Medtech & COVID-19
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Returning to the OR: New Challenges in Elective Surgery During COVID-19

An orthopedic surgeon and an industry executive talk about the "new normal" in elective surgery, even as COVID-19 cases surge in various parts of the country.

Assessing the status elective surgery in the United States continues to be a moving target as hospitals in most states have resumed elective surgery while hospitals in other states are forced to refocus on COVID-19.

At Valley Medical Center in Renton, WA, orthopedic surgeons like William Barrett, MD, have returned to the operating room to perform elective surgery such as hip and knee replacements. But even as Barrett and his colleagues adjust to the "new normal" and work through a backlog of hip and knee procedures, concerns of another government-mandated shutdown lingers in his mind.

MD+DI recently spoke with Barrett and Aldo Denti, group chairman of DePuy Synthes, a Johnson & Johnson company, about how industry and the surgeon community can work together — and leverage digital technology — to do business safely during the ongoing pandemic.

Overcoming elective surgery barriers in 2020

MD+DI: What is the current status of elective surgery where you practice? If back to normal operations, when did you resume hip and knee surgeries?

Barrett: We are back. We took two months off — March, April — and started back in mid-May. The first week we started back a bit slowly, running about 50% capacity, and then the week after that we went back to full capacity and we've been doing that now for about five weeks. So we're operating business as usual, actually about 50% more than usual just because we've had such a big backlog of patients that had to have their surgery cancelled.

MD+DI: I know a lot of surgeons have encountered various hurdles as they have resumed elective surgery, such as limited operating room (OR) time, procedure backlog, and patient hesitation/fears about the virus. What would you say is the biggest hurdle you have encountered at this stage of the pandemic?

Barrett: Those are all potential barriers. Certainly there has been some apprehension on the part of patients. I think one of the unique things about patients with hip and knee arthritis is they hurt a lot, and while they may have some concern [about COVID-19], their pain is often an overriding factor. So that will make them, perhaps, investigate this and decide if it's safe or not. Limited OR time, that can be a challenge, we haven't had that, fortunately our hospital has capacity and we're able to do that. And then there have been some [other] barriers, like all of our patients have to have a COVID test before elective surgeries so there's certain hoops that patients have to jump through.

MD+DI: What has changed for you, as a surgeon, to prepare a patient for elective surgery in the safest way possible?

Barrett: It happened before we started doing surgery. We made a transition from face-to-face, in-person patient visits to telehealth. In a hundred years, I would not have thought I would be doing telehealth in 2020, but I didn't anticipate a pandemic of a lifetime. So, we were doing a lot of telehealth while we were not doing surgery, and so we've ramped that up, and that's really become a mainstay of our pre-op business. Our first post-op visits will be telehealth. Obviously, the patient flow in the hospital, visitation, everybody is wearing a mask, so there's multiple things, incremental changes that have been made that hopefully are for the better for everybody.

MD+DI: To what extent are you concerned about the recent surges of COVID-19 cases impacting your ability to continue performing elective surgery?

Barrett: I have a big concern, in fact Aldo and I were talking about that earlier. I worry about my locale, I worry about the public and the wellbeing of humanity, but Aldo has to worry about a gigantic company, so I think we both share this concern locally and internationally that the impact of these surges could be significant, particularly during the summer. For me, yes, I worry about that, I foresee there may be a time in the future where we get shut down again by government regulations. For now, we're trying to do the best job we can but Aldo, I mean, when you look at this from an international level, what are your thoughts?

Denti: Obviously the world is a very large place and the U.S. is different from other countries of the world, but certainly, Dr. Barrett, I share your concerns. We obviously see rising demand for orthopedic procedures but yet the inability to treat patients because the ICUs are full and sometimes, frankly, the healthcare systems are not in a position to even afford the care in those countries where it's publicly funded. So I share your concern and I also think we are going to see this ongoing inflection of being able to do cases and then having to stop for a while, and it's going to continue like this for quite some time until we find a more normal treatment of the disease. I think that's putting tremendous strain on the hospitals financially, it's putting tremendous strain on our industry financially, and I think that's something that we are all going to have to manage together. But it is certainly making the ability to manage the business very, very complicated because every country literally is in a different phase of recovery from the next and this country, as you've alluded to, we are seeing volatility within the country and even within states.

MD+DI: Dr. Barrett, in what ways has emerging digital health technology and telemedicine solutions played a role in your practice during the pandemic? 

Barrett: That's a really good question because things that were hoovering that seemed to be promising [before the pandemic] have literally been kind of catapulted to the front. Things like telemedicine, like patient engagement apps, because we can't have as many touchpoints with that patient prior to surgery but we still want that patient to feel that one-on-one experience. So patient engagement apps that we've been looking at, and part of a system that Aldo can address, they've been very, very useful to make the patient feel they're being accompanied along that pathway prior to surgery. ... And then in surgery we want to be as efficient as we possibly can because we want to move patients through in an orderly, efficient manner. So technology we use during surgery, computer software for placing images and for placing ... the actual pieces of a total hip replacement ... so there's digital technology and mechanical technology that increase our efficiency and increase our throughput in a safe way.

Denti: One of the things we set our minds to at DePuy Synthes, perhaps a little differently from other companies, is we believe strongly that the advent of digital surgery should be looked at in a slightly different lens. We believe that we need to build things that are personalized and connected, but also provide value for the healthcare system. ... We have looked at, essentially, four different columns of engagement. The first one is looking at pre-operatively, what can we do to assist physicians in streamlining the ability for a patient to decide whether they should or shouldn't have surgery, and there are many things that can be done, Dr. Barrett alluded to a few of them, deciding whether we can work on co-morbidities before surgery, what is the likelihood of that particular patient [having a successful surgery] and how do we help engage patients digitally in a world where face-to-face is not possible? All of those things can be streamlined and can be helped by digital assets. The second pillar is we're helping to prepare for surgery. If you take all of the things I just talked about and then you link that up to a pre-operative planning software, you can now take the conversations that a doctor is having with a patient, take those into a pre-planning software, and then eventually migrate those into a robot. And the robot itself should be built in a way where it's portable, it's also fast, and requires minimum imaging capability and if you do those three things, you're now impacting the efficiency of that surgery and also the outcomes because you're able to track them. The last column is actually helping that patient recover from surgery in a world where perhaps they can't go to a face-to-face with their surgeon or maybe even are limited in their ability to do things like post-operative care. All of that can be put into an ecosystem that is linked, that is streamlined, and that is very efficient. We believe in a world where we can do that automated or even semi-automated, providing tools intraoperatively like our Velys hip navigation system, or Kincise, that make the operative event even more effective. So we're working on those four pillars and we are trying to link them up as best we can in partnership with other companies — we're not trying to do everything ourselves — but that's essentially our vision for the future: personalized, connected, but value-driven as well.

Is this the point of no return for orthopedic education?

MD+DI: In what ways has DePuy Synthes adapted and evolved to help surgeons as they resume elective surgery in a COVID-19 world?

Denti: When COVID first started we realized that many surgeons would have to be called in to deal with complex airway management issues ... so we partnered with Advances in Surgery, which is a company that has helped us to stand up digital education and we did cross-training globally on how to manage airways effectively in the time of COVID. And we could have never thought that we would have well over 100,000 people trained in six months on different issues such as how to train those that are not trained on airway management; surgeons speaking to each other country-to-country on what they're learning like Italians helping Americans learn how to deal with COVID because they had more experience; we've had events talking about the new normal, how to safely engage in an operating room in a world of COVID. All of these things we've stimulated through a different way of working. Another example of that is running innovation through digital. Obviously our innovation agenda can't stop just because we've got COVID, but the way we're interacting with our surgeons, which used to be face-to-face, we've learned that we can do that now digitally and do much of the design work in a virtual world and then leave the face-to-face for those events where we really need it, we've adapted to that. We've experimented with having our representatives helping and assisting surgeons digitally if they could not go into the OR because of [COVID-19 restrictions], we've actually had the ability to assist those staff members through virtual portals. We've also helped to train a tremendous amount of people through virtual just by the fact that those hospitals or private practices that furloughed their employees sometimes hired those people back but in many instances they were no longer experts in orthopedics and we have been able to help re-train all of those staff members virtually. ... I personally, just like Dr. Barrett, cannot see a world where we go back to the way we used to do business, it's going to be a hybrid model. ...The way we interact with our physicians is going to be very different, it's going to be a mix of digital and face-to-face but predominately digital.

Barrett: Just expanding a little bit on what Aldo talked about, about digital education, that's one of the things I think all of us missed, because orthopedics is a very interactive, face-to-face type of specialty, and we've enjoyed that in the past, we've had surgeons visit the OR to learn techniques ... So now what we've done is partnering with DePuy Synthes, trying to figure out ways that we can bring surgeons into the OR with them still at home sitting in their living room. That's one of the areas of intense focus, how to do that, how to keep training and learning moving forward in an era where we can't be together at courses and/or in the OR. While there are so many things that concern us and we feel awful about what people are going through, it's also a very exciting time about what's on the horizon digitally to provide better patient care, better surgeon education, better staff education.

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