Fifteen ASC administrators outline their plan for resuming elective surgeries and discuss how they anticipate their centers will be different going forward.
Raghu Reddy. Executive Administrator of SurgCenter of Western Maryland (Cumberland, Md.): We have created a three-phase approach to ramp our case volume. Phase one is for elective, essential cases lasting two to three weeks; phase two is for elective, semi-urgent cases lasting two to three weeks; and phase three is for routine elective procedures. These stages are not set in stone and can be altered based on several factors, such as the COVID-19 trend in our area, the governor's orders, and the recommendations made by our hospital partner.
We are incredibly conscious of our responsibility towards our patients, staff, and the community to avoid any unnecessary spread and have taken extraordinary precautions with stringent infection control and PPE requirements. We also have a three-person committee that is reviewing the cases and ensuring that the case selection meets the requirements for an essential procedure until we reach phase three. A lot has changed due to this COVID-19 outbreak and we have added additional measures to our already stringent infection guidelines and PPE protocols.
We will continue to proceed with extreme caution adhering to all CDC, HHS and ASCA recommendations and will have these COVID-19 protocols in place for an unforeseeable time. However, we are using this downtime to review our key performance indicators, and any operational efficiencies we can improve upon once we resume the normal operations. The staff furlough was stressful, and but we are thankful for everyone for being so supportive and understanding during this pandemic.
Matthew Ewasko. Administrator of Physicians Alliance Surgery Center (Cape Girardeau, Mo.): Physicians Alliance Surgery Center has created a list of criteria that must be met for elective procedures to be scheduled; urgent cases have been allowed at the center so long as the procedure is acceptable. This list was created in collaboration with my physician ownership group, and insight from our anesthesia providers. Our screening process will allow for the backlog of cases to be seen, while at the same time provide a level of protection for our staff.
The PAT process is followed up with another screening and temperature reading when the patients arrive at the center for their surgery. If the patient has developed any signs/symptoms of COVID-19, or they have a fever, they are asked to return to their vehicle and we will work with them to reschedule their surgical procedure.
Additional measures currently in place at the facility include, screening (including temperature reading) each employee and rep that enters the building; no family or guests allowed in the waiting room (they are waiting in their vehicles); surgical procedures are only being done three days per week instead of five; all staff members are wearing masks while in the building and we are providing masks for the patients if they do not have one already; and we re-routed all deliveries and sales reps to our front door so they can be checked in with our registration desk.
Our current plan is to resume operating five days per week starting on May 18 with our full block schedule available for scheduling. We will still maintain many of our current restrictions for the safety of our staff and patients even as things slowly progress back to normal. An agreement is currently in the works to implement testing of our surgical patients, and once that is in place we will be able to remove our current restrictions on which patients can be scheduled at the facility. Our waiting room area will most likely remain empty to patients and families for another month or two.
Rick Liwang, RN. Administrator of Gulf Coast Outpatient Surgery Center (Biloxi, Miss.): Social distancing, handwashing and masks are different. We are allowing one nurse to monitor the people who come into the lobby and the same person is making sure there are 10 or less people in the waiting room. The rest of the visitors/family members have to wait in the car and are called in when necessary.
Bonnie Brady Lavoie, RN. Vice President of Operations for West Morris Surgery Center (Succasunna, N.J.): Our plan for resuming elective procedures includes designing guidelines and policies approved by our physicians so we are observing CDC guidelines and state recommendation. We plan on a "soft" start with reduced hours and patient volume and decreased staff until such time we are able to increase all those parameters.
Bobbi Freeman, RN. Gastroenterology Endoscopy & GI Lab Rome Manager of Harbin Clinic Endoscopy Center (Rom, Ga.): We resumed operations this week. We are an endoscopy-only ASC and we are selecting procedures based on priority tiering as mandated and physician approval. We have expanded our provider block days to allow for more provider availability. We started with scheduling patients 45 minutes apart rather than our usual 30 to allow for additional room turnover time and increased social distancing.
We are screening all patients at time of scheduling with COVID-19 screening questions, again at one week before, again the day before, and then again at arrival to the center. Patients are instructed to call the GI lab when they arrive and a nurse will advise them when to come to a special entrance for screening. All family members/drivers are to remain in the car. The patient is checked in after screening and brought directly to the GI lab pre/post op room. All patients are given a surgical mask, all staff wear surgical masks (or N95 if in the procedure or reprocessing rooms) and surgical caps.
During the procedure and reprocessing all staff wear face shields as well. The patient rooms and restrooms are disinfected after each use and the procedure rooms are terminally cleaned. We have removed all non-essential equipment and supplies from the procedure rooms as well.
Michelle Eilander, RN. Administrator of Ankeny (Iowa) Park Surgery Center: Our facility resumed elective surgeries on Monday, May 4. We are starting out slow and then will ramp up. We will continually monitor our PPE availability as well as monitor the availability of hospital services in the case that they would need to be transferred to the hospital. We will discontinue elective surgeries if we see a PPE shortage or lack of hospital availability.
We have implemented several new procedures and protocols, including employee screening, visitor restrictions, requirement of COVID-19 testing on all patients within 48 hours of their scheduled surgery and confirmation of a negative result. All patients are required to self-quarantine following their test.
Catherine Retzbach, RN, BSN. Administrator of Memorial Ambulatory Surgery Center (Mt. Holly, N.J.): Our center resumed cases on April 29. We will continue with pre-screening during our pre-op call and again on the day of surgery and are re-scheduling those patients who do not meet the pre-screening guidelines. We have been and will continue to monitor all staff and vendor temperatures daily.
We have limited all vendors who enter the center to only those absolutely needed for surgical cases. All staff, patients and vendors are wearing masks while in the center.
No family/visitors are allowed in the center. Physicians are calling family postoperatively to discuss procedure and follow up care. Nurses are reviewing discharge instructions outside at the discharge exit with family. We are maintaining social distancing in our waiting room by spacing our chairs and sending patients to their cars to wait until we call them if we are at capacity (10 patients).
John Lewis. CEO of Semmes Murphey (Memphis, Tenn.): Our surgery center resumed elective procedures on May 4. We are starting out with lower case volumes as we work to gradually and cautiously increase volumes back to normal levels over time. Our primary focus has been ensuring the safety of our patients and staff while conserving PPE. Our team has made a strong commitment to doing everything possible to create a clean and safe space for our patients, physicians and staff.
During the recent shutdown, our staff used that opportunity to expand and improve procedures and policies that are in line with CDC guidelines related to COVID-19, and we have invested in new technologies that will provide added levels of safety in the clinic, ASC and back-office areas. Some of the things we have done include:
· Purchased and implemented electrostatic disinfecting spray systems
· Purchased and implemented UVC Whole-Room Disinfection Systems
· Required COVID-19 testing for all surgical patients 72 hours prior to any scheduled surgery procedure
· Implemented routine COVID-19 testing for all ASC physicians and staff
· Limited visitors inside the clinic and ASC. As a way to maintain social distancing, we offer to let patients and/or drivers wait in their cars as appropriate.
· We provide (as needed) and require face coverings for all clinic staff, ASC staff and patients.
· All patients, visitors, physicians and staff are screened (questions are asked, temperature scans are completed and oximeter readings will be offered as needed) upon entering any part of the facility.
· We have expanded our telehealth offerings to give patients options to speak to a physician remotely.
· Anyone who fails the question screening, is sick, has an above normal temperature, has low blood oxygen readings or other COVID-like symptoms is not allowed into our facility.
· Our staff and physicians have been working in rotating teams (home one day/onsite one day) as much as possible during this period.
· We have limited the seating and capacity in our waiting rooms, break rooms and other common areas as we continue to encourage appropriate social distancing.
· We will expand our available times during the week and into the weekends to accommodate our patients and ensure that we can take care of them at the most appropriate times.
Patricia Frendak, RN, BSN. Administrative Director of New Britain Surgery Center: We began resuming elective cases beginning May 11. Our turnover times will be significantly impacted. The patient flow will be affected, processes to manage patients have been revised. Testing will be required for surgical cases.
Debra Hagendorn. Administrator of East Hills Surgery Center (Greenvale, N.Y.): We remained open two days a week performing urgent/emergency surgeries during the pandemic. When our governor lifts the restrictions on elective surgeries in New York we will begin elective surgery again on a gradual ramp up schedule until we can reach our full capacity.
Alfonso del Granado. Administrator of Covenant High Plains Surgery Center (Lubbock, Texas): We already started resuming elective procedures on April 27, which was the first day allowed in Texas and completed 15 days of declining cases in our community. We also operated under the GL 20-1007 attestation provision of Texas Governor Abbott's executive order GA-15, which requires that we reserve 25 percent of our capacity for a potential COVID surge, and that we agree not to request PPE from public sources.
We began by ramping up slowly for three reasons: first, safety above all else – we wanted to make sure that everyone was taking appropriate measures and not missing or skipping any steps because of time pressures; second, we have to be able to evaluate the new consumption rates for PPE; and third, allow physicians time to prioritize their patients, taking care of the most pressing cases first. During our slowest weeks we were down to only 10 percent of our normal volume. Last week we got up to 25 percent. This week is at 50 percent. We will probably build to 75 percent and the hold again.
We have also been avoiding cases with high potential for aerosolizing coronavirus, such as upper endoscopy, certain ENT cases, and dental procedures.
We are sustaining all existing COVID-19 screening measures, such as questionnaires, temperature and masks upon arrival, no visitors in the waiting area, none admitted in the back except for minors and others requiring a family member or guardian. Thanks to our relationship with our hospital system, we are able to require COVID NAAT (PCR testing) for all patients. These must be completed no more than 72 hours prior to surgery, and the patient is instructed to quarantine themselves in the intervening period. We do this for two reasons: first, from available evidence, 72 hours is not long enough for a fresh infection to become contagious, so it protects our staff and other patients in our center; second, we don't want patients to undergo surgery, become sick, and have to be admitted to the hospital.
On the administrative side, we have been busier than ever doing fewer cases than ever. We’re keeping PPE under lock and key and checking inventory twice a week, then revising our models weekly to see where we stand and how much more (or less) we'll be able to do in the coming weeks. We also have to stay on top of developments as they happen, both to adjust our practice to match the latest guidelines, and to debunk the myths and rumors that swirl about. With so much on the line, we have to balance the needs of the patients, the staff, and the physicians, and remain a viable business.
Leticia Ramirez, RN, BSN. Administrator of MidAmerica Orthopaedcis (Palos Hills, Ill.): Our plan for resuming elective cases is to perform a COVID test (RTPCR) within 72 hours of surgery. We are contracting with a local company to perform the tests.
Barbara Smith. Administrator of a Multispecialty Surgery Center: We were in the process of opening when Virginia was quarantined until June 10. Our orders for PPE were canceled, getting our occupancy permit became a challenge, and we don't know when our accreditation will happen.
Polly Ladd. Administrator of Crowne Point Endoscopy & Surgery Center (Flint, Mich.): Our plan is to do a 'soft' opening May 18 thru May 29 doing Tier 1 patients mainly with a few Tier 2 if patient diagnosis and assessment fits the criteria. Once the week of June 1rolls around, we are hoping to add more Tier 2 and start Tier 3 patients as well. There will be many different processes; everyone wears masks, patients and any caregivers that must be with patients, otherwise all drivers go to the car.
We will do strict screening at the door with a questionnaire and take the patient's temperature to decide if patient is good to go. All staff will be screened as well. No more than 10 people in our large waiting room at once, chairs are six feet apart. Staff follow social distancing too. PPE will be strictly enforced; I am sure no one will be giving us a difficult time over that!
Turnover time for the procedure room will be longer due to meticulous cleaning. For the time period May 18-29, we will allow one GI physician to work using the two-room strategy to help keep the flow moving, although there will still be an increased turnover time. Discharge instructions will take place on the phone or outside. Many documentation changes will be made prior to re-opening to cover the COVID-19 issue, especially the consent. The pre-admission testing phone call will be longer and more entailed as we have to discuss Tier 1 appropriateness, ensuring patient safety, and follow-up.
Todd Currier. Administrator of Northern Wyoming Surgical Center (Cody): We have implemented a phased approach to resumption of surgical procedures. Each phase period will be evaluated and discussed prior to moving to a new phase (proper PPE, COVID condition within community, hospital capacity, etc.) Proper cleaning of center, lobby and patient care areas will remain in accordance with CDC recommendations.
Phase 1 will include healthy patients with limited comorbidities and also limit the volume of patients within the center at any given time. All patients and staff will wear a mask at all times, no visitors allowed. Phase II will include opening to all typical outpatient procedures but still require all patients and staff to wear a mask, no visitors (or limited), and continue to modify schedule to minimize volume of patients within the center at any given time.
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