Welcome to Mayo Clinic COVID-19 Expert Insights and Strategies. The following activity is supported in part by an independent medical education grant from Pfizer Inc. and is in accordance with ACCME guidelines.

DEVYANI LAL: Good evening. Welcome back to the COVID-19 Expert Insights and Strategies series from the Mayo Clinic. Today it's my pleasure to discuss an important topic, rebooting the surgical practice. Today we have an expert group of panelists that will share with us on strategies that they use to safely reboot the surgical practice in my home institution, Mayo Clinic in Arizona. And I hope that they will be able to share with you what they did to take care of patients that required pandemic, whether it was emergency care or the care of patients requiring elective surgery.

I asked them to share the methods that they've used to enhance both occupational safety of patients as well as of the staff and also discuss what resources they had to lean into as well as barriers that they encountered in safely rebooting our surgical practice.

All of the panelists and myself have nothing to disclose in terms of relevant financial relationships or off-label usage of pharmaceuticals or instrumentation.

This educational activity is supported in part by an unrestricted medical education grant from Pfizer Inc., And all materials presented today will comply with ACCME guidelines.

I am Devyani Lal. I'm a professor of otolaryngology at Mayo Clinic in Arizona. I'm also the course director of the COVID-19 Experts Insights and Strategies series, and I'm the vice chair of education. And it is my honor to welcome my panelists to this discussion.

First of all, I'd like to welcome, thank, and introduce Dr. David Etzioni. He is Professor of Surgery and chair of the Department of Surgery here at Mayo Clinic in Arizona. He also wears a very important leadership hat as chair of our Surgical and Procedural Committee.

Next I'd like to introduce Miss Marialena Murphy. I'm sorry I didn't ask you to raise your hand, but you are labeled. Marialena, hi. She wears several important leadership hats in nursing and administration in our institution. She is the Associate Administrator for Surgery and Surgical Specialties as well as our Interim Chief Nursing Officer. She's the secretary of Surgical and Procedural Committee

Dr. Etzioni, I didn't have a chance to have you wave.

Our next panelist is Dr. Sunny Khurmi. He is an Assistant Professor of Anesthesiology, and he's also a very important part of our Surgical and Procedural Committee. He also is a counselor of the Officers & Councilors of Arizona and represents the surgical specialties and was critical in both the formulation of strategies and the dissemination.

The Surgical and Procedural Committee of our institution is responsible for the day-to-day operations of all the surgical practices and the operating room. And they report to our Clinical Practices Committee and are responsible not just for clinical but also financial performance. They work in close collaboration with other committees such as the Hospital Practice Committee and also with the department chairs and administrators of departments that also utilize the services in the operating room.

Last but most importantly from an infection prevention and control standpoint, we have Dr. Tom Grys, who is the Associate Professor of Laboratory Medicine and Pathology. And as part of the Infection Prevention and Control Subcommittee, he is responsible for the oversight of the organization-wide surveillance and activities for the prevention of control of infection, and this became particularly critical during the pandemic.

So without further ado, I'd like to jump into the discussion and talk to our panelists on what happened when the pandemic first hit our shores. And I'd like to talk a little bit about how we prepared for the pandemic in terms of taking care of patients requiring surgery. And I'd like to first start with Dr. Etzioni and Marialena.

DAVID ETZIONI: So one of my favorite quotes is that "No plan survives first contact with the enemy." I have good colleagues in the military who told me that one. And I think the interesting thing about our initial quote unquote "planning for COVID" is that initially everything that we predicted was about to happen and that would significantly impact our ability to do business as usual ended up not being the thing that actually happened one or two weeks later.

Initially we thought we'd have a critical shortage of gowns and PPE. We ended up not having that. What we ended up having was potentially some problems with testing access or maybe you have problems with staffing supply. So I think it was really hard to plan at the initial phase [INAUDIBLE] because things were evolving so quickly.

I think one of the lessons that we learned was that it's more important to be nimble than it is to be well prepared, but that's a very surgical perspective. Marialena what do you think?

MARIALENA MURPHY: I agree with that. I think that was one of the biggest challenges and maybe learnings from this whole experience was that you really needed to try to plan for the future but knowing that whatever you plan for was probably not going to be the thing that you needed to be thinking about. So there was a lot of rapidly changing priorities that we had to respond to. And a lot of times it wasn't the problem that you thought you were going to have.

I think that the state and federal agencies providing guidance was one of those things that we both wanted to help us make decisions. But then at the same time was sometimes contradictory or would change quickly and made it actually harder because there were times where I was thinking, oh, we just told all of the staff to do x. And now here we are three days later or two days later. We're going to tell them don't do [INAUDIBLE]. That's no good. Now we need you to do this. So a lot of that guidance was rapidly developing and changing as well. So it required us to be able to respond very quickly

DEVYANI LAL: Thank you. I have a follow-up question, Marialena, and that is to your role as an associate administrator, which is a very senior administrative position at our institution as well as the chief nursing officer. How did you address or mitigate the fear of the unknown amongst the staff and especially as news percolated down from China about how this disease was rapidly spreading? And we really didn't know very much about it.

MARIALENA MURPHY: That's a terrific question, I think that that really was a team effort. Our HICS team was really meeting almost around the clock at that time. And we quickly developed mechanisms to get information out to our leaders and have that trickle down to our staff in a very rapid fashion. And that came all the way from the enterprise down to site leadership. We had daily, sometimes more than once-a-day calls for leaders so that we could keep that information coming to our staff.

And as I rounded on the staff, I think that constant flow of communication actually helped to reassure them because they knew we were staying on top of it and if something changed, we would let them know. So even though there was a little bit of, oh, is this crazy, telling them one thing and then having to change it. I think that flow of communication and the transparency was actually something they found very reassuring. At least that's the feedback I've heard from staff.

DEVYANI LAL: I can certainly echo that as a surgeon in the practice because we all knew that we were going on a roller coaster ride, but we knew that we would know exactly where we would be. And that efficiency of communication and the transparency of communication, I think, helped build a lot of trust in the Incident Command Center and the leadership that was running in terms of not just the hospital-associated care but also in the surgical and outpatients practices.

Dr. Grys, if I could pivot to you for the next question, and that relates to your concerns in coming from the perspective of infection prevention and control. What were your concerns as you saw the pandemic coming and how did you advise this group of people to help us prepare for it?

THOMAS E. GRYS: That's a great question. I think transparency, as has been mentioned, is key. I was just going through my notes. It was February 7 that one of our infectious disease physicians gave Medical Grand Rounds sharing what we knew to date, to that day up to what had been published the day before. And it was packed, of course, Medical Grand Rounds, and these days we would say, oh my gosh. We had all these people in one room with no mask, which is funny to think about now.

And when it got into the question and answers, you will hear a lot of times people who talk about emerging disease say, we don't know a lot, so much that you might be concerned. And yet we extrapolate from other viruses, other diseases that we know, and so early on it was thought to be from fomites, from touching things. Obviously aerosols and droplets were definitely in the picture as well. So it was really about sharing what we knew, what we thought was possible, but really being as transparent as we can because you have to maintain that trust.

Like Marialena was saying, if you say something definitively and then you tell them something opposite two weeks later, they start to wonder. But if you say, this is what we think today. And then in two weeks you say, based on what we are now learning, we have to do the opposite. Sorry. Sometimes that happens. Then they'll come along with you.

And so when we looked at this from a practice perspective, it's usually in a risk-based scenario. So where do we think these infected patients might be coming from? Early on pretty much travel to China was key, and if there wasn't travel history there we thought they're probably OK. Obviously that risk factor of travel expanded over time. And then as we learned about potential ways this was being transmitted, then it's looking at what activities in the practice become more risky than they had been based on this new element.

DEVYANI LAL: Thank you. It seems a little silly to go back to the beginning of the pandemic, but I think that there are many lessons learned from this particular pandemic that might apply to the next one. And what I hear from experts like yourself is this is probably not the last pandemic of our professional or personal lives. So those are really good pearls that you shared.

Dr. Khurmi, you're an anesthesiologist. You are well versed with dealing with surgeons. There was a time that you had to tell surgeons that we could either not operate or we had to cut down on the schedule. And actually I was quite surprised by how logical the directions that came from the committee were. And I think that you were able to with Dr. Etzioni get a lot of buy-in on the strategy that you employed. So can you share how you came to the decision to put a brake on the surgical practice, what sort of cases you thought were necessary to go forward, and how you dealt with many surgeons like myself.

NARJEET KHURMI: So my favorite phrase that's come out of this pandemic is that the only thing constant in life is change. And that's something that we learned very quickly early on in the pandemic, that we had to be dynamic and nimble to evolve with a constantly changing situation. And just like Marialena said and Dr. Grys, Dr. Etzioni-- everyone's mentioned this-- transparency was key.

We had to notify the staff that we were up against an unknown and the impact of that unknown was unknown. And as we learned more, we were able to modify our recommendations. The key to our planning was baked on and based on a group effort. Various people from different divisions of the hospital, stakeholders at all levels from general staff to administration to physicians sat at a table to develop a plan that made sense given the information we knew at the time.

We also had to factor in regulatory expectations from our local and state government. And that information was passed on to us by our senior hospital leadership. So everyone was intimately involved with the development of the plans. At the end of the day, we developed a plan that we thought would work and give our patients the best opportunity to have safe surgery and also at the same time keeping our staff safe, their fears allayed as best as we could. But I think it was all based on a hugely collaborative experience.

DEVYANI LAL: I can certainly speak to that because I know that Dr. Etzioni and yourself did reach out to our department in ENT because we were deemed to be somewhat in the high risk considering that we were digging in the nose on certain occasions. And also for your practice, anesthesiologists, there was a lot of concern early on in the pandemic as to how we would be protecting personnel that were inducing anesthesia or were circulating in the OR, et cetera, as well.

How did you educate the staff in the operating room or people that were going to give direct care in the operating room during the pandemic when we knew so little about it? What were your strategies in PPE or environmental reengineering of the operating rooms or perioperative area, et cetera?

NARJEET KHURMI: So first we did but most normal human beings would do is we got on the internet and tried to see what information's out there. What could we learn from the experience in China? What could we learn from the experience in Europe and Italy? Several of us have colleagues, acquaintances that work in those parts of the world and had dealt with the issues that we were starting to see in our own practice. And so we thought we would reach out to them to learn what worked and what didn't work.

We also did some literature searches about prior pandemics or almost pandemics, the SARS virus, the Middle East Respiratory Syndrome. So these were all situations that came up in recent times and over the last 10, 15 years that we could lean on for some guidance.

We determined very quickly what would be needed to remain safe while we practiced our specialty. And once we determined what we needed and that we had the supply to do the work, we then educated our staff by making diagrams, circulating informational sheets by email, also developing a website where people could look at at any time of day.

We also had a handful of subject matter experts-- we called them SMEs-- that were well versed in what it was to be safe, how to use PPE appropriately, how to put on your PPE appropriately, how to take it off appropriately. And so early in the pandemic, in the first few weeks and months, we essentially had somebody available 24 hours a day that we could reach out to, either by person or over the phone, to guide us through a confusing situation.

Long story short, we tried to collaborate and collate information from other people who had already gone through this in various parts of the world and in the US, such as New York City. And we put what we knew at the time to be best practices, we put that on the table and made that our expectation.

At the end of the day, though, what we also acknowledged was that our staff concerns could not be discounted at any degree, whether you're a staff nurse, a physician, a surgeon, a resident, a PA, an administrator. Everybody's concerns needed to be handled appropriately.

And as a group we decided that we would convey that staff should use the PPE to the extent that they felt most comfortable. We did not want to artificially withhold equipment that made somebody safer. We would give them best practice advice based on the clinical situation. However, if somebody wanted to go above and beyond that, they had the freedom to do so. And I think that really helped also.

DEVYANI LAL: Thank you. Those were such great lessons and tips to share with our partners in other areas in Arizona as well as, I think, the audiences that are listening in. If I could direct a question to Marialena-- and if our listeners are wondering why I'm referring to Miss Murphy as Marialena, I think that's what she likes to be referred to.

So as a senior administrator-- and you mentioned the Hospital Incident Command Center-- would you just give us an idea when that kicked in or why that kicked in and what the communication strategy was from an organizational level?

MARIALENA MURPHY: That is a good question. I want to say it actually started early before we started to even talk about shutting down surgical practice or any of that in March. I think as early as February we were-- but it was only meeting on a weekly basis. So we activated the HICS structure, but it wasn't I would say, full blown. And we did that on the tail end, too, so we're still partially activated is what we call it.

So we were able to really ramp that structure up as needed. And as the structure is designed, there's different arms that you can activate depending on what the situation and questions or issues that you're having might be. So concerns with PPE was an early issue, so as we started to grow more concerned about the community spread here in Arizona, we activated that part of the HICS structure and had supply chain at the table as we started to meet more frequently, for example.

Same things with logistics was like, are we going to need additional places for our caregivers to sleep? Are they going to be able to go home? Are we going to need to keep them here? So we were working on a lot of these contingency plans, some of which we did not have to utilize. But we wanted to have mechanisms in place to activate them should that happen.

Now as you all know, March was when we really thought we were expecting that big wave or surge of patients to start rising, and it didn't really happen then. So It was much more gradual than we anticipated that it would be. And we actually didn't see our peak or surge really until early July. So it was interesting how we ramped up and then, of course, ramped down HICS as needed depending on the situation and the needs of the hospital and the staff.

DEVYANI LAL: Thank you. That's a good segue into how you guys came to the decision that it was appropriate to start rebooting the surgical practice into more elective surgeries. And if I could call upon Dr. Etzioni, what sort of resources or what sort of preparedness in terms of personnel, PPE, the pandemic situation, what factors did you consider into say, OK, we are ready to now release some spots for elective procedures. Or how do you go up and then go down, as Marialena pointed out, just in tandem with the demands of the pandemic?

DAVID ETZIONI: So I think that the initial response that our practice had to the threat of the virus was an appropriate response, which was panic. So we panicked, and then after we panicked we basically stopped everything that wasn't an absolute urgent or emergent procedure. Then as we learned more about the virus, as we learned more from our colleagues in lab about the operational characteristics of our tests, there emerged a thought that we could try to get closer to business as usual as long as we implemented certain steps.

And one of the most important of those steps was a paradigm for testing. So we came up with a paradigm for testing. We had a daily monitoring of our availability of supplies, especially PPEs, and then we came up with a plan to move forward. And Dr. Khurmi and I essentially came up with a system to stratify the risk of patients who were going to be going for anesthesia in terms of matching that level of risk to the appropriate level of PPE and other environmental containment efforts that we would do to minimize the risk of in-hospital transmission.

One of the most important things I think I would say as a lesson to be learned at that point was the importance of being flexible and of listening to all the people who are involved in care in every single care context, preop, intraop, postop, to make sure that snafus were dealt with. And I'll just give one concrete example.

Initially our testing strategy was designed so that we would test our preop, preprocedural patients day one, so one day before their planned operation or procedure. And we felt that could work. We had one of the best labs in the country. We have the availability to test that give you a result basically within 10 to 12 hours of the specimen being collected.

So we said, OK, we want to test as close as possible in time to the operation or procedure, so we'll test the day before. We'll get the test drawn by 8:00 AM. We'll have a result back by 8:00 PM. And then we can call up any patient who tested positive and make sure they don't come into the hospital. It made sense. We rolled it out that way. After two or three weeks all parties understood that that approach was completely untenable, so we took a step back.

We worked with our colleagues in ID. We worked with our colleagues in Lab and said, OK, maybe we should be doing this two days before so that if there's a delay, if the patient didn't show up, they shouldn't be on campus, et cetera, then you can still engage in some service recovery. So I think one of the important lessons we learned there was the importance of being flexible. But that's one of the lessons I think we'll carry with us forward into whatever comes next.

DEVYANI LAL: So I really appreciate the responsive nature of the leadership during the pandemic and I think the flexibility, the communication. And I think a lot of us initially in the pandemic were focused on resources such as PPE and whether we'd get HEPA filters, et cetera. But clearly what you are sharing with us is yes, you can overprepare, but you really need to be nimble with disease processes such as this.

So I'd like to just move on from the early preparedness and response to when we went on to rebooting the surgical practice. And I think that some of the panelists have already covered the topics on prioritizing resources, patients with surgery, occupational exposure, which was providing for the highest level that the person was comfortable with.

And I wanted to talk a little bit in terms of what Dr. Etzioni, you mentioned about testing. And I am hoping that Dr. Grys can share some of the testing strategies that he used because at that time testing was not freely available. We were not quite sure of the sensitivity, the specificity, but over a period of time things became more clear with regard to the reliability of these tests. So as you were helping guide the leadership, what were the parts that were going through your head? What kind of resources were you reaching out into?

THOMAS E. GRYS: Those are great questions. A lot of times in the lab, we talk about a couple of things. One is when you collect the specimen, that is already setting some parameters around the best type of result we can get. So if you send us a bad specimen, we can't give you a very good answer. So that's why most labs were looking at nasopharyngeal swabs. We really thought that was the gold standard. And it's not always the most comfortable specimen, but we thought that is where we can detect the virus the best.

Early on there were some swabs shortages, so that became a concern. Not everybody could get the small ones that could go back into the nasopharynx. So that was a challenge. Basically every part of our testing operation was challenged by supply chain at some point early on and still continues, from the swabs to reagents to available instruments to run them on, eventually plastic tips that are used to transfer the specimens, the media that goes in the tubes for the swabs.

Every single thing became in short supply because this was not a local problem. It wasn't a US-- This is a worldwide problem, and a lot of these companies operate worldwide. And so their storehouses went quick. One of the things with supply chain, in the industry often times when you have product sitting-- and the same with Mayo-- if we have things sitting on the shelf, that's value that we should be putting to use at some point. We can't just have that resource sitting.

So a lot of supply chains have been fairly optimized, so to speak, for routine terms. But then when everybody needs the same thing, that becomes a really big problem. So early on we worked very, very closely with supply chain to identify the product we need, a backup, a backup to that, and determined that for our site we used a swab we could get that was dry, and then we had another lab helping us out by pre-filling saline into empty tubes. And we used that as our primary operation for collecting the specimens for several months.

Other labs were switching back and forth. So that's the first chunk is getting the specimen to the lab. The next part is maintaining the testing operation. So that includes having instruments to do the testing on and the reagents. We had committed pretty early on to getting a higher throughput instrument, committed to a volume purchase so that we could maintain reagents supply and they could know that we're going to purchase that.

And then it comes down to having people to run the test. Since a lot of the practice had slowed down, we actually borrowed, I think, five or six people from other Department of Lab Medicine and pathology labs to help out. We trained them in, and they would just do that test for us. And that was huge help. We had about 25 people during our normal operations. So we added about six more to really help accommodate this and keep testing going 24/7.

The logistics of doing the test for the high volume throughput, it's not fast, and there's a couple of steps along the way. And so we really had to staff people at all hours to keep things going. And there were some parts of the summer that Dr. Graff and I were in there pouring off tubes to keep things going because we were just so short of people.

Eventually we got more. We've hired quite a few more people just in the micro lab to maintain this. And then really looking at what testing modalities do you have. There are rapid methods for PCR testing. There are high throughput. There are rare instances that you can get higher throughput pretty fast, but for the most part you either have speed one at a time, or you have a whole bunch that takes six, eight, ten hours depending on the run.

So we would run batches of 24, 48, 96, and more or less that takes a good eight hours or so, and then you throw in some processing and specimen transit time. And to maintain something close to 12 hours turnaround time, that was something that we prided ourselves in. But we also had to remind our colleagues sometimes that if it were 16 hours or 20, we're still promising 24 hours. So just because we do really good most of the time doesn't mean sometimes that we're not going to be taking a little bit longer.

So that's where these conversations were really vital that we were invited to be at the table, so to speak. Of course this was mostly over teleconference and Zoom, but to really have those conversations so we could help our colleagues understand what was feasible for us, what was not going to work, what options we had at a small volume.

So emergent surgeries, we could accommodate a small number of those with a rapid test like a one-hour turnaround. We couldn't do that all the time, but certainly for things like transplant emergent surgeries, we could accommodate a small number. And so there's just a lot of communication to develop that and be flexible, as we mentioned, over time.

And I think it became a question what [INAUDIBLE] we can help answer certain questions in a certain time frame. And then a practice had certain needs of what answers would they want in a certain time frame and how many patients. And it was just a matter of having that conversation to figure out how to keep things going and not over utilize precious fast tests but make sure we were using them if they were going to be helpful.

DEVYANI LAL: You made such great points over there about developing the tests, rapid versus more routine, although I would argue that anything that can come back in 12 hours or 24 hours even today is absolutely remarkable. You're talking about retraining and redeploying, which was to your advantage.

I'd like to ask Miss Murphy, Dr. Etzioni, and Dr. Khurmi how redeployment of their personnel as the pandemic progressed and we were rebooting the surgical practice and the incidents of hospitalized patients went up-- we had to redeploy some of our anesthesiologists, our CRNAs, nurse anesthesiologists, and postop care nurses out to take care of COVID-positive patients either in the ICU or the floor and how that impacted the practice, one.

And number two, were there any other strategies that you used to our advantage in terms of rebooting the surgical practice by reengaging and retraining other folks that were working in the hospital at that time?

MARIALENA MURPHY: I can start out with that, speak to that a little bit. So to answer the question I think I really need to give a little bit of background around some of the financial impact around COVID and shutting down the practice. So when that occurred across the organization, there was some concerns around how would we be sustainable not knowing how much longer this would go on without being able to provide elective care to our patients.

So there were some financial stabilization efforts that were put into place, and some of those that impacted our staffing was we decided to cancel all use of our traveler staff, not use supplementals, and there was a hiring freeze put in place. So that was the right thing to do at the time, especially not knowing what the future might hold. And we also were not seeing the volume of cases at that time that we expected.

So when you think about where we were in the month of May in the community, we weren't really doing the elective practice and we weren't seeing the COVID surge yet. So we were in a good place, I think, at that time. But what happened was as those COVID numbers started to rise in the hospital, particularly in the ICU, our ICU was not staffed to be 100% full anymore now that our travelers were gone.

So we were in a little bit of a staffing pickle. So luckily our PACU nurses, many of them are critical care nurses. Quite a few of them came from our ICU. We also had great support with our education colleagues, our nurse education specialists and many others, creating upskill programs for a lot of our nurses who maybe hadn't worked in the ICU in the past or in emergency room, some of these other areas that we're seeing surges and get them to a competency level that they were able to help and assist in some of these areas.

The CRNAs, anesthesiologists were also tapped to support in those areas as well. And I'll let Dr. Khurmi speak to that specifically. But I think that impacted our ability to care for surgical patients. The overflow plan was our PACU area as well, so depending on how many patients came into the hospital, our response was going to need to be that we would close down the surgical practice again.

So we had a little bit of a sawtooth pattern where we shut down the practice. June became very busy. We had everybody working. And then as July came, we were having to shut it back down to support these COVID patients that we were starting to see the surge in numbers.

So that was really kind of the background around that. I think some of the other strategies that were employed were we utilized our colleagues across the enterprise who actually sent us staff that could come and help in our PACU area and also work in the operating room. So we had about 24 nurses and other staff from the Midwest that came to Arizona to help us during that surge time, which just shows the power of teamwork at Mayo Clinic. It was really quite wonderful to have that collaboration and that support.

NARJEET KHURMI: So I'll take the baton here. When the ebb and flow of the pandemic modeling would show that we had to prepare a certain way for a certain timeline, and it never played out that way. And so we shut the practice down. I think everyone involved, the surgeons especially, were incredibly understanding about the needs of potentially very sick patients filling up the hospital and resources being reallocated. They were incredibly understanding about the notion that surgical care to their patients was going to be curtailed and put on hold.

As we started to see what was actually happening in the community and how it might impact our hospital census, yes, we were able to relaunch a fairly robust surgical practice. That was in part because we had, what I think, a very cohesive and cogent presurgical COVID testing plan. Our lab medicine department was 100% instrumental in making this a viable and realistic option. And I think many hundreds of patients benefited from this collaboration.

But of course, the pandemic wave came to Arizona, and we had to adjust very quickly again. And at this point then it wasn't an issue of do we have enough PPE or we don't understand what the disease is. We knew exactly what it was, and at that point, we now knew that we had to reallocate our staff to other critical areas of the hospital, first and foremost to the intensive care unit but also to the emergency room.

And this is where the genius of Mayo clinic came alive again where we were able to collaborate with ER physicians, understand what their needs and concerns were, and establish a group of anesthesiologists and CRNAs that would function as advanced airway team in the event that there was a sudden surge of patients all at once that needed to be intubated.

Because it was such a dangerous experience to intubate a patient who likely was sick with COVID, the ER physicians thought that it might be better to have a dedicated team specialized to handle this so that it wouldn't take away from their care for other patients that were in the emergency room with other medical problems. So we were able to develop a good plan there.

The intensive care team, the intensivists, led by Dr. Sen, collaborated with our department. They had several sessions on what it meant to take care of a COVID patient in the ICU. They ran multiple simulations and educational sessions to bring us back up to speed to what is the latest and greatest in critical care. Many of us have done critical care in our training. Some members of our department spend 50% of their time as critical care physicians. And so it made sense for the ICU to look to our department to collaborate and be a part of that surge plan when they got busy and it was activated.

So resources were reallocated, and they were reallocated away from the operating room. So by default we had to shut down operating rooms and basically announce that we had x number of ORs to do cases in, and we basically decided based on state regulatory guidelines we would prioritize certain cases over others.

And the basic premise of that was if a surgeon felt that their patient's health was going to decline and result in a suboptimal outcome because they delayed surgery for I think it was 30 days, then we would make every effort to accommodate that surgery as soon as possible. So that was the premise of how we allowed cases to carry forward at the Mayo Clinic.

DEVYANI LAL: Dr. Etzioni.

DAVID ETZIONI: I think Marialena and Dr. Khurmi covered all-- I'm going to focus just for a moment on that last part that Dr. Khurmi talked about, which was there was a point in time at which we had insufficient resources to do all the operations that the practice wanted to do. So we had to come up with a prioritization scheme and then communicate it out, and that was a very delicate process. And I think that luckily we happened upon a good way to do it.

We came up with a draft for a prioritization scheme. We socialized it, and then we stuck to it. We made sure that people knew why, the why for the reason why we couldn't do all the operations that people wanted to do. And I think that we did it in a way that made people feel comfortable with the decision-making process, that it wasn't arbitrary, that it was going to be adhered to consistently. And we were telling people on short notice, that elective case that you want to do that you scheduled even though we told you not to, you can't do it. And I think that because of that, people accept it pretty well

DEVYANI LAL: Thank you. I think all three of you made such excellent points. And as one of the recipients of that communication strategy, it was actually done in a very, very humanitarian way, I think. You put the needs of the patients first, and it wasn't a top-down approach of people who didn't know the patients making the decisions for the patient or the surgeon. You allowed autonomy in terms of guiding the surgeons with certain resource limitations that we had and allowing us to make that decision.

I remember hearing stories, and some of the human stories stick. And as surgeons you always think that the needs of your patients must be very important. I remember that some of our ICU nurses by that time were so overworked because the care that every patient required was so intense that they would come out of rooms and would break down because they were emotionally unable to cope with it and that the personnel that you guys redeployed from the operative areas were actually bailing out our colleagues, our nurses, who were pretty much at that point of time for all we knew putting their lives on the line.

And that sort of communication, balancing out the humanity, the needs of the patient, the care of our own staff, I think that's what got you by. And at least that's what I think. And I can still feel emotional about it when I think about what we went through during the peak of the pandemic and God willing we'll not get there. But thank you for your leadership.

So I am going to move on to our next topic, if I might. And, again, some of which we may have shared already, and that is changes that were necessary in the operating rooms, preoperative holding areas, and the postoperative holding areas that became necessary as we rebooted our practice. If you could share what it took in terms of physical distancing and hands cleansing, personnel, PPE for these folks that were taking care of either COVID-negative, COVID-unknown patients, and COVID-positive patients.

NARJEET KHURMI: So I'll dive in on this. So as my role as the medical director of sort of Surgical Services' perioperatives area, and as the Surgical and Procedural Committee as a whole, we were looked upon to formulate a strategy that would allow the practice to grow back to where it needed to be and where it wanted to be.

We had to start with facilities. We first had to identify locations within our perioperative space where we could bring COVID-positive patients without endangering other patients, the staff, and we established some locations that had negative pressure environment that didn't have it before. Our facilities colleagues were exceptionally quick at getting this set up for us almost within 24 to 48 hour turnover depending on the urgency of what we were asking.

Beyond that, the institution then provided the PPE in more than adequate supply to the preoperative staff so that they could use, depending on the patient that they were receiving from the wards from the ICU-- well, if it was an ICU patient, they would go directly to the operating room-- or from the lobby where patients were coming in from home for their outpatient procedure.

But, again, it goes back to our testing paradigm. We had to make sure that all of our patients were following our expectations about preoperative COVID testing. While we accept that there is a certain level of false positive and false negative in a test, we embraced the notion of testing and asymptomatic patients and the results that came of it universally and consistently, what Dr. Etzioni pointed out to that this was not arbitrary. The information was conveyed very concisely and clearly to the staff about what the expectations are.

And patients were invited in to the preoperative area once we knew that their COVID status was negative. And if it was positive, then they were taken to the appropriate location within the preoperative setting so that they could be taken care of in a safe manner there.

DEVYANI LAL: So the preoperative testing sounds like to me an operational nightmare. How did you guys pull this off, the communication, not just the testing?

DAVID ETZIONI: So Dr. Khurmi used to have a full head of hair. It's true. Before we worked together to implement preop testing, it was like a man. So I'll speak to that one a little bit. ORs are places of habit. ORs function really well when everybody is taking care of patients the same way they have every day for the last five years. Breaking that habit is really hard, and it requires a lot of education, a lot of consistency, a little bit of innovation, and just inventiveness.

One of the things that we did that made it easier for the OR to adapt is we had different colored sheets of paper laminated. These pieces of paper went along with each patient that said at exactly the type of precautions and the way you would organize their care in terms of preop, intraop, and postop care. And that really helped to make everybody feel more comfortable that they knew exactly which patient you'd be taking care of.

But the preop testing thing really was a logistical nightmare. And I think one thing that we learned here is how absolutely critical it is to have nursing involved in anything that's detail oriented about patient care. No other force in the hospital other than nursing will make those systems work. Nurses are the ones who will check, double-check, and triple-check to make sure a patient got something done before they go to the OR or at the OR or before the OR, or whatever. They are the vanguards.

And I think that when you're constructing a system to do anything, initially it was going to require a period of time where you need nursing to take those steps, and they will be there for you. This message brought to you by the Nursing Council.

MARIALENA MURPHY: Thank you, Dr. Etzioni.

NARJEET KHURMI: I just want to echo that. The nursing team that took the reins on making this presurgical testing program function deserves more commendation and accolades than we could probably come up with because our surgical practice does not exist during this pandemic without their all-out effort.

MARIALENA MURPHY: I have to say I agree with you. I think the nursing team did an outstanding job and continues to do that because our surgical patients don't just come from home either. So we also had to Institute inpatient COVID testing for our patients quite rapidly as well. And I recall very clearly having a conversation with one of my nurse leaders around implementing that. And as we were discussing how to get it started, when will we do it, what the challenges were going to be, how are we going to manage it, eventually at some point in the conversation, she's like, are you telling me that we need to do this? And I was like, yes, that's what I'm telling you. We need to do this.