Maintaining Healthcare Safety During the COVID-19 Pandemic- … · 2020. 9. 12. · Maintaining...
Transcript of Maintaining Healthcare Safety During the COVID-19 Pandemic- … · 2020. 9. 12. · Maintaining...
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TRACIE HEALTHCARE EMERGENCY PREPAREDNESS
INFORMATION GATEWAY
ASPR ASSISTANT SECRETARY ~-OR
PREPAREDNES S AND RESPONSE
Maintaining Healthcare Safety During the COVID-19 Pandemic- Speaker Series
September 2020
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Access other video s in this series here: https://files.asprtracie.hhs.gov/documents/maintaining-healthcare-safety-during-covid-19-speaker-series-.pdf
Access the recording here: https://attendee.gotowebinar.com/recording/2181053247045555472
https://files.asprtracie.hhs.gov/documents/maintaining-healthcare-safety-during-covid-19-speaker-series-.pdfhttps://attendee.gotowebinar.com/recording/2181053247045555472
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TRACIE HEALTHCARE EMERGENCY PREPAREDNESS
INFORMATION GATEWAY
ASPR ASSISTANT SECRETARY ~-OR
PREPAREDNES S AND RESPONSE
Access Dr. Prachand’s bio here: https://www.uchicagomedicine.org/find-a-physician/physician/vivek-n-prachand
Vivek N. Prachand, MD Professor of Surgery Chief Quality Officer, Department of Surgery University of Chicago Medicine
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https://www.uchicagomedicine.org/find-a-physician/physician/vivek-n-prachand
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“Elective” Surgery and COVID-19 • Need to balance response to COVID with providing ongoing care to non-COVID patients
• “Elective” ≠ “Optional:” Surgeon and patient elect whether/when surgery is to take place based on medical necessity, effectiveness,and consequences of delay; the need for surgical treatment ofdisease remains
• Decision to proceed with any operative treatment in the setting ofthe COVID-19 Pandemic requires incorporation of novel factorspreviously not overtly considered by surgeons – Dynamic resource limitations (testing, PPE, ICU beds, ventilators,personnel)
– Risk of infection to the health care team and patient – COVID-19 specific perioperative risk (fulminant post-op respiratory failure in asymptomatic COVID+ patients)
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MeNTS Scoring Process • Multispecialty group created a tool that systematically integrates these factors to facilitate decision-making and triage for non-emergent but Medically-Necessary, Time-Sensitive (MeNTS) Procedures – 21 factors associated with poorer outcomes, increased COVID-19 risk to providers, and/or increased resource utilization were identified • Procedure • Disease • Patient
Prachand et al JACS 2020
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OR Time
LOS Anticipated
Post-Op ICU need
Bleeding Risk/EBL
Surgical Team Size
Intubation Needed to Perform Procedure
(Probability)
Surgical Site
1
< 30 min
Outpatient
Very Unlikely
< 100cc
1
:5 1%
None of the
following
2
31-60 min
23hrs
4d
~25%
~ 750cc
>4
~25%
OH NS/Upper
GI/Thoracic
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• Higher score for each factor is associated with poorer outcome, increased risk to providers, and/or increased hospital resource utilization
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Lung Disease (asthma,
COPD, CF)
CV Disease {HTN, CHF,
CAD)
Diabetes
lmmunocompromised*
Ill Sx's (fever, cough, sore
throat, body aches,
diarrhea)
Exposure to known
COVID+ Pt {14d)
1
65yo
M inima l
(rare inhaler) > M inimal
M ild/Moderate On CPAP
(no CPAP)
Moderate Severe
(2 meds) (:2: 3 meds)
Moderate > Moderate
(PO meds on ly) (insu lin)
Severe
Yes
Proba bly Yes
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• Higher score for each factor is associated with poorer outcome, increased risk to providers, and/or increased hospital resource utilization
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Treatment Option EFFECTIVENESS
Non-Operative Treatment Option RESOURCE USE/
EXPOSURE RISK
Impact of 2wk delay in
DISEASE outcome
Impact of 2wk delay in SURGICAL difficulty/risk
Impact of 6wk delay in DISEASE outcome
Impact of 6wk delay in SURGICAL difficulty/risk
1
None available
Significantly worse/
not appl icable
Significantly worse
Significantly worse
Significantly worse
Significantly worse
2 3
Available , 1111 ~NC, UfPO~H INfORMATIO N GATEWAY
• Higher score indicates less harm if non-operative treatment is pursued and/or surgical treatment is delayed
• Limited resources are better deployed for diseases where non-operative care is less effective and where delayed surgical treatment leads to worse disease outcome and/or increases surgical risk
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surgical risk Favorable risk to personnel
Favorable resource utilization
MeNTSScore 21
Reserved OR Capacity for Emergent/Urgent
Cases I
Worse outcomes Excessive risk to personnel
Excessive resource utilization
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Utility of MeNTS Scoring Process • Procedure + Disease + Patient = Total MeNTS Procedure Score (21-105) • Score thresholds can be adjusted in real time based on local resources and conditions in the context of the COVID-19 pandemic – If score exceeds Upper Score threshold, procedure not currently justifiable – Lower Score threshold guides preservation of resources foremergent/urgent cases
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3
2
0 MeNTS Score
COOR Cases 3/20-3126 (N=35) 6 cases deferred
105
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Utility of MeNTS Scoring Process • Procedure + Disease + Patient = Total MeNTS Procedure Score (21-105) • Score thresholds can be adjusted in real time based on local resources and conditions in the context of the COVID-19 pandemic – If score exceeds Upper Score threshold, procedure not currently justifiable – Lower Score threshold guides preservation of resources foremergent/urgent cases
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Operationalizing MeNTS
• All procedure requests must be accompanied by a MeNTS worksheet completed by the surgeon
• Upper and Lower Score Thresholds regularly reviewed and adjusted by OR leadership
• “Borderline” cases discussed MD-to-MD
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COVID-19 Cases 3/22/20 – 6/18/20 at University of Chicago MeNTS MeNTS
implementedcreated
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COVID-19 MeNTS Surgery Scoring System Strengths
– Dynamic flexibility based on resources and conditions – Transparency provides reassurance to our colleagues, trainees, and public that their safetyand resource preservation is being taken into consideration
– Systematically integrates complex factors not usually considered (like a “checklist”) – Applicable across specialties and diseases – Offloads some emotional and ethical workload, reduces risk of moral injury – Can be used along the entire COVID-curve, including the recovery phase as “elective”procedures resume
Weaknesses – Paucity of collective high-quality data in setting of ongoing pandemic – Factors may require updating as data become available (obesity!) – Disproportionate weighting of factors is inevitable – False reassurance/objectivity (~”Pain score”) – Does not anticipate resource availability for management of complications duringhospitalization or readmission
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MeNTS Implementation: Lessons Learned
• MeNTS is NOT a risk calculator for prediction of outcomes. It is an “Index” that incorporates risk of COVID-19 severity, COVID-19 infection (patient/providers), resource use, medical necessity, and time-sensitivity
• Avoid requests to modify MeNTS scoring for individual specialties • Emphasize safety measures that have been implemented at your institution
• Economic considerations are NOT part of MeNTS scoring (patients, public, non-surgical services)
• Acknowledge uncertainties (false negative tests, lateral spread, future resources)
• Avoid the word “elective”
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Contact Us
asprtracie.hhs.gov 1-844-5-TRACIE [email protected]
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mailto:[email protected]:asprtracie.hhs.gov
Maintaining Healthcare Safety During the COVID-19 Pandemic- Speaker SeriesVivek N. Prachand, MDProfessor of SurgeryChief Quality Officer, Department of SurgeryUniversity of Chicago Medicine “Elective” Surgery and COVID-19MeNTS Scoring Process Scoring procedures tablePatient condition, demographics, score tableDisease and impact of delay by week scoreUtility of MeNTS Scoring Process�Utility of MeNTS Scoring Process�Operationalizing MeNTSCOVID-19 Cases 3/22/20 – 6/18/20 at University of ChicagoOR Case Volume RecoveryCOVID-19 MeNTS Surgery Scoring System�MeNTS Implementation: Lessons Learned�Contact Us