Crisis Management in Critical Care and Surgery

April 26, 2023
What COVID-19 taught the healthcare industry, and how it can be applied in the future.

As the healthcare industry continues to recuperate from the longstanding medical and economical effects of COVID-19, the recent governmental ease in public health restrictions is a welcome industry update. However, reduced restrictions should not reduce the importance of many crisis management lessons that were learned the hard way during the pandemic. With this in mind, it is of critical import that healthcare leaders, industry experts, and on-site professionals review existing crisis management protocols, and work together to improve and streamline more effective procedures going forward.

As arguably the most devastating lesson COVID-19 taught healthcare, the error of medical hubris in underestimating what the SARS-Co-V2 virus was capable of was clearly evidenced by the millions of pandemic-related deaths. As such, for hospitals and healthcare facilities around the country, now is the time to be proactive in solidifying crisis management plans across the board, in order to be better prepared for any future medically related crises that may occur. 

According to the American Association of Critical Care Nurses (AACN), disaster drills often “focus on the immediate aftermath of an incident, such as managing the initial triage and patient surge in the emergency department and testing the hospital incident command system.” However, they also point out that a disaster also may require critical care capacity to expand in a rapid and sustained fashion. 

Published in AACN Advanced Critical Care, “Mass Casualties and Disaster Implications for the Critical Care Team” details various considerations to integrate critical care-specific needs into disaster response planning, including the ability to expand capacity for intensive care unit (ICU) beds, the number of trained personnel, supplies, and equipment. As one of the authors of the article, Jennifer Adamski, DNP, APRN, ACNP-BC, CCRN, FCCM, has responded to multiple mass casualty incidents during her nursing career, and helped numerous organizations develop disaster response plans. Currently an assistant professor and director of the adult-gerontology acute care nurse practitioner program at Emory University in Atlanta, Georgia, Adamski is also a critical care nurse practitioner on the critical care flight team for the Cleveland Clinic. 

“Disaster planning can take a general all-hazard approach or one that focuses on a specific hazard that the facility may be at higher risk for, due to its location and other factors,” Adamski said. She added, “Thinking through the ramifications of an incident, preparing for worst-case scenarios and practicing the response can literally save lives when a disaster happens.” 

The AACN also pointed out that, “when disaster surge conditions increase pressure on healthcare operations, facilities move from conventional to contingency or crisis-level standards to meet the needs for their patients. Pre-disaster planning includes taking inventory of available space to expand ICU space, with the possibility that other areas within the hospital may need to become ICUs. When internal space is at capacity, external or remote ICU expansion and field hospitals may be needed.” 

In addition to space and personnel, “facilities must identify supply and equipment needs and vulnerabilities. These include personal protective, redundant oxygen, ventilators, point-of-care ultrasound, and emergency blood components. Some common critical care medications may be in short supply due to increased demand, while others, such as chemical weapon and nerve agent antidotes, may be needed only during specific types of disasters.” 

Another major concern within all healthcare facilities—regardless of a pandemic—is hospital-acquired infections (HAIs), which can present a crisis for patients, as well as for staff. Elliot M. Kreitenberg, cofounder and president at Dimer, pointed out, “To prove a measurable and statistically significant reduction in HAIs with UV surface disinfection machines requires a sample size of 36,000 cases. Many companies in the space promote studies with small sample sizes and high margins of error.” 

He continued, “If we believe reducing environmental contamination reduces the risk of HAIs, then measuring germ-kill of a sample of many surfaces of a room is the best way to measure effectiveness of a UV machine.” 

During the COVID-19 pandemic, Dimer’s UV disinfection technology was used on aircrafts, which subsequently led to applications in healthcare settings. Today, Dimer offers the UVHammer for healthcare. Kreitenberg noted, “It is the only product on the market that is operationally mobile, and can adjust the angle of the lamps to optimize consistent exposure to any surface, quickly. Dimer products uniquely unlock UV-C’s potential by designing for minimal distance, optimized angle and elimination of ‘shadowed areas.’” 

Also focused on preventing an infection crisis in critical care and surgery, Executive Director of Marketing – Infection Prevention at Diversey, Larinda Becker noted the critical importance of patient safety and speed of room turnover. 

She said, “Diversey knows that speed of room turnover and patient safety are both critical, and provides a programmatic approach to reduce the risk of infection and improve patient outcomes, without compromising any time or speed to the process. We have two programs: number one is TurboTurn, a programmatic approach that includes products, procedures and validation; facilities can also radically improve effectiveness and speed of OR turnover with cleaning and disinfecting. Number two is the Perfect Turnover for a similar approach in room turnover for the next patient. These were both implemented to address the need for speed without compromising quality.” Becker continued, “These are based upon having clarity on the appropriate products to do the job, clear roles and responsibilities, along with a process for the workflow and programs for ongoing validation that the work was completed. The need came for challenges customers were facing in having the adequate labor to do the job, increased turnover and some loss of expertise, and high census in facilities. We have demonstrated up to 30% reduction in turnover time, and have not seen increased rates of transmission from the environment.” 

She added, “In addition to the manual cleaning and disinfection, UV-C disinfection technology has also aided in reducing the risk of spread of pathogens while providing extra disinfection for safer and more hygienic areas. This technology has had favorable results in many areas including ICU, CCU and ERs, as well as operating rooms.” 

Addressing crisis management in surgical settings, Renae Battié, MN, RN, CNOR, and Association of periOperative Registered Nurses (AORN) vice-president of nursing, said, “Perioperative departments are expected to have crisis management policies and procedures in place, and you must demonstrate your team has the competency, skill, and knowledge to manage these crises to keep patients safe. Perioperative leaders do risk assessments on what could occur in their department – which informs what type of education, training, drills and simulations the department should do.” 

She added, “The type of scenarios may depend on the area you’re in – such as for tornados or blizzards, or near refineries and industrial plants. Planning adequate supplies for these crises are as important as staffing. Perioperative departments use real surgical scenarios to educate teams on patient crises, and AORN provides a variety of resources for all facilities.” 

One company offering an example of how best to address the role of nasal colonization on infection risk is Nozin, who offers products and programs to help hospitals reduce colonization pressure increasing patient safety. According to Nozin, recent studies confirm that the nose is a “critical reservoir for bacteria and vector of transmission for many of the pathogens responsible for healthcare-associated infections (HAIs). Reduction of nasal colonization has been clinically proven effective at helping reduce surgical site infections (SSIs) and HAIs.” 

When using Nozin Nasal Sanitizer antiseptic, published third-party outcomes data in clinical studies include: a 63% reduction in all-cause SSI; a 51% reduction in S. aureus SSIs; a 98% reduction in total hip SSIs; and a 96% decrease in MRSA bacteremia hospital-wide. 

John Willimann, CEO at Nozin, said, “Despite industry-wide supply-chain challenges, I’m proud that the Nozin team was able to successfully ramp up production so that hospitals could continue to protect their patients without any product delivery interruption. We are witnessing a paradigm shift as hospitals expand their adoption of universal nasal decolonization to protect all patients by reducing colonization pressure and infections.” 

Reducing the rate of SSIs 

In an attempt to reduce the rate of surgical site infections (SSIs), many hospitals and healthcare facilities look to established protocols and procedures, which are enhanced by educational and training policies. However, in spite of concentrated efforts and existing best practices, SSIs remain the most common complication of surgery worldwide, with many causes and few proven solutions to reduce the increasing rate of occurrence. 

According to Chad Flora, BSN, RN, CNOR, gloves U.S. clinical director at Mölnlycke Health Care, “A bundled approach to minimizing surgical site infections (SSIs) continues to be guided by various methodologies based on previous studies, outcomes and even technologies.” Flora referenced a new study that “demonstrated the value of routinely changing sterile gloves and instruments prior to abdominal wound closure, offering one of the first proven methods of reducing surgical site infection (SSI), still regarded as the most common complication of surgery worldwide.” 

He added, ““The ChEETAh trial found that routine change of surgical gloves and instruments before abdominal wound closure reduced the risk rate of surgical site infection (SSI) by 13% at 30 days after surgery compared with the trial control group, which is equivalent to a reduction of one in every eight SSIs.” Flora reported the reduction in SSI was seen across the trial, from large hospitals with advanced perioperative services to small, rural hospitals with only a few beds. A total of 13,301 patients were recruited into the ChEETAh trial, which took place between June 2020 and March 2022. 

Citing data from the CDC, Flora summarized, “The simple, cost-effective process of changing sterile gloves and instruments prior to surgical closure is a best practice that can minimize SSIs and improve lives around the world.  The average cost of just one SSI is an estimated $25,546.” 

In agreement about the cost of SSIs is Dr. Boldtsetseg Tserenpuntsag, director – data unit, Bureau of Healthcare Associated Infections, New York State Department of Health, who reported findings of SSIs associated with hysterectomies. The findings from an analysis of more than 66,000 abdominal hysterectomies performed in New York hospitals revealed key risk factors for surgical site infections (SSIs) following these procedures, including open surgery, obesity, diabetes, gynecological cancer, and age under 45. Published in the American Journal of Infection Control (AJIC), the data can help inform surgical and clinical decisions to reduce post-operative infections. 

“Improved understanding of patient-related, clinical, and surgical factors associated with SSI in hysterectomy, a common surgical procedure in the United States, could help to reduce infections and improve risk models,” said Dr. Tserenpuntsag, adding, “As far as we know, our findings are derived from the most comprehensive dataset to date, making them more generalizable as compared to previous studies on this subject.” 

SSIs are infections that occur at a surgical incision site within 30 days after the incision is made. According to the Centers for Disease Control and Prevention, SSIs account for 20% of all healthcare-associated infections (HAIs), and are associated with a 2-to 11-fold increase in the risk of mortality. SSIs are also the most costly type of HAI with an estimated annual cost of $3.3 billion.       

Product flexibility needed in patient monitoring crises

At GE HealthCare, President and CEO of Patient Care Solutions, Tom Westrick, asserted that the pandemic crisis highlighted the need for adaptable products that are flexible enough to accommodate any future patient-monitoring crises that occur in critical care.

“As hospitals had to quickly adjust from normal to surge operations to respond to the increase in COVID-19 cases, the pandemic highlighted the need to have flexible patient monitoring technologies that could easily adapt to meet a patient’s acuity level. These ‘adaptable acuity spaces’ with flexible, scalable solutions allowing institutions to customize on the fly for patient and case types are on the rise post-COVID-19.” 

He added, “But monitoring technologies require different connections and ports for each new patient vital sign, which can create confusion and prevent institutions from leveraging new clinical capabilities easily. Standardized medical USB connections and flexible software on GE HealthCare’s vital sign monitoring devices allow them to be used at the bedside to deliver the accuracy healthcare teams need to help make proactive clinical decisions. GE HealthCare calls this FlexAcuity, and has been investing in tools and technologies that enable hospitals to standardize patient monitors that can be flexibly deployed across their enterprise.” 

When looking at potential crises in the OR and/or surgical suite, Westrick pointed out the need for a streamlined and efficient plan of organization in order to best address patient and facility crisis-related needs. 

“Real-time healthcare, or having all patient care resources working in concert constantly for the best possible outcomes for each patient and efficiency for the system, can help with many aspects of surgical efficiency and growth.” 

He continued, “For example, GE HealthCare’s Command Center software tiles, or apps, provide a comprehensive view of forward-looking surgical utilization, downstream bed requirements, and potential patient readiness challenges. This is used by perioperative program leaders to focus pre-admission-readiness efforts, plan the surgical grid, avoid over-scheduling for both perioperative and downstream bed utilization, and help maximize utilization with visibility to the true downstream demand based on nuanced algorithms.” 

In times of crisis, having a database of resources can potentially make the difference between life and death for some patients. GE HealthCare addresses that concern with their Regional Capacity System, which tracks healthcare resources in a specific region. Westrick summarized the benefits of the system and noted its vital importance in a medical crisis. 

“If capacity is of concern during a crisis, GE HealthCare’s Regional Capacity System is a framework to track healthcare resources in a specific geographic region, such as a city, state, or country using reliable and automated data sources, and common definitions across health enterprises. The system tracks resources such as ICU, adult, pediatric, NICU, behavioral health and many other types of bed capacity and census, as well as vents, COVID-19 census and associated data, divert status, PPE and more. GE HealthCare helps each state or region set-up their system to include the data elements relevant for them.” 

He added, “The goal of the Regional Capacity System is to help care coordinators make the most efficient and effective use of precious resources by making it easy to know the current state which is constantly changing and highly nuanced.”