by Elizabeth Hofheinz, M.P.H., M.Ed.
7,000…that is roughly the number of surgeries that Hospital for Special Surgery (HSS) in New York has to make up. Fortunately, Dr. Bryan T. Kelly, Surgeon-in-Chief and Medical Director at HSS, has a thoughtful plan and a stellar team.
Dr. Kelly: “Our process has four phases. The first phase – the alpha phase and during the height of the crisis, was when we were only doing surgical emergencies. In phase one, we began doing urgent cases – for those patients who had been delayed for 6 weeks or more and further delay would compromise their outcome due to debilitating pain or exacerbation of underlying medical comorbities. In phase two, which we are currently in, we included priority, non-elective surgeries. Phase three will be when we are allowed to perform elective surgery again. At this point there remains a ban on such procedures in New York City. When we do recommence elective surgeries, it will only be on low risk patients who have no comorbidities. Then the fourth and final phase will be when we take ‘all comers.’”
“Under normal circumstances, we handle the orthopedic care for New York-Presbyterian, which has probably been more affected by Covid than any other hospital in the city. In mid-March we began taking orthopedic cases that were transferred from other institutions because their ERs were vastly over capacity. We increased our ICU beds from 5 to 30, ultimately peaking at 36. We took our PACU’s and OR’s and turned them into ICU beds so we could care for overflow critical care patients.”
“As we slowly monitored the peak of crisis around April 26, we stopped taking Covid patients and then two weeks later we began discharging those patients. We were looking for external and internal indicators so as to gauge when to start urgent procedures. There are varying definitions of case severity, but we define them as follows: emergency (should be handled within 48 hours), urgent (should be attended to within 4-6 weeks due to the risk of chronic conditions), and priority (could wait up to three months but after that you may have suboptimal outcomes).”
Discharge, deep clean, repeat…
“Our strategy was to undertake an extensive cleaning and testing process as floors emptied…until the point where the entire hospital had been cleaned and everyone was tested.”
“Around May 6 we were seeing a decline in deaths, new hospitalizations, and ICU bed occupancy, with a concomitant rise in diagnostic testing capability and contact tracing capacity. At that point we had sufficient internal capacity with regard to ORs, bed space and clean anesthesia machines. Twenty of those machines had been used on Covid patients, and even though they were deemed safe by the manufacturer’s standards, we ordered 35 new machines. Then we allowed surgeons to begin performing urgent cases (those that had been delayed for over six weeks).”
“At that point, surgeons had one operating room per week with strict indicators on patient safety. We were looking to operate on low risk patients with no comorbidities who underwent Covid testing at a maximum of 24 hours preoperatively. For inpatients we began conducting polymerase chain reaction (PCR) testing on the day of surgery in the holding area. Visitors for adult patients had to be prohibited, but pediatric patients were allowed one visitor—who underwent testing as well. Even with urgent procedures we were aiming to minimize the risk of the patient having been exposed because of some unknown sequelae postoperatively. Upon the reinstatement of urgent cases our OR volume increased to around 25%; now we are at a point where we are trying to determine what other types of cases to add to the priority list. While these are indeed nonelective surgeries, these people may have already been waiting for several months.”
“We are attempting to titrate a slow expansion, and our priority over the next couple of weeks is to pay close attention to the outcomes we are seeing. It is a good sign that during the emergent phase we did not see a bump in postoperative complications—as that was in the peak of the epidemic. We are fortunate to have a surgical oversight committee to ensure that these measures are all within the appropriate indications based on urgency and safety guidelines.”
From the beginning of the crisis, HSS has had a multipronged plan that included several multidisciplinary task forces looking at the crisis from different angles. Thus, says Dr. Kelly, when it was time to begin returning to normal, they built a similar type of cross-functional team. “Our Covid preparedness and response team worked on ramping things down, along the way developing a pandemic playbook to document exactly what measures we enacted. In the future, when any type of similar crisis emerges, we will know what we did and what we need to do better. For example, the leadership of the ‘return to normal team’ articulated all of the different workstreams, i.e., what they did, why, and how effective it was.”
“At this point we have a clinical safety team updating screening, testing, and visitor policies. This team is rolling out all preoperative screening, workflow, reagents, etc., and expanding this across 11 satellite locations. We now have enterprise-wide antibody testing for 6,000 people and are also using the data for research purposes. To date we have tested 20% of employees and have found that our staff has an antibody positive rate of 15-18%. This is lower than some of what you see in community testing, which gives me confidence in the efficacy of our PPE because our people were working with Covid patients.”
Another team has been focused on inpatient care, says Dr. Kelly. “These folks are ensuring that as we have more orthopedic inpatients and the census goes up, that we’ve done all the necessary cleaning and testing, as well as identification of capacity issues and maintenance of social distancing. Even in the office we are restricting patients to 24 per day/3 per hour. And our consolidated model has limited the number of care providers to two in any space at any one time. There is no in-person checkin or checkout (both are done via telemedicine). Patients love all of this…it’s the first time in their lives they don’t have to wait for a doctor.”
Adding a vast swath of ORs is not in the cards, says Dr. Kelly. But what is doable is to keep doing what they do best…things that have made HSS the #1 hospital in the country for orthopedics for 10 consecutive years (U.S. News and World Report). “We have 137 surgeons, each with an average backlog of 50 cases. Roughly half of those meet the patient safety criteria…and probably half of the 7,000 are anxious about coming into a healthcare facility. We have examined consumer sentiment and many patients are anxious to even come into New York City. However, we are fortunate that people tend to have a built-in confidence in HSS’ track record of providing superior patient care.”
Asked what gives him pause, Dr. Kelly says, “Every day—depending on the minute—I either feel like we’re moving too fast or too slow. We have essentially been at the epicenter of the worst public health crisis in the last 100 years. It’s been a horrific eight weeks, and no one wants to see this come back. We are moving forward very cautiously.”
To that end, says Dr. Kelly, they are keeping an eye on the mental health of their employees. “Frankly, we are concerned about PTSD. This is being addressed by our crisis management and wellness team. We have even engaged an ex-Green Beret to help our 2,000+ front-line employees with fear of the unknown. We are most concerned that as the adrenaline of the past two months wears off, people will struggle greatly with mental and economic issues. By offering a crisis management team, virtual mental health, and a clinician peer support program we are hoping to mitigate some of the emotional damage caused by this outbreak.”