Resuming Elective Surgery

In this 14-minute episode, Bill Prentice, ASCA chief executive officer, and Michael Patterson, president and chief executive officer of Mississippi Valley Health and ASCA Board member, provide insightful commentary on the latest guidance available to ASCs considering resuming elective surgeries and procedures. Federal and state guidelines, recommendations from professional societies and the checklist ASCA prepared to help its members reopen their facilities are discussed. 

Transcript

Charlie Leonard:   0:06
Hello and welcome to this episode of the Advancing Surgical Care Podcast, brought to you by the Ambulatory Surgery Center Association, or ASCA. My name is Charlie Leonard. I am a member of the ASCA public affairs team and the host of this recording. This recording is taking place on April 22, 2020. As with all of ASCA's COVID-19 communications, please check to make sure you are reading or listening to our most up-to-date postings. The purpose of today's podcast is to discuss how ambulatory surgery centers can safely resume performing elective surgeries. With known cases of the COVID-19 virus receding in some states or within geographic areas of some states, new guidance for the resumption of elective surgery has been issued by the federal government, as well as several state governments and a number of professional medical societies. Last week, ASCA also issued guidance of its own that was developed by a working group of ASC medical directors. Joining me for a discussion of these important developments are Bill Prentice, ASCA CEO, and Michael Patterson, president and CEO of Mississippi Valley Health in Davenport, Iowa. Michael is also a member of the ASCA Board of Directors. Gentlemen, welcome to the podcast.

Bill Prentice:   1:26
Thank you, Charlie. Good to be here.

Michael Patterson:   1:28
Thank you, Charlie.

Charlie Leonard:   1:30
Bill and Michael, let me start by asking each of you this fundamental question. Is the country ready for ASCs to resume performing elective procedures?

Bill Prentice:   1:39
Well, there are really two parts to that question. The first half is, are we generally ready from the standpoint of seeing a decline in the number of COVID-19 cases such that it's safe to resume any number of social functions, including elective surgery? The formula that the federal government has identified, which it calls gating criteria, is the decline in COVID-19 cases for 14 consecutive days in a state or other geographic area. But let's remember that states can use their own judgment and establish their own criteria to determine if, how and when to permit elective surgeries to occur. And we're seeing that authority being used right now in a growing number of states. The second half of the question is, can ASCs safely perform those elective surgeries while this pandemic is still going on? I'm gonna go back and answer the first part of that question, and then we'll turn it over to Michael and let him take the rest of it. In terms of the first part, are we ready? the good news is that the country's commitment to social distancing and the shelter-in-place actions is reducing the spread of COVID-19. And as that happens, there's a growing consensus that ASCs and hospitals can cautiously resume certain cases, particularly those that are deemed clinically necessary. Still, we have to remember that the reality is different regions across the nation are impacted by COVID-19 to varying degrees, and there are some communities that are ready for strategic restart of deferred surgeries at this time, but there are others that are still gonna have to wait. The determination has to be fact based and only carried out if your city, county or state is seeing a low incidence of or a sustained decline in COVID-19 cases, that's the first part. Michael, why don't you take the second half of that question.

Michael Patterson:   3:35
All right, I agree with Bill. If your ASC is located in a state or a region that is experiencing that decline or low incidence in the number of reported cases, you should be preparing now to resume your operations. And as the second half of the question, can ASCs safely resume treating patients? I believe the answer is yes. Now obviously, there are a lot of considerations and I'm sure we'll talk more about them in this podcast. But I fundamentally believe that if we continue to put the health and safety of our patients, providers and staff first, we now have the informational resources to resume most procedures.

Charlie Leonard:   4:13
Bill, let me come back to you. As I mentioned at the outset, in just the last week we've seen guidance from the White House, the Centers for Medicare & Medicaid Services, or CMS, seven state governments and several medical professional societies. On April 20, ASCA released a checklist to help ASCs prepare for the resumption of surgeries and other elective procedures. Bill, can you help our listeners sort through all of this information and better understand what they need to do to safely reopen or to expand their practices?

Bill Prentice:   4:43
Here, I'll give that a try. As you know, ASCA staff and volunteers have worked really hard over the past month to stay abreast of this crisis and to find or develop resources to assist surgery centers in doing the right thing during this pandemic. And that includes all the guidance you mentioned, as well was developing a checklist to help ASCs that are able to take cases and to do so in a safe and responsible way. Michael, I think you'll have more to say about that in a little bit. But as I mentioned on another podcast, we have a COVID-19 Resource Center on the ASCA Website, ascassociation.org, that includes a wealth of information to help ASCA members. And I strongly encourage listeners to go there frequently to stay abreast of what we're working on. But when it comes to the various guidance, we're collecting all of them on that resource page. But for purposes of this podcast, I think I'll just focus on two: the CMS guidance and the ASCA guidance. Before I go any further, though, I want to highlight that listeners should give the most attention to any guidance or requirements that are issued by their state or local officials. As I mentioned a few minutes ago, they are the controlling authority and what they announce will be the North Star for any ASC that is providing care right now, so go there first. That said, when looking at both the CMS and ASCA guidance, there are two primary conditions to consider. The first, as we've covered, is whether the community is ready based upon the prevalence of COVID-19. And as I just mentioned, your state and local officials will be the final judge on that. For the second condition, which has a number of subparts, I'm gonna quote straight from the ASCA guidance, if you don't mind, Charlie.

Charlie Leonard:   6:30
Please go ahead, Bill.

Bill Prentice:   6:31
ASCs should open only if the safety of patients and the broader community can be guaranteed. Every ASC must ensure patient health and the prevention of virus spread by applying the following principles: 1. Screening patients before visits and monitoring their health prior to starting surgery as part of the preoperative procedure. 2. Requiring staff to self monitor and screen for viral symptoms daily. 3. Continuing to use PPE per the latest CDC recommendations for all procedures. 4. Following waiting room spacing guidelines, social distancing, face masking and other recommended procedures for patients and visitors prior to entering the facility. 5. Ensuring heightened disinfection to prevent and mitigate the risk of COVID-19 spread. And, finally, 6. Ensuring patients have been medically cleared by their primary care physician, where applicable. So, I think that it's really important that people go there and look at that guidance to get a better understanding of what we think they need to be doing to safely reopen and do cases.

Charlie Leonard:   7:47
Thank you, Bill.  Michael, another question for you. The  ASCA checklist has 108 steps for ASCs to consider or implement before resuming certain elective surgeries. That is obviously a lot of detail to consider. So that our listeners do not get overwhelmed by that task, can you walk us through the high level considerations that an ASC needs to lock down before resuming certain elective procedures?

Michael Patterson:   8:11
Yes, Charlie, thank you. There are a lot of items on the checklist, but for most ASCs, a substantial number of the items should already be part of their operational routine. Most of the new factors ASCs will need to consider are those relating to mitigating the spread of the virus; for instance, ASCs need to tune in to their local health departments on a daily basis to know if they are experiencing an increase or a decrease in the number of reported cases, either in their city, county or region. For at least the foreseeable future, each of us needs to make clinical judgements and patient prioritizations, such that we can start with patients who have low comorbidities and low surgical risks, and continue to postpone procedures that do not have a clinical urgency to them. Then, ASCs need to put new protocols and procedures in place within their facilities for such things as self-evaluations by staff, new waiting room spacing and patient face masking, following CDC guidelines for the use of PPE and, of course, heightened disinfection procedures throughout the entire facility. Now that said, I want to hit just a couple of topics on the checklist that I think people really need to be in tune to. One is having a downward trajectory in their specific region of COVID cases. And then, has there been an appropriate authorization by either municipal county or state officials to resume elective procedures? Based on the priority list, does the ASC have the necessary staff required for those procedures? And are we accommodating staff who may have family or childcare issues? So, we really need to know that ahead of time before we try to resume and start back up. Another component of this is obviously several new policies and procedures will be needed related to COVID, and has the governing body approved those new policies and procedures to ensure that you're providing a safe environment for patients and staff? The other piece, has your staff been informed of what those new policies and procedures are? Are they educated and has that been communicated to them? Very important so they understand how to care for patients in this new dynamic that we have. Another big component for the operating rooms are air exchanges. Those need to be re-established, we need to follow terminal cleaning guidelines and we need to make sure that we understand what is that time in between each case based on appropriate numbers of air exchanges. Same thing for the endoscopic facilities in that they as well need to have the same or, actually, a different standard based on what their current air exchanges are. Very important to really understand that and know what that is based upon your system. So that way, when we're taking patients in and out, we're sure that that room has clean air.

Charlie Leonard:   11:06
Thank you, Michael. Bill, we haven't talked about testing yet, either for the virus itself or for the antibodies that can hopefully give us some assurances in the future about the immunities and people who have had prior infections. So, how does testing and the continued lack of available testing impact ASCs looking to resume their surgeries and other procedures?

Bill Prentice:   11:27
Well, the first thing I'll mention is that the CDC, the Centers for Disease Control and Prevention, has a lot of resources for healthcare providers on testing, and I strongly encourage listeners to go there and use that as a primary resource. But as we all know, the availability of testing varies greatly around the country. Hopefully, that situation will continue to improve. And I know that there's an additional federal funding coming on the way that should allow for a lot more tests to be available around the country. The short answer here is that if tests are available, by all means, ASCs should use them to protect both patients and staff. But where tests may not be available, patients and staff should be protected by the use of evidence-based infection control practices and the other principles that I mentioned earlier in the ASCA guidance on resuming elective surgery.

Charlie Leonard:   12:24
Michael and Bill, we're getting close to the end of our time for the podcast. Just wanted to ask each of you if you had any concluding remarks or additional thoughts you'd like to share with listeners regarding the resumption of elective surgery.

Bill Prentice:   12:36
Well, Charlie, the only thing that I just want to reinforce is I know that there are many physicians out there, many surgery centers that are eager to get back to work and provide care to their patients. And we just need to be mindful, though, of this pandemic and really follow guidance issued by the federal government, by states, by localities, by clinicians to make sure that we're providing that care in the best possible way.

Michael Patterson:   13:05
Thanks, Bill. Thanks, Charlie. I want to reiterate Bill statements—he's spot on. And I think as we think about how healthcare providers protect patients, protect staff and get back to caring for patients in an environment that they could feel safe in, it's on us as leadership of the ambulatory surgery center industry to ensure that we go about implementing these policies and practices safely, we venture back into these waters of providing elective surgeries and meeting the needs of the community. But I think if we do that on a thoughtful manner that this will allow us to demonstrate our value to the healthcare system. And in addition to that, I would recommend that folks that have an opportunity should go to the ASCA website and look at that checklist, and please utilize these resources so that you know you're not alone and we're out here to help you to safely return to normal operations.

Charlie Leonard:   14:04
Well, Bill, Michael, thank you both for joining us today. That will conclude today's podcast. As Bill noted on an earlier podcast, we are intentionally trying to keep these relatively short but very substantive and to provide as much information as we can in a short amount of time. Once again, we'd like to say that if anyone has any thoughts or suggestions for future topics or how we might improve these presentations, please do not hesitate to send us your thoughts and ideas. We want to hear from you. So thanks everyone for listening. Please stay safe and stay healthy.