Mayo Clinic surgeons share potential strategies for surgical care during the COVID-19 pandemic. Topics include methods to enhance occupational and patient safety, as well as resources and challenges in safely rebooting the surgical practice.
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Welcome to Mayo Clinic Cove in 19 expert insights and strategies. The following activity is supported in part by an independent medical education grant from Pfizer Inc and is in accordance with a C CMI guidelines. Good evening. Welcome back to the Cove in 19 expert Insights and strategy. Siri's from the Mayo Clinic Today it's my pleasure to discuss an important topic rebooting the surgical practice. Today we have an expert group off Panelists that will share with us on strategies that they used to safety. Reboot the surgical practice in my home institution, Mayo Clinic in Arizona. And I hope that they will be able to share with you what they did to take care of patients that required pandemic, whether it was emergency care or the care off patients requiring elective surgery. I asked them to share the methods that they've used to enhance both occupational safety off patients a swell as off the staff and also discuss what resource is they had to lean into as well as barriers that they encountered in safely rebooting our surgical practice. All of the Panelists and myself have nothing to disclose in terms of relevant financial relationships or off label usage of pharmaceuticals instrumentation. This educational activity is supported in part by an unrestricted medical education grand from Pfizer incorporated, and all materials presented today will comply with a C C M E guidelines. I am Devyani Law. I'm a professor of otolaryngology at Mayo Clinic in Arizona. I'm also the course director off the Kobe 19 Experts insights and Siri's strategy, Siri's and I'm the vice chair of education, and it is my honor to welcome my Panelists to this discussion. First of all, I'd like to welcome thank and introduce Dr David Etzioni. He is professor of surgery and chair of the Department of Surgery here at Mayo Clinic in Arizona. He also wears a very important leadership hat a share off a surgical and procedural committee. Next, I'd like to introduce Miss Marie Lena Murphy. I'm sorry I didn't ask you to raise your hand, but you are. Label Marie Lena. Hi. She wears several important leadership hats and nursing and administration in our institution. She's the associate administrator for surgery and surgical specialties as well as our interim chief nursing officer. She's the secretary off a surgical and procedural committee. Dr. Etzioni, I didn't have a chance to have your wave. Our next Panelists is Dr Sunny Core me. He is an assistant professor of anesthesiologist, and he's also part a very important part of our surgical and procedural committee. He also is a counselor off the offices and counselors of Arizona and represents the surgical specialties and was critical in both the formulation of strategies and the dissemination. The surgical and procedural Committee off our institution is responsible for the day to day operations off all the surgical practices and the operating room, and they report to our clinical practices Committee and a responsible not just for clinical but also financial performance. They work in close collaboration with other committees, such as the Hospital Practice Committee and also with the department chairs and administrators off departments that also utilized the services in the operating room. Last but most importantly from an infection infection prevention and control standpoint, we have Dr Tom Grace, who is the associate professor of laboratory medicine and pathology and as part of the Infection Prevention and Control Subcommittee. He is responsible for the oversight off the Organization, wide surveillance and activities for the prevention of control of infection, and this became particularly critical during the pandemic. So without further ado, I'd like to jump into the discussion and talk to our Panelists on what happened when the pandemic first hit our shores. And I'd like to talk a little bit about how we prepared for the pandemic in terms of taking care of patients requiring surgery. And I'd like to first start with Dr Etzioni and Maria Elena. So one of my favorite quotes is that no plan survives First contact with the enemy. Um, have a good colleagues in the military who told me that one. And I think the interesting thing about our initial Quantico planning for Cove it is that initially, everything that we predicted was about to happen and that would significantly impact our ability to do business as usual ended up not being the thing that actually happened one or two weeks later. Initially, we thought we'd have a critical shortage of gowns and PPE. We had having that what you know, having was potentially some problems with testing access or maybe a problems with staffing supply. So I think it was really hard to plan the initial phases up because things were evolving so quickly. I think one of lessons that we learned was that it's more important to be nimble. That is to be well prepared. Um, but that Zaveri surgical perspective really not. What do you think? I agree with that. I think that was one of the biggest, um, challenges. And maybe learnings from this whole experience was that you really needed to try to plan for the future. But knowing that whatever you plan for was probably not going to be the thing that you needed to be be thinking about So there was a lot of rapidly changing priorities that we had Thio respond Thio on a lot of time. That wasn't the problem that you thought you were going toe have. I think that the state and federal agencies providing guidance was one of those things that we both once did to help us make decisions. But then at the same time, uh was sometimes contradictory or would change quickly and made it actually harder because there were times where I was thinking Oh, we just told all of the staff to do X. And now here we are, three days later or two days later, we're gonna tell them. Don't do. That's no good. Now we're gonna dio now we need you to do this, so ah, lot of that guidance was rapidly developing and changing as well. So it required us to be able Thio, respond very quickly. Thank you. I have a follow question, Maria Elena. And that is to, um, your role a zone associate administrator, which is a very senior administrative position, an institution as well as the chief nursing officer. How did you address for mitigate the fear off the unknown amongst the staff and especially as news proclaimed it down from China about how you know, this disease was rapidly spreading and we really didn't know very much about it. You know, that's a terrific question. You know, I think that that really was a team effort are hikes. Team was really meeting around almost around the clock at that time. And we did quickly developed mechanisms to get information out to our leaders and have that trickle down to our staff in a in a very rapid fashion. On that came all the way from the enterprise down Thio site leadership we had daily sometimes more than once a day calls for leaders s so that we could keep that information coming to our staff on. And as I rounded on the staff, I think that constant flow of communication, um actually helped to reassure them because I knew we were staying on top of it. And if something changed, we would let them know. So even though there was a little bit of like, Oh, is this crazy making telling them one thing and then having to change it? I think that flow of communication and the transparency was actually something they found very reassuring. At least that's the feedback I've heard from staff. I can certainly echo that as a surgeon in the practice because we all knew that we were going on a roller coaster, right? But we knew that we would know exactly where it would be. That efficiency of communication and the transparency of communication, I think, helped build a lot of trust and the Incident command center and in the leadership that was running in terms of not just the hospital associated care, but also in the surgical and outpatients practices. Doctor Grace, if I could give it to you for the next question, and that relates to your concerns, uh, in, uh, coming from the perspective off infection control, infection prevention and control. What were your concerns as the as you saw the pandemic coming? And how did you advise this group of people to help us prepare? All right. Yeah, that's a great question. I think you know, transparency, as has been mentioned, is key. I was just going through my notes. It was February 7th that one of our infectious disease physicians gave medical grand rounds, sharing what we knew to date to that day up to, you know, what had been published the day before. And, um, it was packed, of course. Medical, grand rounds and thes days. We would say, Oh, my gosh, we had all these people in one room with no masks, which is, uh, funny to think about now. Um, And when I got to the question and answers, you will hear a lot of times. Um, people who talk about emergent disease say we don't know lot s so much that you might be concerned, And yet we extrapolate from other viruses, other diseases that we know. And so early on, it was thought to be, you know, from phone mites from touching things. Obviously, aerosols and droplets were definitely in the picture as well. So it was really about sharing what we knew, what we thought was possible. But really being as transparent as we can because you have to maintain that trust like Marilyn was saying, It's if you say something definitively and then you tell them something opposite. Two weeks later, they start to wonder. But if you say this is what we think today and then in two weeks, you say based on what we're now learning, we have to do the opposite, you know? Sorry. Sometimes that happens then then they'll come along with you. And so you know, when we looked at this from a practice perspective, it's usually in a risk based scenario. So, you know, where do we think? Thes? In fact, the patients might be coming from early on. It was pretty much traveled to China was key. And if there wasn't travel history there, we thought there probably. Okay, obviously that risk factor of travel expanded over time. Um And then, as we learned about potential ways, this was being transmitted. Then it's looking at what activities in the practice become more risky than they had been based on this new element. Thank you. You know, it seems kind of a little silly to go back to the beginning of the pandemic, but I think that there are many lessons learned from this particular pandemic that might apply to the next one. And what I hear from experts like yourself is this is probably not the last pandemic off our professional personal lives. So those are really good pearls that you shared, Um, topic Core me. You're an anesthesiologist. You are well versed with dealing with surgeons. Um, there was a time that you had to tell surgeons that we could either not operate or we have to cut down on the schedule. And actually, I was quite surprised by how logical. Um, the directions that came from the committee were Andi, I think that you were able to with Dr um Etzioni get a lot of buy in on the strategy that he employed. So can you share how you came to the decision to put a brake on the surgical practice? What sort of cases you thought were necessary to go forth and how you dealt with needy surgeons like myself. So, um, my favorite phrase that's come out of this pandemic is that the only thing constant in life is changed on bats. Something that we learned very quickly early on in the pandemic, that we had to be dynamic and nimble to evolve with a constantly changing situation and just just like marijuana, said and Dr Greece, Doctor Etzioni. Of all everyone's mentioned, this transparency was key. Um, we had to, uh, notify the staff that we were, um, up against an unknown. And the impact of that unknown was unknown. Andi, As we learned mawr, we were able to modify our recommendations. The key to our planning was was baked on on based on a group effort. Um, various people from different divisions of the hospital stakeholders at all levels, from general staff to administration to physicians, um sat at a table to develop a plan that made sense given the information we knew at the time. Um, we also have to factor in regulatory expectations from our local and state government. And we had thio. That information was passed on to us by our senior hospital leadership. So they were. Everyone was intimately involved with the development of the plans. Uh, at the end of the day, uh, way developed a plan that we thought would work and give our patients the best opportunity to have safe surgery and also, at the same time keeping our staff safe. Uh, their fears, Uh, a laid asbestos. We could, um but I think it was It was all based on a hugely collaborative experience. I can certainly speak to that, because I know that Dr um, Etzioni and yourself did reach out to our department in the NT because we were deemed to be somewhat in the high risk, considering that we were digging in the nose and on on certain occasions and also for your practice anesthesiologists. There was a lot of concern early on in the pandemic us how we would be protecting, um, personality, uh, that we're inducing anesthesia or were circulating in the etcetera as well. Um, how did you educate the staff in the operating room or people that were going to give direct care in the operating room during the pandemic when we knew so little about it? What were your strategies and PPE or um, sort of environmental, like reengineering of the operating rooms of peri operative area, etcetera. So first, we we did. But most normal human beings we do is we got on the internet. Try to see what information is out there. What? What could we learn from the experience in China? What could we learn from the experience in Europe? In Italy, several of us have, uh, colleagues, acquaintances that work in those parts of the world and had dealt with the issues that we were starting toe to see in our own practice. And so we thought we would reach out to them to learn what worked and what didn't work. Um, we also did Cem literature searches about prior, um, the pandemics, um, or almost pandemics. Um, you know, the SARS virus, Um, the through the Middle East respiratory syndrome. Uh, these were all, um, situations that came up in our in recent times and over the last 10, 15 years that we could lean on for some guidance. Um, we determined very quickly what would be needed to remain safe while we practiced our specialty. Um, and once we determine what we needed and that we had the supply to do the work with uneducated our staff by, um, making diagrams circulating, um, informational sheets by email. Also developing a website where people could, uh, look at a T any time of day. We also had a handful of a subject matter experts. We call them SMEs, um, that we're well versed And what it was Thio be safe. How? How to use PPE appropriately. How to put on your PPE appropriately. How to take it off appropriately on dso for early in the early in the pandemic and in the in the first few weeks and months, we essentially had somebody available 24 hours a day that we could reach out to either by person or over the phone to guide us through. Ah, confusing situation. But so we basically took, um, long story short we took you know, we tried thio collaborate and collate information from other people who had already gone through this, Um uh in various parts of the world in in the U. S. Such as New York City on Do we put sort of what we knew at the time to be best practices. We put that on the table and made that our expectation. At the end of the day, though, what we also acknowledged was that our staff concerns could not be, um, uh, discounted at any a to any at any degree, whether you're a staff nurse, ah, physician, a surgeon or resident um, p a anak administrator. Everybody's concerns needed to be handled appropriately and as a as a group. We decided that, um, we would convey that staff should, um, use the PPE. To the extent that they felt most comfortable, we did not want to artificially withhold equipment that made somebody safer. We would give them best practice advice based on the city clinical situation. However, if somebody wanted to go above and beyond that, they had the freedom to do so. And I think that really helped also, thank you that those were such great, uh, lessons and tips have to share with our partners in in other areas in Arizona. A swell as I think the audience is as a listening in. Um, if I could direct the question to Maria Elena, if our listeners are wondering why I'm referring to Miss Murphy as Maria Elena, I think that's what she likes to be referred Thio eso as a senior administrator and you mentioned the hospital incident Command center. Would you just give us an idea when that kicked in? A. Why that kicked in and what the communication strategy was from A from a organizational level. You know, that is a good question. I want to say it actually started early. Um, before we started Thio even talk about shutting down surgical practice or any of that in March. I think, uh, this is earliest February. We were, but it was only meeting on a, like a weekly basis. So we activated the hike structure, but it wasn't e would say full blown. So and we kind of did that on the on the tail end, too. So we're still partially activated is kind of what we call it. So we were able to really ramp that structure up as needed. And, um, as the structure is designed, there's different arms that you can activate depending on what the situations and questions or issues that you're having might be. So, uh, you know, concerns with PPE was an early issues. So Azzawi started to grow more concerned about the community spread here in Arizona. We activated that part of the hike structure and had supply chain at the table. You know, as we started to meet more frequently, for example, um think things with logistics, it was like, Are we gonna need, um, additional places for our caregivers to sleep? Are they gonna be able to go home? Or we're gonna need Thio keep them here. So we were working on a lot of these contingency plans, Some which we did not have to utilize, but we wanted to have mechanisms in place to activate them. Does that happen now? As you all know, um, March was when we would really thought we were expecting that big wave or surge of patients to start rising. And it didn't really happen then, right? So it was much grab more gradual than we anticipated. That it would be on DWI actually didn't see our peak or surge really until early July. So it was interesting how we ramped up. And then, of course, ramp down hikes as needed, depending on the situation and the needs of the hospital and the staff. Thank you. That's a good segue into you know how you guys came to the decision that it was appropriate to start rebooting the surgical practice into more elective surgeries. And if I could call upon Dr Etzioni what sort of resource is or what sort of preparedness in terms off personnel PPE theme, the the the pandemic situation? What factors did you consider into saying Okay, we're ready to now release some spots for elective procedures? Or how did you go up and then go down? As as Marie, Lena pointed out, just kind of in tandem with the demands of the pandemic. And so I think that the initial response that our practice had to the threat of the virus was inappropriate response, which was panicked. So we panicked. And then after the panic, we basically stopped everything that wasn't an absolute urgent or emergent procedure. Then, as we learn more about the virus, as we learn more from our colleagues lab about the operational characteristics of our tests, um, there emerged a thought that we could try to get closer to business as usual as long as we implemented certain steps. And one of the most important of the steps was a paradigm protesting. So he came up with the paradigm for testing. We had a daily monitoring of our available the supplies, especially PPE aan den. We came up with a plan to move forward and Dr Coming, I essentially came up with a system to stratify the risk of patients who were going to be going for anesthesia in terms of matching that level of risk to the appropriate level of PB and other environmental containment efforts that we would do to minimize the risk of in hospital transmission. One of the most important things I think, I would say, is a lesson that we learned at that point was the importance of being flexible, Um, and of listening to all the people who are involved in care at every single care context, pre op and drop post op to make sure that snap was dealt with. And I'll just give one concrete example. Um, initially are testing Strategy was designed so that we would test our pre op pre procedural patients Day one. So one day before their planned operation procedure, and we felt that that could work lab. We had one of the best labs in the country. We have the availability test that could be the result, based within 10 to 12 hours of this specimen being collected. So I said, Okay, we want to test as close as possible in time to the operation procedure so we'll test the day before we'll get the test drawn by ADM will have result back by 8 p.m. And then we can call up any patient who tested positive and make sure they don't come into the hospital. It made sense. We rolled it out that way. After two or three weeks, all parties understood that approach is completely untenable. So you take a step back. We worked with our colleagues and I d. We worked with our college and lab and said, Okay, maybe we should be doing this two days before, so that if there's a delay, if a patient doesn't show up they should on campus, etcetera. Then you can still, um, engaged in some service recovery. So I think one of the important lessons we learned there was the importance of being of being flexible. But that's one of the one of the lessons that people carry with us forward into whatever comes next. So I really appreciate the responsive nature off the leadership during the pandemic. And I think the flexibility, the communication, I think ah lot of us initially in the pandemic will focus on resource is such as PP and whether we'd get HEPA filters etcetera. But clearly, you know what you are sharing with us is yes, you Conover prepare. But you really need to be nimble with disease processes such as this. So I'd like to just move on from the early preparedness and response to when we went on to rebooting the surgical practice on I think that some of the Panelists have already covered thetacticsroom on prioritizing resource is patients with surgery occupational exposure which was providing for the highest level that the person was comfortable with. I I wanted to talk a little bit in terms of what doctor is the only you mentioned about testing. And I I'm hoping that Dr Gris can shared some off the testing, um, strategies that he used because at that time, testing was not freely available. We're not quite sure of the sensitivity, the specificity, but over a period of time, you know, things became more clear. Um, with regard to the reliability of these tests, So as you were helping guide the leadership, what were the thoughts that were going through your head? What kind of resource is were you reaching out into? Okay, those are great questions. Um, you know, a lot of times in the lab, we talk about a couple things. One is when you collect a specimen that is already setting, uh, some parameters around the best type of result we can get. So if you spend us Abed's first right, we can't give you a very good answer. So that's why you know, most lives were looking at me as a friend. Jill swabs. We really thought that was the gold standard. Um, and it's it's not always the most comfortable specimen, but we thought that is where we can detect the virus. The best. Um, early on, there was some swabs shortages, so that became a concern. Not everybody could get the small ones that could go back into the NASA Pharynx s. Oh, that was a challenge. Basically, every part of our testing operation was challenged by supply chain at some point early on and still continues from this swabs to regions to available instruments to run them on eventually plastic tips that are used to transfer the specimens. The media that goes in the tubes for the swabs. Every single thing became in short supply because this was not, ah, local problem. It was in the US You know, this is a worldwide problem, and a lot of these companies operate worldwide. And so their store houses went quick. One of the things with supply chain in the industry. Oftentimes, when you have products sitting and stay with me, if we have things sitting on the shelf, that's value that we should be put into use. Um, at some point, we can't just have that resource sitting. So a lot of supply chains have been fairly optimized, so to speak, for routine terms. But then when everybody needs the same thing, um, that becomes a really big problem. So early on, you know, we worked very, very closely with supply chain to identify, uh, the product we need back up, back up to that and, you know, determined that for our site, we used swab we could get that was dry on. Then we had another lab helping us out by pre feeling sailing into empty tubes. and we use that as our primary operation for collecting specimens for several months. Other labs were kind of switching back and forth. And so that's the first chunk is getting the specimen to the lab. The next part is maintaining the testing operation. So that includes having instruments to do that's testing on and the re agents we had committed pretty early on to get a higher throughput instrument committed to a volume purchase so that we could maintain, uh, re agent supply. And and they could know that we're going to purchase that, um, And then it comes down to having people to run the test. Since a lot of the practice had slowed down, we actually borrowed, um, e think five or six people from other department of lab medicine and pathology labs to help out we trained them in, and they would just do that test for us on. That was a huge help. Um, you know, we had about 25 people during our normal operations, so we added about six more, uh, to really help accommodate this and keep testing going 24 7. Um, you know, just doing the test for the high volume throughput is it's not fast on. There's a couple of steps along the way. Eso You know, we really had to staff people at all hours to keep keep things going. Um, and there were some parts of the summer that photograph and I were in their pouring off tubes, um, t to keep things going because we're just so short of people. Eventually we got we got mawr. Um, you know, we've hired quite a few more people just in the micro lab to maintain this. Um, and then really looking at what testing modalities do you have? There are rapid methods for PCR testing. There are high throughput. There are rare instances that you can get higher throughput pretty fast. But for the most part, you either have speed one at a time or you have a whole bunch that takes, you know, 68 10 hours, depending on the run. So we would run batches of, you know 24 48 96 and more or less. That takes a good eight hours or so. And then you throw in some processing and specimen trends of time and to maintain, you know, something close to 12 hours turnaround time. Um, you know, that was something that we prided ourselves in. But we also had to remind our colleagues sometimes that if it were, 16 hours or 20 were still promising 24 hours. So just because we do really good most of the time doesn't mean sometimes that we're not going to be taking a little bit longer. So that's where these conversations we're really vital that, you know, we were invited to be at the table, so to speak. Of course, this was mostly over teleconference and zoom. But to really have those conversations two week, we could help our colleagues understand what was feasible for us. What was not gonna work, what options? We had a small volume, so emergent surgeries, you know, we could accommodate a small number of those with a rapid test, like a one hour turnaround. We couldn't do that all the time, but certainly for things like transplant emergent surgeries, we could accommodate a small number. And so there's just a lot of communication to kind of develop that and be flexible. Aziz, we mentioned over time, and I think you know, it became kind of ah question you know what tools, Uh, that we can help answer certain questions in a certain time frame, and then the practice had certain needs of what answers would they want in a certain time frame and how many patients? And it was just a matter of having that conversation, too. Figure out how toe to keep things going and not over utilized precious fast test. But make sure we were using them if they were gonna be helpful. You made such great, um, points over there about, you know, developing the test rapid versus, um, more routine. Although I would argue that anything that can come back in 12 hours or 24 hours even today is absolutely remarkable. And talking about retraining and redeploying, which was to your advantage, I'd like Thio asked. Miss Murphy, Dr Joni and Dr Kumi, Um, how redeployment of the personalized the pandemic progress and we were rebuilding the surgical practice. Um, and the incidents of hospitalized patients went up. We had to redeploy some of our anesthesiologists R C RN, a nurse, anesthesiologists and post op care nurses out to take care of Kobe positive patients, either in the I C or the floor And how that impacted the practice one, um, and number two were there any other strategies that you use to our advantage in terms of rebooting the surgical practice by reengaging and retraining other folks that were working in the hospital at that time? I can start out with that speech to that a little bit. So, uh, to answer the question, I think I really need to get a little bit of background around some of the financial impact around cove it and shutting down the practice. So, um, when that occurred across the organization, there was some concerns around, you know, how would we be sustainable? Not knowing how much longer this would go on without being able to provide elective care to our patients. So there were some financial stabilization efforts that were put into place. Um, and some of those were that impacted our staffing was we? We decided to cancel all use of our traveler staff, not use supplementals, and there was a hiring freeze put in place. So that was the right thing to do at the time, especially not knowing what the future might hold. And we also we're not seeing the volume of cases at that time that we expected. So when you think about where we were in the month of May in the community, we weren't really doing the elective practice and we weren't seeing the Koven surge yet. So we were in a good place, I think, at that time. But what happened was as those Koven numbers started to rise in the hospital, particularly in the I C u r i c was not staffed Thio be 100% full anymore. Now that are, travelers were gone, so we were in a little bit of a staffing pickles. So luckily, our package you nurses, many of them are critical care nurses. Quite a few of them came from our I see you. We also had great support with our education. Uh, colleagues are nurse education specialists and many others creating up skill programs for a lot of our nurses who maybe had worked in the issue in the past or emergency room. Some of these other areas that we're seeing surges and, uh, get them to a competency level that were they were able to help in assistance. Some of these areas um, the sea Arnas on anesthesiologist were also tapped to support in those areas as well. Now are creamy. Speak to that specifically. But I think, uh, that impacted our ability, um, to care for surgical patients. But it also the over folk flow plan was our pack you areas. Well, so depending on how many patients came into the hospital, our response was going to need to be that we would close down the surgical practice again. So we kind of did. I had a little bit of assault tooth pattern where we shut down the practice. June became very busy. We had everybody working. And then as July came, we were having to shut it back down to support of these, uh, cove in patients that we were starting to see the surgeon numbers. So that was really kind of the background around that. I think some of the other strategies that were employed or we utilized our colleagues across the enterprise who actually sent us staff that could come and help in our pack you area and also work in the operating room. So we had about 24 nurses and other staff from the Midwest that came to Arizona toe help us during that search time, which was just shows the power of teamwork at Mayo Clinic. It was really great. Quite wonderful that of that collaboration and that support. Yeah. So, yeah, I'll, uh, I'll take the baton here. Um, when, uh, you know, the ebb and flow of the pandemic. You know, modeling would show that we would we had to prepare a certain way for a certain time line, and it never played out that way. On dso we shut the practice down. I think, uh, everyone involved the surgeons, especially, were incredibly understanding about the needs of, uh, potentially very sick patients filling up the hospital. And resource is being re allocated. They were incredibly understanding about the notion that, um, surgical care Thio their patients was going to be curtailed and put on hold. Um, as we started toe, see what was actually happening in the community and how it might impact our hospital census. Yes, we were able thio relaunch a fairly robust, um, surgical practice. That was, uh, in part because we had a what? I think a very cohesive and cogent um uh, pre surgical covert testing plan. Our lab medicine department was 100% instrumental in making this a viable and realistic option. And I think many hundreds of patients benefitted from this collaboration. So then, uh, but of course, the pandemic wave came to Arizona, and we had to adjust very quickly again. And, you know, at this point, then it wasn't a knish. You of. Do we have enough PPE or, um, we don't understand what the diseases. We knew exactly what it was. And, um, at that point, we now knew that we had to re allocate our staff to other critical areas of the hospital, first and foremost to the intensive care unit, but also to the emergency room. And this is where, um, the genius of Mayo Clinic came alive again, where we were able to collaborate with E R physicians, understand what their needs on concerns were and establish a group, uh, of anesthesiologists and Sierra Nas that would function as advanced Airway team. Um, in the event that there was a sudden surge of patients all at once, that needed to be intubated because because it was such a dangerous experience to intubate a patient who likely was sick with cove. It um the ER physicians thought that it might be better to have a dedicated team specialized in handling this while at toe handle this s O that it wouldn't take away from their care for other patients that were in the emergency room with other medical problems. So we were able to develop a good plan there. Three intensive care team. The intensive ist led by Dr Sen, um collaborated with our department. Um, they had several sessions on what it meant to take care of a covert patient in the I C. U um, they ran multiple, uh, simulations and educational sessions to bring us back up to speed to sort of what is the latest and greatest in critical care. Many of us have done critical care in our training. Some members of our department spend 50% of their time as critical care physicians on DSO. It made sense for the i c u toe look to our department to collaborate and offer in and be a part of that surge plan. When they got busy and it was activated, so re sources were re allocated on, they were re allocated away from the operating room eso by default. We had to, um you know, shut down operating rooms and basically announced that we had x number of oh, ours to do cases in. And we basically decided, based on state regulatory guidelines, we would, um, uh, prioritized certain cases over others. And the basic premise of that was, you know, if if a surgeon felt that their patients health was going to decline on bond and result in a sub optimal outcome, um, because they delayed surgery for I think it was 30 days. Uh, then we would make every effort to accommodate that surgery a soon as possible. So, um, that was the premise of how we allowed cases toe carry forward A to the Mayo Clinic. Dr. Etzioni? Well, I think, uh, Molina and Dr Kermie covered all gonna focus just for a moment on that last part that Dr Comey talked about, which was there was a point in time at which we had insufficient resources to do all the operations that the practice wanted to do. So we had to come up with a prioritization scheme and then communicated out, and that was a very delicate process. Andi, I think that luckily we happen upon a good way to do it. We came up with a draft for a prioritization scheme. We socialized it and then we stuck to it. We made sure that people knew why the why For the reason why we couldn't do all the operations that people wanted to dio. And I think that we did it in a way that made people feel comfortable with the decision making process, that it wasn't arbitrary, that it was going to be here to consistently. And we were telling people on short notice that elective case you wanted Thio that you scheduled even though we told you not to, you can't do it. And I think that because of that people, people accept her pretty well, thank you. I think all three of you made such excellent points and as one of the recipients of that communication strategy, and it was actually done in a very, very, um, humanitarian way. I think you put the needs of the patients first, and it wasn't a top down approach off. People who know the patients making the decisions for the patient or the surgeon. You allowed autonomy, um, in terms of guiding the surgeons with certain, um, resource limitations that we had, um, and allowing us to make that decision. I remember hearing stories and and some of the human stories stick. And as surgeons, you always think that the needs of your patients must be very important. I remember, um, that some of our ice you nurses by that time we're eso overworked because they care that every patient required was so intense that they would come out of rooms and would break down because they were emotionally unable to cope with it and that the personnel that you guys redeployed from the operative areas were actually bailing out. Our colleagues are nurses who were pretty much at that point of time for all we knew, putting their lives on the line and that sort of communication balancing out three humanity theme needs of the patient, the care of our own staff. I think that's what got you by. And at least that's what I think. And I can still kind of feel emotional about it when I think about what we went through during the peak of the pandemic and, God willing will not get there. But thank you for your leadership. So I am going to move on to our next topic, if I might. And again, some of which we may have shared already. Um, and that is changes that were necessary in, um, the operating rooms, pre operatively holding areas, and the post operative holding areas that became necessary as we rebooted our practice. Uh, on that, you know, if you could share what it took in terms of physical distancing enhanced lensing personnel PP for these folks that were taking care of either covert negative covert unknown patients and covert positive patients. So I'll dive in on this, Um, so a zoo. My role as the medical director of sort of Surgical services Perry Operatives area. We were a surgical and procedural committee, a za hole. We were looked upon to, um, you know, formulate a strategy that would allow the practice to grow back to where it needed to be on where it wanted to be. We have to start with facilities. We first had to identify locations within our peri operative space where we could bring, uh, covert positive patients without endangering other patients. The staff and we established, uh, some locations that had negative pressure environment that didn't have it before our facilities colleagues were exceptionally quick at getting this set up for us almost within 24 to 48 hour turnover. Um, depending on the urgency of what we were asking, um, beyond that the institution then provided the PPE in more than adequate supply to the preoperative staff s so that they could use depending on the patient that they were receiving from from the awards from the I C o. Well, if it was a nice you patient, they would go directly to the operating room or from from the lobby where patients were coming in from from home for for their outpatient procedure. Um, but again, it goes back to our testing paradigm. We had to, uh, make sure that all of our patients were following And are our expectations about preoperative covert testing while we accept that there are a there is a certain level of false, positive and false negative and a test we we embraced the notion of of testing in asymptomatic patients and the results that came of it, um, universally and consistently kind of what Dr Etzioni have pointed out, too, that this was not arbitrary. Um, the information was conveyed very concisely and clearly to the staff about what the expectations are. And patients were invited in to the preoperative area. Once we knew, uh, that their covert status was negative. And if it was positive, then they were taken to the appropriate location within the preoperative setting s so that they could be taken care of in a safe manner there, so that, you know, the preoperative testing sounds like to me an operational nightmare. I mean, how did you guys pull this off? The communication? Not just a testing. So Dr Kermie used to have a full head of hair. Okay, um, it's true. Before we work together to implement testing, it was like a man. Um, so I'll speak to that one a little bit. Um, you know, wars or places that have it or is function really well when everybody is taking care of patients the same way they have every day for the last five years. Um, breaking that habit is really hard, and it requires a lot of education, a lot of consistency, of all the innovation and just inventiveness. One of things that we did that made it easier for the power to adapt is we had different colored sheets of paper, a laminated that told each it thes piece of paper went along with each patient. That said exactly the types of precautions and the way you organize their care in terms of pre op and drop in post op care. That really helped to make everybody feel more comfortable that they knew exactly at which patient would be taken care of. But the pre op testing thing really was a logistical nightmare. And I think one thing that we learned here is how absolutely critical it is to have nursing involved in anything that's detail oriented about based care. No other force in the hospital other than nursing will make those systems work. Nurses are the ones who will check, double check and triple check to make sure patient got something done before they go. Thio are after or before the or whatever. They're the vanguard. And I think that when you're constructing a system to do anything, initially there is going to require a period of time where you need nursing to take those steps and they will be there, appointed this message brought to you by the nursing council. E. I just want to echo that that the the nursing team that, uh, took the reins on making this pre surgical testing program function deserves mawr than mawr commendation and accolades than we could probably come up with because our surgical practice does not exist during this pandemic without their above, you know, all out effort. Yeah. You know, I have to say, I agree with you. I think the nursing team did an outstanding job and continues to do that because our surgical patients just don't just come from home either. So we also had the institute impatient covert testing for patients, uh, quite rapidly as well. And I recall very clearly having a conversation with one of my nurse leaders around implementing that, and she as we were discussing how to get it started. When will we do it? What the challenges we're going to be? How are we going to manage it? Eventually, at some point in the conversation, she's like, Are you telling me that we need to do this? And I was like, Yes, that's what I'm telling you. We need to do this and literally, I think it was by that Friday we had implemented it house wide in the hospital. So the nursing leadership team, uh, and all of the staff that redeployed to the testing tents, who helps manage the testing tent, get that up and running that communication with the pre a pre admit nurses and the patients coming from home. All of those pieces really did work together to make it happen so that we could activate the surgical practice and take care of surgical patients was really impressive teamwork with everyone at Mayo Clinic, but especially the opener, those in all those different phases of care and and I'll say that we've continued. We've we've had our baseline program functioning very well, but we've had to modify it periodically as clinical situations occur. One thing that came up that was causing a lot of consternation amongst surgeons was, you know, waiting for a test result when they thought a patient might need surgery sooner on. Then the downstream impact it would have on staff anxiety. Where is this patient going to go post operatively if we don't know what their covert status is? Um, and again, we're working with the lab with nursing leadership, we were able to come up with a strategy to thio deploy using rapid tests a little bit more freely within a certain scope on a per day basis. But, um what? What? I wanna make a point, that is, the staff. When they are given clear direction about how something is supposed to function, things tend to go better. It was the 67 days where we were in this no man's land about Well, I don't want to wait for a test because this patient needs surgery sooner. That led to a lot of grief. Andi Anxiety. And again, we just went back to what we knew worked clear, concise communication, uh, to the teams. And, uh, once we were able to re establish that level of communication, things went back to smooth sailing. And since then, knock on wood. We've not had to modify our testing plan fantastic. And in in this day, where we are actually, you know, almost up to speed to where we were. If we have a patient that does not have a known covert status, what are the strategies that are being employed for an urgent or emergent procedure? Well, if if it's truly emergent and there is, uh, no timeto wait, um, Then we will proceed with the best interest of the patient at hand on. We will take appropriate, uh, precautions. We will probably behave in the most conservative manner utilizing maximal PPE that is available to us, which includes and 95 mask gowns I protection and for those guys because of a poor fit way, have campers and pepper devices a zone option. So that's the emergent situation on cases where surgery is urgent. But there is time to wait potentially. Um, we, um, exchange communication with surgeons and the surgeons have have, ah a mechanism Thio communicate with the lab to request a rapid test where the turnaround time is about an hour once the specimen is running, Um, and we can then proceed, uh, with surgery once the result is known. And if it comes back as positive now we know to take appropriate precautions. And if it doesn't, if it comes back as negative, then we can dial back RPP, use Onda proceed in that manner. Um so that's kind of how we we've dealt with urgent emergent cases. So at that point in time, we have a trade off between our available tests and are available. PPE um, if there was a relatively urgent but not an emergent case, would we wait a certain amount of time for a standard Kobe test to come back? And when the test came back that we could use the war conservative usage of PP or would we burn one of our precious rapid tests that were in short supply in order for the patient be able to go now? Or would you see the patient with maximum PB e Think that we had, ah, lot of hallway conversations about this three way, four way trade off. Um, and luckily, our colleagues and lab were able to secure um, or stable supply of tests. So we weren't living in fear that we have what other rapid tests. But I think you really do have to have a multi distillery conversation that had come up with a approach that's consistent. Thio those types of resourcefulness. Yeah, I think that's absolutely right. And that's where we really appreciate that two way communications. So we understand the constraints. Um, you know what it means when you can have a result in one hour versus two hours versus four hours. Sometimes labs, you know, they have different options out there. They can develop their own testing and some scenarios. So that's where we always try to give you the information you need, uh, in the right time, because knowing if it takes too long, it's irrelevant. And also, if it's the wrong answer that introduces risk into the equation. And sometimes as leaders in the lab, we have to, uh, not undermined, but remind our practice that these results are the best we can do. You know, we try to get the right answer and every single specimen every single day. We know that doesn't always happen. We know sometimes the sampling wasn't so good. Um, and eso we always have to remind the practice that this is the result. Um, but in a risk based scenario, there is the risk that a result that's negative. Maybe on the wrong specimen test wasn't sensitive enough. Patient had it in the lungs and nasal pharynx. So there are no risk free scenarios. Uh, in this and so what we tried to do is really find, uh, the lower risk path at every circumstance. And, like you said, sometimes that's a trade off between. Do you have more rapid tests or do you have Maurin 95 today? And that changed? I think, for a lot of practices over time, dependent on what they see, what they could secure. If they had been sending out testing, were they able to bring it in? Um, did they happen to have rapid supplies that week? Um, and that's where it's really over time. Over the first couple of months, I think we really were to build stock and supplies and tools and then just move those levers, uh, to try to keep the product is running as smooth as we could. I mean, I'll say that, Alecko, that we we were able, in retrospect, to achieve a real nice balance between, you know, stockpile of PP and a stockpile of of tests that matched what our needs were for. The surgical practice on DAT was just good fortune. In retrospect, So any any tips or strategies to share in taking care off patients who are covert positive but require surgery during the period that they still have positive tests? Eso if they require surgery. Obviously, you know, we would certainly explore all options about, you know, the potential delay of surgery. Um, if they are, um, known covert positive, needing emergency. Urgent surgery. Uh, we would just say that. You know, you have to follow what is best practice. Uh, follow public health recommendation. Socially distances. Best is possible where your PPE face mask and I protection whenever interacting with the patient. Where a gown when interacting with the patient. Andi dispose of thes thes peopie in the appropriate manner so you don't cross contaminate other areas and other patients or staff. Um, I think the color coded sheets that Dr Etzioni mentioned, um, we have these in the patient's chart from the time they're in pre op to the time that they leave the recovery room and they follow the patient. Um, and really what? That is it's a checklist of, uh what? Who the patient is, what the patient type of surgery they're having on. If there's any PPE concerns that need to be dealt with, this paper goes with the patient. It is hung on the outside of the operating room door. Eso that if anyone who has not been involved with that patient's care wants to enter the operating room. They will then see that color coded sheet first and be alerted that Oh, I need to put on X Y and Z or you know what this is a I have I see a green pass and so that is I'm safe to enter with standard surgical attire. Eso I think making sure that you have clearly communicated to all that are involved in the care of the patient about what the needs of the patient are, um is key when we were still, um, you know, early on in the pandemic and we had the first few patients come through covert positive. What we insisted on was toe have ah staff huddle that included the surgeon, the circulator, the attack, the anesthesiologist and the nurse anesthetist on. We would all huddle for a few minutes and discuss what who the patient was in the needs of the patient so that everyone was on the same page that there were no surprises. Um, at any point during that experience with that patient, and I think that was worth its weight in gold to make sure everyone was on the same page. Andi things functioned and moved much smoother from that point on, from a personal but perspective, I could certainly verify that. And the comfort you know, when we do a time out procedure prior to surgery, about the class of the patient, based on how you graded the risk during the surgical procedure and with the patients covert status as just maintain a degree of consistency, degree of confidence and in the entire operating room staff, including the surgeons and nurses and circulators, etcetera so that that's been fabulous. Um, we we have we are coming to almost the end of our discussion today. I just wanted Thio summarize some of the key learning points we work at the Mayo Clinic and and as many of you pointed out, we're really lucky and fortunate to have a really great lab on side, um, and the ability to, um, leverage supply chains and manners that other possible systems or smaller practices may or may not be able to. But I think the lessons that I took away from listening to you is that, um, you know, teamwork, communication, transparency. Those were critical and that to reboot the practice safely. There are some key elements. I think testing certainly for our practice theatric wit, supply of PP to the degree that is required by staff, especially to resume elective practices is very critical. Um and I we all understand that in a care of patients that meeting the needs of patients is important, But, uh, from a financial sustenance, uh, standpoint, it's very important for health care systems to know, not go bankrupt, to be able to support the mission and to keep elected care going. So from that standpoint, I think certainly there have been lots of changes in the way we practice and certainly with some of the procedures based on testing and based on how much time, in terms of turnover we have to give that it's certainly impacted the efficiency of the operating room. So, um, last minute comments from perhaps Marie Lena, you or Dave you on? How do you balance out? You know? Yeah, we are, you know, not operating with the level of efficiency that we have in the past. And perhaps this is going to go on for for a period of time, at least well into next year. S O I think one of the biggest lessons that I've seen come out of this is that in any institution, your most important resource is staff, and they're also your most expensive resource. And I think that when confronted with the front end of the crisis of unclear proportion, like when we just faced that, sometimes we retreat to a stance of financial risk aversion. And we say, perhaps we should preemptively cut back on our staff where we can, and I think that maybe for us, that was a mistake. Um, our ability to manage this crisis well was based on having of staff. And I think if I could do it all over again, that's 11 thing that I would pay more attention to. But at the other day, there is no perfect fix. With this technology. I'll be a little bit, although asking our EMR to change even position or one period at the end of the sentence sometimes requires inactive Congress, Um, so because our information systems and structures are not that nimble, we really do have to rely on staff, and that's where I think we've been able to win the game. Uh, Maria Elena I think the only thing I would add to that is really uh from that communication standpoint is that you know, we're listening to our staff as well, because I think a lot of the issues that needed to be addressed we did through things that they brought forward. So I think, you know, having that bi directional not just from the hikes down, but also from the staff up really did help us to address a lot of those concerns and make sure that everybody on the team, all the staff, had what they needed in order to feel safe and take good care of our patients. Thank you. And and my last question will focus on the most important aspect of why we do what we do. And that's the patient. And I would say that the care in terms of surgery for the patient remains in really good hands and is as optimal as it's always been. But the impact on the pandemic and having visitors with them, someone to come in with them at the time of surgery stay with them has been impacted. So what have we done so far to optimize the patient experience Um, And what are the changes that have come, Perhaps the beginning of the pandemic through now. And where do you see some opportunities? Um, in continuing to improve that experience. So I'll speak for our preoperative staff. I think our pre op nurses are some of the best you'll ever see there. Uh, extremely polite, congenial, smart professionals. I think they've taken it to the next level when it comes to being sensitive. Two patients who are anxious about a surgery and you can see that when you go into the room that there is another. It's almost like next level relationship building that they've taken taken upon themselves to start the process for the patient, um, to enable them to help them get comfortable with the idea that, yes, I'm going to have surgery today. Whether it's elective, urgent or emergent, I think it starts with our preoperative staff and how they interact with the patients having family members come with them. Um, we have made, um, depending on clinical situations. I think this has come up in the I C U also where, depending on clinical situation, we have made, uh, innovative ways to come up with innovative ways for patients to interact with their loved one before they are put to sleep in the I C or before they're taken back to the for surgery. In the operating room, we've used the iPad we've used, you know, face time, Zoom. Uh uh. Effectively. And I think that's really made a big difference in that experience for the patient. Any last minute comments, tips, pearls. Well, I really wanna thank you all on bits. Been delightful being with you and actually, Bean to be able to see your face is because this is the only medium by which we know whether Dr Comey's beard is on or off for longer up. Uh, my hair is still Yeah, and to see you all smile. And And I think sharing the lessons learned, um, and so transparently and honestly and so generously. And I am very, very confident that our audience will be very, uh, grateful for for some of the experiences you have, um, shared with them. And with that, I'd like to thank you all for participating. And I hope that, um if questions arise from some of our listeners, we can forward them to you and uh, good night. It's almost 6. 21 here. And if you were wondering why I was putting myself on hold, there it was because my light goes off after every 30 minutes. So I think it's about to go out for the third time. And I just want to express my gratitude on behalf of the school of continuous professional Development for working beyond your normal, um, hours and taking the time to educate our audience. Thank you. Thank you. That's a low. Thank you. Don't belong. Thank you. Thank you for inviting us.