Surgeons develop COVID-19 response strategy for rural hospitals, health systems

Major metropolitan areas such as New York, Seattle, and Detroit have dominated news of the COVID-19 outbreak, but rural hospitals and healthcare systems must also prepare for a surge of coronavirus patients. To address this, surgeons from the Guthrie Clinic at Robert Packer Hospital in Sayre, Pennsylvania developed a preparedness response plan for dealing with the COVID-19 surge, which was published online ahead of print in the Journal of the American College of Surgeons.

The rural surgery plan takes into account challenges unique to a rural population and geography, and includes greater utilization of telehealth and coordination of resources and communications at affiliated centers spread over a large geographic area.

Robert Packer Hospital is a 267-bed tertiary care teaching hospital in Sayre, a town of about 5,400 people, 270 miles northwest of New York City. It is the primary institution of the Guthrie Clinic, a nonprofit system of five hospitals that serves an area of about 770,000 people in 12 counties in northern Pennsylvania and the southern tier of New York State. The patient population is older, with more comorbid conditions, and is very spread out with about 77 people per square mile. Some of the population does not have internet access, including staff members, which is reflective of many rural cities and towns, said Jean Miner, MD, MHA, MMEL, FACS, a general surgeon at the Guthrie Clinic and co-author of the paper, in a statement.

Key components of the preparedness plan include:

• Implementation of a screening process for visitors and employees
• Having nonessential staff work at home
• Conserving personal protective equipment (PPE)
• Postponing elective procedures
• Having a contingency plan to redeploy a pool of volunteer physicians and advanced practitioners to cover areas where they're needed during a surge of COVID-19 patients

A centerpiece of the response plan is a rapid expansion of telehealth. Like many health systems, Guthrie Clinic has limited the number of in-person clinic visits. With the recent approval for telehealth expansion by the Centers for Medicare and Medicaid Services, Guthrie Clinic saw its number of providers participating in telehealth soar from 12 before the COVID-19 outbreak to 252 providers performing remote office visits and 450 having access to the platform after the outbreak began.

The telehealth system works despite the limits of internet access in rural areas, said Burt Cagir, MD, FACS, co-author of the study and a general surgeon. Most outpatient clinics within the system have telehealth kiosks, and the system is flexible to fit each patient's needs.

Another important element of the response plan is what the authors called “the patient safety huddle,” first introduced in 2016. Senior leadership staff meets for a half hour each weekday morning to review patient safety issues. By 2018, a second huddle was added to identify trends from the previous day or week and to extrapolate forecasts for the next day or week. The huddle works on four staffing levels, front-line, department, hospital, and systemwide, the authors said.

The processes were adopted were developed using the Lean Six Sigma and the plan, do, check, act (PDCA) cycle principles that the healthcare industry has used to improve efficiency and quality. The authors said they hope the plan can be implemented by other facilities.

"Without a doubt this approach is scalable to every urban and rural center," said Miner. “Frequent communication has been key.”

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