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April 24, 2020

'A moral issue': How MU Health Care is weighing when to reopen the health system

Daily Briefing

    Stevan Whitt, the CMO of University of Missouri Health Care (MU Health Care), recently spoke with Steven Berkow, Advisory Board VP of Provider Research, about what criteria the health system is using to make tough trade-offs amid the U.S. coronavirus epidemic and determining when to re-start cancelled services.

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    Question: Stevan, thank you for taking my call today. I want to start by getting a sense of where you are in the cycle of pandemic readiness. Are you staffing up? Or beginning to see Covid-19 caseloads stabilize and preparing for what's next?

    Stevan Whitt: Our staffing for Covid-19 patients is very stable at the moment. We have four positive inpatients and two PUIs (patients under investigation). Local data tells us we're past our peak. We are now working with our staff on how to safely increase our caseloads and care for additional patients without Covid-19.

    Question: So where does that leave you in terms of occupancy rates and your overall financial health? I gather MU Health Care, like everyone else, quickly emptied the house to create capacity to absorb a Covid-19 surge.   

    Whitt: Our occupancy rate is now below 50%, and our scheduled procedures—where most of our hospital margins come from—are down to 20%. We're also at about 50% of our normal clinic visits, and that's with us heavily leveraging telemedicine. On the whole, we're completely prepared and have the capacity to treat an influx of Covid-19 patients, but we've done so at the cost of cutting our patient care by more than half.

    In fact, we're beginning to have a hard time continuing to delay the normal care we do. As you know, "elective" is a misnomer for much of the care we provide, particularly after it's been delayed for a few weeks. For instance, we're increasingly concerned about those who have delayed care for severe pain issues and nerve root entrapments, which are now causing weakness and even paralysis in some instances, and many other conditions requiring good medical care.

    Question: So it sounds like you have ample bed and I assume staff capacity. But where are you on PPE, as that seems to be the Achilles' heel for many hospitals and health systems looking to re-open?

    Whitt: For us, that depends on whether or not you adjust for our conservation efforts. More specifically, a short while ago we predicted a huge shortage of masks. Then a team member from sterile processing suggested how he could re-purpose a machine with UV light in housekeeping to set up a UV room disinfector and disinfect masks. We are using this technique not only to stretch our own mask supply but to disinfect the supplies of other hospitals, police departments, and fire departments across our region.

    Right now, everyone at our hospital has six face masks—three N95s and three solid surgical masks—which they are expected to reprocess every 24 hours. This gives everyone enough PPE for 36 days, from just those six masks, as well as a little bit of a reserve for when a mask is torn, broken, or soiled.

    But without that ability to sterilize and reuse masks originally intended for a single patient interaction, we wouldn't have enough PPE to safely take care of the Covid-19 case load that we currently have, let alone open up our doors to other patients.

    Question: That's impressive. Have you changed your decision-making structure in some way to promote such agility in identifying and acting on creative solutions to pandemic problems?

    Whitt: Like many, we put in place an incident command center, which I think is working really well. Because we deem this a clinical event, our clinical leaders—our Chief Nurse Officer Mary Beck and myself—take turns as the incident commander. We meet daily with members from each of the functional areas necessary to get our tasks done: guest services, infection control, IT, operations, security, staff health, supply chain, and others. Those people meet at 8 a.m. and 4 p.m. every day, seven days a week, making sure we are covering all of our bases.

    Question: Anything stand out to you in particular to explain why your incident command center has been so effective?

    Whitt: Two things come to mind. First, the people representing key functional areas at incident command meetings go well beyond the executive ranks. Areas are frequently represented by frontline leaders with local expertise and a deep understanding of the situation on the ground, as well as what's possible. Having this knowledge in the room definitely speeds up smart decisions. Otherwise, conversations need to be repeatedly paused while information is gathered. As a matter of fact, we hope to keep this dynamic alive after the Covid-19 crisis has passed.

    Second, we have not lost sight of what we want and need from our people to get through this crisis. You don't want one general and a lot of soldiers who just take orders. You need proactive people who come up with creative solutions and make things work. Our incident command leaders have kept this top of mind. While each day we resolve a slew of specific asks, we have also worked hard to communicate to staff our broader thinking or parameters on things like safe PPE use and purchasing along with our expectation that, within these parameters, they make decisions without asking for permission.

    We also let them know that we expect some mistakes. If they make them, you point them out and that's the end of it. Unless it is something illegal or immoral, there's no associated punishment. And far more often, people are using this latitude to innovate. As a matter of fact, we have been rewarding people for coming up with their own solutions and using the incident command to spread them.

    Question: So do you feel like you're ready to re-start canceled care right now? Is there anything holding you back from starting to reopen closed services other than the greenlight from your governor?

    Whitt: I think MU Health Care is close, very close. But it's not just about us. Our calculus for when to reopen goes beyond MU Health Care. For example, we just don't feel right about using PPE for elective procedures if there are other facilities in our area that truly don't have enough. We think we should send whatever excess we have to them. So we have reached out to every single institution in the state to see if they have enough PPE for the next several weeks. We haven't gotten a request yet, but the standing offer is in place. Likewise, we have concerns about the sufficiency of testing supplies across the state.

    Question: Looking a bit farther down the road, have you thought through how you will prioritize services for re-opening? Do you have criteria for what cases to frontload and which to continue pushing back?

    Whitt: Yes, we have a framework for this that takes a two-tiered approach.

    The incident command team sets a weekly budget based on data from our analytics team, which is tracking every single case and the resources needed to treat each case. And it's not just PPE, but also blood, paralytics, sedatives—these are all in short supply right now. We use that data to project the resources we have available to take care of the sickest Covid-19 patients and others for that week. 

    But the actual decisions on which individual patients to pull forward once we start re-opening services will not be made at the incident command level. Instead, the incident command team will give the department chairs group a weekly budget or resource allocation, along with analytics data to help determine medical necessity and resource use, and ask them to determine which cases in their respective areas should be scheduled.

    The reason for this decentralized approach is twofold. First, it avoids the apples to oranges trade-offs that prioritization across different service lines would require. Each department is give the latitude to weigh patient needs and economic constraints in whatever manner they deem prudent. Second, it takes into consideration other goals we have here at MU Health Care. Among other things, we are a teaching facility, but our staff can’t effectively teach if their services aren’t open. In fact, the loss of clinical rotations has been another hidden casualty of the Covid-19 epidemic.

    Question: You bring remarkable professional experience to addressing this pandemic. How has your work as an infectious disease specialist shaped your perspective on the challenge we now face and how to respond?

    Whitt: Health care providers are taking very real risks to provide necessary care to patients. But that has always been our role. In my career, it has been HIV, hepatitis C, Ebola, and H1N1. About every three years there is a new scary thing we have to learn how to deal with, and I think now is a good time for all of us to focus more narrowly on what we need to learn from this disease to treat it.

    But the needed science can’t be allowed to crowd out the moral issues. Again, the scale of this latest epidemic is so huge that it has raised moral questions, about resource trade-offs in particular. And we’ve got to resolve these thoughtfully as well to truly take care of our patients and each other.

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