reactivation planning: playbook · 24.04.2020 · endo – gi. interventional cardiology and...

Reactivation Planning: Playbook Surgery and Interventional/Procedural PlatformsMay 8, 2020

Presented to: Insert relevant presenter information Calibri 16ptPresented on: Month day, YearPresented by: Insert relevant presenter information here

Revision History

• 5/8/2020 updates1. FAQs from IDPH added to slide 42. EDW report added to Estimating Inpatient Needs on slide 9

2

Original document published on 5/5/2020

• Ensure safety for all patients and NM team members.

• Maintain readiness for a COVID-19 resurgence.

• Equip clinical and operational leaders to determine the local sequence, pace and approach for reactivating care based on facility, staff, supply, testing and PPE availability.

• Continue to focus on wellness as we acknowledge and respect physician and employee experiences relative to COVID-19.

• Identify lessons learned and emerging best practices, technologies and tools.

Reactivation Guiding Principles

3

Reactivation Workgroup Structure

4

AmbulatoryHospital

Outpatient Diagnostic

Scheduling and Telehealth

Interventional / Procedural Surgery

Regional and Medical Group Presidents

Re-surge and Resource Modeling

PPE and Testing Guidelines

Facilities

Regulatory Requirements

• IDPH Guidelines for Elective Surgeries and Procedures April 24, 2020− Minimum threshold requirements to resume elective inpatient procedures

(IDPH 4/24/2020*) • Hospital availability of adult med/surg beds exceeds 20% of operating capacity for adult med/surg beds• Hospital availability of ICU beds exceeds 20% of operating capacity for ICU beds• Hospital ventilator capacity exceeds 20% of total ventilators

− Subject to change in the event of the following circumstances:• Rapid resurgence or a second wave of COVID-19• Decrease in statewide hospital COVID-19 testing levels

− See PDF below or the link for FAQs from IDPH

IDPH Minimum Thresholds (IDPH Section C)

*These thresholds do not apply to pediatric procedures 5

https://www.dph.illinois.gov/covid19/community-guidance/elective-surgeries-and-procedures-faqs

Regulatory Requirements

Case Setting and Prioritization

• Each facility should convene and charge a Surgical Review Committee (SRC), composed of surgery, anesthesiology and nursing personnel, to provide defined, transparent and responsive oversight of the prioritization of elective inpatient cases.

• This committee can lead the development and implementation of guidelines that are fair, transparent and equitable for the hospital or system in consideration of rapidly evolving local and regional issues.

• The SRC should rely heavily on elective case triage guidelines for surgical care that have been developed by professional societies.• The SRC should review regularly a list of previously postponed and canceled cases, prioritizing based on clinical considerations and

taking into account the resources and staff necessary for each procedure.

PreoperativeTesting for COVID-19

• Facilities must test each patient within 72 hours of a scheduled procedure with a preoperative COVID-19 RT-PCR test and ensure COVID-19 negative status.

• Patients must self-quarantine until the day of surgery after being tested. • A temperature check must also be completed on the day of arrival at the facility with results of less than 100.4 degrees prior to

proceeding with an elective procedure. • When clinically acceptable, providers should consider using telemedicine for preoperative visits. • In such cases, face-to-face components of the exam can happen after the result of the preoperative COVID-19 test result is known to

be negative.

Protective Equipment

Facilities may resume procedures only if there is adequate personal protective equipment with respect to the number and type of procedures that will be performed, and enough to ensure adequate supply if COVID-19 activity increases in the community within the next 14 days.

Infection Control

• Facility cleaning policies in all areas along the continuum of operative care must follow established infection control procedures.• When possible, facilities should establish non-COVID care zones for screening, temperature checks and preoperative waiting areas. • Facilities should also minimize time in waiting areas, space chairs at least 6 feet apart, and maintain low patient volumes. Visitors

should generally be prohibited; if they are necessary for an aspect of patient care or as a support for a patient with a disability, they should be pre-screened in the same way as patients (as described above).

• Facilities must have the ability to routinely screen all staff and others who will work in the facility (physicians, nurses, housekeeping, delivery and other people who would enter the patient area) with COVID-19 RT-PCR testing.

SupportServices

Other areas of the facility that support perioperative services must be ready to commence operations with uniformly heightened infection control practices, including sterile processing, the clinical laboratory and diagnostic imaging.

IDPH Guidelines for Elective Surgeries and Procedures April 24, 2020

6

Surgical/Procedural Review Committee

7

IDPH requires that each hospital have an SRC to guide prioritization of reactivationFo

rm

Com

mitt

ee

Surgery participants:• Department of Surgery chairs, Inpatient medical directors, Surgical

Services vice president, hospital presidentsProcedural Areas participants:• Medical director, chief(s), Operations director

Surgery Participants:Procedural Participants:

Iden

tify

Volu

me Review canceled and not rescheduled cases for March 15 through present:

• COVID-19 Access Scheduling Dashboard (OR tabs)• Covid 19 Appointment Cancel Reschedule Details Report• COVID-19 OR Cancels and Reschedules Details Report• Epic Workbench Report: COVID Canceled/Rescheduled Appointments

[Scheduling > Reports > Follow Up > COVID canceled/Rescheduled]

Administrator who will compile cases that need to be rescheduled and distribute to surgeons:

Prio

ritize

Vol

ume Categorize cases based on risk to the patient:

• A: Emergency• B: Need to move forward with procedure/surgery

• B1: Most urgent, can no longer be postponed• B2: Less urgent, can wait a little longer

• C: Elective and can wait until adequate resources are available

How this information will be tracked/updated:

https://edw.nm.org/portal/#/app/resources/reports/6250https://edw.nm.org/portal/#/app/resources/reports/6395https://edw.nm.org/portal/#/app/resources/reports/6360

Reactivation Planning Committee

8

Form

Com

mitt

ee

Core Participants: • Inpatient medical directors, Operations director, Surgical

Services vice president, hospital presidentsSupporting Services Representatives: • MD and RN labor pool, anesthesia, diagnostic testing, lab and

blood bank, pharmacy, scheduling, facilities, equipment and IT, EVS and transport, pre-op clinic

Core Participants: Supporting Services Representatives:

Out

line

Proc

ess

Review planning questions and recommendations.

Outline scheduling, pre-procedure covid testing, and day of procedure processes and workflows.

See supporting planning documents on Slide 9 and 10.

Asse

ss R

esou

rces Document resources needed for pre, intra and post procedure

phases.

Create a capacity restoration plan based on available resources.See supporting planning documents on Slides 9, 11-14.

Mon

itor a

nd A

ctiv

ate Outline monitoring process. See supporting planning document on Slide 15.

Define dashboard metrics. Current capacity and resources Future modeling capacity and resources

Create go-live checklist. See supporting planning documents on Slide 9.

Supporting Planning DocumentsTopic Documents

Questions and Recommendations: review, evaluate and implement answers to the questions in the document embedded here.

Procedure Resource Projection Planning: example from NMH for invasive procedures.

Pre-Procedure Testing Workflows: 1. Workflow diagram to demonstrate timing2. Workflow diagram showing who completes each step

1. 2.

Link to NM testing algorithm (see surgery and GI/IR/Cath diagrams)

Results Routing Workflow: pre-procedure test results will go to the COVID-19 results pool.

Link to NM Covid Results Routing Workflow

Known COVID-19-Positive Case Scheduled: day before and day of surgery process.

Patient Transport Workflows: transporting a patient to and from the OR.

Activation Logistics Checklist: for use after a new block is approved.

Estimating inpatient needs (ICU beds, floor beds, ventilators, post-discharge).
https://physicianforum.nm.org/covid-19-algorithms-and-testing-resources.htmlhttps://physicianforum.nm.org/uploads/1/1/9/4/119404942/20200326-covid-19-results-routing-workflow-v10-pdf-3-26-20.pdf
NMH – Procedural Reactivation PlanningGI/IR/IC

*Note: Numbers on these slides are not final; this is to be used as a template example not for execution or approval*

Wyeth

General Notes & Tips

Make sure input is gathered from administration, physician leaders, & nurse leadership to ensure all perspectives & nuances are captured & adjusted for

For resource grids, it was generally easiest to:

Confirm the left hand column is relevant to your area; add what key resources are missing if applicable

Fill out a column for “current state” and “100%” (pre-COVID volumes) first for all categories

Determine the case volume phased steps that make sense between the current state and 100% (and past 100% if necessary & possible); fill in rows accordingly for those volumes

Consider urgency of cases, staffing & supply constraints, & other teams also seeking these resources during this discussion

Distribute & confirm numbers; confirm resources are available for each phase before getting final approval & activating

Note: bed counts were not enough for a full picture; considering & incorporating expected LOS provides a more complete picture of impact on census

Align with other working groups & logistics/support team leadership to ensure future reactivation phases/plans are aligned & preparation work can continue

Recommend creating a spreadsheet version of this data behind the slides to keep everything straight, allow for less rework when dates are adjusted, & help connect to census/resource modeling

NMH Re-Activation PlanGI Procedure Slides

3

Resource NeedsCurrent State:4/20 (32%)Wk 1:5/4(70%)Wks 2-3:5/11 (70%)Wks 4-5:5/25(70%)Wks 6-7:6/8(95%)Wks 8-9:6/22(95%)Wks 10-11:7/6(95%)

Associated CategoryPriority outpatients/inpatientsPriority outpatients/inpatientsPriority outpatients/inpatientsPriority outpatients/inpatientsAll casesAll casesAll cases

# daily cases | # Rooms12 | 3*2 Anesthesia*1 MS24 | 3*2 Anesthesia*1 MS24 | 3*2 Anesthesia*1 MS24 | 3*2 Anesthesia*1 MS32 | 4*4 Anesthesia32 | 4*4 Anesthesia32 | 4*4 Anesthesia

Weekly volume60120120120160160160

LocalInpatient Beds*0/week1 bed/week1 bed/week1 bed/week2 beds/week2 beds/week2 beds/week

GI RN Staffing12121212151515

GI Tech Staffing3333333

Anesthesia StaffingMD: 1CRNA: 2MD: 1CRNA: 2MD: 1CRNA: 2MD: 1CRNA: 2MD: 2CRNA: 4MD: 2CRNA: 4MD: 2CRNA: 4

Pre-Op ClinicTBDTBDTBDTBDTBDTBDTBD

Support ServicesTBDTBDTBDTBDTBDTBDTBD

SystemCOVID Testing 10 tests20 tests20 tests20 tests32 tests32 tests32 tests

Pharmacy (anesthetic meds)TBDTBDTBDTBDTBDTBDTBD

PPE (daily needs)*4-5 sets per case50 sets108 sets108 sets108 sets144 sets144 sets144 sets

Galter GI Resource Needs Status – 4/20

DRAFT

Resource NeedsCurrent State:4/20(0%)Wk 1:5/11(18%)Wks 2-3:5/18(35%)Wks 4-5:6/1(50%)Wks 6-7:6/15(90%)Wks 8-9:6/29(100%)Wks 10-11:7/13(105%)

Associated CategoryN/APriority casesPriority casesPriority casesPriority casesPriority casesPriority cases

# Daily Cases | # RoomsMS weeks 1-5: 60 min casesMS weeks 6+: 45 min cases0 | 016 | 2Sat: 16 | 232 | 4Sat: 32 | 448 | 6Sat: 32 | 480 | 8Sat: 32 | 4100 | 10Sat: 32 | 4116 | 12Sat: 32 | 4

Weekly volume096192272432532612

LocalGI RN Staffing0101419262931

GI Tech Staffing0578111414

Anesthesia StaffingN/AN/AN/AN/AN/AN/AMD: 1CRNA: 2

Pre-Op ClinicN/AN/AN/AN/AN/AN/ATBD

Support ServicesTBDTBDTBDTBDTBDTBDTBD

SystemCOVID Testing *Upper endoscopy/MACN/A4 tests9 tests13 tests22 tests28 tests44 tests

Pharmacy (anesthetic meds)N/ATBDTBDTBDTBDTBDTBD

PPE *3 sets/MS case*4-5 sets/MAC caseN/A48 sets96 sets144 sets240 sets300 sets372 sets

Lavin GI Resource Needs Status – 4/20

DRAFT

NMH Re-Activation PlanInterventional Radiology Procedure Slides

6

Resource NeedsCurrent State50%Phase 175%Phase 290%Phase 3100%Phase 4> 100%

Proposed Go Live Date:5/45/11TBDAs Needed

CategoriesNon-postponableNon-postponable & postponable added incrementally

# daily cases(Fein 4 – 9 angio rooms across; all used currently)30 cases45 cases55 cases65 casesTBD

Working through backlog:1605050600

LocalI/P beds (estimate 50% of cases I/P)Already have, no additional need (Occasional 1 night LOS for UFE [Prentice], kidney biopsies [med], & post complex NIR intervention [NICU])

PACU spaces(anesthesia cases only)1466TBD

Anesthesia Teams0233TBD

Pre-Op Clinic (anesthesia cases only)1466TBD

Support ServicesTransport, EVS (dedicated)TBD

SystemCOVID Testing (AGP cases only)1667TBD

Pharmacy (anesthetic meds)See PACU volumes for anesthesia med needs; no other meds needed

PPE – N95 masks(new for each AGP case)1303035TBD

IR Reactivation Daily Resource Needs – 4/20

WORK IN PROGRESS - DRAFT

*Postponed cases will be prioritized as capacity is incrementally increased

-ALL ANSWERS FOR INTERVENTIONAL RADIOLOGY ARE PER DAY. MULTIPLE BY 5 FOR WEEKLY NEED. We may do a few Saturdays, so x 6 in those scenarios.

Cases broken into emergent/urgent & non-emergent/urgent; currently only doing emergent/urgent, will do blend once capacity increases (i.e. week 2 roughly 30 emergent/urgent, 15

165 patients postponed; need to catch up, roughly 90-95 will not need a bed

Doing walkthrough tomorrow around how to separate positive patients pre/post given bay space w/curtains; testing capabilities

Could tackle about 50 of these cases w/o much effort/addition

Creating a template; goal starting 5/4 (phase 1) or 5/11 (phase 2)

Scheduling about 1 week out; can add on/prioritize backlog as we go

Estimate 50% I/P & 50% O/P

2 cases/room/day

PACU 2x anesth

- beds for IR is mostly post UFE (uterine fibroid embolization) admission – Prentice for 24 hours pain control, kidney biopsies admitted 24 hours to medicine; post complex NIR intervention (embolizations, corotids, etc -> NICU) – small volumes

-”ICU bed” for IR means complex cases that require PACU recovery. Assuming each anesthesia room does on average 2 cases per day.

-”anesthesia staffing” I assume means number of anesthesia rooms (at higher level it could mean number of MDs, CRNAs etc..). But for this, it is number of IR rooms needing anesthesia.

-we do 7 AGPs per day during equilibrium phase, I assume this is phase 3. These AGPs need testing. The response on testing is based on this. However, early on we need to catch up on lung biopsies and other AGPs, and that is why COVID testing goes up to 6 very quickly.

-pre op clinic is based on patient needing anesthesia, this by definition must march anesthesia rooms

-for PPE, I assume you mean N95. Assuming all COVID testing is positive (worst case scenario), since we have 5 people per room in IR (RT/RN/MD/fellow/other), each case needs 5 N95s. I am also assuming we are using new N95s for each case.

7

NMH Re-Activation PlanInterventional Cath Procedure Slides

8

Resource Needs% based on 130-150 normal volumes/mo at 20 case days/moCurrent State25%Phase 150%Phase 2100%Phase 3125%Phase 4150%

Associated Category100% Tier I100% Tier I50% Tier II (A)100% Tier I100% Tier II (B)100% Tier I100% Tier II50% Tier III100% Tier I100% Tier II100% Tier III

Target Go LiveN/A5/4/205/25/20TBDTBD

# daily cases | EP Labs0-3 | 0.53-4 | 1.57-8 | 38-10 | 3 (extended evening hrs)8-10| 3 + (addl weekend)

LocalProcedural area staffing 2 RN + *1 tech + 1 charge nurse3 RN + 2 tech + 1 charge nurse6 RN + 3 tech + 1 charge nurse6 RN + 3 tech + 1 charge nurse6 RN + 3 tech + 1 charge nurse*addl staff or overtime needed

Anesthesia Staffing (with machines)Per request only*Per request only*1 team/day1 team/day2 teams/day

EP Attendings per day12333

EP Fellows per day12444

PACU (beds/day)0-11-23-44-54-5

CROU Post Recovery*Those w/anesthesia go to PACU first*Won’t all be overnight; est. 2/3 overnight in CROU0-33-47-88-108-10

Inpatient Beds (beds/day) [admissions post procedure ]0-10-11-222

Pre-Op; Per anesth; phone call (100%

Associated Category(s)Tier ITier I, some IITier I, II, some IIITier I, II, IIITier I, II, III+

Target Go LiveN/ATBDTBDTBDTBD

# daily cases | 1 room*depends on day; max 2 days/week; some one offs for 11/week total; counts are for days when they occur*1-2/week*dependent on anesthesia cover2/day3-4/day5/dayTBD

LocalVent Needs (Mitral clips only)0-1/week1/week2/week2/week3/week

Procedural area staffing 3 RN; 1 RT; 1-2 invasive tech; 1 charge RNTBD

Anesthesia Staffing*Card anesthesia coverage for MAC*Vent gets gen anesthesia coverage1-2/week2/day3-4/day5/day

Cath Attendings per day1-2

Cath Fellows per day1

CCU/PACU (beds/day) 1-2/week2/day3-4/day5/day

Post Recovery Needs - CCU or ICU beds; 1-3 days LOS1-2/week2/day3-4/day5/day

Pre-Procedure visit (valve team)1-2/week2/day3-4/day5/day

Post Op f/u (valve team) (telemedicine)1-2/week2/day3-4/day5/day

Diagnostic TestingTEE pre: 0-1/wkTTE pre: 0-1/wkTTE during: 0-1/wkTTE post: 1-2/wkTEE pre: 0-1/dayTTE pre: 2/dayTTE during: 2/dayTTE post: 2/dayTEE pre: 1-2/dayTTE pre: 3-4/dayTTE during: 3-4/dayTTE post: 3-4/dayTEE pre: 2-3/dayTTE pre: 5/dayTTE during: 5/dayTTE post: 5/dayTEE pre: TBDTTE pre: TBDEcho during: TBDTTE during: TBDTTE post: TBD

Support ServicesEVS, Transport, Scheduling, Registration, Supply Chain, Pharmacy

SystemCOVID Testing *assume 1/pt at pre-op1-2/week2/day3-4/day5/day

Pharmacy (anesthetic meds)N/A; meds brought by anesthesia, no additional med needs

PPE (N95 masks)10-15 masks/week20/week30-40/week50 masks/week

Cath Lab – Structural/Valvular Intervention – Resource Needs Status – 4/20

DRAFT

Aortic/mitral valvuloplasty – can be done in any room; not high volume; not counted in right now (no anesthesia, conscious sedation for the most part)

Types: RHC/Biopsies, Interventional/Coronary, Structural (mitrial & aortic); valvular vs. non

**10-15% pacemaker rate in TAVR population (50 total; roughly 8 will need pacemaker -> EP)

**Don’t double count TEE here & on the other chart; some of those counts are waiting for this procedure

*Assumption we won’t get 9th floor room right now (using for COVID) – Feinberg – can we confirm this is true or not?

Diagnostic cath possibles (non valve) – about 140; about 50-75 outstanding interventional valve procedures

Variation by day of week: W/Th look different

Side note: TEEs, echo, stress testing (aligned w/diagnostic reactivation)

Transport for these patients done by lab nursing staff

Staffing: (2 RN/1RT per room; 1-2 inv tech & 1 charge float/support all 3)

Anesthesia:

*Conscious sedation, not general anesthesia

*Card anesthesia coverage for MAC,

*Vent gets gen anesthesia coverage

Diagnostic testing:

About half get TEE;

TTE pre all

Pre-d/c echo (TTE)

echo during TEE (echo attend & fellow), TAVR trans thoracic [TTE] (echo tech);

PPE:

N95 masks/each person unless negative test;

10-12 people/case,

those not intubated [non mitral] can be reused for day)

Pre/post visits – 1/pt

10

Cath Lab – Interventional/Coronary/Non-Valvular – Resource Needs Status – 4/20

DRAFT

Resource NeedsCurrent StatePhase 125%Phase 250%Phase 3100%Phase 4 >100%As needed

Associated CategoryTier ITier I, some IITier I, II, some IIITier I, II, IIITier I, II, III+

Target Go LiveN/ATBDTBDTBDTBD

# daily cases | 2-3 labs*depends on day; max 2 days/week; some one offs for ; counts are for days when they occur (M/F non structural, 3 roomsTu/W/Th 2 rooms, 3 rooms after 3pm)0-5 cases | 1 lab 5-10 cases | 2 labs10-15 cases | 2-3 labs15-21 cases | 2-3 labsRequires weekends, evenings, or additional room

LocalProcedural area staffing3 RN/1RT0-1 inv tech1 charge RN4-5 RN/2 RT1 inv tech1 charge RN6-7 RN/2-3 RT1-2 inv tech1 charge RN7-8 RN/3-4RT1-2 inv tech1 charge RN*additional staff or overtime req.

Anesthesia Staffing *conscious sedation, not general0 needs; administered by nurses

Cath Attendings per day11-22-33

Cath Fellows per day11-42-63-6

CROU (beds/day); interventional overnight (1 day LOS; 20%)others no overnight0-50-1 overnight5-101-2 overnight10-152-3 overnight15-213-4 overnight

Post Recovery NeedsIf I/P; go back to their unit (roughly 30-40% I/P**)0-2 beds/day2-4 beds/day4-6 beds/day6-9 beds/day

Post op f/u (telemedicine) 0.5-1/pt; 3-6 mo later (depending on intervention or not)0-5/day2-10/day5-15/day7-21/day

DiagnosticsEKG next day for those overnight (CROU, I/P)TTE next day for ASD/PFOEKG: 0-3/dayTTE: 0-1/weekEKG: 3-6/dayTTE: 0-3/weekEKG: 6-9/dayTTE: 0-3/weekEKG: 9-13/dayTTE: 0-3/week

Support ServicesTransport for I/P cases only; Scheduler; EVS

SystemCOVID Testing *assume 1/pt at pre-op0-55-1010-1515-21

Pharmacy (anesthetic meds)N/A; meds brought by anesthesia, no additional med needs

PPE (N95 masks/each person)25 masks/week50 masks/week50-75 masks/week60-75 masks/week

11/wk avg

>100% difficult; providers on call that cannot be pulled while on call

N95s covered with procedural mask; protects for reuse across cases (discard if soiled)

Aortic/mitral valvuloplasty – can be done in any room; not high volume; not counted in right now (no anesthesia, conscious sedation for the most part)

Types: RHC/Biopsies, Coronary, Non Valvular Structural,

*Assumption we won’t get 9th floor room right now (using for COVID) – Feinberg – can we confirm this is true or not?

*Some weeks don’t have structural cases on Tuesdays (mitral clip); TAVR every Wed/Thurs – assuming will have every week at this point

Diagnostic cath possibles (non valve) – about 140; about 50-75 outstanding interventional valve procedures

Variation by day of week: W/Th look different

Side note: TEEs, echo, stress testing (aligned w/diagnostic reactivation)

Procedural room staffing

(2 RN/1RT per room; 1-2 inv tech & 1 charge RN float/support all 3)

Phase 2 to Phase 3- may be dependent on visitation rules.

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DRAFT

Resource NeedsCurrent StatePhase 125%Phase 250%Phase 3100%Phase 4 >100%As needed

Associated CategoryTier ITier I, some IITier I, II, some IIITier I, II, IIITier I, II, III+

Target Go LiveN/A5/11**TBDTBDTBD

# daily cases | 1 labs**Fein 9; roll into other lab counts since this is not available at this timeM-F; schedule T-Th so higher volumes (9-10/day); M/F (5/day)0-5 cases | 1 lab10-15 cases | 120-25 cases | 140-50 cases | 1TBD

eProcedural area staffing2 RN/1RT0-1 inv tech1 charge RN (cover all labs)TBD

Anesthesia Staffing *conscious sedation, not general0 needs; administered by nurses

Attendings per day (T-T Heart failure; M/F cath lab)1

Fellows per day (T-T Heart failure; M/F cath lab)1

CROU (beds/day)All go to CROU; no overnightVery small amount, rare, might need to admit; all others go home0-510-1520-2540-50TBD

Post op f/u (heart failure clinical team)TBD

Diagnostics**Some get EKG (25%); most TTE (75%) – CONFIRM*Techs come down for service; patient does not go to themEKG: 0-2TTE: 0-4EKG: 2-4TTE: 7-12EKG: TTE: EKG: TTE: TBD

Support ServicesScheduler; EVS; Pharmacy (omnicell); Supplies

SystemCOVID Testing (no AGP/anesthesia) *1/pt assumption0-510-1520-2540-50TBD

Pharmacy (anesthetic meds)N/A

PPE (N95 masks/each person) *same rules as cath lab; counted in cath lab numbersPatient masks (addl. To cath lab numbers)TBD

Cath Lab – RHC/Biopsies/SWAN insertion – Resource Needs Status – 4/209th floor Fein suite (roughly 10 cases/day)

Only RHC now are only recent transplants & symptomatic

To catch up, could add more cases on M/F; would be difficult staffing wise

Instructions beforehand to come in is only pre-contact/work (nurse clinicians); follow up – Heart failure with findings/instructions

Cath lab staff transports patients

EKG/ECHO – those departments need to come down (tech for each)

This room is major resource to help prevent very extended hours in cath lab (existing 3 labs on 8th floor)

Cases ~30 min each

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Resource NeedsCurrent StatePhase 125%Phase 250%Phase 375%Phase 4100%Phase 5125%

Associated Category

# daily cases | Tilt Room0-1 | 1 room1-2 | 1 room2-3 | 1 room3-4 | 1 room4-6 | 1 room5-7 | 1 room (extended hours potentially)

LocalProcedural area staffing 1 anesthesia attending & 1 CRNA1 EP APN2 CROU nursesif TEE 1 echo attending & 1 fellowneed to build in some for breaks

CROU Post Recovery*No overnights0-11-22-33-44-65-7

Pre-Op Clinic (Attending in EP clinic or hospital)0-11-22-33-44-65-7

Post op f/u (telemedicine)0-11-22-33-44-65-7

Diagnostics- TEERoughly half get TEE day of CV0-11-222-33-44-5

Support ServicesScheduler, Transport for I/P cases

SystemCOVID Testing 1 per pt.0-11-22-33-44-65-7

Pharmacy (anesthetic meds)******

PPE

Tilt Room Resource Needs Status – 4/20

DRAFT - Need to add in addl TEE for other groups besides EP

Very anesthesia dependent

EP Estimations (CV w/TEE & ILRs)

**At this rate, at what phase are we catching up/back to steady state**; how many months to get to this point assuming some dates

Most patients are I/P, go back to their beds; or CROU -> home

Don’t expect to need to activate weekends; just use extra capacity if need to add on additional >100%; dependent on anesthesia schedule/resources (anesthesia support 9-3)

Estimate 1/30-1/2 are inpatients; others are quick outpatient cases

Volume of people in room may be limited to preserve PPE; TBD

No pos/neg pressure in this room; if positive, CV & any tilt procedure should be done in EP lab

Estimate 2-3 anesth cases/day; take these volumes + 50% for TEE w/anesth

Of 4-6, maybe 4:1 CV to ILR

Could hold off on tilt table tests at this time (EP nurse)

13

Reactivation Plan

Algorithm for Surgical/Procedural Scheduling

1

Provider identifies case as category A, B1 or B2. Contacts

surgical schedule with request and details.

Place on schedule

COVID Test 72-Hours Prep Result

YES

YES

NO

NO

YES

Proceed? Discussion between surgeon, OR leadership, and patient.

Surgery!

(After Quarantine)

Can tests be done on DOS?

Schedule Tests

Discussion between surgeon and anesthesiologist

Date and Time Available?

Communication back to surgeon’s office

Communication between scheduling and surgeon’s office regarding alternative available times

NO

NO

YES

Results Satisfactory?

Reactivation Scheduling Algorithm

SRC Approval

YES

NEGATIVE

POSITIVE

NO

PST: Preoperative work-up available?

Reference Guidelines

Categories

Committee prioritizes cases based on the risk for the patient if the procedure is postponed, using the following categories:

A: Emergency

B: Need to move forward with procedure/surgery

B1: Most urgent, can no longer be postponed

B2: Less urgent, can wait a little longer

C: Elective and can wait until adequate resources are a

Other Considerations

Inpatients needs and LOS

Review current state of admission delays and home health agency capacity constraints related to the pandemic

Social work should be involved during pre-procedure/pre-op to plan for discharge

Reference for risk calculator from JAMA: https://jamanetwork.com/journals/jamasurgery/fullarticle/2207938

IDPH Guidelines

IDPH Guidelines for Elective Surgeries and Procedures April 24, 2020

Minimum threshold requirements to resume elective inpatient procedures (IDPH 4/24/2020*) [Need to define elective in this context – Category C?]

Hospital availability of adult med/surg beds exceeds 20% of operating capacity for adult med/surg beds

Hospital availability of ICU beds exceeds 20% of operating capacity for ICU beds

Hospital ventilator capacity exceeds 20% of total ventilators

Estimating increased surgical volume

Prep to make decision regarding volume:

Determine what % of budgeting block time you will be allocating (based on # ORs running for X hrs)

Determine what cases will be performed in which ORs (by category/patient class)

Determine # of cases performed each day. Utilize average case time by category and average turnaround time to calculate.

If possible – utilize historical data from a similar time period for anticipated inpatient census. Additionally, using median LOS, avg % inpatient, determine volumes by category determine a weekly sum of bed days (by level of care) needed to cover additional volume.

Validate upcoming week availability

Utilize this EDW dashboard to see ICU census impact for scheduled appointments – see screenshot on next slide for draft

1

EDW Dashboard

2

Dashboard Planned Capabilities:

Filter by hospital

Pull data by new Epic fields (see next slide for details)

Tab for ICU beds, M/S beds, Ventilator needs, anticipated discharge needs

Census based on surgical date, indication for ICU bed/vent needed in request, and historical median LOS by level of care

Epic Build Changes In Progress – ETA by 5/8

Situation: With reactivation process of increasing surgical cases, planning for ICU bed, ventilator, post discharge needs is required.

Background: Scheduled Surgical cases can require use of these resources (ICU, vent, post discharge bed). As we begin to increase the number of surgical case being done each day we need to understand the specific resource needs to insure we have availability to accommodate.

Assessment

Create a few new required fields in surgical case request:

REQUIRED: ALL cases requiring selecting if the case is Category A, B or C

OPTIONAL: IF patient is “inpatient” class type, indicate anticipated discharge needs (home, home health, SNF, acute rehab, other, unknown)

REQUIRED: IF patient is an “inpatient” class type, indicate if patient requires ICU bed or not (y/n)

REQUIRED: IF patient requires an ICU bed, indicate if they need a ventilator (y/n)

Recommendation: Move forward with build of new questions to help plan adequate resource needs. Discussed with system reactivation work group (including Vicki Diep, Sara Williamson, David Lucas-Kamm, Dr. Charles Davidson, Dr. Pat McCarthy, Maura O’Toole, Dr. Riad Salem, Sarah Plaskett, Dr. David Klem, Kristina Whitmore). Approved by Dr Saadia Sherwani VP Surgical Services and Dr. Paul Tamul Director of Anesthesia, Surgical Services

Add additional required questions in the procedural and surgical case request

5/8/2020

DRAFT

3

Patient Class Grouping

Patient ClassInclude in “inpatient” questions?

EmergencyYes

InpatientYes

Surgery – Admission Prior to SurgeryYes

Surgery – AmbulatoryNo

Surgery – AMTFYes

Surgery – IP Rapid RecoveryYes

Surgery – Post Op InpatientYes

Surgery – Post Op ObservationYes

For Case Request Questions

FOR INTERNAL USE ONLY

Surgical/Interventional/Procedural Considerations

Initial Planning

Question for My Department

Recommendations and Resources

My Local Department Plan

How can the local teams coordinate labor pool needs with OR and procedural staffing needs?

How will you manage staffing if there is a new Covid surge and staff need to be put back into the labor pool?

Include staff and physician labor pool coordinators at weekly planning meetings

Please follow the recommended guidance and apply appropriately for your department

What are the common levers we can use to open capacity?

Reduce/decline medicine transfers

Move procedures that are usually 1-2d LOS to outpatient procedures – identify those are and what infrastructure is needed to decrease LOS safely.

Review for cases that can be moved to RIC, Marianjoy, or other facility earlier than "normal" d/c to home to open up an inpatient bed


What cases can be moved to an ASTC? Who can coordinate moving a case to an ASTC?

NMSC in Warrenville cases are solely ortho and pain.

Grayslake is multispecialty.

There are no waivers at this time that allow for expanded services beyond the normal scope of procedures in the ASTCs.


Scheduling




What is NM’s recommended approach to adding volume to both surgery and procedural areas?

1. Add capacity for urgent B1 cases

2. Then move to B2 (100% of B cases)

3. Then start to add C cases, starting with only same day surgery/ ambulatory surgery


How can we level load cases and bed load throughout the week? (instead of front loading)

Review average LOS based on procedure with scheduling team


What happens if a block is opened but after contacting patients there are still open timeslots?

Review openings with Activation Planning committee and determine if cases from the next block should be scheduled


Who will coordinate the postponement and rescheduling of cases across the hospital/facility once surge capacity buffer is exceeded?

Need to consider risk to patient and impact to departments across all specialties if additional procedures need to be postponed


What is the process for determining which B1 case gets priority to move forward with scheduling when we have more B1 requests with not all the capacity in the OR to complete, while still being fair?

Central is utilizing a departmental level block schedule, assigning block time based on which departments have the highest % of Category B cases in the backlog. From there it is up to the departments to prioritize within their area at the patient level.


Define your pre-procedure covid testing workflow. Who is contacting the patient, ordering the test, and following up on the results? When do these steps happen?

If a flag is added to the patient’s chart at scheduling, a centralized group will contact the patent and order the test to be done within 72 hrs of the procedure. All covid test results go to a results pool, and if positive, the covid RNs will contact the patient and the performing provider.

See the playbook slides for variations to this workflow. Some departments might want to contact the patient themselves to notify them of the test requirement/order the test.

Understand the percentage of patients who are not able to get testing completed prior to the procedure, and how performing those tests the day of the procedure might create delays.

Note: all patients must be tested at an NM facility before their procedure. External or patient reported results will not be accepted.


Are there adequate resources to support the pre-procedure testing workflow?

Review the proposed number of cases per day/week with the lab to confirm they can handle the increased volume.

Determine if the providers (or supporting staff) have capacity to follow up on the volume of pre-procedure Covid test results. Engage the labor pool if the department will not be able to contact all of the patients.


If a patient tests positive and procedure needs to be postponed, how far out should we reschedule?

The patient needs to be tested again before the rescheduled procedure.

Asymptomatic patients can wait 7 days and then re-test. Also add in screening CTs when appropriate.

If it’s a B.2 or C case, postpone out as long as possible. Consider that we treat patients as presumed positive and follow TBP for 40 days.

See NM Guidelines on Clinical Clearance: https://nmi.nmh.org/wcs/blob/1390905502607/ambulatory-clinical-clearance-guideline.pdf


Clinical Care




How to operate on COVID+ patients that require surgery?

See workflow map example from NMH in slide deck

Recommendation for healthcare workers in procedural areas to complete competencies in donning/doffing of PPE and CPR protocols through NM Learning.

Stage a donning/doffing area with signs posted for proper use

Modify time outs to include COVID status/PPE use for the case.

Access to the central core is still allowed.

· There is a designated runner in the central core and another runner for the main hallway (if possible).

· If something is needed from the central core the runner opens the door (from the central core) and drops the item on a mayo stand that is in the operating room (by the door to the central core).

· The runner for the central core does not enter the operating room, however.


Will any OR suites be held for Covid only patients?

Review which rooms have negative airflow capability and understand how long it takes to convert the room. Alternate room with negative airflow capabilities for all aerosol-generating procedures.

Either hold a suite for Covid patients or schedule any add ons for the end of the day. If a suite is designated for Covid paients:

· The operating room is exclusively for COVID-positive patients, and a negative operating pressure is preferred.

· In-hospital manual for COVID-19 provide designated ORs (zoning). Scrub area, front chamber to wear PPE, and shower room are separated from non-COVID-19 area. In another area, where can be approached through the COVID-19 patient transfer line, lavatory and staff rooms are designated but can be “grey zone”

Recover Covid patients in the OR instead of PACU


Are we able to repurpose and staff anywhere?

Plan for patients who require overnight observation and whether staff from another area (ex: interventional lab) can take care of those post-procedure patients.


Should we have standard procedures for screening/testing healthcare workers in procedural areas?

Have contingency plans for healthcare workers in procedural areas who test positive, including contact tracing and isolation etc.


What if the patient tested negative 72 hrs ahead but is flagged by thermal screening at arrival?

If patient is febrile upon arrival then they should be re-tested with Alere at the bedside.

· If negative, can assume they are negative.

· If positive, determine whether to proceed with procedure


Are there additional quality metrics that should be measured?

Monitor adherence to new processes and monitor for unintended consequences, eg:

· Employee health data/NETS for healthcare worker exposure

· Number of B/C cases which turn to emergent cases/expire

· Post-op patients who convert to COVID +


Should cases that have a higher likelihood of requiring post-acute care (ex: total joint) be considered differently?

Review current state of admission delays and home health agency capacity constraints related to the pandemic

Social work should be involved during pre-procedure/pre-op to plan for discharge

Use Ortho risk calculator built into Epic.

Reference for risk calculator from JAMA: https://jamanetwork.com/journals/jamasurgery/fullarticle/2207938


Patient Communication




What accommodations do we need for visitors? What should we communicate?

See current visitor restrictions policy on NMI: https://nmi.nmh.org/wcs/blob/1390904395640/20200318-communication-for-visitor-restrictions.pdf


How do we move patients from the car to pre-op/pre-procedure holding?

How do we notify their ride that they are ready?

Outpatient procedures where patients need to be accompanied by someone who can drive them home:

· Have the driver bring the patient to meet staff at the front door. Get contact information from the driver before bringing the patient inside.

OR

· Have staff from the department meet the patient at their car and escort them inside. Get contact information from the driver at the car.


What can we do to help patients feel comfortable with returning to our facility?

Make a video that takes a patient through what to expect at different phases of operative care (pre, immediate pre, intra, postop and post discharge)? We can send a link for patients to watch when the procedure is scheduled.

What written documentation can be available for patients ahead of and when they arrive for their procedure?


Last Updated: April 28, 20201

SAMPLE Pre-Procedure Workflow IDPH Guidelines: • Facilities must test each patient within 72 hours of a scheduled procedure with a preoperative COVID-19 RT-PCR test and ensure COVID-19 negative status. • Patients must self-quarantine until the day of surgery after being tested. • A temperature check must also be completed on the day of arrival at the facility with results of less than 100.4 degrees prior to proceeding with an elective procedure. • When clinically acceptable, providers should consider using telemedicine for preoperative visits. • In such cases, face-to-face components of the exam can happen after the result of the preoperative COVID-19 test result is known to be negative

Scheduling Testing Phase Pre-Procedural Phase

Surgeon’s Office • Coordinates procedure dates with patient and communicates the need for COVID testing 48 hours prior to the procedure

• For testing, the patient should report with identification to:

• Lavin Pavilion 259 E. Erie• Cars enter the testing site from eastbound Erie

Street• Open 7 days a week 7 am-3 pm • Sends case request to Central Scheduling

• Specimen resulted.• Surgeon reviews chart by 9 am the day prior to procedure and contacts

patients with positive or indeterminate results. If changes to the surgical schedule need to be made, this must be completed by 11 am.

• If NEGATIVE: No need to contact the patient and proceed with procedure as planned.

• If POSITIVE and case can be postponed, patient should be rescheduled. If case cannot be postponed, complete procedure in full PPE and COVID designated room.

• If INDETERMINATE/INHIBITED, patient will require same-day, repeat testing, the morning of surgery. Follow same-day testing protocol.

Central Scheduling • Schedules both surgical and NORA cases• Flags all patient charts, except those with local

anesthesia type, with the pre-procedure COVID testing flag

• Patient is then added to COVID Hotline triage pool

Schedule closes at 11 am for next day cases.

Patient

COVID Ordering and Results Teams

COVID triage nurse places future COVID order panel on patient, removes flag which removes from work queue

Specimen is resulted and the COVID Results Team contacts the patient with the results and next steps the day prior to surgery.

COVID Test Site Registration

Checks in patient and releases order

COVID Drive-Through Team

Specimen collected, Pre-Op sticker added to indicate priority

Pre-Op Nursing Calls patient with time of surgery starting at 2 pm the day prior to procedure. PUI screening questions will be asked at this time.

10

SAMPLE Pre-Op Resources

11

Item Regulatory or general consideration(s) Surgery Endoscopy – Bronch Endo – GIInterventional

Cardiology andRadiology

Loca

l Res

ourc

es Pre-op clinic capacity Use telemedicine wherever possible

Pre-op clinic staffing

Diagnostic testing

Syst

em R

esou

rces

COVID testing IDPH• Facilities must test each patient

within 72 hours of a scheduled procedure with a preoperative COVID-19 RT-PCR test and ensure COVID-19 negative status.

• Patients must self-quarantine until the day of surgery after being tested.

• A temperature check must also be completed on the day of arrival at the facility with results of less than 100.4 degrees prior to proceeding with an elective procedure.

• When clinically acceptable, providers should consider using telemedicine for preoperative visits.

• In such cases, face-to-face components of the exam can happen after the result of the preoperative COVID-19 test result is known to be negative.

Surgical and ProceduralScheduling

PPE

SAMPLE Procedural ResourcesItem Regulatory or general consideration(s) Surgery Endoscopy – Bronch Endo – GI

Interventional Cardiology and

Radiology

Loca

l Res

ourc

es

Pre-op/Pre-proceduralspaces

OR or procedural room capacity

SS/Procedure RN staffing

Anesthesia staffing (including NORA)

Vent needs IDPH: Hospital ventilator capacity exceeds 20% of total ventilators

PACU/Procedure recovery set up

PACU/Procedure recovery staffing

Central supply

EVS

Patient transport

Pharmacy – Staff

Pharmacy – Meds

Lab – Blood products

PPE

12

SAMPLE Post-Procedural Resources

13

Item Regulatory or general consideration(s) Surgery Endoscopy – Bronch Endo – GIInterventional

Cardiology andRadiology

Loca

l Res

ourc

es

Vent needs IDPH: Hospital ventilator capacity exceeds 20% of total ventilators

PACU/Procedure recovery set up

ICU beds IDPH: Hospital availability of ICU beds exceeds 20% of operating capacity for ICU beds

Surgical beds IDPH: Hospital availability of adult med/surg beds exceeds 20% of operating capacity for adult med/surg beds

ICU staff (RNs, PCTs)

Surgical bed staff (RNs, PCTs)

Pharmacy – Staff

Pharmacy – Meds

Lab – Blood products

Support services • EVS• Transport

PPE

ResourceNeeds

15% Block 30% Block 50% Block 65% Block 80% Block 100% Block >100% Block

Associated Category 50% Cat B 100% Cat B 100% Cat BCat B backlog

100% Cat B30% Cat C

(ambulatory)

100% Cat B60% Cat C

(ambulatory)

100% Cat B100% Cat C

(include inpt)

100% Cat B100% Cat C

Cat C Backlog

# daily cases | # ORs 25 | 10 OR 45 | 18 OR (only Fein)

70 | 28 OR (only Fein)

90 | 40(add Prent, Lavin)

130| 52(add Prent, Lavin)

150 | 57(add Prent, Lavin)

TBD(add Prent, Lavin

Surgical Beds* 47 74 82 82 82 197 TBD

ICU Beds (exc. G9)* 54 66 71 71 71 85 TBD

Vent Needs* 21 33 35 35 35 55 TBD

SS RN Staffing [how many are needed from labor pool]

Pre-Op: 7PACU: 15

Pre-op: 13PACU: 20

F Pre-op: 13 PACU:20L:11, P: 11

F Pre-op:13 F PACU:20L:11, P: 13

F Pre-op:13F PACU:20L:11, P: 15

TBD

Anest. Staffing (including NORA)

Attending: 10CRNA/Res: 24






TBD

Pre-Op Clinic APP: 11, RN: 2MA: 1-2, Spt: 2

APP: 11, RN: 3MA: 2, Spt: 2

APP: 11, RN: 3MA: 3, Spt: 4

APP: 11, RN: 4MA: 4, Spt: 4

APP: 11, RN: 5MA: 5, Spt: 4

APP: 11, RN: 6MA: 5, Spt: 4

TBD

Support Services (EVS, Transport)

TBD

Block Schedule

COVID Testing 25 per day 45 per day 70 per day 90 per day 130 per day 150 per day TBD

Pharmacy (staff and anesthetic meds)

TBD

PPE Wipes:

Face Shields:Surgical Masks:

N95:

5 per day5 per day230 per day200 per day






TBD

SAMPLE: Capacity Restoration Planning

Syst

emLo

cal

Current State (3/31)

Target Go-Live: (5/4)

*Calculations based actual census:• 100%: 1/1/20 – 2/29/20• 30%: 3/23/20 – 3/30/20• 15%: 3/31/20 – 4/15/20

Available for surgical services use based on other demand (COVID census etc.)Not yet available for surgical services use based on other demand

Monday Tuesday Wednesday Thursday FridayAssess trends over past week.

Each respective chief and PM to evaluate what to begin plans for two weeks out.

Meet with respective planningteams to review resource needs available

Activation leads meet to confirm proposal:1) What units available for

non-COVID2) Additional surgical/

procedural/ambulatory volume proposed

3) Staff re-allocation plans

Meet with respective planningteams to confirmlocal resource availability –confirm questions for system

System presidents meet and discuss – address local questions, confirm plan for week following

SAMPLE: Monitoring Schedule

15

Minimum Two Weeks of Prep Before Activation

Monday Tuesday Wednesday Thursday FridayAssess trends over past week

Confirm plan to move forward in IC

Initiate scheduling of pts and staff

Meet with respective planning teams to prep logistics for next phase

Meet with respective planning teams to prep logistics for next phase

Wee

k 1

Wee

k 2

Appendix

16

Background

• During the COVID-19 pandemic, surgeries and procedures (collectively referred to as “procedures”) for life-threatening conditions or those with a potential to cause permanent disability have been and continue to be allowed.

• Due to the COVID-19 pandemic, hospitals and Ambulatory Surgical Treatment Centers (ASTCs) have deferred nonessential procedures to conserve resources for the care of COVID-19 patients.

• Some procedures that could reasonably be delayed for a time have now been postponed to the extent that potential harm could result from further delay.

• It is important to be flexible and allow facilities to provide care for patients needing non-emergent, non-COVID-19 healthcare.

IDPH Guidance on Elective Surgeries and Procedures April 24, 2020

17

IDPH Definitions

Definition

Elective OutpatientProcedures

• An elective procedure in which the likely and expected course for the patient undergoing the procedure is that the patient will enter and leave the facility on the same day that the procedure is to be performed.

• Procedures may be performed at ASTCs or at hospitals

• Clinical decision-making on whether a case is suitable for outpatient procedure should take into account a classification such as the Elective Surgery Acuity Scale (ESAS).

• For a facility to perform outpatient procedures, all criteria listed IDPH section D must be satisfied.

Elective InpatientProcedures

An elective procedure in which the patient being considered for that procedure is likely to remain in the hospital for more than 23 hours, starting from the time of registration and ending at the time of departure.

For a hospital to perform inpatient procedures, all criteria listed on the next two slides must be met (IDPH sections C and D).

Guidelines April 24, 2020

18

SAMPLE IDPH Facility Dashboard as of 5/11/2020 for Category C Procedures > 23-hour LOS

IDPH Requirement Description Hospital Status

Case Setting and Prioritization

• Each facility should convene and charge a Surgical Review Committee (SRC), composed of surgery, anesthesiology, and nursing personnel, to provide defined, transparent, and responsive oversight of the prioritization of elective inpatient cases.

• The SRC should review regularly a list of previously postponed and canceled cases, prioritizing based on clinical considerations and taking into account the resources and staff necessary for each procedure.

PreoperativeTesting for COVID-19

• Facilities must test each patient within 72 hours of a scheduled procedure with a preoperative COVID-19 RT-PCR test and ensure COVID-19 negative status.

• Patients must self-quarantine until the day of surgery after being tested. • A temperature check must also be completed on the day of arrival at the facility with results of less than 100.4

degrees prior to proceeding with an elective procedure. • When clinically acceptable, providers should consider using telemedicine for preoperative visits. • In such cases, face-to-face components of the exam can happen after the result of the preoperative COVID-19

test result is known to be negative.

Protective Equipment

Facilities may resume procedures only if there is adequate personal protective equipment with respect to the number and type of procedures that will be performed, and enough to ensure adequate supply if COVID-19 activity increases in the community within the next 14 days.

Infection Control

• Facility cleaning policies in all areas along the continuum of operative care must follow established infection control procedures.

• When possible, facilities should establish non-COVID care zones for screening, temperature checks, and preoperative waiting areas.

• Facilities should also minimize time in waiting areas, space chairs at least 6 feet apart, and maintain low patient volumes. Visitors should generally be prohibited; if they are necessary for an aspect of patient care or as a support for a patient with a disability, they should be pre-screened in the same way as patients (as described above).

• Facilities must have the ability to routinely screen all staff and others who will work in the facility (physicians, nurses, housekeeping, delivery and other people who would enter the patient area) with COVID-19 RT-PCR testing.

SupportServices

Other areas of the facility that support perioperative services must be ready to commence operations with uniformly heightened infection control practices, including sterile processing, the clinical laboratory and diagnostic imaging. 19

ICU Beds (Utilization threshold 80%) M/S Beds (Utilization threshold 80%) Ventilators (Tier 1 Utilization Threshold 80%)

NM owns and operates multiple outpatient surgery assets. However, only NM Surgery Center in Warrenville bills as an ASC.

NM’s Existing Outpatient Surgery Assets

Owned Sites Billing Licensing

1 NM Lavin Pavilion HOPD HOPD – Multispecialty

2 Delnor Surgical Services 345(Formerly Tri-Cities ASC)

HOPD HOPD – Multispecialty

3 NM Grayslake ASC HOPD ASC – Multispecialty (Gen Surg, OB/Gyne, Ophth, Ortho, ENT, Plastic, Podiatry, Urology)

3 NM GrayslakeEndoscopy Center

HOPD ASC – Limited Specialty (GI)

4 NM Surgery Center, Warrenville (NMSC)

ASC ASC – Limited Specialty (Ortho, Pain Mgt)

Joint Venture Sites Billing Licensing

5 The Center for Surgery,Naperville

ASC ASC – Multispecialty (Neuro, OB/Gyne, Ophth, Ortho, ENT, Pain Mgt., Plastic, Podiatry, Urology)

6 Midland Surgical Center, Sycamore

ASC ASC – Multispecialty (Neuro, OB/Gyne, Ophth, Ortho, ENT, Pain Mgt, Plastic, Podiatry, Urology)

7 Algonquin Road Surgery Center LLC

ASC ASC – Multispecialty (Neuro, OB/GYN, Opth, Oral, Ortho, ENT, Pain Mgt., Plastic, Podiatry)

1

24

3

7

6

5

NM HospitalLegend

Owned Site

JV Site

Central Region

Northwest Region

North Region

South Region

West Region

Covid Testing in Procedural Areas

• Wednesday morning, April 29, 2020, NM began using Abbott ID Now to test same-day OB and surgery/procedural patients who are being collected on the clinical unit immediately prior to their procedure.

• Patients are currently being tested on the Cepheid platform with a ~2 hour turnaround time from receipt. Abbott ID Now has a shorter turnaround time of ~ 30 minutes from receipt.

• Collection for the Abbott ID Now is a dry NP swab placed in an empty tube, as opposed to an NP swab placed in viral transport medium (VTM). Dry NP swab collection improves accuracy on the Abbott platform.− Specimens should be double-bagged when sending through the pneumatic tube

system. − Any questions about new collection methods should be directed to your site’s lab

leaders.

21

Last Updated 4/29/20

SAMPLE Inpatient COVID Testing Workflow

22

SAMPLE Drive-Through Testing Workflow

23

Regulatory/Facility Readiness

• NM is an “Essential Business” under the Illinois Stay-at-Home Order, thereby permitting employees to return to work.

• As an Essential Business, NM has complied with and will continue to comply with the physical distancing requirements set forth in the order and as modified by the governor and IDPH.

• Designate 6-feet distances for employees and patients queueing to maintain appropriate distance.• Have hand sanitizer and sanitizing products readily available.• Post online information regarding whether a facility is open and how best to reach the facility and

continue services by phone or remotely.• Provide face coverings to all employees who are unable to maintain 6 feet of physical distancing (per

modified order)• Follow new requirements to maximize physical distancing and prioritize the well-being of employees,

including occupancy limits (per modified order)

• In addition, NM will follow applicable guidance from OSHA, CDC, CMS, FDA and other relevant governmental agencies

24

Guiding Principles

Patient Communication Guidelines: Arrival and Appointments

• Inform patient about thermal screening, masking and minimal touch. • Specific update about the No Visitor policy, including exemptions.• Validation that anxiety and stress are appropriate responses to any medical appointment/procedure and these emotions may be elevated as they visit

NM during the pandemic.• Patients should arrive with a fully charged phone and/or should plan to bring a charger if they anticipate spending several hours at NM.• Patients should arrive with questions for their provider already written down. This will help:

− 1) improve time efficiency in face to face visits and − 2) compensate for patient's anxiety/stress which can lead to forgetting importantquestions, and − 3) compensate for family who would be asking the questions.

• Patients should come prepared to take notes and should be reminded to read any printouts they receive at discharge, which may contain detailed information abouttreatment recommendations and future appointments.

• If patients would otherwise be accompanied by someone, they are encouraged to have that person on the phone for the entire visit, as an extra set of ears. That person should already be on the line before the provider enters the clinic room. Reminder to patients: many smart phones and tabletsallow for more than one person to be on the line at once. Patients can still have their support system with them. Those individualsshould be informed in advance of the timing and should write down questions in advance, if they plan to ask any.

• Patients with longer procedures/infusionsshould consider downloading music, a TV show, a podcast, game apps, or bring a magazine or other distraction.

• Patients should be given instructions about how to anticipate interpreter needs.• Patients will benefit from other tips such as: familiarize yourself with a campus map before you enter campus and know your exact location PRIOR to

entering the building. • Provide some directionabout elevators (use a pen, your elbow, etc.), revolving doors, bathroom doors (eg., bring a wipe or tissue to use on doors, carry

sanitizer if you have, etc) or whatever is recommended.• Remind patients to wipe down phones and earpieces after their appointment.• Remind them about what to expect re physical distancing, PPE, thermal scans at entrance, etc.• Patients will also benefit from a reminderabout the frequency and quality of the sanitation on campus, as well as a reminder that the patient will not

be exposed to the COVID units.

25

Source: Kim Feingold, PhD

Understand staffing needs for additional

volumes

Understand gap between currently available staff and

needed staff

Evaluate how many need to be pulled from which labor

pool (based on priority list)

Evaluate implications of

additional volume –added census and reduction in labor

(how does this impact staffing

ratios)

Weigh trade-offs (given riskiness of

staffing impact and patient risk of

postponing surgery/procedure)

SAMPLE: Labor Pool Reactivation CoordinationSurgical Services/Procedural Areas Labor Pool Incident Command?

Pre-op: 7, PACU: 15

CRNA: 27

Pre-op: 0, PACU: 5

CRNA: 3 5 RN from med/surg

2 CRNA from ICU, 1 from GLP

Max. 12 add. ICU pts

0 Impact from SS RN, -2 ICU RN in labor pool from CRNA

TBD

SS 5

/4

TBD TBD TBD Max. 1 add. ICU pts

TBDTBD

Pro

5/4

Other Reactivation Playbooks

• All other playbooks can be found on Physician Forum here: https://physicianforum.nm.org/covid-19-reactivation-resources.html

• Playbooks include reactivation plans for: − Clinics− Facilities− Scheduling− Telehealth− And more

• Playbooks will be updated regularly as new information and recommendations becomes available

27

Saved and updated on NMI

https://physicianforum.nm.org/covid-19-reactivation-resources.html

Reactivation Planning: Playbook Revision HistoryReactivation Guiding PrinciplesReactivation Workgroup StructureRegulatory RequirementsRegulatory RequirementsSurgical/Procedural Review CommitteeReactivation Planning CommitteeSupporting Planning DocumentsSAMPLE Pre-Procedure Workflow SAMPLE Pre-Op Resources SAMPLE Procedural Resources SAMPLE Post-Procedural Resources SAMPLE: Capacity Restoration Planning SAMPLE: Monitoring ScheduleAppendixBackground IDPH Definitions SAMPLE IDPH Facility Dashboard as of 5/11/2020 for �Category C Procedures > 23-hour LOS NM’s Existing Outpatient Surgery AssetsCovid Testing in Procedural AreasSAMPLE Inpatient COVID Testing WorkflowSAMPLE Drive-Through Testing WorkflowRegulatory/Facility ReadinessPatient Communication Guidelines: Arrival and AppointmentsSAMPLE: Labor Pool Reactivation CoordinationOther Reactivation Playbooks