COMMENTARY

Surgeons Can Change. The Pandemic Made It Happen Faster

Mark S. Talamonti, MD; Lakshmi K. Halasyamani, MD

Disclosures

February 18, 2021

Amidst vaccine delays and new strains of SARS-CoV-2, health systems are bracing for the unknown yet again. Fortunately, the healthcare community has learned a lot since the virus first arrived. We are better equipped for a surge in what continues to be an unpredictable outbreak. In addition to remarkable strides in management of infected patients, providing resources to treat this influx of patients has been essential. Will the profound cultural shifts inside major health systems that allowed us to cope, persist or deteriorate as new challenges emerge?

One of the urgent adaptations that allowed the needed increase in hospital capacity was widespread cancellation of elective surgeries.

At NorthShore UniversityHealth System, a five-hospital system in the suburbs of Chicago, that had to cancel 3400 surgeries in 3 days — a monumental challenge.

Our experience was similar to that of hospitals across the nation. These actions, however, were not without consequence. Almost half of canceled or delayed elective surgeries have a potential to inflict significant harm on patients.

As we began to reschedule these procedures, we recognized that engaging our surgeons in a risk-stratifying process in order to prioritize the highest-risk patients was essential. We had to ensure that patients with advanced disease or clinically urgent situations were cared for safely. While we had sophisticated modeling that provided real-time data about what resources were available, the clinical judgement of surgeons about the impact of postponing procedures on individual patients was paramount.

The need to rate the risk for loss of life, limb, or quality of life in our patients affected by surgical cancellations forced us to look beyond our personal and departmental priorities. The traits that make surgeons successful in the operating room — confidence, single-mindedness, focus — became a crutch practically overnight. We now had to serve this higher order, shared priority of saving lives in our community.

Pre-pandemic, surgical cases were typically scheduled within an individual department. Orthopedists juggled with other orthopods for surgical suites. Cardiovascular surgeons coordinated with their cardiovascular surgery colleagues. But now, coordination had to occur across all departments. Practically, this meant that life-saving gynecologic surgeries, which typically represent the smallest volume of surgeries in a given day, were given priority because of the clinical urgency of the procedures for those patients.

The willingness of surgeons to work together across departments was extraordinary. This day-to-day collaboration has forever changed us as a healthcare system.

This shift in dynamics went beyond just hospital surgeons. NorthShore quality and safety leaders decided early on to err on the side of caution by requiring personal protective equipment (PPE) that exceeded mandated guidelines. This was despite supply shortages that had led to the CDC discouraging the use of N95 masks by some health workers. We recommended that all members of the operative and procedural team wear N95 masks for every procedure, a decision that initially frustrated some surgeons who did not agree with the precautions. However, when government officials eventually aligned PPE requirements with our existing approach, not only were we prepared, but trust between surgeons and administration was strengthened.

These events ushered a profound shift in our internal dynamics and resulted in lasting transformation of our culture. Our team's sense of purpose improved. We are better able to prioritize internal and external communication. And our commitment to the communities we serve has been reinvigorated.

Three principles emerged:

1. We exist in the same system for a reason. Forced to think as a unit, our system recognized that our end-goal was to keep our communities healthy overall. This emphasis went beyond departmental priorities and has re-energized our commitment to averting preventable emergency room admissions. This sense of purpose has had a profound impact on the priorities of our staff at all levels. Not only are we more pragmatic about dynamically allocating resources that align with the needs of our community, but our staff is more on board than ever with what may have felt like cumbersome safety protocols pre-pandemic. For example, building on our success with mask compliance among all staff, we are now evaluating broad protective eye gear requirements as a measure that goes above and beyond state and federal requirements to prevent virus transmission.

2. Patient and clinician safety must always be paramount. Risk-stratifying patients could only take us so far. Until we could assure patients of our commitment to safety and quality and demonstrate how we took their personal situations and priorities into account when developing their care plans, our clinical judgement had limited impact. Our approach aimed to holistically understand patients (their genetic risk factors, their caregiver support at home, the drivers of their health decisions), and our clinicians engaged patients in a more personalized manner, which will persist well beyond the pandemic.

3. We must look beyond our own walls to keep our community healthy. The pandemic forced us to turn patients away from elective care that would have improved their lives. We now recognize without a doubt that the preventive behaviors of mask wearing, handwashing, and physical distancing are critical to bending the COVID curve. Similar to the way we ask people to wear seatbelts and avoid drinking and driving so as not to overwhelm our health system with acute care emergencies, health systems that exist to serve communities must improve the public's understanding of these essential strategies to mitigate risk.

And then we must actively partner with community organizations to ensure that this information is communicated by those who are likely to have the most impact. We engaged local educators to apply lessons learned from our health system experience in their return to school plans. We collaborated with communities of faith to promote symptom recognition, safety practices, and testing. We created an infrastructure to support long-lasting initiatives and priorities that go beyond our walls.

As clinicians, we must continually strengthen our ability to improve health and human life. Together, we owe it to our communities to reflect on how the collaboration, ingenuity, and agility required by this pandemic will strengthen our commitment to our values, provide a meaningful place of work for employees, and improve the health of the people we serve.

Today we have a foundation and a culture that has the potential to avert such drastic measures as halting elective surgeries in the future. As an industry, we must continue to invest in connections within our organizations and across industries and communities to mobilize change — whether the next wave strikes or not.

Mark S. Talamonti, MD

Mark S. Talamonti, MD, is professor of surgery at the University of Chicago Pritzker School of Medicine and Chairman of the Department of Surgery at NorthShore University Health System. His clinical expertise focuses on the area of gastrointestinal surgical oncology with specific interests in pancreas and liver cancers.
 

Lakshmi Halasyamani, MD

Lakshmi Halasyamani, MD, is chief medical officer at NorthShore University Health System, having previously served as chief quality and transformation officer where she led efforts to improve quality, safety, and patient experience.

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