In this episode, ASCA Chief Executive Officer Bill Prentice and Stuart Simon, MD, medical director of United Surgical Partners International (USPI), discuss the findings of a survey of more than 700 ambulatory surgery centers conducted this past spring. The survey found essential surgical procedures conducted during the pandemic were performed safely, with virtually no heightened risk of patients contracting the virus either during or following their outpatient surgery.
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Bill Prentice: 0:37
Hello and welcome. My name is Bill Prentice, and I'm ASCA’s CEO and host of this podcast. My guest today is Dr. Stuart Simon. Stuart is the medical director of United Surgical Partners International, or USPI, which currently owns and operates over 400 ambulatory facilities, where they serve more than 13 million patients each year. Stuart has also been an attending anesthesiologist at Baylor University Medical Center for over 20 years, and he's a clinical assistant professor at the University of Texas Southwestern Medical School. He's currently chairman of the Department of Anesthesiology at North Central Surgical Center. Most importantly to me, he's also an ASCA Board member and I want to thank him for his service on the ASCA Board as a clinician. He's provided some invaluable guidance to the association. And I've asked Stuart to come on the podcast today to discuss the findings of a recently completed survey of ambulatory surgery centers that was conducted this past spring to learn whether or not ambulatory surgery patients had a heightened risk of contracting the COVID-19 virus, either during or following their outpatient surgery. The survey was developed and carried out by the ASC Quality Collaboration, or ASC QC, an independent nonprofit organization established by members from the ASC industry, accreditation organizations and other professional associations for the sole purpose of developing and promoting quality measures for ambulatory surgery centers. Both Stuart and I have been active with the ASC QC. The QC initiated the survey back in March when policymakers were first reacting to the spread of the COVID-19 virus and some were calling for the complete nationwide suspension of elective outpatient surgeries. And for some health officials, there was a concern that ASCs needed to conserve their personal protective equipment, or PPE, for the healthcare workers on the front lines of treating COVID-19 patients. But for others, there was an assumption, and only an assumption, that elective surgeries would unnecessarily expose both patients and healthcare workers to a greater risk of becoming infected with the virus. Our reaction in the ASC community was twofold. While we fully supported the notion of preserving PPE, we did not really fully believe that ASCs would accelerate the spread of the virus if we were permitted to continue treating patients. On one level, we knew that ASCs are well-regulated medical facilities that have a number of protocols in place to prevent the spread of any infection. And we also knew that with additional COVID-19 safety measures, which we'll talk about today, ASCs could readily maintain a safe, sanitary environment to treat patients and keep our health professionals protected as well. Still, as with all science, we knew that collecting data is the best way to inform decision-making, and particularly that with respect to the safety of outpatient surgery. So as both the medical director and senior manager of one of the largest ambulatory surgery center operations in the country, Dr. Simon's participation in developing and helping to conduct this survey was invaluable. So, with that introduction, let me now welcome Dr. Stuart Simon to the Advancing Surgical Care Podcast. Stuart, welcome.
Stuart Simon: 3:45
Thank you, Bill. It's great to be here today and I look forward to to our discussion.
Bill Prentice: 3:51
Great. Well, let's start with having you walk us through the top-line results of what was reported by surgery centers that participated in the quality collaboration survey.
Stuart Simon: 4:01
Well, it's really compelling data. We were able to cull data from 709 facilities across the country. And we looked at data between March 15th and April 30th and in that six-week time window, 84,446 procedures were performed in the ambulatory settings that reported. And what was compelling about this is that of that over 84,000 patients, after a two-week follow-up, and two weeks is significant because that really is the typical incubation period for the coronavirus or COVID-19, in that two-week period post-procedure only 16 of those over 84,000 patients were found to be COVID positive. It's really a shockingly low number. It comes out to be a 0.019 percent incidence of positivity, it's almost immeasurably small. And in fact of that 16 patients, just for further information, only two of the 16 that actually were positive required hospitalization.
Bill Prentice: 5:18
Those results are remarkable. You know, were you at all surprised at how few patients reported testing positive postoperatively for the virus?
Stuart Simon: 5:27
Well, you know, I like to answer that question, yes and no. I mean, yes, I was, frankly, surprised that the number was low, and, frankly, lower than what conventional mathematical modeling might have predicted. But I, in fact if you look at it holistically, I'm not surprised because the ambulatory surgery centers, as a core element of what we do is to follow rigorous guidelines to limit any sort of infectious process. So, safety is what we do in those centers and we have just raised the bar during the time of this pandemic to even supersede what we have traditionally done. So, in that sense, I'm really not surprised.
Bill Prentice: 6:16
To continue on from where you just ended, can you go into a little more detail about both the long-standing infection prevention processes that ASCs have used to prevent any infection, and then layer on top of that a little bit of discussion about the additional new procedures that have been put in place since the pandemic started that, you know, some of which I think people are familiar with because they see them walking down the street, but others, you know, are a little more specific to healthcare.
Stuart Simon: 06:48
Frankly, the ASCs are, you know, as I like to say, sort of a bastion of sterility. We have always employed rigorous handwashing, which you've heard a lot about recently, but we've been doing that since our very earliest days, equipment sterilization, rigorous adherence to aseptic protocols. And, you know, although yes, people are seeing the general population in masks and social distancing and that sort of thing, we have in the ASCs historically not only worn masks, but gloves, cap and gown. I mean, this is really part of the natural ecosystem of our surgical facilities. Now, raising the bar on that, in light of what's happened in the pandemic, we are, in fact, not only wearing face masks in terms of the frontline staff and physicians at our facilities, but we are also having all of our patients wear face masks. And we are having everyone in the facility, both the folks who work daily at the facilities and any patients, socially distance; we have rigorous limitation of visitation, if any visitation; and we have even increased our already aggressive surface cleaning protocols. So we've taken what we have historically done, raised the bar on that, applied it to the people who are coming to our centers, and I think that really speaks to why we've seen such an incredibly low number of infections.
Bill Prentice: 8:24
That's fascinating. If you don't mind, I'm going to stop there for a moment because we have a sponsor, and I'd love to give them an opportunity to say a few words.
Underwriting for the Advancing Surgical Care Podcast is brought to you by The Joint Commission, an independent, nonprofit, standard-setting and accrediting body for ambulatory care organizations nationwide. For 45 years, The Joint Commission has helped ambulatory care organizations meet and exceed rigorous performance standards for improved patient safety and enhanced quality outcomes. Begin your journey today! Go to jointcommission.org.
Bill Prentice: 9:05
Stuart, where we left off, you were talking about some of the additional protocols that have been put in place. Two that I think our listeners would be particularly interested in hearing about are screening protocols and testing. Can you speak to both of those?
Stuart Simon: 9:20
Certainly. So, all of our facilities have rigorously screened patients prior to their arrival at our facilities, really for all of what now people are very aware of are symptoms of COVID-19. Things such as fever, cough, shortness of breath, you know, have you been exposed to anybody who may or may not have had COVID? Do you have a sore throat? All of those things are in the conventional screening process, and some of the facilities have employed various forms of testing. What we have found, in fact, is that, and as the data supports, all of those methods are sound, and have, in fact, worked for us. Early on and particularly when we were gathering that March/April data, there was a limited amount of testing that was actually available. And we have seen an increase in the availability of testing but, that being said, what we have done with COVID and what we have done historically with rigorous screening and preadmission testing of our patients has really borne, you know, a lot of fruit for us.
Bill Prentice: 10:40
I don't want to put words in your mouth but after listening to you talk about this, and then putting that in context with the survey and when the survey was conducted, and you kind of hinted at this, that very low infection rate that was found in that survey actually predates the imposition of a lot of these new screening and testing measures that ASCs are now making a commonplace part of their healthcare process. So, I mean, that would make me think that extraordinarily low infection rate from the survey is probably going to be even lower if we did another survey today, now that we're using all those enhanced screening and testing mechanisms that probably weren't fully in place when that first survey was conducted. Am I right?
Stuart Simon: 11:28
Yeah, I think that's a very safe assumption. You know, early on, we really did not have nearly the understanding of this virus and this situation. And now I think we have tried a number of different things and we have demonstrated what does work, and we will not only continue to do what we are doing, because clearly it is working, but we're going to continue to take new data as it comes in and continue to modify our approach to optimize what we can provide for the patients.
Bill Prentice: 12:05
Well, following up on that and the idea that we're learning more every day, you know, I want to go back to the beginning of this pandemic when there were some well-intentioned but misguided proposals, you know, at the beginning of the pandemic, to either force ASCs to stop performing surgeries and other procedures, or somehow to repurpose ASCs into serving as many hospitals and complementing the care that inpatient hospitals were performing on active COVID-19 patients. Now I'd say that most policymakers understand that ASCs are not equivalent of hospitals and not staffed or constructed to treat chronically ill patients. However, I do worry that, you know, when I see that there are proposals to suspend elective surgeries in various states, you know, predominantly aimed at hospitals, not ASCs right now, with the pandemic still obviously active and there could be spikes in other communities, that there could be, you know, revived interest in asking ASCs to postpone elective surgeries. And the thing that I think we've all learned, you know, and had not, I think, provided good guidance on to policymakers is what we mean when we say elective surgery, and that that term can be a bit misleading, and that we need a more nuanced approach to understanding that just because something is scheduled, doesn't mean it's not necessary or indeed sometimes urgent. Can you speak to that?
Stuart Simon: 13:32
Yeah, and I think you've really just hit on it. You know, historically, we've talked in terms of either surgeries being elective, or urgent or emergent. But in reality, "elective" is something of a misnomer and I actually like the term "necessary" much more, and the reason being nobody is showing up to have unnecessary surgery. And so everything that we do, whether it's somebody having their hernia repaired or somebody having a joint replacement surgery, everything we do, although it might be able to be delayed, is actually a necessary surgery. And a lot of people have, you know, over the course of the pandemic, asked me about specifically, what about plastic surgery? And you know, I will tell you that with the exception of a small subset of those procedures, a lot of what we do even in that specialty are reconstructive surgeries that are definitely necessary procedures. So, I do think that distinction on a go-forward basis is actually very important, that what's happening at our facilities is necessary, these procedures need to be done and simply because we might be able to delay them for some period of time doesn't mean that they don't need to happen.
Bill Prentice: 14:58
Really important, and that's something, a message we've been trying to drive home and really talking with, you know, the healthcare media and policymakers over the past couple months, but I think there's a lot of work still to be done there. Before we wrap up today, I would like to comment on the continuing work of the ASC Quality Collaboration. What impresses me most about the collaboration is what it represents, which is an industry-wide commitment to improving quality reporting and measure development that can lead to meaningful information for use by patients so they can get the care that they need safely, for policymakers to use to improve our healthcare system and how it works, and for providers themselves to use for self-improvement. So from your perspective, what else could the Quality Collaboration focus on or what should they be focusing on in coming years?
Stuart Simon: 15:47
So you know, we live in this age of big data. And you know, this is really in my wheelhouse; I have always been an adherent to data and it's from the data that we can really move the needle on improving patient care. And so, you know, we've demonstrated with this very, what I think is a very meaningful study related to COVID-19, we've demonstrated that we can pull data from multiple facilities and really study it and achieve best practices. And it's not just about infections, it's about how many patients are falling in our facilities, how many patients do we have to transfer—all manner of problems can be, and we have the platform now to collate this information and really take that data and put it into a meaningful, useful form.
Bill Prentice: 16:44
That's very well stated. Well, Stuart, I want to thank you for spending a little time with us on the Advancing Surgical Care Podcast and sharing your knowledge and your understanding of this survey and the issues surrounding it. So, once again, thank you.
Stuart Simon: 16:57
Thank you so much for having me.
Bill Prentice: 17:00
This concludes today's discussion with Dr. Stuart Simon. I would like to thank again Stuart for his contributions to the ASC Quality Collaboration and the survey we discussed today. And as always, I thank him for his service on the ASCA Board of Directors. Finally, I would also like to thank the sponsor of our Advancing Surgical Care Podcast, The Joint Commission, a leading accreditation organization helping to keep outpatient surgery as safe as possible for both patients and the healthcare professionals who care for them. As always, if anyone listening has thoughts or suggestions for future topics or how we might improve these presentations, don't hesitate to send us your thoughts. We want to hear from you so that we can serve you better. Thanks for listening. Please stay safe and stay healthy.