So welcome, everyone. This is Corey Adamson out of Atlanta, Georgia. I want to welcome everyone to our fourth lecture in this four-part webinar series hosted by the AANF, and these talks have been about COVID-19-specific issues relevant to neurosurgery. Since this is the last talk of this series, I wanted to quickly throw out a couple of very important thank yous. So we skipped a slide there, but here we go. So there are a few members from the AANF Education Committee who helped to put together this entire series, so thank you to you guys. But the real workforces for this entire webinar effort has been all the faculty who have put together countless hours of lectures for us and have shared their remarkable expertise with us, so thank you to all those faculty. So we're going to jump into our lecture tonight on reemergent strategies for our neurosurgery practices. So how do we get our neurosurgery practices up and going and back up to full steam after this COVID pandemic? So I'm very honored to introduce to you three extraordinary, world-renowned neurosurgery leaders to help give us some guidance on this topic. I'm especially excited about this group for several reasons. They all represent three major cities in our country that have dealt with COVID in different ways. So we have New York City, Pittsburgh, and Chicago. All three faculties wear multiple leadership hats at their institutions, so they have dealt with COVID from very different perspectives. And lastly, they all treat various neurosurgery patient populations, so again, have a terrifically broad experience of how our entire neurosurgery practice has dealt with COVID. We're going to start off with Dr. Jeffrey Bruce, Professor of Neurosurgery from Columbia, then we're going to move to Dr. David Okonkwo, Professor of Neurosurgery from Pittsburgh, and then we're going to wrap it up with Dr. Richard Byrne, Chair and Professor of Neurosurgery at Rush. I want to remind the audience, please use the chat box to say hello to your colleagues out in the world, throw down some comments, and as we approach the end of the hour, please put some questions there for our faculty, and hopefully we'll have some time at the end that we can address some of those questions that we don't get covered during the hour. So without further delay, I'd like to ask our staff to help pull up the slides for our first speaker, Dr. Jeffrey Bruce, and I'll turn the floor over to him. Thanks. It's a pleasure to be here today, and I wanted to thank the AANS and Corey Adamson for organizing this. I noticed on the website this is a free webinar, so hopefully we can more than give you your money's worth. I'd also like to thank Nick Alexiades and Hannah Goldstein, my outstanding chief residents, who provided some help in organizing this talk. Now, I wanted to give you the New York City perspective on this as we have been hit hardest in this COVID pandemic, and the reemergence hurdles we have are considerably higher. You know, New York's infection rate is somewhere around five times higher than the rest of the country, with nearly 20,000 deaths and devastating economic, social, and public health consequences. So from our perspective, you can see in that lower corner there, this is how Broadway is right now. And on the other side, you see it's a New York Presbyterian graph of COVID admissions and ICU utilization that shows that we reached the peak approximately three weeks ago, which now positions us for some type of a phased approach to reopening. We've achieved the crucial goal of flattening the curve as this crisis nearly overwhelmed our available resources. So when a given hospital can open is going to be determined by that individual hospital and specific capabilities. In our case, we're relying on state government directives and therefore we have to take into account such things as the number of infections by population, which in New York City is the largest concentration really anywhere in the world. And we have to account for the trend in hospitalization, utilization, ICU beds, as well as the demographics of the local population, their age, their degree of chronic disease. In our state, Governor Cuomo, who has made quite a name for himself during this pandemic, has issued recent directives to address the suspension of all what they're calling non-essential elective surgeries and non-urgent procedures. So what does that really mean? His directive includes language such as must have or shall mean, must ensure, adequate, minimize, doesn't quite address the definition of elective, especially when we are being considered with things like cardiac and plastic surgery. So right now, really, we're concentrating on the backlog of urgent cases. And once we catch up, there's probably going to be a whole new set of directives, hopefully allowing us to be more expansive in this definition. And one of the first things we need to address is the outpatient clinic. There's no question that telemedicine has been a great advantage and we have used it exclusively in the last month, although it was something we barely used before. It's minimized the number of inpatient or in-person appointments, which is really where I think consulting is going to be for the near future. However, there are instances where patients must come in person, either as a post-op visit for suture removal or for pre-op testing. So going forward, patient communication must be simple, concise, reassuring. Certainly all in-person visits will need universal safety precautions, including PPE. Patients will need to be screened ahead of time to see if they're symptomatic. We'll need a temperature check at the door. Testing for the virus is likely to evolve, and we'll have to interpret the variabilities of that, including how reliable the test is, the timing and the type of testing. This can mean antibody testing or actual virus testing. It makes sense to have staff tested, but how long is that relevant? Shortly after the negative test, you could have a new exposure and be contagious. So the whole testing strategy is going to have to evolve as these tests improve and we understand better what we're getting into. I think we have to expand the physical size of our clinic space so that we can maintain social distancing. UV lighting is also helpful to sterilize these clinic spaces. We're going to need to be very rigid about scheduling to minimize wait time, making sure that there's at least amount of overlap between positions. We're going to have to restructure the preoperative process to accommodate all of this and the flow of patients to avoid overcrowding. Even such things as elevators are going to become a logistical challenge. Finally, we have to be sensitive to our staff as they have emotional and psychological physical needs, not only in their job, but also in their personal lives, which is ultimately going to affect your performance and productivity. I think we may have to deal with quarantining our staff if they're symptomatic as well. So how about moving on to inpatient evaluations? Inpatient evaluations will mostly be concerned with avoiding the spread of the virus and protecting healthcare personnel and patients who are non-COVID. Obviously, universal precautions are going to be needed indefinitely. Our residents are coordinating with their counterparts in emergency medicine and neurology so that consults are streamlined and minimizes the amount of actual direct physician interaction with the patient. So if there's a consult, all three services do not necessarily need to see the patient in person. Within our service, we have to coordinate so that we minimize the number of doctors that we're actually physically rounding on the patients. And obviously, as a hospital unit, COVID patients are going to need to be isolated in designated areas. One of the biggest things on everybody's mind is how to reduce our backlog of operative cases, taking into account resource and space limitations. And again, each hospital is going to be a little different with this. We have an internal committee to evaluate and prioritize operative cases and to make recommendations to a multidisciplinary hospital group that is otherwise not going to be knowledgeable about our kinds of cases. This also means that we need strong representation on any multidisciplinary committee that's going to stratify and prioritize across these surgical services. You've all heard the saying, never let a good crisis go to waste. And I think this is a great time to encourage hospital administration to optimize the OR efficiency. And I think, I don't know about your institution, but turnover time is horrendous at many institutions. And if we can't reduce our OR turnover time and make it more efficient, that's going to be a way to get more cases done. I think at least in the early ramp up, expanding OR times to the night and weekend is going to be helpful, but we should provide incentives for surgeons to use them. And this could be financial or through some kind of effort reduction. I think additionally, allowing and facilitating the use of concurrent surgeries to make things work very well. Finally, there's going to need to be a strategy to overcome patient concerns about COVID. We need effective and efficient patient processing so that they're confident from the time they enter the hospital or clinic and through their entire experience in the system. This will require substantial public relations and website developments to assure patients about safety and addressing their concerns. Now, our own system for stratifying surgical procedures is creating a timeline of urgency depending on whether a case needs to be done in a week, a month or some time beyond that. We also have to consider how much resources are needed in terms of post-op requirements. Can this be done in a surgery center type form with a 23-hour stay? Does it require a step-down unit, ICU, ventilator support? Furthermore, what's the estimated length of stay? And we're going to need frank discussions with patients about the possibility that their surgery could get canceled or they can get moved up. So they have to be flexible. And I think patients will be very understanding if they're educated early on about certain limitations that we're facing. Now, telemedicine and technology are going to be integral parts of moving forward. This initially requires some time and financial investment in individual practices to get it operating efficiently. One of the major adjustments is repurposing staff to facilitate this in a user-friendly way. Comes with some problems. You have to overcome access barriers for elderly patients or patients who are not tech savvy. But I must say, we've been very pleased with the use of telemedicine as an effective way to optimize time. Utilizing the adjuvant personnel to set up the visits and prescreen them increases this efficiency. And right now, at least, it allows you to expand your geographical access to patients and other areas who may not be local. And this is especially important for those with subspecialty practices. There are some legal considerations. Your telemedicine has to be HIPAA protected, but also theoretically has to be limited to patients in a state where a surgeon has a license. This has been a requirement that has been waived during the pandemic and hopefully will be permanently rescinded. Personally, I found that patients love telemedicine. They don't have to worry about a waiting room or parking or travel time. Their whole family can be present. And they're generally more relaxed in this setting. Interestingly, I find that they actually ask less questions and actually use up less time. It's as though when they invest the time and effort to come to your office, they feel they need to get their money's worth. I don't know. It's hard to explain. But there's the obvious disadvantage of not having the direct patient contact and being able to interpret their body language or gauge their understanding of what you're saying, or showing them a model or even their scans. It makes it difficult, but I've actually found these to be relatively minor disadvantages and easily outweighed by the advantages of the telemedicine system. Okay, so moving forward, we want to be able to reintegrate our support staff and our resident trainees. Our neurosurgery residents have performed at extremely high levels on the forefront of this battleground. We've had a very public validation of their just overall character and grit and confidence, as I'm sure they have at probably all of your institutions. Neurosurgeons are unique. No one else can perform their function. So it's important that we keep them healthy. In our own institutions, our residents have been working in COVID ICUs where they provided an important skill set that neurosurgeons have. To me, that was preferable to having them in an emergency room where their skills were probably less needed and where they were at a higher risk of getting sick. Getting back on track now, we're working with our administration to return them to service. And right now, with surgical volume still fairly low, it's not yet a problem. But I suspect as things ramp up and we address the backlog of cases, we're going to need them more than ever. Other considerations are helping our educational process. So we utilize video conferencing. We're also going to have to address the case minimums. Our residents have lost weeks of surgery that are necessary for their case minimums. So we're going to have to make sure that in particular, our chiefs and seniors are getting the operative experience they need. From an academic perspective, you have to see, you have to look at how we're going to resume our clinical and basic laboratory research. It seems to me that there are very few barriers to resuming clinical research once patient care actually resumes. Our research laboratories have been shut down and as considered non-essential. I think this has been somewhat misguided as I think they should be at least as essential as grocery stores. And I think they have significantly less risk. I think the risk is relatively low, given the fact that there are many ancillary personnel already working in the building, including veterinarians, janitors, parking attendants. Furthermore, our researchers are very well versed in laboratory safety and hazards. And as soon as we're able to reopen the labs, we'll obviously need to use universal precautions and optimize social distancing by staggering work hours, using our space strategically, especially other lab space such as tissue culture and dark rooms. It's not yet clear how we're going to utilize COVID testing and if it will be necessary. I mean, we'll have to assume all these precautions. But we obviously want to prioritize research activities with long term implications as soon as we get up and running, such as cell culture and animal breeding activities that require a long ramp up. Okay, I'm going to finish up here by discussing long term and permanent changes, hopefully some positive changes. I'm going to leave the financial concerns and discussion to some of the other speakers tonight. But one of the things likely to come out of this is the need for less regulation. Many regulations have been waived during this pandemic and we're finding you know, they're just not necessary. This includes the use of adjunct health personnel to perform a lot of tasks that might take up a surgeon's time. We found that insurance authorizations and other red tape have been set aside with improved administrative efficiencies in our individual offices. We know we don't need to tell this crowd about medical legal initiatives and how they waste resources. And we'll see where this goes as a political issue moving forward since most of the malpractice was eliminated for COVID related problems. So some of the regulatory compliance reporting, we've also found to be unnecessary. And we've already talked today about telemedicine and the fact that this has been a financial and time saving advantage. In our own institution, we just started using the EPIC electronic medical record a few months ago. I must say I was initially skeptical, but I've come to appreciate the efficiencies in it once the system has been mastered to facilitate the documentation compliance burdens that we have. I think more than ever moving forward, we need to improve our website presence for public relations and providing information. And we should highlight the role that the health care providers have played in this pandemic so that the public can acknowledge the sacrifices that have been made. We also need to use our web presence to provide safety assurances and to provide communication regarding testing, scheduling, and things of that nature. And we can also use this to communicate with referring physicians. So again, we want to utilize the efficiencies that we've developed under these circumstances. Certainly the use of surgery centers and their innate efficiencies will be more popular than ever. The necessity to re-engineer our practices gives us an opportunity to optimize our personnel and workflow. On a grander scale, this pandemic has created leadership opportunities. We've seen us both at a resident and attending level. People who are in the heat of battle have become really true warriors and work to make things better and provide solutions. I think in an academic setting, we certainly can see the value of this. So with that, in these pandemic times, I'd like to thank all you cool cats and kittens out there for joining us, and I hope this has been helpful. Thank you. Thank you, Dr. Bruce. We'll pull up our slides for our next speaker, Dr. Alconqua. Thank you, Corey. Thank you, Dr. Bruce. There were a lot of insightful comments in your presentation. And what I'm going to focus on relates to what you mentioned as the ramp up and backlog of cases. And my goal here is to arm each person who has tuned into this webinar with a better understanding of what's facing us. And we are going to have to shift the conversation that is going to face every one of us from necessary cuts, we need to shift the conversation that's going to be coming down on us from necessary cuts over to a discussion about preparing for the inevitable surge in demand. The reality is the tumors are still growing, spines are still spondylosing, substantial nigras are still degenerating, and our patient population is not going anywhere. And in fact, we are going to have to work even harder on the back end of this COVID-19 pandemic and on the back end of this current shutdown era, in order for us to serve the needs of our population. And I'm always troubled by that term elective surgery, because it is, in my opinion, the very rare circumstance in neurosurgery that an operation is truly elective. This slide shows that in 2019, 92 million procedures were performed in the United States with 60% of them being in this category of quote, elective or non time sensitive. But this steady linear growth that was anticipated over the next three years is no longer relevant to the United States healthcare landscape. And we are entering a period of uncertainty about a number of things about how COVID-19 is going to affect procedural volumes in the U.S. in the coming months and even in the coming years. What has actually happened to procedural case volumes? Well, that's not perfectly clear at present, even though we're starting to get a clue about that. But if we go back to 2013, to the SARS epidemic, which was a contained in time epidemic, but it is also now historical data for us to understand what happened. And this is Canadian data, which is pretty reliable data, given that it's a national health system. And in Toronto, there was a 57% decline in quote, elective procedural volumes during the course of the SARS-CoV outbreak in 2013. Well, now there's starting to be some data to emerge about what's happening in 2019. And this is a very recent report from a group of cardiologists who looked at multiple centers worth of volumes and compared the pre-COVID-19 era to the intra-COVID-19 era and found a very similar reduction in case volumes to what was seen in the Canadian data in 2013, which is this 54% decrease against baseline after restrictions were implemented. Well, the difference between SARS-CoV and SARS-CoV-2, otherwise known as COVID-19, is SARS-CoV had a beginning and an end, and COVID-19, the end is as yet unclear. So what does that mean for all of us? We don't know, but the McKinsey group has started to put together some computational modeling surrounding this, and they've mapped out a series of scenarios that relate to what the incidence of viral burden will continue to look like in the United States, and then tried to measure that against the efficacy or inefficacy of interventions that are put forth at the government level and at the public health level. So let's focus on two of these scenarios, the ones highlighted in blue, where we gain containment of the virus followed by a slow recovery, and let's look at what that looks like to the change in procedural volumes in the United States, and then we'll think about a second, more severe scenario after that. So in the first scenario, we gain relatively rapid control of the virus, and then we see a slow recovery. Now, what happens with that is that it will take until the fall for us to have large-scale widespread return of full procedural case volumes in the United States, and in fact, we can expect a surge up to about 120% capacity in this model, and if we do that and we run that through for three consecutive quarters, it will be September of 2023, I'm sorry, July of 2023, sorry, July of 2021, before we see a return to the pre-COVID-19 baseline rate of surgical case volumes. But in the second scenario, which paints a more dire picture, what happens is that this pushes this out much, much further, and in this scenario, it'll be the fourth quarter of 2021 that we see that surge, and it'll be the third quarter of 2022, so now we're talking about the summer of 2022 before we see a return to the baseline values of the pre-COVID-19 surgical case volumes in the United States. Again, what does that mean for all of us? It means that we should not be talking about cuts in the coming months. We need to be having very frank discussions about what it's going to take to prepare the workforce and prepare the resources necessary for us to meet the pent-up demand, because neurosurgery is going to be very similar to cardiology in that these problems that we take care of are not going away and, in fact, are going to have to be addressed when we are finally in a position to do so. So this nice linear growth in procedural case volumes that was anticipated in the United States is being replaced by a host of uncertainty where it's unclear which of these scenarios is going to play out. We aren't perfectly clear about viral incidents, and we aren't perfectly clear about when a vaccine may become available or what the impact of social distancing or a reopening or a revamping of the American business landscape is going to have on the public health burden. And again, the major difference between SARS-CoV and SARS-CoV-2 COVID-19 is that the only way to describe what's happening in America is, in fact, a flattening of the curve. We are, by no death metric, are we on the back end of this from an incident standpoint with 29,763 new cases on Sunday in the United States. But the United States may be one fantastic country, yet represent vastly different realities. And we heard from Dr. Bruce, who is living and working, frankly, in ground zero for the United States of this pandemic. And if you look at the most recent data, and if you just take the boroughs of New York City and some of the immediately surrounding counties, you have an incidence of 265,000 plus cases. This underestimates the full picture, because this doesn't include Connecticut data. This doesn't include New Jersey data. It's missing some of the cities and immediately surrounding counties of New York. But 265,500 plus cases with 1,880 new cases on Sunday alone. Compare that to where I live and work in Pittsburgh. We have had fewer total cases in Pittsburgh throughout this entire COVID-19 pandemic than New York had on Sunday alone. And on Sunday in Pittsburgh, we had 12 new cases. We are simply living in a vastly different reality than New York City. And the reality in Pittsburgh is reflective of a much, much, much larger and broader landscape of the United States. New York is a special place. Boston is having challenges. D.C. is facing certain issues. Seattle went through its problems. San Francisco had its own share of COVID-19 burden. Pittsburgh has been, frankly, largely spared. And that is true of a much, much, much longer list of cities in the United States than the cities that, in fact, are being overburdened by this particular pandemic. So in Pennsylvania, we had our state officials last Monday say, we are clear to return to elective surgeries. And we at UPMC knew that we had to do everything we could to prepare for a surge. We took all the necessary precautions. We drastically scaled back what we were doing from a surgical perspective. We created central clearinghouses to decide which cases were appropriate to proceed. We armed ourselves with all the PPE necessary for us to accommodate a surge. And thankfully, that surge to date has not yet happened. And in fact, at our peak, only 2% of the ICU beds in the flagship hospital of UPMC, Presbyterian, where I work, were occupied by COVID-19 patients. And even in Pennsylvania, we are basically living in two different countries. Because what's happening in the western part of the state is dramatically different from what has happened in the eastern part of the state. And Philadelphia looks much more like New York than western Pennsylvania. And I'm not sure why this heat map of cumulative incidents isn't going all the way, but the heat map in Philadelphia becomes a very, very dense purple against the spectrum of what's happened in western Pennsylvania, where Pittsburgh is, with a much, much lower incidence. So when we at UPMC take a look at the criteria that have been put forth and set in front of all of us, so you have the gating criteria established by the White House and the CDC that looks at the burden of symptoms in the community, the number of cases, and the trajectory of caseload in the community, as well as the burden of COVID-19 patients in our hospitals. And then we match that up against guidance that's been set forth by the American College of Surgeons, the American Society of Anesthesiologists, the American Hospital Association. And we are ready for phase one, if not phase two, of opening up America again at UPMC in Pittsburgh, Pennsylvania. So that's what we're doing. Well, and if that's the case, what do we need to be prepared for? Well, let's go back to this data from the cardiologists. And what they did was they looked at the cumulative burden of cases that have not been performed because of this ramp down of a 54% decline in case volume. And then they started to mathematically model that against a July 1st resumption date for full services. And when you apply the mathematical modeling to this, what you see is that if on July 1st there is a return to 100% operating capacity and you maintain 100% operating capacity, you never actually catch up with the patient demand that's going to be put forth in front of the cardiac surgeons. If you ramp up to 120% of operating capacity on July 1st, it will take until March of 2021 to accommodate the backlog of cases and the ongoing new burden of cases for patients who need cardiac surgery. And it takes a 200% capacity to wipe out the backlog within three months. This is a reality that all of us are going to be facing in the months ahead. And when that reality faces New York City may be different from when that reality faces Pittsburgh or faces Chicago or faces Nebraska or faces Arizona, but it's going to be a reality that faces every single one of us. Cardiac surgery volumes fell to 54% of baseline. If you model this out against a restoration of a July 1st start date, you would have to get 263% of baseline operating capacity to clear the backlog in one month. We know that's not going to happen, but the sooner we start engaging with discussions with our health systems about how we're going to accommodate the pent up demand, the more prepared we will be when it is time to flick that switch and accommodate. We're seeing this contrasting narrative where story after story of the challenges that the health systems in which we work are facing are being brought forth. UVA losing $3 million a day, furloughing employees and cutting executive and physician pay, Mayo Clinic announcing sweeping pay cuts and furloughs, Quorum's 24 hospital system facing bankruptcy amid pressures from COVID-19. This is what's happening over and over and over again in health systems across the country. Fortunately, in Pittsburgh, we are in a place where we can push forward with our reopening plan. So how are we doing that? We have been performing scheduled surgery throughout the entire COVID-19 pandemic, but with very, very, very carefully selected cases being put forth after central review, during the shutdown phase, but now we've already restarted the broad scheduling of surgery. We want to focus on the younger patients, the patients who are going to have short anticipated length of stay, low medical comorbidity, and try to clear those decks first and avoid the larger more complex cases that are going to require ICU care or rehabilitation stays afterwards. And we're also in a position to deploy wide scale testing. And we are now offering, and in fact, in my practice, we are doing this in 100% of patients, and we can accommodate 100% of pre-op patients with testing for COVID-19 in an effort to protect both the patients and the staff as we ramp up in our reopening plan. And so I'll stop there and turn things over to Rich. Very good. Thanks very much. And thanks, Corey, and AANS staff for putting this together. Jeff and David, thanks for your views from your cities. That was really well done. I have to say that Chicago is quite a bit more like New York City right now than Pittsburgh. I'm really envious of the UPNC scenario because that's not what we're seeing in Chicago. I will be relatively brief just to make sure that we have some time for questions a little bit later on. I'll give a brief introduction to Rush and our COVID attempts. I'll talk about our transition tactics for reemergence in neurosurgery. But because of one of my other responsibilities, which is chair of our medical group finance committee, I'm going to be talking a little bit about the financial impact on US medical centers and secondarily on neurosurgery. I have to say I voluntarily stepped down as chair of our finance committee for the entire Rush University medical group in February, which would have been a great, great idea had I been smart enough to get a replacement for myself, which I didn't. So I remain as the lame duck chair of the finance committee through this financial scenario that's coming. At Rush, I have to tell you, our experts in looking around Chicago and what's going on with Chicago in a flattening of our curve, we're anticipating a two-year impact, a two-year impact, not just of COVID, but of the financial ramifications of COVID. We'll be delighted if it's shorter than that, but we're ready for a two-year impact. So it'd be a little closer to David's scenario number two, we're also a little worried that we may reemerge, but our patients may not for a variety of reasons that I'll go into. So, this is our view from Chicago. Just a word about Rush, Rush is named after Benjamin Rush, who's the only physician assigned to the Declaration of Independence, but he made a name for himself as a doctor when he was the first person to point out the yellow fever epidemic in Philadelphia in 1793. You can see what the solutions for then was, you know, diet and some stimulants and some Peruvian bark, et cetera. His innovation was to add bloodletting and purges to that, which as you might imagine, didn't help a whole lot. Now, we're adding hydroxychloroquine and remdesivir, we'll see how much that helps in the current pandemic. So, it's not surprising that Benjamin Rush's hospital would be built for a pandemic. In fact, our recent addition of the tower 10 years ago was built with the understanding that we would be the bioterrorism and epidemic center for Chicago. So, when COVID came to Chicago, the mayor and the governor pointed to us and said, tag, you're it. So, we have been one of the leaders in this. And not surprisingly, we've been the busiest center in the Chicago area for this since the beginning. If you can take a look at this, you'll see that we screened 18,000 patients with that 5,000 positive. We have 246 admitted right now. Somewhere around half of those are in ICUs. A third of our ED and outpatients tested this weekend were positive. So, this is not going away in Chicago. In fact, today's testing, 40% of our tests were positive. Even though we're doing more and more and more tests because we have more test availability, we're still seeing a lot of positivity. The first graph you see here is the percent of patients in ICU beds that Rush has for the Chicago area. And we've had up to a quarter of the COVID patients in ICUs and on a ventilator at times in the Chicago area. The second graph here you'll see is just taking a look at the where these patients are coming from. They're coming from our emergency department, coming from transfers, and then the proportion of COVID versus non-COVID. We are still taking care of other patients and so on. We take about 1,000 transfers a year in neurosurgery. Those numbers have dropped off somewhat. But the COVID patients are more likely to have stroke, and we are seeing that in Chicago. Nonetheless, we've taken six weeks where we are doing nothing but emergency surgery by state decree. We're opening that up now. The CMS has put out some of its guidelines for this for reemergence. I'm not going to go into detail. Jeff actually did a great job of going over what a lot of those are. They've adopted most of them. We're adopting most of them as well. But some of it's going to be regional. As you can see at UPMC, some of these things aren't quite as urgent as they are in a place like New York or in Chicago. And within the state of Illinois, there's actually 41 counties in the state of Illinois that have zero COVID cases, zero. And then you look at Chicago, and it looks like it's on fire. The Illinois Department of Public Health came out with this recently. We were originally going to open up May 1st. They changed it to May 11th with the following criteria. Maximizing social distancing. They recommended some new workflows. Targeted testing, particularly for procedural patients. Phased reopenings of operating rooms. Eliminating block times in favor of urgency criteria. We just went back to 16 ORs this past Monday. But they're all very, very screened. And they're all based on urgency. And there's no protection for any one service. We all get in line for the same operating room. We've created a case prioritization tool, which I'll show you. But the state has mandated that we maintain 20% of our ICU bed availability as open ICU beds. Now, that's okay if you're a 10-bed hospital and you have two beds open. We can flex up literally, we're at about 150 ICU beds now. But we can flex up to 200 ICU beds, or about 190. So, they're asking us to have almost 40 ICU beds available to flex up, which is, we've had discussions with the state. And they're not interested in our discussion. We simply have to follow their rules. And then we have a COVID Surgical Review Committee. This review committee is key to all this and is leading a lot of our efforts getting back to the operating room. It's led by our former dean. He's been for 13 years. He's a surgeon. He's an active surgeon right now. So, he has a lot of credit and clout within the institution. And people trust him. Chief of Surgery, Chief of OR Nursing, Chief of Anesthesia. And then, of course, they consult with the surgical chairs. So, our plans for post-COVID, which is really kind of during COVID, just reemergence during COVID, is for a weekly expansion in cases, staff, and ORs. We have seven cases going tomorrow. But a lot of those were urgent add-ons. We really aren't going to be doing anything elective until the 11th. Careful measurements of hospital ICU anesthesia and PPE availability. Of course, we can't flex into beds that don't exist. And our rate-limiting step is really going to be ICU bed availability, it looks like now. And then we're planning on ramping up roughly 20% a week as the COVID committee allows us to do. We are doing pre-op routine testing, lab-based testing that takes 48 hours for elective cases with a 95% sensitivity. We're saving our point-of-care rapid testing for emergency cases that has an 84% sensitivity. These are our PPE recommendations, standard PPE for negative low-risk non-airway cases. We're N95 and goggles for positive cases. Our N95 use has gone up quite a bit. I personally, it's difficult to operate in a long case than in a 95. I wore one on Friday, it's not pleasant. We are asking for two negative tests for endonasal or sinus work. This is actually coming from our ENT colleagues. Their societies are asking for this. And if you think about the viral load that you can get from aerosolization from a long endoscopic in a nasal case, I can't blame them for that. We will consider transcranial approaches for a cell or paracellar cases if reasonable as the decocoids is trying to avoid nasal and skull-based cases in positive patients. And then PAPRs we're really just doing for positive emergency cases. Our ENT colleagues are doing them even if it's not positive. This is interesting to note. This is a case that we were going to do today. One of my new junior skull-based colleagues had posted this case and I was going to give him a hand, 14-year-old kid, completely asymptomatic. And we were going to do this today. And unfortunately, his test came back positive, completely asymptomatic. And that's why if you ever get any pushback about, well, we're just going to screen the positive ones, I'll strongly recommend you push back on that. You can imagine the amount of aerosolization that we have in an endoscopic removal of a case like this. This is our OR case prioritization scoring sheet. I won't go into detail about it, but it ranges from eliminating immediate risk of lives through all of the various reasons why you might operate on somebody all the way down to equal benefit medical versus surgical. And then they decide. And then what resources you're going to use. Finally, I'm going to talk a little bit about the economic impact here. A lot of industries are being devastated by coronavirus right now. Here's a list of the obvious ones. There's also quite a bit of devastation to healthcare. You'd think that a surge of patients would bring a business to healthcare, but it actually ends up significantly impacting the bottom line of hospitals and practices. A lot of the private practices are really suffering from this. But most neurosurgeons at this point are either hired by hospital systems or they're hired by universities. And there's a lot of risk right now to these hospital systems and universities, particularly the rural hospitals. And what's happening is besides the fact that there's a lockdown and patients are having a hard time being seen, patients are staying away. They're very frightened of coming to the big centers that have a lot of COVID patients. A lot of patients are losing their insurance right now and are very hesitant to do anything in that circumstance with loss of insurance. Patients now have high co-pays. They have high deductibles. Those will only get higher, unfortunately. So patients are very, very sensitive about choosing to have any healthcare. So one bit of advice I would give you is it's best for you if you're hired by a hospital and if you are hired by a university to keep an eye on what's going on, the financial circumstances of your hospital. You can't go into this blind. I can tell you that every hospital system in America is considering the following GME, GME cuts, PTO time, capital freezes, hiring freezes, protected time, elimination, cutting bonuses, administrative bonuses, furloughing staff. We've looked at all of these at our institutions. We haven't done any layoffs, but depending on how long this goes, and our curve is very flat in Chicago. I mean, every time we look at it, the peak keeps going further into the distance. It doesn't seem like it's really going away. All of these things are gonna be on the table going forward. So it's important to keep an eye on what's gonna happen with your hospital and your hospital system. We're seeing hospital systems fail in this emergency. It's important to know things like the bond rating of your hospital. It takes literally one minute to look it up. And it's all about the understricted cash position, days cash on hand, that's the asset ratio. That's EBITDA, percent funding of pension plan. Our institution is an A1 rating. A lot of the better centers are gonna be around there or maybe a little better. And then when we think about, well, who would bail us out if we had a lot of trouble? You gotta think about your city and state. Chicago and Illinois are literally one step above junk bond rating at this point. So these are all things worth knowing just in case there was an urgency. And if this went on for a year or longer, as some people think it will. In our institution, we just broke ground last year on a new 450 million cancer and neuroscience centers. You can see the picture of it being built here. That hurts our cash position, but all the same, we got into the bond market at the right time and that all went well. Institutions are really gonna be relying on neuroscience and cancer going forward. They are gonna look to us to help bring them out of financial trouble. And I'm just gonna remind myself that back in the time of the great recession 12 years ago, we were in exactly the same scenario. We're building a new hospital tower, $650 million. Everybody was worried about that with the cash exposure and it ended up working out perfectly well. And we're all likely to get through this. So there's gonna be quite a bit of bumpy road ahead of us on the other hand. I'm gonna finally just give a plug to AANF educational materials. This is a AANF webinar, but you just take a look at all the excellent AANF online content and courses. And then finally, I was the scientific program chair for the Boston meeting. And I just want everyone to know that all of that material is going to be released online throughout May. We've got over 200 oral abstracts, breakfast seminars, practical clinic, the brain mapping course and e-posters are all gonna be released in batches throughout the month of May. So thank you all very much for your attention. I hope we have a few minutes for questions. Yeah, thank you very much to our faculty. Thank you, Jeff, David, Rich. Just to remind the audience there, these webinars are saved so you can go back and look them up on the AANF website and review them. I had a couple of quick questions for our faculty here. Rich, I was hoping to start with you. So I've always wondered what the impact on staffing is gonna be several months down the road because of all this news of hospitals potentially going bankrupt and salaries being cut and such. I don't expect your surgery would potentially lose a bunch of staff, but I see a lot of hours in emergency care physicians, maybe ICU staff who might be lost, who might get burnt out. And I'm just curious, do you think there's gonna be a impact on us to really deliver our neurosurgery care because of staffing issues? Yeah, so that's a great question. I think that we're all gonna be asked to sacrifice something eventually, particularly in cities where this may go on for a year or two. I suspect that Jeff in New York City will be in a similar boat. We're gonna end up having to do some cutbacks just in order to maintain a good cash position to make sure that bond ratings are okay. And I can tell you that the trustee finance committee starts off by asking what's the bond position. And there are certain metrics that they're gonna have to follow. Nonetheless, we have to push back for quality and safety and try to protect our teams to the extent that we can. But these are all things that we're all gonna have to think about depending on how long this goes. Hey, Jeff, I had a question for you. You had mentioned the role of using telehealth and how that might be used more in the future. And I have had similar discussions with my colleagues about how we've embraced it and our patients embrace it. And we anticipate really incorporating more telehealth in our future. The one big concern I have though is the huge impact that will have on teaching our students and residents. I mean, we already sometimes struggle with getting those folks into our outpatient clinics to learn how we do neurosurgery in the outpatient clinic. And I worry that our move toward more telehealth is gonna really hurt that experience even more so for our residents. So I'm kind of curious what your thoughts might be with regards to resident education. Yeah, so it's an interesting question. I think one of the new things we're going to have to teach our residents is how to do telemedicine. You know, this is going to be with us and I think it's a real benefit. And so part of that education is learning how to effectively use telemedicine. Now, that being said, I don't see the in-person experience ever going away. I mean, for one thing, we operate on these patients. So they're still coming into the hospital we're seeing them, they're being examined. I can remember back in the day when all patients, pre-op patients were admitted the night before and suddenly insurance companies said, this is crazy. Why are we paying for an extra day in the hospital? And so all the patients were same day admissions. And we thought, my gosh, this is gonna be horrible for resident education and teaching. It turned out to not be because you're still having that patient contact. You're still seeing them. You're still doing a quick H&P in the morning. So whatever we lose in the outpatient clinic experience I think will be gained in the new techniques and skills of using telemedicine. And I think we're never gonna completely get away from that in-person contact. So I think there'll still be opportunities there. Okay, I see that we're at the top of the hour. So that's gonna wrap up this webinar. Thanks again to the faculty for volunteering all your time for this and appreciate those out in the world watching with us. So I wish everybody well, stay safe out there and we'll see you at our next webinar. Take care everybody.

neurosurgery practices

COVID-19 pandemic

panel discussion

reemerging strategies

surgical volumes

less regulation in healthcare

financial challenges

telemedicine

safety precautions