By Don Sadler
A little over a year ago, we were just starting to hear about a new coronavirus dubbed COVID-19. Before the end of March, a worldwide pandemic was declared that we’re still fighting today.
Now is a good time to take a look back at some of the lessons we’ve learned so far, as well as how elective surgeries are resuming and how COVID-19 could change the health care industry and perioperative practice going forward.
Capacity is Key
According to Vangie Dennis, MSN, RN, CNOR, CMLSO, assistant vice president, perioperative services, with AnMed Health in Anderson, South Carolina, the issue that most affects the ability to perform elective surgeries in hospitals is capacity.
“Most hospitals are at 130 to 150 percent bed capacity because of the recent COVID surge,” she says. “So regardless of segregation of outpatients and inpatients and all patients being tested for COVID, there are no available hospital beds even if surgery is performed.”
Dennis believes that elective surgeries should be classified with protocols for urgency. “We cannot limit elective surgeries without impacting the long-term outcomes of patient health,” she says.
Karen Reiter, RN, CNOR, RNFA, CASC, is the CEO of DISC Surgery Center in Newport Beach, California. She says that before the recent surge, her center had gotten back up and running and “really felt we had found our groove in this crazy time.”
“However, we went into another lockdown of cases on January 5 per the CDPH,” she adds. “We are now back to restrictive emergent cases only because of the COVID surge in Los Angeles and Orange County.”
“Very few of the centers I work with stopped performing surgeries, or if they did, it was for a limited time,” says Deb Yoder, MHA, RN, CNOR, RNFA, director of clinical operations and compliance officer for Surgical Management Professionals in Sioux Falls, South Dakota.
“The providers and local hospital were able to come together to create a list of elective urgent procedures that could be completed to meet patient care needs and not jeopardize the future health of patients,” Yoder adds.
However, most of the ASCs Yoder works with are still catching up with cases, she says.
“The hardest issue is having enough product to perform cases and meet patient needs,” she says. “Cases are resuming but with a process of testing patients prior to procedures and working around the delay in obtaining test results.”
What We’ve Learned from COVID-19
David Hoyt, MD, FACS, the executive director of the American College of Surgeons, notes that while the health care industry has had experience with natural disasters and how they affect surgeries, the impact of something like COVID-19 was widely unknown.
“Since this all began, we’ve learned a tremendous amount about the things that are needed in place to deal with a pandemic, like ventilators and PPE,” he says. “The pandemic has also revealed the impact that this level of intense caregiving has on physicians and nurses.”
“I think it will be critical to create an after-action report in a year or so to analyze what was done right and wrong to help ensure that we have durable solutions for the next crisis like this,” Hoyt adds.
Linda Groah, MSN, RN, CNOR, NEA-BC, FAAN, the CEO and executive director of the Association of periOperative Registered Nurses (AORN), believes that one of the biggest lessons learned from the pandemic so far is the need to critically assess the capacity of all the supplies and equipment that are essential to patient care in a crisis.
“This includes beds, ventilators, PPE, medications and so forth,” says Groah. “Supply chain management is critical to this process. For example, stockpiling supplies that are ready to meet the patients’ and staff’s needs and partnering with medical supply vendors to assist with the distribution of PPE.”
Groah also recommends that staff be cross-trained to assist in other areas of the hospital and trained on the proper use of PPE consistent with non-crisis-level patient care. “It’s important that capacity be able to meet the needs of patients without resorting to implementing a crisis level of care,” she says.
Yoder concurs, citing the importance of supplies and material availability and the need for less dependance on other countries for PPE and pharmaceutical supplies as one of the most important lessons learned. “The entire materials chain was broken or stretched to the point of breaking during the pandemic and continues to be tenuous today,” she says.
One of the unintended consequences of the pandemic, says Groah, has been that the focus on prevention and antimicrobial stewardship programs was discontinued or stopped due to COVID-19. “This work will need to be restarted after the pandemic and future planning should include continued use of resources on important projects while meeting the needs of the current crisis,” she says.
In addition, short-term, pandemic-related solutions have been implemented that are not consistent with pre-pandemic accepted practices, Groah adds.
“Returning to acceptable practices will be a slow process,” she adds.
State of-the-Art Infection Control
Reiter’s DISC Surgery Center was built with insight in regard to infection control.
“It features a closed HVAC system for the ASC only,” she says. “Every air exchange for the entire facility is exchanged every three minutes and each exchange goes through pre-post HEPA filters and is UV treated.”
“When we put this system in place the construction company joked that us and the CDC were the only places that could sustain an anthrax attack,” says Reiter. “Now it looks like every cent that was spent was well worth it.”
The isolated cases of COVID-19 that have been picked up in the facility have never spread from one person to another because of the air systems and strict adherence to protocols, says Reiter. “I strongly believe that special air systems like the one we have should be utilized in every new ASC construction going forward.”
Groah notes that during the pandemic, there has been an increased use of telemedicine for preoperative assessments, pre- and postoperative education and postoperative patient evaluations.
“We’ve also seen greater implementation of standardized care protocols in all surgical specialties – this allows another clinician to care for the patient should the need occur,” says Groh. “The result has been optimized length of stay, increased efficiency and fewer complications.”
Hoyt believes that once everyone gets used to doing preoperative assessments and postoperative evaluations virtually, this will become standard practice. “I don’t think it will change back,” he says. “And it could reduce costs – the studies aren’t in yet, but early indications are that it’s cheaper to do it this way.”
“I think we’re going to see a real transformation of the health care industry over the next decade,” Hoyt adds.
Groah believes that pandemics will be added to the list of disasters that are addressed in future health care facility disaster plans. “Also, I believe a nationwide plan will be developed that will provide all facilities with a roadmap to cope with a disaster such as COVID-19.”
“Unfortunately, I don’t think we can ever be fully prepared for a health care crisis of this magnitude,” says Dennis. “Going forward, we need to be better prepared to contain the infection with more aggressive mandates for protection in order to minimize the physical and economic impact on society.”