What unexpected challenges were encountered in resuming elective surgery?
Patients concerned, avoid elective surgery
Hospitals were keen to resume elective surgery given the dire financial consequences of the COVID-19 “shut-down.” When restrictions where initially lifted, there was some prioritization of surgical cases based on the urgency of the proposed procedures. At Rush, the ORs were quickly able to ramp up to pre-COVID-19 levels of operational efficiency. Patients are, however, concerned and fearful about hospitalization in what are perceived as “COVID hospitals,” leading to them delaying or canceling elective procedures. With hospitals not allowing or limiting visitors, undergoing surgery and recovering in hospital alone for days can be a daunting and isolating prospect for the patients and their families. These restrictions further lead to patients avoiding elective, but necessary surgeries. All of these factors have resulted in an influx of surgery to ASCs that are perceived as safer given that most ASCs have not participated in COVID-19 care. For surgeons and their families, returning to regular surgical schedules comes with its own level of stress. This raises questions about steps surgeons need to take to keep themselves and their families safe with so much about the virus still unknown.
Frank M. Phillips, MD, is professor and director, division of spine surgery; section head, minimally invasive spine surgery; and fellowship co-director, spine surgery at Rush University Medical Center in Chicago.
Accept small inconveniences
First, I am so grateful for the opportunity to help my patients by being able to perform life-altering sports medicine surgery again. However, there are some challenges. I’ve spent more time preoperatively talking to my patients about COVID-19. It’s not just that they can’t test positive before surgery, it’s also that they must maintain social distancing and precautions afterwards, since I do not want them to have surgery and then acquire COVID-19. In patients who are reasonable candidates for surgery but have some underlying medical condition, we spend a lot of time talking about the risks and benefits of doing their surgery now as opposed to waiting. No matter what, I am always fine with waiting. While nearly all of my surgeries are “elective,” there are still risks of delaying surgery, including further joint degeneration and more time dealing with chronic pain. The turnover times in the OR are also longer, since our surgery centers have limited staff in the room during intubation and immediately afterwards, so a packed surgical day may not mean quite as many cases. I would strongly advocate for orthopedic surgeons to accept some small inconveniences as a byproduct of these unprecedented times. Think of the whole patient when deciding if and when to do surgery, and not just the injured body part.
Derek H. Ochiai, MD, is co-owner of Reston Surgery Center and Harbor Heights Surgery Center and a board-certified orthopedic surgeon at the Nirschl Orthopaedic Center in Arlington, Virginia.
Protocol to prevent COVID-19 spread
Despite the business challenges presented by COVID-19, our surgery center remained operational, continuing to deliver high-acuity care with no documented spread of new infections. The design of our ASC (100% UV-treated/high-efficiency particulate air-filtered air, high-flow exhaust and isolated work areas) combined with extensive screening, PPE protocols, limited access and effective staff communications, enabled DISC Sports & Spine Center to remain a stable, functional care unit. By embracing a new normal, we’ve created a safer, yet still patient-centric environment.
In the last 4 months, we have had zero viral positive (polymerase chain reaction nasal testing) cases of COVID-19 among staff and their families, highlighting the effectiveness of our protocol management preventing spread in our environment.
To get to this point, we did several important things in addition to following CDC guidelines:
Testing – Although COVID-19 testing remains an enigma due to supply, withdrawal of emergency use authorizations and other FDA limitations, we’ve partnered with a Clinical Laboratory Improvement Amendments-certified lab to test every patient and family member entering the facility and for both antibody and antigen testing of support staff every 2 weeks. Although sourcing testing privately can be a significant cost above insurance coverage, it is one of the most important protocols we put in place to create a comfort level among our staff and patients.
PPE – Rational and appropriate use of PPE is a must. The rapid depletion of PPE without restocking created a massive supply chain problem in the United States. We’ve educated our staff about need and appropriate use, to carefully monitor safety and stock, balancing this against resupply options.
Limitations – We limited access to our facility early on, pausing high-volume procedures, such as elective pain management treatment, and restricting scheduling to urgent spine or orthopedic cases. We reduced flow by curbing all deliveries, outside vendors, food deliveries and other traffic. Initially, we allowed no family members, but now allow tested individuals as this is critical to education and postop care. Vendor reps are only allowed access to critical areas and need to be test-cleared.
Combating fear – It was vital that we communicate well and often with our staff to quell any fears about the facility’s safety. Careful attention to staff needs and concerns is critical as employers of open businesses face constant legal scrutiny. The challenge now is combating public fear that keeps people home, putting off much-needed care. We have learned from this response and established new protocols to create a safe environment focused on quality. Centers can safely mitigate transmission. Patients don’t need to stay home and suffer, sustaining undue pain or possible permanent neurological deficit. We need a social media response on how isolation/control measures have been effective at providing care in top-tier centers.
Robert S. Bray Jr., MD, is a neurological spine surgeon at DISC Sports & Spine Center in Newport Beach, California.