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By Don Sadler

As COVID-19 restrictions have loosened in most parts of the country, elective and non-essential surgeries have been allowed to resume at many hospitals and ambulatory surgery centers (ASCs). While this is obviously good news for patients and health care facilities, the reopening process has been fraught with challenges.

“Shutting down was the easy part,” says Renae Battié, MN, RN, CNOR, vice president of nursing for the Association of periOperative Registered Nurses (AORN). “The restart has been much harder.”

ASCs Are Pivoting

At the onset of the pandemic, as state regulators determined to suspend elective surgeries, many ASCs had to either limit the number and type of cases performed in their facilities or close their doors temporarily, notes The Joint Commission.

“Considerations were made to reduce unnecessary exposure to ASC patients and staff since patient and staff safety is The Joint Commission’s number one priority,” says Pearl S. Darling, MBA, the executive director of Ambulatory Care Services for The Joint Commission.

To preserve access to care and serve the ASC community, as well as mitigate losses, many ASCs were able to pivot, Darling says. “Some have partnered with their local health agencies and health systems to address emergency cases that can be performed safely,” she says.

“Some ASCs have been able to resume elective surgeries while putting precautionary steps in place,” adds Jamie Ridout, RN, MSN, MBA, NEA-BC, CNOR, CASC, the administrator at Capital City Surgery Center in Raleigh, North Carolina. This includes his facility, which Ridout says is running “at full operation.”

According to Ambulatory Surgery Center Association (ASCA) Board President Michael Patterson, RN, ASCs in every state are now free to perform emergency and elective surgeries. “ASCs are experiencing significant pent-up demand, which is a reminder that elective surgery is not the same thing as unnecessary surgery,” he says.

The federal government has enacted a series of waivers making it easier for ASCs to provide outpatient surgery to patients who are unable to get the care they need in hospitals inundated with COVID-19 patients, Patterson notes.

“Many states have followed suit,” he says, “either adopting the federal rules or specifying policies of their own.”

Keith Griffis, the executive director of marketing for Surgical Endoscopy and Systems Integration for Olympus Corporation of the Americas, believes that ASCs – which have been hard hit by the pandemic and are looking for ways to make up lost revenue – are in a good position to pick up the case volumes that have been restricted within hospitals.

“Some patients may be hesitant to visit hospitals where the focus for months has been on fighting the pandemic,” he says. “They may be more likely to want to see a doctor at an ASC.”

The agility of ASCs could serve them well during this time, Griffis adds. “They have the ability to screen and limit COVID exposure in a dedicated facility,” he says. “ASCs can also offer scheduling flexibility and a purpose-driven procedure mix.”

Darling concurs: “ASCs are nimble and responsive, meeting patient needs in ways that other health care settings aren’t able to in these times.”

Reopening Guidance for ASCs

A number of organizations have issued guidance regarding the criteria ASCs should follow in fully reopening their facilities and ramping back up to pre-pandemic levels. ASCA has published a collection of these guidelines in its COVID-19 Resource Center, which is available online atascassociation.org/covid-19.

“For the most part, ASCs can resume cases while ensuring a few considerations are in order,” says Darling. These include the following:

  • Sustained reduction in the rate of new COVID-19 cases in the relevant geographic area for at least 14 days before resumption of elective surgical procedures.
  • Allowance to resume by local municipal, county and state health authorities.
  • Collaboration with local health providers for coordination of care if needed.
  • Assurance that the appropriate numbers of trained and competent staff are on hand.
  • Updated staff with knowledge of current trends and issues regarding COVID-19.

“Most of the statements issued to help ASCs and others resume non-emergent care contain recommendations rather than mandates,” says Patterson. “But in some states, ASCs are now required to conduct COVID-19 tests on their patients before they can have surgery.”

Patterson stresses that ASCs are putting patient safety first by enforcing strict infection prevention practices already in place and adopting new testing, personal protective equipment (PPE) and social distancing protocols designed to prevent the spread of COVID-19.

These measures appear to be working as evidenced by a recent study conducted by the ASC Quality Collaboration. The study found that out of more than 84,000 patients who underwent surgery at 709 ASCs between March 15 and April 30 of this year, only 16 were found to be COVID-19 positive within 14 days of their surgery.

“None of these cases could be linked to the care the patients received in the ASC,” says Patterson.

AORN Roadmap and American College of Surgeons Checklist

AORN has published a comprehensive “Roadmap for Resuming Elective Surgery After the COVID-19 Pandemic.” A joint statement accompanying the release of the roadmap stressed that before resuming elective procedures, hospitals should wait until there has been a sustained reduction in the rate of new COVID-19 cases in the area for at least 14 days.

In addition, hospitals should ensure that they have adequate numbers of trained staff and supplies, including PPE, beds, ICU and ventilators to treat non-elective patients without resorting to a crisis-level standard of care.

The roadmap includes eight key principles and considerations to guide hospital OR personnel in the resumption of elective surgeries. Highlights include the following:

  • Implement a policy for testing staff and patients for COVID-19 that accounts for accuracy and availability of testing and a response when a staff member or patient tests positive.
  • Form a committee that includes surgery, anesthesiology and nursing leadership to develop a surgery prioritization policy. This policy should factor in previously canceled and postponed cases and allot block time for priority cases like cancer and living donor organ transplants.
  • Adopt COVID-19-informed policies for the five phases of surgical care, ranging from preoperative to post-discharge care planning.
  • Collect and assess COVID-19-related data that will be used to frequently re-evaluate and reassess policies and procedures.
  • Create and implement a social distancing policy for staff, patients and visitors in non-restricted areas in anticipation of a second wave of COVID-19 activity.

“The roadmap has been especially helpful as hospitals review their backlog of cases to prioritize which surgeries should be performed first,” says Battié. “Hospitals I’ve talked to recently are back up to between 75 and 100 percent of their pre-COVID-19 volume.”

The full roadmap is available at aorn.org/guidelines/aorn-support/roadmap-for-resuming-elective-surgery-after-covid-19.

Additionally, the American College of Surgeons has published a 10-point checklist offering a set of principles to guide local facilities as they plan for resumption of elective surgical care. The checklist includes:

  1. Know your community’s COVID-19 numbers, including prevalence, incidence rates and isolation mandates.
  2. Know your COVID-19 diagnostic testing availability and develop operational testing policies for patients and health care workers.
  3. Be aware of local PPE availability and develop policies for health care workers.
  4. Know your facility’s capacity in terms of beds, ICUs and ventilators, including expansion capacity (e.g., weekends).
  5. Make sure that a steady supply of products and supplies will be available from traditional or new vendors.
  6. Address workforce staffing issues – for example, through contingency planning and multidisciplinary staffing coverage for routine and expanded hours.
  7. Assign a governance committee to clarify, interpret and iterate policies; make real-time decisions; and initiate and communicate messaging.
  8. Devise a patient communication plan to answer the myriad questions surgery patients may have during the ramp-up period.
  9. Create a surgery prioritization and protocol plan.
  10. Ensure safe, high-quality and high-value care of surgical patients across the Five Phases of Care continuum: preoperative, immediate preoperative, intraoperative, postoperative and post discharge.

Reopening Challenges

Ann Geier, MS, RN, CNOR, CASC, chief nursing officer with Surgical Information Systems, moderated a panel discussion at this year’s virtual AORN conference in which the panelists discussed some of the experiences and challenges they’ve faced in reopening their ASCs.

She says one of the main challenges discussed by panelists was patient testing. “Who should be tested and when?” says Geier. “And what if test results are delayed – should you cancel cases? If so, you’re going to have some very upset patients.”

Staff should also be tested and their temperature should be checked regularly. “Ask staff the standard questions and keep a record of everything in case you need to prove it to a surveyor,” says Geier.

Ideally, an infection preventionist should coordinate all of this and keep everything organized in one notebook. “Make note of all the regulations that have affected your center and the actions you took to comply with them,” says Geier.

Patterson concurs with the testing challenges faced by ASCs. “Testing supplies can be difficult to come by and the time needed to get test results appears to be increasing as more tests are being done,” he says. “ASCA is continuing to work with federal officials and others to reach solutions to this concern.”

Staffing is another big challenge. “At first, some staff whose family members were still at home were reluctant to return to work due to concerns about increasing their risk of exposure to COVID-19,” says Patterson. “Now, some staff still facing additional demands at home do not want to return fully to their former schedules.”

According to Geier, the problem of laid off or furloughed employees who are receiving generous unemployment benefits not wanting to return to work is very real. “So is the problem of childcare for staff with young children at home and nobody to watch them if their school and daycare facilities have been closed,” she says.

In addition, some staff are reaching burnout as their regular eight-hour days are being stretched to 10 or 12 hours or longer.

“They’re tired and grumpy and they didn’t sign up for this,” says Geier. “They need a break but there’s no help on the horizon.”

“The rules and regulations ASCs are facing can be overwhelming and they change constantly,” Geier adds. “It’s a good idea to assign one staff member to keep up with them – otherwise, you can get behind the eight-ball quickly.”

Diligence is Key

Ridout believes that the key to meeting the challenges of reopening lies in “diligence and adherence to the processes you’ve put in place.”

“We all want to keep our staff, patients and visitors as safe as they can be,” he says.

Meanwhile, Darling stresses the importance of assigning leadership oversight and accountability in the areas of staff and patient safety and infection prevention.

“Team leaders can take the reins in ensuring that communication channels are open while continuing to stay abreast of current regulations and infection rates within their community,” she says. “They should also continuously educate their staff on the latest updates in safety and infection control practices.”

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