Phoenix Children’s Health Leaders Ace Surgical Planning in the COVID-19 Era
At Phoenix Children’s Health, clinician and clinical informatics leaders worked quickly, decisively, and skillfully to manage the current moment around the COVID-19 pandemic, after all elective surgeries in Arizona were suspended by Governor Doug Ducey on March 19, following the federal order by the Centers for Medicare and Medicaid Services (CMS) on March 18. The organization halted all elective surgeries, recommencing them in May, in a graduated approach, and leveraging a set of dashboards that they had developed in the meantime.
It was a particularly challenging time for the Arizona patient care organization, as a pediatric care organization. But, months after recommencing elective surgeries, Phoenix Children’s Health leaders feel confident that they handled the moment correctly, and are extremely pleased with how their dashboards, including their “Procedures Pending Scheduling” dashboard (figure 1) and their “Cases Scheduled in CPM” dashboard (figure 2), which provide every physician in the organization with the details on where their procedures stand in terms of scheduling, for those not yet performed, and which procedures have already been performed, with a great deal of helpful detail.
Recently, Daniel Ostlie, M.D., chair of surgery, and Vinay Vaidya, M.D., the organization’s CMIO and senior vice president, spoke with Healthcare Innovation Editor-in-Chief Mark Hagland regarding Phoenix Children’s Health’s success in this area. Below are excerpts from that interview.
Let’s begin with the immediate background to your organization’s situation in March. What was the situation at that time?
Vinay Vaidya, M.D.: On March 19, all elective surgeries were suspended by the governor. We continued to proceed with about 10 cases a day that were emergencies, such as appendectomies, car crashes, dog bites. We delayed everything else. As of March 19, two-thirds of all surgeries were stopped. As a result, we saw a huge loss—a 60-percent loss in April. And one of the requirements now in Arizona is that each patient must be tested for COVID within 72 hours of surgery, and that requires us to test, to monitor patients just before surgery, and to make sure that no one is operated on who is positive.
Still, we’ve been able to recover. We performed 4,199 surgeries in June and July this year, compared to 4,033 in June and July 2019. Part of our success has been in the extensive planning; we had to carefully plan everything. Would patients need ICU care following surgery? How long would they stay? So we made extensive use of data, analytics, and dashboards, to support each of several stages. And that was the origin of our surgical dashboards.
Daniel Ostlie, M.D.: Pre-COVID, we would simply put in an order with the patient’s name, the operation type, and whether it should be done in the main hospital or in an ambulatory surgery center Usually, it was on a next-available basis. That didn’t give the schedulers any sense of level of priority. Now, we have a three-level system of prioritization. Each surgeon determines whether their case is a “1,” a “2,” or a “3.” If it’s a “1,” it needs to be scheduled within the next week; a “2,” within two weeks; a “3,” it goes to the end of the cue. The operating surgeon puts this in when they put in the order.
Vaidya: Unlike as in pre-COVID, it had to be aligned across the hospital.
How did it all work out? Surgeons were realistic in how they ranked the urgency of surgeries? Individual surgeons’ choices were aligned clinically?
Ostlie: Prior to the creation of the dashboard, the vice president of perioperative services, the vice president of anesthesia, and I would evaluate every scheduled surgery. And, for example, an inguinal hernia would not normally be seen as urgent prior to COVID, except in a specific emergency. What was good is that all surgeons experienced the same vetting process. And once we rolled out the “1-2-3” system, there wasn’t a lot of conflict; everyone cooperated well.
Vaidya: You’ve seen it time and again, this national calamity has brought out the best in people. And, with regard to the dashboard [figure 1] we give them a complete visibility of all the orders for surgeries. And then you can look at all the priority cases; or Ostlie’s cases; or type of surgery; or by OR location. And so that completely obviated the need for Excel spreadsheets or email or phone calls or clarifications. The dashboard gave them the worklist. And as soon as they scheduled a patient, all the data was in the system.
Ostlie: The prioritization was really important, because it gave Lisa’s team the things to focus on. Lisa is our vice president of scheduling and access.
Vaidya: We made it easy to look at the dashboard. And what you see, this is live as of today. And you can see that every day, we place about 60 new orders, and the backlog doesn’t look bad, at 166. It was much higher; it was in the thousands. We started in May. So let’s track May, June, July, August, and September here, per the number of surgeries scheduled or performed. Actual number. 1,396 in May. 2,261 in June. 1,937 in July. 1,711 in August. 881 so far for September. And you can compare with last year. And combining June and July, our numbers have actually exceeded last year of 2042; we’re at 111 percent over last year. And combining all five months, it’s 8,186 now, compared to 10,095 last year through the end of September. So we’re on pace to match last year’s.
Ostlie: In July, we had to cancel about 80 cases, for patients who became positive for COVID. Someone gets scheduled and then has to be tested for COVID; so about 80 cases had to be canceled as positive. As of last July, 454 patients scheduled canceled because they got COVID, a family member got COVID, or something else happened. But it’s really been driven by COVID.
Where there any challenges in creating the dashboard?
Vaidya: We live what we prescribe at Phoenix Children’s Health. We squeeze every bit of data that we can get, out of our system. Any electronic data within a mile of our hospital gets sucked into our data lake. We knew how this worked with telehealth. We knew that scheduling is the key. The physicians know what to do. But everything else, you’re now dealing with a large constellation of people from different disciplines. Creating a dashboard that’s dynamic, real-time, and meeting their needs, was the challenge.
Ostlie: Look at all the tabs along the bottom of the dashboard. We kept adding tabs based on expressed needs. The expertise that Vinay and his team had, along with the collaboration of the division directors, we all felt the priority that if we were going to get back on our feet as a hospital, we needed to do this right.
And if you look at our case mix index for June and July, it was the highest in our history. Spine, cardiac operation, both have high CMI. So the high CMI was because we were putting the moxt complex operations into level 1. There were some struggles, but the ability of the entire IT, admin, and clinical temas to work together, was key.
Vaidya: This is very similar to tactical military operations, where someone in norther Virginia is at a screen and can see around the corner, while you’re the foot soldier on the ground. And everything is based on the right information to the right people at the right time, that’s targeted. You need to make sure that people aren’t making phone calls or using Excel files. Make sure that the system shows people what they need. Lok at Amazon or the military, which provide the right kinds of information at the right time.
And there’s a screen involving preadmission COVID-19 testing. So we can see who’s been scheduled for a surgery, who’s been scheduled for their COVID test, and what the result was. It’s all on this screen. We’ve eliminated unnecessary work that would have been lost in friction.
Could you provide an example of how this plays out on a day-to-day basis?
Ostlie: Certainly; let’s take the example of pectus excavatum—funnel chest. These kids present with this sternum intruding into their heart; the sternum actually comes down and compresses the heart. We do an operation to elevate the ternum. Three metal bars go into the subcutaneous tissue. You need one, two, or three bars depending on the defect. One in 2,000 kids have the condition; it’s more common in boys than in girls. When I came, we established a chest-wall center, with a team of people doing the operation. So when COVID hit, we decided to wait on these surgeries. There were no chest-wall operations in April.
Now, after reopening, our pectus surgery is up to 55 from 32 last year. These kids want their operations done in the summertime, and it’s painful. Their chest is corrected immediately; it’s uncomfortable. They like to get it done in the summertime so that they don’t miss a lot of school. It’s technically an elective operation.
Vaidya: We created a dashboard for that, too. The dashboard provides for retrospective analysis; the surgeons can analyze and measure the patient population.
Ostlie: There’s a timing element involved, because, following the surgery, you can’t lift over 25 pounds or do twisting activities for two months. So delaying an operation for a kid who wants to be on the sports field in the fall—it’s not purely elective.
What have been the biggest lessons learned in all this so far, and what might be your advice for those who might follow in your footsteps?
Ostlie: From an institutional standpoint, the core instinct around all of this is not financial; it’s the fact that surgeons like to operate. What’s good is that, generally speaking, if you share a problem with them, generally speaking, they’re going to try to solve it. So I would say if I were in an administrative role, I would engage your surgeons as early as possible. Vinay and I and Bob Meyer talked about this together from the beginning. So, engaging the surgeons, the anesthesiologists, IT, and whoever administratively is running surgery. You need the data elements. That’s important just for the well-being of your surgeons. The biggest lesson learned of all is, don’t ever think you’ve totally got it fixed. Having ten tabs on that one dashboard, that was to satisfy everyone’s needs. Never be satisfied until you’ve got it right; we’re still working on it, but we’ve certainly gotten it streamlined.
Vaidya: Sometimes it’s humbling to know that the basics of what you do make a difference. This wasn’t a completely brand-new thing. But we had promised doctors for ten years that if everything becomes electronic, certain things would happen. This was our way to show to the doctors that all of our investments in data and IT would allow us to provide data to them that was very usable. Information is key. It was key 5,000 years ago; it’s key now. And targeting information can help people focus in with a laser focus. And also, this can be really scalable, whether what’s involved is 30 or 3,000 surgeries. And almost every hospital has data. It should not be difficult to adapt this in other organizations. And everyone has to listen to everyone else. We don’t even talk about IT; that’s a tool. We talk about medicine. And I don’t even use the word dashboard, in discussions here.
In other words, focus on the problem and the solution?
Yes, and as Dan mentioned, we wanted to follow guidelines from the Children’s Hospital Association on how to proceed safely. And with the pandemic, we needed to ensure that we had adequate PPE [personal protective equipment]
Ostlie: We still have not had a single pediatric surgeon or anesthesiologist test positive for COVID. I had a patient, they had eaten, so we couldn’t do the operation that day, and then the weekend was coming. And it would have been six days on Monday, so we required that patient to go dtraight down and get a new COVID test, to adhere to the guidelines.
Vaidya: And you need to focus on balancing outcomes. While you’re trying to focus on one thing, whenever you work on one goal, you need to ask yourselves, did something else break? That is important, and we’re constantly vigilant.