COLLEGE OF POPULATION HEALTH

Spread the Science, NOT the Virus Clinical Lessons from the Northeast Surge

September 1, 2020 | 4:00-5:00 pm ET Jefferson College of Population Health

| THOMAS JEFFERSON UNIVERSITY | COLLEGE OF POPULATION HEALTH Resumption of Scheduled Surgeries & Outpatient Procedures

Presented by

Moderated by

Robert Shipp, PhD, BSN, RN, NEA-BC Vice President Population Health & Clinical Affairs The Hospital and Healthsystem Association of Pennsylvania

| THOMAS JEFFERSON UNIVERSITY | COLLEGE OF POPULATION HEALTH Today’s Panelists

Jaime Bohn, MBA, RN Service Line Administrator, Surgical Services St. Luke’s University Health Network

Michele Cassidy, RN, BSN Network Director, Perioperative Services St. Luke’s University Health Network

Tony S. Reed, MD, MBA, MPhil, CAQSM, CPE, FAAFP, FAAPL Executive Vice President/Chief Medical Officer Temple University Health System

Erik Toth, MA Health Services, BSN Vice President, Cardiovascular Services UPMC Pinnacle Heart and Vascular Institute

| THOMAS JEFFERSON UNIVERSITY | COLLEGE OF POPULATION HEALTH Resumption of Scheduled Surgeries & Outpatient Procedures

Robert G. Shipp III, PhD, BSN, RN, NEA-BC Vice President, Population Health and Clinical Affairs

September 1, 2020 Pennsylvania’s COVID-19 Impact

• March 23, 2020: Hospitals were ordered to suspend non-emergent surgeries and outpatient procedures

• April 27, 2020: Pennsylvania Department of Health (DOH) endorsed guidance developed by the American Hospital Association, the American College of Surgeons, the American Society of Anesthesiologists, and the Association of periOperative Registered Nurses

• This endorsement thereby allowed the resumption of scheduled procedures

▪ 35 days of procedural restrictions

6 Pennsylvania’s COVID-19 Impact

• April 27, 2020

▪ 42,050 total Cases

▪ Female 54%, Male 45%

▪ During April, Pennsylvania averaged 1,355 new positive cases each day

▪ August 27, 2020

▪ 131,156 total cases Source: PA Dept. of Health

7 Hospitalized COVID-19 Patients

Age Range of Hospitalized Patients

2% 5%

• Majority of patients 19% hospitalized were over 10% the age of 50 years

19% 0-29 30-49 50-64 65-79 80+

Not all age data reported, totals may not equal 100% Source: PA Dept. of Health

8 Resumption of Surgery Toolkit

• HAP released a toolkit to assist hospitals in preparing for restarting procedures

• This toolkit is available in the Resource Center at haponline.org

• For additional tools, resources, and questions contact:

▪ Robert Shipp III, PhD, BSN, RN, NEA-BC Vice president population health and clinical affairs [email protected]

9 Resumption of Surgeries and Procedures: A Temple/Community Story

Tony S. Reed, MD, MBA, CPE EVP/CMO Temple University Health System

TEMPLE HEALTH Vital Statistics

• Temple University Health System • Size – TUH-Main Campus – 1,000 beds – TUH-Jeanes Campus – 80% government pay (50% of – TUH-Episcopal Hospital Medicare patients are dual-eligible) – TUH-Northeastern Ambulatory Center – 40% with Behavioral Health Dx – Fox Chase Cancer Center – >300,000 outpatient visits – Temple Faculty Practice Plan – 1,000 providers – Temple Physicians, Incorporated – 10,000 employees – Fox Chase Medical Group • COVID Data – Temple Center for Population Health – Philadelphia case count = 33,000 – Temple Transport Team – Catchment area case count = 18,000 • Lewis Katz School of Medicine at – Tested = 26,000 Temple University – Positive = 3,100 • Kornberg School of Dentistry – Admitted = 2,000 • Temple University School of Pharmacy – Peak inpt = 290 (Apr 22) – Current positivity = 2.5%

TEMPLE HEALTH 11 Factors and Considerations

• Swiftly changing guidance – Anticipated – Regulatory & Emergency Preparedness teams assigned to monitor changes – Daily meetings rotated between 4 groups: Organizational Leadership, Response Team, Recovery Team, & Occupational Health • Organizational Readiness – National Incident Management System (NIMS) framework activated – Daily incident command meetings during peak; 3 times weekly at start of recovery

TEMPLE HEALTH 12 Factors and Considerations

• NIMS Advantage – Logistics Branch handled supplies, PPE, facilities • Keeping it together as a system allowed a big picture view of our current capabilities • Recovery planning began during the peak because we were able to forecast future supplies, PPE, and facility pinch points based on epidemiologic and illness trends • Our predictive model of usage was within 10% of reality • Dedication and Flexibility – Reallocation of assets across the system – Every employee played a role in the response and recovery (ZERO layoffs)

TEMPLE HEALTH 13 Lab Testing

Number of tests run per day based on a Coverage in days based Test Method Site Number of tests on hand rolling 4 day average (excluding weekends) on Average usage

Cepheid PCR TUH 34 1980 58

Luminex PCR TUH 9 10775 1197

Panther PCR TUH 107 700 6

Alinity IgG TUH 7 5000 714

ThermoFisher PCR FCCC 68 3991 58

Beckman IgG JNS 9 2400 266

TEMPLE HEALTH 14 Pre-procedure Testing

Week of Percentage Total Positive 5/11-5/15 1.3% 150 2 5/18-5/22 1.1% 185 2 5/25-5/29 2.7% 261 7 6/1-6/5 1.1% 275 3 6/8-6/12 5.4% 333 18 6/15-6/19 1.5% 328 5 6/22-6/26 1.8% 282 5 6/29-7/3 2.2% 273 6 7/6-7/10 1.8% 385 7 7/13-7/17 2.8% 362 10 7/20-7/2 1.7% 291 5

TEMPLE HEALTH 15 Surgical Patients with Multiple COVID Tests

TEMPLE HEALTH 16 Procedural Area Updates - Radiology

Week Ending 7/12 Week Ending 7/19 Week Ending 7/26 Next Week Scheduled Procedures Cost Center # Cost Center Name Stat Name Actual Budget Variance Actual Budget Variance Actual Budget Variance

HD2025100 Radiology-Special Procedures Procedures 153 120 33 135 120 15 120 35

TEMPLE HEALTH 17 Procedural Area Updates - GI

Week Ending 7/12 Week Ending 7/19 Week Ending 7/26 Next Week Scheduled Cost Center Name Stat Name TY LY Variance TY LY Variance TY LY Variance Patients

Gastroenterology Patients 109 172 (63) 125 173 (48) 189 164 Volume is down 30% compared to LY

Issues/ Barriers to meet budget:

• Physicians seeing fewer patients in the office • All patients to get reminder calls for office visits • Physicians to review charts of patients who are due for surveillance colonoscopy and schedule patients for telemed visit and possible procedure

• Some patients are unable to come in on a separate day for COVID testing • Working with the Lab to make same day testing available

• Higher no-show and cancellation rates / Patients afraid of COVID testing or afraid of getting the virus • Working with Marketing to develop print materials, including fact sheet, FAQs and testimonials

TEMPLE HEALTH 18 Revenue Cycle

Weekly SPU Case Volume Trend Beginning Week of 05/11/20 – Comparison to 2019

Week of Week of Week of Week of Week of Week of Week of Week of Week of Week of Week of 05/11/20 05/18/20 05/25/20 06/01/20 6/08/20 6/15/20 06/22/20 06/29/20 07/06/20 07/13/20 07/20/20 252 195 227 339 362 353 293 323 438 456 643 596 570 460 532 524 520 692 554 742 730 671

800 742 730 692 671 700 596 570 600 554 532 524 520 643 460 500

400 438 456 2020 300 362 353 2019 339 323 293 200 252 227 195 100

0 Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk 05/11/20 05/18/20 05/25/20 06/01/20 6/08/20 6/15/20 06/22/20 06/29/20 07/06/20 07/13/20 07/20/20

TEMPLE HEALTH 19 Community Response

• Our population – Socioeconomically depressed – Black and Latinx community – Large degree of distrust with medical and government establishment • Our response – Established call center - 65,000 FAQ phone calls (~350 calls per day) – Community health workers continued their work throughout pandemic – Center for Urban Bioethics team remained embedded and active – Multi-lingual physicians attended tele-community meetings, provided education, and worked with local news outlets to keep the connection – Campaign currently underway to reassure community that we are open for business - Community groups active in developing the message

TEMPLE HEALTH 20 Nursing Homes, SNFs, & LTACHs

TEMPLE HEALTH 21 UPMC Pinnacle Resuming Cardiac Services Post COVID-19 Surge Erik Toth September 1, 2020

22 Cardiac Services Post COVID-19 Surge

23 Cardiac Services Post COVID-19 Surge

• Initial “knee jerk” response to COVID/No Electives • Patient safety • Risk Stratify – Not “elective” procedure – Urgent vs Emergent • Avoid ED visit • Virtual Platforms

24 Cardiac Services Post COVID-19 Surge

• March 15th services were halted – Noninvasive testing – Cath Lab procedures – Structural Heart procedures – Cardiac Surgery • Keeping patient safety in mind we moved into a risk stratifying approach – Noninvasive testing was opened to urgent/emergent and had to be documented as such in the notes – Caths were stratified as High/Med/Low – SHP took the same approach as Cath – Cardiac Surgery • Obvious slowing of med/low risk slowed CABG • Valvular surgery was prioritized by critical AS and P2 prolapse mitral valve as priority

25 Cardiac Services Post COVID-19 Surge

• Continued surveillance via telemedicine or video visits • April 13th – Reopened the noninvasive labs at 50% capacity • Risk stratified based on urgent/emergent • Increased capacity every two weeks to 100% of prior year • May 11th restarted routine Cath/EP/SH – All surrounding the preprocedural testing to create a safe environment • Started with med risk and moved to the low risk populations

26 Resumption of Scheduled Surgeries and Outpatient Procedures

September 1, 2020

1 St. Luke’s University Health Network St. Luke’s University Health Network (SLUHN) is a non- profit, regional, fully integrated, nationally recognized network providing services at 12 hospitals and more than 300 sites in Lehigh, Northampton, Carbon, Schuylkill, Bucks, Montgomery, Berks, Monroe and Luzerne counties in Pennsylvania and Warren and Hunterdon counties in New Jersey. As a network, SLUHN performs about 42,000 surgeries annually.

St. Luke’s University Health Network 2 Pre-Resumption of Elective Surgeries and Procedures

❑During the peak period of Covid cases across the network, surgical volumes were at 30-50% of pre-Covid volumes. ❑Reduced elective surgeries to: minimize exposure risk of Covid for patients and staff, conserve PPE (especially N95 masks) and blood products, preserve bed capacity during an anticipated surge ❑Covid Procedural Priority List: ❑ Level # 1 - Inpatient Surgery and Elective Cases that could not be postponed ❑ Level # 2 - Outpatients scheduled for surgery with time-dependent medical necessity within two weeks ❑ Level # 3 - Outpatients scheduled for elective surgery that could have been delayed up to 4 weeks without reasonable expectation of detriment to patient. ❑ Level # 4 – Outpatients scheduled for screening procedures and elective surgery that could have been delayed for longer than one month without reasonable expectation of detriment to patient. ❑Cases resumed upon adequate staffing, PPE, bed capacity, and permission from the DOH

St. Luke’s University Health Network 29 Resumption of Elective Surgeries and Procedures

• Resumed 5/11/20 per PA DOH • Required COVID testing if anesthesia involved in surgery or procedure • Testing – Min of 5 days, Max of 7 days prior • Symptom Screening Process in offices and PAT prior to COVID-19 testing PA • TAT for Results • Outpatient = 3-4 days (outsourced testing) • Inpatient = 1 hour (in-house testing)

• Resumed 5/26/20 per NJ DOH • Required COVID testing for ALL surgeries and procedures • Testing – 4 days or 96 hours prior • Symptom Screening Process in offices and PAT prior NJ to COVID-19 testing • TAT for Results • Outpatient = 2-3 days (outsourced testing) • Inpatient = 1 hour (in-house testing)

St. Luke’s University Health Network 30 Strategies to Keep Patients and Employees Safe

❑Symptom screening of all patients and employees ❑Virtual appointments, registration and check-in options ❑Visitation Policy (Outpatient and Hospital) ➢ Limit to 1 for adults ➢ Exceptions made for special circumstances ❑Social Distancing ❑Masking ➢ Required in all outpatient and hospital settings ➢ PPE guidelines provided for all employees ❑Facilities and Equipment Sterilization ➢ Waiting rooms, exam rooms, high touch surfaces and used equipment Ability to make payments on-line or via phone ❑Curbside check-in ❑Patient & Family Texting

St. Luke’s University Health Network 31 Challenges

❑ Turn Around Time (TAT) ➢ Volumes of tests being done ➢ Limited supply of in-house testing re-agent ❑ Testing Kit/Swabbing Supplies ❑ Patient Confidence ❑ PPE Supply and FIT Testing ❑ Limited Mobile Testing Sites ❑ Workflows for testing patients day of surgery (DOS) ❑ Cohorting of Covid-19 positive patients in hospital setting ❑ Communication ➢ Patients ➢ 12 Hospitals ➢ 300+ outpatient facilities ➢ Independent Physicians/Practices ➢ Testing Facilities – Vans, Walk-in Centers ➢ 20 Lab sites ➢ IT/Epic Analysts ➢ Hospital and Outpatient Billing

St. Luke’s University Health Network 32 Communication

Dyad Leaders receiving and Network Command Entity Based disseminating Center Command Centers streamlined information

St. Luke’s University Health Network 33 Changes Made As Result of Challenges

❑ Communication Strategy ➢ Continuously updated PA & NJ Guidelines, Scripting, FAQ’s for staff/providers ➢ Streamlined E-mail communication, Daily/Weekly Covid Update calls ➢ Uploaded all Covid related information on SLUHN internal and external websites ❑ Epic ➢ Changed Epic pre-op order sets to reflect Covid testing recommended (BPA fires) ❑ Turn Around Time (TAT) ➢ PA – Increased to 10 days pre-op ➢ NJ – Increased to 6 days pre-op ❑ Type of Testing ➢ Transitioned from Nasal-pharyngeal swab to Nasal Swabs ❑ Type of Patients Being Tested ➢ Patients from congregate living situations and add-on’s ➢ As of 7/27/20 – Only Surgery Admits need COVID Testing in PA ❑ PPE Guidelines, Reuse and Sterilization of PPE Supplies ❑ Marketing ➢ Patient Education ➢ Regaining Trust Strategy ❑ Staffing ➢ Staffing to Volumes ➢ Sharing/Cross Training of OR Staff

St. Luke’s University Health Network 34 We’re ready for YOU!

St. Luke’s University Health Network 35 Questions?

| THOMAS JEFFERSON UNIVERSITY | COLLEGE OF POPULATION HEALTH Spread the Science, NOT the Virus Clinical Lessons from the Northeast Surge Series

Next Week: Coordinated Response and Business Recovery in Rural Health Care Systems September 8 at 4:00 pm ET | Register Here Presented by the Maine Hospital Association

Featuring: • Jeff Doran, MHA, Northern Light Health • James Jarvis, MD, FAAFP, Eastern Maine Medical Center and Northern Light Health • Mike Whelan, MS, Certified Clinical Engineer, ST. Peter's Health Partners • Sandra Parker, MS, BSN, Maine Hospital Association

Weekly Webinar recordings can be found at Jefferson Digital Commons https://jdc.jefferson.edu/covid-19-ssnv

For more information or questions visit our website or contact [email protected].

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| THOMAS JEFFERSON UNIVERSITY | COLLEGE OF POPULATION HEALTH