EXECUTIVE SUMMARY

The COVID-19 pandemic has led many surgery centers to close and surgeons to put off elective surgeries.

  • Hospitals in the early outbreak areas of the pandemic began to struggle to obtain as many N95 respirators and personal protective equipment as they needed.
  • Nationwide, cities and states enacted social distancing measures in an attempt to slow the virus’ spread and keep hospitals from experiencing patient surges that outpaced their available beds and other supplies.

American life began to shut down as COVID-19 spread across the globe. By the end of March, the options for U.S. surgery centers were bleak: postpone all elective procedures, or step up extreme infection prevention actions.

The American College of Surgeons created a newsletter with COVID-19 guidelines, including how to prepare for the potential need to operate on a COVID-19 patient. For surgery centers, especially hospital-based outpatient departments, stopping elective procedures meant they could free up personal protective equipment (PPE) and other resources that were in scarce supply.

The Association of periOperative Registered Nurses (AORN) created a COVID-19 toolkit and published it on Feb. 14, well before cities and states had started to cope with the pandemic.

“We anticipated global medical supply shortages related to decreased production in China,” says Erin Kyle, DNP, RN, CNOR, NEA-BC, editor in chief, Guidelines for Perioperative Practice, AORN. “At the time we assembled the toolkit, the spread of the virus was very limited outside of China, but we kept a very close pulse on what medical experts had to say about the potential for and likelihood of a pandemic.”

The American Association of Nurse Anesthetists (AANA) also provides online information about how nurses can care for patients with COVID-19. For example, the AANA recommends nurses use the N95 mask as protection against infection from a known or suspected patient with COVID-19. Clinical anesthesia personnel should be a priority in the issuance of N95 masks.

Some hospitals and surgery centers chose to stop elective procedures soon after the virus began to spread in the United States. “We and others are delaying elective procedures so we have maximal resources available for what will be for most centers a surge that exceeds capacity,” says Greg Poland, MD, professor of medicine and infectious diseases at the Mayo Clinic and director of Mayo Vaccine Research Group. “You don’t want to use up precious resources for things that can easily be delayed. That’s where each facility will have to make their own decision.”

The more surgery centers decrease interactions and increase the capacity of the medical system to handle testing evaluation and treatment, the better off the United States will be, Poland adds.

Hospitals in the early outbreak areas of the pandemic began to struggle to obtain as many N95 respirators and PPE as they needed. “Access to N95 respirators went into short supply almost immediately, and we haven’t figured out how that happened,” says Paul Biddinger, MD, MGH endowed chair in emergency preparedness, director of the Center for Disaster Medicine, and vice chairman for emergency preparedness in the department of emergency medicine at Massachusetts General Hospital in Boston.

Biddinger spoke to journalists and others at an Accumen/WIRB-Copernicus Group web conference on March 13. “Manufacturers are trying to distribute to hospitals and not let anyone buy out the market as happened with H1N1 in 2009,” Biddinger said. “Gowns [and] masks are also hard to find.” In some surgery centers that decided to stop elective surgeries, leaders told surgeons that only tier 1 lifesaving procedures would be performed.

Other operations would be reviewed on a case-by-case basis, says Joseph Abboud, MD, senior vice president of clinical affairs at the Rothman Orthopaedic Institute in Philadelphia. Abboud says Rothman chose to end elective procedures. “We follow the guidelines,” he adds. “Certain procedures can be done, which are considered urgent or emergent, and others are deferred to a later date or rescheduled.”

Surgery center staff call patients, move their appointments, and ask them to wait a month to reschedule, Abboud says. “If they’re in a post-op period, we say, ‘Let’s recircle in two weeks,’” he adds.

Meetings with patients are handled via telemedicine, but this also poses challenges. “Telemedicine capabilities are there, but were not expected to be scaled at this level,” Abboud says. “We were not expecting this large of an increase, this quickly.”

At Columbus Laser & Cataract Center in Westerville, OH, the situation continued to evolve through March. “We’re waiting to hear guidance from the government in the next couple of days of what businesses and healthcare providers should do,” says Danielle Bartholomew, OD, human resources manager and optometrist. “In the meantime, we sent out messages to patients to let them know if they’re immunocompromised, have health concerns, or are showing any kind of illness to stay home and reschedule all elective surgeries.”

The center communicated through a text messaging system that also is used to send notifications and appointment confirmations. “We had some patients who chose to reschedule surgery at a later time,” Bartholomew says. “We’ve started to discuss how we’re going to implement our employees being able to do things from home.” Columbus Laser also told staff to use their paid time off if they needed to stay home due to child care or health concerns, since schools were closed. “That’s something we need to reassess on a weekly basis,” Bartholomew says.

While the center still operated under the shadow of the pandemic, staff implemented extra infection procedures, such as wiping the exam lane completely before each patient and disinfecting the lobby frequently throughout the day. Staff also removed magazines and any items people might share. “We placed a notification on the door, telling people if they have any symptoms — coughing or flu-like symptoms or a cold — we would like them to reschedule an appointment,” Bartholomew says.

Menomonee Falls Ambulatory Surgery Center in Menomonee Falls, WI, closed all but one of tis four ambulatory surgery centers (ASCs) in early March, says Dianne Appleby, RN, BSN, MBA, director of the ASC. “We are part of a healthcare system that owns the four ASCs,” Appleby explains. “The one center is open now only to cases that would be deemed non-elective.”

The center that is remaining open follows all federal, state, and accrediting body regulations related to infection control, Appleby says. “In light of the current pandemic, we are tracking and following information from various sites as it relates to shortages of personal protective equipment,” she explains. “Our staff have been directed to follow the normal process for letting us know if they are ill.” To screen patients for COVID-19, ASCs should ask patients questions and explain which symptoms to look for, she adds.

The social distancing measures enacted in March in many cities and states were designed to slow the virus’ spread in hopes of keeping surge demand for hospital beds lower than they would if nothing changed, Biddinger observed. “If we can defer visits, it is extremely important and decreases consumption of resources,” he said. “We’re seeing decreases in available workforce; either physicians, RNs, or others who have exposure to patients with suspected COVID-19, are quarantined for 14 days.”

This cuts into the available health care workforce at a time when greater numbers of healthcare professionals are needed. “There is a lot of healthcare fear, a lot of fatigue,” Biddinger acknowledged. “In my own hospital, we’ve had a command center activated since late January, and I’m running six weeks-plus in emergency response mode, running 16-hour days. That takes a toll on frontline staff.”

While hospitals in some cities prepared early for the pandemic, the federal government lagged. “Problems with [viral] testing in the United States is well-documented and frustrating for everyone involved in this response,” Biddinger noted. “It’s extraordinary to look and see how different the U.S. is for testing, compared with anywhere in the world. There were 23 tests per 3 million people in the United States, the lowest in any industrialized country.”

Without adequate testing, the United States could not know how much disease there is and how widespread it is. “There’s especially a need for testing in inpatient care at hospitals,” Biddinger said. “Without tests, healthcare workers have to treat every patient with symptoms as if they have the disease. This means they are using more PPEs and putting more people at risk.”

The lack of proper testing also makes it harder for physicians to make optimal decisions about which patients to admit to the hospital. “Policies, health systems, and offices will change, depending on how things play out in the next few weeks,” Abboud notes. “Some things are life-altering if you don’t address them in a timely fashion.”

From a surgery center’s financial and operational perspective, the pandemic’s impact is unprecedented and unpredictable. “No one has planned for anything like this from a cash flow perspective,” Abboud notes. “Postponing elective procedures can be done for a short period of time, but for a long period of time, it will be problematic.”