With providers eager to resume elective surgical procedures as COVID-19 cases begin to decline in some regions, a group of prominent trade associations released joint guidelines Friday that are intended to help them assess their readiness to do so.
The guidelines from the American Hospital Association, American College of Surgeons, American Society of Anesthesiologists and Association of periOperative Registered Nurses say cases should only resume when the region has seen a reduced rate of new COVID-19 cases for at least 14 days, and that such a move is first cleared by local and state governments. President Donald Trump's guidance on reopening the economy, issued April 16, left a lot up to governors, included the return of outpatient elective surgeries in the first part of a three-phase strategy.
Elective surgeries are many hospitals' bread and butter, so the halt has been financially devastating for some, especially with the "double whammy" of COVID-19 patients being expensive to treat. The head of Livonia, Mich.-based Trinity Health's Michigan market, for example, projected an up to 60% monthly revenue decline starting in March. Peoria, Ill.-based OSF HealthCare projects a $330 million operating decline over the next six months.
Aside from the 14-day recommendation, the new guidelines intentionally leave a lot up to providers.
"We leave it up to institutions to understand what kind of surgeries they do, what resources they need from the hospital in order to appropriately care for those patients and to double check the availability of those resources, whether ICU beds or physical therapists to work with patients afterward," said Nancy Foster, the AHA's vice president of quality and patient safety.
The guidelines don't say patients have to be tested for COVID-19 before having procedures done, and don't preclude providers from performing procedures on patients who are positive for the virus.
Providers are running into significant challenges with not only having enough tests, but with respect to their reliability and specificity, said ASA President Dr. Mary Dale Peterson. The important thing is now making sure providers use adequate personal protective equipment and that it's worn throughout the hospital, she said.
"We can protect staff and patients by practicing good infection control," Peterson said. "It's not a perfect answer."
Surgeons, anesthesiologists, nurses and others are committed to bringing back elective surgeries, but it has to be done safely, said Dr. David Hoyt, executive director of the ACS.
"Most of them will start slowly, increase their capacity and then they will probably extend hours or operate partly on the weekend to catch up," he said.
While some providers have discussed potentially extending surgery center hours to accommodate pent-up demand, Peterson said she thinks patients will be reluctant to come in for surgeries, especially if they are still under stay-at-home orders.
"I hope I'm wrong on that," she said.
Here is an abbreviated list of the guidelines:
- Timing of reopening: There should be a reduction in the rate of new COVID-19 cases in the relevant geographic area for at least 14 days. Facilities should have appropriate numbers of intensive care unit and non-ICU beds, PPE, ventilators and trained staff to treat all non-elective patients without going into crisis mode.
- Testing within the facility: Facilities should use available tests to protect staff and patients whenever possible. They should implement a policy addressing requirements and frequency for patient and staff testing. They should also have a policy for responding to COVID-19 positive patients and staff members, as well as suspected cases.
- Personal protective equipment: Facilities should not resume elective surgeries unless they have adequate personal protective equipment and medical surgical supplies with respect to the number and type of procedures that will be performed. Facilities should have policies for the conservation of PPE, including extended use or reuse.
- Case setting and prioritization: Facilities should create committees to prioritize case scheduling. The group should have a list of postponed and canceled cases, use priority scoring and consider the resources and staff necessary for each procedure.
- Preoperative: Providers should consider using telemedicine for preoperative examinations. Face-to-face components can happen on the day of surgery. Post discharge: Patients should ideally be discharged home and not to nursing homes as rates of COVID-19 may be higher in those facilities.
- Collection and management of data: Facilities should reevaluate their policies around COVID-19 testing, resources and other clinical information.
- Risk mitigation surrounding second wave: Facilities should have social distancing policies for staff, patients and visitors in nonrestricted areas that include the number of people who can accompany patients and whether visitors in periprocedural areas should be further restricted.