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


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


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


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


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

8


3

2

0 MeNTS Score

COOR Cases 3/20-3126 (N=35) 6 cases deferred

105


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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1

OR Case Volume Recovery

12


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

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