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Flexibility and Rolling With Changes the Focus of ASCs While Reopening

Elective surgeries resume in certain states as COVID-19 cases cross 1 million in the US

BY SAHELY MUKERJI | APRIL 2020

ASCs in multiple states—Alabama, Arizona, Arkansas, Colorado, Indiana, Iowa, Louisiana, Mississippi, North Carolina, Ohio, Oregon, Pennsylvania, South Dakota, Tennessee, Virginia and West Virginia—resumed operation the week of April 27, 2020.

“This has been a long and challenging road, and it appears that we may be facing continued regulations that change frequently going forward,” says Chris D. Skagen, executive director of the Colorado Ambulatory Surgery Center Association in Denver, Colorado, and the Oregon Ambulatory Surgery Center Association in Salida, Colorado. “ASCs will have to have resiliency and mobility going forward.”

Colorado ASCs received an executive order (EO) from the governor’s office on April 26 that clarified what facilities would need to do to resume elective surgery on April 27. “That did not give us much time to prepare,” Skagen says. “Luckily, the criteria in the EO are in line with the existing guidance, and we have been in talks with the governor’s office to keep up with the regulations.”

A lot of the protocols for re-opening were the same as when the ASCs were closing, Skagen says. “For example, there is an intake desk for temperature screening, asking patients if they traveled, giving them hand sanitizer, etc.,” he says. “Everyone wants to see testing, but the question is where are we going to find adequate testing. And what can we do in lieu of a test if it is unavailable?”

ASCs already do a high level of screening for patients, says Tammy Burnett, president of the Mississippi Ambulatory Surgery Center Association in Jackson, Mississippi. “Other than screening visitors and wearing masks at all times, much of this is already covered in what we do,” she says. “The testing is confusing for many and not especially helpful. Thankfully, we do not expect to do a lot of testing if we are properly screening and our surgeons are diligent in their clinical evaluations.”

Going forward, Burnett expects to be busy “catching up and shaking off any rust that accumulated over the last month.”

Certain ASCs have considerable backlogs. “I have heard of a facility that has 2,000 cases in backlog and 150 are being added every day,” Skagen says. “That shows a substantial need for resuming cases. Once we get over the initial hump of the backlog, we may see a lower volume of referrals coming from physicians. All systems will have to ramp up as we see restrictions being eased up.”

Cindy Bishop, executive director of the Louisiana Ambulatory Surgery Center Association in Baton Rouge, Louisiana, says that the ASCs in her state are resuming operation under certain state guidelines. “Medical and surgical procedures shall only be performed under the following conditions: 1) to treat an emergency medical condition, 2) to avoid further harm from underlying medical conditions or disease or 3) time-sensitive medical conditions,” she says. “They want us to evaluate all patients with a screening instrument or test, if available; have at least five days of personal protective equipment (PPE) in store; have an area hospital with ICU capacity in case we need to transfer; perform cases that are time sensitive; ensure that we have adequate staff, including surgical, surgical support, recovery and nursing; follow up with patients in 10–14 days regarding COVID-19 symptoms; follow Centers for Medicare & Medicaid Services’ (CMS) guidelines that came out on April 19; and continue to postpone any procedure in which a delay would not adversely affect the patient.”

The state is defining “time-sensitive” as a procedure that if not done would worsen the patient’s condition, she explains. “So, treat patients with emergency conditions, to avoid further harm from an underlying condition, and time-sensitive medical conditions.”

To prevent a resurgence of COVID-19, ASCs need to keep practicing social distancing with the patients in the waiting room and limit the number of people entering, she says. “We need to follow CMS guidelines and do a gradual re-opening of the surgery centers, not full steam ahead, but just scheduling the backlog of patients right now.”

Oregon ASCs resume elective surgeries on May 1, Skagen says. “I will be speaking with the chief medical officer of Oregon Authority and they are developing the regulatory framework for implementing on the opening day of May 1. We will be hashing out what these different components—PPE, protocols, regulations—look like as we maneuver through a bottleneck in healthcare infrastructure to figure out what is appropriate to take care of public health.”