Surviving the COVID-19 Crisis

The coronavirus has ground outpatient surgeries to a halt. As the nationwide response to the outbreak enters its second month, every possible healthcare resource is being marshalled for the acute treatment of COVID-19 patients.

On March 18, CMS called for the cancellation or postponement of all elective surgeries during the outbreak and released recommendations outlining numerous factors individual providers should consider when deciding whether they should proceed with a procedure as planned or call it off until the coronavirus is contained (osmag.net/Jpw9ZE). The American College of Surgeons (ACS) advised surgeons to curtail elective procedures to preserve necessary PPE and resources for the care of COVID-19 patients. The U.S. surgeon general also asked healthcare systems to halt elective procedures.

ACS joined the American Society of Anesthesiologists (ASA) and the Association of periOperative Registered Nurses (AORN) in calling for surgical facilities to establish Surgical Review Committees consisting of leaders from surgery, anesthesiology and nursing. The committees would serve as administrative bodies that provide "defined, transparent and responsive oversight for triaging surgical cases during the COVID-19 pandemic." The organizations felt it necessary to fill gaps in national guidance on these urgent issues.

Monticello Community Surgery Center in Crozet, Va., is essentially shuttered. The multispecialty facility went from performing 115 cases in one week in March to five the next week, says CEO Andy Poole, FACHE. The facility's physicians are performing only emergent procedures such as repairing detached retinas, fixing fractures and removing cancerous lesions. Staff members are working on securing an emergency loan needed to ensure the center's 30 full- and part-time employees keep getting paid.

"It's been a big hit financially," says Mr. Poole. "We know the case volume will eventually return, but we need a way to take care of our employees, so they'll survive in the meantime."

To that end, Mr. Poole and other surgery centers around the county turned to the emergency Coronavirus Aid, Relief, and Economic Security (CARES) Act, which appropriated $350 billion for small businesses to keep employees on the payroll. Under the CARES Paycheck Protection Program, the U.S. government will guarantee the loans to small businesses who maintain their payroll during the COVID-19 emergency and will eventually forgive 100% of the principal amount borrowed.

Mr. Poole hopes the CARES loan will last until Monticello can reopen. When that happens, he plans to take advantage of the CMS Accelerated Payment Program, which Congress expanded for the duration of the current public health emergency. Facilities such as Monticello can apply for up to 100% of the Medicare and Medicaid reimbursements they would have normally received for three months, and can be repaid over time.

"The CARES loan is for now and the accelerated CMS payments are for when we re-open," says Mr. Poole. "Then we'll have to explore the possibility of using FDA loans to avoid having to dip into our cash reserves."

The past few weeks have seen a sharp drop-off in volume at most surgery centers, reports Mr. Prentice, who says COVID-19 "has created true economic harm and left facilities flat-footed right now in terms of being able to provide care." He hopes the federal CARES Act and the funding contained in it will be used to provide funding to surgery centers immediately, so they can retain staff and pivot to these new, volatile market and public health conditions, while also being able to take care of patients who postponed elective surgeries once restrictions are lifted.

"There are a variety of options available to get some liquidity from the CARES act," says Mr. Prentice. "We just want to make sure all of those options are available for surgery centers so they can get the funding they need to stay open, and have the equipment and staffing to be able to provide the care that we all know they're going to need to provide as this pandemic worsens."

Greg DeConciliis, PA-C, CASC, is feeling the stress of an uncertain economic future. "Not knowing when it's going to end is the worst," says the administrator of Boston Out-Patient Surgical Suites in Waltham, Mass. "We won't be able to take care of our staff forever. Then, when we do reopen, who knows if the elective procedures that were postponed will get rescheduled by the patients. On the other hand, we're also worried that if everyone does reschedule, we'll be faced with a backlog of cases our facility won't be able to handle."

Ms. Hogan has contacted the firm that handles the regular maintenance of her facility's fleet of endoscopes. With no cases being performed for the foreseeable future and therefore no need to maintain the scopes, she worked with the company to renegotiate the contract's monthly fee.

Few if any outpatient surgery centers envisioned a de facto national shutdown such as this, let alone planned for it, says Mr. Poole. "There's a lot of preparing for contingencies in this industry," he says. "But if any center was ready for this one, all I can say is, 'Man, they're good.'"

Some surgery centers are furloughing employees, an unfortunate reality of running a surgical facility with empty ORs. Ms. Hogan hopes her team will be back performing procedures soon, but acknowledges it might take several weeks or months before her facility is back to running at full capacity. In the meantime, she says some members of her team are having a tough time dealing with the uncertainty of a difficult situation. Many still want to help wherever and whenever they can. Driven healthcare professionals don't do well sitting on the sidelines, especially during a national pandemic. Ms. Hogan says some of her staff members have offered to volunteer at the local hospital or help provide care at the county level.

Lakeland (Fla.) Surgical & Diagnostic Center is trying to make the best of a bad situation. On March 20, Florida's governor halted ASCs from performing any elective surgeries. The center finished its few remaining cases and closed completely on March 27. "We just have skeleton staff, mostly admin and maintenance working," says Clinical Director Nikki Williams, RN, CNOR.

The facility paid its staff two weeks' pay with intention to furlough on April 3, but applied for a loan through the CARES Act, so the staff will be able to stay on until May 15. "We're hoping to reopen by May 18, but it depends on the state allowing us to do elective cases," says Ms. Williams.

Her facility continues to monitor the temperatures of all people working in its buildings. The independent facility has a hospital next door.

"We're not sure if they will need to take over our building, so we've been doing inventory on equipment and supplies if that event occurs," says Ms. Williams.

MidHudson Regional Hospital in Poughkeepsie, N.Y., less than 100 miles from New York City, has canceled all elective outpatient cases. The nurses from the hospital's pre-op, PACU and interventional radiology units have cross-trained so they can help with COVID-19 cases in the ICU and medical/surgical unit, says Caryn Solomon, MA, RN, director of nursing and perioperative services.

Most of the nurses who work in the hospital's surgery center have shifted to three 12-hour shifts per week. Some are now working night shifts, and others have been trained to administer coronavirus tests in a tented testing site on the hospital's property. Other surgery center staffers are delivering meal trays to hospital floors and providing other help as needed.

"The surgical team is doing whatever we can to support our co-workers on the other floors," says Ms. Solomon. "We will get through this together."

A shortage of personal protective equipment (PPE) has been a national crisis for COVID-19 responders during the pandemic. Boston Out-Patient Surgical Suites and other facilities who use a management company to conduct their business operations have avoided that problem for now. First, less gear is needed because so many facilities have canceled the bulk of their cases. But many, such as Boston Out-Patient, have been put on an allocation program by manufacturers to receive the average amount of PPE they would order in a month.

"Having a management company helps in many areas at a time like this," says Mr. DeConciliis. "We even donated some of our PPE to a large hospital system nearby."

He's trying to organize a drive for other ASCs to donate surplus supplies of PPE, but there hasn't been a lot of buy-in. "Everyone wants to hold on to what they have," says Mr. DeConciliis. "We're doing what we can. Our staff is even looking into whether we can repurpose blue wrap into masks."

A clinical manager at an Arizona hospital who spoke on the condition of anonymity says supplies of PPE are holding steady for now, but the hospital's administration noticed the suspicious disappearance of N95 masks. "Supplies of PPE are now under lock and key," says the manager. "Staff are required to request the gear they need, and sign for the amount they take."

Proliance Eastside Surgery Center in Kirkland, Wash., located in the same town in which a nursing home had one of the worst COVID-19 outbreaks in the U.S. to date, was put on an allocation system for gowns and masks by its vendor, according to Carmen M. Wilson, RN, BSN, CIC, the facility's director. She says the center has yet to experience a shortage of PPE. Proliance began to perform emergent cases only, and the allocations of PPE they're getting have been sufficient.

The N95 masks at MidHudson Regional Hospital "are like gold," according to Ms. Solomon, who says supplies are carefully distributed and tracked.

Research shows the virus can be carried through fecal matter, so physicians at Ms. Hogan's GI facility have been encouraged to wear the N95 mask during procedures. She has an adequate amount of the masks for now, and has given some to her physicians who are performing urgent cases at the local hospital, where supplies are limited.

ASCA is encouraging its members to adapt to the rapidly changing conditions by enrolling in CMS's "hospitals without walls" program, which lets hospitals send urgent non-COVID-19 or more complex surgical cases their way. ASCs can temporarily convert to urgent care facilities or overflow ERs, serve as COVID-19 triage centers or even provide a place for local hospital care teams to sleep. ASCA assembled a document (osmag.net/CJR4gu) that outlines all the ways in which ASCs could serve during the pandemic.

"We're focused on the mission of trying to make sure ASCs remain open and are able to help however possible," says Mr. Prentice. "Obviously, we're in unprecedented times, and the entire healthcare system is racing to adapt to how we can provide care that has to be provided during the pandemic. We're all cognizant that in many communities, hospitals are above capacity because of an influx of COVID-19 patients."

Mani H. Zadeh, MD, FACS, an ear, nose and throat surgeon in Los Angeles, began seeing a lot of patients — some of them fellow doctors — complaining about the lack of a sense of smell in late February. This was a frightening development because he knew it was a COVID-19 symptom reported in France, Italy, Iran and elsewhere — and that some of the physicians presenting with this symptom had been in close proximity to patients with the coronavirus.

Dr. Zadeh originally prescribed nasal steroids, but then stopped because rapidly emerging data said it was not an effective treatment. He stayed in touch with the patients. Fortunately, none had other symptoms of COVID-19 and all reported that they were feeling better. Still, the current clinical climate is making doctors nervous, because many of them have certainly treated patients who've had the virus.

"It's an odd feeling," says Dr. Zadeh. "You're working with doctors you've known for years, and everyone is wondering if the other person has it."

Mr. Poole says he's offered assistance to two nearby hospital systems and entered his facility's ventilators on a national registry. So far, however, Monticello hasn't been a direct part of the COVID-19 response. He thinks it would make more sense for hospitals to send non-COVID-19 cases to centers such as Monticello. "But I hope it doesn't come to that," he says.

Coronavirus infection rates are expected to peak this month, but questions remain about how long it will take to flatten the curve. Until life returns to normal, whenever and however that will be, surgical professionals without patients to care for have an unexpected opportunity to look after themselves — and each other. Ms. Hogan's staff started a private Facebook page to maintain a sense of community and connection. "We told everyone, 'If you're struggling, reach out,'" she says.

Her team holds impromptu karaoke competitions, Zoom Happy Hours and posts their favorite memes. They're facing an uncertain future together. "We don't know what it's going to look like on the other side of the pandemic," says Ms. Hogan. "But we know we'll get there." OSM