Bring It On

The staff at Proliance Eastside Surgery Center in Kirkland, Wash., must feel like grizzled veterans when it comes to working during a pandemic. In late February, a nearby long-term skilled nursing facility saw its first resident with COVID-19. Within weeks, 81 residents of the facility, 34 of its staff members and 14 visitors contracted COVID. Twenty-three of them died.

That put Proliance Eastside squarely in one of the original hot spots for COVID-19 in the United States. With multiple deaths in the same county, the center's staff had to pivot and instantly change the way they operated. They began by screening patients for symptoms of the virus in the building's foyer. More attention was paid to surface cleaning during room turnovers. When PPE vendors called during the weeks that followed, their typical sales pitches to buy more supplies than the center needed were replaced with alerts of a rationing system that meant the center would be getting a smaller percentage of masks, gowns and gloves — items it desperately needed.

With the community in crisis because of the nearly two dozen deaths at a nearby nursing home, some Proliance Eastside employees weren't able to work full-time because they had children whose schools had closed or older parents who needed care. As would soon be the case at outpatient facilities nationwide, Proliance Eastside limited its caseload to emergent procedures.

Fast forward to November — a full nine months after the first wave of the pandemic — and the changes caused by the coronavirus seem anything but novel. "We're still in the middle of it, and another wave is coming our way," says Director Carmen Wilson, RN, BSN, CIC. "The CDC and the state department of health tell us what the latest practices should be. We add them to our workflow, and two days later we receive another update with new tasks to implement and report to regulators."

Proliance Eastside evolved its symptoms screenings method in the foyer into a "mini COVID clinic," at which a medical assistant or registered nurse swabs patients and sends the swabs to labs for testing. However, while the center has managed to acquire a rapid testing device, they've yet to secure the cartridges that are supposed to accompany it. "The changes are happening quickly, but being able to implement them quickly has been challenging," says Ms. Wilson.

On March 16, the multi-specialty ASC reduced its caseload to about five cases a day performed in a single OR. When the governor allowed more elective surgeries to resume about two months later, the incremental ramp-up to a full workload began, which brought new challenges. A screener position had to be created and staffed to test patients and staff members at the door. The mini COVID clinic required new processes and staff as well.

"We're back to being fully functional, but challenges remain that add up," says Ms. Wilson. "ASCs are small, so social distancing requirements are difficult. We've fit-tested our employees for masks, but the N95s we can get aren't always the ones that fit best. We have on-site kits to test how masks fit on the fly if we need to."

Now, despite ICUs filling up again around Proliance Eastside, Ms. Wilson is planning on keeping the facility operating at full capacity by continuing to make on-the-fly adjustments to how her team operates.

"Previously, we would wait to get all the information needed to make an informed decision," she says. "Now, there's no time for that. A decision we made yesterday and put into place today could be changing tomorrow." Ms. Wilson says that being forced to make too many changes too quickly has taught her the importance of keeping her staff informed at every step. "We need to make sure that what we're doing is correct," says Ms. Wilson. "Right now, in a pandemic, we have no choice but to make changes quickly to meet immediate needs. Once things go back to normal, we're definitely going to take a step back and reevaluate the decision-making process moving forward."

In response to the Black Lives Matter movement, many healthcare professionals took an honest look at the racial and cultural makeup of patient care teams. Some didn't like what they saw. That's a positive development, according to Fabian Johnston, MD, MHS, an associate professor of surgery at Johns Hopkins Medicine in Baltimore.

"The tragic events of this year evolved into a national conversation, and created an awareness of the need for more diversity and equity," says Dr. Johnston. "The stark images of police brutality prompted many people to be more introspective than they had been in the past, and question what impact the overall lack of diversity has on our country."

Surgery is a multidisciplinary specialty in which professionals with various clinical backgrounds work closely together to coordinate the care of patients and achieve optimal outcomes. There's also an inherent dichotomy in the profession that can make change difficult.

"It's steeped in tradition," says Dr. Johnston. "Surgical professionals like the structure of surgery, but is what we're doing now good enough?"

Our diverse backgrounds should be the starting point of conversations centered on understanding, listening and learning. This divisive time in the nation's history could create a more unified republic. "I don't think this is a moment," says Dr. Johnston. "This feels like the beginning of a movement, and hopefully a paradigm shift."

He believes underrepresented groups are now more comfortable pushing for change. "That includes me," says Dr. Johnston. "Early in my career, I wouldn't have spoken out or advocated for equality. I would have done so quietly within my microenvironment. There's a greater recognition that more people need to fill these roles, and that members of minority groups should feel more comfortable advocating for themselves and others."

Even providers who don't prioritize equity and greater representation in health care can agree that quality patient care matters, points out Dr. Johnston. "The nation is diversifying, and disparities in access to providers for minority groups ultimately impacts quality outcomes and the overall cost of health care," he says. "Sometimes we need to reframe issues for people in ways that are relevant to them."

Increasing numbers of allyships are a positive step forward, according to Dr. Johnston. "More surgical professionals who are in the majority feel comfortable speaking up about the need for more diversity," he says. "There's increasing recognition that the responsibility to create change can't fall only on minority groups. It's an open conversation we all need to have. When respected leaders voice their support for greater diversity, equality and inclusion, more people will be pushed to join the movement."

Dr. Johnston acknowledges it can be exhausting to face systemic racism on a daily basis and advocate for change. "I'm also heartened," he says. "I feel good about the trajectory we're on."

Healthcare providers go into medicine to care for patients and to make a difference in the lives of others. They put the needs of their patients well before their own and thrive on adrenaline and plenty of long days. But when the day-to-day stressors are compounded with a nationwide pandemic, many were not prepared for the feelings that came bubbling to the surface. Providers were collectively experiencing many of the same emotions, and knew they couldn't keep ignoring them.

"Everyone is dealing with something right now, which makes it understandable that there's some degree of struggling, pain, hurt or emotional reaction to the world as it stands," says Jessica Gold, MD, MS, an assistant professor of psychiatry at Washington University in St. Louis. "The normalization of mental health issues did not exist before, because even though we would variably have tough experiences together, we were taught to brush them off."

Dr. Gold says COVID-19 is causing extra stressors in a profession that already has high rates of depression and burnout. Providers are at risk of contracting COVID-19 or bringing it home to their families. They worry about not having enough resources for patients or enough PPE to protect themselves. "Day-to-day work looks a lot different for some nurses because people are dying at higher rates than they're used to seeing and they don't know what to do or how to help them," says Dr. Gold. "Families aren't at the bedsides, so providers are providing patients with emotional support."

Depression and suicide were prevalent among providers before COVID-19. Nobody talked about it, which can feel extremely isolating. "But if you're in a place where everybody is sharing that they're not sleeping or eating well, and that they aren't happy, then at least everyone can talk about their struggles in an outward and vulnerable way, and feel a sense of community around that," says Dr. Gold.

She applauds health systems that have stepped up to provide the necessary support to their providers. Many organizations have set up hotlines for providers to call to get support from mental health professionals. Some systems have also increased access to therapists and psychiatrists, and have hired more staff members to prevent burnout among their teams.

Dr. Gold is a big believer in figuring out what kind of coping skills work for an individual. "I think it's really helpful to try various methods to see what they like, and then write down those practices. That way they have a list of methods that they're willing to try, so they can figure out what works best in the moment."

Healthcare providers ultimately need to make their own well-being a priority, according to Dr. Gold. "It's a very normal thing to have emotions, and it's a very normal thing to react to the stress you experience every day," she says. "Getting help is not a weakness."

When the pandemic accelerated in March, Catherine Ann Matthews, MD, FACS, FACOG, had never used telehealth to meet with patients. Within a week, she and her colleagues established a telemedicine program. Nine months later, telehealth has transformed her practice to the point where she doesn't want to fully revert back to in-person visits once the pandemic recedes.

"As a women's health provider, I see a lot of older female patients who struggle to get to the office," says Dr. Matthews, a professor of urology and gynecology at Wake Forest Baptist Health, in Winston-Salem, N.C. "The efficiency by which I'm able to provide care and access patients has radically improved. We've dramatically enhanced in-person visits by having the opportunity to meet with patients initially via telemedicine."

Dr. Matthews also conducts telemedicine follow-up visits with her patients who undergo surgery. A key to her success with telehealth has been shattering the traditional perception of the technology as a physician-driven platform.

"We've found that if we duplicate the exact same workflow via telehealth that we have in person, it dramatically assists everybody," she says. "Having nurses conduct virtual calls with patients before their in-person clinic visits to ask about their medications, allergies and health histories, and inputting that info in the EMR creates the efficiency needed to complete a 30-minute virtual visit."

According to Dr. Matthews, patients have mostly embraced telehealth, especially after getting past the intimidation factor of trying something new. "Sometimes it's anxiety-provoking to make sure they can log on. But once we start the visit, generally speaking, I've heard only positive feedback," she says. "Most people are very surprised by what we're able to figure out by talking together."

With a second wave of the pandemic looming this winter, Dr. Matthews feels much more prepared than she did in the spring. "It's incredibly fortunate that we've got this infrastructure established so any vulnerable person has the opportunity to see us this way," she says. "We're actively encouraging patients to take advantage of the technology so we can limit the exposure to the clinic staff and to other patients. Everyone benefits."

For Dr. Matthews, telehealth dovetails into her enthusiasm for patient-centered outcomes. "Patients need awareness that this is an option for them, and that they actually may have more individualized, dedicated attention from their telemedicine provider as compared to someone who's jumping from room to room," she says. "From a patient-centered perspective, I've found the dedicated time they get from the practitioner may actually be improved in a video as compared to in a busy office."

When the first wave of COVID-19 deaths in the U.S. was first reported, Donna Nucci, RN, MS, CIC, couldn't sleep for days. Ms. Nucci, an infection preventionist at Lawrence and Memorial Hospital in New London, Conn., has struggled to cope with the widespread death caused by this once-in-a-generation pandemic. With more than 275,000 U.S. residents already succumbing to COVID-19, Ms. Nucci is reeling from the damage the insidious virus has caused on many fronts. She's currently in a support group consisting of other infection control professionals who discuss the emotional toll of the pandemic and the impact it's having on their mental health.

"The hardest thing I've ever had to do was change the way we provided guidance because of the nationwide PPE shortages," says Ms. Nucci.

In spite of all the heartache, anger and frustration caused by COVID-19, Ms. Nucci is encouraged by the renewed focus on proper infection control practices. She's hellbent on making the most of the extra attention her profession is getting.

"The safety protocols and precautions we created as a response to the pandemic will need to remain in place," says Ms. Nucci. "We need to have adequate PPE for all the 'what-if' scenarios, no matter how remote the risk."

The effects of the pandemic will be felt long after it's over, and Ms. Nucci sees COVID-19 affecting much more than just the day-to-day infection prevention protocols in place at outpatient facilities. "I think this pandemic will ultimately change the physical design of facilities," she says.

Organizations — particularly smaller, freestanding surgery centers that didn't have the infrastructure to handle a respiratory pandemic and were hit hardest by the coronavirus — will need to make major changes to their air exchange systems. Superior HEPA filtration will become a necessity. "We can't retrofit every facility, but even freestanding ASCs will need to have some type of HEPA filtration system in place," says Ms. Nucci.

Ms. Nucci says even though the task of combating COVID-19 today is herculean, the nation's perioperative community must begin to prepare for another potential pandemic. That includes keeping the current stringent infection control protocols — and looking for ways to be even better.

"There will be a next one," she says. "We were ill-prepared this time around, and we could have done more. That can't happen again."

If the surgical community's response to a pandemic — making operational changes, addressing workers' mental health needs and participating in a civil rights struggle in the middle of it all — the prospect of an improved performance in 2021 is bright. OSM