American Hospitals…Surviving and Treating the Pandemic
Air Date: July 20, 2020
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HEFFNER: I’m Alexander Hefner, your host on The Open Mind at home. I’m delighted to welcome to our broadcast today, Dr. Jeffrey Matthews, he’s professor and chairman of surgery at the University of Chicago. Welcome doctor.
MATTHEWS: Thank you so much, Alexander. It’s nice to be with you.
HEFFNER: Doctor, you’ve seen on the front lines, how surgery and the landscape of hospitals have been altered, perhaps permanently as a result of COVID. I just wanted to give you an opportunity from the outset to explain that to our listeners and viewers.
MATTHEWS: Thanks. It’s been an unprecedented time and my perspective will be from someone who runs a major portion of what hospitals do, the surgical services, who is not a public health expert, who is not an expert on pandemics, who’s not an expert on these kinds of disruptions that happen to a health system, and yet was in the middle of having to respond and create a an approach from a hospital and a hospital system as events unfolded over the course of the last couple of months. You know, we at the University of Chicago Medical Center had stood up a command center and response team to begin to plan for the pandemic actually in January. But the wave of patients didn’t really start to hit us here in Chicago until March really, sort of the middle of March, which is when we sort of went into the response mode.
And we had to do a lot of things very quickly. We had to prepare the hospital to be able to have the capacity to care for patients in unknown numbers with inadequate patient protective equipment, PPE without a real tool kit, or a playbook for what this virus was all about. We were seeing the experiences that were happening in Italy and seeing the experiences that were beginning to happen in this country in Washington and New York City and trying to plan for that was not so simple. Fortunately in the state of Illinois and the city of Chicago, there was pretty good coordination from the state and local level in terms of sharing information, and so the hospitals can sort of work together in that kind of way. But we immediately had to shut down things like elective surgical services.
And as you know, that can be not so easy to define what types of surgery need to keep happening in which don’t need to keep happening because we have to make sure that we have enough bed capacity and ICU capacity to take care of patients. So the consequences of that, and if you think about the operational logistical challenges that it presents to for a hospital getting into that situation, and then at its maximum how it was going to handle and deploy the teams. And then now the phase that we’re in, which is emerging from it, there was this is all pretty unprecedented. And as I say, there, wasn’t a playbook on how this had to happen.
HEFFNER: And in the intervening weeks and months that we anticipate possible resurgence of COVID cases, do you think that your hospital is, has that game plan and is it better or even ideally equipped to handle the situation?
MATTHEWS: I don’t know if anybody is ideally equipped, but I feel much more confident about our ability as an organization to understand what we need to do. We very early on developed a system, I’ll just speak for the point of view of surgical services, because I think it illustrates the broader problem or the broader challenge that a hospital has. We needed to very quickly ramp down our surgical services to create capacity. And we needed to do that in a way that was medically appropriate and ethically appropriate in terms of which patients would get the care when; which patients needed to be postponed my team. My team and I developed a system that eventually was endorsed by the State of Illinois, the American College of Surgeons the American Hospital Association in terms of how to prioritize patients, for what we termed medically necessary, time-sensitive surgical procedures and this approach to medically necessary, time sensitive, surgical procedures was our blueprint during the pandemic for picking out which cases would proceed and which cases should be delayed or postponed, depending upon the situation on the ground: how many beds we had, how many ventilators we had, what were the particular concerns about delaying surgery for somebody versus having a surgery proceed under a pandemic. We’re using that same system to emerge from this, but what we’ve is that we can really titrate this up and down depending upon conditions on the ground and adjust very quickly should we see another wave. Fortunately right now in Chicago, we have really over the last two or three weeks, really seen a dramatic number of hospitalized patients and a dramatic decrease in the number of patients in the ICU and on ventilators due to COVID related disease. If that starts to move in the other direction, we know what to do now, because we have experience from the past few months. And at this point we are less concerned about availability of PPE and some of those other constraints that were challenging before. Plus I think we have better therapies and a better approach on how to actually treat the more severe disease than we did it in the beginning of the pandemic.
HEFFNER: How did the pervasive comorbidities that patients were experiencing and that you all, as medical professionals and doctors were grappling with, how did that factor into the surgical responses respectively across your hospital in terms of which surgeries were being most frequently employed?
MATTHEWS: Right. That’s a, that’s a great question. And that was at the core of the question that we asked ourselves, which was how to understand which patients were too sick to have surgical procedures in a pandemic versus which patients were too well to have surgical procedures during a pandemic when resources were limited. And we thought about it in a number of different dimensions. We thought about. And really for the first time we’ve had to think about hospital resources. Did we have the beds? Did we have the capacity to do it? So what was our, what was our volume capacity? Could we do 10 percent of our usual volume? Could we do 20 percent, 30 percent? And then we looked really specialty, by specialty at the types of diagnoses that a patient might have, that led them to need a surgical intervention. And were there alternatives that could either be used on a temporary basis or could things really be pushed back further?
So for example if somebody had cancer, I’m a pancreas surgeon, so somebody with pancreas cancer who came up, it was diagnosed during the pandemic, we had to ask ourselves, was it better to move ahead with surgery right away? Well, it turns out that we actually have the ability to treat with chemotherapy and radiation treatments upfront, beforehand, and that’s excellent treatment and actually a way that we’re handling these cancers a lot more anyway. So we would push these patients towards having the chemotherapy and not surgery first. We knew that patients that were at high risk of acquiring COVID could have bad outcomes from surgery. So people who say had preexisting lung disease, people who smoked or people with asthma or other diseases, people who were overweight seemed to be a particular risk. And so those types of patients, we would try harder to see whether we could postpone. So this system that we came up with actually scored the patients and in situations on multidimensional hospital conditions, that the situation with respect to the pandemic and the risk of delaying the surgery and then the specific characteristics of the patient themselves, did they have lung disease, heart disease, immunosuppression, diabetes, these sorts of things. And we could come up with a score that actually is, has performed very well in terms of giving us a sense that we were making the right decisions on who whose operation should go first. Now we’re in a different phase, which is an even, another interesting challenge, which is how to reintroduce the needed care for the patients who were postponed. And how do we decide which patients to do first? How do we convince ourselves that it is safe to restart surgery so that the risk of a patient acquiring COVID either in the hospital or bringing COVID into the hospital was going to was, or wasn’t going to be a problem. And so we are now at our institution, University of Chicago, we are now ramped up to about 75 to 80 percent of our pre-pandemic surgical volumes. We still have a lot of patients waiting for care, though,
HEFFNER: Is your sense, doctor, that the mortality rate that we should ultimately define include deaths that were a function of not having medical care, not having surgical options and that that too should be factored into how we assess the fallout from a human perspective?
MATTHEWS: Yeah. I think that that is important information for us to understand. I am concerned as I see the statistics used for political purposes and that, that entry in, rather than just sort of an understanding of what is happening and what happened. I think that there is a little bit of a risk in one direction or another about drawing too many conclusions from these kinds of data. There is no question that there are people whose outcomes from their condition is not optimal because a surgery or other medical interventions were delayed or diagnosis was delayed as a result of the pandemic, but compared to what, compared to the situation where there was no pandemic, okay, I understand that. Compared to the situation where we made different decisions during the pandemic? Well, I don’t know, again, we didn’t really have a playbook. Nobody really knew even the best public health experts didn’t agree in exactly what needed to be done in which situation in which city, in which country, in which health system at what time. So I think that, yes, you’re exactly correct that we need to think about that and assess that impact because it has important implications for how we respond to disasters in the future. But I am a little bit you know, you read the headlines too, more than I do. I think there’s a, there’s a jump to conclusions that can happen perhaps inappropriately
HEFFNER: As it should be. And we should document for our viewers, this is still a pandemic and while your hospital in hospitals, where we’re recording in New York habits, somewhat under control, it took many weeks, actually months for those conditions to re emerge. We’re still in a pandemic and we’re experiencing heightened activity in major cities in states that really didn’t have a quarantine or a stay at home order and then rather arbitrarily without any scientific or medical basis reopened, they’re experiencing a new climb of cases. And how many of your patients, doctor, have required secondary or tertiary surgeries after just recovering whether in the hospital or once they were discharged? It seems like COVID is something that stays with a lot of patients. And the consequence is a permanent one for, for your health.
MATTHEWS: Right. We are just beginning to get data about a couple of different situations that you’ve outlined there. So there are the patients who never had COVID who had to have their care, their surgery altered, postponed, delayed because they, because of the pandemic and because of conditions on the ground, but they weren’t personally affected by having the illness. There was the risk that they might acquire the illness when they were being treated. There’s the risk that they might get the illness during their recovery phase from surgery. But there’s that group of patients. We don’t know what the impact was there on the delays, et cetera. Then there are patients who had emergency surgery during the time of COVID, who may or may not have had COVID when they came in for their emergency surgery here at the South Side of Chicago, where we see many patients through our trauma service. There continued to be a very high rate of trauma admissions. Some of those patients come in with whatever traumatic injury, they have a motor vehicle accident, then a gunshot wound, they have to go to surgery. And during that time we find out, did they actually have COVID when they got shot or when they were in the accident. And we know that the patients who have COVID who have a surgical are at much greater risk of complications and death from those procedures. Then we have a group of patients that are in the situation where they have urgent or semi-urgent surgery that needs to be done. And we don’t know if they have COVID yet. And we would like to make a choice. That’s where the testing issue came in. Could we test all the patients preoperatively? Well, when we didn’t have tests available, we couldn’t do that.
Now, you know, Governor Pritzker in Illinois came out on May 11th with his directive, which is actually informed by some of the work that we had been doing here at the University of Chicago to say that all patients who were having elective surgery needed to have a preoperative COVID test. That’s great because knowing that the patient is in fact negative for COVID disease, doesn’t have asymptomatic COVID disease, makes us a little bit more comfortable that their surgical outcomes will be good. But you know, somebody can have surgery and acquire COVID in the week or two after their operation, and still have some bad outcomes there.
HEFFNER: In terms of health outcomes, after getting off a ventilator or a respirator, what has been most commonly the symptoms, and then the required surgical response, because you’ve seen like a range of medical conditions. We’ve seen stories about of course issues related to the lungs, but really across the whole body from the brain.
MATTHEWS: Right, well, we’re just learning about this. And as I said at the outset, as a disclaimer, I’m not an infectious disease virology expert and I’m a surgeon, so I don’t have the firsthand experience with that. But I can say that there is a long convalescence for patients who had to be cared for in an ICU setting or in a ventilator setting and they recovered. Even if they recover the full recovery is slow. And we are not that far into the pandemic to know how do they get back to a hundred percent from that? Is it just a slow climb back, or is there actually permanent damage? We certainly know that there are some people who have severe consequences of COVID and will have permanent damage, whether it’s lung or heart damage, and kidney damage people. Some people are so ill that they end up having some kidney failure as well.
HEFFNER: As chairman of the department of surgery, what statistics are available to you right now at this stage of the pandemic that you can speak to about those kinds of required surgeries outside of the immediate treatment and putting someone on a respirator?
MATTHEWS: We are, well, in terms of surgical care, the, what we know is that patients who require an operation who have COVID, symptomatic COVID disease, have worse outcomes, so for types of operations that are normally do not have very high complication risks at all, cholecystectomy, a gallbladder removal operation, those actually have been reported to have very high death rates in patients who actually have symptomatic COVID. What we don’t really know yet, because the data’s still aren’t here, but we’re trying through consortiums to gather the data on this is to understand if a patient has asymptomatic COVID disease, they’ve been exposed to the virus, do they also have a worse outcome and by how much? And the fact is, we don’t know the answer to that question yet. So we’re dealing with a lot of unknowns and we’re dealing with a lot of unknown unknowns in answering those questions. We don’t have access to the kind of data that you’re implying which would be incredibly helpful to us, because it’s simply hasn’t been accumulated yet, and it hasn’t gone through peer review and all of that.
HEFFNER: So with respect to…
MATTHEWS: What you see here, but we know that the numbers of patients that we have in our hospital are not enough to be, you know, a statistically meaningful snapshot to be able to draw broad conclusions.
HEFFNER: Right. So when it comes to cardio or neurological function and heart attacks or strokes that folks have had while they were symptomatic, or after some measure of recovery, we just don’t know the answer yet.
MATTHEWS: We don’t know. We know that it happens. And we think we there are ideas about why it might happen, this microvascular disease, this predilection for forming small blood clots and these sorts of things, but we don’t know how often it happens and how severe we just don’t have the data yet, again.
HEFFNER: Dr. Matthews, What would you suggest? It would be helpful to know from a public policy perspective, what you would like to hear from the state and federal authorities on how we can improve outcomes in your distinctive purview, as someone who has helped organize a major hospital’s response to the epidemic, to the pandemic, what kinds of policy reforms either internally within hospital systems or externally from HHS or other medical authorities, would you like to see implemented that you find to be really critical looking at this in hindsight now?
MATTHEWS: Well, I would say that that’s a great question, and there are so many ways that one could take that question, but I will start with the most important one, which is that this pandemic has highlighted the systemic problems that we have with racism in this country and how that has impacted communities and access to health. The fact that we’ve had problems in different socioeconomic and different geographies in our cities of how patients are affected by COVID and how they can see disease just highlights the big public health issue on access to care. This more than anything else has just drunk dramatize what we’ve known for decades about the inequities in our system, in terms of access to care and outcomes for care, if we can’t act on, on the basis of COVID to implement a more just health system in this country then we haven’t really learned our lesson. So there’s that broad issue, I would say specifically, the other thing that has been highlighted is the need to have better state and national coordination for hospital supplies. You know, hospitals are in, you know, this business of medicine. If you look at our supply chain and supply chain management, it has been managed incredibly tightly over the last you know, a couple of years, decades, or so as hospitals have tried to do this, just-in-time, you know, inventory kinds of work and all that. When you’re talking about things like n95s and other PPEs, to then be in a situation where we don’t have a supply chain for that in an emergency, that’s really something that needs to be addressed. So I think it’s time to rethink how we stockpile it’s time to rethink how we stock in our hospitals and inventory in our hospitals for some of these critical things. And the idea that we have international supply chains on them for some of these critical items may not be the best approach. Those would be two areas that I think are incredibly important to be looking at the state and federal level.
HEFFNER: And would you say that that part of the issue is the inequity within medical centers or hospital systems in terms of how they’re staffed or the resources they have? I know you’re getting at the inequities socially and culturally, preexisting conditions being more prevalent in lower income communities. But would you also say the level of care or the accessibility of care, or is it really before you even get to the doctor or hospitals?
MATTHEWS: Well, it’s at many different levels. If somebody has more out of pocket expenses or they can’t leave their work because they’ll, because they won’t have health insurance and they can’t seek out the care you know, that’s a problem. And, you know, you can go in many different levels here. You know, I think at the University of Chicago, we are a tertiary academic medical center that takes care of the most complex disease and all of that, we’re pretty well staffed and we work pretty well, but we, on the South Side of Chicago provide maybe 10 percent, 15 percent of the care on the South Side. And there are a lot of hospital partners that we have here on the South Side and a lot of places that care is delivered in a federally qualified health centers in clinics and doctor’s offices that simply are not resourced to the way that they could be, because the population is under insured or uninsured and we don’t really have the ability to pay for what’s needed. So when you have a dramatic event like a pandemic, or you could imagine another mass casualty event, the system is not capable to be able to flex up to provide those needs.
HEFFNER: As a final line of inquiry, doctor, the question about inequity is a severe and pervasive one. In the midst of the pandemic in the absence of a therapeutic or vaccine, this is not going away, so there’s the argument, there is really the opportunity perhaps with the new administration, for holistic reform the kind of access to coverage and care that you’re envisioning, but realistically knowing the difficulty of health reform under the Affordable Care Act and the subsequent updates to that legislation and the attempts to undo it, what could be realistic in the pandemic? Do you go big, or do you go more specific in the meeting the needs of the communities’ most affected and really plagued by this pandemic?
MATTHEWS: Well, I think that’s that is the question and it’s something that all of us could have opinions on, and I’m not sure that my opinion is more informed than many policy makers and really thoughtful people who have who have worked on this. I just believe that we need to take the, we need to provide basics for healthcare, for access to care and fund it in a way, perhaps we’re fully implementing the Affordable Care Act so that just at baseline we don’t have this dependence on employer backed health systems that we have a better sort of public approach, you know, whether that’s Medicare for All, or some sort of basic level of care that can be provided so that at least primary services can, can be given. That doesn’t seem like it was out of reach. I think we were well down a path for that in years past. I think there was more consensus on that before it got too politicized. And I think if we can go back to that, we will have made a lot of progress that really did help. So if we can get some of that, you know, I think more sweeping reform is ultimately needed, but you’re right, the politics of that is extremely diverse.
HEFFNER: Dr. Jeffrey Matthew is chairman of the department of surgery at the University of Chicago and professor of medicine. Thank you so much for your time today.
MATTHEWS: Thanks so much, Alexander.
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