Restoring our normal office and surgical practice May 1 2020

Our Journey Back to Elective Surgery

It seems to be closer now

April 29 2020

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. Our elective surgery has been brought to a standstill while we have been fighting the COVID-19 with social distancing and shelter in place. Your safety and security continues to be important to our caregiving mission. Dr. Fogel and his staff are responding to the evolving situation, and I wanted to share our specific actions to make sure you receive safe care during this time.

Over the past 6 weeks We have been social distancing by avoiding the office and instead using telehealth with and without video to replace clinic visits. The Governor’s most recent Executive order will allow a limited return to office. I plan to have fewer wide-spread waiting chairs and limit additional visitors to those who require help to walk into the office. I plan to continue to offer tele-health visits to support those who do not want to come to the office.

We are a small medical office and do not have much of the protective equipment today to treat patients in the office. We have been working to obtain masks, gloves, eye protection and all equipment. we will be ready to respond to our Governor when a complete return to medical office practice is announced.

This week the Governor has given instructions to open up surgery again but slowly, beginning with Ambulatory Surgeries and 23 hour stay. As the threat from COVID-19 has diminished and surgical cases will flow back to the ACS’s and then return to larger hospital systems. 

In order to be part of the solution, it is incumbent on your surgeon to plan with next step strategies in the “new normal” 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 work together 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 at the Governor’s Executive Order, we will need to consider the safest possible pathway for patients, physicians, and health care workers. This is a shared responsibility, and the stand-alone 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, I am instituting a detailed system to minimize the risk of COVID-19 transmission based on our current understanding of the disease.

Patient Check-In and Companion 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 someday. 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. Turnover of the Operating room between cases will require 30 minutes in negative pressure ORs with antiviral disinfectant.

Future PPE Technology and Testing

The quick  antibody test that 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.

Hospital or Freestanding ASCs

Hospital based elective surgery will implement safely through testing and protective equipment. We are responding to the Guidance of the Governor as we slowly open elective surgery.  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. At this new beginning the freestanding ASC medical director 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.

GUY R. FOGEL MD Orthopedic Spine Surgeon San Antonio Texas

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