Nitin Khanna, MD Spine Care Specialists, Munster, Indiana

COVID-19: The Pathway Back to Elective Surgery

The novel coronavirus, COVID-19, has taken the world by storm. No one could have ever imagined the scale and intensity of this pandemic, which has upended every aspect of life as we know it. A big criticism of the US health care system is its collective inability to implement a preemptive strategy that may have mitigated the damage done to health care workers, patients, hospitals, and the economy.

In order to be part of the solution, it is incumbent on orthopedic surgeon thought leaders, who by and large have been sidelined during the pandemic, to come up with next step strategies in the COVID-19 era. This strategy will include creating a pathway back to elective surgery once the threat from COVID-19 is diminished. This crisis has made clear the need for all stakeholders, including physicians, healthcare workers, hospital administrators, insurance companies, and, perhaps most importantly, our legislators, to row in the same direction in order to get our health care system back on its feet.

The Role of Ambulatory Surgery Centers

Ambulatory Surgery Centers (ASCs) provide a cost-effective and efficient health care delivery model. Stakeholders include physicians, who force a thoughtful approach to resource utilization in their ASCs. There are many peer-reviewed articles and presentations that have demonstrated the safety and efficacy of outpatient surgery. As we start to bring back elective surgery, we will need to consider the safest possible pathway for patients, physicians, and health care workers. This is a shared responsibility, and the small format of most ASCs allows full control and adherence to diligent safety protocols. Additionally, because freestanding ASCs have no emergency rooms, sick patients, or intensive care unit beds, there is a well-understood decrease in the overall infection risk.

Clinical Pathway

In my practice, we are instituting a detailed system that will minimize the risk of COVID-19 transmission based on our current understanding of the disease.

Patient Check-In and Companion/Visitor Management

Patients must check in alone and have their companion wait in the car unless the patient is unable to enter the building without assistance. Once surgeries are again being conducted, we will update the companion when the patient is checked in, when he or she enters the operating room (OR), and when the procedure is completed. The doctor will meet virtually with the companion after the operation to go over the surgery. The companion will be allowed to see the patient just prior to discharge.

Temperature and Checklist

All patients and staff will have their temperature checked on the day of surgery. Any temperature over 100°F will automatically result in that person not being allowed in the facility. The standard checklist of any recent illness, contact with anyone known to have COVID-19, and recent travel will be completed by the patients and staff daily.


Due to the highly infectious nature of COVID-19 from asymptomatic patients, we believe the evidence supports universal mask-wearing in a health care facility. Thus, we require all patients and staff to wear masks at all times. We anticipate the N95 masks to become more readily available as the infection and hospitalization surges pass. All surgeons and team members will be required to wear N95 masks in the OR during surgery. Proper technique and fit tests for the N95 masks will also be required.

Intraoperative Care

The only staff in the room during intubation will be the anesthesiologist and a nurse, both of whom will be outfitted with personal protective equipment (PPE). All other members of the surgical team will wait outside the OR. Once the patient is intubated, the staff will be able to enter the room and begin positioning and opening the back table to prepare for surgery.

OR Turnover

Turnover will require 30 minutes in negative pressure ORs with antiviral disinfectant. This step may slow down the 2-room strategy that many surgeons employ, but we believe it is necessary to ensure a safe and sterile OR environment.

Future PPE Technology and Testing

Once available, the 5-minute test that Abbot is developing should be used as a prescreen for all patients and staff on the day of surgery. There is a significant cost to performing these tests daily, but the opportunity to layer these different strategies will provide the utmost in safety and confidence to patients, staff, and providers.

In PPE, the next generation surgical masks will need to be created with newer sterilization technology, likely to include ultraviolet light. The ability to operate on longer cases utilizing the N95 mask is a challenge that newer technology will have to address with advanced filtration head gear. Because this virus is spread through aerosol droplets, eye protection will also have to be rethought. The next generation eye protection will require a seal around the eyes that provides for complete protection for health care providers. Surgical gowns will also need to evolve to cover and protect more of the exposed head and neck region.

Contracting With Insurance

Many insurance companies, as well as the Centers for Medicare and Medicaid Services, have been slow to offer competitive facility contracts to ASCs. The politics need to be removed from this equation and increased competitive contracts need to be offered that are in line with hospital reimbursements for similar procedures. Such a change would open access for many patients who are seeking elective surgical care but have valid concerns about out-of-network charges. A “give and take” relationship is necessary, with ASCs providing quantifiable metrics regarding complication rates, patient satisfaction scores, surgeon scores, and outcomes. ASCs cannot be places where a high volume of procedures and expensive care occur with worse outcomes than hospital settings; rather, they must be cost-effective centers with quantifiable improved care.

Hospital or Freestanding ASCs

Some hospitals have their own ASCs and may have the ability to re-open their centers prior to opening the main ORs. Some of the challenges are the shared staff and equipment and the population flow between the 2 facilities. These ASCs likely have some increased risk compared to freestanding ASCs. Strict guidelines to “wall off” the ASC from main ORs will offer a significant advantage. Unfortunately, such a change would likely require going through significant hospital bureaucracy, which can be time consuming and frustrating for providers. Furthermore, the hospital staff and anesthesia department will be more resource constrained while managing COVID-19 patients. As such, allocating resources to elective surgery will likely take longer to implement. On the other hand, a freestanding ASC typically has a physician board that is clinically active, a management company, and a medical director who will ensure laser-focused and timely adaption to rapidly changing events.

Much has been asked of health care providers worldwide in this time of crisis. Healthcare workers will need to be a proactive part of the solution as we start to rebuild.

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