After deciding what their operating model would look like during the COVID-19 crisis, surgery center leaders had to determine appropriate staffing levels — furloughs, layoffs, or fewer hours. Additionally, administrators had to decide whether to ration precious personal protective equipment (PPE) and other supplies, or loan this materiel to frontline facilities in desperate need.
Same-Day Surgery: Did your surgery center close or move to only emergency surgical procedures? If it closed, how did that affect you and surgery center staff? Were personal protective equipment donated to the local hospital?
Harrison: We have limited amounts of PPE, and any PPE we have we need for the “essential” cases we are doing.
Patterson: We have worked closely with our Unity Point Health System partner to develop plans for overflow care of patients needing surgery in the event the hospital becomes full with regular inpatients or COVID patients. It really has been a community effort to ensure patients continue to get the care they need in the appropriate setting. PPE is being managed based on need, and we are working with our county health department to ensure resources are available where they are needed.
Young: It was decided our number of urgent/emergent cases would be so small financially it was best we furloughed all of our staff. We did keep two administrative staff to take care of day-to-day functions as well as work all accounts. We worked with the hospital, loaning them our anesthesia machines, stretchers, IV poles, and patient monitors. This was done through a legal loan agreement. We did allow the hospital to obtain our PPE with the understanding they would replace what was obtained when we opened back up. My nursing staff was offered first priority from the hospital to hire them for [pro re nata] work to assist their staff during COVID-19.
del Granado: Our 46 physician partners, plus the hospital and management company, voted unanimously to continue to provide at least 80% income to the staff as well as maintain their full benefits and deferring their dividends to ensure that we maintained enough cash on hand.
The staff, in turn, elected to reduce their hours further than asked, down to 50%, opting to take part-time jobs or apply for unemployment to help the company preserve its financial viability. This was an impressive and, frankly, moving display of solidarity. I’m proud to be part of this organization.
With regards to PPE, we inventory it twice weekly and keep it always locked up, issuing gear under Centers for Disease Control and Prevention [CDC] protocols for extended and reuse. We have enough to continue operating at our current reduced volume almost indefinitely, and we have donated surplus to the hospital as well. Having said that, we would be unable to sustain more than three weeks of normal operations, so we are on a constant hunt for as much as we can get until the market shortfall is cured.
Millsap: MPSC is working closely with local hospitals to ensure they have the supplies needed to successfully combat the pandemic and treat affected patients. This includes donating surplus medical supplies, PPE, and loaning anesthesia equipment should a shortage of ventilators occur.
Same-Day Surgery: How do you believe this pandemic will change the way same-day surgery centers operate in the future? For instance, what are some aspects of your facility’s disaster planning that you wish had been different before COVID-19?
Patterson: COVID-19 will most likely have a material impact on how healthcare systems and facilities operate, in general, in the coming months. We will need to develop solid screening processes to ensure we are protecting staff, patients, providers, and visitors.
We may hit the peak in the coming months, but that doesn’t mean that COVID-19 won’t exist in our communities for a significant period of time following that peak. We will need to develop solid screening processes, and will look for rapid technology gains to assist with quick detection of the virus, along with appropriate PPE utilization to ensure we continue to provide high-quality, safe surgical care to patients.
Young: I feel we are going to need to perform COVID-19 clearance of patients prior to surgery, just as we perform glucometer checks. At our facility, we perform cataract surgery and ENT [ear, nose, and throat] procedures. COVID-19 lives and thrives in these [patient populations]. If we perform surgery on a patient who is active with COVID-19, but not showing symptoms, we could infect our staff and expose other patients. Testing of staff for COVID-19 antibodies will be vital in the future as well.
Millsap: MPSC follows CDC and CDPH [California Department of Public Health] guidelines to ensure continued quality patient care. MPSC adheres to the highest infection control standards and maintains an infection rate that is among the lowest in the nation. Our equipment sterilization, environmental cleaning, disinfection, and air filtration systems meet national standards. MPSC’s physicians and staff perform optimal hand hygiene practices before and after any patient contact. Additionally, MPSC makes available hand sanitizer dispensers throughout our facilities. Prior to admission to the surgery center, all incoming patients are screened for symptoms of any illness, including those related to COVID-19. Patients are requested to disclose any significant travel history to one of the affected areas in the last 14 days, or if they have known direct contact with a COVID-19 patient. Upon arrival and prior to admission, all patients are screened for fever, cough, [and] shortness of breath. Patients experiencing symptoms or exposure will be required to postpone their procedure until their condition is resolved.
While these reactive measures are proving effective, MPSC is gaining further insight on how to proactively address future widespread crisis. The COVID-19 crisis has clear lessons for what we can do now to stop a future global health emergency. National and international experiences reflect the importance of anticipating and preparing for crisis situations, which includes efficiently implementing government recommendations and organizational response plans, maximizing patient and staff safety in the outpatient surgical environment, and effectively making key clinical management considerations supporting the economic health of our local community.
Mahoney: During this time, I found our staff were amazingly understanding. They were incredibly supportive of each other and came together even more than usual. I felt like our management team went into survival mode. [We asked ourselves] what do we need to do to get through this so we can continue providing care in the future to our patients and to help our staff feel confident that this will pass and we will make it?
del Granado: I believe there will be a continuing reduction in certain types of cases until either a vaccine is developed or enough healthcare personnel are exposed and recover. Several of the physicians, whose specialties include an elevated risk for exposure to aerosolized coronavirus, have expressed their intention to limit their practices to the most necessary cases only. There also will be more patients willing to live with discomfort or accept some limited mobility rather than face the risk of exposure.
Over time, this fear will ease if not fully dissipate. I believe ASCs will return to their upward growth trend sooner rather than later. We’ve modeled several scenarios, and the most pessimistic have us recovering by December 2021, but we believe [sooner] is more realistic.
During that recovery period, and for the foreseeable future, we will continue to equip anesthesiologists and circulators with N95s and face shields, and will continue our current policy of having other staff exit the room during intubation/extubation and for three minutes thereafter until enough N95s are available for everyone. Again, in time, I suspect that a combination of vaccines and herd immunity will diminish the need for some of these cumbersome practices.
DeConciliis: We have planned for, and have policies for, every emergency and disaster possible. We always hope we never have to use them. With a disaster such as this, we have all been forced to make rapid changes in real time, and often on the fly, to adapt and survive. I believe the most prepared ASCs, with strong management and committed surgeons and staff, have adapted the best.
But if a particular ASC has not adapted well, there still is time to act. Preparing for the resumption of operations is something that must start now. ASCs were made for this kind of resurgence. Our “clean” environment, efficiencies, and commitment to our staff and patients will allow us to handle this surge in volume effectively. We should prepare to land on our feet in a much better position. If they haven’t already, patients and surgeons will choose ASCs for their procedures ... We must continue to do our part to assist the hospitals and health systems with the pandemic in every way possible, and, most importantly, stay positive and prepare our facility for the busy road ahead.
Harrison: Hopefully, the states and federal government will understand what a surgical center is and plan for the ASCs to be in all regional planning phases of their emergency planning. We could never have planned or have imagined being ready for such magnitude of a pandemic in any facet of healthcare. I feel our emergency planning team, our board of directors, have responded and executed according to what we knew, moment by moment. We have stayed in contact with our state ASC association for guidance, and stayed connected to our governor’s office weekly.
One item of focus is to understand what exactly our “burn rate” of supplies is: taking a closer look at inventory on hand, and seeing where the basic supply chain was in back orders and allocations. It is difficult to understand what we need on a detailed basis. Another thing to know is when items expect to resume our regular par level. It is a fine balance between having just-in-time inventory and hoarding supplies we don’t need or could [expire].