The Post-COVID Future of Outpatient Surgery

Finally, thankfully, ORs have begun to reopen for elective procedures in communities where COVID-19 cases are on the decline. The coronavirus pandemic that temporarily shuttered outpatient surgical facilities continues to hit pockets of the country hard, but healthcare leaders are beginning to look forward, quite literally, to the gradual return to some semblance of normalcy. There are plenty of unknowns moving forward, but one thing's for certain — surgery will never be the same.

COVID-19 has changed the calculus of pre-op screenings. "We've learned more about the disease," says David Shapiro, MD, an anesthesiologist with extensive ASC management experience who's based in Tallahassee, Fla. "We were probably a bit naive in our ability to protect our patients."

During the pandemic, surgical leaders leaned on response guidelines coming from everywhere — the CDC, state governments and specialty and professional societies. "All those things came hard and fast in a situation that was as dynamic as it could possibly be," says Dr. Shapiro.

Now is the time to reassess and rethink the testing patients must go through before setting foot in your facility. Jay Horowitz, CRNA, of Quality Anesthesia Care in Sarasota, Fla., hopes evidence of additional COVID-19 symptoms will move patient and staff screenings beyond temperature readings and questions about recent travel. "Maybe we should place a pulse oximeter on them, looking for abnormally low readings," he says. "Or ask if they've had a loss of sense of smell or taste."

He thinks point-of-care, rapid-result COVID-19 tests could be a game-changer. "We can test patients and staff right there in the parking lot before they even enter the building," he says. "If everybody comes in the morning and gets a negative test, we're good."

Mr. Horowitz, who primarily works ophthalmic cases, says providers will need to reorient procedurally to account for COVID-19. "We have a plastic drape, for instance, that covers the patient's face and has a little hole so you can see the eye," he says. "If a patient had the virus, where would it most likely be piling up during the case? Under that drape, so we must be a little more careful pulling it off. That's the type of thing we've never had to think about before."

Like many in the industry, Dr. Shapiro is focusing on defining what "elective" surgeries are, an issue that must be resolved as centers reopen, regulatory agencies adjust and patients warily consider returning to healthcare facilities. "Some individuals were equating "elective' with "unnecessary,' which has a lot of negative connotations," he says. "In my mind, "elective' has to do with the consequences of delaying the surgery, not necessarily never doing it. We're really talking about procedures that can be postponed, that everyone feels will be safer when the prevalence of this disease has decreased."

"I think we're going to come out better than we went in."
— David Shapiro, MD

Elective cases can be held off for only so long before it's no longer an elective case, points out John Goehle, MBA, CASC, CPA, owner of Ambulatory Healthcare Strategies and host of The ASC Podcast with John Goehle, in Rochester, N.Y. "If you postpone cataract [surgery] for too long, the cataract gets worse, there's a higher risk of a complication as that cataract gets harder," he says. "It's the same with arthroscopies — the longer damage continues to occur in the joint, the more difficult that procedure is going to be later on, and the chance of an adverse outcome or complication rises."

Postponed colonoscopies might have revealed cancers that have now had months to develop, impacting survival rates.

"You get to a point of deferring things where it's going to affect your health," says Mary Dale Peterson, MD, FASA, president of the American Society of Anesthesiologists. "I think we're getting to that point where we deferred surgery for a month or two in some areas, and now it's time to open the ORs back up if that community is on the tail end of seeing new COVID-19 patients. We've had patients with cancer, significant gallbladder issues, angina, waiting for surgeries. We need to prioritize their care and get those patients into ORs."

Surgical facilities face a significant challenge in managing a backlog of postponed cases and getting back into a somewhat normal case rhythm. "Returning to a "normal' surgery schedule will take time and patience," says Linda Groah, MSN, RN, CNOR, NEA-BC, FAAN, CEO/executive director of the Association of periOperative Registered Nurses. "There are going to be serious scheduling challenges in the months to come as ASCs begin to accommodate the backlog of the canceled surgeries while integrating the surgical needs of the patients.

"Policies that guide decision-making around how the patients are scheduled should be a priority, and everyone on the team needs to understand and adhere to the new policies."

A fly in the ointment, however, is whether patients will feel comfortable having surgeries as the virus lingers. "We can expect the surgeons' relationships with their patients will influence the scheduling because patients could very well be worried about their risk of exposure to COVID-19," explains Ms. Groah. "They may decide their surgery isn't necessary after all, or decide to postpone it to a later date. Surgeons and facilities that can reassure patients of their safety will be the most successful in their return to a full caseload.

"We need to remember this pandemic has created legitimate fear in patients as well as caregivers," adds Ms. Groah. "If there is insufficient PPE or insufficient testing for incoming patients, surgical leaders need to consider whether their return to elective surgeries is safe for the patients and their staff."

Mr. Horowitz wonders what caseloads will be like when the initial push of catch-up cases subsides. "We have a couple hundred on backlog, which we'll knock out in a couple of weeks," he says. "But then what? Is anybody really going to want to come into medical facilities?"

That fear has led him to focus even more on diversifying his anesthesia business across more facilities and specialties. "You never want to have all your eggs in one basket," he says. "What I've learned pretty quickly in this current reality we find ourselves in is that it's not enough to diversify to a plastic surgeon and an eye surgeon and a podiatrist. You have to look at providing service for elective and nonelective procedures.

"Outpatient facilities need to start thinking about this too," continues Mr. Horowitz. "What kinds of services can they provide that won't get shut down by the next pandemic?'"

Alternative uses of outpatient facilities during the pandemic haven't really materialized, but the thought exercise could prove valuable. "I think we're going to come out better than we went in," says Dr. Shapiro. "This will end. All these discussions of the possibilities for delivering different kinds of health care in ASCs will have a long-lasting result [as we] recalibrate because of this pandemic, which has uncovered the best and the worst of health care. We were woefully unprepared to deal with it in a coherent fashion. Medically speaking, there's still so much we don't know."

Dr. Peterson says the relaxation of the regulatory environment to provide flexibility to providers during the pandemic shouldn't be extended permanently. "When the crisis is over, we need to return to optimal levels of care, not crisis levels of care," she says. "We're making do, but that should not be the new normal. We should strive to at least go back to where we were before. The reason why many of those rules are in place is for patient safety and improving the quality of care."

Mr. Goehle, an AAAHC surveyor, foresees more regulations, especially on the infection control side. "Before this, pandemic was one of those things in our emergency plan that was in the back of the book," he says. "Now it's the number one thing, and we know this could happen again very easily."

He thinks facilities will be better prepared for an anticipated second wave of COVID-19. "In the very beginning of this, we had people still coming to work with fevers because they were treating it the same way they treated the flu," he says. "We never had the information to be able to do a pandemic drill. We're learning everything we possibly can from this event. If it does strike again, hopefully we'll have policies in place, we'll have the PPE, we'll know what to do to minimize the spread right away."

Adds Dr. Shapiro, "I'm hoping we don't take our foot off the brakes too soon. I think that's probably our biggest risk right now." OSM