Cardiothoracic Surgery in the COVID Crisis: Global Summit on Reactivating Cardiothoracic Surgery Programs

This special worldwide STS webinar focused on the recovery of cardiothoracic surgery in the post-COVID era. STS President Joseph A. Dearani, MD, along with cardiothoracic surgeon leaders from around the world, shared vision and guidance about:

• Lessons learned from the COVID-19 pandemic in Asia and Europe
• How major health systems address needs and prioritize case types
• Potential consequences of delayed care
• Preoperative screening of patients, families, and health care providers
• Mitigation strategies for the second wave
• Registries/databases for accruing and examining COVID-19 data
• Approaches to physician wellness and PTSD

MODERATOR

Joseph A. Dearani, MD, President of The Society of Thoracic Surgeons

Please note that Dr. Dearani is available for interviews to discuss strategies for restarting routine, elective surgery, as well as safety for patients and health care workers. Contact Jennifer Bagley, The Society of Thoracic Surgeons, 312-202-5865, [email protected], to arrange an interview.

 

PANELISTS

Sanghoon Jheon, MD, PhD, President of the Asian Society for Cardiovascular and Thoracic Surgery

Tomislav Mihaljevic, MD, CEO and President of the Cleveland Clinic

Domenico Pagano, MD, FRCS(C-Th), FETCS, Secretary General of the European Association for Cardio-Thoracic Surgery

Enrico Ruffini, MD, President of the European Society of Thoracic Surgeons

Valerie W. Rusch, MD, President of the American College of Surgeons

Vaughn A. Starnes, MD, President of the American Association for Thoracic Surgery

 

TRANSCRIPT

STS:

Thank you for joining us today. I want to welcome everyone to this special webinar that is part of the Society of Thoracic Surgeons COVID-19 webinar series. The title of the series is Cardiothoracic Surgery in the COVID Crisis and today’s title is “Global Summit on Reactivating Cardiothoracic Surgery Programs.” STS would like to thank Medtronic for their generous support and sponsorship of this webinar and the COVID webinar series. If you have questions you would like to submit to the panelists, please enter them using the Q and A function in Zoom. If you are viewing this webinar on a computer, the Q and A link will appear as an option at the bottom of your screen. Please note this webinar is being recorded and will be available afterwards on the STS website and YouTube channel. The moderator for today’s special session is Dr. Joseph A. Dearani. Dr. Dearani is the current president of the Society of Thoracic Surgeons and the director of pediatric and adult congenital heart surgery at the Mayo Clinic in Rochester, Minnesota. Welcome Dr. Dearani, and let me turn it over to you.

Joseph A. Dearani, MD:

Well, thank you Scott. Good morning. Good afternoon and good evening, depending upon where you are. I would like to welcome our cardiothoracic surgical leaders from around the country and the world for taking and making the time to discuss issues related to COVID-19 in this global summit. Joined by me today is Dr. Sanghoon Jheon, a thoracic surgeon from Seoul, Korea, representing the Asian Society of Cardiovascular and Thoracic Surgery. Dr. Tommy Mihaljevic, cardiac surgeon and current CEO of the Cleveland Clinic in Cleveland, Ohio. Dr. Domenico Pagano, cardiac surgeon in Birmingham, United Kingdom, representing the European Association of Cardio-Thoracic Surgery, and Enrico Ruffini, thoracic surgeon representing the European Society of Thoracic Surgery in Torino, Italy, Valerie Rusch, thoracic surgeon representing the American College of Surgeons in New York. And finally, Dr. Vaughn Starnes, cardiac surgeon from Los Angeles representing the American Association for Thoracic Surgery. We hope you and your families are well and safe and are enduring the continued challenges of this pandemic. On behalf of the panel, we would also like to welcome all of our viewers for watching. We are using a question and answer format and we’ll try to address questions from the viewers as time permits. Thank you and let’s get started. We’ll start off with, COVID-19 has had a profound effect on all of us and the regionalized pattern of this pandemic has become apparent. The peak effects in Asia and Europe seem to have already occurred. What is the single most important lesson that you and your program have learned at this juncture? If there was one thing you wished you had done differently, what would that be? Let’s start with the Asian viewpoint. Sanghoon.

Sanghoon Jheon, MD, PhD:

Okay. Thank you. As Asia is the largest continent, COVID-19 pandemic spectrum is greatly varied from one region to another. Thoracic domain of the ASCVTS collected the status of the thoracic surgery service from 10 major cities… Although some regions are completely collapsed the thoracic surgery services, majority of the leading hospitals have maintained near normal service. The key determinant of whether CT surgery service can be provided during the pandemic appear to be the volume of confirmed or suspected cases in the specific region. If outbreak happens like one in some region, most of the medical resources should be dedicated to care of COVID-19 patients. If we have a pretty established response plan to unexpected virus crisis and the controlling system to reduce import of cases and the limited local spread, time of pandemic could be minimized. In case not prepared, educated resource splitting seems very important between dedicated COVID-19 and the normal clinical services. One thing I regret from Korea’s experience is the distribution of global resources. As you know, most of the COVID-19 patients are asymptomatic or with mild symptom. We recognized treatment should be focused to minimize mortality cases. Currently in Korea, mild or non-symptomatic cases are monitored at medical facilities named Community Treatment Center by minimum medical resources with telemedicine. This system unburdened the hospitals to focus on treating high risk patients. Mild to moderate degree patients are cared in secondary public hospitals. Those are segregated only for COVID-19 patients. Severely ill patients are treated at tertiary hospital, fully equipped with a special ward and ICUs. I just wish we started this earlier sooner. Thank you.

Joseph A. Dearani, MD:

Enrico, how about Italy and Europe?

Enrico Ruffini, MD:

I would like to very, very brief snapshot about the situation in Europe. Europe is currently the most affected continent still. According to the WHO, we have more than 1 million 5, 1 million point 5 cases with 140,000 deaths. So this is a huge, huge impact. The most affected countries in Europe are Spain first, then Italy, then France and Germany. And Italy has been very heavily hit by the pandemic, and for many weeks, we have been second after China in the number of cases. This situation in Italy is very patchy. So in the North, the North was heavily hit and four regions in the North collect more than 80, 80% of the cases. As for my institution, my institution is one of the largest in Italy. So as soon as the crisis occurred, we basically split the hospital into a COVID hospital and a COVID-free hospital because of course we had to take care of the oncologic, the transplantations, and trauma patients, and everything. So we were able to open 200 beds in general in my hospital, with 50 beds for ICU and 30 beds for a high-dependency unit. And at least we were able to cope with the very high peak of the pandemic. Now the problem is of course, how to react with phase two. We are fortunately seeing some decreasing in the number of cases. And starting today, Italy has released at least the total lockdown. So what is the single most important lesson that we’ve learned? First, to be prepared. So we were basically not prepared to this. We underestimated, and I think that we made the same mistakes all over the world. We definitely underestimated the risk, the contagious spread. We thought that probably the virus was similar to the SARS, to the MERS, but this is not. Maybe the mortality’s less, but the contagious spread is extremely rapid. So what I would have done differently, yes, I probably would have taken more precautions in my unit because we underestimate the effectiveness of the PPEs. We will talk about that later. So this, I think, the single most important thing that we have learned and we have not to repeat for the next crisis that unavoidably will happen in the future. Thank you.

Joseph A. Dearani, MD:

Well, Enrico, thank you for that. And we are all sympathetic to what has gone on in Europe and Italy in particular. And I have many dear friends in Italy and we think of you all the time. Domenico, do you have anything else you want to add from the European experience on top of Enrico’s comments?

Domenico Pagano, MD, FRCS(C-Th), FETCS:

Yes, thank you. And really like to add a couple of reflections because our colleagues already discussed the potential shortfalls that we all had. So from a program point of view, I would say that you know, the lesson is the recognition that most of the time we are kind of task orientated and we adopted kind of routine, day to day attitude to life and to our practice. A crisis of this magnitude has provided us with the opportunity to develop a more strategic approach. You know, we knew this was coming, everybody, every healthcare system in the world at the pandemic, at the top of risk management and risk recognition. And there have been some exercises in this country, the UK, in 2016 and there been some exercises in the US under the WHO and of course to develop a strategy for risk management. From a personal point of view, the observation, how resilient we are as individuals and as programs, and the emphasis given on principles like collaboration, solidarity, and empathy, which this is an example. And I think also that this crisis has also provided the opportunity for emerging leadership skills.

Joseph A. Dearani, MD:

Thank you, Domenico. Well, let’s shift to the United States. Valerie, maybe you could comment and maybe just make a reference to your role as leader of the American College of Surgeons and maybe lessons that might have been learned in the non-cardiothoracic surgical specialties that may be pertinent to our specialty.

Valerie W. Rusch, MD:

Thank you very much, Joe. Very early on in the beginning of March, we recognized in the College the need for dissemination of accurate information to the surgical community. And those of you who are fellows of the College have probably realized that we have been putting out an electronic newsletter twice a week. That includes a wide range of information that ranges from how to deliver optimal surgical care under these very, very difficult circumstances. Information about the use of PPE for US surgeons, information about some of the regulatory issues affecting healthcare under COVID here in the US. So I think that has turned out to be one effective strategy to support surgeons in delivering optimal care to their patients. I’ll just mention a few things that we learned at Memorial Sloan Kettering where I work and take care of cancer patients. We were a little bit protected compared to some of the New York hospitals because we don’t have an open emergency room. But we did convert five floors of the hospital to COVID care. And as has been mentioned in the Italian setting from Enrico, separating the COVID from the non-COVID patients, that was effective. We did redeploy staff and we considerably shrank our OR capacity down to 20%, recognizing that many of the operations that we do, just like many of the cardiac surgical procedures, cancer operations are not entirely elective procedures. So we continued to triage patients, have a conversation with each patient about the urgency of their operation and to perform the most urgent procedures, but at a much lower volume. We also instituted routine preoperative COVID testing on every patient coming in for procedures. So they’re all tested 48 hours preoperatively. And while that’s not a hundred percent accurate, I do think it’s been a very helpful strategy in limiting our risks in the hospital to both patients and staff. And we also retest every patient who’s in hospital every 72 hours. Now, obviously we were not able to do that immediately, but we were progressively able to ramp up. You know, it’s the lack of preparedness has been mentioned and I think across New York City and across the US, that was certainly a major deficiency. I might make mention of one initiative that’s occurred within the American College of Surgeons. And this really comes from our Committee on Trauma who have the greatest experience in disaster management. And in Seattle, which was one of the early epicenters for COVID, the physicians in the Seattle area as well as the state leadership in the state of Washington, paired up with Microsoft to develop a software platform that allowed all of the hospitals to look at the load of COVID patients across the entire state and to do what’s known as load balancing. That is, to disseminate patients to different hospitals depending on the needs and capabilities of those hospitals. And so that was a daily event and it really helped to mitigate the patient load and the problems across that state. I think going forward, these are the kinds of strategies that we need to work together on both nationally and internationally to mitigate either a second surge in COVID or other similar pandemics in the future.

Joseph A. Dearani, MD:

All right, well, moving from East to West, Tommy, your perspective. I know Ohio has been rather strict right from the very beginning. Lessons, the most important lesson learned from your viewpoint?

Tomislav Mihaljevic, MD:

Well, I’ll just speak, Joe good morning again, I’ll just speak from a Cleveland Clinic standpoint as an integrated healthcare delivery system that is global. A few things to highlight in addition to what our colleagues had mentioned already. We have geographical presence in the Middle East in the United Arab Emirates, in London, here in Florida, and Ohio. And what we have benefited for as a system was the dissemination of information. We’ve taken care of the first COVID patients in the United Arab Emirates much earlier than the COVID patients appeared in the United States. And we were warned about the severity of their illness and the challenges that that the pandemic can create in a hospital environment. So we started off preparation early at the beginning of January, everything from making sure that we have a sufficient amount of PPE to creating a sufficient surge capacity. We also benefited not only from our geographical presence and daily sharing of information, but also by the fact that here in the United States we are located … and our governor has put the measures early in place of social distancing. We’ve coordinated care across the entire state. As a result, only 2% of our hospital capacity is consumed by COVID patients. We’ve created, we tripled our potential hospital capacity in anticipation of the wave, but the wave simply never appeared. So that we’ve never had more than 150 patients with COVID-19 across our entire system. And just as a reminder, we have 70,000 employees and more than 220 sites across the world where we provide care. So we were very, very fortunate in that regard. What that has allowed us to do is, that has allowed us not only to work as one system, but also to help some of our colleagues in need. So we have sent our intensive care unit nurses and physicians to our neighboring states, to Michigan, to Detroit, as well as New York City. And then we’ll be sending another contingency to the United Arab Emirates. Lessons learned here? I think that is probably becoming obvious that larger and fully integrated healthcare delivery systems have a unique opportunity to flex their resources in ways that can adequately address this pandemic or any other future emergency. Flexibility or distribution of workforce, personal protective equipment, uniformity of protocols and information is, I think, of essence, is an essential for success of us meeting this challenge or any future challenge.

Joseph A. Dearani, MD:

Great. Thank you. And then finally to the West Coast. Vaughn, as a surgeon who has a practice very similar to mine in pediatrics and adults, maybe you could comment and if there’s anything that might be specific to the practice of children with heart disease, that might be important as well.

Vaughn A. Starnes, MD:

I think building on what Tommy has said a little bit, I think one of the things that we’re facing now as sort of a two-phase problem is that because we knew this virus was highly contagious, we initially linked it to highly, highly lethal. So, and we were not really prepared as a nation, I don’t think, and I’ll just say that as a broad statement. So therefore we basically ramped up all of our hospitals and made them COVID hospitals. We basically shut down all the elective things except for the high acuity emergencies, like dissections, et cetera. What that then caused when the surge didn’t come is we had empty hospitals that are now going to face big financial burdens. And at the same time, with all the schools and everything closing down, that is, elementary schools, high schools, some of our nursing staff are now facing childcare problems. And so ramping this up is also going to be a bit of a problem in a basic, a huge financial crisis. So I think our unpreparedness really forced us to do draconian measures about preparing our hospitals, if you would. Basically emptying them out. We didn’t have testing, we didn’t have anything in the beginning. So that I believe was sort of an overreaction, although we didn’t know it at the time. I also think we use generalizations. We took the model of New York and applied it to the entire country. And I think where you have density of populations, vertical living, subways, that model probably doesn’t apply to, say, Nebraska or even LA. We’re still sort of seeing a creeping up of numbers. We think we’ve plateaued. Even our big county hospital, the most we’ve ever had in it is 85 patients. So I think our lessons to learn here is to look at it as a measured response and maybe look closer in the future to epidemiology factors to plan in each region, if you would, how to respond to this virus. As a children’s hospital, we had very few patients. I think we had maybe 10 patients at one time. The children just were not affected and yet we emptied out our children’s hospital, which we’re now trying to ramp back up. And obviously that’s going to create huge financial burdens going forward.

Joseph A. Dearani, MD:

Great. All right, let’s keep moving forward. So the rebooting of cardiothoracic surgery I think should occur in a phased manner. There’s been some some reference to this now. So what would be the best strategies for selection and prioritization of cases, and if there are any ethical issues that should be considered, what might that be? And let’s start with Domenico because I know you’ve written on this, and you have a lot of experience with this. So help us learn so that we move forward in the most effective manner.

Domenico Pagano, MD, FRCS(C-Th), FETCS:

Yeah. So thank you. So really the issue about rebooting cardiac surgery, the timing to restart routine cardiothoracic surgery, depends on a number of things. The type of setting, whether you’ve been working in a hospital like most of our colleagues explained earlier that routinely accepted COVID positive patients or whether you’re working in an institution with no COVID. And really it’s about the ability to establish a COVID-free pathway. The second point is that you have to make an assessment of the status of the epidemic. You alluded, Joe, that that the epidemic has a regional behavior, even within the same nation. Now the risk of infection is clearly higher at times of high prevalence and the severity of the epidemic, and that could be lower when this becomes lower. So the first take-home message for all of this … we need accurate, real-time data to make this assessment. We need to work in collaboration with institutions, biologists, and epidemiologists. We need to use some regional and national data. So I could give you some examples if I may by sharing a couple of slides with you. So, the two things really that you need, in my opinion, is you need to have a system in your hospital to assess how the epidemic is approaching your hospital, how many patients you’re admitting, and what kind of facilities you are freeing. So the hospital where I worked was a major COVID hospital in England second city, Birmingham. You can see here, this is a tool that I have constructed. This is the number of positive patients admitted to hospital over time. And you can see that here we are right down towards the epidemic. You can see also here the dots are where the actual catchment area for the hospitals is coming. You can also have an assessment of all of your inpatients and you can look at, for instance, at the saturations of your ICU services in real time. So that gives you a trend and a feel as to how much resources you are freeing up, so how much elective cases or other elective services you can take. This is not sufficient. As I said, I think you need also to assess the epidemic around you and the region where you are and also in a national framework. So I’ve been lucky to have been part of the task force for COVID-19 of the Italian Society for Cardiac Surgery that developed an index, and this is thanks to the granularity of the data that the Italian government is producing in the public domain every single day. This is an important message because not every community is producing this level of data. So what this has allowed you to do, is to … severity and spread index where you can see by region here. And if you’ve got, you know, an index above 10, you’re still at that part of the epidemic where it is still highly likely to have patients that are symptomatic and infected, and you can see that for instance, Liguria, Lombardia, and Piamonte are still high. So having said that, it’s what you actually do to address some of these issues in more details, in your own hospital. Well, you’ll have to select patients that are clearly three categories. First one is the category of those that are admitted with life-threatening conditions. These are the ones that come in at any time of the epidemic, and these are the ones that you need to treat using your pathways that were alluded before by Valerie. The second is that those who are admitted with urgent conditions like the non-STEMI for instance. Incidentally, we have noticed a decrease in these patients coming into hospital. This is in line with the latest paper published by the Italian cardiologists association seeing that, witnessed a reduction. Although historical data of the patients are actually coming to hospital with this, it’s clear the patients are frightened. And then you’ve got the so-called elective waiting list. Now this could be subcategorized again on the basis of symptoms or anatomical features that many institutions have published an algorithm to work up the patients. In essence, the more resources you free up and the less is the influence of the epidemic on your hospital and in the area… the more you can open I think safely to elective cases. You also mentioned to me about ethics and it’s a very good point. At time of pandemic, with reduced resources, with a high risk of infection, we may have to face difficult decisions. It is inevitable that some patients may be disadvantaged by the circumstances. This decision may span from not being able to provide a treatment, to provide a second best treatment because surgery is not available for that particular patient, or even to defer treatment with all the risks involved yet. In my mind, it’s important that not any individual clinician should make those decisions of this magnitude on his own. The role of the heart team here is more important than ever. Again, collaboration is sharing, and sharing the decision-making burden is also important. The institution should provide an independent ethics support for the process if required. It’s also important that we don’t make shortcuts in the governance. It’s important that we also take these decisions with transparency and they also are well-documented and communicated with the patients and the family.

Joseph A. Dearani, MD:

Valerie, I think coming from an epicenter in the United States, what would you want to say?

Valerie W. Rusch, MD:

Well, I’ll talk a little bit about what the American College of Surgeons has done in collaboration with our other disciplines and then talk specifically about Memorial Sloan Kettering. The ACS, in collaboration with the American Society of Anesthesiologists, AORN, the Association of periOperative Registered Nurses, and the American Hospital Association developed guidelines for ramping up. And many of those guidelines echo what Domenico just outlined on his slides. And these are actually available on the ACS website. They were put out in a press release a couple of weeks ago, and they formed the basis of recommendations from CMS, which is our Centers for Medicare and Medicaid. So there are federal guidelines. Basically exactly what Domenico said about taking into consideration your environment. So obviously New York, very different as you’ve heard from other parts of the country, figuring out whether or not you have the institutional and the regional resources to accommodate patients and to begin to resume more elective operations. Understanding your testing, and I talked a little bit about what we’re doing at MSK. I think that we were ahead of the curve in terms of utilization of testing. We were fortunate to get enough kits to do this, but we really have progressively intensified our testing so that we know for every patient and staff member what their status is and can try to provide the most COVID-free environment. Again, making sure that you have the equipment. That can range from masks, gowns. We were actually very short on OR gowns for a few weeks. And all of the equipment that’s used for cardiac surgery. Domenico I think touched on the issue of case prioritization and scheduling. And this is a very important area and I totally agree with him that this is where multidisciplinary input becomes very, very important. So within the institution, I think it’s important that each service, cardiac, thoracic, but also all of the other divisions and departments, can have a prioritization list for ramping back up their activities and then be interfacing on a daily basis with the anesthesiologists and the nursing teams about what can be accommodated safely in the OR. And that’s what we’ve done at MSK. Initially, twice a day we were looking at the OR schedule, but now we have, you know, gradually ramping back up to a more normal schedule. And then the other area, which I don’t think we really touched on is ensuring that you’re able to discharge patients to an appropriate environment. And that’s certainly been an issue here in New York. What is their family situation? What’s their social situation? And especially in the older patient population, which is true for both cardiac and thoracic, you have to make sure that you have a place for that patient to go postoperatively. Finally, I would make mention that since this infection is not about to disappear anytime soon, it’s important to maintain capacity within our ORs to operate on COVID positive patients. And we have developed an entirely separate pathway for how those patients enter the institution, go through their procedure, recover from anesthesia, and get discharged home. So that’s a very important consideration in high incidence areas. Thanks Joe.

Joseph A. Dearani, MD:

Thanks. Well, there was some reference to testing. I think let’s just go quickly around the horn here to find out exactly what the current testing is for patients going to the OR. Enrico, what are you doing now in Torino, in Italy, in Europe, maybe for that matter?

Enrico Ruffini, MD:

Oh yes. So I can say in my institution, we test every patient at admission, the day of admission. We have a dedicated room for this patient which is treated as possibly positive unless the result of the test is negative. So of course, we triage every patient by phone and in case of any suspected symptom, of course we postpone for 2 weeks surgery. And then we test every patient. We do not do any further tests during the course of the procedures. And let’s say, at least this is for ours. I have to say that too. We are a hub hospital in the Northwest of Italy, and so we have collected many patients from other local, original hospitals that were converted to COVID hospitals. And so our overall activity during this peak reduced by not more than 10%. So we continue to to have this activity. So this is our testing. We do not do any serology, for example.

Joseph A. Dearani, MD:

Okay, great. Tommy?

Tomislav Mihaljevic, MD:

I’m pretty much the same, the same approach. We would test everyone who comes to the emergency room for any kind of acute condition right on the spot. We had developed in-house capacity to test early in anticipation that the FDA is going to loosen their requirements. So we started off relatively strong. We have two pathways. One is for rapid testing for those with acute conditions,. And then the longer turnaround time, which is 8 hours, we use for all elective procedures that typically get tested 48 hours in advance so that we know the result of the test by the time they reached the hospital.

Joseph A. Dearani, MD:

Sanghoon.

Sanghoon Jheon, MD, PhD:

Yeah, so tertiary hospitals in Korea, all patients are required to PCR test before admission, but it is on debate for its efficacy and evidence. The waiting time for results is on average 6 hours. We have separate pathways for inpatients and outpatients after triage, and for the inpatient unit, we have three separate pathways for COVID-19 confirmed cases or high-risk patient by … isolation unit or a general isolation unit and preemptive isolation unit. But we are all checking our employees whenever they have something, a bad feeling, and every morning we send a text message to every employee. They have some symptom or contact history and they should reply before 10:00 AM.

Joseph A. Dearani, MD:

Vaughn.

Vaughn A. Starnes, MD:

We’re testing everyone. We test in our pre-anesthetic area, 48 hours in advance, and those that come in urgently, we do a rapid test. If we have an emergency that goes directly to the operating room, like an aortic dissection, we assume it’s a patient that may have COVID and treat them accordingly in our designated operating rooms for COVID patients. We have seven of our 30 operating rooms designated for COVID patients. And then would take them to an ICU also designated as COVID patient. We would then test them postoperatively. Obviously, if they’re not COVID positive, we would move them into the area of standard ICU care. And we test throughout the hospital stay, every 72 hours, like Val I think referred to.

Joseph A. Dearani, MD:

Valerie, if you could comment, we went through a phase here at Mayo where we were doing CT scans of the chest as part of the screening process. Could you just, there’s a question that came through. Could you just comment on the role, if any, of CT scanning of the chest prior to surgery?

Valerie W. Rusch, MD:

Well, we’ve not been doing that routinely preoperatively. We’ve relied on the preop COVID testing. We utilize that, as I mentioned, 48 hours preoperatively. And we have had a limitation on the number of fast turnaround kits for COVID testing. So that type of testing is really only available in our emergency area. But we have not routinely done CT scans unless the clinical scenario required that, which of course is more common in the thoracic surgical patient population. We have many, many reasons that people come into the urgent care area with shortness of breath where we need to get a CT.

Joseph A. Dearani, MD:

Great. All right, let’s change gears a little bit here. So looking ahead, how will the business of running hospitals or hospital systems change as a result of COVID? And why don’t we start with Tommy, who obviously is an accomplished cardiac surgeon, but now functioning in an administrative role of a premier institution with many other hospitals as part of their system. Tommy, what can you teach us?

Tomislav Mihaljevic, MD:

Well, I would like to offer an opinion and maybe just summarize it in a few points. I’ll speak a little bit about the care that we provide. I think what we’re going to see in the future is going to be a substantially greater emphasis on us being able to provide a continuity of care for the populations that we serve. And I think we’re, while we are still going to be there to provide an episode of care, this is to say the continuity of care provision is going to become a really, really important part of the way that we provide care. The second aspect of the care provision is going to be hinged on a very strong reliance on digital interfaces and a large data management for better coordination, anticipation of the needs of our patients, and our ability to to treat them in a much more tailored and informative fashion. And thirdly, we’re going to push a lot of care into our patient’s homes outside of the hospitals. We will have to come closer to our patients, both in their needs and their physical environment. Second big change is going to be around our caregivers. I think what we’ll have to realize is that the safety and engagement of our caregivers is going to be of paramount importance for us to be able to deliver care. The safety in the workplace and caregiver engagement will become more important than ever, and I believe we as a profession, I think we are gaining and regaining in this pandemic a well-deserved reputation of an honorable profession that serves a greater need, something that we have lost over the last few decades we’ve regained very, very quickly. When it comes to the actual running of the hospitals, I believe that we’re going to see a great shift towards greater integration of hospital systems. Just like after every crisis, we typically, we see the fewer yet larger and better integrated organization come out as a solution, and I think that is going to happen in healthcare as well. Private practices, standalone practices, small to medium hospitals are really struggling right now. They are going to continue to struggle. And I believe that academic, large academic medical centers, profit or not for profit, it’s going to be the way of the future around the world. And lastly, from the community perspective, you know, we are the largest employer in the United States, not only, we’re the largest industry in United States, and we have therefore a phenomenal community impact. I do believe that that community impact will have to be felt for the foreseeable future. The portion of charity care and free care in our communities is going to be a significant task for us to deliver.

Joseph A. Dearani, MD:

Great. So in the spirit of collaboration between local and regional hospital programs, at least we believe that probably should take precedence over competition. So I’ll direct this to Vaughn, since he’s involved with many, many regional hospitals, but are you working on a contingency plan for any resurgence or recurrence in a situation where you would collaborate with your regional hospitals who also may happen to be your competitors?

Vaughn A. Starnes, MD:

Well in the Los Angeles area, we have many hospitals, and as I said earlier, some of them are really are struggling right now with what to do next. And we are reaching out and partnering with them. Our university hospital’s primarily a quaternary center. We really do not take care of many primary conditions, and we are partnering with several of those hospitals in the region to be a popoff for those kind of patient populations. We have cardiac surgery programs now in eight different hospitals that we run under USC. And we are even triaging, if you would, between those hospitals. We got one hospital in Santa Monica of St John’s where we’ve done all of those patients that we thought were acceptable to do ECMO on, we’ve done ECMO in that hospital and with a good result, we’ve only had one death out of 10 we’ve put on ECMO, which is pretty extraordinary. But these have all been very young. So yeah, I think there will be further cooperations. I think this is going to bring about consolidations of even maybe healthcare systems to look at an overall regional approach to medicine, which in the end might be better for our patient populations.

Joseph A. Dearani, MD:

Sanghoon, what’s the storyline in Seoul? I suspect you probably have many hospitals in close proximity. Any sort of themes in terms of collaborating, working together?

Sanghoon Jheon, MD, PhD:

Yeah. Actually, I totally agree. Collaboration should be taking precedence. After I started, I tried to introduce a story about Daegu city, which was epidemic. More than 70% of Korean patients were from there. Hospital directors communicated real-time using a social network service, sharing information of availability of ICU beds, ventilators… The decision around the sending and the receiving patients were made, shifted in the group chatting room without going through bureaucracy. And many healthcare workers volunteered to work in Daegu city. For Seoul, it is not severely attacked, so including my hospital. We have a very concrete collaboration of networks or more local and the regional hospitals, even competing hospitals. We are very actively sharing critical information of the course of the respiratory failure and the critical experience of the ECMO and we are very good in collaboration. Thank you.

Joseph A. Dearani, MD:

Great. Great. So we’ll change gears a little bit again here now. So it’s evident that there’s a strong regional element with this pandemic. I mean, some geographic areas have been devastated, and others have been relatively spared, both worldwide and even within our own country. As the United States starts easing restrictions, like stay at home orders and restrictions on elective operations, what policies and protocols, you know, for example, with regard to distancing or testing or personal protective wear, do you think are most important to consider for healthcare workers and the general public overall? And are there any policies that have been missed? Why don’t we start with the Domenico representing Europe. Any comment on that?

Domenico Pagano, MD, FRCS(C-Th), FETCS:

Yes. Thank you. So, first of all I noticed that you call it physical distancing, and I agree with you. We need a separation of bodies, but we don’t need a separation of minds at this time. I think that there is variety within Europe; the healthcare system is so different. And of course the political policy may be different, but I would say that that our principles from within the hospital, principles from outside the hospital, from within the hospital, there are institution-based systems to reduce infection to healthcare workers. And also the cross infection with patients. And these are the usual reduction in outpatient clinics, reduction in the in-person meetings, visiting bans for relatives. But actually if you think about that, that also creates an opportunity for the future. Again, this pressure showed us that we can change the way we deliver healthcare. There is more need, this was alluded to before from Korea, that we need more telemedicine. And maybe the way we look at the hospital in the future, it’s much different than we look at it today. Going back on the institution-based education and implementation of testing for healthcare staff is important. I’ll give you an example. In Italy, over 11% of the total population that tested positive was healthcare workers. And this really meant for about 20% of healthcare workers at any given time. Now there are very good examples. And that’s where I come with the idea of collaborating and share experiences. For instance, I know, and I’ve seen the data from the part of our region, which was a really high epidemic or endemic situation. And they implemented quite, quite early asymptomatic testing for all healthcare routinely. And also an education program. They’ve achieved so far less than 2% infection on healthcare. So you have to be aggressive. Outside the hospital, it’s about education, the press, and the politics of the region had to have a role to play. But I also think that seminars like this, and the collaboration among different associations, have a major role to play in the education aspect of it.

Joseph A. Dearani, MD:

Valerie, you obviously have a very broad view of this representing all the surgical specialties. If you could make a recommendation or two to our government officials that you think would be reasonable, if you think you have any suggestions in terms of the conversation, what would you suggest?

Valerie W. Rusch, MD:

Well, I think there’s no question that we need a better regional and national preparedness plan. As I mentioned we were really caught short, and as was mentioned by some of the other speakers, I think that this type of planning originates with the physicians. Politicians come and go. They may or may not respond with good leadership or in a timely manner, but we in the medical community, I think, have a need to develop better preparedness plans and optimize communication plans, as was just, as Domenico just mentioned. I think that’s incredibly important. I do think as was mentioned before, that telehealth, telemedicine, is going to really be an increasingly important part of what we do in this country, where in some states, the distances are great, and telemedicine has really been an important need, but not very accessible. I think that’s going to change, and that is going to be part of our future and we need to work on developing that more. And I totally agree with the point that was made about widespread testing. It’s going to take a while. In my own hospital, we’re implementing that starting with the highest risk areas of testing, of the hospital. But we’ve got to test staff, as well as patients.

Joseph A. Dearani, MD:

Great. All right, we’re going to change gears again for Enrico. I think, as you said earlier, you’re in a geographic area that has been perhaps hit the hardest. Depression and suicide of healthcare providers is becoming more prevalent. What has been your approach to address and maintain physician and healthcare worker wellness and strategies to minimize posttraumatic stress syndrome, which is becoming more and more evident that this is going to be a problem amongst our profession.

Enrico Ruffini, MD:

Yes. Thank you. I think this is a major point because we are living, all the world is living, in a very depressive state now because we all know, we don’t know how long it will take and everything. And the healthcare personnel is in the front lines of this. So we know that we, as surgeons, are likely to be exposed to this kind of depression and something. So the wellness, the psychological aspect, I think, is a very important point. My personal experience is that my unit was, as I said, in a COVID-free environment. So we basically continue, we have continued to do what we have done before. So we were not very, we were not very hit by the wave. And so we have continued to do the same work that we did before. So, in the regular meeting that we do, I didn’t record any major, let’s say, psychological effect. I think that we have to be very careful speaking about the community above the fray of people, the elderly, for example, the adolescents, and these people. I think that has to be spotted by the public, by the medical personnel, and be helped. But I think this is a very important thing. From my personal point of view, I went through infection because I had COVID pneumonia so I had the experience of being in a COVID ward. And I have to say that apart from the physical state, I think the psychological effect, psychological impact of this new thing that is the virus, I think it’s very, it’s very important. And this is something that we cannot underestimate, medical, medical-wise, but also community-wise. So this is very important. Thank you.

Joseph A. Dearani, MD:

One of the things that I’ve done, this has been going on for a couple months now, is I actually call three or four of my surgical colleague friends, either nationally or internationally, just to check in and see how they’re doing and kind of get a sense for how things are going, particularly those that are working in really, really, very difficult areas. Sanghoon, there’s a question about mitigation strategy for a resurgence. What, anything specific in Asia that you would want to comment on?

Sanghoon Jheon, MD, PhD:

Once again, please?

Joseph A. Dearani, MD:

Mitigation strategies for second wave.

Sanghoon Jheon, MD, PhD:

Okay. So I think many experts expect the secondary wave will be coming, so we need to prepare for the worst-case scenario that includes a big second wave of coronavirus infection in the fall and winter. And even in the best-case scenarios, people will continue to die from the virus. Of course, every effort is on the way to develop vaccines or new drugs against the virus. I think that the public understanding and the cooperation is most important. We had actually a painful lesson in Korea. All it takes is only one. A single symptomatic individual who attended a religious event triggered the explosion of cases in Seoul, the largest city in Korea. So government should provide transparent information to the public and these data should be shared globally. We also need to refine our pandemic manual once again as early as the second wave is reaching capacity of our medical resources. There is no need for panic because the fatality of the COVID-19 is not so high. We still have time until the second wave or any other outbreaks for that matter. We need to emphasize education, helping people understand that the best way to fight this is to protect others and themselves by keeping social etiquette, wearing masks in crowded areas, washing hands frequently, coughing manners, and the proper physical distancing as much as possible. I think the emerging infection of COVID-19 may happen at any time in the future. And we should prepare for these infectious crisis. So we have to have a new normal system to respond to these situations.

Joseph A. Dearani, MD:

Great. Great. For Dr. Starnes here, the delay of cardiac interventions in surgery, as we know, can result in mortality. Ours is a specialty where the operations are never really truly elective, and CT surgery service lines contribute substantially to the bottom line in many institutions. And you made some reference to financial issues before. So with that in mind, do you think that cardiothoracic surgical services should be prioritized during the recovery from the pandemic?

Vaughn A. Starnes, MD:

Well, I have to speak from the perspective of my department of surgery hat. I think we have to have a fair-handed process as we introduce surgeries in our hospitals. You know, our GI surgeons with esophageal cancers, our thoracic surgeons with lung cancers, they all too need to have a priority on our OR scheduling. So I think we have to look at as a community, as we introduce more and more surgeries, I think rather than prioritizing a particular service, you look at standing hours, weekends, working later into the evening, keeping our operating rooms open. I’ve formulated a group that consists of several different surgeons and anesthesiologists to look at prioritization the day before anything goes on the books. So I think we’d want to go on in a fair-handed price, I mean a fair-handed way. Obviously also looking at transplants and everything else because I think to say CT surgery is the most important because it’s going to generate the most money and those are the cases need to get done first, I just don’t think will work in a political way in any institution. We’ve been able to continue to do cardiothoracic surgeries in our institution at a good rate. And no one has seemed to mind that because they know the urgency of the cases. But I think we do have to be fair-handed in how we approach this as we open up the cases. And I’d just like to say, you know, as you look at opening up your hospitals, you also not only have to consider the inpatient but also the outpatient areas. I think the outpatient areas can be a great popoff for plastic surgery and other areas, ENT, that gives them the opportunity to start increasing their patient flow of patients.

Joseph A. Dearani, MD:

Great. Completely, Vaughn. Domenico, I think you wanted to make a comment about this.

Domenico Pagano, MD, FRCS(C-Th), FETCS:

Ah yes, thank you. Actually a comment that may link the two things together. We’ve alluded to a second wave – would be a little bit controversial, optimistic, on one hand we hope that there isn’t one. And you know, if we look at the other pandemics or infections, actually they mostly disappeared before even a vaccine was produced. So, but that doesn’t mean we need to throw off our vigilance. But there are other types of second waves that need to be aware of. And the first one is that patients have not received treatment, not just the cardiac patients. Just to mention those who missed the opportunity or early diagnosis for cancer, there will be a reduced life expectancy in the future. This is a strain on financial and economic resources everywhere. And if we end up in a deep recession, it is very likely that a deep recession will bring a second wave of mortality because we know a recession … quite a lot particularly for those disadvantaged. In terms of mitigation for these and looking at what cases to do and so on, I think it’s a time for us not only to prepare for the second wave, but to reflect and learn from the lessons and the mistakes we’ve made. We have the advantage of having now developed, established some pathways, some protocols, the pillars of collaboration and sharing information. But this is a time where we look back and we learn lessons in order to be prepared. So I think a second wave is not just about the virus. It’s a second wave about how society’s going to afford to continue the healthcare system in various scenarios.

Joseph A. Dearani, MD:

Great. Well, I want to give everybody a chance to comment now here at the end as we sort of get ready to wind down a bit. But this has obviously been challenging. It’s been difficult, it’s been devastating in some circumstances. But is there a silver lining for our specialty with this pandemic? What, if anything, has been the most positive thing to come out of it? Why don’t we start with Enrico?

Enrico Ruffini, MD:

I think that we have learned at least two words that we have to keep in mind for the future. One is interconnection, the other one is, of course, collaboration, integration. So these are three magic words that we have to use and we have, we will use for the future. I think that every crisis brings opportunities. So it would be a pity if mankind would not use this crisis to be better after this. And we have learned, for example, that the use of webinars, we have a huge technology to talk to each other without physical contact. We can share information, we can give advice, for example, to people. We can reach out many people in every corner of the world without, of course, physically going there. And I think this is something that we have to learn. This is, I think, the good thing of this crisis, of course, and don’t forget for example, that during this month, because I’m very sensitive to this, during this month, the CO2 emission has reduced so much and the skies have never been so clear and blue like this. So we have to take the advantage to think about that for the future. The message is for mankind to be better, to be better for the future. So this is, in my opinion, the good news from this, from this pandemic. And again, we have to be prepared. The other word that I think we have to be used to is the preparedness. This will not be the last one. This is just the beginning. Second waves, new viruses will appear, and it would be nice if mankind has learned something about this pandemic in order not to repeat the same mistakes that we have made so far.

Joseph A. Dearani, MD:

Valerie?

Valerie W. Rusch, MD:

Well, I would completely echo what Enrico said. Imagine, for instance, that we had had to confront this pandemic in the pre-internet era – how hard it would be and how much the electronic interface has facilitated our coming together within the medical community and interfacing with our patients and with each other. In many ways, this pandemic has brought healthcare workers back to a sense of their primary mission of taking care and doing good for others. And I think that’s important. And also I think that in some countries, certainly in the US, healthcare workers and physicians, including physicians, have felt unappreciated and embattled in recent years. And this has really brought to the fore a new appreciation for what those of us in medicine do to care for others. And I think it’s sort of a golden moment in that regard, relative to what I’ve seen in terms of public perception for the past few decades.

Joseph A. Dearani, MD:

Vaughn.

Vaughn A. Starnes, MD:

Well, I think one of the things that it has done is it’s gonna make telemedicine ever so important. I think we’ll be interviewing our patients more and more by telemedicine because I think they’re going to be a little afraid to come back to the in-person clinics for a while. So I think that COVID has pushed forward what may have taken 3 to 5 years, to push it forward to now. Half my clinic now is telemedicine. And I must say, it works out very well. So I think as we’ve gotten used to Zoom conferences and webinars, we better all get used to this form of communication also with our patients. So I think that’s going to be one of the silver linings of this COVID epidemic.

Joseph A. Dearani, MD:

Sanghoon.

Sanghoon Jheon, MD, PhD:

The collaboration in our community has been amazing. We have been sharing information, the critical course of the critically ill patients, and then we are starting to take history of ECMO and the penetrate the cares. When I called for expert consensus statement for surgery among Asian surgeons, the response was truly heartwarming. So by this moment, we are trying to develop new educational models. As you know, the healthcare in Asian countries are very heterogeneous. Many of the Asian young doctors are looking for proper educational chairs, but at this time we have very limited chance to provide them educational course. So we are developing the extended availability into our educational course and then we also communicate our patient to keep their personal health record and their lifelong data together with our in-hospital cardiac database. Together with them, we can have, we can extend, expand our telemedicine system more widely for our patients. We are also developing the new collaboration data collection system for the critically ill patient, pneumonia cases of the COVID-19 patients so that we can develop AI program to alert timing or ventilated care. So I believe this pandemic will be a turning point of our global cooperation among cardiothoracic surgeons.

Joseph A. Dearani, MD:

Tommy.

Tomislav Mihaljevic, MD:

Well, I do believe that this global pandemic will be an accelerator for the changes and transformation in healthcare that was, that we always wanted to do. Now we’ll just be able and be forced to do it faster. If you just reflect briefly on it, beginning of this pandemic, could we use the instruments and the techniques from 14th century to combat a pandemic in the 21st century? We have yet to start to use the tools of technology, data sharing, and analytical platforms that we have today in order to be more effective in delivering care. So I’m very optimistic. I do believe that we’re going to emerge from this with a greater sense of importance that we as healthcare professionals caring not only for the health of the nation, but also as really as a foundational group that allows the stability of an entire society. So I’m very, very optimistic. I do believe that we are going to become more cohesive. I think we’re going to rely on science and collaboration particularly in research more than we’ve ever had before. I believe that we’re going to be more, better, better integrated. So I do believe that there is a silver lining to all of this.

Joseph A. Dearani, MD:

Domenico.

Domenico Pagano, MD, FRCS(C-Th), FETCS:

Yes, I have little to add in terms of technicalities. But I think that we will survive this. I think that we will do that by using the adaptability of the human race. I think that we can do that by working together. Some people say this is like a war. The difference is that we are all on the same side. And I think that hope is a good fuel.

Joseph A. Dearani, MD:

Great. Well, listen, there’s, we’ve touched on some of the questions. There’s hundreds of questions. We’ll never get through them all. I think to be fair to our panelists and to our viewers, I want to thank all of our viewers and the STS staff for organizing this great webinar. A sincere thank you to our panelists,, my colleagues and friends for devoting your time to discuss strategies for an effective comeback of cardiothoracic surgery during this COVID-19 crisis. I believe actually this is the very first time that a global summit of leaders representing our most prominent societies has occurred in cardiothoracic surgery, perhaps in most of medicine for that matter. That is a silver lining for me. It has brought our specialty closer together. Major leaders from our prestigious organizations all around the world, having an open, honest dialogue and sharing lessons learned. So we persevere and prevail in our resolve to protect our patients, our fellow surgeons, and healthcare workers everywhere in the world as we recover from this crisis. So be well and stay safe. Thank you again.

 

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