Some surgery centers chose to pause elective surgeries during the COVID-19 pandemic. With certain areas gradually reopening public life, how can surgery centers resume routine business?

Seattle and surrounding areas were the first to cope with COVID-19, starting in late January. But after weeks of battling the virus, recovery was slow, and hospitalizations remained high.

Before reopening, surgery centers should develop a plan that includes its environment readiness, supply availability, staffing, scheduling, and regulatory issues.

Defeating the virus and economic recovery likely will take time.

As COVID-19 spread across the United States, some surgery centers stopped most elective surgeries, sometimes repurposing their space to take emergent cases or turning operating rooms into critical care units to accept overflow from nearby hospitals. Others did what they could to survive during the pandemic.

Now that many places have gone through a surge of COVID-19 cases and some governors have begun to lift stay-at-home orders, the question for surgery center leadership is: When and how should we resume normal operations? The answer varies according to the facility’s location and needs of the local healthcare system. Hospital-based and ambulatory surgery centers also can follow the April 19, 2020, guidance, issued by the Centers for Medicare and Medicaid Services, “Opening Up America Again."

“To date, we’ve been very fortunate that the treatment needs of COVID-19 cases have not exceeded hospital capacity in most places,” says Bill Prentice, chief executive officer of the Ambulatory Surgery Center Association. “Ambulatory surgery centers remain ready to help where needed while also preparing to resume performing postponed surgeries in states that are reducing restrictions based upon reductions in COVID-19 cases.”

Determining when an area is seeing an end to COVID-19 cases is challenging, according to infectious diseases physicians and scientists. For example, by mid-April, Seattle had been combating COVID-19 for more than eight weeks. Washington was the first U.S. state hit hard by COVID-19. Seattle and surrounding areas prepared and built capacity, basing their plans on what was happening in China, South Korea, and Italy.

Still, weeks after shutting down most of its public life, tackling the pandemic through ramped-up testing, and drawing on its experienced healthcare and public health experts, Seattle still had a way to go to end the crisis.

“As we work through this pandemic in a way that’s ahead of the curve than most of the country, we continue to see significant gaps. We see outbreaks in vulnerable communities and still disjointed access to testing,” said John B. Lynch, MD, MPH, an associate professor in the department of medicine, division of allergy & infectious diseases, at the University of Washington. Lynch spoke about COVID-19 at an April 17 virtual media briefing hosted by the Infectious Diseases Society of America.

Lynch is one of many experts who have spoken about the COVID-19 pandemic to media and peers in numerous virtual events since March. Same-Day Surgery has attended more than a dozen of these events and also spoke with infectious disease and surgery center experts. These insiders have painted a picture about what is happening as the pandemic matured and surgery centers decided how and when to resume normal operations.

Here is a look at what these experts are saying and how it might affect surgery centers:

Even the earliest outbreaks are not ending as quickly as hoped. “Gov. Jay Inslee [of Washington] was early to getting Seattle to social distancing work, and that was really important to slowing down the epidemic,” Lynch said. “We still have yet to see a decrease in hospitalized cases, even now, two months into this work.” Two barriers remain: lack of enough test kits, and a public health sector that is not a strong as it was during the last pandemic: AIDS. “We have incredible public health people here, but they were overwhelmed because of years and years of underfunding,” Lynch said. “They have a long way to go to coordinate testing.” Seattle also tested tens of thousands of people for COVID-19. The city has access to an experienced clinical virology lab that can perform 5,000 tests per day, he added. “We’re still woefully undertesting,” Lynch noted. “Moving forward, we need 10,000 to 20,000 tests per day, and we’re going to need a several-fold higher capacity for testing, in addition to access. There is still a long way to go to get to that point.”

SARS-CoV-2, the virus that causes COVID-19, also appears to be resilient as it spreads around the globe. Hong Kong, South Korea, Taiwan, and other areas appeared to have successfully ended their outbreaks, only to see a resurgence weeks later. In Hong Kong, the public had begun wearing masks and staying at home early on. They appeared to have defeated the viral spread. But in late March, COVID-19 cases resurged.

There are minimal tactics for resuming elective surgeries. “Unless we go about this with a well-planned, organized effort, we will see chaos in the operating room,” warned Linda Groah, MSN, RN, CNOR, NEA-BC, FAAN, chief executive officer and executive director of the Association of periOperative Registered Nurses (AORN). Groah spoke at an AORN web conference about leadership and COVID-19 on April 14.

The first step in reopening a surgery center likely will depend on the center’s state regulations and specific COVID-19 guidance. Areas that reopen should have a sustained reduction in COVID-19 cases for at least two weeks, and their hospitals must be able to safely treat all hospitalized patients without resorting to a crisis mode.

These states also should be able to test everyone with COVID-19 symptoms and provide contact tracing, monitoring, and testing. Testing is the key barrier. “Testing is not readily available for all people who want to be tested right now,” Groah said.

Once a state can reopen after the pandemic, surgery centers should create a pathway forward to resume surgery, she added. The pathway should address these considerations: environment readiness, supply availability, staffing, scheduling surgery, and regulatory issues. “This is about managing your supplies, and not just personal protective equipment,” Groah explained. “It’s all [about] supplies. We know there may be a shortage of drugs from the anesthesia perspective.” Disposable supplies and N95 masks might be in short supply for a while longer. “How do we bring staff back in for work?” Groah asked. “Some people are working in other areas of a hospital and are being retrained.” Surgery centers should manage schedules, following an order and guidelines on how to determine which surgeries are the highest priority and should be performed first, she added. Finally, surgery centers need to consider testing patients and staff for COVID-19 for some period after their area’s pandemic surge eases.

COVID-19 vaccines and cures will not be ready for some time. “A vaccine — if everything goes well, we’re probably looking at about a year to a year and a half,” said Sumit Chanda, PhD, director and professor of the immunity and pathogenesis program at Sanford Burnham Prebys Medical Discovery Institute in La Jolla, CA. Chanda spoke at a COVID-19 web media conference on April 2. “In the meantime, what we’re looking to do is develop existing therapeutics and see if they have any efficacy against the virus,” Chanda reported. “Right now, there are several exciting compounds that are in clinical trials.”

Two possibilities are remdesivir and favipiravir, similar antiviral agents developed to treat other viruses. Researchers are testing their efficacy against COVID-19. “Typically, a drug discovery effort takes five to 10 years,” Chanda noted. “I think our best shot now, to get something to market and into patients quickly, is to take old drugs and see if they work against the current coronavirus that is circulating.”

Economic recovery also will be slow. “I think it’s going to be a long period of economic recovery, and things are going to get worse before they get better,” said Bernard Weinstein, PhD, associate director of the Maguire Energy Institute at Southern Methodist University in Dallas. Weinstein spoke at a COVID-19 media web conference on April 9.

“There have been some forecasts that we could see the gross domestic product contract by as much as 25% in the second quarter, and that’s unprecedented — at least it’s unprecedented since 1930,” Weinstein said. “It’s not just us, it’s the rest of the world. There is some evidence that China’s economy is starting to open up, but already we’re seeing that the recovery process in China is very slow.”

China’s economy is held back because domestic consumers are using caution and because the rest of the world is not buying what China produces, Weinstein explained. “The next six to 12 months will have some evidence, but I really think it’s going to be a pretty long and hard slog,” he predicted. “It’s not like we can flip on a switch and get the recovery revved up quickly.” There likely will be a U-shaped recovery, starting in the middle of the summer of 2020, assuming the virus is brought under control, Weinstein added.