Resuming Elective Surgeries after COVID-19 Restrictions

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When the COVID-19 Pandemic began, the Centers for Disease Control and Prevention (CDC) as well as the US Surgeon General recommended the interim cancellation of elective surgeries until the COVID-19 situation has been contained to safe levels. Just last week, Maryland’s Governor announced that healthcare facilities in the state could resume critical elective procedures, especially for those undergoing cancer treatments or treatment of other critical illnesses. While some of these states are resuming elective procedures, patients in many other states are still left waiting. It is important to become familiar with the guidelines for resumption as well as operation of elective procedures during the COVID-19 crisis.


When and How?
There should be a sustained reduction in the rate of new COVID-19 cases as well as increased availability of equipment such as Personal Protective Equipment (PPE), ventilators and non ICU-beds prior to the resumption of elective surgeries. These factors will vary depending on geographic location as well as guidance from medical professional organizations and government agencies.
The following list, provided in a joint statement by the American College of Surgeons and several other health organizations, highlights some basic guidelines facilities will need consider prior to resuming elective procedures:
•    Timing - There must be a sustained reduction in rate of new COVID 19 cases in the relevant geographic area for at least 14 days.
•    Authorization – Any resumption of surgeries should be authorized by appropriate municipal, county and state health authorities.
•    Ability – Facilities are safely able to treat all patients requiring hospitalization without resorting to crisis standards of care.
•    Equipment - Does the facility have appropriate number of ICU and non-ICU beds, PPE, ventilators, medications, anesthetics and all medical surgical supplies?
•    Staff - Does the facility have available numbers of trained and educated staff appropriate for the planned surgical procedures, patient population and facility resources? Given the known evidence supporting health care worker fatigue and the impact of stress, can the facilities perform planned procedures without compromising patient safety or staff safety and well-being?


Prioritization
After surgeries resume, the next step will be prioritizing when individuals can have their procedures performed. An article from Advisory Board highlights some examples healthcare facilities may consider in prioritizing elective surgeries.


Clinical Urgency
•    Consider effectiveness of non-operative treatment options
•    Impact delay in surgery will have on disease/condition outcome
•    Impact of delay in surgical difficulty and risk
•    Position of service in care pathway and implications for disease diagnosis and prognosis


Strategic & Financial Importance
•    Importance of service for system goals and priorities
•    Average margin per-case
•    Pre-crisis market share
•    Potential competitive advantage from earlier restart 


Feasibility
Physical capacity

  • Medical and surgical bed capacity
  • ICU capacity
  • Operating room and procedure room capacity
  • Pre and post-operative visit availability.

Labor availability

  • Surgeons
  • Anesthesiologists
  • Nurses

Supplies and equipment

  • Personal Protective Equipment (PPE)
  • Ventilators
  • Testing capabilities


Considerations for Operation
Upon resumption of elective procedures, healthcare facilities will need to adapt policies for operation during the COVID-19 Pandemic. The following guidelines were presented in a the statement from the American College of Surgeons and other healthcare organizations.


Phase 1 – Preoperative
1.    Create a guideline for preoperative assessment process.

  • Patient readiness can be coordinated by anesthesiology-led preoperative assessment services.

2.    Guideline for timing of re-assessing patient health status:

  • Special attention and re-evaluation are needed if patient has had COVID-19 related illness.
  • A recent history and physical examination within 30 days per Centers for Medicare and Medicaid Services (CMS) required for all patients. This will verify that there has been no significant interim change in patient’s health.
  • Consider telemedicine as well as assessments by nurse practitioners and physician assistants for components of preoperative evaluation.
  • Certain face-to-face components can be scheduled on day of procedure, especially with healthier patients.
  • Surgery and anesthesia consents per facility policy and state requirements.
  • Lab testing and radiologic imaging procedures needs. Testing and repeat testing without indication should be discouraged.
  • Assess preoperative patient education classes vs. remote instructions.

3.    Hold an advanced directive discussion with surgeon. This is especially important for patients who are elderly, frail or COVID-19 survivors.
4.    Assess the need for post-acute care (PAC) and address before procedure.


Phase II - Immediate Preoperative
1.    Guideline for pre-procedure interval evaluation since COVID-19 related postponement.
2.    Assess need for revision of nursing, anesthesia, surgery checklists regarding COVID-19.


Phase III – Intraoperative
1.    Assess need for revision of pre-procedure interval evaluation since COVID-19 related postponement.
2.    Guideline for who is present during intubation and extubation.
3.    Guideline for Personal Protective Equipment (PPE) use.
4.    Guideline for presence of nonessential personnel, including students.


Phase IV – Postoperative
1.    Adhere to standardized care protocols for reliability in light of potential different personnel. These protocols help to optimize length of stay efficiency and decrease complications.


Phase V – Post Discharge Care Planning
1.    PAC facility availability.
2.    PAC facility safety.
3.    Home setting. Ideally, patients should be discharged home and not to a nursing home as high COVID-19 rates may be present in these settings.


Caring For Staff
The healthcare system has been overwhelmed by the COVID-19 Pandemic. Prior to and during the resumption of elective procedures, caring for hospital staff is paramount. As the COVID-19 crisis continues without a clear ending, it is important to consider how to care for staff members performing elective procedures during the crisis. A list from the Healthcare Advisory Board highlights steps facilities should consider implementing when assigning staff to elective procedures.


Provide updates to staff through designated communication channels
Communicate to staff about how they will be organized, what procedures they should expect to perform and when, how to manage referrals, how to manage pre- and post-procedure processes, and what information is being shared with the community.


Expand emotional support
1.    Make internal experts such as psychologists and social workers available to hospital staff.
2.    Make resources for coping with anxiety available for staff such as web-based and written materials.
3.    Available opt-in resources such as confidential phone lines for support services.


Take care of necessities for staff
1.    Availability of housing for staff worried about spreading COVID-19 to their families.
2.    Options for partnering with organizations providing things like meals, childcare and other services.
3.    Be knowledgeable of staff’s needs and necessities.


Empower workers who have been working furloughed or reduced hours
1.    Provide options for engaging surgeons and other staff whose work is not prioritized in the short-term (i.e. orthopedic surgeons, etc.).
2.    Provide options for cross-training staff to perform new procedures.
3.    Re-engage furloughed staff.
4.    Create strategy to provide visibility and recognition to planning and leadership teams.


Questions?
The COVID-19 Pandemic has caused a great deal of distress for patients and healthcare workers alike. Resuming elective procedures will be a process that provides a great deal of planning and consideration. Talk to your trusted RCM&D advisor today if you have any questions on resuming elective procedures.

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