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Building A Strong Pandemic Model: Fewer ER Visits, “Plan B” and More Advanced Surgeries

By Mantu Gupta, MD
Chairman of Urology, Mount Sinai West and Morningside Hospitals, New York City
Director, Mount Sinai Kidney Stone Center; Director of Endourology, Mount Sinai Health System
Professor of Urology, Icahn School of Medicine at Mount Sinai

COVID-19 has taught us a lot. We’ve seen its effect on every aspect of healthcare. As we’ve responded with changes to our facilities and protocols, we’ve not only addressed the immediate challenges, but also prepared ourselves for the next wave and, perhaps, the next pandemic. In my practice, the experience has led to some new approaches that will change the way we work in the future.

Fewer ER Visits, More “Plan B”
From March 15 to May 31, 2020, we saw only 8 emergency patients who required stenting for obstructing kidney stones, compared to 51 patients during the same weeks in 2019. Those who came in were much sicker compared to last year: 87.5% COVID-era patients were high risk (very sick), compared to 31% in 2019. Although people were in severe pain and some had fevers, they delayed going to the ER until their condition had deteriorated.
At the same time, I saw a significant increase in patients coming to my office with kidney stone emergencies because they did not want to go to the ER. In response, I set aside one day per week for emergencies in the office. Patients filled the schedule. To avoid sending most serious cases to the hospital, I tripled the number of stents I was placing in the office.
This approach reflects another necessary change in the COVID-19 era: when patients have to wait for elective surgery, we need a “plan B” to safely buy them time. Patients with kidney stone obstruction, infection, or severe, intractable pain are at risk for lost kidney function, septicemia or death. Rather than scheduling surgery right away, we drained the kidney with a stent or, in cases of obstruction, a nephrostomy tube. With the kidney drained, only patients with severe infections needed to stay in the hospital – the rest could safely defer surgery for several weeks.

Switching to Outpatient Procedures
In this pandemic, we always want to treat people on an outpatient basis and avoid a hospital stay that could expose them to additional risk. When we resumed elective surgery, instead of using traditional percutaneous nephrolithotomy (PCNL), which requires a drain and an overnight stay, we began doing a lot more ureteroscopic and mini PCNL laser procedures and sending patients home the same day.
This is possible in part because we use a high-powered laser (Pulse 120H, Lumenis) with MOSES Technology that enables us to fragment stones much more efficiently. By “dusting” the stone into very small particles, we can aspirate them or leave them to wash out in the urine stream. Ureteroscopy is almost always an outpatient procedure, made shorter by the laser. In addition, it is now possible to use the high-powered laser with miniaturized instruments in a mini PCNL procedure. Unlike traditional PCNL, we can take an outpatient approach with mini PCNL because the incision is very small and the efficiency of MOSES Technology makes surgery shorter, even for larger stones.
Now that we are doing more outpatient procedures, we will not be going back to the way we used to do things. We have the technology to send patients home the same day, and the pandemic helped push us to realize that potential.

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