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Resuming Cases in Elective Surgery Centers

06/03/2020

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 

As increasing numbers of ambulatory surgery centers (ASCs) begin resuming elective cases, there are a number of practicalities to be addressed for both patients and staff.

Your returning staff is your highest priority. We know that unfortunately, many organizations had to furlough staff members. Some of those individuals have taken other jobs, experienced illness in their families or are fearful of returning to work. Those champions who are excited to get back to work may not know the changes you’ve made to adjust to the “new now,” so reorientation may be needed in order to help them understand and commit to comply with your new policies and procedures. It is important to show consideration of their personal situation and concern about their safety at work.

Issues Surrounding Scrubs
Wearing scrubs is a provocative issue right now. Many health care workers prefer not to take scrubs home out of concern for family members. Others have concerns about being seen in public wearing scrubs.

For those organizations that do not provide laundering in house, the Centers for Disease Control and Prevention (CDC) provides instructions for routine laundry. Scrub exposure management examples might include asking employees to wear street clothes to work and then change upon arrival.  

State and Local Requirements
It’s crucial to know your state and local laws and regulations. Some local authority requirements may be more stringent than requirements from the state. 

Questions to raise as you move forward:

  • Is your physical space ready?
  • Are your patients fearful about scheduling elective surgery?
  • Have patients lost insurance?
  • Are COVID-19 tests required?

Test-Based Strategies
Testing is another complicated point. If tests are required, find out if you have to conduct them yourself. There are some organizations selling COVID-19 tests that are not approved by the Food and Drug Administration (FDA).

If your state doesn’t have a requirement, consider following the CDC’s guidance on testing. In areas where there is a high prevalence of COVID-19 – testing is recommended.

If a patient’s test result is positive, the CDC recommends that surgery be delayed. Patients may be infectious until:

  • he/she has had two negative test results more than 24 hours apart; or
  • at least 72 hours have passed since symptom resolution AND it’s been 7 days since symptoms first appeared

In areas with little to no regional COVID-19 presence:

  • proceed with elective surgeries for patients without symptoms
  • delay if there are symptoms

Incremental Opening
Many surgery centers returning to elective surgeries are opening one or two rooms and/or one or two services at a time. It might be a good idea to have a resource analysis conducted by all key players.

An important human resources consideration: While it may seem simplest to bring back those staff with most seniority first, consider what services are being provided first and bring back the appropriate clinical staff in those areas.

Review your ASC goals, priorities and backlog to decide which cases to start first. Other considerations may include:

  • clearing backlog on previously scheduled surgery dates
  • priority service lines or providers
  • age group or patients with certain medical conditions for initial exclusion (such as patients from nursing homes)
  • ability to safely conduct aerosol generating procedures

Procedural Risks
There’s no exact laundry list of procedures and their risk. Some procedures are at higher risk of generating aerosol and, by extension, transmitting potentially contagious respiratory droplets. Those include procedures performed at:

  • endoscopy centers
  • ear, nose and throat (ENT) centers
  • dental surgery centers

Alternatively, procedures in the following settings are generally at low risk of generating aerosol:

  • cardiac/vascular intervention labs
  • eye surgery centers (although this population might have higher risk)
  • radiology suites
  • telehealth organizations
  • pain clinics

The overarching driver here is safety. Each organization will have different risk assessments and will find individualized solutions using block scheduling, modified hours, etc.

Discharge Changes
New factors complicating support for quality post-op care can compromise the surgery just performed.

Pertinent questions include:

  • Is your supply chain still appropriately active?
  • What is your patient’s living situation? If it’s an aggregate living community, will they allow the patient to return right after surgery? Will they allow home care?
  • Will physical therapy and other adjunct services be available?

Right now, the questions seem overwhelming but we’re learning more about COVID-19 every day. Now that we can provide care for our patients again, let’s stay in touch about winning practices to protect staff in ambulatory organizations and to also help ensure your staff and patients are safe when you return to an enhanced surgery schedule.  

Stay tuned for my next blog post on flow considerations in outpatient surgery centers.

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