How University Hospitals Is Resuming Elective Surgeries

May 20, 2020 - As quickly as the number of confirmed COVID-19 cases went up, the volume of joint replacements, spinal fusions, and other elective, non-emergent services dropped, in some cases up to 99 percent since the public health crisis started.

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In March and April, hospitals rapidly canceled these services and many more to prepare their organizations for a potential surge in patients infected with the novel coronavirus. With fewer elective services taking place, providers freed up capacity, personal protective equipment (PPE), and provider availability all while reducing unnecessary exposure.

But now that the surge is over in many states, some hospitals are opening their doors back up to patients who had delayed their procedures out of caution for the coronavirus. The question is: how do hospitals manage pent up demand for services while still ensuring the safety of their providers and patients?

As Ohio geared up to reopen, that question was top of mind for leaders at University Hospitals.

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University Hospitals is an 18-hospital network with over 40 outpatient health centers and 200 physician offices throughout northern Ohio. The state’s governor Mike DeWine ordered all Ohio providers to postpone elective surgeries on March 17, but as of May 1, providers received the green light to resume some delayed services.

“In Ohio and within our hospitals, we've had a very low census of COVID patients, which is, I think, because of the early enacting of social distancing,” Dan Towarnicke, vice president of perioperative services, recently told RevCycleIntelligence. “Different cities are experiencing different issues, but we've been very fortunate in Ohio to not reach anywhere near the peak that we were anticipating.”

However, out of an abundance of caution, University Hospitals still reduced its surgical volumes to about 30 percent of its pre-pandemic norm. Some of the surgeries postponed, including hip and knee replacements and percutaneous coronary interventions, account for up to 50 percent of total payments made to a hospital.

The health system has slowly increased its capacity to about 80 percent as of mid-May under the direction of a comprehensive plan to reopen surgical lines of business.

Resuming postponed, medically necessary surgeries at University Hospitals was and still is a team effort. Towarnicke is just one member of a large multidisciplinary team that addresses issues with ramping up surgical operations.

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“Our implementation team has over 30 members on it, with someone from finance and patient financial services to marketing, IT, and operations in the hospital lab. It is really a comprehensive group of people who are involved in touching a surgical patient, which is pretty vast in the hospital setting. We work together to develop workflows and policies to meet the needs of our recovery,” Towarnicke said.

University Hospitals is taking a system-wide approach to resuming surgeries delayed during the governor’s order. In order to get 18 hospitals and dozens of other ambulatory surgery centers back to pre-pandemic volumes, the implementation has first and foremost looked at its data.

“What was important initially was understanding what the demand would be as we were reopening,” Towarnicke stated. “With the help of Hospital IQ and their performance measurement tools that we have implemented here, we were able to get very granular by provider, by service line, by location to understand what the total number of cases that were postponed due to the COVID event.”

The granular data enabled the implementation team to understand how much operating room (OR) minutes were needed to accommodate the pent-up demand for surgeries across University Hospitals. Combining that data with the health system’s current demand, the team was then able to recognize how many OR blocks were needed by location and service to reopen successfully.

“That's how you really get back into your staffing and what you need to do from the standpoint of extending your existing block schedule from eight to ten hours and also opening up all hours on the weekend when ORs are typically not running elective cases,” Towarnicke explained.

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Once the implementation team had the data to understand surgical demand, the next step was putting information into the hands of surgeons.

One of the more important relationships at a health system is the one between a patient and his surgeon, and for University Hospitals, ensuring surgeons had visibility into the OR was critical to resuming elective, non-emergent surgeries.

“We wanted to ensure is that our surgeons were in contact with their patients, not just when we knew we were going to reopen but throughout the process,” Towarnicke explained. “Through our analytical tools, we produced patient lists and distributed them to our surgeons so they could go back and call those patients to let them know, effective May 1, we were going to be able to do their surgeries.”

The patient lists were key to prioritizing the case backlog. Surgeons used the lists to determine who needed to be seen first based on their acuity, as well as who was cleared to go into the OR without administrative delays.

“What we wanted to also be able to do if a surgeon had multiple patients all with the same acuity was give them financial clearance information,” Towarnicke stated.

Patient lists included whether a candidate for surgery was already financially cleared by the revenue cycle team and/or if he had an insurance authorization already approved. This enabled surgeons to schedule patients with the same acuity efficiently; those with financial clearance could be scheduled sooner since there were no administrative roadblocks, while the revenue cycle team worked to clear and schedule the other patients.

And while administrative staff scheduled OR time, the implementation team set safety standards across the health system to minimize exposure to COVID-19 as ORs reopened.

“What we've been working on the most over the last two to three weeks is installing processes for patients to get preoperative COVID testing,” Towarnicke explained. “Given the different testing capabilities of the health system and what we have available to us, we have several different workflows and triage processes that have been implemented across the system so that patients can be tested within 72 hours of their procedure. Then, they're asked to-self isolate.”

The health system is currently doing this for all endoscopy, cath lab, and electrophysiology surgical patients, and it is working on applying that level of testing to surgical patients in dermatology, interventional radiology, and other areas of invasive surgery, Towarnicke reported.

But reopening surgery lines at University Hospitals would not have been as successful without the help of technology.

“For our health system to get back online it's very important that surgeons have visibility into and access to the OR,” Towarnicke emphasized.

It needs to be easy for surgeons to release or pick up OR time in order to meet pent-up demand for services and not just at their normal hospitals, but wherever the surgeons have privileges, Towarnicke explained. Gaining visibility across the system is key.

Unfortunately, many hospitals and health systems still rely on email, fax, and other manual processes to manage OR time. Surgeon access modules through a tool like Hospital IQ, which is used across University Hospitals, can help healthcare organizations book a growing backlog of patients efficiently.

“It is critical to our recovery and it's going to give our teams a lot of good visibility into where they can put patients on the schedule that they normally wouldn't have access to,” Towarnicke concluded.