'We have been busier than ever doing fewer cases than ever': Texas ASC administrator details surgery ramp-up, outlook for 2020

Lubbock, Texas-based Covenant High Plains Surgery Center Administrator Alfonso del Granado outlines the ASC's plan to resume elective procedures while also planning for an unknown future amid the pandemic.

Question: What is your plan for resuming elective procedures in the future? What will be different at the center?

Alfonso del Granado: 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. [Recently] we got up to 25 percent...We will probably build to 75 percent and then 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.

Q: How has the pandemic affected your plan for growth in the next 6 to 12 months?

ADG: Although the impact is measurable, we're reasonably confident for the mid-term. We have a great number of active surgeon partners whose patients have waited out the quarantine and are now backlogged, and we expect this to take months to catch up. The greatest impact for us will be on cash collections, as we expect more patients will qualify for financing their deductibles and coinsurance than before, and the finance terms will likely be longer as well. That said, our worst-case models have us down but still profitable for 2020, normalizing caseloads by May of next year, and revenues returning to par for 2021.

Q: What does the "new normal" look like for ASCs?

ADG: It’s really hard to say what the 'new normal' will be for the long term, though I expect the eventual widespread availability of vaccines, herd immunity, and human apathy will put pressure on the system and tip the balance back closer to efficiency versus safety. In the interim, expect continuing PPE-preservation measures, including CDC guidelines for extended- and re-use of N95 masks, as well as decontamination measures recommended by the recent NIH study.

We also expect ongoing restrictions on patient family members as well as OR visitors and observers. We are now considering allowing students back so long as they are tested regularly and we have enough PPE, but we expect that to relax more as things stabilize. We are acutely aware of the likelihood of a resurgence, both seasonal as well as due to human behavior, so we are remaining cautious, but also cautiously optimistic.

As challenging as this crisis has been, it has also shown the resilience of organizations prepared to deal with the unexpected. This has been a growing trend over the years, as the healthcare landscape changes more and more rapidly, and COVID-19 has just been the latest, though most severe test of that ability to anticipate and adapt. More than ever, ASCs need to continually grow and improve in order to succeed.

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