Updated April 24, 2020
In the coming days, PYA will provide our perspective on what will be required to get the U.S. healthcare industry re-started and moving forward. Flattening the COVID-19 curve remains our collective highest priority. At the same time, we all recognize the critical need for a safe, timely, and orderly return to the pre-crisis healthcare delivery model.
From PYA’s perspective, the steps to ensure a safe and successful re-start of our healthcare system will require a set of interrelated actions on the part of providers. This includes, but is not limited to:
Fundamentally, we believe there are lessons to be learned from “the path in” to the crisis that can be leveraged on “the path out.” The crisis disrupted the supply/demand equilibrium of the pre-pandemic national health system. Ensuring we avoid additional disruptions as we return to normal will require forethought and game planning.
The broader issue of re-starting the economy as a whole is addressed in the April 16 White House/CDC Guidelines – Opening Up America Again. The Guidelines identify three data-driven gating criteria a region or state should satisfy before proceeding to a phased opening:
The Guidelines note that “[s]tate and local officials may need to tailor the application of these criteria to local circumstances (e.g., metropolitan areas that have suffered severe COVID outbreaks, rural and suburban areas where outbreaks have not occurred or have been mild).”
Regarding healthcare, the Guidelines state that once a state or region reaches Phase I (i.e., initially satisfying the three gating criteria), “elective surgeries can resume, as clinically appropriate, on an outpatient basis at facilities that adhere to [Centers for Medicare & Medicaid Services (CMS)] guidelines.”
As states or regions progress to Phase II (i.e., no evidence of a rebound and that satisfy gating criteria a second time), “elective surgeries can resume, as clinically appropriate, on an outpatient and inpatient basis at facilities that adhere to CMS guidelines.” (emphasis added)
CMS Phase I Recommendations
On April 19, CMS released its recommendations, Re-opening Facilities to Provide Non-emergent Non-COVID-19 Healthcare: Phase I. In this document, CMS advises as follows:
- To fullest extent possible, utilize telehealth modalities to deliver needed care.
- Evaluate incidence and trends in coordination with state and local public health officials.
- Evaluate the necessity of the care based on clinical needs.
- Ensure availability of adequate workforce and supplies (PPE, medications, equipment) to support pre-, intra-, and post-procedural care without jeopardizing surge capacity.
- Establish non-COVID care (NCC) area, i.e., defined space in which non-emergent non-COVID-19 services will be furnished.
- Screen all patients and all other individuals entering that space.
- When adequate testing capability is established, screen patient with laboratory testing before care; also regularly screen staff by laboratory test.
- Prohibit visitors unless necessary for aspect of patient care.
- Do not rotate staff between NCC and COVID care areas.
- Separate NCC area from other facilities to the highest degree possible (i.e., separate building or designated rooms or floor with a separate entrance and minimal crossover with COVID-19 areas).
- Establish plan for thorough cleaning and disinfection prior to using any spaces for non-COVID-19 patients.
- Ensure equipment, such as anesthesia machines used for COVID-19 patients, is thoroughly decontaminated, following CDC guidelines.
- Continually evaluate whether region remains at low risk of incidence; be prepared to cease non-essential procedures if there is a surge.
ACS, ASA, AORN, and AHA Roadmap
On April 17, American College of Surgeons, American Society of Anesthesiologists, Association of periOperative Registered Nurses, and the American Hospital Association published their Roadmap for Resuming Elective Surgery After COVID-19 Pandemic. The Roadmap includes guidance on timing for re-opening elective surgeries and policies for COVID-19 testing within a facility, which is generally consistent with the White House/CDC guidelines and CMS recommendations.
The Roadmap, however, goes further by addressing care prioritization and scheduling. It recommends a facility “establish a prioritization policy committee consisting of surgery, anesthesia and nursing leadership to develop a prioritization strategy appropriate to the immediate patient needs.” In developing this strategy, the committee should consider the following:
- List of previously canceled and postponed cases
- Objective priority scoring (e.g., MeNTS instrument)
- Specialties’ prioritization
- Strategy for allotting daytime “OR/procedural time”
- Identification of essential healthcare professionals and medical device representatives per procedure
- Strategy for phased opening of operating rooms
- Strategy for allotting and increasing OR/procedural time availability
Immediate Next Steps
With this new guidance, a health systems’ immediate “re-opening to-do list” should include the following:
- Engage with local public health officials to develop a model or tool to measure COVID-19 spread in the local community. If appropriate, agree to local Phase I criteria.
- Identify appropriate space for an NCC area and plan for necessary modifications.
- Develop procedures and processes for NCC area operations.
- Develop process to quantify surgical capacity based on available pre-op testing, staff, PPE, supplies, medications, equipment, and post-op care.
- Establish a charter for, convene, and secure necessary resources for a prioritization policy committee.
If you have any questions related to the strategic re-entry into the healthcare economy or need additional guidance related to COVID-19, visit PYA’s COVID-19 hub, or contact one of our PYA executives below at (800) 270-9629.