An Interview with L. Scott Levin, MD, FAOA, Calvin Jordan, and Neil Ravitz
In the late spring of 2020, Chair of Penn Orthopaedic Surgery L. Scott Levin, MD, FACS, FAOA, and Department lead administrators Neil Ravitz and Calvin Jordan, were tasked with restoring programs that had been shuttered in March 2020 by COVID-19. Recently, we spoke at length to these three department leaders about the challenges faced before and immediately after the Department’s return to surgery. Following necessary precautions, Jordan, Senior Director of Operations for Penn Orthopaedics and Ravitz, Chief Administrative Officer of the Penn Musculoskeletal and Rheumatology service line and Penn Orthopaedics’ Chief Operating Officer, joined us remotely from their homes. Dr. Levin spoke from his office at Penn Medicine University City.
Penn Orthopaedics: Journal of a Pandemic Year
The COVID-19 pandemic arrived in Philadelphia in early March, when the first positive case in the city appeared at the Hospital of the University of Pennsylvania. In the days that followed, non-urgent patient access to Penn Medicine’s six hospitals and numerous outpatient facilities slowed to a near halt. Surgery programs and in-hospital procedures were placed on an indefinite hiatus, and outpatient visits ceased for a time altogether. Lockdowns and other precautions were initiated as patients with COVID-19, eventually numbering in the thousands, began to arrive at Penn Medicine, first at its city hospitals, and later in its regional locations.
Over a period of weeks, a now familiar transition to virtual telemedicine took place, particularly in primary care and the outpatient programs. Testing sites opened throughout the hospital system, and safeguards were introduced to ensure the protection of both healthcare professionals and patients. Necessary surgeries for cancer and trauma continued.
“Even during the height of COVID in the Spring, our orthopedic trauma team, led by our board certified traumatologists Samir Mehta and Derek Donegan, and other surgeons, including myself, would take call,” Dr. Levin says. “We were available all day, every day to care for any patient with any injury.”
Still, these surgeries represented a small share of the pre-COVID surgery schedule for the Department.
By early May, the first wave of the COVID-19 pandemic in Philadelphia was subsiding. There was always the chance that the disease would come roaring back as we’ve seen in the fall, but in looking towards that possibility there was also the sense that the System’s clinicians, nurses and support personnel had learned enough about the virus and its idiosyncrasies to handle a surge when it arrived. By May, it seemed a fitting time to reinstate in-person visits and surgery to the Department of Orthopaedic Surgery.
The Hardest Thing To Do
Every stage was harder than the one before it,” says Neil Ravitz. “We thought shutting down was the hardest thing we’d have to do—until we tried to turn things back on.” As it happens, getting back to full speed was the most difficult challenge the Orthopaedics team would face.
For the Department’s leaders and that of its service lines, the circumstances involved in restoring the surgery program presented a number of complexities involving not only the Department, its administrators and surgeons, but the leadership of Penn Medicine, the state and city government, the local and national press, and not least of all, the patients, their physicians and families.
The challenges were many. At issue were such concerns as patient and provider safety, triaging procedures by need and precedence, the roll-out of surgery across the health system’s individual orthopaedic programs, local and national political and social upheavals, insurance concerns, administrative support mechanisms, and finally, the need for a return to financial stability.
Decisions, Choices and Collaborations
We, collectively as a team never worked harder not doing surgery. L. Scott Levin, MD, FACS, FAOA, on the Surgical Ramp-Up after COVID-19, June 16, 2020. Ultimately, the return to “normal” procedures involved a series of measured, systematic decisions both within the health care system and with outside entities, Levin, Ravitz and Jordan attest. The focus throughout was on scientific data, appropriateness of care, and patient and provider safety.
“We, collectively as a team never worked harder not doing surgery.”
L. Scott Levin, MD, FACS, FAOA, on the Surgical Ramp-Up after COVID-19, June 16, 2020
“We knew we had to provide patients with the assurance that care could be delivered to them safely,” Dr. Levin reflects. “Patients had to know that they wouldn’t contract COVID coming into the clinic or our outpatient surgery units. And I think our whole team did that admirably during the transition.”
Following a series of town hall meetings, webinars and video conferences to ensure communication across the Health System, the plan came into focus. An infrastructure for pre-procedure testing was put in place with Penn Pathology and Laboratory Medicine. Protocols were developed, informed by long-established guidelines for hygiene and Centers for Disease Control directives for social distancing, coupled with contactless workflows, staggering of staff, and the establishment of reasonable goals for program resurgences.
During this time, the true collective power of Penn was essential to the return to surgery. Our colleagues in Pathology and Laboratory medicine set up an enormous testing infrastructure so we could test all patients prior to surgery, ensuring both the safety of the patient and our staff prior to procedures. It was also on full display with relationships between system CEO Kevin Mahoney and the offices of Governor Wolf, Mayor Kenny, and state leaders in New Jersey to establish safe guidelines to take care of patients.
“I think we were fortunate that Kevin was able to speak and work closely with governmental officials,” Ravitz says. “And we got to a point where they were comfortable and we had a very executable plan.”
“Essentially, we got agreement from the health system and our state and local leaders that if anyone was going to do it safely with a protocol in place, it was Penn Medicine,” Jordan adds.
Impartiality was also a vital concern for both patients whose care or surgical procedures had been interrupted, and those in need of immediate care. To address these issues, the Department adopted the Medically Necessary Time Sensitive (MENTS) system, a methodology developed at the University of Chicago.
Prioritizing Surgical Need: The MENTS System
According to its authors, MENTS provides a system to allow surgery departments to integrate resource limitations and provider and patient COVID-19 transmission risk into the decision-making process for surgical prioritization and appropriately weigh individual patient risks with the ethical necessity of optimizing public health concerns. Thus, a young, otherwise healthy patient with arthritis who needs a hip replacement and a patient with multiple medical comorbidities who might be hospitalized post-surgery for days or weeks and require nursing home and social support can be systematically defined and their respective surgeries scheduled accordingly. MENTS has been endorsed by the American College of Surgeons(ACS). Dr. Levin became Chair of the ACS Board of regents in October.
The Unexpected Triumph of Telemedicine
A concept introduced at Penn several years ago, telemedicine began a rapid, unanticipated, and largely successful ascent in March.
Telemedicine was something we were dipping our toe in prior to COVID-19, but there were issues about payment models and a clear preference among providers and patients for in-person appointments at that time,” Ravitz says. Because telemedicine was not widely used prior to COVID-19, there were many questions about how the Department could ramp up in time to maintain the vital patient/clinician connection, according to Calvin Jordan. But within a few weeks, Jordan recalls, the Department went from two or three telemedicine patients a week to two or three hundred. He credits the information technology division at Penn Medicine, and ultimately, the patients, who rose to the occasion. Telemedicine is what I’d call a positive disruptive innovation,” Dr. Levin says. “It’s given us the ability to contact and evaluate our patients, and I think, will have a permanent place in medical practice.
The Resurgence in Place
On May 4, 2020, Dr. Levin announced the return of Penn Orthopaedics’ surgery and other in-hospital services. As of early December, the surgical cases for the Department have been back to almost 100% of pre-covid volume since early Fall and we continue to provide safe and effective care during the pandemic.
The balance sheet was a consideration, of course, but it wasn’t the driver for the return to surgery,” says Calvin Jordan, Sr. Director of Service Line Operations for the Department of Orthopaedic Surgery Musculoskeletal Service Line. “Our goal, financially, was to hold onto our people so we were in position to best serve the patient community in West Philadelphia, our city and the region.
As a result, in addition to all the other feats accomplished during resurgence and beyond, Penn Orthopaedics has held onto its staff—all of them, support personnel, researchers, surgeons—an accomplishment largely echoed throughout Penn Medicine.
Reflecting on these outcomes in the wake of the pandemic’s impact on the region, Dr. Levin credits open and honest communication with his staff, the assistance of capable administrative and service line leaders, and the resilience of the Department’s patients in the face of unprecedented challenges.
“Communication was key,” he says, “because people want to know how much you care before they care how much you know.” Thus, he and his administrators engaged faculty in the decision-making process and ensured that they understood the processes involved in the resurgence.
“Because we’d prepared for every possibility, we were able to ramp up quickly,” Dr. Levin says. “We were prepared, too, to shift tactics and strategy, if needed—to turn on a dime, as we say.”
The careful planning, the protocols, the investment in communication and safety paid off. Soon, unexpected benefits began to emerge, as well. Carefully selecting the right patients for surgery, the Department was able to increase discharge to home rate and getting patients out of the hospital. Accordingly, the Department’s average length of stay dropped to a historic low, and the patient discharge-to-home rate soared. This effort was critical to keeping patients out of rehab facilities and nursing facilities that were hot beds for Covid.
“These things are good for patients, cost-effective, and reduce the burden on the health system for continued patient care,” Dr. Levin says. “In addition, the metrics used to evaluate the Department in terms of quality and efficiency of care improved, benefiting our regional rankings.”
The impartial approach to providing care and the broad restoration of surgery during the pandemic has had another benefit felt among the city’s disadvantaged - not as a consequence of the resurgence plan, but as a result of the Department’s historic mission in West Philadelphia.
“As long as I lead, we take care of princes and paupers and everybody in between,” Dr. Levin says. “We've never differentiated delivery of musculoskeletal or orthopedic care at Penn Orthopaedics on ability to pay. We are privileged to take care of everyone.”