Industry Voices—7 things to consider before reopening your operating room

Responding to the COVID-19 pandemic required extreme measures by operating rooms throughout the nation.

Fortunately, we’ve started seeing signs that the first wave of this crisis might be coming to an end, and hospitals and health systems are starting to create project plans allowing them to once again perform elective surgeries and procedures.

The time, then, is now to begin planning for how ORs should address the overflowing case demand and backlog of surgical procedures that were canceled. Dealing with both at once requires a plan.

RELATED: CMS releases guidance for how health systems can restart elective procedures canceled due to COVID-19

1. Consider patient and employee safety first.

The No. 1 factor to consider when resuming elective surgeries is patient and employee safety. Hospitals should aim to book surgeries at least 14 days out, 10 at a minimum. Patients being added to the surgical schedule should automatically be tested for COVID-19. Though at-home tests have recently gained approval from the FDA, this test should be done at the hospital.

If their results come back positive, those patients should be removed from the schedule and rescheduled only once they’ve tested negative, twice. Once a patient’s surgery has been scheduled and they’ve been tested for COVID-19, the patient should then be instructed to self-isolate from then until their procedure date.

A local hospital we’ve worked with recently began contacting patients to reschedule their canceled elective surgeries and found that nearly 40% were unwilling to. That anecdote says to us that all ORs will be dealing with a lingering fear from patients who might equate a trip to the hospital with a higher risk of infection.

Testing and self-isolation of patients should be the bare minimum. One step beyond means coordinating with a marketing department to ensure that all of the safety precautions being taken are communicated to patients, whether through scripts on phone calls, copy on websites or anywhere else where those patients' fears might be addressed.

2. Create a COVID-19-specific cancellation code.

It’s important to understand the number of cases that have been or will be cancelled due to COVID-19, for both reporting purposes and beginning to address surgical case backlog. Once you’ve created a COVID-19-specific cancellation code, take a retrospective look at all of your cases since the pandemic started (we’d recommend at least March 15) and recode cancellations that are particular to COVID-19. This can help identify cases that still need to be completed and will allow your surgical team to appropriately estimate OR demand in the coming months. 

3. Evaluate your OR demand and capacity.

Create a pipeline report by surgeon and specialty that identifies projected cases and case time needed to complete backlog cases. Backlog cases are those that were canceled by the hospital due to COVID-19 and those that were never scheduled by the surgeon’s office. Evaluate the case times, turnover times and needed hours of block to complete the backlog for each surgeon. This will be important as your OR adjusts blocks and times during the restart period. Our colleague Gail Pietrzyk, corporate director surgical services at Universal Health Services, reminds us that facilities will only have a few weeks to work through their backlog before physician offices resume normal scheduling, so it’s important to use this window of opportunity judiciously.

RELATED: Resuming elective procedures will depend on testing, PPE, decline of COVID-19 cases, providers say

Finally, evaluate your OR capacity during current prime-time hours and consider extended hours with a goal of optimal utilization to address the current backlog of cases.

4. Prioritize cases using a scoring system, such as the Medically Necessary Time-Sensitive (MeNTS) scale.

A scoring system will help determine how to prioritize cases and when to proceed with certain surgical operations in light of resource limitations and exposure risks posed by COVID-19.

The MeNTS prioritization scale’s methodology, developed by investigators and surgeons at the University of Chicago, addresses elective surgical procedures and guides both surgeons and OR leaders across different specialties in prioritizing case types and patient safety. There are 21 factors considered in the scoring system, scored on a scale of 1 to 5. Thus, a total score can range from 21 to 105. The higher the score, the greater the risk to the patient, the higher the utilization of healthcare resources and the higher the chance of viral exposure to the healthcare team. A full list of factors and a sample MeNTS worksheet can be found here.

This system is ideal for any OR, not just academic medical centers or large health systems. The assessment of resources and risk is applicable anywhere, which makes this a strong tool for prioritizing and determining cases to go forward with amid the COVID-19 pandemic.

5. Develop individualized plans to adjust blocks based on prior utilization, and extend release times to accommodate a backlog of deferred cases.

There needs to be a concentrated effort to enforce block policies to ensure optimal efficiency and maximum utilization to accommodate a backlog of cases. OR leaders should consider extending block release times out by at least seven days (with cardiac and trauma being the exceptions to this) to allow specialty teams more flexibility in scheduling as the surgeon offices begin booking cases again.

Take some time to review your block utilization numbers from January and February. OR leadership should consider temporarily releasing blocks that had less than 50% utilization in those months.

Additionally, consider a “Surgery Saturday.” This would require opening a couple of your ORs on a Saturday for high-volume surgeons with consistent case-time procedures. This would be for shorter cases like hernia repairs or similar cases (less than 45-minute case times).

Pietrzyk stresses not to be too quick to break up block schedules; your first goal should be to maximize existing blocks and work with surgeons to extend release times if blocks can’t be maximized.

6. Consider a modified visitor policy specifically for surgery patients.

Remember the stat about 40% of patients refusing to reschedule their procedures? The cases that would have required an overnight stay were even more likely to be declined, with the new visitor restriction policies being cited as one of the driving factors.

Simply put, patients who have to stay overnight for observation don’t want to wake up and not be able to see their friends and family members. These fear and safety concerns are understandable and should be addressed with good policy and precautions.

If you’re leading an OR at a hospital that doesn’t have any active COVID-19 cases or that can restrict cases to a specific floor or floors, it might be worth considering a modified policy for visitors. Testing and self-quarantine requirements used to keep surgical patients safe could be extended to a specific visitor for the purposes of a planned elective case. If the design of your OR allows family members to stay, do everything you possibly can to let them.

RELATED: Oklahoma, Texas and Alaska to begin allowing elective surgeries

7. Use CMS’ “Hospital without Walls(PDF) exemption to complete cases at an ambulatory surgery center (ASC) instead of the hospital.

Maximize volume of surgical cases in a way that promotes patient safety and preserves resources at the main hospital. This will also protect inpatient capacity at your main campus. The Hospital without Walls initiative allows currently enrolled ASCs to temporarily enroll as hospitals and provide hospital services. During this time, ASCs can bill procedures as if they’re being performed at the hospital.

Patients will feel safer at an ASC because there’s not an attached emergency room. Some of the hospitals we work with have shifted as much of the outpatient volume as possible to forcibly segregate some of their surgery patients, a move which has the added benefit of helping to solve some of the visitor policy issues.

For more information, ASCs that want to enroll to receive temporary billing privileges as a hospital should call the COVID-19 Provider Enrollment Hotline or review the CMS Medicare provider enrollment relief FAQ (PDF).

The COVID-19 pandemic represents an unprecedented threat to the health, safety and mental well-being of anyone willingly coming to a hospital or health system. That goes double for those patients who might choose to find themselves in an OR.

Just because there’s no precedent, however, doesn’t mean there’s no hope of reopening without a hitch. Hopefully, these seven considerations go a long way toward turning this unprecedented time into one where ORs don’t just survive, but thrive.

Sharon Ulep leads operational performance solutions in the acute healthcare space at Plante Moran. Regan O’Connor is a senior consultant on the healthcare strategy and operations team who specializes in surgical transformation and process improvement.