Get Ready to Reopen

Karen Curley, RN, nursing director of procedural services at UConn Health Surgery Center in Farmington, Conn., is helping to reopen the facility, which stopped hosting elective procedures on March 17. Nearly a month later, the center began to gradually add elective cases.

“The decision to start slowly was made in the interest of staff and patient safety, the availability of COVID-19 testing and adequate levels of PPE supplies,” says Ms. Curley. “We wanted to make sure we had all the necessary resources in place.”

• Prioritizing screening. All patients scheduled for surgery at LSDC must obtain negative COVID-19 test results within five days of their scheduled procedures. Most of the center’s patients originate from a large clinic in town, so Ms. Williams asked referring physicians to coordinate the testing for the patients they refer for surgery.

You know what they say about best laid plans.

“Testing has been hit or miss,” says Ms. Williams. “We’ve waited up to nine days for results. We thought securing testing in time would be an easy process, and did not anticipate the delays we’re seeing.”

She thinks the clinic was unprepared for the overwhelming demand for screening when the state began to reopen and the strain that put on the local lab responsible for processing the tests. In hindsight, Ms. Williams believes she could have communicated more clearly with the clinic about their testing process.

LSDC now sends patients who don’t have tests completed within 24 hours of their procedures to the local hospital, which can provide results within five hours. “We’re paying for the rapid turnaround, but we’re keeping cases on the schedule and the patients are getting their surgeries done,” says Ms. Williams.

The facility’s online registration portal now includes questions about possible COVID-19 exposure and symptoms, which staff review during the pre-screening process. On the day of surgery, patients are screened at a makeshift station set outside the center’s main doors. They’re asked to sign a COVID-19 form, on which they acknowledge the procedure they are about to undergo is elective and they are incurring some risk by entering the facility.

On the form, a staff member notes patients’ responses to questions about their possible exposure to COVID-19 and symptoms of the virus they might be experiencing, including cough, shortness of breath and fatigue.

The staff member conducting the screenings takes patients’ temperature readings and oxygen saturation levels, and notes them on the form. A case is immediately canceled if a patient has a temperature of 99.5 degrees or higher or an oxygen saturation level of 94% or less, which is an indicator of COVID-19 pneumonia. In some cases, patients can schedule an urgent chest X-ray, which, if clear, would allow the procedure to proceed

LSDC’s staff members and surgeons have their temperatures taken and answer questions about possible exposure to COVID-19 before entering the facility each day.

Dr. Marx says Upstate Hospital’s patients must be tested within 24 and 72 hours of their surgeries, a tighter window that works due to the health system’s resources. However, testing has been difficult to complete for the large numbers of patients who travel several hours for access to surgical care unavailable in their rural communities. “We’re trying to coordinate timely testing with local primary care physicians, but it’s been challenging,” says Dr. Marx.

• Ramping up gradually. Ms. Williams says LSDC decided to build up its case volume slowly to ensure the facility could maintain social distancing requirements and appropriately clean patient care areas between cases. The center’s ORs operated at 50% capacity for two weeks after reopening. The facility’s leaders then reevaluated the center’s new protocols to determine if case volume could be ramped up to 75% capacity in weeks three and four.

The results are mixed, according to Ms. Williams. She says the facility’s four ORs have reached the capacity goal, but case volumes in the five GI procedure rooms remain stagnant due to a perfect storm of misfortune: furloughed staff in the clinic that refers patients to the center, delays in securing COVID-19 test results and the retirement of a top-producing physician.

Elective cases were halted at UConn Health Surgery Center on March 17 and began again almost a month later. During the first week back, the center hosted only 12 cases in its five ORs, limiting the scheduled procedures to pain management procedures and hand and wrist surgeries — cases that can be done with local blocks instead of general anesthesia, which increases COVID-19 exposure risks during aerosol-producing intubation and extubation.

“We wanted also to maintain social distancing protocols and stagger start times by 30 minutes to ensure patients didn’t cross paths,” says Ms. Curley.

The center added more involved orthopedic cases, such as shoulder scopes, the second week after reopening and planned to bring all five of its rooms back up to speed on June 1.

“The center’s leadership meets weekly to discuss testing trends and infection rates throughout the state,” says Ms. Curley. “We keep monitoring and rehashing our status.”

Dr. Marx says Upstate Hospital is limiting the number of total cases each of its four facilities can accommodate per day based on PPE burn rates and the additional time it takes to terminally clean ORs between cases.

“Surgeons want what they want when they want it,” says Dr. Marx. “We’re trying to accommodate all their requests.”

Upstate’s surgeons are working through a backlog of approximately 1,500 cases, a reasonable amount when it’s broken down across several facilities and specialties. “We expect to be back to normal capacity sometime between August and January, depending on the incidence of COVID-19 in our community and possible state restrictions that would require us to slow down,” says Dr. Marx.

• Proper PPE. All staff members at LSDC are required to wear an N95 mask while in the facility. Each worker is assigned five masks. Individual masks are tagged with the employee’s name and the numbers one to five, which is the number of times the masks can be safely disinfected with UV-C light. At the end of each day, staff members remove their masks, tick off one of the numbers to keep track of how many times the masks have been disinfected and drop them off in a temporary disinfecting station set up in a physician conference room next to the back door where staff arrive and leave each day. The masks are treated with two five-minute cycles (front and back) and placed in a clean bag for pick up the next morning.

During procedures involving aerosolization, which can occur during upper endoscopies and intubation/extubation, staff at LSDC must wear face shields and isolation gowns in addition to N95 masks. The center currently has adequate supplies of PPE, but shortages are a constant concern.

“Materials management is in constant communication with clinical staff members, who provide a running total of PPE supplies,” says Ms. Williams. “We’ve fulfilled requests based on daily needs.”

In addition to wearing a surgical mask over an N95 mask, staff at UConn Health Surgery Center must wear a face shield whenever they interact with patients, including in pre-op and the PACU.

Patients at both surgery centers are required to wear masks at all times during their stay.

• Focusing on surface cleaning. Instead of swooping into ORs as soon as cases end to prepare the rooms for the next patient, staff at LSDC now wait outside while a UV-C light-emitting robot completes two 10-minute disinfection cycles. Staff wait 15 minutes after the robot completes its work to allow one complete air exchange to occur. They then enter the room to terminally clean flat surfaces, equipment and supplies, the anesthesia machine, walls and floors. To account for the additional time these new cleaning regimens require, LSDC doubled the time typically allotted to scheduled procedures.

The surgery center’s staff have also been instructed to regularly clean high-traffic areas. When patients leave the lobby for the pre-op area, the chair where they sat must be thoroughly cleaned before another patient can occupy it. All surfaces in pre- and post-op bays, including equipment and mobile computer stations, are wiped down between patients. “Our staff has always been careful about cleaning surfaces,” says Ms. Williams, “but we reemphasized the importance of being more diligent than ever.”