Ambulatory Buzz

Information on all things ambulatory from The Joint Commission

Patient Flow Considerations for Your Newly Re-Opened Ambulatory Surgery Center

06/10/2020

Editor’s note: This information was previously presented as a webinar. The replay is available online.

Lorrie Cappellino, RN, MS, CNOR, surveyor, Ambulatory Health Care 

Last week, I blogged about assessing if your organization is ready to re-open for elective cases. Today, I’m following up on the patient flow consideration that need to be made for a successful re-opening

Now more than ever, it’s important to look at flow. Let’s dive into the details about re-imagining patient flow.

This starts with scheduling. 

Pre-Arrival Protocols
Once you’ve decided to resume elective care, plan a strategy for internal scheduling to include COVID-19 relevant questions on pre-op questionnaire.  

Another important decision is whether to allow an escort. If so, the escort needs to be made aware of your policies on face covers and screening. You’ll need to determine in advance how you’ll provide education and if you’ll do pre-screening on escorts.

It’s never been this challenging to determine the spacing of cases. Back-to-back cases with short turn-over times may no longer be possible. Though unusual, case line-up may be determined by your visitor policy. If you have a waiting room that can only accommodate four, it may be necessary to adjust the surgery center to accommodate the front-end process.  

These days, we all need to be “big thinkers.” Start by looking at the flow of your ASC’s intake area. Consider an initial assessment of patient temperature and other factors while the patient is still in the car. Create a back-up for inclement weather. Another risk mitigation strategy could be moving the front desk to the main doorway, so a symptomatic patient or escort cannot pass through a common area before screening.

You might consider installing plastic or plexiglass to avoid close contact between patients and staff. Other options to avoid touch include processing payments in advance or online. The goal is a no-touch environment but that’s not always possible. Frequent hand hygiene and distancing are the key to source control.

Escort Policies
If your ASC continues to allow escorts, here are some questions to ponder:

  • How will you accommodate a bathroom for escorts?
  • Will escorts be allowed to be present during aerosol generating procedures such as intubating a child or providing a nebulizer treatment in the recovery room?
  • If patients come from a distance, will you need a plan for providing access to bathrooms or restaurants that are open in the area?
    It’s more important than ever to communicate and set expectations with patients and their caregivers up-front.

Pre-Op Controls
An actual blueprint may be helpful in planning your organization’s flow. 

When patients move back to the pre-op holding area, The Joint Commission and other associations such as the Association of periOperative Registered Nurses (AORN) DO NOT have a requirement that patients change clothes for surgery, but they do talk about how contaminated textiles could contaminate the environment or health care provider’s hands.  

Considerations here include:

  • air turbulence when patients change clothes in an open bay
  • processes for cleaning lockers between patients

In many eye surgery ASCs, patients leave their clothes on and are covered with a blanket for surgical procedures. Now might be a good time to look at your processes overall to see what might work best for you. Disinfection and security of patients’ personal items requires some thought. Examples include:

  • glasses
  • cell phones
  • personal inhalers

Keep in mind the high level of activity at the patient’s bedside, especially when a lot of pre-op activity is occurring. Designating dedicated durable medical equipment—such as blood pressure cuffs or stethoscopes—might help prevent movement of contaminated equipment outside the patient’s bay. 

Inter-Operative Controls
The amount of aerosol generated in a given procedure determines the appropriate inter-operative  controls. Appropriate safety precautions to use for aerosol generating procedures include:

  • limiting personnel
  • ventilation
  • distancing
  • additional personal protective equipment (PPE)

There are many high-risk touch points in the anesthesia work area that puts providers at risk. A clean-to-dirty workflow might be the best strategy for patients requiring intubation. 

Other engineering controls to avoid virus spread include:

  • placing a sheet of sheer plastic on the patient while intubating or throughout the case
  • placing suction under the drape to reduce further droplet exposure
  • using smoke evacuators 
  • placing a wet saline gauze over the patient’s nose and mouth after extubation

While these measures reduce airborne particles, some clinicians believe these may slow intubation and extubation times. In today’s surgical environment, once a risk assessment is complete, an extended room turnover for some cases may be best. In those cases, the Centers for Disease Control and Prevention (CDC) provides a resource for the recommended time, based on air exchanges to clear remaining aerosols.

ASC Post-Op
Decide in advance if staff should wear additional PPE in post-op, given that patients may cough when devices are removed. A respirator mask may also be appropriate during other times in the recovery area. It’s important that staff have supplies available and know when to don the appropriate PPE.

Expect patient assessment to be more difficult than in the past. Patients may be wearing masks when they arrive after their surgical procedure. In open bays, it’ll be a challenge to keep patients 6 feet apart. 

These certainly won’t be the last challenges that arise and it’s going to be increasingly important to work together. Please share your winning practices with one another in the comment section of our blogs. Stay safe out there!


Lorrie Cappellino is an Ambulatory Care Surveyor with The Joint Commission. She has extensive surgical suite and executive health care leadership experience and is a certified perioperative registered nurse.