you are interested in obtaining more information on that. So if you wouldn’t mind addressing one last question for us, that would be great. 

JO QUETSCH: Thank you so much for everyone joining today, and thank you to all of our presenters.

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