By R. Chris Jones, MD, Chief-of-Staff, TriStar Centennial Medical Center
Shortly before Governor Lee issued Executive Order 18 on March 23 prohibiting elective surgeries, TriStar Centennial Medical Center had stopped performing these cases. We needed to prepare.
All Tennesseans were bearing witness to the dire situations seen in other areas of the country and the world, and the models for Nashville didn’t look promising. We needed to be certain that we could (1) care for the surge of COVID-19 patients, (2) maintain an adequate supply of PPE, and (3) safeguard the health of our non-COVID-19 patients and healthcare workers. Each week of preparations brought new challenges. Exactly how do we define elective surgeries? What medicines and therapies are best for our COVID-19 patients? How would we adapt to a strained national PPE supply chain? How do we develop an ethical guideline for distribution of limited resources in the event that the community reaches crisis levels of patients? How do we test the patients that need testing while not burning through limited supplies? Each one of these questions, and many more, were handled at an accelerated pace as our administrative team and medical staff assembled ad hoc task forces to tackle these challenges. An equally challenging question, and one that is also being managed by close-knit administrative-medical staff collaboration, is how to resume elective cases.
Dr. Craig Morrison, orthopedic surgeon, and DeNene Cofield, vice president of Perioperative services at Centennial Medical Center, quickly assembled a team to facilitate the reboot of elective cases at our institution. Dr. Morrison enjoys a reputation for almost stoic responses to any environment. But that stoicism belies an empathy and kindness towards others that garners him great respect within our community. And although you won’t meet a kinder person than DeNene, her extroverted personality would lead few to call her stoic. She is as fair and balanced as you could ever hope for a leader to be, and the two of them working together are a formidable team.
Attempting to answer the question of how to resume elective surgeries first requires examining the very reasons we hit pause in the first place. Can we now be reasonably assured that we can (1) care for any potential surge of COVID-19 patients, (2) maintain an adequate supply of PPE, and (3) safeguard the health of our non-COVID-19 patients and healthcare workers? The social mitigation strategies employed by Tennessee citizenry have diminished the probability of an overwhelming spike of COVID-19 patients, and ICU capacity in the Nashville Metro area is at lower levels than expected. PPE supply chains have been strengthened nationally by increased production from existing and new manufacturers. Our focus then, in this new era of COVID-19, is to adapt our healthcare delivery so that we can deliver the healthcare that our region needs while minimizing the risk of COVID-19 related complications to our patients and healthcare workers.
Ideally, all patients would be tested with a rapid, point-of-care (POC) test for COVID-19 as they enter the hospital. The nation may have that capacity one day, but in the meantime, we still have patients that need medical care, and those patients may suffer if they experience delays. One of the perks of being Chief of Staff of the medical center is frequent dialogue with the many and varied members of our medical staff. I have heard too many stories these past weeks of citizens in our community who delayed seeking medical care, only to then suffer permanent injury or disability as a result. We have done an admirable job as a community of sheltering at home to reduce the spread of this virus, but we also need to emphasize that necessary healthcare still needs to occur. Severe or concerning symptoms require the proper attention, and we are off balance when we don’t seek evaluation for chest pain, shortness of breath, passing out, difficulty speaking and the like.
The COVID-19 era has required that we identify new practices and implement new policies in order to provide specific safeguards for delivering safe healthcare. The first step in delivering safe healthcare, in any era, is to have a safe hospital. Heather Rohan, TriStar Division president, and Scott Cihak, CEO for Centennial Medical Center, have made patient safety a foundational principle. That culture has helped us develop protocols for maintaining safety as we face this pandemic. Steps like limiting entrances to the hospital, screening everyone entering the buildings, limiting non-essential visitors, cohorting COVID-19 patients into a common area, using different entrances for different types of patients, and other policies have helped us maintain a high standard of safety despite this new threat.
Regardless of the availability of testing, there are recommendations that we should make for our patients scheduled for elective procedures. Common sense tells us that we should delay elective surgery if a patient has new signs or symptoms of illness that could be related to COVID-19. Strict social distancing, and even home quarantine, may be one of the best measures a patient may take prior to surgery to prevent a COVID-19 complication after surgery. And obviously, having non-urgent surgery soon after a known exposure to COVID-19 should be avoided if at all possible. The medical staff is supportive of the Healthcare Specific Guidance in the Roadmap For Reopening Nashville, which includes starting the reboot of elective surgeries with lower risk patients (less than 70 years old without significant illnesses). Defining “lower risk” is an inexact science, but we have identified several resources to help us make the determination of who is lower risk versus higher. The ingenuity of our medical staff has been on display, as well, with Dr. David Huneycutt (cardiology) along with several other members of our medical staff developing a telehealth consult team to help determine a patient’s risk prior to surgery.
Delivering healthcare, when done right, is a calling. The team that we have assembled is mission-driven to provide the healthcare that our region wants and needs. The COVID-19 pandemic presents a scale of challenge that most of us have not faced, but any challenge can be faced when the mission is placed first. We remain vigilant to ensure we have the resources needed to care for any future surges of COVID-related illness, but also prepared to deliver the healthcare that our region has come to expect.
R. Chris Jones, MD, is a native of East Tennessee and an alumnus of the University of Tennessee – Knoxville, where he graduated summa cum laude. He received both his bachelor’s and master’s degrees in nuclear engineering at UTK before attending Vanderbilt University School of Medicine. He graduated medical school in 1998, earning induction to the Alpha Omega Alpha Honor Medical Society and receiving the Medical Student Award for Research in Nuclear Imaging. Jones subsequently served as intern and resident on the Osler medical service at Johns Hopkins Hospital in Baltimore, Md. He later completed a fellowship in cardiovascular disease at The Cleveland Clinic Foundation and furthered his cardiology training by completing an electrophysiology fellowship at St. Vincent Hospital in Indianapolis under the tutelage of Dr. Eric Prystowsky. He is certified by the American Board of Internal Medicine in Cardiovascular Diseases and Cardiac Electrophysiology. He served as Department Chair of the Cardiovascular Center at TriStar Centennial Medical Center from 2008 until 2016, president-elect of the Centennial medical staff from 2016 to 2018, and is currently the president of the medical staff. He also has served as director of electrophysiology research for Sarah Cannon Research Institute since 2009.