The administration of spike monoclonal antibody treatment to patients with mild to moderate COVID-19 is very challenging. This article summarizes essential components and processes in establishing an effective spike monoclonal antibody infusion program. Rapid identification of a dedicated physical infrastructure was essential to circumvent the logistical challenges of caring for infectious patients, while maintaining compliance with regulations and ensuring the safety of our personnel and other patients. Our partnerships and collaborations among multiple different specialties and disciplines enabled contributions from personnel with specific expertise in medicine, nursing, pharmacy, infection prevention and control, EHR informatics, compliance, legal, medical ethics, engineering, administration and other critical areas. Clear communication and a culture where all roles are welcomed at the planning and operational tables are critical to the rapid development and refinement needed to adapt and thrive in providing this time-sensitive beneficial therapy. Our partnerships with leaders and providers outside our institutions, including those who care for underserved populations, have promoted equity in the access of monoclonal antibodies in our regions. Strong support from institutional leadership facilitated expedited action when needed, from a physical, personnel, and system infrastructure standpoint. Our ongoing real-time assessment and monitoring of our clinical program allowed us to improve and optimize our processes to ensure that the needs of our COVID-19 patients in the outpatient setting are met.

Since the introduction of a hospitalist physician model of care by Wachter and Goldman in 1996, important changes have occurred to address the care of hospitalized patients. This model was followed by the introduction of laborist physicians by Louis Weinstein in 2003, although large health maintenance organization practices have used this model since the 1990s. The American Congress of Obstetricians and Gynecologists supported the laborist model in a 2016 statement that was reaffirmed in 2017, recommending "the continued development and study of the obstetric and gynecologic hospitalist model as one potential approach to improve patient safety and professional satisfaction across delivery settings." Based on a recent American College of Obstetricians and Gynecologists publication, the problem is an anticipated staffing shortage of 6000 to 8800 obstetricians and gynecologists by 2020 and nearly 22,000 by 2050. The current workforce in obstetrics is aging, retiring early, and converting to part-time employment at an increasing rate. At the same time, the number of patients seeking obstetric and gynecologic care is dramatically increasing because of health care reform and population statistics. The solution is the use of alternative labor and delivery staffing models that include all obstetric providers (health care professionals). We present an alternative to the physician laborist modelda midwife laborist model in a collaborative practice with obstetricians practicing in a high-risk community setting.

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Surgical removal of the uterus is one of the most performed procedures in women, with >600,000 hysterectomies performed per year in the United States alone, most for benign indications. Over the past decade, laparoscopy has become the more popular approach for completion of the hysterectomy globally. The increased uptake of minimally invasive approaches played a role in the adoption of outpatient hysterectomy with estimated volume ranging between 200,000 and 300,000 cases per year. And with more surgeries done in a same-day-discharge setting, screening for iatrogenic surgical injuries would be of paramount importance. The risk of iatrogenic injury to the bladder or ureters during the hysterectomy was estimated to be 0.21%. The rate of injury varied significantly between the different routes, with the highest being for total laparoscopic hysterectomy (0.31%), followed by laparoscopic assisted vaginal hysterectomy (0.29%), total vaginal hysterectomy (0.24%), total abdominal hysterectomy (0.2%), and laparoscopic subtotal hysterectomy (0.14%). Even though the risk of urinary tract injury is extremely low, the consequences related to additional repair, prolonged recovery, resulting disability, and loss of employment, especially if not immediately recognized, could be substantial. The most common risk factors for urinary tract injury are pelvic malignancy, history of pelvic radiation, history of cesarean delivery, prior abdominal surgery, endometriosis, adhesions, broad ligament leiomyomas, and low-volume surgeons (<10 per year). Prompt intraoperative recognition and repair of iatrogenic injuries reduce the risk of significant morbidity (e.g., fistulae formation, deep pelvic infections, and possible deterioration of kidney function). Although cystoscopy may be used intraoperatively to detect such an injury, the question of how often it should be used remains controversial. Although the value of routine cystoscopy per case may be low, the value of routine cystoscopy for the patient and the low-volume surgeon could be high. So, although universal cystoscopy is not required, surgeons early in their career might wish to adopt universal cystoscopy until surgical fortitude is established and experience in assessing level of risk is possible. At that stage, selective cystoscopy could be utilized more appropriately in a cost-effective manner. When index of suspicion is high, or when injury is detected, timely consultation with a urologist may help alleviate the long-term complications by prompt diagnosis and repair when needed. Practice environments that foster collegiality and surgical mentorship for young surgeons optimize outcome and expedite their progress to proficiency, similar to what surgical fellowship programs offer their trainees.

Introduction: The coronavirus disease 2019 (COVID-19) pandemic has impacted health care organizations throughout the world. The Southwest Minnesota Region of Mayo Clinic Health System, a community-based health care system, was not immune, and in March 2020, our outpatient services were deferred and decreased by 90%. Method: This article is a review of the approach we used to safely reactivate outpatient care, the tools that we developed, and the outcomes of these reactivation efforts. A novel Outpatient Practice Reactivation Framework was established and used that included Outpatient Clinic Appointment Dashboard, Decision Matrix, Access Management, Virtual Care, and Patient Safety. This framework was guided by patient demand for care and by safety principles, as recommended by state and federal agencies and our internal infectious disease department guidelines. Results and Conclusions: Over the course of 9 weeks, ambulatory visit volumes and clinic utilization rates returned to pre-COVID levels (Pre-COVID fill rate range: 87% to 94%, post-COVID fill rate range: 86% to 89%) exceeding target fill rate of 80%, as a result of establishing the initiative as a shared priority, committing to a robust schedule and decisive actions, creating and maintaining a well-defined structure, taking an inclusive approach, overcommunicating and providing sufficient data for transparency, developing guiding principles, and training and educating staff.