Considerations for Bringing Your Patients Back Safely and Efficiently
Hospitals across the country responded to the COVID-19 pandemic quickly, efficiently and selflessly. To prepare for a potential surge in COVID-19 patients, most organizations suspended virtually all elective procedures in mid-March with a twofold purpose: to stop the spread of the virus to patients and staff, and to conserve critically important personal protective equipment (PPE), intensive care unit (ICU) beds and ventilators. This necessary action resulted in a backlog of patients awaiting “elective,” but not “optional” procedures. In addition, many of the nation’s hospitals, whose operating margin is directly dependent on their surgical volume, found themselves in a significant financial downturn that continues to worsen every day. As communities across the United States begin their recovery, health systems must consider the following 10 actions to bring elective procedures back in a way that prioritizes safety of the patients and hospital staff.
1. Track current federal, state, and local government directives and guidelines issued by professional societies daily:
- Monitor daily updates to availability of testing, PPE, ICU beds and supplies in addition to the local COVID-19 census to be vigilant of potential recurrent waves.
- Perform a daily review of clinically relevant guidelines by key senior clinical leaders (e.g. a surgeon, anesthesiologist, head of infection control and chief medical officer).
- Establish guidelines for ramp-up or wind-down protocols for elective surgeries based on the trajectory and census of local COVID-19 positive cases.
2. Establish clear guidelines for ICU bed allocation based on the following considerations:
- Holding in reserve for COVID-19 positive patients.
- Available as needed for COVID-19 negative medical-surgical patients.
- Emergent use for unexpected surgical complications or medical emergencies.
- One approach is to maintain enough ICU beds to sustain all operations for 14 days.
3. Establish and continuously assure par levels of PPE to prepare for potential COVID-19 waves:
- One approach is to maintain a par level of 14 days across all clinical areas for PPE to approve posting of elective cases.
- Develop guidelines for the type of masks and gowns that must be used in various circumstances (e.g. N95 respirators vs. surgical masks).
4. Implement a plan to pursue system-wide testing
capabilities and set testing guidelines for patients and staff to allow
elective cases to be posted. Implement guidelines for testing based on
the following considerations:
- Based on the trajectory and census of local COVID-19 positive cases, one approach is to set availability of testing kits for all patients presenting for elective surgeries and/or requiring hospitalization to at least seven days to reactivate elective cases.
- Wherever rapid testing is available, it should be utilized for all patients admitted to the hospital.
- Another approach may be to both screen patients via a targeted questionnaire and perform off-site testing 48 hours prior to the procedure (ensuring that the results are back before patient presents to the pre-operative area).
- Implement periodic testing and consistent tracking of test results for all re-opened procedural area staff. One approach could be every two weeks with daily symptom monitoring and temperature checks.
5. Institute an interdisciplinary Surgical and Procedural Recapture Task Force to oversee and triage all elective procedures:
- Develop an objective prioritization matrix accounting for types of surgical cases and patient-specific factors to clinically sort cases within each service for posting on the OR schedule.
- Conduct review of the surgical plan and elective cases to be performed 48 hours prior to day of surgery across all procedural areas and provide the final approval.
- Suspend block schedule temporarily and manage OR schedule by prioritizing clinically necessary cases.
- Develop principles and plan for cancellations of elective cases.
6. Realign clinical and non-clinical staff to support all procedural areas including protocols for:
- Anesthesia coverage across all procedural areas and flexing as needed;
- Ancillary clinical services like radiology, pathology/lab, etc.; and
- Re-opening and flexing essential non-clinical services like environmental services, sterile processing department, supply chain department, etc.
7. Prioritize reopening standalone ambulatory surgery centers
or well-separated hospital outpatient department (HOPD) operating rooms
to hospital's main operating rooms based on the following considerations:
- Allows managing an isolated set of patients and staff given constraints of testing kits and PPE; and
- Prioritizes minimally invasive procedures that typically do not require ICU beds.
8. Leverage telehealth to advance pre-operative and post-operative care rapidly:
- Virtual visit to complete registration, updated history and physical, pre-authorization and screening for COVID-19.
- Virtual follow-up 10-14 days post elective surgery to screen for COVID-19 symptoms.
9. Implement a focused patient outreach and engagement program to:
- Educate and prepare patients to receive procedural care; and
- Address patient safety concerns.
10. Implement focused interdisciplinary programs to support:
- Training and cross-training of staff on new COVID-19 procedures and protocols;
- Emotional well-being of clinicians and other healthcare professionals; and
- Internal and external communication.
As a result of the COVID-19 pandemic, U.S. healthcare organizations are facing an unprecedented dilemma in that many will emerge severely damaged economically while also needing to position themselves as leaders in their communities. To respond to the clinical needs of patients and consumers, healthcare organizations must accelerate welcoming back patients in need of elective procedures. However, they must do so in a way that acknowledges patients’ fear of COVID-19 exposure, produces a system of care focused on patients’ needs and safety, respects joint decision making (especially in situations where testing may not be readily available), creates diligent readiness for the likely unavoidable waves and overall considers this challenging time a unique opportunity to transform the clinical care delivery model.
