UT Health Austin, Year 3: People, Process, PPE, and Purpose

Page 1


Dedication A Heartfelt Thank You

This year’s review is dedicated to everyone who is contributing their work and expertise to the care and support of others during the COVID-19 pandemic, and to everyone doing the essential work that allows our city, and our society, to thrive. It would be impossible to name every individual (in UT Health Austin, the Dell Medical School, Ascension Seton, and beyond) who deserve our appreciation, but as the stories that follow illustrate, only a motivated, coordinated team could have met a challenge of this complexity and magnitude. While this review focuses exclusively on work related to direct patient care, the positive impact of this amazing team on public policy, education, and the health of the greater Austin community continues to make a real difference in the lives of us all.


CONTENTS 06

28

Part ONE: When Something Small Gets Really BIG

Part THREE: Meanwhile, Back at the Ranch: New Partnerships, New Leaders, and New Opportunities to Make a Difference

08

Silent Thunder; Invisible Lighting: It Begins

30

12

Our Doctors Make Mouse Calls

UT Health Austin and Ascension Seton/Dell Children’s Medical Center Unveil New Partnership Programs

16

33

Part TWO: Every Line is the Frontline; Every Worker is Essential

Looking Ahead: Lessons Learned and a Renewed Sense of Purpose

18

Surgery Slowdown

22

Hospital Ramp-up

26

Contact Tracing (Revisited)

1


INTRODUCTION SCIENCE BECOMES MEDICINE WHEN KNOWLEDGE BECOMES ACTION

Photo provided by Centers for Disease Control and Prevention

UT Health Austin welcomed our first patient on October 17, 2017. Each year since, we have presented an annual review, highlighting some of the successes accomplished by our clinicians and staff during the preceding year. Normally, those accomplishments include introducing new specialty clinics, delivering compassionate healthcare to our patients and their families, and conducting noteworthy medical research, as well as training and mentoring the Dell Medical School’s next generation of clinician leaders. However, as we all know, 2020 turned out to be anything but a normal year. For most of us it started inauspiciously enough, with reports of an unusual, pneumonia-like illness in Wuhan, China beginning in December of 2019. Then, at a pace that felt both deceptively slow, and disturbingly quick, things started happening. The cause of this mysterious illness was a coronavirus, a tiny, spherical particle, only about 120 nanometers (nm) in diameter (for comparison, a human hair is 60,000 to 100,000 nm wide). Each coronavirus particle contains a “single-stranded” RNA genome, which is capable of hijacking a human host’s cellular mechanisms to reproduce itself, even if its own status as a living thing is a function of semantics, at best. It is called a coronavirus because, under an electron-microscope the spikes that project from its surface form a haze-like aura similar to the corona surrounding a star or planet when viewed in the night sky. Since all known coronaviruses that infect humans have been traced back to an animal origin—creatures like bats, civets (small, nocturnal mammals native to southeast Asia), and camels—this one is assumed to have “jumped” species from an animal host, though what host that may be remains unclear. What is clear is that this coronavirus is “novel,” meaning that no one has ever been exposed to it, so no one has immunity against it.

2


So, it spreads. What follows in this year’s rather unique review is the story of how UT Health Austin’s clinicians, staff, and community partners came together to respond to what has become the deadliest global pandemic in over a century. It is a story of professionalism and commitment. It is a story of collaboration and insight. And, while this pandemic has exerted a tremendous strain on every aspect of our lives, exposing long-standing vulnerabilities in our social fabric, and in the American healthcare system as a whole, it is a hopeful story, because it also reveals opportunities for growth; and improvement. As we will see, the ways in which the medical professionals at UT Health Austin and the Dell Medical School are addressing the novel coronavirus pandemic of 2020 contain what is, in essence, a menu of lessons learned that promise to positively impact the ways in which healthcare is delivered in Austin, and beyond. Those lessons include four critical activities:

• Organizing the skills and expertise of experienced clinicians into

carefully coordinated, multidisciplinary teams

• Connecting those teams with real-time information

• Allowing the clinicians themselves to create the kind of practice

environments they need to ensure that that the skills of a range of

supporting staff can deliver maximum impact and benefit for patients

• Utilizing a mix of existing and entirely new technologies that

improve and sustain reliable, omni-directional communication as a catalyst for efficiency, safety, and innovation

It has been said that science becomes medicine when knowledge is put into action to address an illness, ease suffering, and minimize or prevent the damage of disease. At UT Health Austin, we understand that every challenge is an opportunity, and that continuous improvement is a way of life. We have all learned a lot this year, and working together, we intend to spend the coming years putting what we have learned into action.

3


4


5


PA R T O N E WHEN SOMETHING SMALL G E T S R E A L LY B I G

First identified near the Ebola River in Zaire (now the Democratic Republic of Congo) in 1976, the Ebola virus is highly contagious, causes severe bleeding and organ failure, and has a lethality rate of nearly 90% in humans. In September of 2014, several months after an outbreak in a remote village in Guinea, an airline passenger from Liberia died of the virus in Texas, infecting two nurses (both of whom survived) and sparking concern about a possible Ebola outbreak in the United States, over 5,700 miles from the passenger’s point of origin. Multiple organizations around the globe immediately mobilized, successfully containing the virus on site. Famously, Paul Farmer, MD, PhD, Chair of the Department of Global Health and Social Medicine at Harvard Medical School, and co-founder of the international non-profit Partners in Health, said that there are four things that are essential in the fight against the spread of an infectious disease such as Ebola. They are, “staff, stuff, space and systems.” Today, the world is facing another pandemic, officially named “Severe Acute Respiratory Syndrome Coronavirus-2” (SARS-CoV-2) by the International Committee on Taxonomy of Viruses. It is the seventh coronavirus known to infect humans, and while most coronaviruses cause mild upper respiratory tract infections, like the common cold, some, such as SARS-CoV, MERS-CoV (Middle East Respiratory Syndrome), and now SARS-CoV-2, can cause life-threatening disease. The disease caused by SARS-COV-2 is called COVID-19, for COronaVIrus Disease first reported in 2019. It is the fifth documented global pandemic since the 1918 “Spanish Flu,”a pandemic being an epidemic, or a contagious disease originally confined to one region, that escapes containment and infects multiple countries around the world. 1

6


Given the profound impact of pandemic disease on human history, with plagues (a word taken from the Greek “plaga,” which means a “strike” or a “blow”) such as the Biblical “ten plagues of Egypt,” or the bubonic plague known as the “Black Death” (which originated in China in 1334, arrived in Europe in 1347, and reduced the global population from approximately 450 million people to possibly less than 300 million by the year 1400), it might feel a bit remarkable that our collective human response to a new pandemic, at least initially, has changed very little over the centuries: Stay away from other people. That is pretty much it, at least at the start. Which is where Dr. Farmer’s four S’s come in: We need a Staff of appropriately trained doctors, nurses and community healthcare workers, who are armed with the right medical Stuff (equipment), working in a sanitary (and connected/coordinated) Space, using an organized infrastructure of Systems to effectively isolate the illness and treat people who are infected with the pathogen that causes it. Medicine is, after all, an eminently practical science, and art. While COVID-19’s mortality rate is running at about 3% globally, nowhere near Ebola’s 90%, though higher than the 1918 flu’s 2.5%, it has still infected over 35 million people, causing more than a million deaths as of October 6, 2020; with almost seven and a half million cases and over 210,000 deaths occurring in the United States.2 By any measure, this is a public health event of historic proportion, and its impact stretches far beyond the confines of the healthcare world. Culturally, economically, socially, and emotionally, the blow struck by COVID-19 has been profound.

1 Despite its name, the first observed cases of the “Spanish Flu” were reportedly documented in the United States at Fort Riley, Kansas. 2 COVID-19 Dashboard by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University.

7


SILENT THUNDER; INVISIBLE LIGHTING: IT BEGINS

“We knew it was coming. Starting in late December, early January, we heard reports about the ‘Wuhan pneumonia.’ Then came the first confirmed case in the United States, which was someone who had traveled from China to the state of Washington. Then, there were cases reported in Chicago and California. On February 29, we had our first U.S. coronavirus fatality in Kirkland, Washington—which we later found out actually took place on February 6. After that, more cases were reported in a nursing home in that same city. So, we knew it was coming; and we were getting ready.” Amy Young, MD Chief Clinical Officer, UT Health Austin

8


Standing in the fifth-floor service elevator in the parking garage

communities. We were about 180 miles inland, but we were

of the Health Transformation Building, better known to UT

getting ready for Hurricane Camille. We had been following

Health Austin clinicians and their patients as the HTB, Amy

its progress from where it formed as a tropical depression

Young, MD, fully PPE (personal protective equipment) outfitted

south of Cuba. Now it was a Category Five hurricane, and it

in mask, eye protection, gloves, gown and hair covering,

was barreling straight at us. This was 1969. I think Camille

was mentally reviewing, her checklist, again, for collecting

is still ranked as the most powerful storm to ever hit the

a nasopharyngeal specimen from a PUI, or Person Under

Gulf Coast. Katrina was deadlier, and did more damage, but

Investigation. As a surgeon, Dr. Young is a trained checklist

Camille was really big, and I remember my father pulling our

maker. As someone who has spent the vast majority of her

boats into a dry dock, which he had never done before. As we

life within 200 miles of the Gulf Coast, she is also accustomed

were battening down the hatches, he tied a canoe to a tree. My

to disaster planning, particularly for hurricanes, which also

most vivid memory of that night is how that canoe lifted up off

involves checklists. For her, checklists are second nature, and

the ground and thrashed in the wind up on the end of its rope.

as the car she was waiting for emerged onto the parking garage

Then it got really dark.”3

ramp, she couldn’t help but think of a flying canoe. “I was just a little girl,” she explains. “I grew up in Mississippi in a house near this gigantic reservoir, which was a 30,000-acre lake that provided fresh water to the surrounding

3 In all, Dr. Young has experienced five hurricanes: Camille, Allison, Isaac, Danielle, and Katrina. For four of them, she was involved in emergency planning and response in a hospital or health system setting.

9


Standing next to Dr. Young, also gowned and masked, holding a newly arrived test kit, was Jenifer Harrison, RN, MSN, UT Health Austin’s Senior Director of Clinical Operations. The test kit consisted of four vials containing various detection reagents and a reactive media, a sterile swab (which is a really long Q-Tip) that would be inserted far into the subject’s nasal cavity, and a hazardous materials sample container in a sealable, clear plastic bag. As the car stopped and the driver’s side window rolled down, Jennifer

As would soon be widely reported in the media, The

was thinking that, “Yes, this is right; this is the way to do it.”

University of Texas at Austin’s President at the time, Gregory L. Fenves, and his wife, Carmel, had just returned

Prior to this early morning on Thursday, March 12, 2020, Dr.

from New York where they attended several events with

Young and Jennifer Harrison spent a lot of time planning for

UT Austin alumni and students. Even though personal

this moment. They knew it was only a matter of time until

health issues were not normally a topic of public

the novel coronavirus that everyone was hearing so much

discussion, it would be President Fenves himself who

about would appear in Austin, Texas. Its specifics were still

would reveal to the press that he and his wife had both

not entirely clear. It was very contagious, obviously, but just

been tested for coronavirus exposure, an announcement

how contagious, and what its exact method of transmission

that came just a couple of hours after Texas Governor

was, those details were still the subject of study. What was

Greg Abbott declared a state of emergency on Friday,

indisputable was that the disease known as COVID-19 made

March 13. Ultimately, President Fenves’ test came back

a portion of the patients it infected very seriously ill; and

negative; his wife tested positive, and went on to make a

for the elderly, and people with certain pre-existing health

full recovery.

conditions, it could be deadly. As an organization, UT Health Austin needed to be prepared.

“We had been in our regular Wednesday operations meeting,” Jennifer recalls, “working through our plans

“In February, we started screening patients as they came

for moving patients safely through the building, when

in for their regular, in-person appointments,” Jennifer

Dr. Young got the call that we needed to test our first

remembers. “As recommended by public health authorities

patient. I think we were all there, including Kate Nolan, our

at the time, we focused on fever, upper respiratory

Clinical Quality Manager, and Lorrayne Ward, who was our

symptoms, and travel history because we really had no idea

Executive Administrative Director at the time. It was the

how far the virus had spread into the general population.

same core team that would expand to include Dr. Parker

Travel was a key red flag because the virus was obviously no

Hudson, Dr. Rama Thyagarajan, Dr. Mike Pignone, and a

longer confined to the west coast. New York was emerging

whole range of experts, including Dr. Jason Reichenberg

as a major hot spot, which was why we were being so careful

and several other clinicians from Ascension Seton, our

with our first suspected COVID-positive patient: she had just

hospital collaborators. It was this extensive team that

gotten back from a trip to New York. Also, this patient was

became laser focused on making sure we were all doing

the university President’s wife.”

everything we could to keep our patients, our healthcare staff and other critical workers, safe.” With that word, “safe,” in mind, the team had conducted several mock walk-throughs, moving a patient from the lobby, down the hall, up in an elevator, to an exam room for a test, and back. Ultimately, as a group, they decided that what they were doing, was just not going to work.

10


“As we were mapping our patient routes,” Kate Nolan, who

At 5:30 the next morning, Kate got a call at the gym where she

has a Master’s Degree in Public Health with a concentration

was working out. It was Jennifer. Their first test had come back

in Epidemiology, and who is certified in infection control,

positive. An hour later she was in the clinic organizing a nurse

remembers, “I kept a running list of how many people we passed,

triage line, doing her part on a team that was, as of 8:00 a.m.,

and how close to one another we got, especially in the elevator.

running at full speed.

New public health recommendations were starting to emerge that mentioned it would be best to not even let someone who

“From that moment on,” Dr. Young concludes, “everything was

was potentially positive enter the building.”

different. Thinking about that morning made me realize how many hurricanes I’ve seen. Maybe my life experience helped

“And that’s where we were all going in our minds,” Jennifer

prepare me for this pandemic, helped me think about it in a

agrees. “Until you actually walk a patient through the building,

systematic way that influenced our response as a team. But it

you don’t realize how many people are around, how close they

also made me realize that, with something big like a hurricane,

can be, and how many surfaces and objects you touch. I kept

you can see the lightening, you can hear the thunder. It’s all

thinking about everything we would need to clean and sterilize

around you, and you know it. That morning, driving into work in

every time we interacted with a single patient, all day, every

the dark, knowing what was waiting for me, what was waiting for

day. And that’s when I knew that Dr. Young was right when she

all of us, I understood that this time, in this storm, the thunder

brought up the testing they were doing in China and the state of

was silent, and the lightening was invisible. The storm was

Washington, where patients never left their cars.”

every bit as powerful, maybe even more powerful than anything else I’ve ever seen. But this time, keeping track of its size and

In about two minutes the test was done, the sample was sealed,

intensity, and knowing how close it was to home, that would take

and the patient was on her way.

a lot more work than just counting the seconds between the flash of lightening, and the crash of thunder.”

11


OUR DOCTORS MAKE MOUSE CALLS

“After our first COVID-19 patient tested positive, it was just all-hands-on-deck,” remembers Lorrayne Ward, who now serves as UT Health Austin’s Executive Director of Planning and Business Development. “And we were really doing three things simultaneously. First, within 24 hours, we stood-up a drivethrough coronavirus testing capability; with all the personnel, equipment, physical logistics and technical infrastructure needed to support it. Second, we started scaling back our traditional, in-person visits to minimize the risk of exposure for our patients and clinicians, which meant that we had to reach out to every patient who had an upcoming appointment for all but the most serious or acute conditions. And third, we were increasing our telehealth capabilities to connect patients and clinicians so we could offer a meaningful option beyond cancelling or rescheduling. Even during a pandemic, people have health issues that need to be addressed; and while telehealth was already a part of our practice, this was going to be at a scale that was much more pervasive and volume-intensive than anything we had ever done before.”

12


Someone coming to work at UT Health Austin during this initial period invariably walked into a flurry of activity, especially on the HTB’s tenth floor, which is where all administrative functions are located. Conference rooms, offices, cubicles, meeting areas and even hallways were buzzing with people scrolling over screens, talking on desk- and cell-phones, and drawing flow diagrams on white boards (and on more than a few white walls, which would later need to be scrubbed). Coffee cups and snack wrappers, food sent in by local restaurants as their contribution to the effort, and yellow sticky notes and laptops covered every surface. And, something new: The intermittent, rather startled expressions of people who, engrossed in the dynamics of their particular fast-moving team, suddenly realized that they should not be standing so close together, or huddled around the same table, computer, or speakerphone. Some minor variation of the phrase, “You know, we really shouldn’t all be in here,” started drifting around, as the conceptual content of their work intersected with the reality of the moment. “That’s when we added another dimension to our discussions,” Lorrayne observes. “Very early on, while we were still getting our heads around the magnitude of the task, we realized that this wasn’t going to be a one-and-done. It wasn’t going to be a short-term emergency. That’s when we shifted from a ‘whatever it takes right now’ kind of mind-set to a deliberately systematic approach that we could sustain over time. Our single most important resource is our skilled staff, and we put a lot of energy into creating safe and effective schedules to make sure we were balancing COVID-related work and non-COVID-related patient care in our clinics to maximize the reach of our entire team. That included making sure that people took care of themselves, and remembered to do things like eat and sleep.”

The Austin City Limits (ACL) music festival began in 2002 as a single-weekend outdoor concert event staged in Zilker Park, immediately south of Lady Bird Lake. It expanded to two consecutive weekends in 2013, and has since grown into a cultural centerpiece for music lovers near and far. It is also a major economic driver for the city of Austin. In 2019, the festival attracted almost a half a million attendees, and generated about $300M for area businesses, sustaining or creating approximately 1,500 restaurant-, hotel-, and transportation-related jobs. By itself, ACL week generates four percent of Travis County’s total annual hospitality business. On July 1, 2020, the Austin City Limits music festival, scheduled for the early fall, was officially cancelled because of COVID-19.

13


“What really defines that time in my mind,” says Sue Cox, MD,

protect us, never actually happen. Think Y2K, or the Millennium

Dell Medical School’s Executive Vice Dean for Academics,

Bug.

who is board-certified in obstetrics and gynecology as well as maternal-fetal medicine, “was how everyone just wanted to help.

As December 31, 1999 approached, computer programmers

People wanted to roll up their sleeves and do something useful.

everywhere realized that, because of the way a lot of code was

And contact tracing became one immediate need our medical

written, instead of advancing to 2000 at midnight on New Year’s

students could jump in and meet.”

Eve, operating systems around the world could well interpret the 00 rollover as a cue to reset themselves back to 1900. This could

Contact tracing is the process of identifying people who have

make machines that controlled power, water and phone systems,

come into close proximity to an infected person. Ultimately, the

railroad, airlines, and traffic safety networks, and who-knew-what-

goal of contact tracing is to support a population’s first line of

all, to go haywire. So, in the months leading up to the new year,

defense against the spread of an infectious illness, which is called

thousands of hours and millions of dollars were spent correcting

containment. If a virus is not allowed to move from one living host

a potentially disastrous problem. When, at midnight, the problem

to another, not allowed to replicate and grow, it will eventually

failed to materialize, instead of crediting the foresight of a lot of

disappear, or at least be reduced to so small an amount in

tired IT people, most of the world just shrugged it off, wondering

nature that the likelihood of contagion becomes remote. For

what all the fuss had been about. To this day, Y2K is sometimes

example, during the Severe Acute Respiratory Syndrome

used as shorthand for “getting worked up over nothing.”

(SARS) pandemic that was first reported in Asia in February of 2003 (an illness also caused by a coronavirus), containment

Telehealth, on the other hand, is much more obvious in its impact

efforts were so effective that only 8,098 SARS cases were ever

in allowing clinicians and patients to interact while contributing

confirmed world-wide, of which 774 resulted in death. As far as

to the group’s virus containment effort. And there were quite a

can be determined, no other case of SARS has occurred, or at

few clinicians, including Karl Koenig, MD, Medical Director of UT

least none have been reported, since 2004.

Health Austin’s Musculoskeletal Institute, who thought that it was about time we really leveraged this flexible online tool.

“But,” says Parker Hudson, MD, an Infectious Disease Specialist and Director of Dell Medical School’s Internal Medicine Residency

For years, telehealth services have promised to make clinical

program, “for contact tracing to be truly effective, first, it has to

encounters more convenient and, for certain specialists, such as

happen, which can be a challenge because it’s just a ton of work.

nutritionists and physical therapists, potentially more effective.

That’s why we were so fortunate to partner with Austin Public

Telehealth, it was said, could expand the availability of care to

Health and, over time, a group of amazing volunteers, starting

a larger portion of the total patient population, and maybe even

with our medical students and eventually expanding to include

decrease some long-standing workflow issues, such as no-

people from the community who volunteered their time to make

show appointments. However, prior to the COVID-19 pandemic,

a difference. Also, contact tracing relies on the cooperation

concerns about data security, the limitations of some technology

of the people identified as at-risk contacts when they’re asked

platforms, and a reticence on the part of major payors such as

to self-quarantine. Given that COVID-19 has a long incubation

Blue Cross Blue Shield to pay for telehealth, inhibited its growth.

period and, as the evidence would seem to indicate, leaves up to

But then, in March and April 2020, driven by the overriding need

half the people who are actually infected with it asymptomatic,

created by the pandemic to limit the personal interactions of

rendering them oblivious to the danger they pose to the people

people while maintaining their access to care, important payors,

around them, a self-quarantine generally lasts 14 days. That’s a

such as Medicare, began announcing that, at least for the duration

long time, especially as it drags on for the people who otherwise

of the emergency, telehealth visits would be reimbursed in much

feel well and have obligations, like work, that make it very hard for

the same way as in-person appointments.

them to stay home.” “That was an important step,” Dr. Koenig who, in addition to

14

Which points to one of the inherent challenges of epidemiologic

being an orthopedic surgeon has a Master’s Degree in Evaluative

interventions: When done really well, they can seem rather

Sciences from the Dartmouth Institute for Health Policy and

pointless because the things against which they are meant to

Clinical Practice, explains. “Because, at UT Health Austin, led by


forward thinkers like Dr. David Ring4 and Dr. Mark Queralt,5

and the whole integrated range of activities that would deliver our

we’ve always believed that telehealth could be an important part

model of care to patients.”

of a truly patient-centered model of care. If I, as a clinician, can interact with a patient in their own home, it changes the dynamic.

After a no-sleep weekend, the team settled on Zoom as their

It improves communication, and it makes a whole range of

preferred platform because it was easy to use, and could handle

important activities much more convenient.”

the volume of traffic our clinical practice would generate. By Monday morning, UT Health Austin’s transition to a predominantly

As an example, Dr. Koenig cites decreased travel time to and from

virtual practice was well underway. Everyone in the Access and

his office for people who have recently undergone surgery.

Outreach Center (AOC), the scheduling team that serves as the first point of contact for the majority of patients, was trained and

“As an orthopedic surgeon,” he says, “I routinely see my patients

ready to set up virtual appointments in a way that was not only

two weeks post-surgery to determine how they’re doing, and

convenient, but also HIPAA9 compliant, ensuring patient privacy.

to check that their incision is healing well. Telehealth eliminates the need for my patients to travel, which they appreciate. For

“We did several hundred telehealth appointments in the

patients with a hip fracture, who tend to be older and often

first week,” Aaron recalls. “We learned very quickly how well

need to recover in a skilled nursing facility, telehealth allows us

telehealth facilitates a traditional, one-on-one, patient-to-clinician

to avoid using an ambulance to transport them to and from a

interaction. But UT Health Austin is more than that. Our patients

relatively short appointment. It’s quicker, it’s less expensive, and

are the central focus of an integrated care team made up of all

it’s safer; and, when you add some basic tools, like a digital scale,

the various specialists they need for their particular set of issues.

blood pressure cuff, or pulse oximeter, telehealth can potentially

So we made it our mission to make sure that our telehealth

be utilized across a wide-range of specialties. Some services,

service reflected that model of care. It was the clinicians in the

including behavioral health, can actually be improved, because

Musculoskeletal Institute who led the way.”

the clinician has the opportunity to observe and understand the patient’s home environment. While the current circumstances

Today, a Musculoskeletal Institute telehealth appointment at UT

are obviously terrible, the need to keep us all safe during this

Health Austin features a virtual lobby where the patient is greeted

pandemic has jump-started telehealth as a clinical tool; over time,

by a medical assistant (MA) who performs a full check-in before

I think that’ll prove to be an impactful change.”

returning, virtually, to another room in which the full care team is gathered to review the patient’s situation. Each provider then

Aaron Miri, CHCIO,6 Chief Information Officer for UT Health Austin

visits with the patient and conducts their part of the interaction.

and the Dell Medical School, agrees, adding, “When it became

Multiple providers interact with the patient individually, or as

obvious that we needed to have a technology solution up and

a team, with various conversations continuing uninterrupted

running as soon as possible, the Information Technology team

throughout, and hand-offs happening between providers in real-

knew we had three hurdles to overcome. First, we simply could

time.

not compromise on a single regulatory, compliance, or security issue because, as we always say, healthcare is really about trust.

“The result is a simple-to-use service that is virtually identical to

Patients need to have complete confidence that their interactions

an in-person experience,” Dr. Koenig concludes. “It’s convenient,

with their care team are private, and that their personal health

and patients love it. Anyone with Internet access can use the

information is secure, which is where we really relied on our

service, and Aaron and his team made sure that it works on

compliance experts, Leah Stewart and Tim Boughal. They put

multiple devices, including smart phones. To me, this way of

in a lot of long days and nights working through the most exacting

partnering technology experts and clinicians to develop solutions

details. Second, there was the physical equipment, all the devices,

that fundamentally improve the way healthcare works, makes me

cameras and speakers that needed to be acquired, distributed,

feel optimistic about the future. I very much hope that the progress

connected, networked and managed. And third, there was the

we’ve made in the telehealth space during this very difficult time

online platform itself. As everyone in the industry knows, there is

persuades insurers and other payors that the changes they

no clear telehealth leader; everyone does it a little differently. Plus,

made in covering these kinds of appointments should become

we have the added complexity of being an academic healthcare

a permanent part of the choices Americans have when they are

organization. So the solution we implemented needed to support

deciding what is best for them and their families when it comes to

the clinical practice, the residency program, the medical school,

receiving the healthcare services they need.”

7

8

4 Upper Extremity Clinical Director, Musculoskeletal Institute 5 Clinical Director, Back and Neck Pain Center, Musculoskeletal Institute and Mulva Clinic for the Neurosciences 6 College of Healthcare Information Management Executive (CHIME) Certified Healthcare Chief Information Officer (CIO) 7 Leah Stewart, J.D., Dell Medical School Associate Vice President for Legal Affairs. 8 Timothy Boughal, Senior Compliance Officer, Dean’s Office, Dell Medical School. 9 HIPAA, the Health Insurance Portability and Accountability Act of 1996, is a federal law that protects sensitive patient health information from ever being disclosed without a patient’s knowledge or consent.

15


PA R T T W O EVERY LINE IS THE FRONTLINE; EVERY WORKER IS ESSENTIAL

“In addition to PPE, or ‘personal protective equipment,’ another new phrase to enter the public pandemic lexicon is the ‘R0’ (pronounced R-naught, or R-zero) number. Simply stated, in epidemiology, the R0 number is a mathematical way to determine if a communicable disease is spreading or not. It represents the expected number of new infections caused by contact with one infected person in a population in which no one is immune to the disease. So, if the R0 number is greater than one, the infection is spreading; an R0 number of less than one means that the infection will eventually burn out. Like any data-driven model of an actual, ongoing event, the R0 number has its limitations. But it’s a useful tool for helping decision-makers in the planning process, and it gets more accurate as more information becomes available over time.” Parker Hudson, MD, MPH Assistant Professor of Internal Medicine and Infectious Diseases, Program Director, Internal Medicine Residency, Dell Medical School

16


“I was born in Japan, and that’s where my parents and my brother still live. Japan was hit by COVID-19 earlier than the United States, and one day, when I was talking to my parents on the phone, I asked them if there was anything they needed. They said things like hand sanitizer and face masks were getting hard to find, so I went to the store and filled a big box with supplies and shipped it off to them. I remember arranging the pump bottles and face masks in that box very vividly, because, you know, my dad is in his eighties. I was concerned. But then, it was only a few weeks later, as Japan’s containment strategy was dropping their new case rate, when my parents, who pay attention to American news, started worrying about me coming in to work every day.” Lorrayne Ward, MBA, MPP Executive Director, Planning and Business Development, UT Health Austin and the Dell Medical School

17


SURGERY SLOWDOWN

“The number one thing that kept me up at night during the pandemic’s initial phase was making sure our hospital was ready, and that our healthcare workforce was safe.” Michael Pignone, MD, MPH Chair, Department of Internal Medicine Dell Medical School

In any complex system, changing how one part of the system functions invariably impacts how the rest of the system works. Much like how making a change to where a particular subassembly is first introduced into an assembly line can fundamentally impact the integrity of the entire process, altering how an important part of a hospital’s daily operation is managed can create ripples across dozens of critical functions throughout the organization. As UT Health Austin’s ambulatory (or outpatient) care clinicians were working through the details of “drivethrough” coronavirus testing (for suspected infections among our patients and as a safety measure for associated healthcare professionals, including at the Dell Seton Medical Center at The University of Texas hospital), contact tracing, telehealth visits and the workforce changes related to a shift from a majority in-person to a substantially remote-patient model of care, Kevin Bozic, MD, Chair, Dell Medical School Department of Surgery and Perioperative Care and Executive Director of UT Health Austin’s Musculoskeletal Institute, was deeply involved in some very complicated system-level thinking. “Working closely with our partners at Ascension Seton,” Dr. Bozic says, “our team focused on doing everything we could to help prepare our hospital environment to maintain efficient operations if, as we were seeing in Italy and later in New York, we experienced a dramatic increase in COVID-19 admissions here in Austin. Because surgery is an inherently high-risk activity for patients and medical staff, it was our responsibility to ensure that every procedure we performed was carefully and thoroughly thought through. We started that process by first addressing our elective surgery protocols.”

18


Elective, or as it is also called, planned surgery, is any surgery that can be scheduled in advance. Unlike urgent, or “emergent” procedures, which are always prioritized, elective surgeries, while they do address conditions that cause pain or limit function, are performed to improve a patient’s quality of life

safety lens. We had to ask ourselves: Are we bringing patients of

rather than to save the patient’s life, or to preserve a limb.

unknown COVID-19 status into the hospital and thereby exposing

Elective procedures are often categorized by how long a patient

healthcare workers and other patients to what could actually

can safely wait for a surgery to be performed. For example,

be unnecessary risks in order to perform elective procedures

Category 2 elective surgeries are for treatments that should

that could safely be postponed? The availability of PPE was also

happen within 90 days, while Category 3 procedures can be

being considered, so we had to determine if we were using scarce

safely scheduled any time in the coming year. Examples of

PPE and other resources that would be more urgently needed

elective surgery include hip or knee replacements, hernia

in the emergency department (ED) or ICU. And then there was

repairs, and cataract extractions.

bed capacity, and potentially using ICU beds and ventilators that would soon be in very high demand. We were looking at models

The primary issue that made surgery become the focus of

that suggested that we could soon see tens of thousands of

so much attention was a dual concept that quickly assumed

patients overrunning our hospitals. There was even talk of setting

center stage in both the healthcare community’s planning

up overflow tents, which we did eventually see in other, highly

efforts and the media’s coverage of the evolving pandemic. This

impacted cities.

was the relationship between “flattening the curve,” or lowering the new infection rate in the population through containment

“So, we organized a group of surgeon leaders and hospital

strategies such as social distancing and temporarily closing

administrators, led by Stuart Wolf, MD, Associate Chair of Clinical

high-risk gathering places (e.g. bars and restaurants), as a

Integration and Operations, and Co-Chair of the Ascension Seton

way to prevent a major influx of newly infected patients all

Surgical Network Clinical Care Council, that met every day. We

seeking hospital care at the same time, which could potentially

coordinated with Ascension leadership in St. Louis, who provided

overwhelm the system; and, simultaneously, “raising the line,”

guidance we could use as we made local decisions. And we talked

which meant increasing the capacity of local hospitals to treat

to our colleagues around the country at places such as Johns

large numbers of seriously ill, and infectious, patients. Raising

Hopkins, the University of Michigan, Geisinger Health System,

the line meant increasing the availability of both Intensive Care

Duke University and Mass General, to share our experiences and

Unit (ICU) beds, and the ventilators (machines that pump

learn about what they were doing in their facilities. The result

oxygen into a patient’s body, helping the patient breathe, or

was a temporary, but very substantial slowdown in the number

even breathing for the patient) that were initially so much a part

of elective procedures our surgeons were performing, which

of COVID-19 critical care.

created an entirely new set of issues.”

But it was even more than that.

Suddenly, as Dr. Bozic recalls, surgeons who had been extremely busy, found their schedules essentially cleared.

“Every change that was made inside the hospital in preparation for this anticipated influx of COVID-19-positive patients

“These are very skilled, very motivated medical professionals

impacted some other part of the hospital,” Dr. Bozic explains.

with a lot of experience,” he says. “And they wanted to help.

“When we evaluated our elective surgery protocols, it was

So, we organized a task force to work through the logistics of

through a stringent

redeploying surgeons to do COVID-related work. For example, our orthopedic surgeons could go to the emergency department and take care of all the musculoskeletal complaints so the ED physicians could concentrate on triaging other emergencies. We had general surgeons who could go to the ICU and care for non-COVID-19 patients, allowing our critical care clinicians to focus their attention on the patients who needed their skills the most. We had our plan, we had our people, we were ready. But the citizens of Austin had a surprise in store for us, because that initial tsunami of seriously ill patients didn’t happen.”

19


On Tuesday, March 24, Mayor Steve Adler’s “Stay Home—Work

changing. Patients who are in pain will often have their surgery date

Safe Order” closed all Austin bars and restaurant dining rooms for

set in their mind as the day their journey to a more comfortable life

the next six weeks in order to prevent the spread of coronavirus.

will begin. But as the pandemic drags on, more people are losing

The order, which also limited social gatherings to 10 or fewer

their jobs, and their insurance. There are new considerations and

people, was respected by the vast majority of Austin residents

new consequences. And for many, just coming into the hospital

who, according to a research paper in the “Proceeding of the

feels like more of a risk than before. COVID-19 has a long reach,

National Academy of Sciences of the United States” (PNAS) ,

which is why the work we did creating a clear, data-driven plan for

achieved an initial drop in projected COVID-19 transmission rates of

how we can safely balance the surgical needs of our patients with

approximately 95%. Since that time, through periods of state-wide

the realities of the current circumstance is so important.”

10

11

“re-openings,” the rates have risen and fallen, making the work accomplished by Dr. Bozic and his surgical planning groups in the

And what really impressed Dr. Bozic, he emphasizes, beyond just

first month of the pandemic all the more prescient.

the willingness of everyone to contribute their own skill set to a larger, collective effort, was the level of collaboration among all

“As we know,” he observes, “surgery is a significant part of a

the various stakeholders, here in Austin, and well beyond. The UT

hospital’s operations, and altering a surgical schedule impacts

Health Austin clinical practice, the Dell Medical School, Ascension

everything from laboratory services to supply orders and room

Seton, privately practicing physicians throughout Austin, the Travis

scheduling. We are also an academic organization, so we have

County Medical Society, Austin Pubic Health, Central Health, the

residents in training and other students who rely on the learning

Community Care Collaborative, the State of Texas, and more, came

experiences they have in the operating room as a valuable part of

together to do what is best for the community, and for patients.

their education. And then there are the patients themselves. While an elective surgery may not be considered life-saving, it can be life-

“As we weather this pandemic,” Dr. Bozic concludes, “we’ll continue decreasing and increasing the number of surgeries we do based on the rate of transmission we’re experiencing, the number

10 Extended several times, “Stay Home, Mask, and Otherwise Be Safe” orders are currently in effect through December 15, 2020. 11 Timing social distancing to avert unmanageable COVID-19 hospital surges. Daniel Duque, David P. Morton, Bismark Singh, Zhanwei Du, Remy Pasco, Lauren Ancel Meyers. Proceedings of the National Academy of Sciences, Aug 2020, 117 (33) 19873-19878; DOI: 10.1073/pnas.2009033117

of COVID-related hospital admissions we’re seeing, the availability of PPE and ICU beds, and the severity of the cases we are called upon to treat. To maintain that real-time flexibility, we’ll rely on this network of information and communication we put in place, on testing and contact tracing, and on this ever-expanded tool of telehealth. But it’s the way we’ve all come together to make sure that we can continue delivering care safely through the peaks and lulls of this ongoing emergency that has proven, at least to me, that when we work together, with our community as our focus, we’re capable of meeting any challenge that comes our way.”

20


21


H O S P I TA L RAMP-UP “Okay,” says William Brode, MD, assistant professor in Dell Medical School’s Department of Internal Medicine and a practicing clinician in the Dell Seton Medical Center at the University of Texas, “the other day I administered holy communion for the first time. So, that was new. I was in the patient’s room, full PPE in compliance with our anticontagion protocols, while a priest stood socially-distanced out in the hall and talked us through it. I went to Fordham University in the Bronx, which is a Jesuit school. But, I wasn’t a science major. I actually majored in peace and justice. So, I guess there’s a thread in there somewhere.”

Dr. Brode has some experience with new experiences. After graduating from Loyola University of Chicago with honors in global health, he worked in rural Bolivia to improve diabetes treatment. He served as the chief resident of global health through the University of Washington in partnership with the University of Nairobi in Naivasha, Kenya (where he taught both American and Kenyan medical trainees). He is a medical educator with a particular interest in improving the ways in which the medical system connects patients to the healthrelated community resources they need. And he was there, on site, as the team at Dell Seton Medical Center, made up of Ascension Seton, UT Health Austin, and Dell Medical School clinicians, got ready for what pretty much every model agreed would be a crush of COVID-19 patients.

22


“Though it didn’t last,” he remembers, “at the very start, the

Medical School clinicians who went to New York to volunteer

hospital became weirdly quiet, feeling almost empty. There was

when New York was surging, and their experiences were

a short period of time in which we were dramatically drawing

invaluable here at home. We had nurses travel to assist

back on elective surgeries while the general public was hearing

Ascension hospitals in Detroit and they brought their

more and more about this communicable virus every day. Johns

learnings home to us as well.”

Hopkins was tracking cases on a new website that everyone seemed to be looking at, and people started second-guessing

Immediately following the first verified case in Austin on

whether they really needed to see a doctor, or if they even wanted

March 13, the new case rate in Travis County started rising,

to be around medical stuff for a while. So, we had what amounted

though not at the precipitous slope some models predicted.

to about a 10-day dress rehearsal which, in retrospect, was really

But Austin was by no means spared, and cases reached

helpful. It allowed us to get the hospital wards, the nurses, and

their most alarming heights (so far, at least) between

all the other team members, the pharmacy, respiratory therapy,

the beginning of June and about the middle of August,

Emergency Department, and the staff all organized and aligned.

peaking at 753 new cases reported in a single day on July

Which was important because, once confirmed cases started

8. It is the nature of this infectious disease that creates the

arriving, things could change on the floors very quickly. It wasn’t

roller coaster graphs that are becoming the signature of

long before circumstances demanded that, in everything we did,

COVID-19. Clinicians soon came to understand that the

we worked as a flexible, highly-integrated, high-functioning team.”

virus spreads very efficiently through microscopic droplets released when people sneeze, cough, talk, sing, or breathe,

Our preparations were a concerted effort,” says Elizabeth

and that symptoms first manifest anywhere between five

Schulwolf, MD, Medical Director of the Dell Seton Medical Center,

to 14 days following infection. About half of everyone who

and an associate professor in Dell Medical School’s Department of

has the virus, doesn’t know they are sick, but they are still

Internal Medicine. “And it wasn’t exclusively local. We had national

contagious, and with the summer months, nice weather,

support with resources, resource allocation, and the sharing of

holidays, barbeques, family trips, parties, and other group

best practices and protocols for taking care of patients from a

activities, these “super-spreader” events reveal themselves

structural perspective, much of which was informed by what we

as rolling spikes in new cases (and hospital admissions) in

learned from New York. We had a couple Ascension Seton/ Dell

the following days and weeks.

“As COVID-19 spread, the availability of personal protective equipment such as the now-famous N95 face mask, quickly became a significant issue— as both a current, here-and-now problem, and an important factor in the planning work we were all doing around hospital-based operations. Every surgical procedure requires an adequate supply of a range of equipment to keep the patient, and the clinicians, safe. I was privileged to be part of the group responsible for balancing the competing priorities that emerged as we did everything we could to contain the spread of the novel coronavirus while ensuring that patients continued to safely receive the care they needed. The conversations were detailed, and each situation was carefully reviewed as we considered the personal healthcare needs of each individual patient, while also understanding that we had a responsibility to the public health and well-being of the wider community. “As a result, I have to say that I’m incredibly proud to work with organizations that handled the COVID-19 pandemic so well. UT Health Austin/ Dell Medical School and our colleagues and partners at Ascension Seton were thoughtful and measured in our approach to the ongoing emergency, incorporating changes in the data we received with deliberation and care. “Personally, I think the most significant lesson I took from this experience, is that we must all accept that the information upon which we base our decisions is a moving target. As an integrated team we learned that no data set, which is really just a snapshot of a moment in time, is perfect or totally complete, so the decisions we make will inevitably change as our knowledge base evolves. While that might make our work more challenging, it also means that we have the opportunity to learn and grow, which is the very definition of a data-driven, continuously-improving system of care.” J. Stuart Wolf, Jr., MD, FACS Associate Chair of Clinical Integration and Operations, Professor and Division Chief, Surgical Subspecialties, Department of Surgery and Perioperative Care Dell Medical23 School


“So, what we were really doing was two things,” explains Dr.

able to crank up virtual meetings comprised of the right

Schulwolf. “First, we were, as they say, raising the line, which

people, who are all now familiar colleagues, and make

means we were working to increase our hospital’s capabilities

decisions based on new knowledge and experience.”

so that we could care for whatever patient load we faced. And second, we were quantifying how we treated COVID-19 patients,

It is exactly at the intersection of new knowledge and

creating a system through which we could document what we

experience that Dr. Brode spends a great deal of his time.

were doing, when we were doing it, and how effective our efforts

Together with Saurin Gandhi, DO, (who became “editor in chief”

were so that we could learn, literally, from every single patient we

of what soon turned into a formal, collaborative project), and

treated, and use what we learned to treat the next patient just

Kristin Mondy, MD, Chief of Division of Infectious Disease and

that much better.”

an associate professor in Dell Medical School’s Department of Internal Medicine, he helped develop what became known

A central concept in raising the hospital’s capacity is called

as the “COVID-19 Manual,” a resource that, over the course

“cohorting,” a process in which trained teams of clinicians are

of its many drafts and revisions, has become something of a

dedicated to identified ICU and non-ICU areas that only treat

guide for hospital services as well as the group’s most current

COVID-19 patients, and that can be created and repurposed

understanding of a variety of therapeutic issues.

as volume demands. To prevent cross-contamination between patients and clinicians, stringent isolation practices require every

“We started writing in late March, just before the first meeting

person entering these designated areas to be appropriately

of our therapeutics committee,” Dr. Brode recalls. “We’re an

protected by PPE. And visitors and other non-essential human

interdisciplinary, interprofessional group that was formed

contact is prohibited (a deeply unsettling aspect of this disease

because, even though we were being called upon to treat

that has led to so much emotional and psychological pain for

COVID-19 patients, there were a lot of unknowns. We needed to

families enduring the uncertainty and stress of a loved-one’s

establish good clinical guidelines for our care and, as evidence

illness while being prevented from physically sharing space or

for certain treatments began to emerge and we increased

providing the comfort of personal contact). Because a hospital

our own direct experience as we cared for these patients,

must care for COVID-19 patients while also maintaining its other

we needed a way to iteratively evaluate and operationalize

essential medical services, all efforts must be made to protect the

treatments. Because it seemed like every patient encounter

healthcare workforce, all the while making sure that the hospital

we conducted revealed something new about the particulars

itself does not become an amplifier of the disease. Also, over

of our work, we started creating a manual as a way to collate

time, a hospital’s staff may be required to stretch itself in terms of

important information and standardize our operations. We

hours committed and roles performed since, as has happened so

had our providers shadow other experienced providers for

often around the country, total staff availability can be impacted

in person-training, and our faculty and residents all pitched

when medical professionals themselves get sick, or are forced to

in and contributed different sections of the manual. The first

self-isolate following a suspected coronavirus exposure.

time I sent out a summary of our work to date, I didn’t know exactly what to call the contents of that summary. So, I said

“The amount of coordination is tremendous,” Dr. Schulwolf

that they were our ‘consensus recommendations.’ Everyone

says. “And I learned a few things about myself as a leader in the

liked that, and soon the work was compiled into a full packet

process. Probably the most important thing I learned, from a

of ‘therapeutics committee consensus recommendations’

system perspective, was that, even though I didn’t necessarily

which is now a living document that is updated regularly as

want to have a lot of meetings, particularly at a time when there

our experience with things like convalescent plasma, and the

was so much work that physically needed to be done, as an

latest medical literature, guides our progress.”

organization, those meetings were incredibly important. We had to get all the stakeholders together, being mindful of their time

And, that progress has been impressive.

while making sure that everyone felt heard, and invested. Later, this work paid dividends because the dynamic we created at the

“I think there are a lot of reasons for the success we’ve achieved

beginning translated into quicker, more efficient interactions later

to date,” concludes Dr. Schulwolf. “First and foremost, there’s

on. Now, given the demands of our work, and the pace at which

the dedication of the team, and the way they work as a group.

we are learning about this disease, practically every new memo

Our nurses are amazing, and with our low nursing ratios, we

that comes out has the potential to evolve what our teams are

are able to

doing during the next hour. Getting everyone physically together doesn’t always work, but we’re

24


care for patients in our acute care units who otherwise may have needed to be in the ICU. Actually, beginning in July and running through late October, as a system, we decided to cohort all COVID-19 cases here at the Dell Seton Medical Center, not only so we could consolidate our resources, but because our teams function at so high a level that, when we analyzed our data from April through June, we discovered our mortality rate was significantly below even our most optimistic projections. “That’s a source of real pride for all of us, and it’s the kind of achievement that only happens when you have creative, innovative people participating in a system of care that encourages them to bring their ideas to the table. They need to be heard, and they need to see their contributions actually put into practice where they can make a difference. From ideas about how to better conserve PPE, to improving our treatment protocols, to delivering care that nurtures our patients and their families in a way that help them understand that, even at a time when being apart is a critical part of the process, they really aren’t alone, it has been personally gratifying for me to see how our teams have stepped forward and distinguished themselves. To a great extent, I credit Amy Young and our Seton executive and network leadership teams for providing an environment, a forum, really, that helped bring people together across Dell Medical School and Dell Seton Medical Center in a more productive way. Getting to know one another as people, and as professionals, has built bridges between clinicians, creating a level of collegiality that, I believe, may well be the most lasting legacy of this entire experience.”

“I liken what is happening with the COVID-19 pandemic, a little bit, to the beginning of the AIDS epidemic, when healthcare professionals were seeing cases coming in that they had never seen before. People were dying at an unbelievable rate, and we didn’t understand why, or know what to do. Emotionally, psychologically, it’s like a war. The threat is real, it’s external. It’s a new virus, an unknown enemy. We don’t know how long it’s going to go on; we don’t know how long this road is going to stretch out before us. With COVID and the AIDS epidemic, though there are obviously specific differences, there is one key similarity, and that’s uncertainty. “When you talk to healthcare workers today, even the most experienced intensive care workers, nurses and doctors, the most experienced emergency room doctors, they’ve never experienced anything like this. We’ve seen healthy 30-year-olds come in, test positive, and then a few days later, they’re dead. And we don’t know enough about the virus to know why they are so susceptible. It’s not just about age, or genetics, or concurrent medical conditions. We’re fighting this enemy, day after day, and it creates anxiety because, in addition to the patients in your care, you have your own life. Your spouse, your kids, aging parents and friends. And you have to worry, ‘Am I going to bring this infection home with me?’ “Because the situation is long-lasting and, to a great extent, defined by uncertainty, we developed our mental health hotline, which is a collaboration between the Dell Medical School Department of Social Work and Department of Psychiatry, and Ascension Seton. We now have mental health professionals available 24/7 to provide emergent and anonymous mental health care for healthcare workers. This is the most significant experience of our lifetimes. And as experienced as healthcare workers may be, they’ve never experienced anything like this. It’s our privilege to provide this service because, by taking care of our healthcare workers, we’re helping take care of us all.” Charles B. Nemeroff, MD, PhD Matthew P. Nemeroff Endowed Chair, Professor and Chair, Department of Psychiatry, Director, Institute for Early Life Adversity Research, Dell Medical School

25


C O N TA C T T R A C I N G (REVISITED)

On Thursday, September 10, 2020, Christina Salazar, MD, a boardcertified obstetrician-gynecologist in UT Health Austin’s Women’s Health Institute who specializes in the management of complex conditions such as endometriosis, chronic pelvic pain, and ovarian cysts, performed the very first surgery in UT Health Austin’s brand-new Ambulatory Surgery Center. Located on the first floor of the HTB, the newly designed surgery center is fully equipped with the latest technology and devices, and features three state-of-the-art operating suites, generous and well-equipped postanesthesia areas, and 13 private, 110 square-foot rooms that enable patients to prepare for and then recuperate from surgery with their families present for support. As an accomplished surgeon, and as the medical lead who oversaw the construction and final go-live of the new facility, Amy Young, MD, a boardcertified gynecologist who is also the Dell Medical School’s Vice Dean of Professional Practice, scrubbed up and was present to observe the first practical use of the new space.

26


“In the best of times, under normal circumstances, starting a new

by (ideally) noon each day. Called the “COVID-19 Minute,” it

Ambulatory Surgery Center is a lot of work,” she says. “But the

became, and remains, the single most reliably-opened email

COVID-19 pandemic made the process all the more challenging.

during the pandemic. And it is an example of how effective

With so many people giving so much of their time and effort to see

communication can help a lot of busy people work together, even

this project through, I simply had to be there when it all culminated

when being together is about the last thing they can do.

into exactly what everything we do is all about: Delivering the best possible care topatients. That group effort, from designing all the

“Throughout this experience,” concludes Dr. Young, “what

necessary physical details on a blueprint, to seeing every individual

we created was an integrated system of care. We utilized the

component functioning in its place, for me, captures the essence

knowledge and the resources that we had available to create a

of what’s been happening throughout our practice, with our faculty

system in which we could see what was going on in the hospital,

and staff, and all our partners, especially Ascension Seton. And

and tailor what we were doing upstream and downstream in the

it’s something that we can’t lose sight of, because it’s crucial:

ambulatory space to affect the work the inpatient teams were

Through everything, through the pandemic, the uncertainty and

doing. We created a system that allowed us to take care of people

the shortages, these healthcare professionals came together and

in our community in a way that was transparent to every clinician,

they took care of the patients who needed them. And that’s exactly

educator, researcher, and leader.

what they continue doing, every day. They’re working, innovating, learning, and using the latest available tools and information to

“We had a common purpose, and collaboration and

take care of patients. Every day. That’s why we’re here.”

communication, were key. We came together in an environment where we each did our absolute best individually and collectively,

As an example, Dr. Young proudly sites the contact tracing system

where we focused on applying our skills to the best of our abilities,

originally developed as a tool to augment the testing work first

and we trusted everyone else in that system, to do the same. And

started as a containment strategy in the fight against a spreading

we got it done.

virus. Refined and streamlined, this system has been expanded to contribute to the efforts of multiple departments and groups

“We aren’t finished, there is still no cure for this disease, and

across The University of Texas at Austin to keep the students,

when (and if) a vaccine becomes available, there will be plenty of

faculty, and staff who returned to campus in September to begin

issues related to production, transportation and distribution to

the Fall Semester healthy and safe. Several clinicians, including

work through. But we elevated the level of care delivery with our

Dr. Young, are working with university groups that represent

partners in our community when it counted. We were able to all

disciplines and activities as diverse as Language Pathology, the

focus on our larger goal, and I think that we all see that the system

School of Nursing, University Health Services, Texas Athletics,

we still are creating is full of potential for the future. While, in some

and IT, creating evidence-based guidelines to inform plans of

ways, this system of care might be seen as a conclusion, as the

action for organizing classrooms, essential in-person services

result of our work, I think that it’s actually a really great place to

such as security and food preparation, and systematic and

start.”

ongoing population testing. As experience demands, these guidelines are continually iterated and updated. And the university’s communications professionals are keeping everyone informed through the concise, frequent dissemination of reliable information. Which was yet another lesson learned. All through the pandemic, a leadership team of over 30 UT Health Austin, Dell Medical School, and Ascension Seton clinicians and staff came together as the “COVID-19 Task Force” in a Zoom virtual meeting every morning at 7:45. While the frequency of the meeting varied over time, from seven days a week, to five, three, and now two days per week, the one thing that never varied was the two-page summation of the day’s discussion sent by the Dell Medical School’s Communications team to the entire staff by

27


PA R T T H R E E : MEANWHILE, BACK AT T H E R A N C H : N E W PROGRAMS, NEW LEADERS, AND NEW OPPORTUNITIES TO MAKE A DIFFERENCE

28


29


U T H E A LT H A U S T I N AND ASCENSION SETON/DELL CHILDREN’S MEDICAL CENTER UNVEIL NEW PA R T N E R S H I P PROGRAMS

While addressing the impact of COVID-19, the disease caused by the novel coronavirus SARS-CoV-2 pandemic, was obviously a major priority of 2020, other aspects of the UT Health Austin clinical practice could not, and did not stop making forward progress. Below, are just two highlighted examples of the collaborative work our clinicians accomplished over the past 12 months. Heart Failure, VAD (Ventricular Assist Device), and Transplant Program On Friday, July 31, the Texas Center for Pediatric and Congenital Heart Disease at Dell Children’s Medical Center, in partnership with UT Health Austin, the clinical practice of the Dell Medical School at The University of Texas in Austin, announced the opening of the Heart Failure, VAD, and Transplant Program, the first pediatric heart transplant program in Central Texas. The heart transplant team includes UT Health Austin nationally recognized pediatric heart surgeons Carlos Mery, MD, Charles Fraser, Jr., MD, and Ziv Beckerman, MD, as well as Dell Children’s Medical Center’s pediatric cardiologist Chesney Castleberry, MD. The collaboration between Dell Children’s Medical Center, UT Health Austin, and the Dell Medical School at The University of Texas at Austin brings together medical professionals, medical school learners, and researchers who are all part of the integrated mission of transforming healthcare and redesigning the academic health environment to better serve society.

30


“Two years ago, we made a commitment to create a program that

is a miraculous thing and there is pretty much nothing like it in the

would really provide the very best care possible to children and

entire field of congenital heart disease; Taking a child that’s heart has

adults with congenital heart disease, so they would not need to, or

stopped functioning as it should, and providing them with another

want to, leave their community to seek care elsewhere. This is a big

chance at life,” says Dr. Ziv Beckerman.

step in honoring that commitment by being able to provide care to the most vulnerable of our population, children with end-stage heart

The Heart Failure, VAD, and Transplant Program projects anywhere

disease in which the only hope is to replace their own hearts,” says

between two and six transplants will be completed within the first

Dr. Carlos Mery, Surgical Director of the Heart Failure, VAD, and

year of practice with the goal of growing the practice to complete

Transplant Program.

as many as 20 transplants in a given year, which is on par with large transplant centers.

The Texas Center for Pediatric and Congenital Heart Disease at Dell Children’s Medical Center is the only pediatric program in

New Digestive Health Comprehensive Gastroenterology Care

Central Texas offering comprehensive heart care for newborns,

Clinical Partnership Program

infants, and adolescents. This cardiac care unit is fully equipped with

UT Health Austin and Ascension Seton are excited to announce a

state-of-the-art equipment and provides patients with an advanced

new Digestive Health clinical partnership that brings together medical

transplant multidisciplinary care team to manage all aspects of pre-

and surgical specialists, integrated behavioral health experts, and

and post-transplant care.

medical researchers to provide comprehensive care for general gastroenterology (GI), inflammatory bowel disease, and disorders of

“To be able to offer, for those who critically need it, a cardiac

the liver, pancreas, esophagus, and more. This collaboration allows

transplant opportunity is really part of our commitment to the

for specialized teams across healthcare entities to come together

holistic care of children and families with cardiac disease. It’s also an

under the mission of transforming healthcare and redesigning the

imperative part of a tier one congenital heart surgery and cardiology

academic health environment to better serve society.

program, which we seek to have here,” says Dr. Charles Fraser, Jr., Director of the Texas Center for Pediatric and Congenital Heart

Housed in the clinical spaces at UT Health Austin with access to the

Disease at Dell Children’s.

full-scale hospital resources at the neighboring Dell Seton Medical Center at The University of Texas and other Ascension Seton

In 2018, the Texas Center for Pediatric and Congenital Heart

locations across Austin, the Digestive Health team has the ability

Disease was established and is still led by Dr. Charles Fraser, Jr.,

to provide the most advanced treatments available to patients

whose vision for the Texas Center for Pediatric and Congenital

in Central Texas and beyond with a focus on patient-centered

Heart Disease is to build on his experience to optimize the entire

outcomes, cutting-edge research, and medical education.

continuum of care of patients with congenital heart disease in a compassionate, calm, gentle environment that also nurtures and

“This is our first clinical practice partnership with UT Health Austin,

supports patient families.

bringing together the best of clinical and operational expertise to expand our specialty care to serve our community,” says Clay

“I’ve seen so many kids from my community have to relocate all or

Carsner, Chief Operating Officer at Ascension Medical Group

part of their families a significant distance and wait for six months

in Texas. “Together, we are advancing the latest research and

to over years for a new heart. And to me that felt very unfair to the

technological developments in this field of medicine and building

members of my community. I am hoping to offer an option here in

an integrated system of care that is a collaborative resource for

central Texas so that we really minimize that time that families are

clinicians and their patients.”

away from their community and really try to take care of the entire patient and the members of their families who are all affected by

“This partnership allows patients and families to stay close to home

the needing of a new heart,” says Dr. Chesney Castleberry, Medical

for all of their health care needs, making our team-based model of

Director of the Heart Failure, VAD, and Transplant Program.

care more convenient than ever before,” says C. Martin Harris, MD, UT Health Austin’s Health Enterprise Associate Vice President and

The establishment of the Heart Failure, VAD, and Transplant

Professor of Internal Medicine at the Dell Medical School.

Program means patients and their families will no longer have to travel out of town for this life-saving complex surgery and they

Digestive Health is led by Medical Director and Dell Medical Chief of

will be better supported throughout their lifetime journey with

Gastroenterology and Hepatology Deepak Agrawal, MD, MPH, and

congenital heart disease. “It is our goal to provide every possible

Surgical Director, F. Paul “Tripp” Buckley, MD, who is an associate

heart-related care for our population and the community here. And

professor in Dell Medical School’s Department of Surgery and

I’m very happy to say that we are getting there. Heart transplant

Perioperative Care. Dr. Agrawal and Dr. Buckley will lead a team of GI and surgical subspecialists who are national leaders at the forefront of their field.

31


With scheduled patients already traveling from over 30 states and five countries, Dr. Buckley says, “We are proud to serve our local community, all of Texas, and patients nationally and internationally. This is a testament to our patient-centered, integrated approach designed to decrease wait times for consults and diagnostics as well as optimize outcomes that matter to patients.” “More than 60 million Americans are affected by digestive diseases, and the available diagnostic and treatment options are increasing in number and complexity,” says Dr.Agrawal. “With input and collaboration from subspecialized gastroenterologists, surgeons, and behavioral health experts, we are able to give patients choices regarding how they would like to move forward with treatment, which is often unique in gastroenterological care.” With advancements in any field of medicine, innovation most often comes from the close collaboration of a variety of specialists and

Common conditions treated at Digestive Health include: • Achalasia • Colorectal cancer • Crohn’s disease • Colitis • Eosinophilic esophagitis • Fatty liver disease • Gastroesophageal reflux disease • Heartburn • Hepatitis • Hiatal and paraesophageal hernias • Inflammatory bowel disease • Redo surgical procedures

teams. Because GI is a broad field, clinicians and patients both benefit from Digestive Health’s multidisciplinary team approach to care delivery and care advancements.

“Since the number one recommendation for battling COVID-19 is to stay home, which is not a choice for people experiencing homelessness, who are the people I spend most of my time treating, our team has been working with a broad community coalition of medical and social service providers to increase access to testing, and with local hotels and motels who are making space available so people with COVID-19, or who are suspected of having COVID-19, can voluntarily quarantine themselves. “By its nature, these are very vulnerable, very high-risk people. There’s a high prevalence of mental health conditions, and substance use disorders. There’s an information gap, and a lower level of health literacy. And their outcomes, in general, are worse, because up to 40% of this population, which already lacks access to hygiene supplies and healthcare services, is over the age of 50, making very common chronic conditions such as heart and lung disease more complex and difficult to manage. “While this pandemic has exposed many inequities in our society, it has also demonstrated ways in which our healthcare system is fragmented and inefficient. I very much hope that, as medical professionals, we can take this opportunity to better integrate our hospitals, clinics, and public health services through shared information and better communication, which I see as fundamental to everything we do.”   Tim Mercer, MD, MPH Chief of the Division of Global Health, Department of Population Health Assistant Professor, Departments of Population Health and Internal Medicine Dell Medical School

32


LOOKING AHEAD: LESSONS LEARNED AND A RENEWED SENSE OF PURPOSE “Sir Isaac Newton once said, ‘If I have seen further than others, it is by standing upon the shoulders of giants.’ To me, that is a perfect description of the kind of partnerships we created during our COVID-19 response. “Partnering allows us to align the best of our organization, and the best of our colleagues’ organizations, and proceed from a new and stronger place.

C. Martin Harris, MD, MBA, is the Associate Vice President and Chief Business Officer of the UT Health Austin/Dell Medical School Health Enterprise. He is also a professor in the Dell Medical School Department of Internal Medicine, and the former Chief Information Officer of Cleveland Clinic, where he spent 23 years building what became one of the nation’s premier, technology-enabled medical care delivery infrastructures, fully supported by a common electronic health record that served more than eight million patients. Dr. Harris earned an MBA from the Wharton School of the University of Pennsylvania, where he focused on health system design, which has been his driving passion throughout his career. In 2016, he joined Dell Medical School at The University of Texas at Austin specifically, as

“With the right partners, we can see farther than we have ever seen before. We can reach higher than we have ever reached before. We can do better than we have ever done before. And tomorrow?

he says, “To help create a truly transformative, 21st century academic integrated

“With the right partners, tomorrow will be brighter than we could ever have imagined before.”

draws a parallel between two things that, at first glance, seem utterly unrelated:

C. Martin Harris, M.D., MBA Associate Vice President of the Health Enterprise and Chief Business Officer, Business Affairs UT Health Austin and Dell Medical School

“I was recently given the honor of introducing Dr. Charles Fraser12 at a Dell Medical

system of care in one of America’s great cities.”

When asked to explain what a “system of care” is, and how it works, Dr. Harris

pediatric heart surgery, and the COVID-19 pandemic.

School Grand Rounds,13” he says, “and it was during that talk, to over 250 clinicians participating in the event online, that Dr. Fraser said something that is so simple, and yet so true, that it stuck in my mind. He said that clinical excellence in his specialty, which is pediatric and congenital heart surgery, is only achieved by the team. You can have the most brilliant surgeon in the world, but that surgeon will only perform to his or her brilliant best if the team is brilliant too. It’s the team that is the real achievement. It’s the team that is the secret to success. It’s the team that makes the difference.”

Charles Fraser, MD, is an internationally renowned heart surgeon who has distinguished himself over his long career by delivering outstanding patient

12 Charles D. Fraser, Jr., MD, Chief of Pediatric and Congenital Heart Surgery, and Adult Congenital Heart Surgeon, UT Health Austin Texas Center for Pediatric and Congenital Heart Disease at Dell Children’s Medical Center. 13 Where and when Grand Rounds became an integral part of medical education is a matter of debate, but some historians trace the tradition back to 1889, when William Osler, MD at Johns Hopkins, made “rounding,” which was literally a trip around the great rotunda beneath the hospital’s famous dome, a part of his students’ training. Today, Grand Rounds are generally open to the entire medical profession in a community, and help doctors and other healthcare professionals stay up-to-date on evolving areas of medical practice, tending to focus on big picture overviews of the newest research and treatments.

33


outcomes that are documented through clear and transparent

status and well-being is the central focus of everything the team

metrics. An alum of The University of Texas at Austin, he completed

does, so the team itself must have all the various disciplines and

a surgical residency at Johns Hopkins Hospital, and a pediatric

skills present to deliver that full-range of care. The measure of

cardiac surgery fellowship at the Royal Children’s Hospital in

that care is “excellence,” as we’ve already described, and the

Melbourne, Australia. He was the Chief of the Division of Congenital

team is the recognized care-delivery unit, so its leadership is

Heart Surgery at Texas Children’s Hospital in Houston for over 20

crucial. Throughout the care cycle, each important process and

years. He has performed more than 18,000 corrective operations

function is carefully standardized where appropriate for efficiency,

for children and adults with congenital heart disease, contributed

and meticulously measured to ensure quality and ongoing

to over 300 peer-reviewed professional publications, and helped

improvement.

develop leading pediatric and heart and lung transplant and mechanical circulatory support programs. Dr. Fraser has dedicated

This annual review began with a quote by Dr. Paul Farmer that

his life to caring for children who enter the world with some of the

described the things needed to successfully confront a pandemic,

most serious medical issues imaginable. And, as a result of a career

which were, “staff, stuff, space and systems.” A coordinated team

spent relentlessly pursuing excellence in every aspect of medicine

of experts with all the skills necessary to address a patient’s full-

and medical research, when he reveals the “secret” to his success,

situation, using the latest equipment, in facilities designed for the

people tend to pay attention.

purpose, and connected by all the systems, physical and digital, they need to function as a team at all times, fits Dr. Farmer’s

“To understand what Dr. Fraser means when he says that the

definition and, in the era of COVID-19, might be restated as people,

team is all-important,” Dr. Harris explains, “we need to understand

PPE, processes, and purpose.

what a team is, in the context of delivering true clinical excellence. Because that’s the goal: clinical excellence. Meaning that each and

“In our slightly modified rendering of Dr. Farmer’s famous

every time a patient experiences care, that care is delivered to the

observation,” Dr. Harris says, “‘Purpose’ is key. A team is a

height of the team’s ability. It is the attractive force, the shared

partnership, and partnering to a purpose is the foundational

energy that draws people who are called to the caring professions

principle of modern medical practice. The way our clinicians

together. They strive to deliver excellence every time, and to make

responded to the coronavirus pandemic is a perfect example of how

the next encounter better because of what they learned from every

partnering to a purpose works. When you step back and analyze

encounter that preceded it. Excellence starts with outstanding

the past six months or so, what did we all do? UT Health Austin,

medical education and training, and it continues through the

the Dell Medical School, Ascension Seton, Austin Public Health

process of care delivery, outcomes measurement, and continuous

and a number of other important groups put the right people and

improvement. It also relies on advances in research that inform the

processes together, all driven by the clear purpose of containing

next generation of medical professionals in a continuous cycle that

the virus. We used the equipment and facilities we had, and we

never ends, because there will always be more to learn for people

went out and found the things we needed. We organized ourselves

who are curious and hungry for new knowledge. As you’re probably

into a multidisciplinary, multilayered unit that purposefully focused

noticing, in medicine, there are certain words, such as ‘team,’ and

on minimizing the suffering caused by a dangerous new threat.

‘excellence,’ that carry a lot of meaning.”

Dr. Fraser and his team built a pediatric and congenital heart disease service on those same principles. And we’re expanding

Creating a team capable of functioning at the level Dr. Harris, and

that same model out with our new Digestive Health group, which

Dr. Fraser describe begins with a defined and clearly articulated

is a partnership between UT Health Austin and Ascension Seton

vision for what the team is there to do. At UT Health Austin, our

clinicians.”

care model is patient-centric, which means that the patient’s entire Which brings Dr. Harris back around to where he began, literally; it reminds him of the reason why he became a physician. “I remember when I was in medical school at the University of Pennsylvania. Computers in medicine where very new at the time. But the one place computers were being reliably used was in our Emergency Department to record patients as they came in. I realized that if I constructed the right set of questions, I could run a report and actually show, in virtually real-time, a graph of the busiest times for the ED, and what conditions were being treated on different days, or during different parts of the year. Something that would have taken thousands of hours to do manually was suddenly

34


accessible because of a new technology. It was a pivotal moment in my life, and it’s one of the great things about a medical school: there’s an energy involved with medical education that makes things happen. We have that same kind of energy here at the Dell Medical School. And we have the energy of research, of discovering new knowledge, at the medical school, with our clinician scientists, and through the world-class research science being conducted at The University of Texas at Austin. You need that energy of learning, of discovering, and of having a problem to solve. It’s important, and irreplaceable. “In some ways, COVID-19 provided us with enormous jolt of energy because it gave us a clear and common problem to confront. That’s what I meant when I brought our COVID-19 response and Dr. Fraser’s definition of a team together. An integrated system of care is a larger team, made up of a range of smaller teams that partner to achieve a common purpose. That purpose is the energy that drives the whole thing forward. And, I have to say, judging by our experience over the past several months, there is real energy happening here. We all know Austin is a special place. And I am more confident than ever before that special things are going to happen in Austin in the years to come.”

35


36


For the latest news and updates, follow UT Health Austin on social media!

@uthealthaustin