Part of the preparation for an ASC in the State of Florida to obtain a license and operate as an ASC has been to prepare its Emergency Preparedness Plan and its Comprehensive Emergency Management Plan. Once the policies for the EPP and the CEMP are completed, the Administration of the Center must make certain the CEMP is submitted to the county emergency management department and that the staff is in-serviced and drilled on the Emergency Management Plan. The organization develops policies inside of the EPP that define actions to be taken in the event of a disaster. Specific duties are identified for the RN Circulator, the surgeon/physician, anesthesia providers, technicians, receptionists---all the staff of the ASC. Staff are trained in these duties and are drilled, such that, should a disaster occur, each staff member knows and functions inside of their defined duties in order to maximize the efficiency of the drill and best promote safety in the event of a disaster.
The organization is charged by the regulations to identify all potential disasters that might impact it. A list of these would be placed in their Emergency Response Manual. Part of emergency response would include their inventory of Personal Protective Equipment and their procedure(s) for “sheltering in.” The most prominent potential disaster is always the one most Floridians would identify first and foremost, i.e.; hurricanes. While epidemics and pandemics may be on their potential disaster list, and while the Safety Officer may have completed a risk assessment for disasters and may even have completed a Pandemic Preparation Checklist, few really paid a lot of credence to such a potential event. Was a pandemic possible? Certainly, but not probable. After all, the US is a world leader in healthcare. We are on the forefront of medical innovations. We are in the age of readily available antibiotics. Things like SARS and EBOLA happen “over there” and if they do breach our borders, they are contained quickly, having little impact on most of us, let alone our ASCs. Healthcare leaders watched the outbreaks of measles, mumps, and chickenpox imported from other countries. We geared up to identify any EBOLA and SARS-inflicted patients, but these, relatively speaking, were minimal interruptions in our daily schedule.
ASC leaders have been warned by their licensing and accreditation agencies to be prepared for another “Spanish Flu-like” epidemic. CMS pushed for a 90 percent compliance in influenza inoculations. Skepticism was rampant among ASC staff members. “Yeh, right” was a frequent response from staff when advised of the dangers of not getting the flu vaccine when flu season rolled around each year. After all, the Spanish Flu pandemic was in 1918. Lots of things have changed since then, and besides (a frequently heard argument), ‘things are different now from what it was back then’. Few really believed it would, or could, ever happen again. AND YET…HERE WE ARE!
Your center is in the middle of the pandemic response. Most surgery centers are closed or are experiencing grossly reduced caseloads. They are being restricted by Governor DeSantis’ Executive Order regarding the non-performance of elective surgery. ASCs are restricted to performing only urgent or emergent procedures or those that if not performed could cause a deterioration of the patient’s condition. Subsequently, Gov. DeSantis has advised hospitals that they have the right, authority and power to transfer patients to ambulatory surgery centers, nursing homes, rehab centers, etc. for healthcare delivery in the face of the coronavirus and its rapid spread.
County Emergency Management agencies are demanding inventories of available supplies from the ASCs to include emergency equipment. Center managers are being told that these supplies may be confiscated if needed by hospitals. One must assume that this inventory transfer will no longer occur with the new governor order mandating ASCs to be prepared to take patient transfers from hospitals!
How does such a transfer process impact the ASCs? It would make the most sense that the hospitals would transfer the “not as sick” patients to the ASCs. It would be ludicrous for hospitals to transfer the critically ill patient to these centers, as most of the staff in an ASC are “surgically bent,” i.e., are not medically trained to take care of “sick” patients. Pre-Op/PACU and OR staff are trained to deliver care to patients preparing for surgery or recovering patients from surgery---NOT caring for infectious patients. These staff members are not critically trained, for the most part.
In addition, most ASCs have a two-week turn-around policy of their supplies and those supplies are geared toward surgical patients, not medical. Nevertheless, the ASC must prepare for an influx of patients should hospital bed availability become compromised.
Prepare a Pandemic Packet. In this packet would be the primary policies addressing infection control, pandemics, masking, wearing of PPE, gloving, universal precautions, disinfection, emergency vendors, among others. Review these with the staff; especially, those policies providing both patient and staff safety.
Perform a supply and equipment inventory identifying items needed. Communicate with your emergency vendors, identifying additional supplies and quantities that will be needed. Meet with your emergency vendors to discuss availability and delivery times or obstacles. Arrange for alternative resources, as needed. Be reasonable when ordering. Do not hoard, as this makes shortages even worse. Plan for what you will need without stockpiling to the extent that once the back orders come through, you are left with a huge overstock. Understanding that the country is in a STATE OF EMERGENCY, look at alternative processes. In the face of a huge shortage of masks, changing masks after every surgery case or encounter with a sick patient makes no sense. You may have to wear the same mask all day. Homemade masks and hair covers may be used and sent to the laundry. In performing the inventory, take these alternatives into consideration.
Look at your linen supply. Again, you need to be aware of the possible influx of patients. You will need extra linens to include blankets and pillows. Consider your inventory of towels and washcloths or do you need to order “bath packets”? You may have patients overnight. ASCs traditionally don’t have washcloths or towels, but with medically sick patients, there will be a need.
Look at your temperature taking equipment. Do you need more equipment as well as more sheaths/covers than normal? You may be taking temperatures more frequently.
Consider blood pressure cuff covers and order these accordingly. What about housekeeping supplies? All inventory may have to be boosted.
Staffing will be a big issue. Many ASCs use predominately part-time staff who also work at other ASCs. Call in your part-timers A.S.A.P. and get a commitment. Review your emergency policy on volunteers and contact those. Develop a schedule for staff and volunteers. Anticipate that the hospital may be sending staff persons to supplement your staff. Discuss this influx with your existing staff and develop a plan on how to orient staff being sent in as well as volunteers. Determine how credentialing will be conducted regarding volunteer LIPs. Review those policies. Some states are waiving licensure for physician and nurse volunteers for that state granting reciprocity across all borders.
Set up your volunteer station, your triage area, and your disaster control station. Call a meeting with your Administrator, Medical/Anesthesia Director, ORS, and Safety Officer to discuss the patient and staff flow as well as documentation records identifying what is in use, what is anticipated will be coming from the hospital, what is electronic, and what is hard copy. Develop a plan for record flow.
Determine a plan to care for the staff and volunteers. How will nourishment be provided for these critical persons? How will you staff the night shift? Discuss this internally and with the emergency management agency plus the potential hospital transferees.
Review your policy on Death in the Facility. While, conceivably, the ASCs will not get critical patients, death can, and most likely, will occur. You and your staff need to be prepared.
This difficult and challenging time is a time that is going to require some major “thinking outside the box” for the average ASC management and staff team. That thing none of us thought would ever happen, is now on our doorstep. It is now time to implement those emergency policies.
Management and key persons need to communicate throughout the day to determine what is working and what is not. This is the time management needs to be on the front lines to assist. Provide moral support, and professional counseling as needed for the staff. Have those counselors available even by phone or telecommunication.
When this is all over and done, sit down with your policies and make those revisions that, based on the experience you just had, will need revision. Many innovations happen during wars and this is a war.
Anne Dean, BSN, HCRM is President of the ADA Group, a consulting firm specializing in the development and compliance of ambulatory surgery centers worldwide. Ms. Dean is involved in the development of ASCs from the “ground up” working with architects to create the most efficient surgery, or office based, center possible for the client. All aspects of the development are captured by the ADA Group in order to successfully guide the center through the licensure, certification and accreditation processes. The ADA group prides itself on creating long-term relationships with its clients through the delivery of a quality product in the programs the company puts into place in the Center.