Your Roadmap to Recovery

COVID-19

By: Jared Bilski

Published: 5/15/2020

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Guidelines are a tremendous asset, but your facility must forge its own path forward with elective surgeries in the COVID-19 era.


On April 17, the Trump administration issued a three-step plan for reopening the American economy as parts of the nation begin to emerge from the coronavirus outbreak. The plan's first phase green lighted elective surgeries performed in outpatient facilities where COVID-19 cases are decreasing, truly welcome news for idle surgical teams. Since the announcement, nearly half of U.S. states have been given the go-ahead to resume elective surgeries. The staggered reopening of outpatient facilities amid these uncertain times has left many surgical administrators with more questions than answers.

To help guide your ramp-up to resuming surgeries, the Association of periOperative Registered Nurses (AORN) teamed up with the American College of Surgeons (ACS), the American Society of Anesthesiologists (ASA) and the American Hospital Association (AHA) to create a roadmap that guides the readiness, prioritization and scheduling of elective surgeries to ensure maximum patient safety (osmag.net/6vPaBF). Use the roadmap to answer these key questions before reopening your ORs:

  • Are we ready to reopen? There should be a sustained reduction in the rate of new COVID-19 cases in your community for at least 14 days, according to the roadmap. But even if your state's governor has deemed it safe to resume elective cases, expect a lag between when you decide to reopen and when your facility will be ready to start performing surgery.

"It might take a full week to reset for surgery," says Julie Maiden, the director at Surgical Eye Center in Greensboro, N.C. First, she says, perform a deep terminal cleaning with EPA-approved cleaning solutions. Then, make sure every staff member is aware of the physicians' and anesthesiologists' guidelines for appropriate patient selection.

Ms. Maiden also recommends addressing the many logistical issues involved in reopening ORs after a significant hiatus, including ensuring every piece of equipment is in good working order, and checking expiration dates on medication vials and supplies.

"Touch base with your vendors before reopening," says Ms. Maiden.

"because there may be special circumstances regarding certain pieces of equipment due to the down time." For example, she cites the sterilizers her facilities uses and how they will have to perform three test cycles before the equipment is ready to go again.

  • How and when will we test? The only way to ensure the safety of patients and your staff is through rigorous COVID-19 screening and testing protocols, according to Vangie Dennis, RN, MSN, CNOR, CMLSO, executive director of perioperative services at WellStar Atlanta Medical Center & Atlanta Medical South. Her home state of Georgia has been a leader in reinstituting elective surgeries, her facility's testing protocols are already established and go well beyond standard temperature checks and questionnaire screenings.

"We require system-level COVID-19 testing for any patient coming in for surgery," says Ms. Dennis. "Patients must complete testing within 96 hours of their scheduled procedure to ensure there are no gaps in the schedule. ?Testing is completed at remote sites and a drive through located outside the hospital."

  • Do we have proper PPE? As this issue went to press, Lakeland (Fla.) Surgical & Diagnostic Center was gearing up to reopen — and it was taking great measures to ensure staff safety. "We're requiring our staff to wear N95 masks at all times, except when they're on lunch," says Nikki Williams, RN, CNOR, the OR director at Lakeland. In addition to the masks, OR staff will also wear full scrub jackets, head coverings, gloves and isolation gowns. Foot coverings or booties will also be required for staff who don't keep their work shoes in their lockers — a policy change that's bound to impact busy surgeons who come in and out of the facility. And even with all the PPE in place, Lakeland adding an extra layer of protection by limiting staff exposure during high-risk aerosolizing procedures like intubations, during which only anesthesia staff can be present in the OR. The process will also involve a plastic intubation box placed around the patient.

ALTERNATE USE Smoke evacuators can capture viruses such as SARS, HPV or HIV at a 99.9% efficiency rate.   |  Vangie Dennis, RN, MSN, CNOR, CMLSO

Although proper PPE is certainly a must for your staff during the pandemic, maintaining an adequate inventory presents its own set of challenges. Ms. Williams has taken several steps to maintain PPE levels. "We have around 300 N95s right now, and we just purchased another 600," she says. To make that supply last, Lakeland will reprocess the masks with a five-minute sterilization cycle on each side.

Plus, Lakeland is reviewing their PPE supplies weekly and casting a wide net that goes beyond its usual vendors. "When the pandemic first hit, we had an opportunity to purchase a shipment of 300 N95s, and we jumped on it," says Ms. Williams.

How long will staff be required to wear N95s round the clock? Like most facilities learning to adapt to a rapidly evolving situation, Ms. Williams says only time will tell. The facility has, however, made its COVID-19 policy a live file, so that leadership can react and make necessary changes to its protocols as efficiently as possible.

Another piece of safety equipment that could benefit your facility in multiple ways is a smoke evacuator. If placed correctly, it will remove viruses in the same manner as utilized to evacuate surgical smoke. ?Smoke evacuators are designed to remove smoke and aerosols. ?The constituents of both can basically contain the same type of bacteria or viruses.

"We know smoke evacuators can capture viruses, whether it's SARS, HPV or HIV, and they capture at a 99.9% efficiency in the matrix system with its filters, so why wouldn't we use it for inductions?" asks Ms. Dennis.

  • How should we tackle the backlog? Perhaps the most challenging aspect of your return plans has to do with case mix and staffing challenges. How do you even decide which delayed cases to tackle first? Elective procedures at Ms. Dennis's facility are being staggered, with the biggest service line, ortho, being rolled out first, followed by urology.

"This way I can see how the scheduling impacts my staffing matrix," says Ms. Dennis. As her facility assesses the volume of its top service lines, it will be able to staff accordingly and prevent long operating hours, something that it wouldn't have avoided if all service lines started simultaneously.

Speaking of extended hours, something the roadmap mentions as a means of increasing OR/procedural time as you ramp up cases, you may do well to exercise caution here — at least until your staff adjusts to the return.

"You don't want to burn out your staff," says Ms. Dennis.

"You will lose your staff to other centers if you focus on volume at the expense of your people."

Another tactic she's using to bolster case efficiency is the removal of block scheduling. "I'm doing all open blocks for scheduling," says Ms. Dennis. "I have a team of five doctors who assess the urgency and efficacy of the cases and we forecast out three days in advance to try and appropriately stack cases to optimize the surgery schedule, utilization and be ability to cover our services."

So far, the scheduling move has been working well. In fact, Ms. Dennis says her hospital's OR utilization rate is around 75% since making the change.

The next wave

Finally, there's the question in the back of everyone's mind right now: How do we avoid getting caught off-guard in the event a second wave of COVID-19 hits? There's no easy answer to this question, of course. Ms. Dennis hopes the steps she's taking right now — mandatory pre-procedure testing and rigorous patient assessments, limiting visitors and making them wait in their cars, assigning and reprocessing N95s to avoid shortfalls in PPE, and looking into the use of reusable respirators — will ensure her facility is well-situated to handle whatever the future holds. But regardless of the specific protocols you decide to take to protect patients and staff as you slowly resume elective surgeries, you must maintain those protocols consistently for the long term.

"We can't let our guard down," says Ms. Dennis.

"Whatever happens, we can't get comfortable. That's how we prepare ourselves for another possible surge. It's our new normal." OSM

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