ASCs Reopen Across the Country

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ASCs Reopen Across the Country

After COVID-19 lockdown, surgery centers implement revised policies and new rules

As governors in multiple states lift stay-at-home restrictions, ASCs resume operation after being temporarily shut down or performing emergent surgeries only with minimal staff.

Manatee Surgical Center in Bradenton, Florida, performed emergent surgeries only during the lockdown, says Linda Nash, CASC, ASCA Board treasurer and administrator. “We looked at each procedure on a case-by-case basis,” she says. “We canceled all cosmetic cases and routine cataracts and went from 30–40 cases per day to maybe five per day. We furloughed most of our staff and had one GI team and one OR team—a tech and a nurse in each team—the billers, the scheduler and one receptionist in the business office.”

The ASC performed multiple pediatric dental cases, mostly infected, rotting teeth, and certain GI procedures, such as if a patient had dysphagia, so food would not become impacted in their esophagus, or rectal bleeding that could be cancer or cases where a patient would be in the hospital if not attended immediately, Nash says.

Surgicenter of Kansas City in Kansas City, Missouri, performed 20 percent of its normal load during the lockdown, says Janie Kinsey, RN, CASC, ASCA Board member and administrator. “We treated a lot of fractures and followed the Centers for Medicare & Medicaid Services’ guidelines on what could be delayed.” The ASC retained all its staff during the lockdown but limited the number of employees going in to do procedures.

Harmony Surgery Center in Fort Collins, Colorado, stayed open three days a week during the lockdown and consolidated its cases, says Rebecca Craig, RN, CASC, immediate past president of ASCA’s Board and chief executive officer of the ASC and Peak Surgical Management. “We went from 80 cases per day to about 12,” she says. “We followed the criteria from the American College of Surgeons on which cases were emergent and what our doctors deemed needed to be done for the health and welfare of their patients. We also followed federal and state orders on procedures that could not wait a certain time period.” The center decreased staffing hours more than 50 percent for most of its 103 employees and approximately 80 percent were on unemployment.

Like most ASCs, Harmony had a backlog when going back to full speed, Craig says. “We were super busy the first couple of weeks and now we are beginning to level off,” she says. While certain procedures, such as screening colonoscopies, are slower to return and are back by only 40–50 percent, other procedures, such as pain management and surgical volume, are above the budgeted volume. “Our total case volume is currently running around 70–90 cases a day.”

Surgicenter of Kansas City tried to do a slow ramp-up, but it was difficult, Kinsey says. “We resumed at half capacity and will go up to full capacity by the end of the month,” she says. “We are doing an extra 100 orthopedic cases this month, but we have not started the cataract cases yet, because they are higher risk patients. If we included the cataract cases, we would probably perform 100–150 more cases per month, which is 40 percent of our normal volume. It has been busy.”

Manatee Surgical Center also went back to a big backlog, Nash says. “We expect to perform about 600 cases per month,” she says. There are still patients who do not want to have their procedures done yet. A lot of our patients are elderly and are in that at-risk group, so they are hesitant.”

All three centers have implemented new protocols to stave off COVID-19 infection.

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While in lockdown, Nash and her staff spent half the day reading and writing new policies and the other half performing emergent procedures, she says. “Every day, there was something new to learn on what to do and what not to do, new information, new studies and new protocols. We also used the time to set up for when we resumed full-time operation.”

The ASC got back to full-time operation and a “new normal” the week of May 4, Nash says. “It was a slow week and it gave us time to bring in the staff and service-in new policies.” The “new normal” includes cheat sheets in every OR and procedure room to remind staff when to wear N95 masks, protective gowns, disposable caps and eye protection, which is any time they do a procedure that can cause aerosolization, she says. The center has a Sterrad Sterilization System that sterilizes N95 masks. “We are allowed to sterilize those masks twice,” she says. “So, we haven’t had any shortages. It is a new routine every morning you come in: you look at your cases to see if you need the PPE and the N95.”

The center changed its cleaning protocol and now every flat surface gets extra cleaning, Nash says. Staff keep nothing on the counters and the facility is mopped more frequently than before. “We clean computers with alcohol wipes, other equipment and surfaces with sanitizing wipes, and allow extra dry time for the cleaning solutions to dry,” she says.

Manatee also changed its visitor policy. “We took most of the chairs out of the visitor lobby to discourage visitors from waiting in the center,” Nash says. “Unless we have pediatric patients, then the parents need to stay.” All visitors must wear a mask. The pens that the patients use must go in a “used pens” basket and are wiped down with alcohol wipes. When patients register, the receptionist must clean every area that the patient has touched. “It slows things down, that’s the new normal now,” she says. “You have to have patience.”

The ENT patients at Manatee are sent to the local health department for COVID-19 testing three days before their procedure and are supposed to self-quarantine after the test, until they go in for their procedure, Nash says. “We do a thorough vetting before procedures. We have several nursing homes in our county that had COVID-19 cases, and we don’t allow patients from those nursing facilities.” Even after the vetting, when they come for their procedure, the receptionist takes the patients’ temperature, she says.

The Surgicenter is still hammering out its new after-COVID policies, Kinsey says. “Everyone’s wearing a mask: patients, staff and vendors. We have limited visitors. They are dropping patients off, not staying in the waiting area. All vending machines have more infection control. We are not doing actual testing for COVID but screening everyone who enters the building, taking temperatures and asking a series of questions.” Given the turnaround time for testing, between 48 and 72 hours for results, expecting patients to self-quarantine for that long did not seem realistic, she says, so the center is not testing. “Orthopedic cases are lower risk, anyway, and the PPE usage is the same,” she says. “We are not doing high-risk ENT or GI procedures. So, it did not seem like a good use of our government’s resources for us to do testing.”

The “new normal” is a huge focus on infection control, Kinsey says, but ASCs historically have already done that well. “So, just continue doing what we do and keep everyone safe.”

Like Surgicenter, Harmony is not testing for COVID either. “We treat everybody like they have COVID,” Craig says. “Our local hospitals, are testing patients three days prior to their procedure, but we are concerned with the accuracy of the test results.”

The ASC is texting patients three days prior to their procedure, and the day before, to ask if they are showing COVID symptoms, she says. When they arrive for their procedure, staff takes patients’ temperature. “If it’s 100 degrees or above they may not have their procedure, we reschedule,” Craig says.

The center asks everyone to bring a mask and provides masks to those who show up without one, she says. The furniture in the waiting room has been taken out and re-arranged to abide by the social distance guidance. Family members may not wait at the center; they can drop their patients off and pick them up.

The biggest change in the “new normal” is taking temperatures at the door and limiting family members/visitors, Craig says. “Since being back and implementing this new visitor policy, our whole attention can be focused entirely on the patient, which our nursing team has really appreciated,” she says. “When the patient is ready to go home, we complete discharge instructions with family members in one of our three consult rooms outside our clinical area. This gives us a chance to connect with the family members and concentrate on post-operative planning one-on-one to educate them. The nurses like this updated process and feel it has improved our customer service in addition to increasing our efficiency.”

The staff take their own temperature, as well, when they arrive and must wear PPE at all times, she says. “There was a debate about wearing a surgical mask over the N95, so the N95 could be reused. Most employees and physicians are choosing to double-mask to preserve the N95.”

Some members of the staff are fearful of performing procedures that have to do with the airway, such as anesthesia, ENT, EGDs, she says. “There has been a lot of anxiety because they are in the direct line of fire. They wear full facial shields or helmets along with all other PPE during all EGDs, intubations and extubations.”

The biggest challenge right now is trying to keep staff morale up because they have so much going on at home in addition to work, Craig says. “It’s been a roller-coaster because first their hours were drastically reduced. Then they started getting unemployment checks and were enjoying being home with their families. And then we asked them to come back. There were some mixed emotions; some didn’t want to come back, but they needed to, and we needed them.”

Once back, there is the fear factor of working with patients who might have COVID. “It is an anxious, fearful time,” she says. There are employees whose spouses have lost their jobs and they are trying to teach their kids at home, so it is doubly stressful. We are just trying our best to support each other through this difficult time.”

The center just celebrated an employee appreciation week to keep people’s spirits up, she says.