By Rajiv K. Sethi, Aditya V. Karhade, Michael G. Glenn and Gary S. Kaplan—

Until the Covid-19 pandemic struck, surgical patients in the U.S. had been increasingly traveling to designated Centers of Excellence, health systems that met stringent criteria for providing exceptional, high-value care for specific procedures such as knee replacement and spinal surgery. In some cases, large employers such as Walmart entered into contracts with the COE providers to care for their employees, whose travel to the specified provider for evaluation and, if needed, surgery, would be fully covered. In other cases, patients would travel from afar using other coverage to receive this specialized care.

Our institution, Virginia Mason, along with others including Geisinger, the Mayo Clinic, and Johns Hopkins are designated Centers of Excellence. Among the services patients have traveled to us for are complex spine surgeries, one of the most challenging procedures.

By shutting down most travel, the pandemic might have put an end to such programs, at least for the duration. But at Virginia Mason, prior investments in telemedicine technology for virtual patient encounters and virtual multidisciplinary perioperative clinical-team conferences have allowed us to continue providing surgery and other spine care to both local and remote patients traveling from hundreds or thousands of miles away, as well as to enhance virtual patient care broadly.

The Spine Team Approach

Based in Seattle, we were among the first organizations to confront the Covid-19 pandemic and, as such, had no blueprint to guide our response. Regulatory guidelines were constantly evolving and there were widespread shortages of personal protective equipment (PPE). Travel restrictions were keeping patients from many states away from Seattle and, fearing infection with the novel virus, local patients were deferring needed care. A ban on elective procedures resulted in precipitous and profound decreases in clinical care revenue and financial pressures were intensifying.

The pandemic forced us to quickly respond to novel clinical challenges, but we also needed to develop new ways to coordinate our sophisticated care teams and to safely engage with patients, including those traveling to Virginia Mason for complex spine surgery.

Like many leading organizations, Virginia Mason emphasizes a multidisciplinary approach to value-based care, which focuses on improving outcomes while reducing costs. The “Seattle Spine Team Approach” is a fully developed example of such comprehensive and condition-specific care. This model involves pre-surgical team conferences (now held virtually) that include orthopedic surgeons, neurosurgeons, physiatrists, pain medicine specialists, specialty-trained nurses and physician assistants, hospitalists, psychologists, and anesthesiologists. These conferences, along with the requirement that two attending surgeons are present during complex spine surgeries and the institution of a tailored intraoperative anesthesia protocol, have resulted in a three-fold reduction in major complications in the most complex spinal procedures. Many team members see these conference as the cornerstone of the entire spine care program.

When a patient is referred for spine surgery, the team holds a virtual “patient clearance” conference to evaluate whether he or she will decisively benefit from the procedure or may be as effectively treated without it. (In our prior studies of in-person visits where referred patients were presumed to need lumbar surgery, we found that 58% in fact didn’t need it.) For those patients found to be good candidates for surgery, the team conducts a risk stratification to determine which require immediate surgery and begins pre-surgical “optimization,” evaluating patients for surgical risk factors such as obesity, diabetes or smoking. In non-urgent cases, the team postpones surgery to allow time to address these.

Our clinicians have embraced the virtual conference format. We have seen increased attendance and continued engaged discussion by our clinical staff. Further, providers who rotate between clinical sites can attend these more easily than the previous physical meetings. As a result, the spine team has now committed to all-virtual patient-clearance conferences as its “new normal” and expects to continue with these virtual conferences even after restrictions on in-person meetings are lifted.

Combining Virtual and Hands-on Care

A recent case illustrates how we are integrating traditional destination care and new virtual care models. A 57-year-old man from Alaska had been experiencing progressive weakness in his arms and legs and for several weeks was unable to get timely outpatient evaluation because of the pandemic. As his symptoms became severe, his local doctor referred him to one of our physicians. The team held a virtual care conference and the same day a consultation with his local doctor, determining that the patient would require complex cervical spine reconstructive surgery. Within a day of those meetings, the patient was on a plane from Alaska to Seattle where he was scheduled to undergo immediate surgery at Virginia Mason. Two weeks later, the patient returned to Alaska and all further communication with the patient and his local doctor has been conducted virtually. Within three months after surgery, the patient had regained full use of his arms and legs and returned to work. We are continuing to follow him through serial virtual visits that include his surgeon, specialized spine physician assistants, rehab physicians and pharmacy.

While the pandemic hasn’t substantially interrupted our destination care program for patients needing urgent specialized spinal surgery, it has underscored the less dramatic, but equally important element of the program—it’s focus on identifying candidates for surgery who in fact can be effectively managed without it. It’s now clear that, going forward, many nonsurgical patients could receive a comprehensive evaluation and treatment without physically traveling to Seattle. These patients can be managed virtually by our non-operative spine specialists and continue their treatment plan without travel-related interruption. With virtual multidisciplinary care we have actually increased access to quality care while, with the decrease in required travel, dramatically reducing the costs of evaluation and treatment.

Acknowledging the terrible human suffering and financial toll of Covid-19, we anticipate some positive lasting changes. Virtual multidisciplinary conferences and telemedicine allow us to provide our model of care to all patients, not just those in COE programs. For patients back home after surgery, telemedicine allows for close and timely follow-up without the burden of travel. Virtual multidisciplinary conferences can improve care by allowing same-day, real-time assessments of the urgency of patients’ needs and facilitating immediate triage. In addition, they can serve as a consult resource for patients’ local providers. The potential silver lining of the current Covid crisis may be its role as a catalyst to enable a better paradigm of value-based care.

Read Full article here >

 

Less than 2 weeks before the 5th Annual Safety in Spine Surgery Summit on March 13, NewYork-Presbyterian Hospital received its first COVID patient. These were the early days of an unprecedented strain on the city’s healthcare system. NYC is still fighting a hard battle every day and continues to rise to the challenge.

Despite taking the necessary step to cancel the live Safety Summit in March, we were still committed to providing top-tier educational resources to the spine surgery community. Our local faculty gathered for discussion and our long-distance faculty recorded their own presentations. In the words of Dr. Flynn & Dr. Vitale, it’s more a mission than a course. Thanks to our faculty and supporters, we’re now pleased to present these to you as a free Safety Summit Online CME video series.

Surgeons, PAs, and Nurses can earn 4.2 hours of CME/CE credit by viewing this series of lectures and panel discussions. Learn from experts in spine surgery, neuromonitoring, medical device approval, malpractice, and more. Plus, gain invaluable insight from Stephen Harden of LifeWings, a leader in transforming patient safety programs around the country. We’ve also provided the full text of the outstanding abstracts submitted for this meeting. In addition, you can review the E-Poster presentations, representing some of the best new research in our field. This CME-accredited course is available through February 2021.

We hope you’ll take advantage of this year’s on-demand learning experience. We look forward to joining together in person again for the 6th Annual Safety Summit in Spring 2021. Until then—stay healthy. Stay safe.

Click here for more information.

Less than 2 weeks before the 5th Annual Safety in Spine Surgery Summit on March 13, NewYork-Presbyterian Hospital received its first COVID patient. These were the early days of an unprecedented strain on the city’s healthcare system. NYC is still fighting a hard battle every day and continues to rise to the challenge.

Despite taking the necessary step to cancel the live Safety Summit in March, we were still committed to providing top-tier educational resources to the spine surgery community. Our local faculty gathered for discussion and our long-distance faculty recorded their own presentations. In the words of Dr. Flynn & Dr. Vitale, it’s more a mission than a course. Thanks to our faculty and supporters, we’re now pleased to present these to you as a free Safety Summit Online CME video series.

Surgeons, PAs, and Nurses can earn 4.2 hours of CME/CE credit by viewing this series of lectures and panel discussions. Learn from experts in spine surgery, neuromonitoring, medical device approval, malpractice, and more. Plus, gain invaluable insight from Stephen Harden of LifeWings, a leader in transforming patient safety programs around the country. We’ve also provided the full text of the outstanding abstracts submitted for this meeting. In addition, you can review the E-Poster presentations, representing some of the best new research in our field. This CME-accredited course is available through February 2021.

We hope you’ll take advantage of this year’s on-demand learning experience. We look forward to joining together in person again for the 6th Annual Safety Summit in Spring 2021. Until then—stay healthy. Stay safe.

Click here for more information.

 

ATTENTION:

The NYP Leadership and Dr. Vitale have made the difficult decision to cancel the 5th Annual Safety in Spine Surgery Summit. This is due to both hospital policies as well as following the CDC current guidelines to limit gatherings of 25 or more people.  Many of our faculty are subject to restrictions on travel and business conferences as well due to COVID-19.

We are still committed to communicating the Safety in Spine Surgery Summit message worldwide.  We are working on filming some of the key content to be made available on-line as a CME module. More details will be available soon, but it will likely be later this spring that those videos are available at the Safety in Spine Surgery website.

If you have already registered for the course, please contact us regarding your refund options and cancel any hotel and travel arrangements.


 

5th Annual Safety in Spine Surgery Summit Details:

Chair: Michael G. Vitale, MD, MPH

Co-chairs:

  • John M. Flynn, MD
  • Roger Härtl, MD
  • Rajiv K. Sethi, MD

First do no harm!

Statistics still show unacceptably high numbers of medical and surgical errors. Join us to learn from a diverse faculty about safety and quality advances—plus tips and tools to help us all improve.

Spine surgeons, members of spine surgery teams, OR directors, hospital executives, and more will benefit from this program, and most importantly, so will all of our patients.

Call for Abstracts

Abstract Submission closed on December 13.

Registration

Pre-Course Registration: $95

Main Course Registration:
Surgeons: $575
Residents/Fellows/Allied Health: $375
Healthcare Admin/Corporate: $675
Late Fee (After Feb. 11): $75

The Thursday optional pre-course will be held at:
The Warwick New York Hotel
65 W. 54th St.
New York, NY 10019
Map >

All Friday sessions will be held at:
The Heart Conference Center
173 Fort Washington Avenue
New York, NY 10463
Map >

Shuttle service for participants will run between the Warwick and The Heart Conference Center on Friday morning and evening. Further details will be provided in registration confirmation materials.

 

Hotel Accommodations

S3P Meeting at Warwick Hotel, NY

The Warwick New York Hotel
65 W 54th St.
New York, NY 10019
Map >

The deadline for hotel reservations at our group rate has passed. To inquire about available rooms and rates at the Warwick, please contact Francesca Acosta at (212) 314-7752 or facosta@warwickhotels.com.

CME

9.5 hours available

Dr. Michael Vitale on 3rd spine surgery safety summit: "The appetite for information regarding safety in spine surgery is seemingly endless."

Excerpt from Becker's Spine Review | Written by Megan Wood | May 14, 2018

Back in 2012, Michael Vitale, MD, chief of pediatric spine and scoliosis surgery at New York City-based NewYork Presbyterian Hospital/Columbia Orthopedics, realized that there was a great opportunity to improve the safety of spine surgery. To call attention to the topic, he collaborated with 24 national experts to set goals for reducing surgical site infections after spine surgery. This small forum grew into the first Safety in Spine Surgery Summit in 2016; the second annual summit occurred in 2017 with a crowd of 200 attendees.

"The appetite for information regarding safety in spine surgery is seemingly endless," said Dr. Vitale, who chairs the summit. "People are really excited about the responsibility to do better."

Summit Co-Chair Lawrence Lenke, MD, surgeon-in-chief of The Spine Hospital at NewYork-Presbyterian/Allen and chief of spinal deformity and the orthopedic surgery spine division at Columbia University Medical Center, agreed, emphasizing the critical role safety plays in the spine industry: "[Spine safety] is a topic that has to be priority number one for physicians and surgeons. It is a very unique discipline of surgery where complications are real, often far too common and can have devastating adverse effects on outcomes."

The 3rd Annual Safety in Spine Surgery Summit occurred April 20 in New York City. The summit goes beyond the talked-about technical complications, such as neurologic deficit, and hits on the less obvious culprits — system failures, siloed teams and weak cultures. Each year, the summit's theme changes, with this year's titled, "Toward New Rules of Engagement for an Increasingly Complex Spine World."

"Dr. Vitale is saying [patient safety] is a science, as important as doing an operation," said Paul C. McCormick, MD, medical director of the Spine Center at NYP/CUMC and a co-chair of the summit. "How you set up the operations and engage people are all important things that can be managed, assessed, evaluated and made better."

Each summit includes a pre-course, where participants focus on a deliverable. This year, the group finalized a best practice guideline for Halo Gravity Traction, a procedure designed to decrease the curvature degree in children with idiopathic scoliosis. Previous efforts have focused on developing best practices for infection, neurological safety and wrong level spine surgery, and are available at www.safetyinspinesurgery.com.

This year, 20-plus faculty shared lessons from micro to macro, with discussion focused on how to optimize individuals, teams and the healthcare delivery system as a whole.

Without doubt, the impact of complications like surgical site infection (SSI) can have a tremendous burden on patients, their families, surgeons, hospitals, and society as a whole. As with most complications in healthcare, SSI should be thought of as the result of a combination of host, technique, systems and culture challenges. When multiple defects accumulate, SSI overwhelms the various countermeasures and a clinical infection ensures.

When the defects all align, it allows for these factors to allow passage through the “Swiss cheese” of host, perioperative, and systems defenses. Our role in making care better extends far beyond the time in the operating room. Our highest performance can only come from the ability to develop a high functioning team with unique and synergistic inputs across the entire care continuum, starting well ahead of surgery to include culture and involvement of multiple stakeholders all working towards a shared goal with everyone understanding the importance of the role they play. The greatest opportunity to improve quality, safety, and value lies in the period before the skin incision and long after it is closed. Increasingly, it’s not just the surgeon’s role in acting as the captain of the ship but understanding the importance of “slowing the machine” to consider the full spectrum and extent of potential surgical risk and working with the team to attempt to optimize preoperative care and potentially alter the characteristics of the surgical approach for a given patient.

Work at S3P is dedicated to exploring the role of the multidisciplinary team in minimizing the possibility of complications after spine surgery. Interventions and risks are being explored as efforts to affect the host, surgical technique, culture and systems of care. As with all quality improvement efforts, these must adapt over time to create sustained and iterative improvements in care. Our team began this journey several years ago and we look forward to involving you in this as well.

How Lessons from Cycling Can Inform Efforts at Continuous Improvement

A recent conversation with an avid cycler helped me draw interesting parallels between how sport and the pursuit of skill so often intersects with our mission to make care better in healthcare. Britain’s national efforts in cycling provide such an interesting case study, taking a program who had never won a single gold medal in its 76 year history to winning seven out of 10 gold medals in two consecutive Olympics and applying the same discipline to lead one of the most successful professional cycling teams ever.

Sir Dave Brailsford, the coach responsible for these efforts, took the principles of the Toyota Production System, also called lean, to infuse the team with the spirit of Kaizen, or continuous improvement. He thought that if the team broke down everything they could think of that went into competing better on a bike, and then improved each element by 1%, then these marginal gains could achieve a significant aggregated increase in performance. This came from everything to the traditional areas of experimenting in wind tunnels for aerodynamic, to applying 5S techniques to the mechanics team truck and painting the floor white to prevent slips from grease, to teaching athletes about proper hand hygiene from a surgeon. This even went as far as requiring all athletes to sleep on team provided mattresses and pillows so athletes could sleep in the same posture with the same support every night. Taken together, they felt that it gave a competitive advantage.

These principles of looking at strategy, human performance, and continuous improvement have the same applications to how surgery is performed. For strategy, so much cognitive effort needs to be spent on understanding patient’s unique attributes, understanding plans for surgery, and involving the team. This can also involve slowing down the machine and working with a multidisciplinary team to understand the approach. With S3P efforts, this include recommending using multidisciplinary indications conferences with anesthesia, medicine, and nursing to fully discuss a patient’s treatment plans.

For human performance, this truly involves a surgeon treating themselves as athletes, caring for their physical conditions and optimizing their movements. But this also involves attention to behavioral psychology and creating an environment for optimum performance. This may involve routines the evening and morning before surgery to cognitively rehearse the procedures but also can include preventing heuristic biases from affecting decision making. At S3P, this involves the development of formal risk stratification scores to formalize the requirements and opportunities for “slowing the machine” and optimizing patients’ modifiable risk factors.

The final aspect of continuous improvement plays heavily into Sir Dave’s efforts at finding marginal gains. The same principles are applied within my own OR. For the past year, we have been using the comprehensive unit-based safety program to work with my operative team to fully map out the steps involved in preparing a patient for surgery to incision. From there, we brainstormed ways to drive more efficiencies. Things included marking with tape the position of the table and posting laminated photos of the way the lights should be set up. While each step would only save several minutes at most, as we found more and more opportunities for efficiencies, this began to increase our time to set up by up to 20%. Today, we are applying this across the entire continuum.

Identifying these principles as critical success factors and ensuring they are in place can allow everyone to focus on improvements and reach an optimal place to improve quality, safety, value, throughput and efficiency.

One of the questions I often received prior to the first annual spine safety summit in 2016 is “why organize another Spine Surgery conference?” My answer is inevitably, “how could we not?”

The time could not be more urgent. At every talk I give, I always like to put the audience in the right mindset, which is “how will the next patient be harmed?” Somewhere out there, there’s a patient coming to your waiting room or in a cab or on a plane that may be harmed. The question isn’t if, but when.

In reality, no one is safe, the patient or the surgeon, including the emotional toll that comes from potentially harming a patient.

As a field, we are not doing well. Even if we pride ourselves with 99.9% positive outcomes, we are still left in the dust by others who are doing better. As a framing picture, we would find this unacceptable if:

  • Amazon failed to deliver 1,600 parcels each day
  • USPS lost 506,000 pieces of mail each day
  • 1,019 surgeries went wrong every month

We always need to ask ourselves, how far would you be willing to go to avoid harm? Often times, the answer isn’t from punishing physicians and nurses. It’s not an issue of bad physicians or nurses harming patients, but a poor system setting up good physicians and nurses that eventually harms patients. Even the most technically skilled and fantastic of surgeons can’t do a great job, unless they have the infrastructure to support them and a team surrounding them with good communication. More and more, with lessons from high reliability organizations such as aviation and nuclear power as well as from the peer-reviewed literature, we are learning that over focusing on the concepts of individual skills undervalues the reality that care is a result of the entire episode of care, requiring a systematic approach to managing everything within the realm of influence, from preoperative access to recovery and rehabilitation.

Just like Jim Reason’s timeless model, the Swiss Cheese Model of Medical Error, if we think about all of the elements of risk, host, technique, systems, and culture, then we realize that medical error and complications occur only when all of the holes line up just right.

As we start this blog, I am hopeful that the Safety in Spine Surgery Project (S3P) will evolve into a platform where we can engage the wisdom of the entire industry to shrink the critical holes that too often lead to poor outcomes for our patients:

  • Variability
  • Lack of Infrastructure
  • Individual Thinking & Decision Making
  • Lack of Information in a Data Rich System
  • Poor Culture

S3P will provide an infrastructure and platform in which we can work together to tackle some of these issues throughout spine surgery and hopefully implement strategies across the board. But we need participation and buy in at ever level, from industry partners, hospitals, peers and colleagues, and each individual physician. Patient safety and quality starts with physicians, but it doesn’t end there.

This is such an exciting time and we would love your feedback on how S3P can take quality in spine surgery to the next level. In future blog posts, we’ll talk more about some of the frameworks for change we envision and the efforts that have evolved as a result. We look forward to hearing from you.