The recent coronavirus disease 2019 (COVID-19) pandemic has created unprecedented challenges to healthcare delivery worldwide. The rapidity, frequency, and severity of infection across populations by severe acute respiratory syndrome coronavirus 2, the virus responsible for COVID-19, has strained hospital resources including intensive care, inpatient and rehabilitation unit beds, ventilators, blood products, personal protective equipment, disinfectants, and staff. As a result, and to help “flatten the curve” of additional COVID-19 cases, most hospitals across the United States have halted elective surgical procedures and outpatient clinic visits during the peak of their local surge. These temporary restrictions often have come in response to government-imposed injunctions and are intended both to conserve vital resources and to protect patients and staff. It is estimated that over 28 million time-sensitive surgeries have been delayed due to the pandemic, leading to a likely progression of many disease states, morbidity, and even mortality.1 For the sake of clarity, and in keeping with the common vernacular, we will refer to both COVID-19 and its causative virus (severe acute respiratory syndrome coronavirus 2) as COVID for the remainder of this manuscript.
As the incidence of new COVID cases lessens in specific geographies, and as injunctions against elective surgeries and outpatient visits are lifted, healthcare systems must develop policies and protocols to facilitate safe, timely, and orderly resumption of normal operative and clinic activities. These processes must consider allocation of resources and staff previously redeployed to care for patients suffering from COVID, while continually assessing ongoing needs in a rapidly changing healthcare environment. We describe the recommendations of a task force within a multi-institutional healthcare delivery network to construct a model for resumption of elective operations and procedures across a multitude of care sites spanning a wide geographic footprint.
MedStar Health (MSH) is a not-for-profit healthcare corporation consisting of 10 hospitals, 3 ambulatory surgery centers, numerous ambulatory clinic locations, and multiple other sites of care spanning 3 jurisdictions (the District of Columbia, Maryland, and Virginia). The hospitals range from large, tertiary academic centers to smaller community-based facilities.
In anticipation of the lifting of injunctions imposed in all 3 jurisdictions through the peak of the COVID surge, the leadership at MSH created a multidisciplinary task force to develop system-wide guidelines for resuming elective surgeries/procedures. The primary focus areas included the establishment of a governance structure at each hospital and healthcare facility, prioritization of elective cases by service line and type of procedure, designation of suitable locations for performing specific procedures, preoperative COVID testing policies and protocols, protocols for patient care in the outpatient setting, assessment of the needs and availability of staff, personal protective equipment, and other vital resources (blood products, intensive care and inpatient beds, rehabilitation, and skilled nursing facilities) required for resumption of elective procedures. Within our system, as in many others, resources for COVID have been constrained and staff have been redeployed from perioperative areas, including the operating rooms and postanesthesia care units, to cover the needs of intensive care units (ICUs) and emergency departments.
The task force consisted of representatives from multiple surgical service lines, anesthesiology, nursing, operations, quality and safety, and supply chain and was chaired by 2 hospital presidents. The task force held daily virtual meetings over the course of 5 days and presented recommendations to system leadership 8 days after the first meeting. We shared the final work product with hospital and system leaders 2 days thereafter. Our go-live date occurred less than 3 weeks after our first meeting.
The final recommendations included the creation of an elective surgical algorithm, policies, and operational models for preanesthesia testing, management of outpatient clinics supporting procedural and surgical services, COVID testing, case prioritization, resource management, and a governance structure to ensure compliance. The guidelines apply to all entities within MSH. As the policies were drafted, we paid specific attention to government regulatory requirements in each of the system’s jurisdictions.
Each hospital president was asked to establish a perioperative leadership team (PLT) charged with the reinstatement and daily assessment of the elective operative/procedural schedule at their institution. The PLT, consisting of a minimum of a surgeon, a nurse, and an anesthesiologist, reports directly to the hospital president. The PLT has full authority to implement the case prioritization protocol and determine the appropriate daily operative volume. In addition, the PLT collaborates with internal stakeholders (eg, nursing, intensive care physicians, supply chain leaders) on a daily basis to assess capacity, including COVID testing capability. The specific responsibilities of the PLT are listed in Table 1 and Figure 1.
MSH established a MedStar Triage Officer (MTO) and team in response to the pandemic. Historically, the MedStar Transfer Center managed transfers from DC, Northern Virginia, and Maryland to MSH’s tertiary care facilities for advanced care services. The newly created MTO was responsible for load balancing patients across the health system to prevent overload at any hospital during the pandemic’s surge. This team evaluates bed capacity twice daily, and when one facility is approaching maximum capacity, the MTO initiates transfers to other MSH facilities that are less stressed. Thus, a virtual hospital is created across the system ensuring no one entity is overwhelmed. The MTO is available to the PLTs for managing ICU, intermediate care, and medical/surgical bed utilization to capacity to facilitate increased elective surgical volume and the continuing needs of COVID-19 patients.
Elective Surgical Algorithm and COVID Testing
The complete elective procedure decision algorithm can be found in Figure 2. The Medically Necessary Time Sensitive (MeNTS) procedure scoring system developed by Prachand et al2 is a widely cited and comprehensive approach developed during the COVID era to assess patients requiring surgery for factors that could affect postoperative risk and impact hospital resources. The MeNTS scoring system, however, is lengthy, difficult to apply broadly to a large patient base, and does not provide hard stops for factors that critically impact hospitals, such as ICU capacity and blood product availability. As a result of these limitations, we elected to simplify the MeNTS scoring system to stratify postoperative risk. Within our simplified MeNTS scoring system, we reduced the MeNTS criteria from 21 to 5 factors, and we changed the scoring from a 5-point to a 3-point system. After piloting the simplified MeNTS system with a random sampling of 80 patients across multiple specialties, we established a threshold score of 10, which could be modified if capacity were to change. By following the guidelines, we postpone patients with a MeNTS score ≥ 11 due to their potential for increased utilization of critical resources, whereas patients with a score ≤ 10 can be scheduled for their elective procedure. Surgeons must list the score on the booking form to schedule an operative case (eg, left thyroid lobectomy with nerve monitoring [MeNTS 9]). We do not allow elective case bookings that do not contain a simplified MeNTS score.
Preoperative COVID testing is mandatory for all elective surgical cases and all interventions requiring intravenous sedation or airway monitoring, including aerosol generating procedures such as bronchoscopy and flexible upper endoscopy. Procedures not requiring airway monitoring (eg, pain injections) do not require preoperative testing; however, rigorous screening continues to be mandatory. Our complete algorithm for COVID testing before elective procedures can be found in Figure 3. Our policy of mandatory preoperative COVID testing is contingent on adequate capacity across our geographic area. We acknowledge that other healthcare systems may need to adopt alternative policies based on their local resources. COVID testing location information was disseminated to all providers within our system, and a methodology to upload outside test results was created. Based on testing resources (particularly reagent availability), our policy is to have all COVID testing performed 4–5 days before a scheduled procedure. Patients are instructed to self-quarantine from the time of testing until the date of the operation. All handouts and electronic communications to providers include links to detailed on-line policies and procedures so that updates can occur in real time.
COVID-Negative Test Algorithm
If the preoperative test is negative for COVID, then an assessment is made as to whether the patient likely will require an ICU bed, blood products, postdischarge rehabilitation, or a skilled nursing facility. Each one of these requirements results in a “go/no-go” decision based on resource availability and patient safety. For example, due to the increased risk of COVID exposure at a skilled nursing facility, the potential need for one constitutes a “no-go” (as of this writing) and results in case postponement (Fig. 2). Patients for whom surgery is planned to proceed undergo screening for new COVID symptoms on the day of the procedure. If symptoms have developed, rapid in-house COVID testing is performed and must be negative for surgery to proceed. Dialysis patients are tested morning of surgery as they are unable to quarantine.
COVID-Positive Test Algorithm
Procedures on patients testing positive for COVID are postponed for a minimum of 30 days. Before rescheduling, patients must be retested. Two negative tests separated by >24 hours are needed to clear patients to proceed with surgery under standard precautions. If the COVID test remains positive, the case is postponed if elective (eg, bariatric surgery). Cases that were previously considered elective and have since become urgent necessitate discussion with the PLT about the risk/benefit of proceeding under COVID precautions.
Ambulatory Clinic Management
Comprehensive guidelines for ambulatory clinic sites caring for pre- and post-surgical patients also were created to maximize safety and minimize COVID exposure risks to both patients and staff. The guidelines include a rigorous check-in process for screening of all patients, reconfiguration of waiting rooms to allow for social distancing of at least 6 feet, management of queues in the lobby of clinics to accommodate similar social distancing requirements, and a rigorous cleaning protocol for exam rooms (Appendix, Supplemental Digital Content 1, http://links.lww.com/AOSO/A0). Accompanying guests and family members are limited to only the parent of a minor or those who aid with handicaps. Otherwise, patients are mandated to enter the clinic space alone with accompanying guests picking-up and dropping-off outside.
The temporary halting of elective surgical procedures in many locations across the United States during the peak of the COVID crisis has led to the need for establishing priorities and protocols for their gradual resumption. We have presented the recommendations of a multidisciplinary panel within a large, multi-institutional healthcare system to address these challenges as prohibitions against elective operations are lifted in our jurisdictions.
Our recommendations contain several important elements. The overriding goals are safe resumption of operative procedures, assuring the availability of personnel and supplies, conserving resources for current or potential future COVID patients, and minimizing risks to both patients and staff. We consider the establishment of a local governance structure at each hospital and surgical facility to be essential for success. Frontline leaders have been shown to improve care.3,4 Although policies have been established for our entire healthcare system, their daily enactment is left to local leaders who have the most in-depth knowledge of available resources, including personnel, and constraints at their facilities.
We consider preoperative testing for COVID to be mandatory, assuming the availability of appropriate resources. Studies have found a higher risk of perioperative morbidity and mortality than otherwise expected in patients with active COVID infection.5,6 Infected patients also expose hospital staff to an unnecessary risk, which can be mitigated by postponing elective cases for patients testing positive. A case prioritization scoring system is useful to identify patients and procedures least likely to require limited resources such as hospital or ICU beds, ventilators, blood products, or rehabilitation/nursing facilities. As personnel, facilities, and supplies allow, cases from service lines strategic to hospital finances also can be undertaken in a safe and responsible manner.
It is imperative that institutions are aware of their local regulatory environment. In the State of Maryland, the Department of Health issued specific requirements for the reinstatement of elective surgery and procedures.7 Our workgroup ensured each directive was specifically addressed in our planning to ensure compliance.
Even when the COVID pandemic has passed, hospital systems and surgical centers will require policies and procedures for COVID screening and testing, case prioritization, and supply chain management. This will allow us to care for our surgical patients while protecting their safety and that of our staff. Our guidelines consider these factors and are applicable to tertiary academic medical centers, smaller community hospitals, surgery centers, and all service lines, providing a roadmap for resumption and maintenance of an elective surgical schedule for many healthcare organizations.
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