On March 13, 2020 our lives seemingly changed overnight when President Trump declared a state of emergency. The United States was deemed under attack by an invisible enemy, the novel coronavirus (COVID-19) pandemic. This “new” virus required swift action across the country in an effort to slow transmission, and “flatten the curve,” so that our hospitals could care for the unknown volume of critically ill patients. In response to the emergency, the entire country shifted gears. We began social distancing, working from home, wearing masks in public and preparing for the “new normal.”
Hospitals also had to spring into action; the way we did things yesterday was no longer acceptable. We needed to prepare for the unknown, and it almost immediately became apparent how significantly underprepared for this pandemic our health care system was. We identified there was not enough personal protective equipment (PPE) for staff to safely care for these patients. We recognized that there could be a significant shortage in ventilators – equipment required to care for the numerous patients with respiratory failure. We needed to adapt.
In an effort to preserve resources and free up staff to provide the necessary care for COVID patients, on March 18, the White House recommended canceling all non-essential elective surgeries, including dental procedures. Those cancelled procedures were considered elective based on urgency, not to be confused with optional or necessary. While this strategy was helpful in freeing up resources, it came with a price. And those who paid it were the patients seeking relief for conditions that were deemed elective, yet necessary to increasing the quality of and, in some cases extending, life.
For hospitals, the impact was also substantial from a financial perspective. The decrease in elective procedure revenue, combined with associated factors such as reductions in inpatient stays and emergency department visits, forced many to initiate pay cuts and, in some instances, furlough employees. This leaves many leaders asking, ‘Now what? How do we safely resume elective surgeries in an effort to help patients and sustain hospital systems?’
Reopening America and “gating criteria”
The first step to “Reopening America” came on April 16, when the Trump administration announced “gating criteria,” along with a three-phased approach to launch into our new normal.
The gating criteria is intended for the community, city and state to evaluate their population as it relates to the COVID crisis. Once hospital and government officials agree that the community is experiencing a 14-day reduction of symptomatic or confirmed COVID cases, and the hospital has the capacity to treat all patients under normal versus crisis conditions, the organization can proceed to Phase I recovery.
Immediately following the release of the gating criteria, the Centers for Medicare and Medicaid Services (CMS) followed suit. On April 19, CMS issued Re-opening Facilities to Provide Non-emergent Non-COVID-19 Healthcare: Phase I. This phase includes resuming outpatient elective procedures for those organizations that can adhere to the requirements outlined in the guidelines.
The CMS guidelines focus on ensuring hospitals are asking themselves the right questions to accurately assess if they are “ready” to start elective procedures. The questions include:
- Do you have adequate facilities, workforce, testing and supplies (including PPE) to resume outpatient elective procedures?
- Have you updated your policies to include source protection for both patients and staff?
- Have you established a process for screening and testing both staff and patients for influenza- like symptoms, as well as restricting visitors in accordance with the Centers for Disease Control and Prevention (CDC) and CMS guidelines?
- Have you established Non-COVID Care (NCC) areas inclusive of staffing protocols to reduce the risk of virus transmission?
- Have you disinfected and sanitized all equipment in accordance with the manufacturer guidelines and CDC recommendations to ensure there is no disease transmission?
- Lastly, if you resume elective surgery, would utilization of these resources jeopardize your ability to handle a surge?
Once you have appropriately addressed these questions, your organization is ready to resume elective surgeries.
Prioritizing elective surgery during reopening
Your facility has successfully met all of the gating criteria and the plan for resuming procedures has been thoroughly evaluated. But how do you decide which patients, procedures or providers are first to proceed? Obviously, everyone feels their case is the most important. For those having to make these challenging decisions, refer to the objective scoring criteria provided in the Joint Statement: Roadmap for Resuming Elective Surgery after COVID-19 Pandemic, from the American College of Surgeons (ACS), American Society of Anesthesiologists (ASA), Association of periOperative Registered Nurses (AORN), and the American Hospital Association (AHA).
These guidelines cover key steps, such as timing, testing, and case prioritization and scheduling. While the entire roadmap provides value, the section on case prioritization provides an excellent outline for rescheduling, including a reference to an objective priority scoring tool for medically necessary time-sensitive (MeNTS) procedures.
While in March it felt as though our lives changed forever, and even more so when elective surgeries were cancelled leaving patients and hospitals in unfamiliar territory, it’s now time to start looking ahead to a new normal. Regardless of where your hospital is as it relates to resuming elective cases, it’s never too early to start planning. Begin by reviewing the gating criteria, and the three phases of reopening offered by the administration, followed by ensuring you are able to adhere to the guidance provided by CMS. Once those two steps are achieved, consider convening a hospital committee comprised of appropriate stakeholders to devise an objective plan for scheduling new and existing patients for elective procedures.
For additional perspective on this topic, read our clinical guide recently featured in Modern Healthcare, “Vizient/Sg2 guidance for resumption of electively scheduled surgery and procedures in the COVID-19 era.”
About the author. An accreditation advisor at Vizient, Mitch Gesinger supports member organizations with regulatory and accreditation compliance in the hospital, ambulatory and critical access hospital settings. His clinical and leadership experience includes pediatric intensive care, as well as adult and pediatric neurosciences. In addition to his regulatory knowledge, Gesinger is well-versed in the principles of high reliability, including leadership, robust process improvement, change management and safety culture. A certified Joint Commission professional, he has completed the University of British Colombia Infection Control Risk Assessment training.